ASCO GI & ASCO GU

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Palex80

Palex80

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Hey!


ASCO-GI abstracts are out, ASCO-GU abstracts will become available in mid February.

My picks for ASCO-GI:

Neo-AEGIS demonstrating comparable OS with either Magic/FLOT or CROSS. CROSS leads to better downstaging and less toxicity. Limitation: majority of Magic/FLOT arm had Magic, which isn't as active as FLOT.

Reasonable randomized Canadian trial looking at 1x8 Gy vs. BSC for patients in pain with terminal metastatic liver disease or HCC.



Looking forward to this ASCO-GU abstract:

An update of the British trial on adaptive bladder RT (using a rather simple method, not a fancy MRI-linac).

LBAs are not available yet.




Will anyone attend ASCO-GU in February? Message me if you want to grab a coffee. :)
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More interesting stuff at ASCO-GU:

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis.​

Primary endpoint is: "To determine whether there is improved quality of life after SBRT compared with surgery at 2 years post treatment, using EPIC score to measure urinary incontinence and bowel bother."


Testosterone recovery in patients with prostate cancer treated with radiotherapy and different ADT duration: Long-term data from two randomized trials.​

Could be interesting to see how long it actually takes for testosterone to recover, I've seen various results.


10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016).​

Another CHHiP-update


Outcomes of patients with brain metastases from renal cell carcinoma treated with first-line therapies: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).​

Could be of use in practice, when thinking about delaying SRS.


Results of a multicenter, randomized, phase 3 trial of trimodality therapy with I-125 brachytherapy, external beam radiation therapy, and long- versus short-term androgen deprivation therapy for localized high-risk prostate cancer (TRIP/TRIGU0907).​

Could be interesting to see how much ADT is worth when dose-escalating.


Metastasis-directed ablative radiotherapy in castrate-resistant oligometastatic prostate cancer: A retrospective study of 8 high-volume French centers from the COLib (Cercle des Oncologues Libéraux).​

We have seen a lot of data and some trials for MDT in mHSPC, but not so many in mCRPC.


As I said before, PM me for coffee, if you are going to SF! :)
 
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Palex80 said:
More interesting stuff at ASCO-GU:

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis.​

Primary endpoint is: "To determine whether there is improved quality of life after SBRT compared with surgery at 2 years post treatment, using EPIC score to measure urinary incontinence and bowel bother."


Testosterone recovery in patients with prostate cancer treated with radiotherapy and different ADT duration: Long-term data from two randomized trials.​

Could be interesting to see how long it actually takes for testosterone to recover, I've seen various results.


10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016).​

Another CHHiP-update


Outcomes of patients with brain metastases from renal cell carcinoma treated with first-line therapies: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).​

Could be of use in practice, when thinking about delaying SRS.


Results of a multicenter, randomized, phase 3 trial of trimodality therapy with I-125 brachytherapy, external beam radiation therapy, and long- versus short-term androgen deprivation therapy for localized high-risk prostate cancer (TRIP/TRIGU0907).​

Could be interesting to see how much ADT is worth when dose-escalating.


Metastasis-directed ablative radiotherapy in castrate-resistant oligometastatic prostate cancer: A retrospective study of 8 high-volume French centers from the COLib (Cercle des Oncologues Libéraux).​

We have seen a lot of data and some trials for MDT in mHSPC, but not so many in mCRPC.


As I said before, PM me for coffee, if you are going to SF! :)
Click to expand...
Thanks for previewing these. As an aside, does anyone really consider the CHIP dose to be dose escalated? The EQD2 at a/b=3 is 72Gy
 
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grenz said:
As an aside, does anyone really consider the CHIP dose to be dose escalated? The EQD2 at a/b=3 is 72Gy
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Good point! We often give 21 x 3 Gy = 63 Gy for exactly this reason., if we can meet constraints and we do not see risk factors for late bowel/bladder toxicity.
 
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Palex80 said:
More interesting stuff at ASCO-GU:

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis.​

Primary endpoint is: "To determine whether there is improved quality of life after SBRT compared with surgery at 2 years post treatment, using EPIC score to measure urinary incontinence and bowel bother."


Testosterone recovery in patients with prostate cancer treated with radiotherapy and different ADT duration: Long-term data from two randomized trials.​

Could be interesting to see how long it actually takes for testosterone to recover, I've seen various results.


