Protons are blowing Rad Onc's boat out the CMS water

[TheWallnerus]

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So why don't we treat PMRT/RNI to 40 Gy then? Would certainly save the patient at least 5 fractions. Or does that not fit the SDN narrative of avoiding cutting fractions at all cost because there goes our bonus.

“We” do. The royal we. In the UK around 99% of all RNI is 15 fraction if I’m reading their latest stats correctly.

 

[thecarbonionangle]

Many places are already doing 40.05/15 and 42.56/16 for RNI. not new to many many!

 

[Tsigolonco noitaidar]

Because it has been done that way for 50+ years and at least theoretically raising local control by a few percent points without downside.

No downside to increasing dose from 40 Gy to 50 Gy to CW and regional nodes? 🤔

Just playing devil's advocate, but it would seem inconsistent to say 40 Gy is okay for the IMNs but 50 Gy is required everywhere else--especially if the rationale is "that's the way we have always done it".

 

[Tsigolonco noitaidar]

Many places are already doing 40.05/15 and 42.56/16 for RNI. not new to many many!

Yes true--but specifying the dose/fractionation is key. When folks prescribe to the 80% isodose line for IMNs, they are not doing 40.05 Gy in 15 fx...they are doing 40 Gy in 25 fractions which is actually 1.6 Gy per fraction! Also, when places utilize the hypofrac regimens for RNI, they are covering the entire field with that dose/fractionation. They are not selectively choosing a lower dose/fractionation for the IMN region specifically.

 

[deleted1111261]

Many places are already doing 40.05/15 and 42.56/16 for RNI. not new to many many!

Original PMRT studies used HF.

 

[TheWallnerus]

Original PMRT studies used HF.

Hypofx for PMRT is older than all of us. From EBCTCG 2014.

 

[RickyScott]

Original PMRT studies used HF.

Many also used one field a day.

 

[metallica81788]

Round and round we go!

 

[thecarbonionangle]

Tampa General Hospital, Florida Cancer Specialists, Proton Therapy Partners and Florida Urology Partners Come Together with Plans to Open the Region’s First Proton Therapy Center | Tampa General Hospital

The first of its kind on the West Coast of Florida, this free-standing proton therapy center – backed by the region’s top academic medical center and leading community partners – aims to provide cancer patients with advanced and alternative life-saving treatment.<em><br /> </em>

www.tgh.org

 

[elementaryschooleconomics]

Round and round we go!

Yes, this went the way I expected - which means I haven't missed some new data (phew).

As always:

 

[medgator]

Tampa General Hospital, Florida Cancer Specialists, Proton Therapy Partners and Florida Urology Partners Come Together with Plans to Open the Region’s First Proton Therapy Center | Tampa General Hospital

The first of its kind on the West Coast of Florida, this free-standing proton therapy center – backed by the region’s top academic medical center and leading community partners – aims to provide cancer patients with advanced and alternative life-saving treatment.<em><br /> </em>

www.tgh.org

TGH and moffitt had an ugly divorce. They posted jobs this cycle at Astro

 

[medgator]

No benefit to protons in cardiotoxicity outcomes in nsclc

DEFINE_ME

We did not find any difference in incidences of CAEs between IMRT versus PSPT, a finding that may be explained by larger volumes in the high dose region (V40-V70 Gy) even though the mean heart dose was lower with PSPT (P > .05, not shown).

 

[jondunn]

No benefit to protons in cardiotoxicity outcomes in nsclc

DEFINE_ME

in before someone comes in and says 'yah but it wasn't IMPT'

that's YUGE in the proton handbook. along with other famous lines like:

'You would want proton if it was you'

and

'The price will come down'

still waiting, folks!

 

[Lamount]

in before someone comes in and says 'yah but it wasn't IMPT'

that's YUGE in the proton handbook. along with other famous lines like:

'You would want proton if it was you'

and

'The price will come down'

still waiting, folks!

As well it should be… are you going to decline to treat post op NSCLC because of Lung ART, where 90% where treated with 3D? I’m not. I use IMRT, and treating the entirety of level 7 with 3D is morbid.

PSPT = 3D

Here is a paper that addresses this exact question

 

[jondunn]

As well it should be… are you going to decline to treat post op NSCLC because of Lung ART, where 90% where treated with 3D? I’m not. I use IMRT, and treating the entirety of level 7 with 3D is morbid.

