ASTRO 2023

[CaesarRO]

Fantastic Fasttrack

Dostarlumab like results here with 6x the patients. Amazing.

With improvements in systemic therapy I'm seeing the role of RT as being strongest in sites where we can compete directly with Surgery. Organ preservation and decreased morbidity is a worthy goal

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[communitydoc13]

Discuss…

Agree, dose escalation trial. 28 fractions is the regimen I overwhelmingly use (although still slightly more toxic acutely than 7920 in 44 IMO).

Fantastic Fasttrack

Very, very good. The type of study to bring up at Uro tumor board or even send to other docs.

Not just good because results are what we want, but because it provides a useful framework for patient inclusion/exclusion

 

[A_DeMichele]

re: PSA control with fractionation
I thought there was an opposite signal, standard fractionation has better outcomes in low risk patients?

 

[RadOncDoc21]

Regardless of whatever fractionation you choose, there will be shame!

 

[communitydoc13]

re: PSA control with fractionation
I thought there was an opposite signal, standard fractionation has better outcomes in low risk patients?

There was data back in the day that supported a very low alpha/beta ratio for prostate cancer. This was used as justification for some hypofractionation trials (the idea being that if the a/b of tumor is lower than the a/b of late effects, you might move to a better therapeutic ratio at higher fractions and lower total dose).

I was in residency when we had an investigator initiated, moderately hypofractionated prostate trial that was functionally trying to increase BED based on the very low a/b presumption. (A little bit more hypo than 60/20 but not much). The increase in toxicity was so notable that the trial quickly closed before coming close to accrual goals.

 

[A_DeMichele]

There was data back in the day that supported a very low alpha/beta ratio for prostate cancer. This was used as justification for some hypofractionation trials (the idea being that if the a/b of tumor is lower than the a/b of late effects, you might move to a better therapeutic ratio at higher fractions and lower total dose).

I was in residency when we had an investigator initiated, moderately hypofractionated prostate trial that was functionally trying to increase BED based on the very low a/b presumption. (A little bit more hypo than 60/20 but not much). The increase in toxicity was so notable that the trial quickly closed before coming close to accrual goals.

I'm thinking a subset analysis of CHIP or PROFFIT or whatever?

 

[elementaryschooleconomics]

Agree, dose escalation trial. 28 fractions is the regimen I overwhelmingly use (although still slightly more toxic acutely than 7920 in 44 IMO).

Just because I believe talking about this reduces the shame factor created over the last few years:

Currently (late 2023), I primarily use 70/28 for intermediate risk, and 7920/44 in high and very high risk. I cover nodes electively in high and very high (and/or boost gross nodes); I do not cover nodes electively in intermediate risk.

If there's high levels of urinary issues at presentation, I will do 7920/44 regardless of risk group.

I do this because I have specifically observed a higher GU toxicity with moderate hypofrac. I can't speak to the magnitude of GU tox overall, but my experience tracks with what is reported in the literature, namely that the GU tox shows up much earlier with the moderate hypo regimens.

I am also under the impression based on prior publications that RTOG 0415 was 73.8/41, NOT 79/41. It was also run from 2006-2009, which was a different planet in terms of radiation technology.

In short: if I hear anyone using this trial to imply better biochemical control with moderate hypofrac, I will burn the Earth.

 

[SneakyBooger]

I would personally not opt for SBRT prostate for me or five fraction whole breast for my wife.

110%.

 

[fiji128]

Anything else of substance coming out of Astro 2023? Just one or two trials is it?

 

[RickyScott]

Anything else of substance coming out of Astro 2023? Just one or two trials is it?

Anything else of substance coming out of Astro 2023? Just one or two trials is it?

Seems to be a new low scientifically

 

[Ray D. Ayshun]

Seems to be a new low scientifically

Something about E.I., so I guess Nelly's performing, which would be a cool throwback.

