ASCO 2023

[thecarbonionangle]

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Doom at times feel very eminent for this field. It is like staring at an abyss, and yet you standing on the edge still, determined, unafraid, and meekly hopeful.

 

[Chartreuse Wombat]

eminent

imminent?

Imminent and eminent only differ in pronunciation by one vowel sound, which is why they are occasionally confused. Eminent is often used to describe someone or something that stands out above others in a noticeable way, while imminent is used to describe something that is about to happen very soon.

Maybe both? 🙂

 

[RadOncMegatron]

Doom at times feel very eminent for this field. It is like staring at an abyss, and yet you standing on the edge still, determined, unafraid, and meekly hopeful.

When are we going to stop running trials to get rid of XRT?!?! What kind of field does this? I mean if it was one or two trials or one or two sites but it’s going insane.

 

[TheWallnerus]

Doom at times feel very eminent for this field. It is like staring at an abyss, and yet you standing on the edge still, determined, unafraid, and meekly hopeful.

Human beings don’t change until they reach a precipice (whether physical, spiritual, or emotional)

Maybe we’ll change

Nahhhh

 

[Palex80]

I don’t buy this more toxicity with chemo argument. Giving 4 less cycles of folfox in the chemo alone arm not going to change anything in terms of local recurrence.

MedOncs be like

 

[Ray D. Ayshun]

When are we going to stop running trials to get rid of XRT?!?! What kind of field does this? I mean if it was one or two trials or one or two sites but it’s going insane.

Reducing toxicity is fine, but this trial strikes me more as sociology-like than science, as in, "we know we need to not give RT, how do we design a trial to prove that?" Taken from the abstract, I have a big problem with the following:

"Node positive" is not part of staging. These patients were N1. That's easy to write. It takes fewer letters. The fact that the NEJM published such a sloppy description in the abstract is a problem, nevermind all the other questions about this trial. It suggests they are interested in eliminating radiation from the care of not only those eligible for the trial (nvm the imbalanced allocation of T3N1s), but essentially any N-stage.

 

[TheWallnerus]

Reducing toxicity is fine, but this trial strikes me more as sociology-like than science, as in, "we know we need to not give RT, how do we design a trial to prove that?" Taken from the abstract, I have a big problem with the following:

View attachment 373058
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"Node positive" is not part of staging. These patients were N1. That's easy to write. It takes fewer letters. The fact that the NEJM published such a sloppy description in the abstract is a problem, nevermind all the other questions about this trial. It suggests they are interested in eliminating radiation from the care of not only those eligible for the trial (nvm the imbalanced allocation of T3N1s), but essentially any N-stage.

History is written by the winners ladies and gents!

Losers whine about the NEJM abstract. Winners go home and f**k the prom queen and eliminate RT.

 

[RadOncDoc21]

History is written by the winners ladies and gents!

Losers whine about the NEJM abstract. Winners go home and f**k the prom queen and eliminate RT.

Just make sure to protect yourself!

 

[Fpg1245]

History is written by the winners ladies and gents!

Losers whine about the NEJM abstract. Winners go home and f**k the prom queen and eliminate RT.

Steamrolling RT.

What’s that saying? If you’re explaining you’re losing. Bitching about the nuances of an abstract not gonna move the needle one bit.

Your med oncs were either sold or they weren’t. Not much you can do about it

This is why I don’t get the reluctance to start LDRT for OA. Or other benign conditions especially in the over 50 crowd.

 

[thecarbonionangle]

Everyone thinking about enrolling in the White and similar studies breast radiation omission studies should stop. Anyone thinking about it should take that idea out back and bury it. we need to put an end to this full stop. I refuse to enroll in any of these studies.

 

[thecarbonionangle]

History is written by the winners ladies and gents!

Losers whine about the NEJM abstract. Winners go home and f**k the prom queen and eliminate RT.