10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016).​

Another CHHiP-update


Outcomes of patients with brain metastases from renal cell carcinoma treated with first-line therapies: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).​

Could be of use in practice, when thinking about delaying SRS.


Results of a multicenter, randomized, phase 3 trial of trimodality therapy with I-125 brachytherapy, external beam radiation therapy, and long- versus short-term androgen deprivation therapy for localized high-risk prostate cancer (TRIP/TRIGU0907).​

Could be interesting to see how much ADT is worth when dose-escalating.


Metastasis-directed ablative radiotherapy in castrate-resistant oligometastatic prostate cancer: A retrospective study of 8 high-volume French centers from the COLib (Cercle des Oncologues Libéraux).​

We have seen a lot of data and some trials for MDT in mHSPC, but not so many in mCRPC.


As I said before, PM me for coffee, if you are going to SF! :)
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Incredible how much more relevant this ASCO sub-site meeting is compared to our own primary meeting.
 
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If they keep accepting non-rigorous studies, why would anyone try to do real science? Far easier to do this then something that actually improves patient care.
 
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FindMeOnTheLinks said:
Had the same thought. Astro is progressively becoming a joke
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Curious what the board thinks. Say you have a few thousand CME dollars a year and you like to go to 1-2 meetings a year that are not ASTRO.

What would you pick?

I've never been to ASCO and may go one year for fun, but tend to find smaller meetings are better when Im actually trying to learn something.
 
If they would only hold ACRO / ASTRO like somewhere nice and have private practice tracks with highlights .. not. gonna. happen.

American Radium Society has entered the chat
 
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Palex80 said:
Good point! We often give 21 x 3 Gy = 63 Gy for exactly this reason., if we can meet constraints and we do not see risk factors for late bowel/bladder toxicity.
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Many people would argue that relevant a/b is < 3 so it's all good.
 
NotMattSpraker said:
Curious what the board thinks. Say you have a few thousand CME dollars a year and you like to go to 1-2 meetings a year that are not ASTRO.

What would you pick?

I've never been to ASCO and may go one year for fun, but tend to find smaller meetings are better when Im actually trying to learn something.
Click to expand...
Community Oncology Alliance is a great alternative . Community Oncology Alliance
 
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sirspamalot said:
If they would only hold ACRO / ASTRO like somewhere nice and have private practice tracks with highlights .. not. gonna. happen.

American Radium Society has entered the chat
Click to expand...

Gfunk6 said:
Community Oncology Alliance is a great alternative . Community Oncology Alliance
Click to expand...
Looks like COA is at the Gaylord palms, not far from where acro is holding their meeting next month, and just a week later

communityoncology.org

Annual Conferences - Community Oncology Alliance

communityoncology.org communityoncology.org
 
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dieABRdie said:
Incredible how much more relevant this ASCO sub-site meeting is compared to our own primary meeting.
Click to expand...
It's brutal. All interesting work above. Not a single US presenting author.
 
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Seth Meyers No GIF by Late Night with Seth Meyers


Well, I am anyway. Living the #life ain't so bad.
 
Palex80 said:
More interesting stuff at ASCO-GU:

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis.​

Primary endpoint is: "To determine whether there is improved quality of life after SBRT compared with surgery at 2 years post treatment, using EPIC score to measure urinary incontinence and bowel bother."


Testosterone recovery in patients with prostate cancer treated with radiotherapy and different ADT duration: Long-term data from two randomized trials.​

Could be interesting to see how long it actually takes for testosterone to recover, I've seen various results.


10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016).​

Another CHHiP-update


Outcomes of patients with brain metastases from renal cell carcinoma treated with first-line therapies: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).​

Could be of use in practice, when thinking about delaying SRS.


Results of a multicenter, randomized, phase 3 trial of trimodality therapy with I-125 brachytherapy, external beam radiation therapy, and long- versus short-term androgen deprivation therapy for localized high-risk prostate cancer (TRIP/TRIGU0907).​

Could be interesting to see how much ADT is worth when dose-escalating.


Metastasis-directed ablative radiotherapy in castrate-resistant oligometastatic prostate cancer: A retrospective study of 8 high-volume French centers from the COLib (Cercle des Oncologues Libéraux).​

We have seen a lot of data and some trials for MDT in mHSPC, but not so many in mCRPC.


