My department holds fast to the "Chris Crane palliative" SBRT or standard chemo-RT. I don't see us changing until/unless we get an MR-Linac. I know one of our "competitors" in the region is doing 67.5/15 without an MR-Linac, but I don't know the details (because I learned they do this through patients who went for second opinions).
I'm presently dealing with a patient who "passed" the chemotherapy step, as in had a local response with no systemic progression. He's unwilling to undergo a whipple regardless of what that means. In turn, this is the last best chance.
Based on some of the crane mdacc/mskcc papers, regular old cbcts and breath hold is okay. I'm just wondering how many ppl are doing this outside of academic centers. Standard chemort is safe and reimburses well, but seems completely ineffective, and alot of times, gets stopped early. The results of these hypofractionated regimens are impressive as long as you don't explode the duodenum.
Right thanks. My impression is it's more of a 45 Gy in 15 fx regimen, and more of a match to duodenum approach. Even that seems better than 33/5 with maybe a larger area to 25/5, or old faithful, 5040 plus xeloda, which is generally more like 45ish hol xeloda.
No hatin on MR Linacless folks, as I am one. Just wondering if there are better options that are equally safe, less toxic, and/or more effective than chemoRT. though now that i know it's only 9 mil i'll run it up the chain.
Have delivered 75/25 or 67.5/15 at least half a dozen times over past several years. Vast majority of Cranes experience not on an MRI Linac. I have had no severe complications nor have others I know who have adopted this approach. I believe he averages around 80% GTV coverage and is not shy with expansions. Basically expand your duodenum/stomach by 5-6 mm and make sure high dose PTV does not touch. Would start with 75/25.
if you are not adapting on a daily basis, arent you leaving a lot of planning charges on the table?
even with these doses, I had the impression that his long term local control was still around 50% (with good gtv coverage) so room to go higher...
The problem with this approach is that we have negative data from a randomized trial.
pubmed.ncbi.nlm.nih.gov
Nobody does gem monotherapy afaik so not really relevant imo. Hard to interpret things with trials using arms that aren't socThe problem with this approach is that we have negative data from a randomized trial.
LAP07 randomized patients without disease progression after gemcitabine to further gemcitabine vs. 5FU-chemoradiotherapy with 54 Gy.Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial - PubMed
clinicaltrials.gov Identifier: NCT00634725.
There was no effect with chemoradiation on OS. And even more importantly: 32% of patients progressed locally despite CRT in comparison to 46% on gemcitabine. That was a statistically significant difference, but still 1/3 of patients were not locally controlled with that chemoradiotherapy despite the fact that they had mediocre chemotherapy (bearing a higher risk of distant progression and thus never experiencing local failure a.k.a. "You don't need to worry about local progression if your liver îs full of metastases").
What we do not know is how that trial would have turned out if the induction was rather (m)FOLFIRINOX or Paclitaxel/Gemcitabine. It does seem however that 54 Gy with capecitabine will not control this disease well enough.
The problem with this approach is that we have negative data from a randomized trial.
LAP07 randomized patients without disease progression after gemcitabine to further gemcitabine vs. 5FU-chemoradiotherapy with 54 Gy.Effect of Chemoradiotherapy vs Chemotherapy on Survival in Patients With Locally Advanced Pancreatic Cancer Controlled After 4 Months of Gemcitabine With or Without Erlotinib: The LAP07 Randomized Clinical Trial - PubMed
clinicaltrials.gov Identifier: NCT00634725.
There was no effect with chemoradiation on OS. And even more importantly: 32% of patients progressed locally despite CRT in comparison to 46% on gemcitabine. That was a statistically significant difference, but still 1/3 of patients were not locally controlled with that chemoradiotherapy despite the fact that they had mediocre chemotherapy (bearing a higher risk of distant progression and thus never experiencing local failure a.k.a. "You don't need to worry about local progression if your liver îs full of metastases").
What we do not know is how that trial would have turned out if the induction was rather (m)FOLFIRINOX or Paclitaxel/Gemcitabine. It does seem however that 54 Gy with capecitabine will not control this disease well enough.
True, but it is just as much of a misinterpretation to think that with better systemic regimens, that conventionally fractionated RT would all of a sudden make the OS improvement leap. Could theoretically be true but I'm not buying it anywhere close to how much I'd but Chris Crane's data or even "palliative SBRT".