This right here, folks

 

[metallica81788]

Everyone thinking about enrolling in the White and similar studies breast radiation omission studies should stop. Anyone thinking about it should take that idea out back and bury it. we need to put an end to this full stop. I refuse to enroll in any of these studies.

When I first arrived at my new job I was approached with possible trials open. I'm not a clinical trials person at baseline and this is a community hospital in a mostly rural poor location but has larger network associations with bigger places. Was hoping to avoid any trial association here honestly.

Three of trials were for breast radiation omission and I flat out told the research coordinator I will never consider those trials.

 

[theradiator]

When I first arrived at my new job I was approached with possible trials open. I'm not a clinical trials person at baseline and this is a community hospital in a mostly rural poor location but has larger network associations with bigger places. Was hoping to avoid any trial association here honestly.

Three of trials were for breast radiation omission and I flat out told the research coordinator I will never consider those trials.

That's great kudos to you but the next m0r0n (or Canadian) will happily open the study

 

[medgator]

Just make sure to protect yourself!

Mask up!!

 

[Ray D. Ayshun]

Mask up!!

We are at least working to prevent exposure to patients by reducing our need to see them.

 

[sirspamalot]

ALARA: As little as referrals allow

 

[RickyScott]

This specialty has always had a contingent of MFs who showcase their "worthiness" by virtue signaling radiation omission, hypofractionation, or 3D instead of IMRT, while their hospitals price gouge patients.

 

[sirspamalot]

This specialty has always had a contingent of MFs who showcase their "worthiness" by virtue signaling radiation omission, hypofractionation, or 3D instead of IMRT, while their hospitals price gouge patients.

 

[Palex80]

Mask up!!

Where did he get that test kit? I haven't seen one in months.

 

[Neuronix]

Several posts deleted for making fun of a woman based on her looks. That's just a low blow. Please stop.

 

[OTN]

I had a conversation with my main rectal ca referring medonc yesterday about PROSPECT. We both agreed that the data shows increased toxicity with chemo alone, so it makes sense to continue chemoRT for neoadjuvant rectal ca treatment. Conversation took about 30 seconds. Fin.

I genuinely do not understand how you can look at that data and come to the conclusion that omitting radiation is the answer. I come to the polar opposite conclusion, as I am interested in reducing toxicity in my patients.

 

[Ray D. Ayshun]

I had a conversation with my main rectal ca referring medonc yesterday about PROSPECT. We both agreed that the data shows increased toxicity with chemo alone, so it makes sense to continue chemoRT for neoadjuvant rectal ca treatment. Conversation took about 30 seconds. Fin.

I genuinely do not understand how you can look at that data and come to the conclusion that omitting radiation is the answer. I come to the polar opposite conclusion, as I am interested in reducing toxicity in my patients.

Why is this in the nejm, though? It's kinda scandalous I think

 

[TheWallnerus]

I had a conversation with my main rectal ca referring medonc yesterday about PROSPECT. We both agreed that the data shows increased toxicity with chemo alone, so it makes sense to continue chemoRT for neoadjuvant rectal ca treatment. Conversation took about 30 seconds. Fin.

I genuinely do not understand how you can look at that data and come to the conclusion that omitting radiation is the answer. I come to the polar opposite conclusion, as I am interested in reducing toxicity in my patients.

Kind of like Both Sides Now by Joni Mitchell. Apt to be the blue dress/gold dress of GI oncology.

 

[deleted1111261]

Kind of like Both Sides Now by Joni Mitchell. Apt to be the blue dress/gold dress of GI oncology.

That is perfect title for an episode if we do one. You’ll get no credit, tho

 

[sirspamalot]

Several posts deleted for making fun of a woman based on her looks. That's just a low blow. Please stop.

A mod's work is never done...

 

[communitydoc13]

When are we going to stop running trials to get rid of XRT?!?! What kind of field does this? I mean if it was one or two trials or one or two sites but it’s going insane.

