An interesting take by ASTRO on toxicity
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Well the med oncs and drug reps used to tell me that erbitux skin toxicity in h&n was related to response?!?!
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LMAO. The bias is real. Toxicity is bad unless it's from the machine that you support!!!
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This is not really a surprise as protons deposit more dose to the skin. Given that skin toxicity is an issue for breast cancer (and a reason for IMRT in some patients) this is kind of a big issue !
"Surgeons spare the skin with skin-sparing mastectomies. Is this a good thing or a bad thing?" The skin is not a target for therapy in breast cancer except in very rare cases. Protons probably give more skin dose. Although tangentially glancing photon beams *could* rival protons' skin dose.
Hahahaha. Don’t think I put 2 and 2 together to realize this was likely propaganda.
Here's the link to the IJROBP paper it's referencing: https://www.redjournal.org/article/S0360-3016(19)30647-9/fulltext
I love one of the conclusion statements (bolded my emphasis): "When compared to patients receiving photon radiation, a significantly higher rate of ≥ Grade 2 RD was observed in patients undergoing proton radiation, with very low rates of grade 3 toxicity in both groups. Rates of skin hyperpigmentation did not differ significantly between modalities. Women should be counseled regarding the possibility of increased grade 2 toxicities, though this may present a dosimetric advantage for physicians when treating patients in the post-mastectomy setting, or when skin was involved on presentation. "
Or.... ya know.... bolus works really well too if you just wanna roast the skin.
I love one of the conclusion statements (bolded my emphasis): "When compared to patients receiving photon radiation, a significantly higher rate of ≥ Grade 2 RD was observed in patients undergoing proton radiation, with very low rates of grade 3 toxicity in both groups. Rates of skin hyperpigmentation did not differ significantly between modalities. Women should be counseled regarding the possibility of increased grade 2 toxicities, though this may present a dosimetric advantage for physicians when treating patients in the post-mastectomy setting, or when skin was involved on presentation. "
Or.... ya know.... bolus works really well too if you just wanna roast the skin.
Just when I thought the integrity of the red journal couldn't get any worse...
We're probably only halfway down.
Should be reworded
Women should be counseled regarding the possibility of increased financial toxicity to the proton center if they refuse treatment, though this may present an economic advantage for physicians when treating patients with a modality that costs 300%+ more than photons with inferior outcomes.
I love questionable math and spurious assumptions. Let's make some...
Assume local recurrence rate in Stage I ER+ with photon RT and anti-E is ~2%. Assume that a very large randomized trial could show that protons could statistically significantly lower the LR by ~25% to 1.5%. This would mean you'd need to treat 200 women with protons instead of photons to prevent a local recurrence in just 1 woman.
Assume 300,000 women a year get breast cancer. Assume 2/3 present as favorable Stage I. This is ~200,000 women a year. Assume ~30 proton centers in US right now at cost of ~$100 million apiece, total $3 billion. Assume out of these 200,000 women, 1000 (1/200) could have a local recurrence prevented if we switched to proton instead of photon treatment.
That's gonna cost ~$3 million per female to prevent a local recurrence with protons in Stage I breast cancer. They are treating Stage I breast cancers at proton centers right now, so says this study.
Assume local recurrence rate in Stage I ER+ with photon RT and anti-E is ~2%. Assume that a very large randomized trial could show that protons could statistically significantly lower the LR by ~25% to 1.5%. This would mean you'd need to treat 200 women with protons instead of photons to prevent a local recurrence in just 1 woman.
Assume 300,000 women a year get breast cancer. Assume 2/3 present as favorable Stage I. This is ~200,000 women a year. Assume ~30 proton centers in US right now at cost of ~$100 million apiece, total $3 billion. Assume out of these 200,000 women, 1000 (1/200) could have a local recurrence prevented if we switched to proton instead of photon treatment.
That's gonna cost ~$3 million per female to prevent a local recurrence with protons in Stage I breast cancer. They are treating Stage I breast cancers at proton centers right now, so says this study.
The reason protons are worth more than photons is they decrease toxicity except when they increase toxicity. In those cases, their value is increased toxicity.
For head and neck cancer patients receiving cetuximab + RT there are still observations supporting this:
Correlation between the severity of cetuximab-induced skin rash and clinical outcome for head and neck cancer patients: The XXXX experience - PMC
The purpose of the present study was to evaluate severity of cetuximab-induced skin rash and its correlation with clinical outcome and late skin toxicity in patients with head and neck squamous cell carcinoma treated with chemoradiotherapy and ...
www.ncbi.nlm.nih.gov
Predictive Value of Cetuximab-Induced Skin Toxicity in Recurrent or Metastatic Squamous Cell Carcinoma of the Head and NECK - PMC
Background: Skin toxicity is a common adverse event during cetuximab (Cmab) treatment. However, few reports have investigated the correlation between skin toxicity and the efficacy of Cmab in patients with recurrent or metastatic squamous cell ...
www.ncbi.nlm.nih.gov
I am not aware of any data against that theory.
