ASCO 2025 thread

[Palex80]

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I thought, I'd start an ASCO 2025 thread.

Interesting abstracts

1. Concurrent and adjuvant Pembrolizumab in primary radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/243800

2. Adjuvant Nivolumab after postoperative radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/245968

3. MWA or SBRT for liver metastases

https://meetings.asco.org/abstracts-presentations/244881

4. Low-dose olanzapine for nausea

https://meetings.asco.org/abstracts-presentations/246464

A few breast RT-omission trials are apparently in progress

https://meetings.asco.org/abstracts-presentations/252167

https://meetings.asco.org/abstracts-presentations/252183

https://meetings.asco.org/abstracts-presentations/252185

 

[temujim]

I thought, I'd start an ASCO 2025 thread.

Interesting abstracts

1. Concurrent and adjuvant Pembrolizumab in primary radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/243800

2. Adjuvant Nivolumab after postoperative radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/245968

3. MWA or SBRT for liver metastases

https://meetings.asco.org/abstracts-presentations/244881

4. Low-dose olanzapine for nausea

https://meetings.asco.org/abstracts-presentations/246464

C-POST also made a big splash. Simultaneous publication in NEJM. Large DFS benefit, but OS curves superimposable -- hidden in supplementary data.

 

[ramsesthenice]

C-POST also made a big splash. Simultaneous publication in NEJM. Large DFS benefit, but OS curves superimposable -- hidden in supplementary data.

Absolute failure by NEJM. Journals (especially high impact) should present data in the abstract much more objectively. I understand that follow up is only 24 months and survival data is immature, but there is no reason to not state the 2 year OS data for both arms. The clear implication from a strong reduction in reducing failures is a higher cure rate and better survival.

I review for them periodically and have been part of numerous attempted multi site publications. The IO bias is unreal. Radiation or standard chemo trial showing positive OS benefit with < a couple hundred patients per arm…too small to evaluate in a meaningful way. RT trial showing PFS but not OS benefit…meaningless. Promising study with IO and 14 MMRd rectal patients…ACCEPT.

There will never be a perfect system and I’m not actually knocking the IO trials. Cercek’s results held up with more time and patients. And we all know local failures of cutaneous SCCs can be highly morbid so this study really is meaningful regardless of the final survival data. None of this makes the differing standards for publication any more appropriate or easier to swallow.

 

[thesauce]

I thought, I'd start an ASCO 2025 thread.

Interesting abstracts

1. Concurrent and adjuvant Pembrolizumab in primary radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/243800

2. Adjuvant Nivolumab after postoperative radiochemotherapy for SCCHN

https://meetings.asco.org/abstracts-presentations/245968

3. MWA or SBRT for liver metastases

https://meetings.asco.org/abstracts-presentations/244881

4. Low-dose olanzapine for nausea

https://meetings.asco.org/abstracts-presentations/246464

A few breast RT-omission trials are apparently in progress

https://meetings.asco.org/abstracts-presentations/252167

https://meetings.asco.org/abstracts-presentations/252183

https://meetings.asco.org/abstracts-presentations/252185

The breast RT omission ones seem to be comparing RT to Tamoxifen/AI alone. Now we have the data that RT is superior so these trials add nothing regardless of the outcomes.

 

[TheWallnerus]

Now we have the data that RT is superior

Nettlesomely, this is debatable.

 

[TheWallnerus]

I am really bothered by this. How can you be exhausted AND energized. That’s like saying “I’m hungry but satiated” or “on fire but freezing” or “in a lot of pain but very comfortable”… in other words can we even really trust a medical oncologist 😉

 

[RadOncMegatron]

Love to hear people’s thoughts on

PANOVA-3 TTF for pancreatic ca

https://ascopubs.org/doi/10.1200/JCO-25-00746

CHALLENGE Trial exercise for colon cancer

https://meetings.asco.org/abstracts-presentations/244420

 

[NotMattSpraker]

Love to hear people’s thoughts on

PANOVA-3 TTF for pancreatic ca

https://ascopubs.org/doi/10.1200/JCO-25-00746

CHALLENGE Trial exercise for colon cancer

https://meetings.asco.org/abstracts-presentations/244420

I am disappointed that Optune still has not included a sham control in one of their trials. Given that this critique has been around since the very first trial, its a little sus. Low toxicity though, so I think it should be offered if you already have a TTF program up and running.

