ASCO 2026
Started by Palex80
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Pretty remarkable curve separation
I guess this means PCI for NSCLC could finally show significant benefit for certain subsets 😉
Exactly, those 3% ALK mutated ones kept screwing all the trials!
Any news on the prostate plenary that will show a benefit to second generation arb prior to surgery? (Proteus) sounds like it will really hurt us. Kind of like neoadjuvant in stage 3 nsclc.
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ROADS is interesting and probably practice-changing, but I would not declare postop cavity SRS dead based on the ASCO abstract alone.
Randomized phase III trial in resected brain metastases, comparing intraoperative Cs-131 collagen tile brachytherapy/GammaTile versus standard postop SRT. The headline result is very strong: markedly lower surgical-bed recurrence with tiles, with no obvious major toxicity penalty, and an unexpectedly large OS difference.
The logic makes sense. The biggest weakness of postop cavity SRS is operational: delay after surgery, cavity evolution, contour uncertainty, missed or late treatment, and systemic therapy interruption. GammaTile solves a lot of that by treating immediately at resection, before the cavity changes and before the patient falls into the postoperative scheduling abyss.
That said, the OS delta is too large for me to swallow whole without seeing the manuscript. I’d want to look carefully at histology, systemic therapy balance, extracranial disease status, salvage patterns, and how many patients on the control arm actually received timely, high-quality postop SRT.
Bottom line: very strong local-control signal, real logistical advantage, and likely useful for selected large resected brain mets. But I want the full paper before pretending this invalidates well-executed postop cavity SRS.
Even if the result is real, few currently practicing rad oncs will be able to justify doing this because brachy reimburses so poorly vs fSRS (technically and wRVU wise), not to mention the OR time suck away from clinic (especially if you’re not hospital based).
They’ll just do it without us like a lot are doing with Y-90
IR can do that because they can become authorized users of radioactive materials. Neurosurg can’t.
The data look good but will be curious to see full text. OS advantage seems more than I would expect.
This can be a logistics nightmare though for the rad onc (coordinating OR time and clinic, etc).
I have not thought in wRVU terms in a while, but I think the rad onc could get about 10-15 wRVUs for CNS brachy; the NSG gets 25+. For multi-fx SRS the rad onc can get 20+ wRVU iirc. And, goes without saying, those SRS wRVUs are less laborious than those brachy wRVUs.
Every Asco seems to chip away at major indications for xrt. Our urologists resisted operating on very high risk pts up until now.
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Subsequent therapy was received by 42.4% of the patients in the apalutamide group and 56.7% of those in the placebo group; the most common therapies were hormonal therapy (in 34.0% and 46.5%, respectively) and postoperative radiotherapy (in 26.6% and 36.8%), primarily salvage radiotherapy (Table S4).
I wonder, why so little salvage radiotherapy was given to these patients.
They were all high-risk and at 5 years bCR was still something >50% in the ADT+apalutamide group.
Most recurrences were detected early, since they all had PSA measurements for follow-up. Awful.
EDIT: I read the protocol.
One can clearly see, that a radiation oncologist was not involved here.
It's not "SALVAGE" radiotherapy when you give RT for "lymph node involvement or other high-risk features", that's ADJUVANT, you idiots!
No word on TRUE salvage radiotherapy in the protocol.
This is simply stupid.
The protocol basically tells you to ignore any PSA rise and follow-up until metastasis is detected. WTF?
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The real problem is that whatever the flaws, urologists will use it as a justification to operatez
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One rad onc’s stupid trial is another urologist’s “disruptive” (per the editorial) trial.
Just remember history is written by the winners.
It’s definitely a chip in the rad onc’s patient load, but maybe not a major one. On average only about one out of ten referred prostate XRT patients are high risk. But hey a chip here and a chip there you start talkin’ real money in a little while.
SENOMAC Trial
This one is interesting because some rad oncs try to gauge the delivery and/or extent of their ENI based on ALND extent (or whether done etc.), maybe even mastectomy vs lumpectomy, etc. Seems reading those tea leaves becomes a more and more bootless exercise as the years go by, although details on radiation approaches from the trial may be interesting. Or, more likely, super "blue dress/gold dress" type stuff.
This one is interesting because some rad oncs try to gauge the delivery and/or extent of their ENI based on ALND extent (or whether done etc.), maybe even mastectomy vs lumpectomy, etc. Seems reading those tea leaves becomes a more and more bootless exercise as the years go by, although details on radiation approaches from the trial may be interesting. Or, more likely, super "blue dress/gold dress" type stuff.
Maybe one in ten overall pts is high risk, but in my practice they are a higher percentage of the pts sent from urology, who try to operate on every low and intermediate risk pt.
It's a little apples to oranges, but it just goes to show that when the molecule is right, biochemistry can trump radiobiology in treating solid tumors
Post-op srs is underperforming in this trial for some reason.
Agree logic is good, but the srs world is moving towards pre-op srs which takes care of most of those issues you identified.
I hate post-OP SRS. I find margins too tight, to be honest. I prefer to FSRT with a more generous margin.
The trial did allow FSRT for larger cavities, not sure how the distribution was.