And your final sentence is what I'm asking more or less. Should it be done in the "community?" I'm perfectly equipped to duplicate the motion management and contouring/constraint guidelines. And it feels like there's enough data for 67.5/15 (no interest in 90/15 portion) to not be considered off-protocol. But I'm frequently wrong, on-line at least.
Not necessarily. It depends on what point we are talking about.
Mr/ct on rails not needed. Until very recently, he was using truebeam. Vast majority of pts not treated with mri.
epistemology of evidence in setting of non randomized trials: when standard of care has no long term survivors,but several decent sized series report 15-20%, that constitutes some evidence.
pubmed.ncbi.nlm.nih.gov
Bingo. Prevent symptomatic local progression. SBRT and conventional are equally good at this and thus I feel zero need to drag these poor patients in for weeks and weeks of their already limited life. Agree that "palliative" RT is an utter waste...if you're trying to make them comfortable by reducing symptomatic local progression, might as well do it in the quickest manner possible. Rad oncs need to seriously ask themselves what the goal of care and goal of RT really is in these patients. The more that one takes a cold hard look, the more they realize conventional fractionation is nonsense for what the goals of care are.
So us in the community with the knowledge of his techniques should bypass this for the right patient just because we're not academic?If practicing outside of an academic center off-trial with no license to dose-escalate, generally stick with 54 Gy and under per NCCN guidelines. See also:
2019 ASTRO Clinical Practice Guideline for Pancreatic Cancer <3
Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline - PubMed
The role of radiation in the management of pancreatic cancer is evolving, with many ongoing areas of active investigation. Radiation therapy is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is important...
I believe Crane's data, and I think we just need patience for that line of evidence to mature into guideline-level practice. Until then, just be thankful we have FOLFIRINOX and Gem/Abraxane.
“no license to dose-escalate...??”If practicing outside of an academic center off-trial with no license to dose-escalate, generally stick with 54 Gy and under per NCCN guidelines. See also:
2019 ASTRO Clinical Practice Guideline for Pancreatic Cancer <3
Radiation Therapy for Pancreatic Cancer: Executive Summary of an ASTRO Clinical Practice Guideline - PubMed
The role of radiation in the management of pancreatic cancer is evolving, with many ongoing areas of active investigation. Radiation therapy is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is important...
I believe Crane's data, and I think we just need patience for that line of evidence to mature into guideline-level practice. Until then, just be thankful we have FOLFIRINOX and Gem/Abraxane.
I just turn the machine on and wait for the timer to go off then flip the patient over and do it again since I have a cobalt teletherapy unit. We still use radium for brachytherapy.
Obviously, it must be obtained from a non-accredited fellowship. Maybe columbia can help us out.
Thanks. I'm sort of having trouble reconciling the various instances where we say, on SDN, "gosh, the academic docs don't respect our abilities," and then in other cases, "you should do what we all kinda know is the less-effective thing, or else, send them to an academic center." As stated above, chemoRT is aggressive (prophylactic) palliation. Are we delusional to think dose escalation is actually curative? I don't think so. Can we community practitioners, many of whom were at a big academic center recently enough, pull this off with CBCT and motion management? Appears so. Is it okay if we have some grade 5 toxicities? That's a tougher question, but the practitioners of the alternative curative local therapy are willing to accept that risk.
Thanks, I agree with both. Not to deify Crane, but this quote from an article about the recent ASTRO pancreas guidelines, which he was not a part of creating, is what's gnawing at me.
I agree with what you’re saying, but I’ve been consistent: I’ve never said I can’t do something just because I’m in the community. I disagree vigorously that we provide care that is anything other than world-class, and I have called out academic docs directly to them when they have the temerity question the quality of care I provide to my patients without knowing anything about me or my practice.
Certainly some may treat better than others, but 33 gy still has 100% failure rate at the end of the day.
Right, not referring to you. I'm happy to hear you're doing it. More of a comment on some of the comments re following guidelines, which are created by academic committees and their biases, warranted or not, which they in turn don't follow, or get out of by saying something should only be done on trial, or worse, on registry, both of which are euphemisms for "at academic centers."
Edit: This became more of a general response the more I started typing and is not directed specifically to you @Neuronix . I think you are a great example of what an academic attending should be.
Bowel perforation. I haven't heard of any Grade V unless its bowel perf in this setting.