PSPT = 3D

Here is a paper that addresses this exact question

I'm not treating all post-op N2 because it has now been shown in multiple recent trials to not be oncologically sound. it's not because of toxicity.


whether there are certain subsets that may benefit in the setting of adjuvant immunotherapy now that this will be part of the SOC is another investigational question.

 

[TheWallnerus]

PSPT = 3D

“Oh brother” in the immortal words of Charlie Brown. You just moved the football, Lucy. Fruit Street (MGH) just called from 2001 and wants its brand new proton center revamped. The inherent benefit of protons is not the Bragg Peak (looks great in 2D) but the watered-down er spread out Bragg Peak (looks not as great in 2D)? Man one of these days we are all gonna have to get together and be honest. And maybe whistleblow all the “PSPT” places that were paid multiples of 3D for years.

 

[deleted1111261]

As well it should be… are you going to decline to treat post op NSCLC because of Lung ART, where 90% where treated with 3D? I’m not. I use IMRT, and treating the entirety of level 7 with 3D is morbid.

PSPT = 3D

Here is a paper that addresses this exact question

Wait. Huh? What is your rationale to treat? Multiple negative “primitive trials”? A negative meta-analysis? Two recent negative prospective RCTs that treated N2 patients? Give me a break about 3D. The argument always was about evaluating higher risk patients. The ANITA and Lally studies that I assume you’re holding your hat on used 100% non-IMRT. This is one of those cases where I think the community knows better to move on, while the academic folks continue to hold on (“but no IMRT” “but no full publication”).

Friends- we lost this one (like many others). There’s always 5 fraction breast!

EDIT: that study is not for pN2 post op. It’s about intact lung cancer. I cannot think of a more apples to oranges comparison.

 

[Lamount]

“Oh brother” in the immortal words of Charlie Brown. You just moved the football, Lucy. Fruit Street (MGH) just called from 2001 and wants its brand new proton center revamped. The inherent benefit of protons is not the Bragg Peak (looks great in 2D) but the watered-down er spread out Bragg Peak (looks not as great in 2D)? Man one of these days we are all gonna have to get together and be honest. And maybe whistleblow all the “PSPT” places that were paid multiples of 3D for years.

Are you questioning the cost or the science? I’m with you on the former but would certainly enjoy debating you on the latter.

 

[Lamount]

Wait. Huh? What is your rationale to treat? Multiple negative “primitive trials”? A negative meta-analysis? Two recent negative prospective RCTs that treated N2 patients? Give me a break about 3D. The argument always was about evaluating higher risk patients. The ANITA and Lally studies that I assume you’re holding your hat on used 100% non-IMRT. This is one of those cases where I think the community knows better to move on, while the academic folks continue to hold on (“but no IMRT” “but no full publication”).

Friends- we lost this one (like many others). There’s always 5 fraction breast!

EDIT: that study is not for pN2 post op. It’s about intact lung cancer. I cannot think of a more apples to oranges comparison.

Let’s take a look at some of those negative data.
PORT C
The primary analysis was DFS in IIT population.
…but 24% of RT arm REFUSED to get RT (not that they progressed or were too sick, but REFUSED) and 6% of those on the observation arm actually received RT! Yikes.

So what happens when we look at DFS in per protocol population, or better yet, as they were actually treated?

What conclusion do you draw from these data?

 

[deleted1111261]

Let’s take a look at some of those negative data.
PORT C
The primary analysis was DFS in IIT population.
…but 24% of RT arm REFUSED to get RT (not that they progressed or were too sick, but REFUSED) and 6% of those on the observation arm actually received RT! Yikes.

So what happens when we look at DFS in per protocol population, or better yet, as they were actually treated?
View attachment 345433


What conclusion do you draw from these data?

What prospective evidence are you hanging your hat on? Is it a perfect study? Heck no. Do we know PORT reduces recurrence? Heck yes. Does this matter? It does not appear to.

 

[TheWallnerus]

Are you questioning the cost or the science? I’m with you on the former but would certainly enjoy debating you on the latter.

I am but a parishioner in the church. The Proton Priests preaching different gospels at me at different points in time confuse me. If they really thought that PSPT=3D, why did they ever use it instead of IMRT?

 

[jondunn]

Plenty of my friends I’ve asked in academics immediately stopped PORT about a year ago when the trial results came out at ESMO or ESTRO or whatever. It just doesn’t pass the smell test. The field has moved on. Catch up!

 

[jondunn]

That’s truly interesting. When I saw the results and social media critiques of the study and then also asked our clinical liaisons in Houston, it appeared that party line was to “keep treating”.