Haha. As predicted. And very blue dress/gold dress, too, except the urologists own the dress factory. And will claim the homerun and tell us there's no crying in baseball.
in rad onc a “standing O” refers to the departmental policy of putting an avoidance ring around every PTV to optimize the OAR doses 😉
I’m not sure about this. What I’ve heard from my urologists is compensation from RALP has gone down so much that their time is better used elsewhere. Even more of a case if they’re putting in hydrogels for your EBRT patients. If the urologist fashions themself as a “urologic oncologist” then yes they’re going to operate. But this might not move the needle for other urologists.
OS difference is a huge red flag here - going to need to see the manuscript
My initial thought: the honesty is admirable from this UF rad onc
Meanwhile…
90 day global on those surgeries also to see them and manage complications
I always wondered what it would mean for society if surgeons weren’t being incentivized to operate
Now I wonder what it means if rad oncs aren’t incentivized to irradiate. The circle of life.
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I miss those days. The urologists at my first job were the most reasonable bunch I ever met. I like the folks here and like where I trained, they will offer surgery to anyone with prostate cancer. Node positive? "Yes they have a node, but I can get to it."
Once we get the full details it will be interesting to see how much this moves the needle. The folks that were always going to operate will have more ammunition but statistically will have a hard time increasing their operative volume significantly. Will it be enough to move the surgeons who were resistant to treat high risk patients...not sure yet.
Big picture, effective neoadjuant therapy should help reduce recurrence risk. But the real question still comes down to how many patients still end up needing post-operative radiation at some point. You won't know without long term follow up. A thoughtful oncologist who is trying to avoid the added toxicity of doing both modalities knows that just putting off the need for salvage therapy by a couple of years is not much of a win.
They'll operate on anything but do they at least believe in adjuvant therapy?
Some will just squat for months or years so to avoid ruining their pristine operating record by
The full puplication will be interesting..
Tough even with OS difference aside, local control was excellent in the tile based radiation group, so if a department manages to implement these, this will probably be a valid alternative to post-OP SRS, while being more convenient for the patient and oncologist (and probably also cheaper?).
From a radiation biology standpoint especially in larger metastases dose to the tumorbed is also probably higher, which can explain the better local control......
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Been my practice. Impressive to watch 10-12 sub cm brain 🧠 mets melt away after a few months of tagrisso
I’ve thought back to residency days early this century and the proportion of whole brain RT patients on service at any time. Was very common! I’d estimate as many as one in five treated patients on a given day.
As far as surgeons or medoncs know (or care), radiation is radiation is radiation.
But new drug names can be invented forever: “Oh - that trial used ABC drug and didn’t work? That’s an older regimen! We use BCD now (which differs by one insignificant side group). Yeah it only improves survival by 3 days but NOW what is the evidence that we still need radiation?”
If radiation ever comes back in the picture, medoncs will just say “we tried that and it didn’t work.” T4 colon or certain ovarian scenarios are a couple examples - good luck with radonc getting back into that no matter how strong the data is. Once we’re out, we’re out.
The older I get, the more I understand conspiracy theories. Drug companies truly are in control.
Urologists still seem pretty aggressive with RALP especially if it comes down to patient choice.
I had a 75 yo Fav int risk G7 low vol disease worried about GU incontinence post RALP. Told him about Sbrt…3 hours later he called up saying he’s getting surgery…you can’t win.
That being said, I have heard that they generate more RVUs in the clinic than they do in the OR.
“Once we’re out, we’re out” - the hard truth of it all. EBM be damned.
T4 colon. Man that brings back some memories. Yes kids we occasionally would get surgical or med onc referrals to give radiation for colon cancer. Wild stuff. Iirc, after lots of promising retrospective data a poorly accrued somewhat negative/somewhat positive phIII trial got us booted from the colon game… and not a single rad onc anywhere ever again took up any interest trying to get it back.
RIP esophageal, colon, gastric, and lymphoma radiation
Apalutamide is apparently not interchangeable with enzalutamide and the other -lutamide's but even some rad onc's think that EORTC 22922 radiation is identical to present day radiation. The brainwashing is bad when rad onc's also are swallowing the green juice of other specialties.
Some of the neurosurgeons have equity in the GammaTile company, there is no way in hell they don't. They have equity, they do the surgery, they place the tiles. Yeah, no bias to see here, move along.
Interesting trial. Agreed on the issues of adjuvant vs. salvage (and when salvage was not used, why not?) here the full publication
Also what is tricky is the placebo arm in this trial is still periop ADT, which is not standard of care given negative or unimpressive results of prior trials of neoadjuvant ADT (though data more limited in high risk patients then we would like). So would have loved to see either an ADT + apa vs. no systemic therapy or a three arm trial design here, though they say a subcohort showing this will come out at some point
Also not sure i get the NED numbers. Figure 2 shows an event free survival of ~50% for ADT + apa. But they say only 20% of patients were NED at 4 years. What's going on with the other 30%?
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i am fortunate to work with surgeons who see the utility of XRT and often ask about considering XRT for stuff such as T4 colon. it caught me off guard and makes tumor board much more interesting. Ultimately, the ones i work with want what is best for the patient - good cancer outcomes, minimal morbidity.
Bladder will soon be on the list.
For radical cystectomy maybe.... Ditto for rectal. Xrt will replace surgery
bladder could be a real paradigm shift. It is a “typical” solid malignancy that is being cured by systemic therapies.
Without chemorads?
