No, I'm an RO.
The only long term survivors of pancreatic adeno are Whipple patients … they’re not common, but surgery patients have significantly better survivals (and institution doing the Whippling matters too)
I've seen some good control 1-2 years out with chemo rt, eventually they all fail and met out though. It's basically aggressive palliation without surgery
Ive seen a few ampullary that were managed trimodal and all alive.
ro-journal.biomedcentral.com
Are you trolling me?
Stereotactic ablative radiotherapy (SABR) as primary, adjuvant, consolidation and re-treatment option in pancreatic cancer: scope for dose escalation and lessons for toxicity - Radiation Oncology
Background Stereotactic ablative radiotherapy (SABR) offers an alternative treatment for pancreatic cancer, with the potential for improved tumour control and reduced toxicity compared with conventional therapies. However, optimal dose planning and delivery strategies are unelucidated and...
A series that size is all you will get unless you are in a fantasy land where you think upper GI surgeons are going to play ball. Results are encouraging.
You are not wrong, just naive. To your point, a Whipple is an extremely morbid procedure and even with it the vast majority of patients eventually recur. It’s fair to question how many patients actually benefit from a Whipple and question the cost/benefit ratio. In that respect, a less morbid alternative is appealing so there is an opening. However, the hurdle is there is no denying that long term survival is seen in about 20% of resected patients and <5% (and that’s being very generous) of unresected patients. Based on the recent PRODIGE data, that ratio in resectable patients may favor surgery even more in the FOLFIRINOX era. If you were a patient in otherwise good condition and had a resectable tumor and a good surgeon would you decline surgery? I wouldn’t. Most of my Whipple patients end up doing pretty well functionally after about 4-6 weeks of recovery.
And good data in patients not eligible for surgery. It’s a great analogy.
I have 3 patients alive > 5 years after presenting with metastatic disease and getting chemo and RT only. Only 1 of them is NED. I obviously can't give you names. But I will also argue this isn't evidence of anything special regarding chemo or radiation in particular. This is just evidence that some people have good biology. What we need is good evidence of spectacular local control in a majority of patients with some intervention. I think its possible. Just hasn't happened yet.
Oh now we are curing local AND metastatic pancreatic cancer with local RT
I think he had series of 20% survival 5 years out ?
Here is an OS I randomly pulled from one of Crane's efforts. Twenty percent survival @5y in unresectable would be pretty amazing. But even if true. It's one guy. At one place. Is anyone else replicating 20% 5y OS in unresectable? I don't even know if a trial of SABR in Whipple-able, pylorus-sparing*-pancreaticoduodenostomy-able patients would have equipoise.
Here is an OS I randomly pulled from one of Crane's efforts. Twenty percent survival @5y in unresectable would be pretty amazing. But even if true. It's one guy. At one place. Is anyone else replicating 20% 5y OS in unresectable? I don't even know if a trial of SABR in Whipple-able, pylorus-sparing*-pancreaticoduodenostomy-able patients would have equipoise.
* make sure your surgeons do this
No, you don’t have equipoise now. You are nicely making my argument here. There is very limited data that maybe, there is a chance something could rise to the 20-30% range in a prospective controlled trial and get us there. Honestly, would probably need to be better than that but that’s getting into the details. At this point there is nothing that rises to that level. But my point to the OP is there are a lot of trials in unresectable that might eventually get us there. And that is where we have to start. We have essentially no proven role in the resectable setting at all. No cooperative group or IRB is going to sign on for an RT vs surgery trial. Nor should they at this point.Here is an OS I randomly pulled from one of Crane's efforts. Twenty percent survival @5y in unresectable would be pretty amazing. But even if true. It's one guy. At one place. Is anyone else replicating 20% 5y OS in unresectable? I don't even know if a trial of SABR in Whipple-able, pylorus-sparing*-pancreaticoduodenostomy-able patients would have equipoise.
* make sure your surgeons do this
I won’t even call it a wager. If we ever have a >100 patient published series in unresectable pancreatic cancer where high dose radiotherapy is a local treatment and the 5y OS is 20% or better, I will pay you and the OP a hundred bucks. If an immunotherapy is a component of treatment in said such hypothetical future series, I will pay you a dollar.
Huh?
*Whew* (wipes forehead)
*Whew* (wipes forehead)
Did you see that KM though:
If just one more dude in the BED>70 arm had died at t>=~47mos, that 18% woulda went to hell. That's what I call:
I have one long term survivor from 75/25
As the old "joke" in long-term survivors in GBM goes... I wanna see the path review
5yr OS 18% (95% C.I.: 0-68%)
This is pretty good!
Yeah, in this universe, unresectable will never approach the survival of resectable. But correct me if I'm wrong @bigman1, that was not your premise. I think the premise of the OP was flawed ("I thought overall survival was less than 20% at 5 year mark for all stages head of pancreas"). While resectable pancreatic adenoCA is itself a not common entity, within that group long-term survivors are not that uncommon (if you believe the American Cancer Society e.g.). Not to be a wet dishrag, but the 95% C.I. on that 31% 3y OS would overlap with published chemo-only or chemoRT survivals (roughly only about 10 patients in the BED>70 arm were available for events/censoring by the 3y mark and were the basis for the 31% metric).
Take with a grain of salt but 20% overall survival was with adjuvant 5fu. I thought latest trials adding adjuvant xeloda + gem and (maybe folfirinox), we are now in the low 30s?
Maybe so re: 30%, but I don't think SABRing has synergized or "caused" that ~30% has it? And it's 30% @5y?
It is a quite sophisticated technique MSKCC uses with adaptive replanning. They have published on the specifics of it.
I meant adding more active chemo adjuvantly following the whipped. For unresectable pancreas,we have 50 years of evidence that 50.4 does nothing, and some good data from Chris crane that his approach has better than 0 activity, so I use it. Probably have given it to 15 pts so far. Also the volumes from mskcc, they are huge- he is not skimping on anything. Very little toxicity in my experience.
Definitely not for the faint of heart
Ding ding ding. I hinted at this earlier when I said something about probably better would be needed post-PRODIGE. If we are really going to get into the weeds determining equipoise in these very different populations is no simple task. Its hard to compare OS in patients who are resectable vs unresectable given the stark differences in survival between the groups. Doing something with focal therapy (no doubt combined with systemic therapy) to get 20% 5 year OS in unresected patients is a much bigger deal than getting a similar outcome in the resectable setting. Just compare the absolute improvements in survival with FOLFIRINOX in the advanced vs early adjuvant settings. What bar should we be looking for? And if the real question is can SBRT or any form of dose-escalated RT (or whatever experimental therapy is being tried) really be considered ablative, specific evaluation of local control has to be a critical part of that. I obviously don't have the answers as to what we would need. But I can confidently say that even though I like a lot of the approaches being tried and think they have some potential in the unresectable setting, I have seen nothing even close to compelling enough that I would recommend trying it as an alternative to surgery for a friend or loved one.
Sounds like you are saying exactly what I am saying.
His name was Joey Jo Jo...Shabadoo.
Yes sir, thats what I mean to say. Thank you.
