Are there any new advances or developments in radiation oncology that people are excited about?
Positive developments in the field/Expanding indications for RT
- Thread starter Lamount
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Cardiac SBRT, oligomets, and arthritis RT would be my top 3. But the biggest advancement in radonc is that some people are finally realizing the dangers of residency expansion.
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Radiation oncologist's answer to "new advances or developments in radiation oncology that people are excited about?"
- cardiac SBRT
- Oligomets
- Benign RT
Lol. But I generally agree!
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Flash?
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Personally, I love the Oncology side of things but I think departments that rebrand as the department of Radiation Medicine have the right idea. Keeps doors open a bit.
Palma with ARREST and Timmerman with PULSAR are trying to find a role for us in polymetastatic disease as well
ROforbetterorworse
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Radiation has such a bad connotation. Half my consult is telling patients they won't get "real radiation"
Radiotherapy & Oncology as in Europe is optimal approach IMO
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Excited for science? Cancer treatment? Yes. Excited about Flash for the future of RadOnc as a field? Not so much. Talk about reducing the number of required physicians. If Flash works the way the proponents think it might... it's a Black Swan event-type game changer for the field. Probably would pick up a few indications and make some surgeries obsolete, but definitely wouldn't need as many radoncs around to do it.
On the other hand, if it doesn't work to that degree, the likely outcome is it doesn't replace surgeries and turns an already hypofractionated world into one of single fractions with minimal nuance to volumes.
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Radiopharm if we can get the reimbursements figured out.
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No
Ha! Asked and answered.
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Oligomets on the immediate horizon. However, it's kicking the tires on the same old car. Some radiopharm but likely not transformative. Radiopharm will be a turf war and it isn't clear many want to take on the fight. Plus, some of this will be centered in major academic centers as opposed to private clinics. Cardiac has promise but I doubt it will be transformative for the field as a whole.
This is where Ralph has had a moment of clarity in his senility.
This is where Ralph has had a moment of clarity in his senility.
ROforbetterorworse
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What is the time frame you're looking for in the future?
Nothing happening in next 5 yrs that I'm aware of
Oligomets P3 trials currently enrolling so those results won't be out for a while.
As a field, what is our backup plan if these trials are negative?
Cardiac SBRT can't get reimbursed for right now, but promising.
Will likely remain as last ditch effort for patients though as cards is not going to just hand over keys to the castle...
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I guess you’re saying that doing a lot of heart SBRT for us is probably... not in the cards.
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No. Sadly, we have and always will marched to a different beat.
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In addition to what was previously mentioned, I think there are some interesting new radiosensitizers in trials. The hafnium oxide nanoparticles, xevinapant (Merck KGaA Bolsters Head and Neck Cancer Pipeline With Debiopharm Breakthrough Therapy | BioSpace), PARP inhibitors, etc
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My gut tells me that at some point oligomet sbrt will be shown to have a survival benefit with improvements in systemic therapy. The likelihood, however, of positive results from first phase 3 trials is low, based on history.
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This is one of those situation where if you restage frequently and with advanced modalities can find oligomets in a lot of patients, just by virtue some mets precede others temporally. Anecdotally, I get sense mskcc picks up increased oligomets because of how frequently they image with advanced modalities. I actually agree with this approach, but who know if it is the right one.
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Designing the trial is not that hard. Patients on IO can be randomized to focal therapy vs continued IO at the time of oligo progression. It would probably take a huge number of patients to show a significant improvement in OS (or even PFS) so you would be looking at a multi site trial.
Implementing the trial is another thing. Patients hate the idea of not doing anything if they progress. And unless insurers put a hard stop on covering IMRT or SBRT we are not all that motivated to do much different. We are just going to have to go by the favorable survival times reported in any number of single arm or retrospective studies from high volume centers like MSKCC
OS would take a lot of patients an. PFS is problematic because the patients who could be accrued already are progressing, and presumably, those areas that are growing will stop once they get RT... but most importantly as you reference, the randomization is very difficult.
Evicore has been known to pushback on treating oligoprogression with either SBRT or IMRT citing a lack of data... so there is a need
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One “positive” development that will likely come to radiation is personalized precision, some other adjective) radiation. OnGoing COBRA (colon) study at ASCO GI really heralds the future here. only pts with residual ctdna seemed to benefit from chemo in stage 3 after resection of the primary? Retrospective data, but prospective part of the study is already complete.