As I said before, PM me for coffee, if you are going to SF! :)
Click to expand...


Glad to see they changed the primary endpoint of PACE-A to PRO's from BCR rates. Don't love EPIC scores (they seem to understate symptoms IMO compared to IPSS or other scales IMO). Comparing BCR rates between surgery and XRT is a fool's errand, since by definition surgical recurrences will be detected earlier due to threshold definitions of BCR. Also surgical and post-XRT BCRs are different in prognosis due to differing potential of salvage options. Ideally the real thing we care about is MFS or CSS, but no way we will get anywhere close to the accrual to show a difference there.

Very curious to see the TRIP results, how long to do ADT for with trimodal is a big unanswered question.
 
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RealSimulD said:
Very rarely does it come out of one of our institutions. As I’ve said over and over, Tata Memorial, a large center in a very poor country is doing much more inspiring work than any of the centers here.
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Same reason pharma has moved a lot of their clinical research to other countries -- way less expensive. Difficult in the US to run a meaningful trial for less than 3k per patient. That's NCTN reimbursement level and most centers choke on that but do it anyway because their pipe dream of NCCN designation depends on participation. What percentage of private practices contribute? Gotta be low. Rad onc has no pharma to turn to for support. NIH/NCI underfunds rad onc. Try getting institutional funds. And heaven forbid the radiation intervention is investigational. That prices the trial pretty much out of every sponsor.
 
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DoctwoB said:
Glad to see they changed the primary endpoint of PACE-A to PRO's from BCR rates. Don't love EPIC scores (they seem to understate symptoms IMO compared to IPSS or other scales IMO). Comparing BCR rates between surgery and XRT is a fool's errand, since by definition surgical recurrences will be detected earlier due to threshold definitions of BCR. Also surgical and post-XRT BCRs are different in prognosis due to differing potential of salvage options. Ideally the real thing we care about is MFS or CSS, but no way we will get anywhere close to the accrual to show a difference there.

Very curious to see the TRIP results, how long to do ADT for with trimodal is a big unanswered question.
Click to expand...

Abstracts are posted now.

PACE-A: only comments on PROs, no cancer outcomes. No huge surprises. More incontinence with surgery. More bowel issue with SBRT. Not sure which butchers they are using with a 43% 2 year pad use rate in the surgical cohort. Also 20% of their surgeries were pure-lap, so Dinosaur butchers. Also interesting disparity in clinician vs. patient reported GI side effects.

Testosterone recovery data is interesting, as expected T recovery does decrease with duration of ADT. The real interesting question is why we don't consider T supplementation more often. Patients who naturally recover their T are "allowed" to have normal T, but it is risky to supplement someone who doesn't recover to get them to the same level? Don't buy that.

TRIP data looks like a big win for 6 months of neoadjuvant vs. ADT vs. 6 months neo and 2 years adjuvant. Potentially practice changing stuff, our practice had been do to 6 months for 4+3 and 1-2 years based on tolerance for high risk. Need to see more data/subgroups, but this looks exciting. This would also be a big win for brachy in general, if Trimodal therapy mean you get 6 months of ADT vs. 2 years with XRT alone, many patients would want that brachy. Big questions I have is the breakdown of patients (how many high risk by cT2c/cT3 or PSA >30 vs. GG4+), and how this may be effected by novel hormonal therapies which many high risk patients are now recieving
 
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bad link. I can't find abstracts either
40% pad rate at 2 years is a norm after surgery
 
Agree. The surgical outcomes on study seem like what I’m used to.
 
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seper said:
bad link. I can't find abstracts either
40% pad rate at 2 years is a norm after surgery
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Yes - if just 1 pad/day counts as "pad usage" then I think that's completely in range of what I see.
 
sirspamalot said:
Anyone going to actually not give high risk patients on routine IMRT 18-24 months of ADT based on the trimodality study?

No Way Smh GIF by Amazon Prime Video
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No one. We need to see patient characteristics from this as well. May represent a cohort where we would not expect a benefit to longer ADT regardless of local intervention.

It is well established that brachy boost will delay biochemical failure at some cost. Not a bad thing in the right patient and in the right hands.

I believe that brachy boost saves essentially zero lives.
 
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We should have an initiative for ASTRO / Red Journal.

