ASCO 2017: interesting stuff

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Palex80

Palex80

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Gfunk6 said:
I'm not changing my practice without AT LEAST 10 year follow up


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Hopefully for the prostate patients and not for the spinal cord compressions. If so, I'm referring all of my SCC cases to you.
 
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I do expect some criticism once the paper on SCORAD III come out and there are subgroup analyses.
However, it will be HUGE relief for me and my therapists if all cord compressions can get 8 Gy X 1. These patients are tough to deal with, and there are a lot of them in tertiary hospitals.
 
seper said:
I do expect some criticism once the paper on SCORAD III come out and there are subgroup analyses.
However, it will be HUGE relief for me and my therapists if all cord compressions can get 8 Gy X 1. These patients are tough to deal with, and there are a lot of them in tertiary hospitals.
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....................

edit: didn't read abstract...
 
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shogun0660 said:
842ee13d7e911b3a837571fde43630a1.jpg
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Because a bedbound and an ambulatory cord compression patient can have very different outcomes
 
As indicated in abstract, 60-70% of these patients were walking pre/post XRT. That's a pretty robust population, IMHO

medgator said:
Like everything we do, there are going to be nuances. This is probably a VERY reasonable thing to do in a bed-bound metastatic RCC patient who has a much worse OS (as indicated from the randomized patchell study) compared to a good PS, ambulatory metastatic breast patient, where i would still offer 2-3 weeks, personally if surgery was off the table.
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seper said:
As indicated in abstract, 60-70% of these patients were walking pre/post XRT. That's a pretty robust population, IMHO
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And of course i skimmed the abstract too quickly and missed that key line :slap:

That being said, is anyone actually going to do this? A big chunk of these patients were prostate CA and those pts can live for awhile under the right conditions.
 
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I firmly believe that 1 x 8 Gy are a bad idea for spinal cord compression. The problem is however that the comparison arm with 5 x 4 Gy is also a bad idea. Actually anything involving radiation therapy with "standard doses" without surgery and spinal cord compression is a bad idea.

I am going overboard here, but "What ethical committee agreed to this trial?"
A patient with a spinal cord compression and an apparent surivival ">8 weeks" according to the inclusion criteria should get SURGERY first. What happened to surgery?

Furthermore look at their OS data... Median survival of 12 weeks for the entire group? That's 3 months... What patients were put on this trial? Bearing in mind that almost half of them where prostate cancer patients, I wonder if we are talking about patients who have failed every single line of available systemic treatment for prostate cancer and then entered the trial. And nowadays if you get metastatic prostate cancer you have something like 6 lines of therapy available...

This pretty much reminds me of the QUARTZ trial for CNS-metastatic NSCLC, where half of the patients were dead within 8 weeks. Kind of hard to show a difference there too, if half of your population is dead within 8 weeks. 8 weeks is the prognosis among the worst of all brain-met patients according to the GPA-scores, yet QUARTZ claimed to have enrolled patients "who couldn't get stereotactic treatment". In the UK you are only entitled to stereotactic treatment if you have one brain lesion and controlled extracranial disease, meaning that probably less than 15% of all brain met patients get stereotactic treatment.

All these NHS-funded trials have one thing in common: flawed designs and clinical outcomes that do not reflect what we see in daily practice.
I have the impression that the "worst of the worst" possible patients are being pushed into these trials.
 
QUARTZ was such garbage- "couldn't get stereotactic treatment" makes no sense, as nearly all patients with brain mets could be treated stereotactically. To top it off, in their analysis patients with 5+ mets (the very population for which most of us would move to whole brain from SRS) did have an OS advantage to WBRT, but of course that was never mentioned in any of the press releases.
 
OTN said:
QUARTZ was such garbage- "couldn't get stereotactic treatment" makes no sense, as nearly all patients with brain mets could be treated stereotactically. To top it off, in their analysis patients with 5+ mets (the very population for which most of us would move to whole brain from SRS) did have an OS advantage to WBRT, but of course that was never mentioned in any of the press releases.
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Can you imagine the waiting list through the UK NHS system with all those extra patients to treat? I'm sure this scc trial will have a lot of uptake in the UK and plenty of skepticism stateside, just like quartz
 
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Data are data. For a walking patient with < 6 months expected survival (physicians overestimate survival), 8 Gy X 1 will probably be standard.