Only a matter of time before this appears in low risk breast? Take out the primary and do a blood test a few weeks later- think of all the unnecessary xrt we will save.
www.onclive.com
Only a matter of time before this appears in low risk breast? Take out the primary and do a blood test a few weeks later- think of all the unnecessary xrt we will save.
ctDNA and Molecular Alterations Among Important Treatment Considerations in CRC
Atrayee Basu-Mallick, MD, discusses the emerging role of ctDNA as a predictive biomarker in early-stage CRC and the growing importance of molecular testing in the advanced-stage setting.
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Yes, there are certain individuals already working on using ctDNA to eliminate radiation in breast cancer...One “positive” development that will likely come to radiation is personalized precision, (some other adjective) radiation. OnGoing COBRA study at ASCO GI really herald the future here. They are finding that only pts with ctdna seemed to benefit from chemo in stage 3 after resection of the primary? Only a matter of time before this appears in low risk breast? Take out the primary and do a blood test a few weeks later- think of all the unnecessary xrt this will save.
ctDNA and Molecular Alterations Among Important Treatment Considerations in CRC
Atrayee Basu-Mallick, MD, discusses the emerging role of ctDNA as a predictive biomarker in early-stage CRC and the growing importance of molecular testing in the advanced-stage setting.
ROforbetterorworse
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It feels like more and more insurance companies are using Evicore or outsourcing to third party deniers.
By the time the data comes out, we'll be denied 75% of these treatments.
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Evilcore saves them a bundle and probably keeps half.. Win, win
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Or say you’re an insurance company. For the sake of argument, let’s say Cigna, who is hard capped to make profit at 20% of revenues by the ACA. What can you do to increase that profit number (other than raise premiums/prices every year, which they also do)? Maybe... own a mail order pharmacy like ExpressScripts and make them insanely profitable by shunting them the money you “can’t” profit from anyway. Maybe even have that pharmacy company buy a utilization company called “eviCore” that you can shunt even MORE money to and make incredibly profitable. All while “only” keeping 20% of your primary business revenue to meet the requirements of the ACA.
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That 20% rule in the ACA May destroy medicine in the US. We weren’t on a great trajectory before but that one is the killer.
From the humanity standpoint, I think the ctDNA data will be good for the cancer patients.
Imagine how many colon or breast ca pts that can be spared from unnecessary chemo? Let's say the absolute gain of adjuvant chemo for breast is about 9-10%, one has to treat 100 pts to see the benefits in those 10 pts.
Imagine the crystal ball (ctDNA) is so perfect, then chemo is only given to those 10 that benefit from it.
Now medoncs have to rely on stage IV diseases to make a living...
If this is true, then medoncs will have the same oversupply crisis as we do: too many medoncs, not enough adjuvant chemo to give...
Full circle...But they can always retrain to become hospitalists...
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Is that profit just based on obamacare plans or all of their insurance business collectively (including Medicare advantage and medicaid)?
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Will be offset by survival improvements in cancer. Every time a 150 k drug increases survival by 3 months, that’s 3 more months of chemo
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Retrain? Can't medoncs just be hospitalists?
If they have maintained their board certification then yes. Must have meant re-take boards.... no need to "re-train" as in repeat residency.
ROforbetterorworse
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My concern with ctDNA is how it is being implemented
Minority of studies focused on ctDNA and deescalation of systemic therapy
Majority rather on how to further escalate systemic therapy
In contrast, the ctDNA featuring RT studies including breast cancer are looking at removing RT
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Obvious trial is to obtain ctdna after lumpectomy in early stage breast, but in parallel we could be studying ctdna after chemo but before xrt in locally advanced breast ca. Maybe if chemo gets rid of all the ctdna, we can omit radiation in that population as well?
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I am honestly getting very tired of off-trial, off-label ctDNA. I am personally quite skeptical of the current technologies being sensitive enough to determine who can avoid adjuvant therapy (chemo or radiation). Far more often than not the ctDNA goes negative after surgery and then turns positive after 6-9 months in patients who are going to recur. I mean I guess if we are talking about moving towards a delayed salvage vs adjuvant strategy that could work but just straight up treat/no treat...no chance.
But for the moment, I wish they would just stop getting them on everyone of our GI patients (literally every one of them). As an example, I have a guy with a cholangiocarcinoma who's CT DNA turned positive 12 months after finishing post-op CRT (for positive margins). Its been positive for 12 months now and he still has not developed any macroscopic disease. They are holding off on treating until he does. What good have we done this guy? If I were him I would much rather be ignorantly blissful than living with the anxiety that it is going to come back.
