ASCO 2023

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Ray D. Ayshun said:
The fact that neuropathy is higher in the xrt arm makes the entire tox data suspect in my eyes as would indicate that not even oxali was "deescalated"
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Perhaps 45 Gy to the pelvis adds to late neuropathy??
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A_DeMichele said:
Perhaps 45 Gy to the pelvis adds to late neuropathy??
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Probably just a random fluke. Folfox is not likely to be the regimen in 10-15 years anyway, something more active and less toxic. Local control was 98-99%. If the chemo arm had 8 cycles instead of 12, I doubt anything would change ie local control would suffer.
 
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Explanation I've seen for the neuropathy in the CRT arm is that FOLFOX was given adjuvant in that arm, so closer to time of PRO assessment.

The "game" med Onc plays here is long tox balanced out. So who cares about acute tox if at a year there's no diff.

We do the same with prostate hypofrac vs conventional.
 
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A_DeMichele said:
Perhaps 45 Gy to the pelvis adds to late neuropathy??
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That's fair, but I'm just not seeing what they're seeing, or close to it. At the same time, this could've been a factor:

"Differences between groups were similar 6 months after surgery (Appendix Table A4, online only), at which time 186 of 655 (28.4%) patients who completed PRO-CTCAE assessments were still receiving chemotherapy (33 of 348 [9.5%] FOLFOX; 153 of 307 [49.8%] 5FUCRT). Differences between groups were also similar at 18 months after surgery in a post hoc analysis (Appendix Fig A1; Appendix Table A5, online only)."

If 50% of one group and 10% of the other is on chemo at a certain time point, would you be surprised if one group had higher rates of chemo-related toxicities 6 and 12 months later?
 
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CaesarRO said:
Explanation I've seen for the neuropathy in the CRT arm is that FOLFOX was given adjuvant in that arm, so closer to time of PRO assessment.

The "game" med Onc plays here is long tox balanced out. So who cares about acute tox if at a year there's no diff.

We do the same with prostate hypofrac vs conventional.
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Around 75% in both arms got adjuvant folfox or in some cases xelox, but patients who got folfox upfront had shorter duration of postop chemo on average.
 
Found this from a study re the timeline of recovery from oxali induced neuropathy
1686146953255.png
 
If 45 Gy cause nerve damage, wouldn't we be seeing this a lot more often?
I am thinking of all the men with prostate cancer and women with endometrial cancer than regularly receive RT of the pelvic lymphatics.
 
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Right, I wouldn’t be so quick to label radiation induced (insert outcome), especially when there are multiple factors involved. I say this because I’ve been known to cause radiation pneumonitis in patients that never received radiation.
 
Do patients with such low risk rectal cancers need 6 cycles of FOLFOX? I understand the high risk patients with T4 , N2 disease and threatened circumferential resection margins have high risk of systemic failure, but what is the data to support 6 as opposed to 3 or 0 cycles of FOLFOX in patients with lower risk disease like the ones in the PROSPECT study?
 
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revaldo29 said:
Do patients with such low risk rectal cancers need 6 cycles of FOLFOX? I understand the high risk patients with T4 , N2 disease and threatened circumferential resection margins have high risk of systemic failure, but what is the data to support 6 as opposed to 3 or 0 cycles of FOLFOX in patients with lower risk disease like the ones in the PROSPECT study?
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It's unclear. Most of the data regarding chemo in rectal cancer is extrapolated from colon cancer, and yes, we are potentially overtreating some patients with 6 cycles of FOLFOX.
 
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Doctorer said:
It's unclear. Most of the data regarding chemo in rectal cancer is extrapolated from colon cancer, and yes, we are potentially overtreating some patients with 6 cycles of FOLFOX.
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As rad oncs, using the pronoun “we” very loosely above ;)
 
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Doctorer said:
It's unclear. Most of the data regarding chemo in rectal cancer is extrapolated from colon cancer, and yes, we are potentially overtreating some patients with 6 cycles of FOLFOX.
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Right, the biggest concern I have with these MRI directed therapies is the ability of community radiologists to accurately interpret rectal MRIs and accurately detect EMVI , proximity to CRM, and accurately diagnose lateral pelvic lymph nodes. This is why the Mercury study approach has not be widely adopted in the United States. We also routinely have rectal cancer patients managed by general surgeons and who knows whether these patients are getting a quality TME. Is this approach safe to implement outside of practice settings with strong colorectal multi-disciplinary care and experienced radiologists?
 