 

[Mandelin Rain]

Something about E.I., so I guess Nelly's performing, which would be a cool throwback.

I saw several St. Lunatics in the lobby this morning.

 

[metallica81788]

Anything else of substance coming out of Astro 2023? Just one or two trials is it?

I saw something about HCA PCI, which is pretty pathetic if that's on the plenary

 

[RickyScott]

I saw something about HCA PCI, which is pretty pathetic if that's on the plenary

Sounds like there are plenty of panels on short term adt for prostate cancer and post mastectomy radiation following reconstruction. And a lot on mentorship, well being fluff.

 

[fiji128]

Sounds like there are plenty of panels on short term adt for prostate cancer and post mastectomy radiation following reconstruction. And a lot on mentorship, well being fluff.

Ya haven't been seeing much on the twitter besides the fluff.

 

[OTN]

Given the low rates of GI toxicity in PACE-B*, do we think Drs. Zelefsky, Efstathiou, Baumann, Frank, and Spratt will be mentioning the biggest controversy of all at their Boston Scientific-sponsored "Current Controversies in Prostate Cancer Perirectal Gel Spacing" talk which is being promoted by ASTRO and held this afternoon?

If they don't even bring up the "should we even be doing this in the setting of PACE-B results" question, then how are the rest of us supposed to view their supposed scientific independence, given that Boston Scientific is sponsoring them?

*(6/384 SBRT patients had any grade 2 toxicity. I read the methods of the trial, no rectal spacing devices were used)

 

[fiji128]

Given the extremely low rates of GI toxicity in PACE-B, do we think Drs. Zelefsky, Efstathiou, Baumann, Frank, and Spratt will be mentioning the biggest controversy of all at their Boston Scientific-sponsored "Current Controversies in Prostate Cancer Perirectal Gel Spacing" talk which is being promoted by ASTRO and held this afternoon?

It looks like it’s sponsored by Boston Scientific so I’m gonna to guess no.

https://x.com/astro_org/status/1708912278567874765?s=42&t=JT-MpdQWW2BUYxIQ93k8wA

 

[elementaryschooleconomics]

Seems to be a new low scientifically

I'm confused about what's happening here...the Presidential Symposium is supposed to be the flagship "thing", right? And it was a lot about...best practices for designing clinical trials, or talking about trials that had results presented elsewhere?

Am I totally off base? I think there was some DEI stuff and carbon footprints?

My Twitter/X feed is almost entirely mentorship and career development.

What???

 

[sirspamalot]

Anyone taking ASTRO seriously at this point? I mean really.. taking blood/fistula money from a gel company is like openly advocating for neutrons (or protons almost, at this point).. its just wrong.

 

[fiji128]

The keynote in our largest scientific meeting of the year is essentially about social work.

 

[OTN]

The keynote in our largest scientific meeting of the year is essentially about social work.

View attachment 377326

"Arif Kamal, MD, MBA, MHS, FACP, FAAHPM, FASCO serves as the first-ever chief patient officer for the American Cancer Society"

They had an acronym competition and he won. First prize was the keynote.

 

[sirspamalot]

IDCDY ?

 

[elementaryschooleconomics]

I am deeply, deeply passionate about this aspect of medicine. I loathe the focus on perceived "hard" science/skills and either subtle or outright derision of classically labeled "soft" skills.

That being said, ASTRO is at a crossroads here. We can't continue on pretending to keep pace with the other specialties/STEM disciplines in terms of what these conferences are usually about, which is novel/innovative pharmacological or procedural advances. It ends up being a direct-to-TV comedy.

But that doesn't mean it HAS to be "bad". Michael Jordan would look ridiculous at a chess tournament. Albert Einstein wasn't going to win a home run derby.

We could pivot and just go all-in on DEI, communication, climate, etc - explicitly. Meaning ASTRO makes a statement about this outright, and lets ASCO, AACR, ESTRO, etc have the "classic" stuff.





