Rad Onc Twitter

[Mandelin Rain]

I always (for as long as I was aware of it) thought PAE would be a good adjunct after definitive XRT in prostate ca.

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[drowsy12]

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[OTN]

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Starts out with a misunderstanding of how PE tries to make money in medicine (no one would ever intentionally create a 'toxic asset' in order to turn it around and sell it that's not how any of this works- sure, they may saddle it with a ton of debt which is then paid back to the PE firm a la Red Lobster real estate, but they weren't planning on prepping Red Lobster for a sale), then says we should all ask around about ROCR to see if we support it.

 

[medgator]

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Urology even trying to own IR procedures. I’ve got to think if rad onc had even half the ownership culture of urology we wouldn’t be giving up radiopharm and going the employed route in droves.

Radiopharmaceuticals are too niche to move the needle for us, how about we do the low hanging fruit like stopping the push to eliminate rt and reduce fractions while we overtrain in the specialty?

Uro and derm are damn good about keeping a lid on how many they train every year. Biggest thing we can do to effect change is control our own supply.

 

[medgator]

Half is about all I would want. Crazy to me that we have local urologists trying to treat metastatic prostate cancer, giving concurrent chemo for bladder, etc, etc.

Jaw dropped when I heard about giving prolia in the office to his long term ADT pts

 

[Palex80]

1. It's a unplanned subset analysis.
2. And most important...

 

[evilbooyaa]

View attachment 387134

1. It's a unplanned subset analysis.
2. And most important...
View attachment 387135

If systeimc therapy improves (Like FOLFIFIRNOX vs Gemcitabine), the distant recurrence rate will decrease and mean higher percentage of patients develop localy primary recurrence.

Just take the damn win when we get it, wtf??

The trial conceived in 2008 JUST resulted. But you want to now immediately re-run the trial and not offer sequential chemoRT because the chemo has changed? Nah, f that. Patients get chemoRT at conclusion of their post-op chemo as a standard now. If GI Med oncs/surgeons want to exclude it, THEY have to run a non-inferiority trial where the standard arm is chemo followed by sequential chemoRT vs an experimental arm of chemo alone and 'demonstrate' non-inferiority.

 

[Mandelin Rain]

Those aren't small differences.

If a drug showed those outcome differences in LN- Pancreatic cancer, it'd be on the cover of Time Magazine

 

[Palex80]

If systeimc therapy improves (Like FOLFIFIRNOX vs Gemcitabine), the distant recurrence rate will decrease and mean higher percentage of patients develop localy primary recurrence.

Just take the damn win when we get it, wtf??

The trial conceived in 2008 JUST resulted. But you want to now immediately re-run the trial and not offer sequential chemoRT because the chemo has changed? Nah, f that. Patients get chemoRT at conclusion of their post-op chemo as a standard now. If GI Med oncs/surgeons want to exclude it, THEY have to run a non-inferiority trial where the standard arm is chemo followed by sequential chemoRT vs an experimental arm of chemo alone and 'demonstrate' non-inferiority.

The only problem is that adjuvant mFOLFIRINOX has demonstrated an OS benefit over adjuvant Gemcitabine for the entire population in a larger trial.

https://www.nejm.org/doi/full/10.1056/NEJMoa1809775

Now, some people try to look at subgroups there too.

But, let’s be frank. If you had a pT2 pN0 pancreatic cancer and (for whatever reason) did not get neoadjuvant chemo, would you go for gemcitabine + RT or for mFOLFIRINOX?

 

[evilbooyaa]

The only problem is that adjuvant mFOLFIRINOX has demonstrated an OS benefit over adjuvant Gemcitabine for the entire population in a larger trial.

https://www.nejm.org/doi/full/10.1056/NEJMoa1809775

Now, some people try to look at subgroups there too.

View attachment 387153


But, let’s be frank. If you had a pT2 pN0 pancreatic cancer and (for whatever reason) did not get neoadjuvant chemo, would you go for gemcitabine + RT or for mFOLFIRINOX?

 

[Palex80]

Because we have no evidence, that „more“ is better. It could even be, that the net benefit of RT shrinks with better chemotherapy. FOLFIRINOX can increase local control too.

 

[medgator]

Because we have no evidence, that „more“ is better. It could even be, that the net benefit of RT shrinks with better chemotherapy. FOLFIRINOX can increase local control too.

Even in localized unresectable, the answer is always more and better chemo? Just odd

 

[evilbooyaa]

Because we have no evidence, that „more“ is better. It could even be, that the net benefit of RT shrinks with better chemotherapy. FOLFIRINOX can increase local control too.

In Table S3 of PRODIGE 24, locoregional alone (13.4) or LR + distant recurrence (9.7%) made up 23% of all the patients (as opposed to 28% having isolated distance recurrence), cumulative 54.2% DFS event

Yes, those numbers are better than Gemcitabine - 18% LR alone, 17.1% LR+ distant, or 35% of all patients, compared to 33% distant recurrence, cumulative 73.2% DFS event.