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revaldo29 said:
Right, the biggest concern I have with these MRI directed therapies is the ability of community radiologists to accurately interpret rectal MRIs and accurately detect EMVI , proximity to CRM, and accurately diagnose lateral pelvic lymph nodes. This is why the Mercury study approach has not be widely adopted in the United States. We also routinely have rectal cancer patients managed by general surgeons and who knows whether these patients are getting a quality TME. Is this approach safe to implement outside of practice settings with strong colorectal multi-disciplinary care and experienced radiologists?
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Yup, it's definitely an issue since MRI reads for rectal can be so variable depending on where you are (although I've noticed that radiologists are getting better) and TME quality does matter. I do reach out to my radiologists in the edge cases, especially if they don't explicitly comment on things like the CRM or lymph nodes.

Haven't yet figured out a way to tell a surgeon their TMEs are ****ty.
 
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Doctorer said:
Yup, it's definitely an issue since MRI reads for rectal can be so variable depending on where you are (although I've noticed that radiologists are getting better) and TME quality does matter. I do reach out to my radiologists in the edge cases, especially if they don't explicitly comment on things like the CRM or lymph nodes.

Haven't yet figured out a way to tell a surgeon their TMEs are ****ty.
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It's less about the radiologist and making sure the technologist does the right slices angles on the MRI with the right coil and all that... can't read most stuff with a **** MRI technique/sequence/angle.
 
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^^ This. And since we are giving pelvic IMRT these days, but for decades gave boxy 3 field or whatever how is neuropathy suddenly being counted against radiation is just nuts.

Anyone do the COI analysis for the chemo regimens being promoted? Lol.

I think its all highly questionable ... and preop CRT should remain the standard for any kind of 'risky' rectal cancer. You want to do chemo for T1-2N0 (hey, throw in some immuno too, maybe superficial xray to boot) and watch and wait.. by all means do so. Selected T3? Uh.. dunno.

N+?

Come On Biden GIF by GIPHY News
 
RickyScott said:
Probably just a random fluke. Folfox is not likely to be the regimen in 10-15 years anyway, something more active and less toxic. Local control was 98-99%. If the chemo arm had 8 cycles instead of 12, I doubt anything would change ie local control would suffer.
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We should encourage people to try not to compare late toxicity of 3% versus 8% in a study that isnt even remotely powered for toxicity differences.

FOLFIRINOX is already making a play!

Id strongly suggest checking out Dr. Jethwa's twitter account and looking at the last week's posts. Tons of coverage of multiple trials. There is a lot to be positive about for radiotherapy actually.


1686157597993.png
 
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RadOncDoc21 said:
Except for the job market.
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When I stop getting unsolicited pathological overachiever 6 page resumes and a 2 page cover letter why they want to treat patients where they grew up and why they are more qualified to draw circles around prostates for the next 30 years then I’ll feel better.
 
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I Love ESTRO. They sound like what ASTRO should aspire to.
 
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took the time to go through oral abstracts involving radiation today - if you weren't depressed already

FOWARC trial for rectal - no benefit for RT
PEACE-1 - prostate RT for limited metastases some benefit on endpoints other than OS
PROSPECT - already well covered
SWOG S1826 - less than 1% of patients need RT with Nivolumab for Hodgkins
2 infusions of immunotherapy for skin cancer to avoid 'mutilating or extensive surgery and/or RT' for skin cancer
INDIGO vorasidenib to delay RT for IDH1/2 low grade glioma
IELSG37 no benefit for RT primary mediastinal B cell lymphoma
ICoLP immunochemotherapy without RT for larynx preservation
SWENOTECA surgery instead of RT for stage II seminoma <3 cm

I checked out at this point. Great job academic radiation oncology!
 
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If they can figure out how to keep people on long term immunotherapy without devastating side effects (other than $) while keeping disease in check.. then I guess we're done here.

Say, any chance I can do a "degree at home" in Medical Oncology? You know, maybe shadow my friendly medonc next door?
 
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theradiator said:
took the time to go through oral abstracts involving radiation today - if you weren't depressed already

FOWARC trial for rectal - no benefit for RT
PEACE-1 - prostate RT for limited metastases some benefit on endpoints other than OS
PROSPECT - already well covered
SWOG S1826 - less than 1% of patients need RT with Nivolumab for Hodgkins
2 infusions of immunotherapy for skin cancer to avoid 'mutilating or extensive surgery and/or RT' for skin cancer
INDIGO vorasidenib to delay RT for IDH1/2 low grade glioma
IELSG37 no benefit for RT primary mediastinal B cell lymphoma
ICoLP immunochemotherapy without RT for larynx preservation
SWENOTECA surgery instead of RT for stage II seminoma <3 cm

I checked out at this point. Great job academic radiation oncology!
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The stock price for RT is low… I’m going all in now!
 
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sirspamalot said:
Beavis And Butthead Comedy GIF by Paramount+


Yeah it sure is: 1997 isn't coming back.
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1686250607434.jpeg


I’m going all in on salvage radiation being the future! I’m selling all my definitive radiation stock as it is a sinking ship.
 
