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Inoperable stage III NSCLC should get concurrent chemoRT. No role for sequential in patients who can tolerate concurrent. No established role for induction chemotherapy in NSCLC.
Current accepted doses are 60 (some do up to 66) Gy in 30 (or 33) fractions, with concurrent Cis/Etop or Carbo/Taxol. No role for dose escalation to 74Gy per RTOG 0617.
Consolidation with Duravalumab is a now-evolving standard of care after definitive chemoRT per the findings of the PACIFIC trial. No role for consolidation with chemotherapy.
I'm not sure on the rationale of 55/20 with concurrent chemo. Sometimes a hypofractionated regimen is chosen in patients who aren't undergoing chemotherapy (45 to 60Gy, depending on normal structures in 15 fractions).
These are US principles at least. Not sure if our European colleagues are doing other things.
Current accepted doses are 60 (some do up to 66) Gy in 30 (or 33) fractions, with concurrent Cis/Etop or Carbo/Taxol. No role for dose escalation to 74Gy per RTOG 0617.
Consolidation with Duravalumab is a now-evolving standard of care after definitive chemoRT per the findings of the PACIFIC trial. No role for consolidation with chemotherapy.
I'm not sure on the rationale of 55/20 with concurrent chemo. Sometimes a hypofractionated regimen is chosen in patients who aren't undergoing chemotherapy (45 to 60Gy, depending on normal structures in 15 fractions).
These are US principles at least. Not sure if our European colleagues are doing other things.
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Durvulumab was FDA approved earlier this month for consolidation in stage III lung with compelling data. It's been in the nccn guidelines for several months now
60-70 Gy with chemo concurrent followed by durvulumab is SOC imo
60-70 Gy with chemo concurrent followed by durvulumab is SOC imo
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50-55/20 has been used in europe for 30 years and some of the original chemorads trials. Depends on your country, (also true in bladder)
The real change recently is imfinzi which triple pfs. regarding consolidation- we do it all the time, but a large trial (hoosier?) actually showed decreased survival with taxane based consolidation
The real change recently is imfinzi which triple pfs. regarding consolidation- we do it all the time, but a large trial (hoosier?) actually showed decreased survival with taxane based consolidation
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TIL that at least the British are doing 55/20 (BED10 70.13) with concurrent cisplatin/vinorelbine. Why don't they compare it head to head with 66/33 (BED10 79.2) with Carbo/Taxol or Cis/Etop?
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That data has also been published.
Carbo taxol is easy to give hence why med oncs like it, but in fit patients the data is better for cis regimens
FWIW, it seems we are out of etoposide. From what i understand, generic chemo is limited to something like 4% profit margin by law, so no one wants to deal with producing it. Have some small cell pts now who cant get it.
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The winning arm of one of the major trials establishing the appropriate sequencing of carbo/taxol with radiation in advanced NSCLC (Belani et al) had consolidation chemotherapy baked in. There was no strictly concurrent arm. Hence why we are now stuck with consolidation chemotherapy when using carbo/taxol.
The Hoosier Oncology consolidation chemo study (Hanna et al) used platinum/etoposide and demonstrated increased toxicity of adjuvant docetaxel without benefit, hence why we do not see consolidation chemo used typically in this setting.
The Hoosier Oncology consolidation chemo study (Hanna et al) used platinum/etoposide and demonstrated increased toxicity of adjuvant docetaxel without benefit, hence why we do not see consolidation chemo used typically in this setting.
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Yup.... a lot of these generics aren't worth it until one company corners it and jacks up the price enough to make a big profit on it. Exhibit A Martin Shkreli and dalteparem
Opinion | Shortchanging Cancer Patients
The Medicare Prescription Drug, Improvement and Modernization Act of 2003, signed by President George W. Bush, put an end to this arrangement. It required Medicare to pay the physicians who prescribed the drugs based on a drug’s actual average selling price, plus 6 percent for handling. And indirectly — because of the time it takes drug companies to compile actual sales data and the government to revise the average selling price — it restricted the price from increasing by more than 6 percent every six months.
The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.
The Medicare Prescription Drug, Improvement and Modernization Act of 2003, signed by President George W. Bush, put an end to this arrangement. It required Medicare to pay the physicians who prescribed the drugs based on a drug’s actual average selling price, plus 6 percent for handling. And indirectly — because of the time it takes drug companies to compile actual sales data and the government to revise the average selling price — it restricted the price from increasing by more than 6 percent every six months.
The act had an unintended consequence. In the first two or three years after a cancer drug goes generic, its price can drop by as much as 90 percent as manufacturers compete for market share. But if a shortage develops, the drug’s price should be able to increase again to attract more manufacturers. Because the 2003 act effectively limits drug price increases, it prevents this from happening. The low profit margins mean that manufacturers face a hard choice: lose money producing a lifesaving drug or switch limited production capacity to a more lucrative drug.
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1. "European" doses are quite diverse. Most do 66 Gy probably, some will only give 60 Gy depending on DVH. I know colleagues who still push for 70 Gy. In the Netherlands some series are running with simultaneous boost.
2. Chemo is generally Platinum & Etoposide or Vinorelbin. Less Taxanes than in the US and certainly less of the weekly Paclitaxel schedule, which as I understand, is very popular in the US. Taxanes cause pneumonitis, so many European radiation oncologists do not like them.
3. Concurrent whenever possible, but there are patients that will receive sequential treatment too. Elderly or frail patients will get sequential CRT. Usually 4 cycles is standard.
4. Consolidation with durvalumab is starting to happen now.
2. Chemo is generally Platinum & Etoposide or Vinorelbin. Less Taxanes than in the US and certainly less of the weekly Paclitaxel schedule, which as I understand, is very popular in the US. Taxanes cause pneumonitis, so many European radiation oncologists do not like them.
3. Concurrent whenever possible, but there are patients that will receive sequential treatment too. Elderly or frail patients will get sequential CRT. Usually 4 cycles is standard.
4. Consolidation with durvalumab is starting to happen now.
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