Yeah well MDACC is huge into treating. In every disease site. But they too will stop, if they haven’t already.

 

[communitydoc13]

What prospective evidence are you hanging your hat on? Is it a perfect study? Heck no. Do we know PORT reduces recurrence? Heck yes. Does this matter? It does not appear to.

I agree this is usually a lost battle but I do occasionally treat post-op N2 (1/3 of last referrals that I’ve gotten).

1. Non ideal mediastinal dissection (no level 2/4 in lower low dissection with equivocal nodes)

and….Patient unlikely to tolerate salvage chemorads with adjuvant immunotherapy.

That being said, I’m convinced that I’ve caused more pneumonitis with post-op, post-chemo 54Gy than I have with concurrent to 60-66.

 

[TheWallnerus]

Does PORT mean pretty obsolescent radiotherapy?

 

[elementaryschooleconomics]

Yeah well MDACC is huge into treating. In every disease site. But they too will stop, if they haven’t already.

"There's the right way, the wrong way, and the MD Anderson way!"

 

[RickyScott]

I agree this is usually a lost battle but I do occasionally treat post-op N2 (1/3 of last referrals that I’ve gotten).

1. Non ideal mediastinal dissection (no level 2/4 in lower low dissection with equivocal nodes)

and….Patient unlikely to tolerate salvage chemorads with adjuvant immunotherapy.

That being said, I’m convinced that I’ve caused more pneumonitis with post-op, post-chemo 54Gy than I have with concurrent to 60-66.

Lungs are smaller and often have effusions. I used to give 45-50 and would only give 54 for positive margin. Postop immuno makes this all moot.

 

[Tsigolonco noitaidar]

in before someone comes in and says 'yah but it wasn't IMPT'

that's YUGE in the proton handbook. along with other famous lines like:

'You would want proton if it was you'

and

'The price will come down'

still waiting, folks!

I'm going to bring the discussion back to the paper. Yes, it was PSPT and yes that makes a difference. Agree with point that PSPT = 3D. Also as the authors mentioned, and if I am interpreting their words correctly, if the high dose volumes were higher in the PSPT patients then that might contribute to why heart doses weren't different and therefore why CAEs were not different.

 

[jondunn]

the intellectual rigor of proton enthusiasts is alarmingly low.

The smartest ones will tell you the truth in private.

 

[TheWallnerus]

Agree with point that PSPT = 3D

I am glad you agree that PSPT should have never been used clinically on patients in the IMRT era. That was sad. It should have been challenged and shamed by all of rad onc. I was told time and again that PSPT was the superiorest RT. At least all the men in the Internet prostate cancer forums believed it was.

 

[Tsigolonco noitaidar]

I am but a parishioner in the church. The Proton Priests preaching different gospels at me at different points in time confuse me. If they really thought that PSPT=3D, why did they ever use it instead of IMRT?

Does your point support an argument to not use IMPT now?

 

[medgator]

. It should have been challenged and shamed by all of rad onc

We were too busy shaming IMRT for breast cancer, shaming too many cheap fractions in freestanding centers while PPS exempt was charging 5 figures for srs and shaming rad oncs who partnered with urologists to try and avoid patients getting cryo'd and HIFU'd

You know, the important stuff

 

[Lamount]

What prospective evidence are you hanging your hat on? Is it a perfect study? Heck no. Do we know PORT reduces recurrence? Heck yes. Does this matter? It does not appear to.

In this trial, if one looks at who got PORT vs who didn’t, it improves DFS

 

[temujim]

I am glad you agree that PSPT should have never been used clinically on patients in the IMRT era. That was sad. It should have been challenged and shamed by all of rad onc. I was told time and again that PSPT was the superiorest RT. At least all the men in the Internet prostate cancer forums believed it was.

Why fight about protons? IMPT is a newish drug. Let's test it. And use it off label in the meantime... if you can get reimbursed. This is the med & surg onc way.

 

[jondunn]

Why fight about protons? IMPT is a newish drug. Let's test it. And use it off label in the meantime... if you can get reimbursed. This is the med & surg onc way.

Surgery/device way, absolutely

This is NOT the Med onc way.


Drugs are incredibly regulated and if rad onc was subject to the FDA regulatory complex, we would be embarrassed

 

[medgator]

Why fight about protons? IMPT is a newish drug. Let's test it. And use it off label in the meantime... if you can get reimbursed. This is the med & surg onc way.