So let's say that better chemo in pancreatic cancer reduces the global cancer risk, with about half being distant alone, half including recurrent recurrent. 23% of FOLFIRINOX patients have local recurrence. Happy to get post-op RT based on RTOG 0848 to lower that risk ALARA.

 

[Mandelin Rain]

Because we have no evidence, that „more“ is better. It could even be, that the net benefit of RT shrinks with better chemotherapy. FOLFIRINOX can increase local control too.

2+2 = 2?

Only in rad onc.

 

[Mandelin Rain]

If this was a trial of Gem +/- elective hip arthroplasty and had the same results, Stryker would already have bill boards on every high way in America.

Meanwhile in rad onc land: But.... the chemo, while standard then, is no longer standard. Would not bang.

 

[communitydoc13]

2+2 = 2?

Only in rad onc.

Well to be fair, in radonc...

2+2+2+2 < 4+4

 

[RadOncDoc21]

Well to be fair, in radonc...

2+2+2+2 < 4+4

Academic rad onc:

2+2=protons

 

[drowsy12]

Well to be fair, in radonc...

2+2+2+2 < 4+4

2+2 is non inferior to 4.

 

[TheWallnerus]

Two plus two…

The number of clinical years and research years for our Holman scholars?

 

[Palex80]

If this was a trial of Gem +/- elective hip arthroplasty and had the same results, Stryker would already have bill boards on every high way in America.

Meanwhile in rad onc land: But.... the chemo, while standard then, is no longer standard. Would not bang.

I am going to repeat myself. It‘s an unplanned subgroup analysis. And it‘s a systemic treatment no longer offered to the majority of patients.

We faced the same argument in prostate cancer,
In a much bigger trial with a prespecified subgroup analysis and adequate power, RT was able to raise the OS in M1-oligo-mHSPC (Stampede Arm H). Yet, when that trial ran, s.o.c. was ADT only and less than a quarter of the patients had additional treatment.

When the question was asked, if people would still offer RT to the primary for a patient with M1-oligo-mHSPC getting an ARPI on top of ADT, opinions were split. The majority would still do it, but the general feeling was, that we don‘t really know if the OS benefit is still there. When PEACE-1 came out last year, we had evidence that the OS benefit was gone. In PEACE-1, patients had Abi / Docetaxel on top of ADT.

The bottom line is: The role and net-benefit of RT changes, when systemic treatment changes. It is likely the reason, numerous trials will continue to come out negative.

 

[RickyScott]

I am going to repeat myself. It‘s an unplanned subgroup analysis. And it‘s a systemic treatment no longer offered to the majority of patients.

We faced the same argument in prostate cancer,
In a much bigger trial with a prespecified subgroup analysis and adequate power, RT was able to raise the OS in M1-oligo-mHSPC (Stampede Arm H). Yet, when that trial ran, s.o.c. was ADT only and less than a quarter of the patients had additional treatment.

When the question was asked, if people would still offer RT to the primary for a patient with M1-oligo-mHSPC getting an ARPI on top of ADT, opinions were split. The majority would still do it, but the general feeling was, that we don‘t really know if the OS benefit is still there. When PEACE-1 came out last year, we had evidence that the OS benefit was gone. In PEACE-1, patients had Abi / Docetaxel on top of ADT.

The bottom line is: The role and net-benefit of RT changes, when systemic treatment changes. It is likely the reason, numerous trials will continue to come out negative.

The unplanned sub group is what is disturbing. These almost never work out in subsequent trials.

 

[grenz]

I am going to repeat myself. It‘s an unplanned subgroup analysis. And it‘s a systemic treatment no longer offered to the majority of patients.

We faced the same argument in prostate cancer,
In a much bigger trial with a prespecified subgroup analysis and adequate power, RT was able to raise the OS in M1-oligo-mHSPC (Stampede Arm H). Yet, when that trial ran, s.o.c. was ADT only and less than a quarter of the patients had additional treatment.

When the question was asked, if people would still offer RT to the primary for a patient with M1-oligo-mHSPC getting an ARPI on top of ADT, opinions were split. The majority would still do it, but the general feeling was, that we don‘t really know if the OS benefit is still there. When PEACE-1 came out last year, we had evidence that the OS benefit was gone. In PEACE-1, patients had Abi / Docetaxel on top of ADT.

The bottom line is: The role and net-benefit of RT changes, when systemic treatment changes. It is likely the reason, numerous trials will continue to come out negative.

When you narrow PEACE 1 down to the low volume subset that got Abi, the N is way too low to say RT no longer improves OS.

 

[Palex80]

New fear unlocked.

 

[MidwestRadOnc]

View attachment 387277

New fear unlocked.

Stop contributing to IO-hesitancy with your fear mongering!

We freak out over rare one offs with IO yet if you try and discuss or publish any events even remotely critical of c*vid v*x you’re STILL an anti-science quack.

