ASTRO releass guidelines for SOC for oropharyngneal XRT

[Gfunk6]

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New ASTRO guideline establishes standard of care for curative treatment of oropharyngeal cancer with radiation therapy - American Society for Radiation Oncology (ASTRO)

Am I missing something here? What they published here is exactly what I learned in residency ~ 7 years ago. These "guidelines" are published in all major/minor Rad Onc textbooks and study guides. What exactly was accomplished here?

 

[evilbooyaa]

I think to say that all the stuff that people have been trying (adding Cetuximab to CRT, doing induction chemotherapy, trying to justify TORS for stage III or IV disease) over the past 7 or so years has all been negative, and to just stick with what we know works, despite the push for all of the things I mentioned.

Maybe it'll be different in 7 more years depending on the results of the de-escalation protocol.

 

[seper]

You're right, nothing too new here. I liked how they are coming strongly against induction chemo. Also, it is interesting to see distinction between bad and good stage III (T3N0-1 vs. T1-2N1).

 

[medgator]

You're right, nothing too new here. I liked how they are coming strongly against induction chemo. Also, it is interesting to see distinction between bad and good stage III (T3N0-1 vs. T1-2N1).

In the community, I'm going to treat those the exact same assuming the pt is fit for chemo 🙂

 

[PruritisAni]

Maybe it'll be different in 7 more years depending on the results of the de-escalation protocol.

This was/is already an utter failure (at least in prelim abstract form).

 

[Spiced Meats]

This was/is already an utter failure (at least in prelim abstract form).

Which study? UNC/UF HPV+ trial looked promising.

 

[evilbooyaa]

This was/is already an utter failure (at least in prelim abstract form).

Link?

 

[PruritisAni]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

 

[OTN]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

Yeesh that does not sound good. Kind of a strange study, though, with induction, etc. Going to 54 Gy may have been a bit aggressive as well. Was the UF study more straighforward? Something like 60 Gy + cisplatin vs. 70 Gy + cisplatin? I haven't seen the protocol yet.

 

[Spiced Meats]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

E1308 was published recently in JCO recently - the patients with <T4<N2c disease with <10 pack years - the only ones who should really be considered for deintensifcation - had excellent PFS ~ 95% with albeit small numbers. The UNC trial was just a phase II looking at pCR after 60 Gy with reduced dose weekly cis - had ~90%. But who knows how that plays out long term.

 

[radiation]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

PFS numbers don’t appear to be very different than HPV positive pts in the Ang trial

MMS: Error

and all comers on Eisbruch trial

Multi-institutional trial of accelerated hypofractionated intensity-modulated radiation therapy for early-stage oropharyngeal cancer (RTOG 00-22). - PubMed - NCBI


The only UF/UNC data I have seen published in abstract form was in 2015 and it looked very promising

http://www.redjournal.org/article/S0360-3016(15)03190-9/abstract

I’m not aware of any prospective RT trials showing better than 80% PFS at 2 years for definitive oropharynx?

 

[evilbooyaa]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

That included induction chemotherapy. And went very aggressive with de-escalation (54Gy rather than the 60 proposed otherwise). I wouldn't take that study to mean all de-intensification is dead. Induction chemo has no role in routine management of H&N cancer is the conclusion I would take away from that trial.

 

[nkmiami]

Ecog 1308 : 20% failire in 2 years is discouraging in my mind. The data out of Uf I think (preliminarily) echoed this roughly 20% failure.

This is short term follow-up and does not have me enthusiastic moving forward.

The Ang RTOG trial and the p16 reanalysis of the erbitux trial both had local failure rates of 10-15% in HPV+ nonsmokers. 20%- which I assume includes distant failure, would be in line with those results. That being said, induction is crap. I had several pts in academia end up in the icu and 2 others who quit after TPF. The radiation is also much harder to tolerate after induction. The induction experience was based on good performance patients who were willing to commute into Boston and several other large centers every day.

 

[scarbrtj]

That being said, induction is crap.

I'll take Things I Can't Say to Some of My Hem/Onc Colleagues for $1000, Alex.

 

[medgator]

I'll take Things I Can't Say to Some of My Hem/Onc Colleagues for $1000, Alex.

Your heme/onc colleagues shouldn't be in the driver's seat when it comes to getting referrals from ENT 😉

My "heme onc colleagues" sometimes call me up and ask me whether they should give concurrent erbitux or cisplatin (weekly or high dose) after I send them the referral...

Lots of referrals should come directly to us, and that's especially true for GYN onc, h&n, anal, skin and breast*













*- assuming the above are NOT owned by a competing group with in-house radiation 😀

 

[hot sauce]

In the community, I'm going to treat those the exact same assuming the pt is fit for chemo 🙂

To clarify you would treat a T1N1 oropharynx cancer with chemoRT?

 

[medgator]

To clarify you would treat a T1N1 oropharynx cancer with chemoRT?