HAHAHAHAHAHAHAHAHA

I know this will never happen, and I can't wait till the Presidential Symposium next year has one of those "healthcare design" folks to tell us about optimizing the physical space of a clinic for the patient journey.

Then, we'll get blown up on Twitter/X with some interim update of accrual in the DEBRA trial.

 

[elementaryschooleconomics]

 

[sirspamalot]

View attachment 377328

Tired of ASTRO's pathetic leadership, pathetic focus, and pathetic taint with industry. Where'd our shiny wrapper new President go again? Oh yeah, thats right..

 

[RickyScott]

I am deeply, deeply passionate about this aspect of medicine. I loathe the focus on perceived "hard" science/skills and either subtle or outright derision of classically labeled "soft" skills.

That being said, ASTRO is at a crossroads here. We can't continue on pretending to keep pace with the other specialties/STEM disciplines in terms of what these conferences are usually about, which is novel/innovative pharmacological or procedural advances. It ends up being a direct-to-TV comedy.

But that doesn't mean it HAS to be "bad". Michael Jordan would look ridiculous at a chess tournament. Albert Einstein wasn't going to win a home run derby.

We could pivot and just go all-in on DEI, communication, climate, etc - explicitly. Meaning ASTRO makes a statement about this outright, and lets ASCO, AACR, ESTRO, etc have the "classic" stuff.





HAHAHAHAHAHAHAHAHA

I know this will never happen, and I can't wait till the Presidential Symposium next year has one of those "healthcare design" folks to tell us about optimizing the physical space of a clinic for the patient journey.

Then, we'll get blown up on Twitter/X with some interim update of accrual in the DEBRA trial.

I am deeply, deeply passionate about this aspect of medicine. I loathe the focus on perceived "hard" science/skills and either subtle or outright derision of classically labeled "soft" skills.

That being said, ASTRO is at a crossroads here. We can't continue on pretending to keep pace with the other specialties/STEM disciplines in terms of what these conferences are usually about, which is novel/innovative pharmacological or procedural advances. It ends up being a direct-to-TV comedy.

But that doesn't mean it HAS to be "bad". Michael Jordan would look ridiculous at a chess tournament. Albert Einstein wasn't going to win a home run derby.

We could pivot and just go all-in on DEI, communication, climate, etc - explicitly. Meaning ASTRO makes a statement about this outright, and lets ASCO, AACR, ESTRO, etc have the "classic" stuff.





HAHAHAHAHAHAHAHAHA

I know this will never happen, and I can't wait till the Presidential Symposium next year has one of those "healthcare design" folks to tell us about optimizing the physical space of a clinic for the patient journey.

Then, we'll get blown up on Twitter/X with some interim update of accrual in the DEBRA trial.

Aren’t you tempted to go into to one of these how to be a mentor sessions to see who actually attends? I bet you much of the audience would be in favor of residency expansion.

 

[elementaryschooleconomics]

Aren’t you tempted to go into to one of these how to be a mentor sessions to see who actually attends? I bet you much of the audience would be in favor of residency expansion.

Honestly, my feelings about that are hard to explain.

Once upon a time, I would have been in that room. Well, maybe not literally, but metaphorically. I wasn't just born with my current opinion and attitude, it's a reaction to my disappointment in "the establishment".

I use SDN almost like a personal journal, because as long as some version of these forums exist, future med students thinking about their career will find all this. They can read this stuff, they can read ASTRO's stuff: they can decide for themselves.

But there's a contingent of attending Radiation Oncologists who are baked into the system. I guess they ARE the current establishment. I can picture them in those rooms right now. I can picture them designing future sessions with a similar theme.

They're the minority at this point, but they're in the key positions. Of the >5000 Radiation Oncologists, only ~1000 are at institutions with residency programs. Not all of them are metaphorically in "the establishment" - but institutions with residency programs derive the most benefit from the current system.