I was so excited about CHALLENGE that I wrote a blog post #Exercisumab — Matt Spraker, MD, PhD

 

[TheWallnerus]

I am disappointed that Optune still has not included a sham control in one of their trials. Given that this critique has been around since the very first trial, its a little sus. Low toxicity though, so I think it should be offered if you already have a TTF program up and running.

I was so excited about CHALLENGE that I wrote a blog post #Exercisumab — Matt Spraker, MD, PhD

I won’t bore with a bunch of link vomit, but the evidence shows that exercise (yoga etc) improves survival in node positive breast cancer better than RT does. Exercise also improves locoregional recurrence. If we truly put our moneys where our mouths were, there would be a workout center in every chemo and/or rad onc center. And insurances would reimburse for it.

 

[evilbooyaa]

I am disappointed that Optune still has not included a sham control in one of their trials. Given that this critique has been around since the very first trial, its a little sus. Low toxicity though, so I think it should be offered if you already have a TTF program up and running.

I was so excited about CHALLENGE that I wrote a blog post #Exercisumab — Matt Spraker, MD, PhD

Liar! You specifically said you are NOT Matt Spraker!

I won’t bore with a bunch of link vomit, but the evidence shows that exercise (yoga etc) improves survival in node positive breast cancer better than RT does. Exercise also improves locoregional recurrence. If we truly put our moneys where our mouths were, there would be a workout center in every chemo and/or rad onc center. And insurances would reimburse for it.

And here is the truth as to why we don't push exercise for all of our patients. No physician gets reimbursed for making sure their patients exercise.

I am disappointed that Optune still has not included a sham control in one of their trials. Given that this critique has been around since the very first trial, its a little sus. Low toxicity though, so I think it should be offered if you already have a TTF program up and running.

I was so excited about CHALLENGE that I wrote a blog post #Exercisumab — Matt Spraker, MD, PhD

Similar thought process to LDRT for OA for the non-believers... But anywyas, TTF is low toxicity for the ones who can tolerate, which is a small fraction of even my GBM patients... Not sure if the skin reaction is any less painful/annoying on the abdominal area though. I think no harm to throwing whatever sticks to a horrible disease as an option for patients.

I am really bothered by this. How can you be exhausted AND energized. That’s like saying “I’m hungry but satiated” or “on fire but freezing” or “in a lot of pain but very comfortable”… in other words can we even really trust a medical oncologist 😉

Energized to throw 6 figure IO at all sorts of clinical situations for a PFS benefit without OS benefit due to having pharmaceutical money lining her pockets: CMS Open Payments

 

[Palex80]

I won’t bore with a bunch of link vomit, but the evidence shows that exercise (yoga etc) improves survival in node positive breast cancer better than RT does.

But what about...

 

[NotMattSpraker]

And here is the truth as to why we don't push exercise for all of our patients. No physician gets reimbursed for making sure their patients exercise.

You can push it in your E/M visit and if you saw people back to track their progress it is a good use of the G2211. It is likely that most or all of your patients have a condition that is directly treated with exercise such as fatigue, gait instability, or deconditioning. I will add this C-code if Im using G2211 and I select it as my indication for sending to PT.

I realize this doesn't really negate your overall point, but does get you an additional fraction of a wRVU.

 

[communitydoc13]

And here is the truth as to why we don't push exercise for all of our patients. No physician gets reimbursed for making sure their patients exercise.

I believe the control arm in the trial was encouraging exercise. You need a trainer (ritual seems to be super important...maybe ritual is the key behind Optune...also interpersonal interaction).

RFK Jr is almost always wrong, but if he could get personal trainers paid for by CMS (they would have to formulate some baseline group service that they could provide via medicare), this would actually be great. (Of course the biggest preventative health intervention would be to invest in public transport and walkable/bikeable cities with major financial disincentives to take your car places).

Regarding Optune...I have claimed for a long time that that ish works. Not only that, but I am confident that cells respond to all sorts of relatively low frequency EMR...and that the therapeutic potential of such has just never been remotely optimized...in cancer or any other disease process.

 

[radiation]

I am disappointed that Optune still has not included a sham control in one of their trials. Given that this critique has been around since the very first trial, its a little sus. Low toxicity though, so I think it should be offered if you already have a TTF program up and running.

I was so excited about CHALLENGE that I wrote a blog post #Exercisumab — Matt Spraker, MD, PhD

Using a sham would be near impossible to get pts to agree to be randomized to and I don't even think ethical at this point. The original Stupp trial itself didn't even use a placebo control in the control arm.

We have 30+ years of negative randomized GBM trials, but the one therapy that actually has an OS benefit in multiple cancers needs to have a sham control? Would you want your family member to go a trial that makes them wear Optune cap every day for 6 months with possibility of it being sham?