I know this sounds like overly innovative for stodgy organizations, but bear with me.

A CALL FOR PAPERS: "Using radiation therapy to treat cancer in patients to improve cure rates or decrease toxicity."

I know this is a niche area, but maybe we can garner enough interest to get something going.
 
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seper said:
bad link. I can't find abstracts either
40% pad rate at 2 years is a norm after surgery
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Every individual surgeon is better than the garbage surgeons that do surgeries in multi-institutional trials opened in major centers both in the US and nationwide....

Remember the same discussion from Gyn/Oncs when LACC came out.
 
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It just doesn’t jive with real world experience. We track our data. I’m at 86% pad free at 3 months at 98% 1 year. I am not the best surgeon in the world. Patient selection and/or luck? Maybe. It’s also a bad outcome in that some patients will wear pads “just in case” while others will leak into their underwear. Or wear a pad when they go to the gym or play tennis, but no other times, etc.

And come on, pure lap prostrates is a red flag. It would be like you saw in the methods section that 30% of the patients were treated with cobalt.
 
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DoctwoB said:
And come on, pure lap prostrates is a red flag. It would be like you saw in the methods section that 30% of the patients were treated with cobalt.
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Why? Are there any data showing that the same surgeons doing a prostatectomy robotic or laparoscopic based, would produce different functional results?

I know several urologists that have done hundreds of prostatectomies open or laparoscopic and who do not want to switch to a robotic approach. Their incontinence rates are not higher than those of their robotic-only colleagues.

Also bear in mind, that sometimes robotic surgery may not be an option for other reasons: obese patients, previous extensive surgery in the pelvis.
 
RealSimulD said:
We should have an initiative for ASTRO / Red Journal.

I know this sounds like overly innovative for stodgy organizations, but bear with me.

A CALL FOR PAPERS: "Using radiation therapy to treat cancer in patients to improve cure rates or decrease toxicity."

I know this is a niche area, but maybe we can garner enough interest to get something going.
Click to expand...
Under the prior editor and continuing with the current editor my impression was there was an effort to only accept prospective trials, pushing the retrospective stuff we all rely on to guide our practice -- the spaces where randomized trials are not feasible or practical -- to Practical RO or Advances. The problem is higher impact oncology trials go to JCO, Annals, etc. That left a small sliver of phase I or phase II randomized or single arm or trials rejected from other journals to populate the pages. RJ impact factor has gone up, so by this measure suppose a success?

But this does leave a lot of room --- personally think the gray zone thing is nice though of variable quality. But now seeing more and more the ideological stuff come to the foreground. These editors truly live in a bubble. No idea that a good percentage of their readership is not in their bubble and does not agree with the infusion of politics into medicine. But you can also read the same editorial in NEJM, JAMA, Lancet etc. No one needs to read it again in RJ.
 
Palex80 said:
Why? Are there any data showing that the same surgeons doing a prostatectomy robotic or laparoscopic based, would produce different functional results?

I know several urologists that have done hundreds of prostatectomies open or laparoscopic and who do not want to switch to a robotic approach. Their incontinence rates are not higher than those of their robotic-only colleagues.

Also bear in mind, that sometimes robotic surgery may not be an option for other reasons: obese patients, previous extensive surgery in the pelvis.
Click to expand...

Actually lap vs. robotic prostate is one of the very few areas where we do have randomized data proving superiority of the robot for continence outcomes. If you saw one you would understand why. It is the difference between a beautiful 2 or 3 layer circumferential mucosa to mucosa vesicourethral anastamosis and putting in a few stitches, a foley, and a prayer.

Open, in very skilled hands, is equivalent. Good luck finding those hands. There are about 10 or fewer surgeons in the US I would trust to do an open prostate on one of my family members. Most of them are getting old enough that I wouldn't feel great about them either, even though they are/were technically excellent.

Of course there are patients who are not RALP candidates. but they aren't lap prostatectomy candidates either. And those patients are fewer and far between as we do cases with lower Trendelenburg, lower pneumo pressures, single port, extraperitoneal, etc. And finally, the patient with a BMI of 45 would probably not be the best open candidate as well and be better off with XRT.
 