If the node is right near that 3cm mark, I'd consider it, would be a tough call, otherwise no.

 

[radiation]

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(17)30246-2/fulltext?rss=yes

Use the induction to risk stratify who gets de-escalation, not a bad idea

 

[evilbooyaa]

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(17)30246-2/fulltext?rss=yes

Use the induction to risk stratify who gets de-escalation, not a bad idea

That's what E1308 looked at as well, in a bigger setting, which is where the outrage is about 80% 2-year PFS control after using 'risk stratification' to de-intensify. People are making arguments that 80% 2-year PFS in HPV+ OroPhx SCC with dose de-escalation isn't acceptable to go with dose-de escalation across the board (maybe for < T4, < N2c, < 10-pack year smokers?).

PFS numbers don’t appear to be very different than HPV positive pts in the Ang trial

MMS: Error

and all comers on Eisbruch trial

Multi-institutional trial of accelerated hypofractionated intensity-modulated radiation therapy for early-stage oropharyngeal cancer (RTOG 00-22). - PubMed - NCBI


The only UF/UNC data I have seen published in abstract form was in 2015 and it looked very promising

http://www.redjournal.org/article/S0360-3016(15)03190-9/abstract

I’m not aware of any prospective RT trials showing better than 80% PFS at 2 years for definitive oropharynx?

1st study is retrospective.
2nd study doesn't have concurrent chemotherapy, and thus 80% isn't bad.
3rd study, let's wait for the paper with actual DFS rates, although the CR rate does look somewhat promising. Non-tainted by IC. Patient selection.

 

[radiation]

That's what E1308 looked at as well, in a bigger setting, which is where the outrage is about 80% 2-year PFS control after using 'risk stratification' to de-intensify. People are making arguments that 80% 2-year PFS in HPV+ OroPhx SCC with dose de-escalation isn't acceptable to go with dose-de escalation across the board (maybe for < T4, < N2c, < 10-pack year smokers?).



1st study is retrospective.
2nd study doesn't have concurrent chemotherapy, and thus 80% isn't bad.
3rd study, let's wait for the paper with actual DFS rates, although the CR rate does look somewhat promising. Non-tainted by IC. Patient selection.

Your points are well taken and I understand the sentiment. Those the studies that I use for my benchmark for what "should" be results for IMRT-based definitive oropharynx. When I hear people say 80% at two years is "too low", I am just wondering what the number should be and where that number is coming from? Retrospective series or prospective trials?

 

[temujim]

I would make the argument that E1308 was a failure by it's own metrics. Response to induction chemotherapy was not a biomarker -- ie it did not predict those patients who would do better (the primary outcomes). They ended up picking patients who did well no matter what by clinical factors. The UCLA/UCD study is a much cleaner study, though smaller numbers.

But seriously, why on earth would you want to do induction chemotherapy? Sure the UNC/UF study was muddied by the use of neck dissection, but results will probably hold up. NRG HN002 tested 60 Gy +/- cisplatin... those results will be available in a few years. In the meantime it's not clear to me that induction x2 followed 54-60 Gy + chemo has better outcomes or is less toxic than 66 Gy + chemo. I'm not putting my patients through induction -- phase III data is wholly negative and this "de-escalation" by substitution of induction is still very much experimental.

That's what E1308 looked at as well, in a bigger setting, which is where the outrage is about 80% 2-year PFS control after using 'risk stratification' to de-intensify. People are making arguments that 80% 2-year PFS in HPV+ OroPhx SCC with dose de-escalation isn't acceptable to go with dose-de escalation across the board (maybe for < T4, < N2c, < 10-pack year smokers?).



1st study is retrospective.
2nd study doesn't have concurrent chemotherapy, and thus 80% isn't bad.
3rd study, let's wait for the paper with actual DFS rates, although the CR rate does look somewhat promising. Non-tainted by IC. Patient selection.

 

[medgator]

Your points are well taken and I understand the sentiment. Those the studies that I use for my benchmark for what "should" be results for IMRT-based definitive oropharynx. When I hear people say 80% at two years is "too low", I am just wondering what the number should be and where that number is coming from? Retrospective series or prospective trials?

Being out in practice for 5+ years, I can count my oropharynx failures on one hand if that... I would think most of us would agree that these patients are very curable using standard chemo/xrt...

 

[Reaganite]

Being out in practice for 5+ years, I can count my oropharynx failures on one hand if that... I would think most of us would agree that these patients are very curable using standard chemo/xrt...

Agreed, I think I've had 1 and this was a guy where the cancer had basically replaced his head.

I've been doing my own sort of dose de escalation on these OPX cases in that I stopped any sort of accelerated dosing regimen, I always re-scan for boosts and sometimes sooner to make sure my elective neck PTVs aren't unnecessarily extending into the parotids as patients lose neck circumference, no 59.4 to the "high-risk" area (whatever that is...), tight margins (no CTV expansion for my 70Gy volume as long as I have PET and MRI), etc. But I still give 70 Gy to GTV!