Med oncs don't shame their private practice brethren and actively try to put them out of business

 

[Lamount]

I am but a parishioner in the church. The Proton Priests preaching different gospels at me at different points in time confuse me. If they really thought that PSPT=3D, why did they ever use it instead of IMRT?

I couldn’t say… I am not Christian, let alone a priest 😎. I am, however a firm believer in the notion that protons are worse than photons when uncertainty is not modeled correctly

 

[jondunn]

I couldn’t say… I am not Christian, let alone a priest 😎. I am, however a firm believer in the notion that protons are worse than photons when uncertainty is not modeled correctly

I will give you credit that you can’t speak for the past of proton but only the current and future

 

[jondunn]

anyways important question - did the paper say how much lower the mean heart dose was?

 

[Lamount]

Does PORT mean pretty obsolescent radiotherapy?

Not sure there are degrees of obsolescence, but this gave a chuckle nonetheless

 

[temujim]

Surgery/device way, absolutely

This is NOT the Med onc way.


Drugs are incredibly regulated and if rad onc was subject to the FDA regulatory complex, we would be embarrassed

I'll let all the med oncs who use carbo/taxol in so many situations where there is no phase III supporting data know they should be embarrassed.

 

[Lamount]

I agree this is usually a lost battle but I do occasionally treat post-op N2 (1/3 of last referrals that I’ve gotten).

1. Non ideal mediastinal dissection (no level 2/4 in lower low dissection with equivocal nodes)

and….Patient unlikely to tolerate salvage chemorads with adjuvant immunotherapy.

That being said, I’m convinced that I’ve caused more pneumonitis with post-op, post-chemo 54Gy than I have with concurrent to 60-66.

In my group, the strongest advocates of PORT are the surgeons… pretty much every pN2 patient is referred to us (except they sometimes don’t refer LUL with one level 6 LN as they feel it’s likely “suprahilar”). My volumes tend to be tighter than LungART protocol.

 

[Lamount]

Med oncs don't shame their private practice brethren and actively try to put them out of business

Neither do I.

 

[Tsigolonco noitaidar]

I am glad you agree that PSPT should have never been used clinically on patients in the IMRT era. That was sad. It should have been challenged and shamed by all of rad onc. I was told time and again that PSPT was the superiorest RT.

I am glad you agree that PSPT should have never been used clinically on patients in the IMRT era. That was sad. It should have been challenged and shamed by all of rad onc. I was told time and again that PSPT was the superiorest RT. At least all the men in the Internet prostate cancer forums believed it was.

Please don't put words in my mouth. Perhaps I should have been clearer but when i say 3D = PSPT I mean that they are analogous. I don't mean that they are the exact same modality or that they have the exact same outcomes. And I would certainly not make a blanket statement that because 3D and PSPT are analagous that therefore PSPT << IMRT in all cases (HINT: 3D is better than IMRT in some cases, and indeed PSPT is better than IMRT in some cases too).

Finally, I am not really here to argue whether PSPT should or should not have been used in the past. Instead, I wanted to specifically address the point that PSPT in this specific paper did not have a benefit over IMRT. I think it's an interesting finding and like any result in any paper, there are always caveats.

 

[jondunn]

I'll let all the med oncs who use carbo/taxol in so many situations where there is no phase III supporting data know they should be embarrassed.

This is a -really- bad post

 

[Lamount]

anyways important question - did the paper say how much lower the mean heart dose was?

I think IMPT vs PSP mean heart dose was 6.6 vs 10.7

 

[jondunn]

I think IMPT vs PSP mean heart dose was 6.6 vs 10.7

View attachment 345438

So only 4 gy difference

Actually what I had meant was the One about 3D proton vs photons

 

[deleted1111261]

In this trial, if one looks at who got PORT vs who didn’t, it improves DFS

Are we moving away from ITT, to justify doing what we wish to do ? I’m just a community doc, so it’s hard to know which way the winds are blowing with regards to this.

 

[deleted1111261]

This is a -really- bad post

Why?

 

[medgator]

Neither do I.

Unfortunately many others do... Just look at where ASTRO PAC or choosing wisely had focused their efforts, not to mention the really tone deaf Palliative care/bone met "vetting" article that was published within the the last couple of years

Making the Most of a Crisis: A Proposal for Network-Based Palliative Radiation Therapy to Reduce Travel Toxicity - PMC

A multipronged model is proposed to improve the delivery of palliative radiotherapy by increasing access to care and reducing travel burden for patients.

www.ncbi.nlm.nih.gov