What happens when the patients don't make it to surgery?
www.clinicaltrials.gov
Insane. Most of the pts I see end up having sx eventually. Crazy they would give chemo only despite dysphagia, anemia etc from the tumor. Pretty risky if their counts drop from chemo
I can't wait to have to "justify my value" in front of med-oncs at the next tumor board re esophageal patients! Thanks ASCO!
"We conducted CheckMate 577, a global, randomized, double-blind, placebo-controlled phase 3 trial to evaluate a checkpoint inhibitor as adjuvant therapy in patients with esophageal or gastroesophageal junction cancer. Adults with resected (R0) stage II or III esophageal or gastroesophageal junction cancer who had received neoadjuvant chemoradiotherapy and had residual pathological disease were randomly assigned in a 2:1 ratio to receive nivolumab (at a dose of 240 mg every 2 weeks for 16 weeks, followed by nivolumab at a dose of 480 mg every 4 weeks) or matching placebo. The maximum duration of the trial intervention period was 1 year. The primary end point was disease-free survival."
In principle, these data would potentially support top gear. It does appear that FLOT and CRT are doing different things if you look at the pathological outcomes. So the combination might make sense. Of course, let’s not forget that CRITICS, which is not that much different from Topgear (except it was post op CRT in CRITICS), was a negative study. I have to be honest, it definitely dented my hope that top gear will be helpful in the end.
I have 3 esophagi on treat presently, and it's the chemo that usually has to be held due to n/v or heme, which is happening in 2 right now. I give 28 fx. Getting them through 23 would be a walk in the park. Standard-of-care notwithstanding, getting the typical GEJ patient through 23 fx CRT is way easier than how ever much FLOT/ECF, which I imagine that medonc has no experience with.
I'm in a similar situation and not worried, inasmuch as that's applicable here, What's bothersome is the tweet from Dr. Kasi where he puts a house emoji in front of 5-FU and then an X and radiation emoji like it's fun to have a CI fanny pack for 3 days and scary to get evil RT that can cause cancer and heart damage, unlike alkylating agents and taxanes.
To be fair to Pashtoon, he did post his tweet from Iowa. For practitioners in rural states (especially if they work in agriculture) without easy access to a radiation center, doing chem from home every 2 weeks for 4-6 months may be more realistic than staying away for 5 weeks for RT. He’s not wrong on that part. But I am confused where he was going with the “better systemic therapy” part. FLOT has literally every GI active chemo other than irinotecan and it still didn’t beat out CRT. I guess he is envisioning FLOT or FOLFIRINOX + IO next? There just are not many more options at this time. And since most of what is in the pipeline synergizes with RT, it’s not a given intensified chemo + IO would win out.
I'm not seeing why the future doesn't support going after definitive CRT for esophagus and rectal, and I'm also not sure why preopanc isn't a bigger deal.
I disagree. I've done chemo. There's nothing more defeating and depressing than the night before the next cycle. If I had to do it again and my options were 4.5 weeks of CRT then surgery vs 8 weeks of chemo then surgery then 8 weeks of chemo, I'd choose the former every time. Getting it over and getting on with life is more convenient in my book.
The only way radiation survives in any form more than niche is organ preservation strategies and finding ways to combine with pharma companies and show them how radiation can improve their profit.
I agree with your reasoning and similar arguments could have been made in lymphoma (reducing chemo with xrt etc), but that’s not how things turned out.
Yeah I understand. The everyday thing is a tough sell. We have a different perspective then patients.
Organ preservation is not going to save GI xrt. surgeons won’t give up esophagectomy (just like bladder) . For rectal cancer, APR only required in minority of cases. Even without any new drugs/regimens over the next ten years, future doesnt look good.
I actually disagree with you on organ preservation for rectal cancer. It is not only an issue of avoiding APR. LAR syndrome is real and a lot of surgeons and centers are in on avoid LAR when able as well. There will be regional variability but a lot of east coast and mid west centers (including ours) are all in on w/w for rectal cancer and this has essentially cemented our role in rectal cancer which could very well have been threatened by the PROSPECT regimen. A lot of high volume panc centers are also all in on preop RT for most patients and again, my panc volume here is much higher than where I trained. If TNT trials with FOLFIRINOX and CRT pan out, we would be in good shape. Same for dose escalated SBRT for borderline resectable cases. I don't think the future for GI is as grim as you do. But I am wrong a lot so there is always that 🙂
Would probably still try to sim and do a sum plan....
Send for proton. Get heart dose down.
Good thought but not an option. Patient runs a farm and says no way no how can they be gone that long. They could get away with an IMRT plan but the cumulative heart dose would be fairly high. I told them to consider periop chemo. Reviewing the images (today) I am frankly quite surprised that their oncologist didn't recommend it anyways. They are calling it esophageal but the GTV is >70% in the stomach. Looks more like a gastric extending into the lower esophagus.
Totally agree and unfortunately I do more esophageal re-irradiation than I would like and other than strictures major complications are relatively few and far between. One of our thoracic surgeons (until very recently) would simply not operate on someone who ever had non-regional adenopathy at any point in the diagnosis regardless of responses to chemo and then radiation following the dogma that once metastatic, always metastatic. I mean them no disrespect and clearly most of the data would argue they are justified in their thinking. Over the last few years we have seen pretty clearly in the people that I radiated AFTER good they have a CR to non-regional nodes (and we are only talking patients with non-visceral, non-osseous non-regional disease) that about half of the failures really are local only and stay that way for many months as evidenced by me having to give a second round for palliation. Once our sample size gets a little bigger I will publish our results because I think it will be helpful information (thought I guess I might end up doxing myself...everyone try to forget this conversation 😉). In this case heart dose is the main concern. It took a good hit the first time around apparently.
