ASCO 2023

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Palex80

Palex80

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Abstracts are out. A selection of interesting stuff:

LBAs (results pending):

This is the long awaited analysis of PEACE-1, testing RT to the prostate for mHSPC.
Perhaps confirmation of STAMPEDE Arm-H results, perhaps not.

Phase III trial on chemo-RT vs. chemo as neoadjuvant treatment for rectal cancer.
I have a bad feeling about this...

Immunotherapy may enter the stage in nasopharyngeal cancer.

A randomized trial on immunotherapy on top of s.o.c. for GBM.
I cannot imagine that this one will be positive, it´s GBM.

A come back for consolidative RT in PMBCL?


Results available:

Perhaps we can deescalate treatment in nasopharyngeal cancer?

Should we be regularly imaging the brain in all stage III NSCLC after primary RCT?

Nimorazole (hypoxia modifier) doesn't work in HNSCC

A radiation dermatitis trial that made it into the plenary!

14.920 wet pads ... ehhhh 14.920 patients with pads after radical prostatectomy.

Small trial from TATA Memorial hospital looking at optimal adjuvant treatment of gallbladder cancer. Chemo and Chemo-RT appear equivalent.

Induction chemotherapy prior to radiochemotherapy for esophageal cancer is probably not worth it.
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Thanks for these summaries. One point I’ve raised about this PEACE trial comparison, is the sample size in the cohort who got Abi is going to be way underpowered for an OS endpoint.

What naysayers about Arm H say is we don’t know if RT to the primary improves outcomes when advanced anti-androgen is given. The PEACE-1 comparison of Abi+RT vs Abi alone among low volume patients is going to have a grand total of no more than 500 patients, and probably a lot less depending on the % of patients enrolled who were low volume M1. Compare that to the 820 patients on Arm H with low volume M1.
 
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Good points. I'd like to add that >60% of patients in PEACE-1 received docetaxel on top of ADT. This is considerably more than in STAMPEDE.
 
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For those like me who were wondering about the addition of chemoRT in the rectal ca trial:

N1048 (PROSPECT) is a two-arm study with one to one randomization. The control arm of the study includes standard chemoradiation for rectal cancer. The choice of capecitabine or 5FU for sensitization is up to the treating physician. The intervention arm includes six cycles of neoadjuvant FOLFOX followed by restaging. Patients with clinical response to induction FOLFOX proceed directly to surgery. Those patients with poor response (estimated at less than 20 percent decrease in the tumor burden) will undergo chemoradiation first. In this manner, the intervention arm is a dynamic strategy that includes radiation for tumors that do not respond to FOLFOX and omission of radiation for those that do.
 
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Uh you don't "order" the test I would think, but maybe they could put forward a table of exact details so we can figure out what the "clinical and histopathological predictive biomarker" is..
 
OTN said:
For those like me who were wondering about the addition of chemoRT in the rectal ca trial:

N1048 (PROSPECT) is a two-arm study with one to one randomization. The control arm of the study includes standard chemoradiation for rectal cancer. The choice of capecitabine or 5FU for sensitization is up to the treating physician. The intervention arm includes six cycles of neoadjuvant FOLFOX followed by restaging. Patients with clinical response to induction FOLFOX proceed directly to surgery. Those patients with poor response (estimated at less than 20 percent decrease in the tumor burden) will undergo chemoradiation first. In this manner, the intervention arm is a dynamic strategy that includes radiation for tumors that do not respond to FOLFOX and omission of radiation for those that do.
Click to expand...

Interesting paradigm. In my experience working in a couple different multiD groups, patients seem to want to avoid surgery more than RT. My first thought is that a lot of patients present with symptoms and I am not sure how this would play out in groups that offer NOM with RT first as a standard option. Im excited to see how the GI talking heads discuss this trial once its presented.

Palex80 said:
Should we be regularly imaging the brain in all stage III NSCLC after primary RCT?
Click to expand...

Interesting study, but I have a lot of questions since it is retrospective. Looking forward to hearing more, hopefully people talk about it online.
 
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sirspamalot said:
Uh you don't "order" the test I would think, but maybe they could put forward a table of exact details so we can figure out what the "clinical and histopathological predictive biomarker" is..
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Yes you do order the test through a portal just like Decipher. Slides are sent, images taken and slides returned; no tissue destroyed. The biomarker is proprietary of course. I will admit the opacity is troubling but welcome to AI.
 
Chartreuse Wombat said:
Yes you do order the test through a portal just like Decipher. Slides are sent, images taken and slides returned; no tissue destroyed. The biomarker is proprietary of course. I will admit the opacity is troubling but welcome to AI.
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Needs further independent verification... This slide image analysis outsourcing for $ is concerning.
 
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sirspamalot said:
Sending your slide image in (plus clinical info) for some proprietary analysis that should then result in a major decision regarding patient care?