This isn't forever. There are some residents and junior attendings who have bought into "the establishment", but a specialty doesn't crash almost overnight because the majority of its doctors are happy, that's for sure.

I hope they give out ribbons at these sessions. I hope those trinkets spark joy for some folks.

 

[RickyScott]

Honestly, my feelings about that are hard to explain.

Once upon a time, I would have been in that room. Well, maybe not literally, but metaphorically. I wasn't just born with my current opinion and attitude, it's a reaction to my disappointment in "the establishment".

I use SDN almost like a personal journal, because as long as some version of these forums exist, future med students thinking about their career will find all this. They can read this stuff, they can read ASTRO's stuff: they can decide for themselves.

But there's a contingent of attending Radiation Oncologists who are baked into the system. I guess they ARE the current establishment. I can picture them in those rooms right now. I can picture them designing future sessions with a similar theme.

They're the minority at this point, but they're in the key positions. Of the >5000 Radiation Oncologists, only ~1000 are at institutions with residency programs. Not all of them are metaphorically in "the establishment" - but institutions with residency programs derive the most benefit from the current system.

This isn't forever. There are some residents and junior attendings who have bought into "the establishment", but a specialty doesn't crash almost overnight because the majority of its doctors are happy, that's for sure.

I hope they give out ribbons at these sessions. I hope those trinkets spark joy for some folks.

I also think there is a contingent of upstart lackeys whose professed enthusiasm is really performative careerism.

 

[RickyScott]

https://x.com/henningwillers/status/1708966558121525695?s=46&t=bNjInwwyz2DPnd4UFJOtbg

https://x.com/5_utr/status/1709005720723550567?s=46&t=bNjInwwyz2DPnd4UFJOtbg

 

[Mandelin Rain]

 

[fiji128]

https://x.com/henningwillers/status/1708966558121525695?s=46&t=bNjInwwyz2DPnd4UFJOtbg

https://x.com/5_utr/status/1709005720723550567?s=46&t=bNjInwwyz2DPnd4UFJOtbg

Who is giving 66 Gy in 33 fractions to gross disease in Head and Neck cancer with 6 fractions a week? Why design a trail with this as the comparison arm and then claim 55 Gy in 20 fractions is non inferior to something that no one or at least very few are doing? Just more bizarre stuff coming from the world of "academia."

 

[RickyScott]

Who is giving 66 Gy in 33 fractions to gross disease in Head and Neck cancer with 6 fractions a week? Why design a trail with this as the comparison arm and then claim 55 Gy in 20 fractions is non inferior to something that no one or at least very few are doing? Just more bizarre stuff coming from the world of "academia."

regimen is fine for the 3rd world, extreme settings, but how can you make any alpha beta conclusions when trial is not powered to pick up 30% increase in local failure? Seems almost parody to hype soren bentzens alpha/beta talk on this trial as the best presedential symposium in history.

 

[TheWallnerus]

I think as much as I hate yet another fraction-decreasing study, the ideas behind this HYPNO study were pretty cool.

The trial was ran in this part of the world... maybe 66/33 is used a lot there, IDK. But it has a time-adjusted EQD2 of about 70/35, so it should be fine to consider it as essentially equivalent to 70/35 imho.

As far as the rationale for the study, here it is. It's all based on LQ. I think we see yet another GIANT win for the LQ model in this study in that LQ has yet to be invalidated. Be careful about thinking LQ doesn't work. It's the basis for decreasing prostate fractions, why 5 fraction breast works, etc. We have a model that predicted gravitational waves (I'm speaking metaphorically obv). The waves were found. The waves are now admittedly rocking everyone's reimbursement boat!

 

[fiji128]

I think as much as I hate yet another fraction-decreasing study, the ideas behind this HYPNO study were pretty cool.

The trial was ran in this part of the world... maybe 66/33 is used a lot there, IDK. But it has a time-adjusted EQD2 of about 70/35, so it should be fine to consider it as essentially equivalent to 70/35 imho.