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DoctwoB said:
It just doesn’t jive with real world experience. We track our data. I’m at 86% pad free at 3 months at 98% 1 year. I am not the best surgeon in the world. Patient selection and/or luck? Maybe. It’s also a bad outcome in that some patients will wear pads “just in case” while others will leak into their underwear. Or wear a pad when they go to the gym or play tennis, but no other times, etc.

And come on, pure lap prostrates is a red flag. It would be like you saw in the methods section that 30% of the patients were treated with cobalt.
Click to expand...

I won't argue about lap only prostates as that is outside my realm, but 98% pad free at 1-year? That'd be pretty wild. I would publish that and market it as a means to drive referrals.

I'm seeing 1-year pad free rates of maybe 75-80% even in the most contemporary prostate surgery analyses.

There is this one paper, which is the results of literally just one surgeon (unclear why the paper has 9 authors then) that shows a 97% continence rate at 1-year: Five-year Outcomes for a Prospective Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

So, not saying it's impossible, but would definitely publish your amazing results. And send to your marketing team.
 
RealSimulD said:
IF is dick measuring.
Impact is not how many people quote you. It’s patient impact.
All the ideological papers quote each other.
This is a game, not real life
Click to expand...
I don't disagree. Though would be amusing to hear you repeat the first line to the current editor.

But patient impact? How do we determine who is good rad onc (or even a good doctor) and who is not? How would you propose to measure patient impact of a publication?
 
Palex80 said:
More interesting stuff at ASCO-GU:

PACE-A: An international phase 3 randomised controlled trial (RCT) comparing stereotactic body radiotherapy (SBRT) to surgery for localised prostate cancer (LPCa)—Primary endpoint analysis.​

Primary endpoint is: "To determine whether there is improved quality of life after SBRT compared with surgery at 2 years post treatment, using EPIC score to measure urinary incontinence and bowel bother."


Testosterone recovery in patients with prostate cancer treated with radiotherapy and different ADT duration: Long-term data from two randomized trials.​

Could be interesting to see how long it actually takes for testosterone to recover, I've seen various results.


10-Year efficacy and co-morbidity outcomes of a phase III randomised trial of conventional vs. hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CHHiP; CRUK/06/016).​

Another CHHiP-update


Outcomes of patients with brain metastases from renal cell carcinoma treated with first-line therapies: Results from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC).​

Could be of use in practice, when thinking about delaying SRS.


Results of a multicenter, randomized, phase 3 trial of trimodality therapy with I-125 brachytherapy, external beam radiation therapy, and long- versus short-term androgen deprivation therapy for localized high-risk prostate cancer (TRIP/TRIGU0907).​

Could be interesting to see how much ADT is worth when dose-escalating.


Metastasis-directed ablative radiotherapy in castrate-resistant oligometastatic prostate cancer: A retrospective study of 8 high-volume French centers from the COLib (Cercle des Oncologues Libéraux).​

We have seen a lot of data and some trials for MDT in mHSPC, but not so many in mCRPC.


As I said before, PM me for coffee, if you are going to SF! :)
Click to expand...

So, uh, about GU. I've started to read through these. Are you all seeing a lot of requests to delay SRS in patients with brain mets? This seemed to come up a lot when I was a late trainee. I don't hear about it too much now. Add this study to the pile arguing do not delay brain directed local therapy!

Even the response data doesn't really make the idea so compelling.
 
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NotMattSpraker said:
So, uh, about GU. I've started to read through these. Are you all seeing a lot of requests to delay SRS in patients with brain mets? This seemed to come up a lot when I was a late trainee. I don't hear about it too much now. Add this study to the pile arguing do not delay brain directed local therapy!

Even the response data doesn't really make the idea so compelling.
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I only see it with EGFR+ (Osimirtinib eligible/naive).

Rarely a melanoma with diffuse small mets.

In either case I think reasonable to watch closely and hold xrt .

No way I’d want to watch a renal cell.
 
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OTN said:
"...but also something embedded in legal systems and policies" is what I disagree with.

The best example of systemic prejudice that I can think of is the fact that schools are paid for by property taxes.
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Redlining? Charging higher rates to certain minorities?



www.epi.org

A comment on Bank of America/Countrywide’s discriminatory mortgage lending and its implications for racial segregation

Longstanding federal inaction in the face of widespread discriminatory mortgage lending practices helped create, and since has perpetuated, racially segregated, impoverished neighborhoods.
www.epi.org www.epi.org
 
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sirspamalot said:
Anyone going to actually not give high risk patients on routine IMRT 18-24 months of ADT based on the trimodality study?