Sorry, it’s the way it’s going to be. Each new systemic therapy re-contextualizes XRT, and the world is now pretty adept at running trials to prove efficacy of new systemic agents.

Take a look at trials in breast for abemaciclib or olaparib, both winners, both with awesome international names in a long author list, both now cornerstones for emerging standard of care in different types of high risk breast CA.

If you are a breast academic with ambition, these are the folks you want to ingratiate yourself to. You will be happy to run a +\- XRT trial.

We need to start giving the drugs.

 

[sirspamalot]

Or taking them.

 

[Palex80]

It's a lot easier to run a trial omitting radiation and setting a generous margin of non-inferiority on a not necessarily valuable endpoint, than actually running a trial to improve outcomes. Acceptance is often higher by both clinicians and patients.

 

[sirspamalot]

 

[dieABRdie]

I had a conversation with my main rectal ca referring medonc yesterday about PROSPECT. We both agreed that the data shows increased toxicity with chemo alone, so it makes sense to continue chemoRT for neoadjuvant rectal ca treatment. Conversation took about 30 seconds. Fin.

I genuinely do not understand how you can look at that data and come to the conclusion that omitting radiation is the answer. I come to the polar opposite conclusion, as I am interested in reducing toxicity in my patients.

Similar here. Light years difference between the academic centers and the true community.

Community med oncs care VERY MUCH about toxicity.... the last thing they want is more reasons to actually go to the hospital.

 

[radoncftw]

Similar here. Light years difference between the academic centers and the true community.

Community med oncs care VERY MUCH about toxicity.... the last thing they want is more reasons to actually go to the hospital.

i think we all have our own biases, but in my patients with GI cancers who have gotten FOLFOX or FOLFIRINOX chemo...the late chemo toxicity (i.e. neuropathy) seems to be their only complaints. I almost never see late RT toxicity.

In my mind - you would design a trial omitting oxaliplatin or finding an alternative to that.

Med Oncs never seem to care about the toxicity of chemo or immunotherapy. It is ignored.

 

[Ray D. Ayshun]

i think we all have our own biases, but in my patients with GI cancers who have gotten FOLFOX or FOLFIRINOX chemo...the late chemo toxicity (i.e. neuropathy) seems to be their only complaints. I almost never see late RT toxicity.

In my mind - you would design a trial omitting oxaliplatin or finding an alternative to that.

Med Oncs never seem to care about the toxicity of chemo or immunotherapy. It is ignored.

They eliminated oxali in forwarc. No statistical difference. Though numeric. Let a randoc design the trial and they'll throw in oxali concurrent with imrt planning, say it's more toxic, and **** it up for everyone.

Edit: sorry, say it's equally toxic

 

[ramsesthenice]

There is another reason that people do omission trials. They are cheap. Far and away the hardest part about doing good trials is getting funding to support them. But in an omission trial you can bill everything to insurance and really the only costs are for data management, DSMC, etc. Maybe a couple grand per patient plus start up costs. For comparison's sake, I have 2 funded ISTs I sponsored for RT + novel drugs with correlative tumor immune or normal tissue analyses and the per patient costs are closer to $25-30K (not including salary support). Both are powered for around 40 patients and come in at a little over a million dollars.

 

[Palex80]

There is another reason that people do omission trials. They are cheap. Far and away the hardest part about doing good trials is getting funding to support them. But in an omission trial you can bill everything to insurance and really the only costs are for data management, DSMC, etc. Maybe a couple grand per patient plus start up costs. For comparison's sake, I have 2 funded ISTs I sponsored for RT + novel drugs with correlative tumor immune or normal tissue analyses and the per patient costs are closer to $25-30K (not including salary support). Both are powered for around 40 patients and come in at a little over a million dollars.

Very well said.
Plus, omission trials often attract funding from grant givers who aim at promoting this type of science. De-escalation of treatment is sexy. Patients also love it (in curative scenarios).