Palex80 said:
I firmly believe that 1 x 8 Gy are a bad idea for spinal cord compression. The problem is however that the comparison arm with 5 x 4 Gy is also a bad idea. Actually anything involving radiation therapy with "standard doses" without surgery and spinal cord compression is a bad idea.

I am going overboard here, but "What ethical committee agreed to this trial?"
A patient with a spinal cord compression and an apparent surivival ">8 weeks" according to the inclusion criteria should get SURGERY first. What happened to surgery?

Furthermore look at their OS data... Median survival of 12 weeks for the entire group? That's 3 months... What patients were put on this trial? Bearing in mind that almost half of them where prostate cancer patients, I wonder if we are talking about patients who have failed every single line of available systemic treatment for prostate cancer and then entered the trial. And nowadays if you get metastatic prostate cancer you have something like 6 lines of therapy available...

This pretty much reminds me of the QUARTZ trial for CNS-metastatic NSCLC, where half of the patients were dead within 8 weeks. Kind of hard to show a difference there too, if half of your population is dead within 8 weeks. 8 weeks is the prognosis among the worst of all brain-met patients according to the GPA-scores, yet QUARTZ claimed to have enrolled patients "who couldn't get stereotactic treatment". In the UK you are only entitled to stereotactic treatment if you have one brain lesion and controlled extracranial disease, meaning that probably less than 15% of all brain met patients get stereotactic treatment.

All these NHS-funded trials have one thing in common: flawed designs and clinical outcomes that do not reflect what we see in daily practice.
I have the impression that the "worst of the worst" possible patients are being pushed into these trials.
Click to expand...
 
I actually liked QUARTZ study. My take is most of this patients on that trial were admitted, with poor PS. Only the greediest radiosurgeons would do inpatient SRS 🙂

OTN said:
QUARTZ was such garbage- "couldn't get stereotactic treatment" makes no sense, as nearly all patients with brain mets could be treated stereotactically. To top it off, in their analysis patients with 5+ mets (the very population for which most of us would move to whole brain from SRS) did have an OS advantage to WBRT, but of course that was never mentioned in any of the press releases.
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Palex80 said:
Possible practice chaning trial:

18 vs. 36 months of ADT for high-risk prostate cancer.
No OS benefit for longer duration of ADT but worse QoL.
This may chance practice für high risk disease, just like RTOG 9910 did for intermediate risk prostate cancer.

Duration of androgen deprivation therapy in high risk prostate cancer: Final results of a randomized phase III trial. | 2017 ASCO Annual Meeting Abstracts


Post abstracts you found interesting too!
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Would it be premature to offer 18 months to a high risk prostate patient based on this abstract?
 
FistLength said:
Would it be premature to offer 18 months to a high risk prostate patient based on this abstract?
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I already end up doing that sometimes when patients can't tolerate the side effects of ADT. 6 months probably too short, 3 years too long, 18 months just right 🙂
 
medgator said:
I already end up doing that sometimes when patients can't tolerate the side effects of ADT. 6 months probably too short, 3 years too long, 18 months just right 🙂
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Goldilocks and the androgen deprivation therapy!

On topic - I think SCORAD III is hard to extrapolate. Certainly looks nice, but difficult to show non-inferiority when everybody dies so soon. I think it will end up being utilized like the QUARTZ trial (at least in the US), where Rad Oncs can utilize it as a justification to treat 8Gy x 1 in poor PS folks (similarly to how we can use QUARTZ to justify not treating poor PS NSCLC with WBRT), but certainly not mandatory to treat all spinal cord compressions with 8Gy x 1.
 
RadOncDoc21 said:
Still trying to take us out the game:


Efficacy and safety of nivolumab (NIVO) plus ipilimumab (IPI) in patients with melanoma (MEL) metastatic to the brain: Results of the phase II study CheckMate 204. | 2017 ASCO Annual Meeting Abstracts
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Response rate of 56%. Is that really something to hang your hat on when there's something that will give you a much higher response rate? 48% G3-4 AE rate? That's acceptable with a response rate of 56%?

The conclusion is laughable, IMO: A paradigm shift in asymptomatic melanoma patients with BMs.

We're going to have to show a paper like that recent Magnusson paper from Yale in EGFR-mutated NSCLC showing that patients do worse if you push SRS back in favor of a TKI than if you start upfront with it? Except now with Ipi and Nivo, in Melanoma patients.
 
evilbooyaa said:
Response rate of 56%. Is that really something to hang your hat on when there's something that will give you a much higher response rate? 48% G3-4 AE rate? That's acceptable with a response rate of 56%?

