why can't download NRG protocols like older RTOG PDFs?

[FreakFlag]

remember when RTOG protocol PDFs were easily downloadable through their website? great resource for understanding open questions in radonc, and seeing up-to-date contouring + planning parameters.

why are the newer NRG protocols so hard to find and/or impossible to obtain? is there some backstory to why they're so hard to access now?

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[RickyScott]

It is disgusting.

 

[RO5231]

Supposedly the NRG procotols are on the CTSU website now, but not sure what is required to access them.

www.ctsu.org

 

[RickyScott]

Why should there be any restriction. This is taxpayer funded.

 

[RO5231]

Why should there be any restriction. This is taxpayer funded.

Yeah, I remember I used to be able to Google the older rtog protocols and links would be accessible from their website. Even those have disappeared.

 

[SubserviantToABR]

Here's is Sue Yom's unsatisfying answer, screenshotted for posterity. Here is the link to Dan Golden's tweet:

 

[w00tz]

Super annoying. They were very helpful.
What use are the results of these trials if we don't know how to apply them?

 

[deleted969641]

I have always been puzzled why protocols are so hard to find. I feel like a kid trying to steal music off of Napster when trying to find open protocols online.

Why have this secret elite club and not disseminate up-to-date contouring guidelines and dose constraints? Who says I want to treat the experimental arm off trial? Why not the standard arm? Shouldn't we do what's right for patients in the community who are unable to travel and get on one of these trials?

This is one of the more frustrating and bizarre things in our field. Childish really. Kind of like how attendings in residency would not share their database of study PDFs with you. Once I asked if I could take a thumbdrive and copy the PDFs for my reference and studies as a resident and the question was literally ignored with silence. I guess I was expected to go online and pay $39.99 for all of the articles.

Glad to see that others are as perplexed and annoyed about this as I am. I've never heard anyone mention it before and thought it was just me.

 

[RickyScott]

I am guessing there is some personality disorder at work here.

 

[RadOncDoc21]

I’m not surprised. Rad Oncs are the worst when it comes to supporting each other.

Crabs in a bucket at an all you can eat seafood restaurant!

 

[deleted969641]

I am guessing there is some personality disorder at work here.

Maybe some brazen and more tech-saavy resident than I am can make a Napster for protocols. Not that I would ever participate in something so horribly unethical, but hypothetically, if such a database were to come to fruition, please PM me the link and secret access code so I can report it.

 

[seper]

these academic types try to put their copyright on every ppt slide.

 

[metallica81788]

Those replies by Sue Yom (FTR I have no clue who she is) are embarrassing. Aren't we all in the same boat and trying to improve? Protocols are helpful for many reasons. They can be extremely helpful for solo practioners without a large network of resources behind them.
Answers like that show why RadOnc is ultimately doomed by these "thought leaders" - we should be able to openly access protocols.

 

[StIGMA]

"I value (my own career and maintaining my status in the radonc hierarchy) more than (helping our field via knowledge dissemination and helping patients by distributing good standards of care)"

I've heard there's a fair bit of strife in that department. Wouldn't be surprised if that attitude is an extension of the culture there (focused primarily on protection of presumed intellectual property vs. advancement/dissemination of knowledge). It's not an uncommon attitude at some places unfortunately.

 

[Ray D. Ayshun]

Those replies by Sue Yom (FTR I have no clue who she is) are embarrassing. Aren't we all in the same boat and trying to improve? Protocols are helpful for many reasons. They can be extremely helpful for solo practioners without a large network of resources behind them.
Answers like that show why RadOnc is ultimately doomed by these "thought leaders" - we should be able to openly access protocols.

New editor-in-chief of the red journal fwiw. Fortunately, there's really no protocol for deferring rt we'll need access to.

 

[Music Man Stan]

As a person who has access to all these protocols, I agree it’s very silly to keep them behind a password.

I would like to inform everybody here that you are sadly not missing out educationally by not having access to these protocols. The protocols are written to be simple and easy to follow and mandate margins (and target volumes) much larger than I personally practice off-protocol.

Let me give some concrete examples.

NRG HN 004 is looking at cetuximab vs durvalumab for patients ineligible for cisplatin. The protocol CTV 70Gy is GTV + 5-10mm margin trimming at bone or air, and the CTV 56Gy is another 1cm expansion from the CTV 70Gy. PTV margin is 3-5mm. So imagine a lymph node sitting between the SCM and the scalene muscles. Your 70Gy volume goes 0.8-1.5cm into the scalene muscles, and then your 56Gy volume goes 1.8-2.5cm deep into the muscles. That's a lot of muscle radiation.

