Future innovation for radiation oncologists

[drowsy12]

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Careful throwing stones. I have seen a prominent academic Rad Onc put this in a letter about proton therapy for prostate cancer.

I would throw stones at him or her too

proton folks are also WILD!

 

[drowsy12]

Nowhere in my post did I suggest that this was "US academic led."

wasn't addressing you.

 

[theradiator]

Nowhere in my post did I suggest that this was "US academic led." However, it does overwhelmingly affect a US medical student deciding what career to pursue and all of my points are still germane to the original questions.

Regardless, it's irrelevant whether it's Europe or the US leading the charge. The bottom line is that if there was enough meaningful innovation left to be done in radonc we would be occupying our time doing that instead of fellating one another over our practice altering hypofractionation studies. Just this week I had our academic mothership poach a post-op H&N patient to enroll them on a phase 1 trial of 4 weeks instead of 6 weeks PORT. They now drive an hour into a busy city, past our center 5 minutes from their house, for the sake of "science." These are solved disease sites that we continue to devote resources to trying to solve differently, to the detriment of ourselves and oftentimes our patients. I would love this to be a boring topic, but it continues to go on and it continues to be relevant to a medical student asking if they should join our field.

The treatment we do today is almost identical to the treatment we did a decade ago when I started residency except we do less of it. Even when we do come out with expensive new technologies (MRI-L, Protons, Ethos), we simply use them to offer the exact same treatments we could do on a conventional LINAC but we charge more money for them. The only reason we haven't hit rock bottom yet is that our palliative treatments have gotten more expensive a la SRS/SBRT and patients are living longer due to systemic therapies, allowing us to do more of them.

Your post actually puts academic radiation oncology in an even more unflattering light. Treatment escalation substituting whole brain for repeated courses of SRS is largely invented and driven by neurosurgeons (ie., specialists who actually believe in the therapeutic potential and safety of radiation) rather than our own specialty.

 

[communitydoc13]

The treatment we do today is almost identical to the treatment we did a decade ago when I started residency except we do less of it. Even when we do come out with expensive new technologies (MRI-L, Protons, Ethos), we simply use them to offer the exact same treatments we could do on a conventional LINAC but we charge more money for them. The only reason we haven't hit rock bottom yet is that our palliative treatments have gotten more expensive a la SRS/SBRT and patients are living longer due to systemic therapies, allowing us to do more of them.

If you want to experiment with dosing, there are so many other interesting questions that could be answered other than number of fractions.

The kinetics of XRT both as a single modality and in concurrent therapy are so important and so evident in the now totally unfashionable radbio literature. I have no doubt that there remain opportunities to markedly improve the therapeutic ratio here.

It's been a space for progressive XRT clinical research for like 50 years. Some notable victories in SCLC, prechemo NSCLC and pre-chemo head and neck CA (work is now 30+ years old).

Continuous, hyperfractionated, accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: mature data from the randomised multicentre trial. CHART Steering committee - PubMed

This analysis of mature data confirms that CHART is superior to conventional radiotherapy in achieving local tumour control and survival in locally advanced NSCLC. This demonstrates the importance of cellular repopulation as a cause of failure in the radiotherapy of NSCLC. The reduction in the...

pubmed.ncbi.nlm.nih.gov

I suspect that timing is pretty important when integrating IO into XRT based therapy.

Never mind that intrafraction kinetics almost certainly matter...we just ignore this. (FLASH as an exception...but kinetics even among standard external beam formats can be widely variable)…check this out.

https://academic.oup.com/bjro/article-pdf/4/1/20220013/54034834/bjro.20220013.pdf

It's just both difficult to do this research and without significant financial support. Most trials will be negative (as is true for all truly progressive work). There's no pharma out there paying for it. It is not sexy (exempting the name FLASH).

Picking an estimated iso-effective dose schedule and then comparing to SOC fractionation with a non-inferiority trial is easy. Although some such trials have stopped accrual early due to excess toxicity and been forgotten about.

 

[Seaweed_Man]

The kinetics of XRT both as a single modality and in concurrent therapy are so important and so evident in the now totally unfashionable radbio literature. I have no doubt that there remain opportunities to markedly improve the therapeutic ratio here.