 

[medgator]

Agreed, I think I've had 1 and this was a guy where the cancer had basically replaced his head.

I've been doing my own sort of dose de escalation on these OPX cases in that I stopped any sort of accelerated dosing regimen, I always re-scan for boosts and sometimes sooner to make sure my elective neck PTVs aren't unnecessarily extending into the parotids as patients lose neck circumference, no 59.4 to the "high-risk" area (whatever that is...), tight margins (no CTV expansion for my 70Gy volume as long as I have PET and MRI), etc. But I still give 70 Gy to GTV!

Yup, I do standard fx with chemo for my hpv cases, and dose painting/accelerated fx with chemo for patients with bulkier non hpv scc.

I'm in no rush to go below 70Gy or omit chemotherapy until I see compelling, long term data as the patients I do see in f/u several years out do eventually recover their swallowing and salivary function... last thing I'd want is for me to suboptimally treat these patients

 

[nkmiami]

Agreed, I think I've had 1 and this was a guy where the cancer had basically replaced his head.

I've been doing my own sort of dose de escalation on these OPX cases in that I stopped any sort of accelerated dosing regimen, I always re-scan for boosts and sometimes sooner to make sure my elective neck PTVs aren't unnecessarily extending into the parotids as patients lose neck circumference, no 59.4 to the "high-risk" area (whatever that is...), tight margins (no CTV expansion for my 70Gy volume as long as I have PET and MRI), etc. But I still give 70 Gy to GTV!

I have done exactly the same. In most large departments, the size of the PTV 70 has decreased over the past 10 years. I now expand 1 cm from gtv to form a PTV for both nodal and primary. (these always shrink further into the gtv during treatment, and all failures have been in the gtv) Even the RTOG on the erbitux vs platinum trial allows a 1.5 Gy/ low neck volume? Also, pushing for a lot more weekly cis 30-40, which is so much less toxic than 100.

 

[evilbooyaa]

I would make the argument that E1308 was a failure by it's own metrics. Response to induction chemotherapy was not a biomarker -- ie it did not predict those patients who would do better (the primary outcomes). They ended up picking patients who did well no matter what by clinical factors. The UCLA/UCD study is a much cleaner study, though smaller numbers.

But seriously, why on earth would you want to do induction chemotherapy? Sure the UNC/UF study was muddied by the use of neck dissection, but results will probably hold up. NRG HN002 tested 60 Gy +/- cisplatin... those results will be available in a few years. In the meantime it's not clear to me that induction x2 followed 54-60 Gy + chemo has better outcomes or is less toxic than 66 Gy + chemo. I'm not putting my patients through induction -- phase III data is wholly negative and this "de-escalation" by substitution of induction is still very much experimental.

Couldn't remember the name for HN002 - I kept looking for it but just kept finding the NasoPhx trial (HN-001).

HN-002 is the trial that will make or break de-escalation, IMO. Wouldn't offer it off protocol at this time.

Yup, I do standard fx with chemo for my hpv cases, and dose painting/accelerated fx with chemo for patients with bulkier non hpv scc.

I'm in no rush to go below 70Gy or omit chemotherapy until I see compelling, long term data as the patients I do see in f/u several years out do eventually recover their swallowing and salivary function... last thing I'd want is for me to suboptimally treat these patients

Generally doing 70 and 56Gy most of the time, omitting the 63Gy for standard fractionation chemoRT. Attendings here aren't doing really any accelerated fractionation. Will do hypofrac if early stage H&N (like larynx) without chemo. Are people doing accelerated for oropharynx with chemo on board?

 

[seper]

No, since Ang trial did not show benefit.

Couldn't remember the name for HN002 - I kept looking for it but just kept finding the NasoPhx trial (HN-001).

HN-002 is the trial that will make or break de-escalation, IMO. Wouldn't offer it off protocol at this time.



Generally doing 70 and 56Gy most of the time, omitting the 63Gy for standard fractionation chemoRT. Attendings here aren't doing really any accelerated fractionation. Will do hypofrac if early stage H&N (like larynx) without chemo. Are people doing accelerated for oropharynx with chemo on board?

 

[medgator]

Couldn't remember the name for HN002 - I kept looking for it but just kept finding the NasoPhx trial (HN-001).

HN-002 is the trial that will make or break de-escalation, IMO. Wouldn't offer it off protocol at this time.



Generally doing 70 and 56Gy most of the time, omitting the 63Gy for standard fractionation chemoRT. Attendings here aren't doing really any accelerated fractionation. Will do hypofrac if early stage H&N (like larynx) without chemo. Are people doing accelerated for oropharynx with chemo on board?

I still do it if it's a ridiculously bulky hpv negative tumor, no data, just my gut reaction. I peg those patients and they've done fine