ROforbetterorworse
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Maybe current trials fail, although the colon cancer data was quite optimistic. At some point in the next 20 years, It is not unreasonable for this technology to develop to the point where it impacts adjuvant radiation. Right now all ctdna is looking at genes, but epigenetic stuff is right around the corner in a big way (grail etc)
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Oh don't get me wrong, ctDNA is here to stay and I think it can do a lot of things. Deciding who is cancer free right after surgery? Not one of them. It will 100% end up impacting adjuvant therapy decisions in the future. For diseases that have a preponderance for local regional failure first, delaying regional therapy until ctDNA turns positive may not have a negative impact on survival and could help people avoid over treatment (think prostate cancer adjuvant vs salvage). Trials randomizing patients with negative ctDNA to observation vs adjuvant therapy are almost certainly going to show better PFS with adjuvant therapy if they are adequately powered. But that isn't necessarily the question is it? What you would really want to know is does it compromise long-term outcomes. Design of these trials requires some pretty careful thought lest we end up in a number of sequential trials to end up with usable answers. I can already hear the conclusions at ASCO: "The trial failed to meet its primary end point but there was no difference in survival suggesting ctDNA may be able to spare people unnecessary treatment without compromising survival. Further investigation is warranted." sound familiar?
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Industry funds treatment escalation/continuation studies because it serves their interests. So systemic therapy treatment escalation studies will dominate. It's not a level playing field. And it's shooting ourselves doubly in the foot to use any money we (radonc) have to eliminate ourselves when we could otherwise use that money to develop new/better uses for RT.
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I think the cobra study involved guardant/NRG . Big money can also be made if your ctdna test can predict need for adjuvant therapy.
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Of course, anything that serves that companies interest.
ROforbetterorworse
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Agree 100%
Problem is the perverse academic incentive at the n=1 level for promotion OVER what is better for the field globally
Many in our field would do anything for promotion...
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Massages?
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I mean often this personalized/precision tech is presented at Astro conferences etc like it is a positive development for the field (including the mdacc doc at recent online session with sue yom and the great Dan Golden. No one is a Luddite, but just can’t reconcile promoting this development next to Dan Golden speaking about recruiting under grads?
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Seems intuitive to me that ctDNA has a higher potential to select those who wouldn't benefit from chemo than those who wouldn't benefit from adjuvant RT.
Studies would just need to look at the right thing. If we only look for ways to reduce RT, that's all we'll find.
The oncotype trials did make a big impact on the adjuvant chemo question in breast, so I think there is some room to avoid complete pessimism on that front.
Studies would just need to look at the right thing. If we only look for ways to reduce RT, that's all we'll find.
The oncotype trials did make a big impact on the adjuvant chemo question in breast, so I think there is some room to avoid complete pessimism on that front.
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Agree completely. To be fair, there are more studies looking at with holding adjuvant chemo than radiation.
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Can you name another field which has no exit back up strategy ( we cannot fall back on general IM or rads), at the bottom of the referral chain, tied down under a single declining use and fractions modality, where “leaders” persistently think of ways to decrease utilization? Some call this “negativity”, but i’m a swamp half full type so I call it reality.
this is going to be an absolute disaster. The breadlines are coming.
this is going to be an absolute disaster. The breadlines are coming.
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Hilariously, I think the kids over in EM stole our negativity crown. They're a lot bigger specialty so their collective voices are louder, but man, I've really enjoyed Reddit over the weekend after the workforce study came out.
It is remarkable the trajectory of decline for them. It blows ours out of the water and I actually feel bad for them.
Cross lurking has gone through the roof as well.... misery loves company.
Just to clarify what I mentioned above...
- If ctDNA (or whatever else) causes fewer adjuvant chemo, and if a medonc (who has finished 3 years of IntMed) cannot find a job, he/she can always go back to be hospitalist.
In this case "retraining" means tagging a long with a current hospitalist(s) to re-learn how to manage the usual inpt (stroke, sepsis, MI, diabetic ketoacidosis, infectious diseases etc. etc.). The vast majorit of medonc's are board-certified in I.M.
They may have to do some MOC to keep their I.M. requirements.
But AFAIK, they can always go back to their roots.
- We have a much bigger problem, the only thing we can go back to is Primary Care (if even possible) w/o retraining in residency. All radoncs went through 1 + 3 or 1 + 4 (1 yr transitional internship, 1 yr surg internship or whatever and 3-4 yrs of radonc).
Since the vast majority of radonc's have only 1 yr of internship, the only thing we can do is PCP in "the middle of the corn field". IIRC, most recent PCPs have 3-yr family medicine residency. The old-school 1-yr internship PCP is still there but I am not a PCP, so I don't know the rules for PCP. Does anyone know if radonc can do PCP (after tagging a long with a PCP for let's say 6 months to re-learn the rope)? I know this (working as a PCP) sounds depressing but it is better than driving Uber...
PS: Sorry about my Uber joke...
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