I know... I was being tongue in cheek about proton cheerleaders who might try to insinuate the same thing. I've generally found erbitux to be quite tough and toxic for patients, certainly much more so than weekly low dose cisplatin which is a lot cheaper, and the recent data in hpv has not looked great eitherFor head and neck cancer patients receiving cetuximab + RT there are still observations supporting this:
Correlation between the severity of cetuximab-induced skin rash and clinical outcome for head and neck cancer patients: The XXXX experience - PMC
The purpose of the present study was to evaluate severity of cetuximab-induced skin rash and its correlation with clinical outcome and late skin toxicity in patients with head and neck squamous cell carcinoma treated with chemoradiotherapy and ...Predictive Value of Cetuximab-Induced Skin Toxicity in Recurrent or Metastatic Squamous Cell Carcinoma of the Head and NECK - PMC
Background: Skin toxicity is a common adverse event during cetuximab (Cmab) treatment. However, few reports have investigated the correlation between skin toxicity and the efficacy of Cmab in patients with recurrent or metastatic squamous cell ...
I am not aware of any data against that theory.
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Cetuximab is not an atoxic drug. And whenever I can give cisplatin, I will give cisplatin before I consider cetuximab.
But the theory that skin toxicity --> predictive factor when giving cetuximab may still be valid. I have actually "used" this theory on occasion to motivare patients experiencing toxicity not to drop the drug.
Am I the only one who doesn't think this is so controversial? The authors argue the dosimetric advantage that protons provide regarding lung and heart dose can come at increased grade 2 dermatitis... but in breast cancer, sometimes skin is target.
Whether the decreased lung and heart dose is worth the increased financial toxicity is another conversation entirely.
Whether the decreased lung and heart dose is worth the increased financial toxicity is another conversation entirely.
Heart and lung dose improvement is almost a non problem. There are one to two million women in America walking around who’ve had their breast irradiated and doing just fine heart and lung wise. Skin toxicity is perhaps one thousand times more a tangible, visible toxicity in breast RT than heart and lung toxicity. If I tried to start selling a new RT treatment for breast cancer that showed significant increases in toxicity and patient complaints, with no cure rate increase, and it was a lot more expensive... that would ordinarily be controversial.
How the heck are we ever going to show CMS the relative cost effectiveness of photon radiation in the curative and palliative oncology management while the powers at be are trying to find ways to positively spin the clinical toxicity of financially toxic proton therapy?
While drug spend goes up with increasing indications for single and combo immunotherapy in metastatic and locally advanced malignancy across the spectrum, we are busy trying to make our speciality more cost effective by decreasing fractions and indications (save protons....)
But to make that conclusion without once mentioning the word bolus in the discussion? I won't get into the flaw of saying a 'dosimetric advantage' with no evidence of clinical toxicity benefit.
An interesting take on protons by BCBS (not a new take, granted)
Mississippi doctor battles brain cancer, but state's insurance denies his treatment
Mississippi doctor battles brain cancer, but state's insurance denies his treatment
Usually means somebody who is CV trained (works open heart cases, can do TEE, etc.).
I'm disappointed (and will continue to be) at physicians and medical centers that are willing to charge US citizens 150k cash, out of pocket, for a therapy that does not have any proven benefit compared to a therapy covered by medical insurance. Whether they do this for money, personal belief, or something else is irrelevant to me.
If I had a patient that could only come see and be treated by me by paying 10k and the alternative was treatment at a different facility which would be fully covered, I would say to go to the different facility! I can live not making the RVUs off that one patient, but I can't live with them having an unnecessary 10k in medical expenses, even if the treatment they would get would be inferior in my mind.
Are there many centers that do this? I agree, that's terrible.
The academic proton centers I know will only use protons when it has been approved by insurance... or for a wealthy foreign patient whom has made the trip to the US specifically for protons. Of course, they don't "deny" protons to people who's insurance doesn't approve (because that would also be unethical), but everyone works hard to dissuade them. I have never seen anyone who isn't a billionaire pay out of pocket.
My experience with one particular very large, very well-known academic medical center has not been the same as yours.
D
deleted941485
My experience at a large academic proton facility was similar. A lot of patients from overseas even got free housing from the center! Pay with cash whatever the chargemaster wrote down...done paid for. They ranged from the relatively healthy and functional to the dying child that under normal circumstances in the healthcare system would have been put on hospice (or euthanized?).
Make no mistake at large institutions the proton dollars are flowing just not from your friendly neighborhood BCBS but rather the large overseas capitalist class.
Evil, ASTRO hears you! You will be paid less! Win/win!
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Probably out there but would never get published.