 

[theradiator]

And academics can demonstrate research productivity through clinical trial accruals etc.

 

[NotMattSpraker]

There is another reason that people do omission trials. They are cheap. Far and away the hardest part about doing good trials is getting funding to support them. But in an omission trial you can bill everything to insurance and really the only costs are for data management, DSMC, etc. Maybe a couple grand per patient plus start up costs. For comparison's sake, I have 2 funded ISTs I sponsored for RT + novel drugs with correlative tumor immune or normal tissue analyses and the per patient costs are closer to $25-30K (not including salary support). Both are powered for around 40 patients and come in at a little over a million dollars.

While you are right, I am guessing the correlative studies are driving your per patient cost because that is sky high. You can do a good radiation trial for much less money if you control the spending of your biology people 🙂

 

[ramsesthenice]

While you are right, I am guessing the correlative studies are driving your per patient cost because that is sky high. You can do a good radiation trial for much less money if you control the spending of your biology people 🙂

Yes and no. Correlatives definitely add up, but that isn't really where the problem comes in a lot of the time. This is going to shock absolutely no one, but the admins are even harder to reign in. The nanosecond there is external funding involved, they want to see maximum salary support and collect every last cent in "research billing" that they can. $10,000 for research nursing to collect CTCAEs and compile the data is not unusual.

You are right though. We have plenty of good radiation trials (such as prospective MRlinac trials) we manage to keep within our own hands and they are cheap.

 

[temujim]

There is another reason that people do omission trials. They are cheap. Far and away the hardest part about doing good trials is getting funding to support them. But in an omission trial you can bill everything to insurance and really the only costs are for data management, DSMC, etc. Maybe a couple grand per patient plus start up costs. For comparison's sake, I have 2 funded ISTs I sponsored for RT + novel drugs with correlative tumor immune or normal tissue analyses and the per patient costs are closer to $25-30K (not including salary support). Both are powered for around 40 patients and come in at a little over a million dollars.

Underappreciated point. Good luck to funding a trial for a new indication of RT.

 

[FindMeOnTheLinks]

Yes and no. Correlatives definitely add up, but that isn't really where the problem comes in a lot of the time. This is going to shock absolutely no one, but the admins are even harder to reign in. The nanosecond there is external funding involved, they want to see maximum salary support and collect every last cent in "research billing" that they can. $10,000 for research nursing to collect CTCAEs and compile the data is not unusual.

You are right though. We have plenty of good radiation trials (such as prospective MRlinac trials) we manage to keep within our own hands and they are cheap.

Do you have trouble with research admin taking a cut of the grant funding as well? We have dealt with this extensively, even when external industry funding was basically given to the faculty sponsor as a no-questions-asked honorarium to fund the trial, admin side of things steps in and takes 30% because reasons

 

[ramsesthenice]

Do you have trouble with research admin taking a cut of the grant funding as well? We have dealt with this extensively, even when external industry funding was basically given to the faculty sponsor as a no-questions-asked honorarium to fund the trial, admin side of things steps in and takes 30% because reasons

Depends on what you mean. All requests for external finding have to go through our DSP (department of sponsored research) review and they are laser focused on making sure they agree with the budget. We stick to the finalized budget but often I end up submitting rates which are obviously non competitive. Always worry it ends up hurting the priority score. On the flip side, our F&A rate is below the median, so that has to help. The Anderson’s and joint centers help ne here. Some are literally above 60%.

 

[RickyScott]

Depends on what you mean. All requests for external finding have to go through our DSP (department of sponsored research) review and they are laser focused on making sure they agree with the budget. We stick to the finalized budget but often I end up submitting rates which are obviously non competitive. Always worry it ends up hurting the priority score. On the flip side, our F&A rate is below the median, so that has to help. The Anderson’s and joint centers help ne here. Some are literally above 60%.

Institutionalized academic research has become a mini medical industrial complex for our fake “nonprofit” medical centers. Adversarial to actual research.