NRG/RTOG 0631 is out: 1 x 16 Gy "SRS" not better than 1 x 8 Gy EBRT for bone mets?

[Palex80]

Radiosurgery of Spine Metastasis—NRG/RTOG 0631 RCT Final Results

This randomized clinical trial assesses whether patient-reported pain relief was improved with stereotactic radiosurgery compared with conventional external beam radiotherapy for patients with 1 to 3 sites of vertebral metastases.

jamanetwork.com

DISCUSS!

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[Palex80]

On a side note:

"Interventions: Patients randomized to the SRS group were treated with a single dose of 16 or 18 Gy (to convert to rad, multiply by 100) given to the involved vertebral level(s) only, not including any additional spine levels. Patients assigned to cEBRT were treated with 8 Gy given to the involved vertebra plus 1 additional vertebra above and below."

and

"Indeed, the major limitation of this study is that patient compliance of pain reporting was low. At 24 months, only 47 patients completed the NRPS."

That would be 47/339 eligible patients.
However, 177/339 (52%) were dead at 24 months already. I would not say that being dead is inadequate "patient compliance".

 

[Fpg1245]

As SY would say…

 

[RadOncMegatron]

Very interesting finding with lots of caveats. Good article to post here. Is worse pain in a palliative setting worth the possible local control??? Would still do for renal cell, melanoma, etc., but honestly a little surprised. Due to the paywall I don't have the full article, does it mention local control results?

 

[deleted1111261]

2 positive studies for pain (Canadian, Mdacc).

1 negative study with some interesting caveats - 1) treated different volumes in each arm 2) pain inventory was different 3) follow up numbers as listed above are quirky.

I would lean in favor of positive studies.

 

[Gfunk6]

This trial was far too simplistic, they should have made it 2 x 2 plus/minus 6 months of pembrolizumab.

That way we could at least sneak our negative findings under the radar as long as pembro did SOMETHING good on subset analysis.

 

[BobbyHeenan]

2 positive studies for pain (Canadian, Mdacc).

1 negative study with some interesting caveats - 1) treated different volumes in each arm 2) pain inventory was different 3) follow up numbers as listed above are quirky.

I would lean in favor of positive studies.

I have anecdotally had more success with fractionated regimens both in terms of pain control and local control. 2-5 fractions over the years have served me well in these cases.

 

[Palex80]

Due to the paywall I don't have the full article, does it mention local control results?

Unfortunately not. This was not a study endpoint. All we know is that vertebral compression fracture rates were similar in both groups.

 

[grenz]

I saw on Twitter that there was a significant imbalance in performance status between the arms (SBRT had twice as many PS 2), and higher PS was associated with higher dropout

 

[grenz]

Unfortunately not. This was not a study endpoint. All we know is that vertebral compression fracture rates were similar in both groups.

This isn’t surprising. The MSKCC trial showed that dose matters (27/3 vs 24/1)

 

[sirspamalot]

Meh. There is enough evidence that treating asymptomatic bone mets with SBRT is $imply not necessary.

 

[TheWallnerus]

Does rad onc really know how to run good trials anymore. The shoddiness and room to poke holes big enough to drive trucks through gets old.

 

[seper]

SBRT is obviously not good for pain control. Time, additional tests, cost, tumor swelling.

I am so upset I never got an idea to put this in any of my abstracts: “to convert to rad, multiply by 100”!!

 

[OTN]

Meh. There is enough evidence that treating asymptomatic bone mets with SBRT is $imply not necessary.

Unless it's oligometastatic prostate, renal cell, or lung cancer

 

[deleted1111261]

SBRT is obviously not good for pain control. Time, additional tests, cost, tumor swelling.

I am so upset I never got an idea to put this in any of my abstracts: “to convert to rad, multiply by 100”!!

Why "obviously"?
2 positive studies. 1 negative.

 

[sirspamalot]

 

[deleted1111261]

Meh. There is enough evidence that treating asymptomatic bone mets with SBRT is $imply not necessary.

Pain is a symptom

 

[sirspamalot]

Meh. 300 x10 is good 'nuff.

 

[Palex80]

Meh. 300 x10 is good 'nuff.

Is that cGy or rad?

 

[TheWallnerus]

Is that cGy or rad?

Centigrays are, like, totally rad

 

[evilbooyaa]

Just do 24/2 for anyone you were thinking 16-18 x 1 and continue

Or can continue doing 16 x 1 for non-spine bone met

Why are we all so worried about this result? One negative result in the first trial in this space, versus 2 more recently established trials that are positive.

 

[seper]

best radiation surgery for a spine met is 5 Gy x 5 3D-CRT with a 1cm margin

 

[sirspamalot]

VCF is not a department at UCSF

 

[grenz]

Just do 24/2 for anyone you were thinking 16-18 x 1 and continue

Or can continue doing 16 x 1 for non-spine bone met

Why are we all so worried about this result? One negative result in the first trial in this space, versus 2 more recently established trials that are positive.

The SC24 trial did the sbrt fractions on consecutive days. Are people doing every day, or every other day?

 

[taserlaser]

I work with a guy who trained in Toronto and he does every day. I worked with some other experts elsewhere and they did every other day. Prob doesn’t make much difference imo, but we do daily here.