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theradiator said:
took the time to go through oral abstracts involving radiation today - if you weren't depressed already

FOWARC trial for rectal - no benefit for RT
PEACE-1 - prostate RT for limited metastases some benefit on endpoints other than OS
PROSPECT - already well covered
SWOG S1826 - less than 1% of patients need RT with Nivolumab for Hodgkins
2 infusions of immunotherapy for skin cancer to avoid 'mutilating or extensive surgery and/or RT' for skin cancer
INDIGO vorasidenib to delay RT for IDH1/2 low grade glioma
IELSG37 no benefit for RT primary mediastinal B cell lymphoma
ICoLP immunochemotherapy without RT for larynx preservation
SWENOTECA surgery instead of RT for stage II seminoma <3 cm

I checked out at this point. Great job academic radiation oncology!
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What were the results from FOWARC? I've never heard of it, but seemed to also be on the way to proving there was no benefit to oxali.
 
I mean maybe SBRT spot-ology is the only real future we have left, and it DOES pay so as long as UM doesn't run interference (besides breast) too hard.. I guess...

season 5 starz GIF by Power
 
I’m more optimistic now then ever before… mainly because I’m a lunatic, but when all these neoadjuvant therapies fail, we’ll be the ones they call.

That’s my investment thesis on the rad onc stock. That’s the only shot I have now in making a living in this field, so it has to work!
 
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From FOWARC final paragraph:

In summary, the final results from the FOWARC study show
that mFOLFOX6 with or without radiation did not signifi-
cantly improve 3-year DFS relative to fluorouracil plus ra-
diation in patients with locally advanced rectal cancer.
However, although the study was not set up to detect
noninferiority among treatment arms, no difference in
outcomes was found between patients who received
mFOLFOX6 without radiotherapy and those who received
standard fluorouracil plus radiotherapy, which warrants
additional investigation to clarify the role of radiotherapy in
neoadjuvant treatment of locally advanced rectal cancer.
Long-term follow-up also is required to establish any dif-
ferences in OS

That said, if you extrapolate to the PROSPECT trial, can anyone think of a way to reduce long term neurotoxicity to near zero?
 
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At a certain “top institution”, the GI surg onc’s and heme onc’s are already cancelling rad onc referrals for T3 upper rectal cancers.

“Radiation is not recommended based on PROSPECT. There’s nothing to discuss.”

I’m glad the rad onc “leaders” at that institution are controlling the narrative at their tumor boards, bodes well for us in the community.
 
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yesmaster said:
At a certain “top institution”, the GI surg onc’s and heme onc’s are already cancelling rad onc referrals for T3 upper rectal cancers.

“Radiation is not recommended based on PROSPECT. There’s nothing to discuss.”

I’m glad the rad onc “leaders” at that institution are controlling the narrative at their tumor boards, bodes well for us in the community.
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Crazy that we have a trial which shows one arm had less toxicity, yet that is the arm we are eliminating. I do agree with the European consensus, however, that lots of PROSPECT patients likely were overtreated.

Additionally, I haven't been routinely recommending XRT for high T3N0 rectal cancer routinely for some time now.
 
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chemo+surgery?
chemo+more chemo+radiation(short/long)+surgery?
chemo(+/- more chemo)+radiation+observe?
chemo+immuno+observe?

I give up.

ps. For your friendly CRSurg : how much bidness you guys gonna lose if we drop surg? I mean.. hemicolectomies might go away with chemo immuno eventually too. Maybe we all just go away with maybe an occasional FLASH treatment as consolidation after chemoimmuno. Its not even Monday, what a cynic.
 
sirspamalot said:
How "high" and how many MRI risk factors before you cry uncle and give our blessed rays?

..asking for a friend..
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Typically if it's mid/high rectal (ie, likely an LAR candidate), with negative lymph nodes, a negative CRM, negative EMVI, I tend to not recommend neoadjuvant treatment, especially in a younger patient.
 
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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.
 
yesmaster said:
At a certain “top institution”, the GI surg onc’s and heme onc’s are already cancelling rad onc referrals for T3 upper rectal cancers.

“Radiation is not recommended based on PROSPECT. There’s nothing to discuss.”

I’m glad the rad onc “leaders” at that institution are controlling the narrative at their tumor boards, bodes well for us in the community.
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Everyone told me this was not supposed to happen. All the GI experts on twitter especially!
 
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Ray D. Ayshun said:
Is there any knowledge of subgroup analysis from the prospect trial? Specifically, wondering about the T3N+ groups, of which there were more on the CRT arm.
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This was the only "discussion" I've seen thus far

 
Salvage radiation- just embrace it!
 
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