The conclusion is laughable, IMO: A paradigm shift in asymptomatic melanoma patients with BMs.

We're going to have to show a paper like that recent Magnusson paper from Yale in EGFR-mutated NSCLC showing that patients do worse if you push SRS back in favor of a TKI than if you start upfront with it? Except now with Ipi and Nivo, in Melanoma patients.
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Dual immune blockade is no joke. That can be rough.

The issue with withholding brain radiation and waiting to see if your 50/50 shot of getting a response is that unlike a solitary lung met or some other relatively "benign" area to have growth - if you fail your systemic therapy and your met is in a bad location (motor strip, for example), then you progress to have new symptoms...there may be no turning back the symptoms/effects of that disease progression. I can kind of understand the enthusiasm for holding back on whole brain, but SRS is generally pretty well tolerated.
 
seper said:
Data are data. For a walking patient with < 6 months expected survival (physicians overestimate survival), 8 Gy X 1 will probably be standard.
Click to expand...
Half of the patients were dead after 2 months in the trial.
 
I challenge anyone to count, how many of your nonsurgical cord compression patients are alive at 4 months? It is < 30 % for me. That's why I think 8 Gy X 1 for cord compression makes sense, given the results.

evilbooyaa said:
Goldilocks and the androgen deprivation therapy!

On topic - I think SCORAD III is hard to extrapolate. Certainly looks nice, but difficult to show non-inferiority when everybody dies so soon. I think it will end up being utilized like the QUARTZ trial (at least in the US), where Rad Oncs can utilize it as a justification to treat 8Gy x 1 in poor PS folks (similarly to how we can use QUARTZ to justify not treating poor PS NSCLC with WBRT), but certainly not mandatory to treat all spinal cord compressions with 8Gy x 1.
Click to expand...
 
I talked to one of our medoncs last week about the delaying brain RT in melanoma data, and he very much agreed that it was terrible data, and led him down the path of offering brain RT first prior to systemic treatment for those patients. He independently brought up all the issues we did (who wants a 40% chance of progression in the brain?), so I think as long as our referring medoncs know the data well, which we can help with, I think that trial argues in favor of RT for those patients.
 
OTN said:
I talked to one of our medoncs last week about the delaying brain RT in melanoma data, and he very much agreed that it was terrible data, and led him down the path of offering brain RT first prior to systemic treatment for those patients. He independently brought up all the issues we did (who wants a 40% chance of progression in the brain?), so I think as long as our referring medoncs know the data well, which we can help with, I think that trial argues in favor of RT for those patients.
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That med-onc sounds reasonable. Given that a lot of drugs in 2nd or 3rd line settings have a 10-20% response rate for metastatic cancers though, I worry that will not be the overall takeaway from most med-oncs. 56% looks positively spectacular in comparison to that.
 
I wonder what the rate of progression leading to craniotomy or WBRT was in a population of tumors that were asymptomatic and < 3 cm (aka mostly SRS candidates)?
In SRS-eligible patients with good MRI surveillance would expect craniotomy rate to be low single digits and WBRT rate to be 10-20%.
 
GOG258 and Portec3 results lead to less radiation therapy being used in high risk endometrial cancer.

A randomized phase III trial of cisplatin and tumor volume directed irradiation followed by carboplatin and paclitaxel vs. carboplatin and paclitaxel for optimally debulked, advanced endometrial carcinoma. | 2017 ASCO Annual Meeting Abstracts

Final results of the international randomized PORTEC-3 trial of adjuvant chemotherapy and radiation therapy (RT) versus RT alone for women with high-risk endometrial cancer. | 2017 ASCO Annual Meeting Abstracts

I already had my first debate with our gynecologists who view GOG258 as proof that radiation therapy is not helpful in endometrial cancer.
Portec3 actually shows less than expected benefit of adjuvant chemo, but that diesn't seem to interest anyone.

GOG258 was designed with flaws in my opinion. It would have been prudent t do a head to head comparison between adjuvant chemo +/- EBRT sequentially in surgically staged patients.
 
Palex80 said:
GOG258 and Portec3 results lead to less radiation therapy being used in high risk endometrial cancer.