NRG GI-002 was looking at veliparib or nivolumab added to neoadjuvant CRT for rectal. They are STILL using the old 0529 atlas (going 1cm into the bladder) despite everybody having access to daily CBCT to make sure that the bladder/uterus have not somehow shifted anterior by 2cm. This is despite more modern (and smaller target volume) consensus guidelines being released (Valentini, Green Journal, 2016). So imagine that you have a person with a uterus between your mesorectal fascia and bladder. That's a lot of needless uterine and bladder radiation. No wonder insurance companies try to deny IMRT - of course you're not going to see differences if your PTV is that big.

 

[Neuronix]

Maybe some brazen and more tech-saavy resident than I am can make a Napster for protocols. Not that I would ever participate in something so horribly unethical, but hypothetically, if such a database were to come to fruition, please PM me the link and secret access code so I can report it.

Sounds like another good use for the sdn private rad onc forum. Post in there if you want a specific protocol.

 

[radoncopotamus]

The supposed reason is to make it harder for pharma or other groups to copy RTOG/NRG protocols and open competing trials as easily. This happened before a few times and NRG felt burned by specific companies. Not sure how much sense it makes though because it is not hard to get a CTSU account and have access to all the protocols anyway.

 

[RickyScott]

The supposed reason is to make it harder for pharma or other groups to copy RTOG/NRG protocols and open competing trials as easily. This happened before a few times and NRG felt burned by specific companies. Not sure how much sense it makes though because it is not hard to get a CTSU account and have access to all the protocols anyway.

Really silly. I would hand it over to them for a slice of pizza.

 

[Chartreuse Wombat]

The supposed reason is to make it harder for pharma or other groups to copy RTOG/NRG protocols and open competing trials as easily. This happened before a few times and NRG felt burned by specific companies. Not sure how much sense it makes though because it is not hard to get a CTSU account and have access to all the protocols anyway.

I am calling BS if that is an excuse. These companies employ many people as medical writers and can cook up a protocol in weeks. Hubris on the part of NRG if they think this will keep large companies from opening competing trials. It takes 1/3 to 1/2 the time to open a study with industry and they have many folks who would be happy to send a pdf. (Full disclosure) I am the PI of an Phase III NRG study

 

[gmsquid]

NRG HN 004 is looking at cetuximab vs durvalumab for patients ineligible for cisplatin. The protocol CTV 70Gy is GTV + 5-10mm margin trimming at bone or air, and the CTV 56Gy is another 1cm expansion from the CTV 70Gy. PTV margin is 3-5mm. So imagine a lymph node sitting between the SCM and the scalene muscles. Your 70Gy volume goes 0.8-1.5cm into the scalene muscles, and then your 56Gy volume goes 1.8-2.5cm deep into the muscles. That's a lot of muscle radiation.

I’ve treated multiple patients in this protocol. I have never contoured my Ctv into muscle unless involved and did not get a protocol violation. The ctv is supposed to be anatomically confined. They give examples to anatomical barries if spread like you mention.

A 2 cm margin on primary tumor with low dose isn’t unreasonable when people don’t know how to contour hn. It ensures that people cover the parapharhyngeal space for tonsil tumors and don’t mess up other things like covering the entire larynx for larynx tumors.

 

[seper]

I like Intro sections of phase III RTOG protocols. Good XRT overview for a given disease site.

 

[evilbooyaa]

Sounds like another good use for the sdn private rad onc forum. Post in there if you want a specific protocol.

What an excellent idea.

I’ve treated multiple patients in this protocol. I have never contoured my Ctv into muscle unless involved and did not get a protocol violation. The ctv is supposed to be anatomically confined. They give examples to anatomical barries if spread like you mention.

A 2 cm margin on primary tumor with low dose isn’t unreasonable when people don’t know how to contour hn. It ensures that people cover the parapharhyngeal space for tonsil tumors and don’t mess up other things like covering the entire larynx for larynx tumors.

Still, taking a lymph node and putting a 5-10(!)mm CTV expansion on it and giving ALL of that 70 especially in HPV+ is stupid when we give 50 or 56 for high-risk microscopic disease. Just do GTV + 5mm PTV for a trial, yeesh.

This gives me an idea for another thread.