 

[wandering star]

I believe the control arm in the trial was encouraging exercise. You need a trainer (ritual seems to be super important...maybe ritual is the key behind Optune...also interpersonal interaction).

I was very impressed at how much exercise the control arm was getting. Looks like 16 recreational MET-hours a week in recreational activities (I assume "recreational" means "deliberate" and not, like, the activity that is recorded in some accelerometer studies). That translates to about 5 hours of walking at 3 mph, or running 10 miles per week on a treadmill. The control arm is already meeting the ordinary CDC guidelines, and the intervention arm is running at about 50% more than that.

https://www.nejm.org/doi/full/10.1056/NEJMoa2502760

I mean, I guess they enrolled people on an exercise trial, and the folks who signed up were willing to exercise? How much benefit would they have seen if the control arm just sat on the couch?? I assume it would be even greater.

The discussion of the paper does talk about the trainer and social interactions and so on, and they play it down based on past studies. Of course, hard to know for sure.

 

[medgator]

And here is the truth as to why we don't push exercise for all of our patients. No physician gets reimbursed for making sure their patients exercise.

Definitely push for weight bearing exercise (along with calcium+vit D) in my prostate pts on long term ADT.

I think Medicare has a quality measure now checking to make sure they have all bone dexa scans before starting adt as well

 

[NotMattSpraker]

Using a sham would be near impossible to get pts to agree to be randomized to and I don't even think ethical at this point. The original Stupp trial itself didn't even use a placebo control in the control arm.

We have 30+ years of negative randomized GBM trials, but the one therapy that actually has an OS benefit in multiple cancers needs to have a sham control? Would you want your family member to go a trial that makes them wear Optune cap every day for 6 months with possibility of it being sham?

The hypothesis is that the extra visits and support that comes with the device is extending survival. In my opinion, it's a reasonable hypothesis given the Temel palliative study and similar research. If the control patient gets the extra care and cant tell which arm they are on, I would recommend my family member enrolls in the trial. If they really believe that the electric field is important, then they shouldnt do it.

Its just a critique of the trial that could be addressed and it should be considered. I still think the therapy should be offered because of the lack of other options and the data that it works.

 

[medgator]

.

Its just a critique of the trial that could be addressed and it should be considered. I still think the therapy should be offered because of the lack of other options and the data that it works.

Same OS benefit in Gbm as tmz. There's definitely something to it

 

[NotMattSpraker]

Same OS benefit in Gbm as tmz. There's definitely something to it

You caused me to look this up. This is kinda wild. Early palliative care in Temel also had the same numerical median survival time benefit as Stupp TTF in GBM, 2.7 months. 🙂

Fun coincidences, but not sure what this has to do with the biological effects of electric fields.

Again, a physician can recognize this type of uncertainty, be unsure how something works, and still prescribe it. We do that a lot in medicine.

 

[Palex80]

Bear in mind that TTF for GBM was given together with TMZ vs. TMZ alone.
From what we know so far, TTF works when given together with another form of treatment.
There have been trials giving it alone, but they were not as successful as the randomized one.

 

[theradiator]

You caused me to look this up. This is kinda wild. Early palliative care in Temel also had the same numerical median survival time benefit as Stupp TTF in GBM, 2.7 months. 🙂

Fun coincidences, but not sure what this has to do with the biological effects of electric fields.

Again, a physician can recognize this type of uncertainty, be unsure how something works, and still prescribe it. We do that a lot in medicine.

let me steelman these factually accurate but perhaps incomplete assertions.

the Temel paper is a classic but there are numerous subsequent RCTs looking at early palliative care compared to usual care. while most showed some type of QOL or other benefit, to my knowledge none replicated the same stunning survival advantage. of course, none of these papers were published in the NEJM or picked up by mainstream media and thus the conventional narrative is that palliative care is some type of unalloyed good (based on the Temel trial) and therefore we always need more of it.

as for TTF, in contrast to other interventions for cancer that required multiple confirmatory randomized trials, the original trial has never been validated. in my market, the overwhelming majority of neurooncologists do not prescribe TTF (non-believers) and therefore it is heavily marketed to radiation oncologists instead. unclear how much traction TTF-1 will receive in the expanded indications of advanced cancer tested that will be more dependent on medical oncology.

interesting examples of how perceptions of evidence-based medicine are implemented in clinical practice.