Yeah you better believe I'm skeptical.
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But we have three analyses!

Seriously though, is an analysis to a trial what a trial is to a trial?
 
elmo count GIF by Sesame Street


You think this meme is a joke? So is the belief one can rely solely on severely financially compromised and highly opaque "analyses" lol.
 
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NotMattSpraker said:
Interesting paradigm. In my experience working in a couple different multiD groups, patients seem to want to avoid surgery more than RT. My first thought is that a lot of patients present with symptoms and I am not sure how this would play out in groups that offer NOM with RT first as a standard option. Im excited to see how the GI talking heads discuss this trial once its presented.



Interesting study, but I have a lot of questions since it is retrospective. Looking forward to hearing more, hopefully people talk about it online.
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Yeah, this will impact Europeans but is a big nothing burger in most of the US. The NCCN has made TNT the preferred SOC for LARC and is close to making watch and wait SOC beyond high volume centers.

It’s not a meaningless trial. It does show with good surgery, you probably don’t need trimodality therapy for most folks. But like was said above, patients are way more afraid of surgery than radiation. And QOL analyses from modern studies suggest it’s justified.
 
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ramsesthenice said:
close to making watch and wait SOC beyond high volume centers.
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I have mixed feeling about this. The failure rate is pretty high (see OPRA) and the surveillance pretty vigorous.

I have had some absolute winners (needed APR, now NED with essentially perfect QOL) and the worst outcome of my career (recto-sigmoid fistula and eventual Grade 5). Surgery does seem more difficult as time goes by.

My present paradigm is to avoid APR. Low lying tumors get OPRA protocol with chemorads up front. If LAR is possible, I'm not trying to avoid it and go chemo first, then chemorads, then surgery.
 
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Very high rates of erectile dysfunction with TME.
 
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communitydoc13 said:
I have mixed feeling about this. The failure rate is pretty high (see OPRA) and the surveillance pretty vigorous.
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OPRA is a good example of the issues at hand. I would say most centers don’t routinely observe near complete responders like they did. The looser you make the criteria, the higher the failures you are going to see. On the other extreme, there was an early Dutch experience which required a negative tumor site biopsy that saw <10% failures. What is the right balance?

Surveillance is rigorous which does bring up some interesting questions. I do think there are meaningful improvements in QoL even for patients who are LAR eligible. But there is no denying that watch and wait surveillance is a huge expense. Its always interesting to figure out how to take that into consideration. From a purely scientific and medical outcomes perspective, I would opt for surveillance if possible even if I were an LAR candidate. At what point is the added cost great enough that I tell people they shouldn't do what I would want to do for myself? Tough questions.
 
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ramsesthenice said:
I would opt for surveillance if possible even if I were an LAR candidate.
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Yeah, this is the way I think. Have a small volume T3N0 who I agreed with who said basically he would go along with TNT but then wanted to wait and see. My medonc chirped that a recent trial with immuno alone plus observation might be the future.

Oh well, there goes another indication..
 
sirspamalot said:
Yeah, this is the way I think. Have a small volume T3N0 who I agreed with who said basically he would go along with TNT but then wanted to wait and see. My medonc chirped that a recent trial with immuno alone plus observation might be the future.

Oh well, there goes another indication..
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I mean, that's an MSI status issue. Two different diseases, already factored into guidelines (appropriately IMO).
 
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sirspamalot said:
My medonc chirped that a recent trial with immuno alone plus observation might be the future.
Click to expand...

Haha we have short term follow up on 12 patients from a small subset of people with rectal cancer. Whenever I share patients with a med onc that genuinely believes significant volumes of cancers will be treated with systemic therapy alone, I follow the patients very, very closely.

Some med oncs like to defer local treatments and drug people until they are in the ER with an oncologic emergencies. They are the worst. So much unnecessary morbidity.

Maybe one day we will get there. Not today.
 
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Highlighted by Simul on Twitter

pubmed.ncbi.nlm.nih.gov

Impact of 18F-Labeled Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Versus Conventional Staging in Patients With Locally Advanced Breast Cancer - PubMed

In patients with LABC, PET-CT detected more distant metastases than conventional staging, and fewer PET-CT patients received combined modality therapy. Our randomized trial demonstrates the utility of the PET-CT staging strategy.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

How can radiation oncology design studies like this to expand indications for RT? Note that improving overall survival is not a requirement or even expectation for expanding indications for imaging.
 
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theradiator said:
How can radiation oncology design studies like this to expand indications for RT? Note that improving overall survival is not a requirement or even expectation for expanding indications for imaging.
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Well, if the oligometastatic concept (meaning that we can SBRT synchronous metastases and enhance survival) proves itself, then we could push for more upfront SBRT in many stage IV cases, where we usually only intervene later or when symptoms arise.
 