No Way Smh GIF by Amazon Prime Video
I
Click to expand...
In practice, I’m willing to stop at 12 months for many men who get brachy + external for high risk prostate CA and have some cardiovascular risk factors or who absolutely hate the side effects. Plenty of data to suggest that: Androgen Deprivation Therapy Duration and Radiotherapy Dose for High-risk Prostate Cancer

Waiting for the full results of this trial but seems like all truly high risk folks. Certainly will push me even more to brachy boost, personally, and more de-escalation of ADT if the results look as good as the abstract.

In my experience, with modern brachy, ADT side effects impact QOL far more than any small increase in GU side effects from brachy.
 
Good time for Jonathan Haidt's moral foundations theory. (Please don't engage with Ben Shapiro's introduction to Haidt, it's nonsense).

I'm sure both OTN and SirSpam are professional ballers and highly ethical docs. No doubt, their moral foundations are different.

It is pretty much impossible to deny the primacy of race regarding the foundation of our country, our policies, laws, constitution and pretty much everything American in a very formal and structural way through the late 1960s. That a residue of this will take centuries (if ever) to go away has to be the null hypothesis. That race remains primary in our politics today is also undeniable IMO. I doubt OTN would deny this. I am much more concerned with efforts to suppress this narrative than those to bring it forward.

It should be debatable whether present DEI initiatives, affirmative action, diversity training, etc. are effective and the right way forward.

Meanwhile, how often to do brachy boost and how much ADT remain the questions of the day. I would consider this Androgen Deprivation Therapy Duration and Radiotherapy Dose for High-risk Prostate Cancer work to be very dubious. As dubious as the work inferring a meaningful interaction regarding the time interval from start of ADT to start of XRT and clinical outcomes. An example of very refined statistical work that is claiming more insight than is real.

Proven Reserves Exploitation - Problem with Cubic Splines

www.proven-reserves.com www.proven-reserves.com
 
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It’s all fun and games until someone brings cubic splines into the situation.
 
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Auger electron PSMA targeted radioligand therapy. Pretty cool…
 
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I just removed a ton of posts about DEI. We allow (hesitantly) discussion of these topics in the "Dare you to reply" thread. SDN also has another forum dedicated to these discussions.

Please don't let DEI discussions take over every thread. Unfortunately these discussions spiral downwards as there are strong feelings on both sides. This then distracts our own discussions about science and patient management.
 
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Palex80 said:
Interesting. It goes on to show that with a highly effective local treatment, need for systemic treatment may decrease in well staged patients who are not a high risk for nodal / systemic relapse.
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Why do you suppose these patients were particularly well staged? Probably just a CT. I also wonder if they treated pelvic nodes.
Anyway, more experienced prostate RadOncs always say that brachy boost takes away some of the need for ADT.
 
seper said:
Why do you suppose these patients were particularly well staged? Probably just a CT. I also wonder if they treated pelvic nodes.
Anyway, more experienced prostate RadOncs always say that brachy boost takes away some of the need for ADT.
Click to expand...
No nodes treated in the trial
 
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seper said:
Why do you suppose these patients were particularly well staged? Probably just a CT. I also wonder if they treated pelvic nodes.
Anyway, more experienced prostate RadOncs always say that brachy boost takes away some of the need for ADT.
Click to expand...
I suppose they were well staged and selected, since rates of metastatic failure were low, despite no regional treatment and short ADT.
 
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seper said:
Why do you suppose these patients were particularly well staged? Probably just a CT. I also wonder if they treated pelvic nodes.
Anyway, more experienced prostate RadOncs always say that brachy boost takes away some of the need for ADT.
Click to expand...

Think we're going to need the final paper or like all the slides given the amount of interest in this trial. May be practice changing if people can feel confident that they're trading away tox of long-term ADT for some potential increase in say GU tox...
 
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WanderingRad3 said:
Thoughts on this?
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Palex80 said:
Interesting. It goes on to show that with a highly effective local treatment, need for systemic treatment may decrease in well staged patients who are not a high risk for nodal / systemic relapse.
Click to expand...
Agreed. Similarly most neoadjuvant systemic trials haven’t shown benefit in surgical patients, though it is possible that in a high risk population with novel hormonal agents that we might see more signal. I’ve always felt that xrt with brachy was more analagous to surgery in terms of local control then standard xrt with ADT (which is not to say it isn’t similarly effective, but clearly differing mechanisms).
 