View attachment 377347

As far as the rationale for the study, here it is. It's all based on LQ. I think we see yet another GIANT win for the LQ model in this study in that LQ has yet to be invalidated. Be careful about thinking LQ doesn't work. It's the basis for decreasing prostate fractions, why 5 fraction breast works, etc. We have a model that predicted gravitational waves (I'm speaking metaphorically obv). The waves were found. The waves are now admittedly rocking everyone's reimbursement boat!

View attachment 377349

Still needs to be compared to 70 Gy in 35 fractions with 5 fractions/week IRL and not have huge non inferiority margins.

 

[TheWallnerus]

Still needs to be compared to 70 Gy in 35 fractions with 5 fractions/week IRL and not have huge non inferiority margins.

I don't know about the huge non-inf margins (I think 10% was specified per trial, and that was confirmed at p=0.04), but comparing 70 Gy vs 66 Gy on paper is just going to be a waste of resources/time/effort given that we have so much DAHANCA data, and this data right here. You've got to consider practicality at some point. There is "no" way 66/33 in 5.5 weeks is oncologically substandard vs 70/35 in 7 weeks, and there is no way it has more late effects.

 

[deleted1111261]

I don’t mean to be insulting - because this is truly observational - but it is so “radonc” to have great concerns over 66/33 w/6 fx a week vs 70/35. Both are reasonable. Just different.

Is the presumption that 70/35 is substantially better and the spread would have made it non-inferior?

I have a hard time believing that.

This doesn’t change anything for me and in my opinion did not need to be done.

Sick of non-inferiority studies

 

[RickyScott]

I don't know about the huge non-inf margins (I think 10% was specified per trial, and that was confirmed at p=0.04), but comparing 70 Gy vs 66 Gy on paper is just going to be a waste of resources/time/effort given that we have so much DAHANCA data, and this data right here. You've got to consider practicality at some point. There is "no" way 66/33 in 5.5 weeks is oncologically substandard vs 70/35 in 7 weeks, and there is no way it has more late effects.

Fair enough. Agree with LQ, just sick of hypofrac and non inferiority

 

[TheWallnerus]

I don’t mean to be insulting - because this is truly observational - but it is so “radonc” to have great concerns over 66/33 w/6 fx a week vs 70/35. Both are reasonable. Just different.

Is the presumption that 70/35 is substantially better and the spread would have made it non-inferior?

I have a hard time believing that.

This doesn’t change anything for me and in my opinion did not need to be done.

Sick of non-inferiority studies

This study changes nothing for sure. The LQ mental masturbation deeply spoke to me though; kudos to them for that.

No changes… OTOH if ROCR goes in, watch me doing a lot of 20 fraction head neck chemoRT!

 

[BobbyHeenan]

I don’t mean to be insulting - because this is truly observational - but it is so “radonc” to have great concerns over 66/33 w/6 fx a week vs 70/35. Both are reasonable. Just different.

Is the presumption that 70/35 is substantially better and the spread would have made it non-inferior?

I have a hard time believing that.

This doesn’t change anything for me and in my opinion did not need to be done.

Sick of non-inferiority studies

Agree.

Especially those that AT BEST shave 2 weeks off of a 6-7 week course and just accept up to 20% worse in the "non inferiority" margin.

Thank the rad onc Gods for Siva, Livi, and Palma trying to expand the field and improve outcomes, not just shave fractions.

 

[communitydoc13]

66 in 6 fractions per week is better than 70/35/5 fractions per week without chemo.

Treatment time matters for H&N squamous and several way to do this.

Hyper-fractionation and acceleration a great way to maximize therapy to toxicity ratio!!!! 2 OTVs/week! But, high utilization and harder to get patients on board. All of this was worked out in the pre-combined modality setting and culturally dismissed once we started giving concurrent chemo. It was all very cool 25 years ago.