A randomized phase III trial of cisplatin and tumor volume directed irradiation followed by carboplatin and paclitaxel vs. carboplatin and paclitaxel for optimally debulked, advanced endometrial carcinoma. | 2017 ASCO Annual Meeting Abstracts

Final results of the international randomized PORTEC-3 trial of adjuvant chemotherapy and radiation therapy (RT) versus RT alone for women with high-risk endometrial cancer. | 2017 ASCO Annual Meeting Abstracts

I already had my first debate with our gynecologists who view GOG258 as proof that radiation therapy is not helpful in endometrial cancer.
Portec3 actually shows less than expected benefit of adjuvant chemo, but that diesn't seem to interest anyone.

GOG258 was designed with flaws in my opinion. It would have been prudent t do a head to head comparison between adjuvant chemo +/- EBRT sequentially in surgically staged patients.
Click to expand...


That first trial's cut-off seems a bit high: "A 28.5% reduction in the rate of recurrence or death was considered significant." I guess it's relative risk reduction, but still.

I think with high-risk endometrial carcinoma, it's prudent to take care of systemic disease first, then consolidate with radiation afterwards. I would continue to recommend adjuvant chemo followed by sequential RT rather than the cisplatin-RT regimen that has become more popular

In regards to PORTEC, I'm surprised that C-RT followed by Chemotherapy beat out RT alone (with no adjuvant chemo?), although for stage III (node positive disease) it did help.
So maybe Stage II disease should get just Pelvic RT, no chemo? That'd be an interesting conclusion.
 
These preliminary GOG 258 results confirm my old suspicion, that upfront RT is detrimental for stage III uterine cancer. RT compromises tolerance of future chemo. In our center, people mostly use "sandwich" or "consolidation" RT approach.
 
seper said:
These preliminary GOG 258 results confirm my old suspicion, that upfront RT is detrimental for stage III uterine cancer. RT compromises tolerance of future chemo. In our center, people mostly use "sandwich" or "consolidation" RT approach.
Click to expand...
I've always used carbo/taxol x 3 cycles before and after EBRT+/-vag cuff HDR. Didn't even realize people did upfront RT
 
medgator said:
I've always used carbo/taxol x 3 cycles before and after EBRT+/-vag cuff HDR. Didn't even realize people did upfront RT
Click to expand...

Don't do the sandwich technique here, but I never fully understand the rationale - If RT up front isn't well tolerated (because of chemo adherence) then why do RT in the middle of the chemo, and jeopardize dosing on the 4th through 6th cycle? Have people seen local recurrences on chemo that necessitate earlier RT administration?
 
Between sandwich and consolidation, I prefer consolidation. However, some senior Some GynOncs tell me they are afraid to delay RT that much, since high proportion of uterine cancers do not respond to chemo at all.
 
I looked at the endometrial studies and saw this: chemo doesn't add much to radiation and radiation doesn't add much to chemo. Tough to rectify exactly what it means in concert.

I'm sticking with sandwich.
 
Palex80 said:
I firmly believe that 1 x 8 Gy are a bad idea for spinal cord compression. The problem is however that the comparison arm with 5 x 4 Gy is also a bad idea. Actually anything involving radiation therapy with "standard doses" without surgery and spinal cord compression is a bad idea.

I am going overboard here, but "What ethical committee agreed to this trial?"
A patient with a spinal cord compression and an apparent surivival ">8 weeks" according to the inclusion criteria should get SURGERY first. What happened to surgery?

Furthermore look at their OS data... Median survival of 12 weeks for the entire group? That's 3 months... What patients were put on this trial? Bearing in mind that almost half of them where prostate cancer patients, I wonder if we are talking about patients who have failed every single line of available systemic treatment for prostate cancer and then entered the trial. And nowadays if you get metastatic prostate cancer you have something like 6 lines of therapy available...

This pretty much reminds me of the QUARTZ trial for CNS-metastatic NSCLC, where half of the patients were dead within 8 weeks. Kind of hard to show a difference there too, if half of your population is dead within 8 weeks. 8 weeks is the prognosis among the worst of all brain-met patients according to the GPA-scores, yet QUARTZ claimed to have enrolled patients "who couldn't get stereotactic treatment". In the UK you are only entitled to stereotactic treatment if you have one brain lesion and controlled extracranial disease, meaning that probably less than 15% of all brain met patients get stereotactic treatment.