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Palex80 said:
Well, if the oligometastatic concept (meaning that we can SBRT synchronous metastases and enhance survival) proves itself, then we could push for more upfront SBRT in many stage IV cases, where we usually only intervene later or when symptoms arise.
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As long as I don't have to give 28 gy in a single fraction, sounds good.
 
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OTN said:
For those like me who were wondering about the addition of chemoRT in the rectal ca trial:

N1048 (PROSPECT) is a two-arm study with one to one randomization. The control arm of the study includes standard chemoradiation for rectal cancer. The choice of capecitabine or 5FU for sensitization is up to the treating physician. The intervention arm includes six cycles of neoadjuvant FOLFOX followed by restaging. Patients with clinical response to induction FOLFOX proceed directly to surgery. Those patients with poor response (estimated at less than 20 percent decrease in the tumor burden) will undergo chemoradiation first. In this manner, the intervention arm is a dynamic strategy that includes radiation for tumors that do not respond to FOLFOX and omission of radiation for those that do.
Click to expand...
This is a favorable group of rectal cancer patients. No T4, no N2, no obstruction, high enough where LAR is anticipated, MRF has to be clear on pre-treatment MRI, needs to have at least 20% response to chemo to omit RT. PROSPECT: Chemotherapy Alone or Chemotherapy Plus Radiation Therapy in Treating Patients With Locally Advanced Rectal Cancer Undergoing Surgery - Full Text View - ClinicalTrials.gov

It would not be surprising if higher rectal cancers with unthreatened MRF that respond well to chemo do just fine without chemoRT.


1685729862836.png
 
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This trial was designed before RAPIDO and PRODIGE-32 results were available.
 
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Palex80 said:
Conclusions: No improvement in PFS or OS was observed with the addition of ipilimumab to temozolomide. This study does not support further investigation of this regimen in this setting.

Surprised Meme GIF
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GBM is just an animal of a disease.
 
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Need FLASH adaptive MRI proton planning!
 
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Ray D. Ayshun said:
Anyone know if there's a trial out there asking if FOLFOX is even necessary in patients who get CRT? I thought FOLFOX's role in rectal cancer has been extrapolated from colon cancer, where CRT isn't involved. My patients are more bothered by the neuropathy than anything I do to 'em,
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I think this is answered essentially by the TNT paradigm. Adjuvant FOLFOX was recommended but poorly adhered to with German paradigm. Moving it pre-op increased adherence and improved outcomes from decreased distant disease. One of the major criticisms of the RAPIDO trial IIRC is the non mandated coverage of standard arm with adjuvant FOLFOX. It was institutional choice.
 
CaesarRO said:
I think this is answered essentially by the TNT paradigm. Adjuvant FOLFOX was recommended but poorly adhered to with German paradigm. Moving it pre-op increased adherence and improved outcomes from decreased distant disease. One of the major criticisms of the RAPIDO trial IIRC is the non mandated coverage of standard arm with adjuvant FOLFOX. It was institutional choice.
Click to expand...

We are a TNT shop with NOMS being the next frontier. I dont think our surgeons will use this to counter but hey they might.
 
„Brutal effects of pelvic radiotherapy“

H&N patients after RT be like…
Am I A Joke To You GIF
 
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Brutal effects? Check out 12 month toxicity in both arms. In any case, a statistically higher rate of neuropathy in the CRT arm is curious. Perhaps we should think about a way to spare patients the brutal effects of oxaliplatin.
 
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Ray D. Ayshun said:
Brutal effects? Check out 12 month toxicity in both arms. In any case, a statistically higher rate of neuropathy in the CRT arm is curious. Perhaps we should think about a way to spare patients the brutal effects of oxaliplatin.
Click to expand...

Did I read this right that 75% of the patients in the folfox arm ended up getting adjuvant folfox??

Also I don’t think I’d describe any of these trialists as “brave”
 
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Ray D. Ayshun said:
Brutal effects? Check out 12 month toxicity in both arms. In any case, a statistically higher rate of neuropathy in the CRT arm is curious. Perhaps we should think about a way to spare patients the brutal effects of oxaliplatin.
Click to expand...
I gotta say. I really need to rethink my life choices and weekly OTVs with my chemoRT rectal patients. I thought they were doing very well with standard fract and IMRT. “Sir, how brutal is the treatment thus far” will be my new interrogation i suppose.
 
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TheWallnerus said:
I gotta say. I really need to rethink my life choices and weekly OTVs with my chemoRT rectal patients. I thought they were doing very well with standard fract and IMRT. “Sir, how brutal is the treatment thus far” will be my new interrogation i suppose.
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I didn't see a graph for "blood coming out of my ass."
 
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Wonder if IMRT was allowed, or did the prior radoncs f that up by doing a trial with concurrent oxali? another reason to cut residency spots is to prevent new bored radoncs from doing poor trials.

Edit: NVM
1685898431182.png
 
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Are there shortages of oxaliplatin or is it just carbo and cisplatin?
 
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