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DoctwoB said:
Agreed. Similarly most neoadjuvant systemic trials haven’t shown benefit in surgical patients, though it is possible that in a high risk population with novel hormonal agents that we might see more signal. I’ve always felt that xrt with brachy was more analagous to surgery in terms of local control then standard xrt with ADT (which is not to say it isn’t similarly effective, but clearly differing mechanisms).
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There is actually a danger here. If adjuvant ADT+ARSI trials after surgery show an OS benefit, there may be a push against adjuvant/salvage RT in these patients (after all adj/salv RT never showed an OS benefit, with the exception of one trial) and in favor of systemic treatment.
 
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Palex80 said:
There is actually a danger here. If adjuvant ADT+ARSI trials after surgery show an OS benefit, there may be a push against adjuvant/salvage RT in these patients (after all adj/salv RT never showed an OS benefit, with the exception of one trial) and in favor of systemic treatment.
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Valid point but I think there will be regional variation. My thoughts have always been that the SWOG trial showed an OS benefit because it was actually a salvage trial. I don't remember the exact numbers right off hand but I think around 1/3rd of patients had a detectable PSA and the inclusion criteria was <0.5 wasn't it? By modern standards, it was not an adjuvant trial. True adjuvant (node negative, undetectable PSA) is dead but the reality is that salvage radiation is curative for a lot of men and I think even most urologists would agree with that sentiment. It remains to be seen if adjuvant ADT + ARSI will be curative or just kick the can (which may still be good enough).

Where I think we could get into trouble is if adjuvant ADT + ARSI keeps men from getting to the point of needing salvage in the first place. While that would hurt our numbers, that's kinda the goal of adjuvant systemic therapy.
 
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Palex80 said:
There is actually a danger here. If adjuvant ADT+ARSI trials after surgery show an OS benefit, there may be a push against adjuvant/salvage RT in these patients (after all adj/salv RT never showed an OS benefit, with the exception of one trial) and in favor of systemic treatment.
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I don't buy it, and I would consider adjuvant pretty much dead already. Also, prolonged systemic therapy here sucks.

The lack of survival benefit in given salvage trials is just the reality of a cancer that overwhelmingly takes years to kill a man when untreated and a population of men who are roughly 70 at diagnosis (or at salvage after surgery). Competing risks. In the era of OS expectation approaching 6 years in the de-novo metastatic setting, we are never demonstrating OS survival benefit from local therapy in localized prostate cancer with reasonable trial sizes.

However, our best data for OS survival benefit from local treatment is in the metastatic setting. (and at 55 Gy)

And, per the old Trock paper Prostate cancer-specific survival following salvage radiotherapy vs observation in men with biochemical recurrence after radical prostatectomy - PubMed the salvage cases that are most likely to impact survival are often the same ones for which we are unlikely to achieve durable biochemical control.

Combine this with lots of population based data that our most ablative technique (surgery) probably is not saving many lives relative to non dose-escalated XRT +/- ADT and I think you can make an argument that something funny is going on here. Namely, prostate cancer that poses a significant risk to life within 10 years is extremely unlikely to be truly localized, but does have it's natural history positively impacted by some local treatment.

I think we are moving away from the concept of "cure", which is good. The old active surveillance criteria were absurdly stringent, because they didn't want to impact likelihood of "cure". However, cure was most likely to be achieved in men who were never going to experience distant progression or death by prostate cancer even in the setting of observation.

The better question for me is, what combination of local therapy and systemic therapy optimizes QOL while minimizing risk of symptomatic prostate cancer or death long term. What is worse, an increased risk of long term ADT at age 75-80 or an increased risk of toxicity at age 70?

Right now, for low metastatic burden disease, the answer is something like 55Gy with ADT and next gen androgen blockade

Right now, for favorable intermediate risk prostate cancer in younger men (60ish down), I consider it to be surgery, with consideration of salvage XRT at biochemical failure +/- some ADT.

In between is quite discretionary (+/- brachy boost, +/-ADT, surgery, duration of ADT). Given the competing risks in this population, I think this is fine.
 
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