 

[NotMattSpraker]

let me steelman these factually accurate but perhaps incomplete assertions.

the Temel paper is a classic but there are numerous subsequent RCTs looking at early palliative care compared to usual care. while most showed some type of QOL or other benefit, to my knowledge none replicated the same stunning survival advantage. of course, none of these papers were published in the NEJM or picked up by mainstream media and thus the conventional narrative is that palliative care is some type of unalloyed good (based on the Temel trial) and therefore we always need more of it.

as for TTF, in contrast to other interventions for cancer that required multiple confirmatory randomized trials, the original trial has never been validated. in my market, the overwhelming majority of neurooncologists do not prescribe TTF (non-believers) and therefore it is heavily marketed to radiation oncologists instead. unclear how much traction TTF-1 will receive in the expanded indications of advanced cancer tested that will be more dependent on medical oncology.

interesting examples of how perceptions of evidence-based medicine are implemented in clinical practice.

Good points. I like the VA study that did validate the effect, but is retrospective. For what its worth, I argue all the time with med oncs that "dont believe" in palliative care (weird) and refer for that too.

I tend to be curious and skeptical in scientific discussion with other doctors, but in clinic I am practical. I dont really see the problem with that. If you replicate the intervention, you should get the benefit. Thus I prescribe the intervention (in theory, I dont personally see a lot of CNS).

Is the argument that I should prescribe it but also not have any skepticism around the TTF studies?

By the way, it's highly impractical to continue to use treatments that show NO benefit in a phase III trial. Great examples are radiating prostates with proton therapy or ypN0 breasts. A lot of radiation oncologists don't seem to have any issue doing that. 🤷‍♂️

 

[communitydoc13]

Is the argument that I should prescribe it but also not have any skepticism around the TTF studies?

Unless there is actual fraud (I doubt it), the TTF studies pretty consistently show efficacy. (Of course trials are all about efficacy and you've selected kinda special people to participate. I think the prescribing docs are just worn out by the whole efficacy/effectiveness disparity. Lots of regular folks just never being compliant with this. My patients usually give up on it.)

Novocure has a press release on like 20 papers from 2024, lots of preclinical stuff. Not fabulously well understood but clearly multiple mechanisms available for actual "physical" impact on malignancy.

Not clear to me that the dosimetry of this stuff (including all the changes you get with penetration, heat generation, flexibility with transducers etc that go with changes in frequency) is in anyway tuned up. This is an ideal initiative for a radonc department.

Is anyone in our field doing foundational work with this stuff?

I'd drop my cush community job right now if someone gave me a lab, 1/3 of my salary and some private dough to do this. Gotta be some legit academic radoncs taking a deep dive on this stuff?

Anyone?

 

[TheWallnerus]

Good points. I like the VA study that did validate the effect, but is retrospective. For what its worth, I argue all the time with med oncs that "dont believe" in palliative care (weird) and refer for that too.

I tend to be curious and skeptical in scientific discussion with other doctors, but in clinic I am practical. I dont really see the problem with that. If you replicate the intervention, you should get the benefit. Thus I prescribe the intervention (in theory, I dont personally see a lot of CNS).

Is the argument that I should prescribe it but also not have any skepticism around the TTF studies?

By the way, it's highly impractical to continue to use treatments that show NO benefit in a phase III trial. Great examples are radiating prostates with proton therapy or ypN0 breasts. A lot of radiation oncologists don't seem to have any issue doing that. 🤷‍♂️

Being skeptical about a study’s results but then changing practice to align with the study’s experimental arm sure does unnecessarily accelerate entropy in the universe. 😉

I’m thinking of the elongated title of Dr. Strangelove.

 

[NotMattSpraker]

Being skeptical about a study’s results but then changing practice to align with the study’s experimental arm sure does unnecessarily accelerate entropy in the universe. 😉

I’m thinking of the elongated title of Dr. Strangelove.

Amazing post.

I say it to patients all the time. Biology is chaotic, cancer is unpredictable. We do the best we can. My weird thought process at least feels better to me than making clinical decisions to improve the profitability of the company 🤷‍♂️

(Not suggesting thats whats happening with TTF, way off topic now)

 

[TheWallnerus]

Amazing post.

I say it to patients all the time. Biology is chaotic, cancer is unpredictable. We do the best we can. My weird thought process at least feels better to me than making clinical decisions to improve the profitability of the company 🤷‍♂️

(Not suggesting thats whats happening with TTF, way off topic now)

In all seriousness skepticism is good. I believe “borked” became a verb after Judge Bork got borked on his unsuccessful way to the Supreme Court. A little surprising (Werner) Bezwoda’d didn’t become a similar neologism in oncology.