That basic foundational 4R level radbio would remain a mystery to many radoncs in 2023 and the substrate for a plenary is effing baffling.

 

[TheWallnerus]

66 in 6 fractions per week is better than 70/35/5 fractions per week without chemo.

Treatment time matters for H&N squamous and several way to do this.

Hyper-fractionation and acceleration a great way to maximize therapy to toxicity ratio!!!! 2 OTVs/week! But, high utilization and harder to get patients on board. All of this was worked out in the pre-combined modality setting and culturally dismissed once we started giving concurrent chemo. It was all very cool 25 years ago.

That basic foundational 4R level radbio would remain a mystery to many radoncs in 2023 and the substrate for a plenary is effing baffling.

I have done 52.5 to gross and 50 to elective, in 25 days, with a 6 day 18 Gy 1.5 per fraction bid boost (70.5 Gy in 31 elapsed days iow) for a decade and a half. It cures a lot of HNSCC. The 6 days of bid is very doable, logistically and toxicity wise (especially since the final treatment volumes are so much smaller than the initial ones). I get two OTVs that last 6 days of treatment, but still net just a total of 7 whole course… just like the “bland” 70/35

 

[communitydoc13]

I have done 52.5 to gross and 50 to elective, in 25 days, with a 6 day 18 Gy 1.5 per fraction bid boost (70.5 Gy in 31 elapsed days iow) for a decade and a half. It cures a lot of HNSCC. The 6 days of bid is very doable, logistically and toxicity wise (especially since the final treatment volumes are so much smaller than the initial ones). I get two OTVs that last 6 days of treatment, but still net just a total of 7 whole course… just like the “bland” 70/35

https://www.redjournal.org/article/S0360-3016(00)00663-5/abstract

Published 23 years ago

 

[sirspamalot]

Karen Fu knew what to do...

 

[yesmaster]

Given the low rates of GI toxicity in PACE-B*, do we think Drs. Zelefsky, Efstathiou, Baumann, Frank, and Spratt will be mentioning the biggest controversy of all at their Boston Scientific-sponsored "Current Controversies in Prostate Cancer Perirectal Gel Spacing" talk which is being promoted by ASTRO and held this afternoon?

I was very disappointed by the part of this talk on rectal wall injury.

One of the speakers was dispelling so-called misconceptions regarding spaceOAR, but the evidence was very flimsy. It was mostly just “in my experience this doesn’t happen”, “this isn’t a problem in hands of skilled operator”, “real world rates of RWI aren’t in fact higher than reported in the literature because I say so.”

I’m open minded, but that talk in particular was very unhelpful.

 

[sirspamalot]

Name and shame, its just like fractions innit

God bless ASTRO leadership, those kind thoughtful souls..

 

[RickyScott]

I was very disappointed by the part of this talk on rectal wall injury.

One of the speakers was dispelling so-called misconceptions regarding spaceOAR, but the evidence was very flimsy. It was mostly just “in my experience this doesn’t happen”, “this isn’t a problem in hands of skilled operator”, “real world rates of RWI aren’t in fact higher than reported in the literature because I say so.”

I’m open minded, but that talk in particular was very unhelpful.

No one addressed the fda database?

 

[sirspamalot]

 

[deleted1111261]

What a dismal meeting (science wise).

The vendor hall remains the prize jewel of the weekend, as well as the parties and socializing.

I do want to continue going for the first weekend bc I enjoy the event we have.

But, I don’t think I took home much for my patients.

 

[RickyScott]

Name and shame, its just like fractions innit

God bless ASTRO leadership, those kind thoughtful souls..

No reason not to name. This is an educational session, right?

 

[sirspamalot]

Nah, I mean they naming and shaming US (in community practice) lol..

ASTRO: They never miss an opportunity to (scratches out miss an opportunity, pencils in..) "Shame community radoncs"