ASTRO 2025

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medgator

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Got a message from Simul:

They released all the plenaries accidentally yesterday

Sbrt prostate worse than HF, 8% failure vs 4%

Head neck protons negative study

TTF better intracranial control but no Os benefit

Bladder - Vedang study bigly positive for adjuvant RT

Breast - protons have less SOB at 6 months if you look at GR 0 vs 1-4. But not if you look
At gr0-1 vs 2-4
Click to expand...
 
medgator said:
Got a message from Simul:
Click to expand...

I didn't realize this was an accidental leak haha, was very curious why all the other abstracts are hidden.

Torpedo is fascinating, looking forward to commentary on that one. At the very least, their toxicity profile with IMRT was more consistent with what I see in real life compared to MDACC's trial as reported (different eligibility though). Wonder if well ever get that paper...

"Breast - protons have less SOB at 6 months if you look at GR 0 vs 1-4. But not if you look At gr0-1 vs 2-4"

Bruh.
 
This is embarrassing from LBA 1, but does inspire the reader to check out this paper that I've always liked: Patient Perceptions in a Nonblinded Randomized Trial of Radiation Therapy Technologies: A Novel Survey Study Exploring Therapeutic Misconception - PubMed


1758921791517.png
 
Conclusion: For locally advanced OPSCC, IMPT does not reduce longterm gastrostomy dependence or severe weight loss and does not improvelong-term patient-reported physical quality of life or swallow functioncompared with IMRT. There is no requirement for IMPT as an alternative to high quality IMRT.
Click to expand...

But what about "****ty" quality IMRT that is performed in non-academic medical centers???

Conclusion: At 10 years, WPRT did not improve OS in men with UIR orFHR PC. However, the follow-up is relatively short, with most cancerrelated deaths expected beyond 10 years. Additional follow-up is warrantedto determine whether the early trends in BF ultimately translate into differences in OS or metastases. The high PCS rate and relatively low morbidity(by physician report) confirms that ADT + PORT appears to represent anexcellent treatment option for men with UIR or FHR PC. Future studiesincorporating biomarkers may help us determine whether there are subsetsof patients who would benefit from WPRT.
Click to expand...

The cult of whole-pelvis radiation therapy will never die. Two randomized studies showing no OS advantage, yet the excuses keep coming. But what about 50 year follow-up? But what about the fact that it has relatively low morbidiy by physician report? But what about the fact that treating whole pelvis will allow insurance to permit me to deliver 44 fraction IMRT?

-------------------------------------------------

Also before anyone gets too excited about urinary toxicity on HF vs SBRT in PACE-B and PACE-C:

1. Clinical target volume to planning target volume margin was 4-5mm isotropic, except 3-5mm posteriorly. These are IMRT margins.
2. Fiducials were optional.
3. Non-robotic (CK) treatments were optional.

If you treat SBRT this way, then these results apply to you.
 
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Gfunk6 said:
Also before anyone gets too excited about urinary toxicity on HF vs SBRT in PACE-B and PACE-C:

1. Clinical target volume to planning target volume margin was 4-5mm isotropic, except 3-5mm posteriorly. These are IMRT margins.
2. Fiducials were optional.
3. Non-robotic (CK) treatments were optional.

If you treat SBRT this way, then these results apply to you.
Click to expand...
What are your margins for prostate SBRT???
 
Gfunk6 said:
But what about "****ty" quality IMRT that is performed in non-academic medical centers???



The cult of whole-pelvis radiation therapy will never die. Two randomized studies showing no OS advantage, yet the excuses keep coming. But what about 50 year follow-up? But what about the fact that it has relatively low morbidiy by physician report? But what about the fact that treating whole pelvis will allow insurance to permit me to deliver 44 fraction IMRT?

-------------------------------------------------

Also before anyone gets too excited about urinary toxicity on HF vs SBRT in PACE-B and PACE-C:

1. Clinical target volume to planning target volume margin was 4-5mm isotropic, except 3-5mm posteriorly. These are IMRT margins.
2. Fiducials were optional.
3. Non-robotic (CK) treatments were optional.

If you treat SBRT this way, then these results apply to you.
Click to expand...
I’ll give it to them, we live in a time of alternate reality. They publish a litany of dosimetric and retrospective studies (with obvious caveats) proclaiming the superiority of protons for years, do an RCT that plainly shows (like in prostate) they were wrong, and rather than owning it or making a valid conclusion, double down and say the (very expensive) experimental therapy is not required? If protons were a drug, we would move on. But instead, it’s technically got blanket clearance as a treatment, and “we” will keep beating this drum.

Look, I don’t blame them for doing the trials. They could have been right. I long argued that simple physics and rad bio argued the significance of low dose bath was overestimated in adult populations while that of range uncertainty at depth was likely underestimated. I’m wrong a lot. But in this case, it looks like at least some of that has played out twice now.