It's been a space for progressive XRT clinical research for like 50 years. Some notable victories in SCLC, prechemo NSCLC and pre-chemo head and neck CA (work is now 30+ years old).

Continuous, hyperfractionated, accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: mature data from the randomised multicentre trial. CHART Steering committee - PubMed

This analysis of mature data confirms that CHART is superior to conventional radiotherapy in achieving local tumour control and survival in locally advanced NSCLC. This demonstrates the importance of cellular repopulation as a cause of failure in the radiotherapy of NSCLC. The reduction in the...

pubmed.ncbi.nlm.nih.gov

I suspect that timing is pretty important when integrating IO into XRT based therapy.

Never mind that intrafraction kinetics almost certainly matter...we just ignore this. (FLASH as an exception...but kinetics even among standard external beam formats can be widely variable)…check this out.

https://academic.oup.com/bjro/article-pdf/4/1/20220013/54034834/bjro.20220013.pdf

It's just both difficult to do this research and without significant financial support. Most trials will be negative (as is true for all truly progressive work). There's no pharma out there paying for it. It is not sexy (exempting the name FLASH).

Picking an estimated iso-effective dose schedule and then comparing to SOC fractionation with a non-inferiority trial is easy. Although some such trials have stopped accrual early due to excess toxicity and been forgotten about.

I think this point is interesting, as well as what @MidwestRadOnc posted about time between fractions, alternating dose between fractions, etc. I'm wondering what it takes to do this kind of research instead of joining on the hypofrac train at a big academic center? Also, wondering why Varian, GE, etc. don't end up funding this kind of research (as well as lobbying congress to keep rad onc reimbursements up) the same way pharma gets involved for heme/onc and other specialties in a financial/political sense?

 

[Seaweed_Man]

Also as a side note--how do you guys feel about radiopharm/theranostics becoming a large part of rad onc's bread and butter in the future? I know this is a turf war at academic centers with nuclear med, but on the private practice side, how prevalent is radiopharm administration and how much of a future do you think there is with this in radiation oncology? Heard from a few people that radiopharm reimbursement may increase from CMS, and i feel like the logical assumption would be that big pharma encourages/funds research to increase radiopharm indications.

 

[thecarbonionangle]

Careful throwing stones. I have seen a prominent academic Rad Onc put this in a letter about proton therapy for prostate cancer.

The recently published retrospective prostate data out of the mecca is definitely being quoted by prominent academics to say that protons has higher cure rates in UIR and VHR/HR PCA

 

[temujim]

Your post actually puts academic radiation oncology in an even more unflattering light. Treatment escalation substituting whole brain for repeated courses of SRS is largely invented and driven by neurosurgeons (ie., specialists who actually believe in the therapeutic potential and safety of radiation) rather than our own specialty.

Neurosurgeons believe in getting paid for not doing surgery, with essentially no responsibility (they're not the authorized user). What's not to like?

 

[ramsesthenice]

The recently published retrospective prostate data out of the mecca is definitely being quoted by prominent academics to say that protons has higher cure rates in UIR and VHR/HR PCA

Sigh. Let’s play this out. Radiation is a focal therapy. Improved cure rates with a “better” focal therapy implies better local control and/or doing a better job of preventing metastatic progression (most likely by getting better local control before it can spread). If we open the door to believing retrospective data saying protons are better, are we really in a position to dismiss similar surgical data? Oh wait…it has the same limitations.

 

[evilbooyaa]

The recently published retrospective prostate data out of the mecca is definitely being quoted by prominent academics to say that protons has higher cure rates in UIR and VHR/HR PCA

Jesus ****ing Christ.

 

[NotMattSpraker]

The recently published retrospective prostate data out of the mecca is definitely being quoted by prominent academics to say that protons has higher cure rates in UIR and VHR/HR PCA

LOL oh yea. I forgot that is how we do science now in this field. You just run a single arm study and compare it to some cohort you find in a paper and say its better.

That is so much more lame than a biased randomized trial from pharma.

We can't even be the best at cheating 🤣