Suspect this website will get censored soon for contributing to proton and spaceOAR hesitancy along the same lines.

 

[evilbooyaa]

I am going to repeat myself. It‘s an unplanned subgroup analysis. And it‘s a systemic treatment no longer offered to the majority of patients.

We faced the same argument in prostate cancer,
In a much bigger trial with a prespecified subgroup analysis and adequate power, RT was able to raise the OS in M1-oligo-mHSPC (Stampede Arm H). Yet, when that trial ran, s.o.c. was ADT only and less than a quarter of the patients had additional treatment.

When the question was asked, if people would still offer RT to the primary for a patient with M1-oligo-mHSPC getting an ARPI on top of ADT, opinions were split. The majority would still do it, but the general feeling was, that we don‘t really know if the OS benefit is still there. When PEACE-1 came out last year, we had evidence that the OS benefit was gone. In PEACE-1, patients had Abi / Docetaxel on top of ADT.

The bottom line is: The role and net-benefit of RT changes, when systemic treatment changes. It is likely the reason, numerous trials will continue to come out negative.

What does PEACE-1 have to do with prostate RT?

Oligomet M1 prostate cancer receiving ADT and Abi should 100% receive prostate RT until a trial proves it is unnecessary. Why assume benefits are NOT additive across two different modalities (local vs systemic) when there are active trials accruing to give us an answer? Sure, if the trial is open at your instituion, then enroll in it.

Now, to the above line, I would 100% understand if a medical oncologist had an opposing opinion.

Palex, as a Rad Onc, why do you have such a negative opinion of our field and barrier for entry?

You'd rather advocate for patients to get combo Abi/Docetaxel rather than 55/20 prostate alone RT (+/- Abi)?

 

[TheWallnerus]

What does PEACE-1 have to do with prostate RT?

Oligomet M1 prostate cancer receiving ADT and Abi should 100% receive prostate RT until a trial proves it is unnecessary. Why assume benefits are NOT additive across two different modalities (local vs systemic) when there are active trials accruing to give us an answer? Sure, if the trial is open at your instituion, then enroll in it.

Now, to the above line, I would 100% understand if a medical oncologist had an opposing opinion.

Palex, as a Rad Onc, why do you have such a negative opinion of our field and barrier for entry?

You'd rather advocate for patients to get combo Abi/Docetaxel rather than 55/20 prostate alone RT (+/- Abi)?

Palex does a way better job of explaining/defending his logic than I ever could, but I don’t see a single thing he’s ever said as being a “negative opinion of our field.”

Carry on.

 

[evilbooyaa]

Palex does a way better job of explaining/defending his logic than I ever could, but I don’t see a single thing he’s ever said as being a “negative opinion of our field.”

Carry on.

Maybe the previous post was a bit harsh, but I feel like I'm seeing a trend that anything that supports radiation in any manner is immediately poo-poo'd. But seriously, if the trial is going to give us a result like this and we're not going to listen to it, while simultaneously ignoring, then why do we even run trials in the first place, if the first thing we're going to say is "well, it's out of date"?

 

[Palex80]

What does PEACE-1 have to do with prostate RT?

Peace-1 featured a 2x2 design,

One question was if ADT + Abi was better than ADT. The other question was if RT to the prostate in M1 mHSPC adds anything.

The second question was presented at ASCO 2023

ASCO 2023: Prostate Irradiation in Men with De Novo, Low-Volume, Metastatic, Castration-Sensitive Prostate Cancer (mCSPC): Results of PEACE-1, a Phase 3 Randomized Trial with a 2x2 Design

ASCO 2023 results from the phase III PEACE-1 trial, prostate irradiation in men with de novo low-volume metastatic castrate-sensitive prostate cancer (mCSPC), PEACE consortium, Prostate Cancer Consortium in Europe.

www.urotoday.com

Oligomet M1 prostate cancer receiving ADT and Abi should 100% receive prostate RT until a trial proves it is unnecessary. Why assume benefits are NOT additive across two different modalities (local vs systemic) when there are active trials accruing to give us an answer? Sure, if the trial is open at your instituion, then enroll in it.

Peace-1 does not show an OS benefit anymore with the addition of RT, unlike Stampede-Arm-H. The likely reason is that Abi eliminates this effect. It‘s only PFS that‘s better.

You'd rather advocate for patients to get combo Abi/Docetaxel rather than 55/20 prostate alone RT (+/- Abi)?

Treating mHSPC with ADT+RT only is no longer considered sound. These patients need an ARPI and high-volume disease benefits from triple therapy. The net benefit of RT in this scenario is unknown.

 

[Palex80]

Maybe the previous post was a bit harsh, but I feel like I'm seeing a trend that anything that supports radiation in any manner is immediately poo-poo'd. But seriously, if the trial is going to give us a result like this and we're not going to listen to it, while simultaneously ignoring, then why do we even run trials in the first place, if the first thing we're going to say is "well, it's out of date"?

Because we are running the wrong trials, quite often. This is my personal opinion.