But fear not my friends. “We” will find another solution in need of a problem. Protons vs photons with concurrent and/or adjuvant IO. In some diseases, protons probably do cause less lymphopenia. Is it meaningful?
 
Pointless said:
What are your margins for prostate SBRT???
Click to expand...
Probably 3 mm. He uses (or at least use to use) a CK. I use 3 mm with an MRL. I’ll be honest, after looking at a lot of these using continuous cine imaging, I think 3 mm on a TureBeam is totally doable. Bladder and rectal filling sure can move the prostate. But if you can beam on immediately after imaging, the risk of significant motion should be minimal. Using static 9 beam plans, we average abut 95% time within the envelope. Considering those are twice as long as a VMAT treatment, you should do as good if not better on average.
 
Gfunk6 said:
But what about "****ty" quality IMRT that is performed in non-academic medical centers???
Click to expand...


idk I wouldnt quibble with this too much. high quality planning isn't a academic or non-academic issue. also they're European, they don't care about the silly community vs academic issue American SDN-ers care about.

they should be credited for the way they reported the trial. they're quite clear. Proton is NOT necessary to spare tox as compared to good IMRT. this should be stated based on the results.

and yes people should aim to treat in the most modern, high quality planning as possible, as you say in your very same post in regards to prostate SBRT. I (like you it sounds like) try to deliver the best planning approaches I can despite being a lowly 'community' member. we need to stop propagating this stuff. it's 2025.

I wonder how Steve Frank will address this lmao.
 
drowsy12 said:
idk I wouldnt quibble with this too much. high quality planning isn't a academic or non-academic issue. also they're European, they don't care about the silly community vs academic issue American SDN-ers care about.

they should be credited for the way they reported the trial. they're quite clear. Proton is NOT necessary to spare tox as compared to good IMRT. this should be stated based on the results.

and yes people should aim to treat in the most modern, high quality planning as possible, as you say in your very same post in regards to prostate SBRT. I (like you it sounds like) try to deliver the best planning approaches I can despite being a lowly 'community' member. we need to stop propagating this stuff. it's 2025.

I wonder how Steve Frank will address this lmao.
Click to expand...
Fwiw, I think gfunk is non-academics and making light of this common backup plan for when proton trials are negative: "we're sure it still beats care in the community..."
 
Gfunk6 said:
2 mm. Treat on CK, 4 fiducial tracking.
Click to expand...
2 feels aggressive to me, no matter what your imaging protocol is, but to each their own. I wouldn't denigrate someone giving 5 mm expansions with 3 posteriorly, I suspect that is in line with what most do. The prostate can definitely move during delivery and anyone who uses fiducials knows that lining those up on orthogonals is not the most precise endeavor.
 
Pointless said:
2 feels aggressive to me, no matter what your imaging protocol is, but to each their own. I wouldn't denigrate someone giving 5 mm expansions with 3 posteriorly, I suspect that is in line with what most do. The prostate can definitely move during delivery and anyone who uses fiducials knows that lining those up on orthogonals is not the most precise endeavor.
Click to expand...
Data says that lining up fiducials on orthogonals can rationally allow 2mm PTVs. That’s pretty precise.
 
The Steve Frank spin on that proton head/neck trial is going to be wild.

They need to let the breast trial play out - seems odd to present the endpoints they did.

The knee arthritis trial is promising.
 
The plenary is a bit weird. Outside Vedangs bladder trial (which still might not convince our surgeons), it’s mainly two negative proton trials and poor man’s pace b?

The clinical trials section looks more interesting honestly. Some promising ones there as per the prostate 0924 trial.
 
Whoops I meant except the prostate trial.

Balance and lunar look important, as does the knee arthritis trial. The duputuryens trial is disappointing but at least they tried.

0924 is useful for the opposite reason, no need to radiate nodes it seems
 
BobbyHeenan said:
The Steve Frank spin on that proton head/neck trial is going to be wild.

They need to let the breast trial play out - seems odd to present the endpoints they did.

The knee arthritis trial is promising.
Click to expand...

Knee arthritis trial is very interesting given that it contradicts prior data. They also used a composite end point that tries to capture pain and function over time. The VAS pain is really noisy, and I could see that being especially true in this population given my clinical experience thus far. Not uncommon for me to treat a patient's knee, then they say their pain is the same but now they are walking an extra mile a day.

This RCT matches my clinical experience of about 70% improving significantly in pain or function with just one cycle of 3 Gy.

drowsy12 said:
they should be credited for the way they reported the trial. they're quite clear. Proton is NOT necessary to spare tox as compared to good IMRT. this should be stated based on the results.
Click to expand...

This is what it looks like when a health system(s) is genuinely evaluating a limited resource to find how best to use it for patient benefit. American investigators clearly have other goals.

Frank's trial was pretty messy if you just look at the CONSORT diagram. Lots of people getting the wrong treatment. The tox profile in Torpedo was way better than I expected after seeing Frank's data. I honestly don't know what to make of it and I want to assume the best of intents. I just dont know how to reconcile the (limited) data available...