All these NHS-funded trials have one thing in common: flawed designs and clinical outcomes that do not reflect what we see in daily practice.
I have the impression that the "worst of the worst" possible patients are being pushed into these trials.
Click to expand...

They can make the non-inferiority margin as big as they want and base the conclusion off of that: "The noninferiority margin was 11% " ... am I the only person that thinks 11% is not a small number?
 
More interesting stuff:

Phase III randomized trial comparing weekly versus three-weekly (W3W) cisplatin in patients receiving chemoradiation for locally advanced head and neck cancer. | 2017 ASCO Annual Meeting Abstracts

Weekly cisplatin is inferior to 3-weekly-regimen in LA SCCHN.

The 3-weekly-regime is SOC in the US, but weekly schedules are quite popular in many parts of Europe. I expect this trial to have an impact in daily practice here.

I've always wondered: We give cisplatin in cervical cancer on a weekly basis, because the trials were mostly performed like that. Would it be interesting to look into a 3-weekly-schedule in cervical cancer too?
There are quite a lot of critics of the popular carboplatin/paclitaxel regime in LA NSCLC too, when you think of it...
 
^Interesting. Seeing a lot more of qWeekly cisplatin from our H&N med-oncs. More in those that Med-Onc feel can't tolerate the q3 week regimen, but the scales seemed to be tipping towards qWeekly even in pretty good PS patients. Should push for more q3 week administration. Surprised that 95% of patients got greater than 2 cycles in the q3week arm.
 
I too have seen med onc switch to q weekly on much more head/neck patients in the past few years. I agree though that with full dose Q3 week, that final cycle often doesn't get completed.

Anecdotally, I think the nausea has been less with the qweek dosing...this seems congruent with double the rate of hospitalizations seen in that study (15 vs. 30% of patients hospitalized for side effects.

I guess moral of story for me may be to push med oncs to try Q3 weeks in the more fit patients.
 
One should note that the weekly dose of cisplatin in the trial was rather low with 30 mg/m2. I've seen 40 mg/m2 been utilized a lot. With 30mg/m2 you "only" get 210 mg in a 7 week long radiation schedule. So perhaps the weekly arm was simply underdosed?
 
True, we give Cis 40mg/m2 qweek as well. Wonder if that affects results significantly (difference between 210 vs 280 total mg/m2 in qweekly regimens wheh compared to 300mg/m2 total in q3week
 
Palex80 said:
More interesting stuff:

Phase III randomized trial comparing weekly versus three-weekly (W3W) cisplatin in patients receiving chemoradiation for locally advanced head and neck cancer. | 2017 ASCO Annual Meeting Abstracts

Weekly cisplatin is inferior to 3-weekly-regimen in LA SCCHN.

The 3-weekly-regime is SOC in the US, but weekly schedules are quite popular in many parts of Europe. I expect this trial to have an impact in daily practice here.

I've always wondered: We give cisplatin in cervical cancer on a weekly basis, because the trials were mostly performed like that. Would it be interesting to look into a 3-weekly-schedule in cervical cancer too?
There are quite a lot of critics of the popular carboplatin/paclitaxel regime in LA NSCLC too, when you think of it...
Click to expand...


I thought there was a trial from Korea a while ago suggesting that 75 mg q 3 weekly in cervical cancer may be better than weekly.
Personally, I was always partial to weekly in head and neck cancer until this came out last week. The weekly carbo taxol in lung cancer certainly increases pneumonitis.
 
Hey you Rad Onc pros, sorry for the tangent, but I can't seem to find a better thread to ask my questions.

I submitted an abstract to the Palliative and Supportive Care in Oncology Symposium this upcoming October and have some questions about the process.
1) What are the chances of my abstract getting accepted for a poster presentation?
2) If I am selected, would I be asked to present at BOTH poster sessions or just one?
3) Is it easier to rent a car and drive around or just uber? I'm not planning on staying at the Grand Hyatt, but I'm also not sure if parking is ridiculous and expensive (I plan on driving around the city a little, too, maybe going to the beach).
4) Any ideas of ways to secure funding to help me pay for the conference and hotel?

Thanks in advance!
 
Although we deal with palliation, we're not supportive care or palliative care physicians. I would try the Palliative care subforum on SDN. Make a new post about it there, or try the general medical student forums.

My uneducated answer to all of your questions is "No idea".
 
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