Suffice to say that I will not be recommending my patients travel for a proton opinion until these papers are out and we can make better sense of the benefit, if it exits.
 
MegaVoltagePhoton said:
Whoops I meant except the prostate trial.

Balance and lunar look important, as does the knee arthritis trial. The duputuryens trial is disappointing but at least they tried.

0924 is useful for the opposite reason, no need to radiate nodes it seem
Click to expand...
I like 0924 and want to see the details of the patients and how it compares on average to POP-RT. I’ll be honest, I have a hard time with POP. It’s believable to me that nodal RT could be beneficial in higher risk cohorts and it helped convince me to get more aggressive in patients with multiple high risk features and/or high volume, high grade disease. But some things about the data, like showing essential no failures after 3ish years just be adding nodal RT seem…different from any bPFS curve I’ve ever seen published in high risk cohort and my own personal experience. I’ve always suspected applying POP to all high risk patients was questionable and it sounds like 0924 will back that up.
 
ramsesthenice said:
I like 0924 and want to see the details of the patients and how it compares on average to POP-RT. I’ll be honest, I have a hard time with POP. It’s believable to me that nodal RT could be beneficial in higher risk cohorts and it helped convince me to get more aggressive in patients with multiple high risk features and/or high volume, high grade disease. But some things about the data, like showing essential no failures after 3ish years just be adding nodal RT seem…different from any bPFS curve I’ve ever seen published in high risk cohort and my own personal experience. I’ve always suspected applying POP to all high risk patients was questionable and it sounds like 0924 will back that up.
Click to expand...
Looking at the cohort of 0924, this looks like a torally different population than in POP-RT. I agree with your assessments. I recommend WPRT only in high-risk disease with at least 2 high-risk factors and without comorbities.
 
Palex80 said:
Looking at the cohort of 0924, this looks like a torally different population than in POP-RT. I agree with your assessments. I recommend WPRT only in high-risk disease with at least 2 high-risk factors and without comorbities.
Click to expand...
That is my suspicion as well and I don’t think the studies will contradict each other but rather help provide additional clarity regarding appropriate patient selection. The gulf between who was included in POP and all previous nodal RT studies was vast. Treating nodes is tolerable but not entirely benign. Having data to confirm my suspicion that omission in favorable(ish) high risk patients is quite valuable. I know plenty of people who routinely treat nodes in all high risk patients. Wrong? No, but potential unnecessary.
 
All in all, a good ASTRO lineup with another negative proton trial, a positive dose dependent OA trial, and a negative extreme hypofrac prostate trial. A win for the community, for value based care, and for common sense medicine.

Thank you UK and South Korea.
 
Palex80 said:
it appears that a good chunk of GU toxicity in prostate SBRT results from dose to the urethra. Margins of 2mm, 3mm or 5mm will not affect that. Careful patient selection and dose constraints to the urethra will, IMHO.
Click to expand...
Agree. We get MRI, fuse it and avoid hotspots to urethra.
 
CurbYourExpectations said:
Are people in actual agreement with any of these practices?

"this is what I do, must be right" type ****?

You believe in this Gfunk?
Kekw

Shrink it 1mm,
Animated GIF
Click to expand...
I do very high volume prostate SBRT. You think I just randomly picked 2 mm for the lulz?

journals.plos.org

Dosimetric impact of intra-fraction prostate motion under a tumour-tracking system in hypofractionated robotic radiosurgery

For CyberKnife-mediated prostate cancer treatment, a tumour-tracking approach is applied to correct the target location by acquiring X-ray images of implanted fiducial markers intermittently. This study investigated the dosimetric impact of intra-fraction prostate motion during CyberKnife...
journals.plos.org journals.plos.org

www.frontiersin.org

Frontiers | Prostate SBRT: Comparison the Efficacy and Toxicity of Two Different Dose Fractionation Schedules

Background: CyberKnife SBRT is capable of producing dosimetry comparable to that created by HDR brachytherapy. Our original CyberKnife prostate SBRT schedule...
www.frontiersin.org www.frontiersin.org

Reducing PTV margins for prostate SBRT with motion compensation and gating techniques - PMC

The purpose of this study is to investigate the dosimetric accuracy of prostate SBRT when motion is considered. To account for target movement, motion compensation and gating techniques were investigated with PTV margins reduced to 2 mm. To allow ...
pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov

Don’t hate me, cause you ain’t me

There is a reason that we have a separate dedicated meme thread.
 
CurbYourExpectations said:
I mean, people apparently know who I am, I think I'm the one who doesn't know.
Click to expand...
Many of us know who GFunk is. They use to make themself very available to meet in person at meetings like ASTRO (and maybe still does at other meetings) and provided me advice when I was finishing up residency. Multiple people know who I am, and I’ve given enough details that anyone who was particularly interested could probably figure me out pretty quickly with minimal google searching. FWIW, I don’t know who you are.
 
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