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

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RealSimulD said:
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.
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That’s a fair question. I agree that IIT is a more conservative/more rigorous standard when you are trying to see if something is better as it includes those in the tx arm who are artificially weeded out be being too sick to tolerate tx. But in this case, the fact that they counted patients from the control arm who actually got RT as still being control… strains credulity. Also, they specifically say that those from the experimental arm who did not receive tx “REFUSED” RT (as opposed not being treated because of progression/exclusion due to illness).

IIT is more conservative and rigorous… but it doesn’t mean it’s always the best way of analyzing the data. I don’t have a hard and fast rule on this one… I try to consider the stats on each paper individually
 
Tsigolonco noitaidar said:
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.
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IMRT should always be better than 3D, depending what is optimized.
 
Lamount said:
That’s a fair question. I agree that IIT is a more conservative/more rigorous standard when you are trying to see if something is better as it includes those in the tx arm who are artificially weeded out be being too sick to tolerate tx. But in this case, the fact that they counted patients from the control arm who actually got RT as still being control… strains credulity. Also, they specifically say that those from the experimental arm who did not receive tx “REFUSED” RT (as opposed not being treated because of progression/exclusion due to illness).

IIT is more conservative and rigorous… but it doesn’t mean it’s always the best way of analyzing the data. I don’t have a hard and fast rule on this one… I try to consider the stats on each paper individually
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So, again it’s not perfect
But every prospective trial has been negative
Some have shown harm
Meta-analysis negative
NCCN Rec came from two unplanned subgroup analyses.
This is shaky, shaky ground

If a patient has an adverse outcome, what leg do I have to stand on?
 
RealSimulD said:
So, again it’s not perfect
But every prospective trial has been negative
Some have shown harm
Meta-analysis negative
NCCN Rec came from two unplanned subgroup analyses.
This is shaky, shaky ground

If a patient has an adverse outcome, what leg do I have to stand on?
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If your concern is liability, I think the NCCN is sufficient. The “adverse outcome” would also likely be a slightly increased risk of heart disease… so hard to tease out.

If your concern is what is best for the patient… I think that is an individualized question. Like I said, my surgeons always want it for pN2, but I will decline sometimes if the patient got really beat up from chemo.
 
Lamount said:
If your concern is liability, I think the NCCN is sufficient. The “adverse outcome” would also likely be a slightly increased risk of heart disease… so hard to tease out.

If your concern is what is best for the patient… I think that is an individualized question. Like I said, my surgeons always want it for pN2, but I will decline sometimes if the patient got really beat up from chemo.
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Gentleman’s bet of $1 that the NCCN will change its Rec?
 
After the recent TWO negative studies came out, i started saying no to this and once MO and CT surg saw my notes commenting on the papers (they did not seem to know about it and just went off NCCN). Does it hurt that the referrals dried up? Sure but it was the right thing to do….

I’ll repeat again that 1308 was a total missed opportunity. Trial should have been 0617 winning arm mandating IMPT and IGRT to get a modern look comparison with SOC doses and most modern proton therapy. Is anybody aware of an ongoing or planned study which will actually answer this question or is it that we don’t want to know. You know what nancy lee would say folks!
 
thecarbonionangle said:
Do you guys do SFO or MFO for lungs?
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I can’t answer the question (yet) as it would narrow things down a bit too much and I like some semblance of anonymity

I would say that SFO is a little safer from a robustness perspective, but less conformal. There is a hybrid between the two that is becoming more widespread… kinda like a feathered MFO
 
Lamount said:
I can’t answer the question (yet) as it would narrow things down a bit too much and I like some semblance of anonymity

I would say that SFO is a little safer from a robustness perspective, but less conformal. There is a hybrid between the two that is becoming more widespread… kinda like a feathered MFO
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Not trying to dox you would never do that but i ask because from my conversation with many physicists most places are doing SFO and not MFO. People speak of “IMPT” but really a better distinction is MFO/SFO when discussing this. If most people are doing SFO means they still mostly doing “3D”. True IMPT, MFO, is challenging in the lung and most physicists will tell you SFO is far more robust in a tissue with tons of uncertainty and movement. As you say MFO, is less robust and less safe which is why is is not done as often despite modern machines in most centres with IMPT.

Of course as you said some are looking at hybrid techniques and arc based proton treatment, but the argument against this approach is you are basically spreading the dose around essentially ending up with IMRT…
 
thecarbonionangle said:
Not trying to dox you would never do that but i ask because from my conversation with many physicists most places are doing SFO and not MFO. People speak of “IMPT” but really a better distinction is MFO/SFO when discussing this. If most people are doing SFO means they still mostly doing “3D”. True IMPT, MFO, is challenging in the lung and most physicists will tell you SFO is far more robust in a tissue with tons of uncertainty and movement.

Of course as you said some are looking at hybrid techniques and arc based proton treatment, but the argument against this approach is you are basically spreading the dose around essentially ending up with IMRT…
Click to expand...

I assume newer machines allow for MFO?
 
jondunn said:
I assume newer machines allow for MFO?
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Yes modern IMPT machines, not PSPT, allows for both MFO and SFO techniques. Bilateral head and neck for example might be MFO. an ipsilateral head and neck can get a good plan with SFO. Prostate is almost always SFO unless you trying to avoid a hip implant. Lung is usually SFO in most places….

anyways, im not into flagellating ourselves over this. As i said, we should all be hoping some technological advancement hits gold or we in big trouble folks!
 
thecarbonionangle said:
Not trying to dox you would never do that but i ask because from my conversation with many physicists most places are doing SFO and not MFO. People speak of “IMPT” but really a better distinction is MFO/SFO when discussing this. If most people are doing SFO means they still mostly doing “3D”. True IMPT, MFO, is challenging in the lung and most physicists will tell you SFO is far more robust in a tissue with tons of uncertainty and movement.

Of course as you said some are looking at hybrid techniques and arc based proton treatment, but the argument against this approach is you are basically spreading the dose around essentially ending up with IMRT…
Click to expand...
Agree… but would say that SFO is only 3D-ish. It is still better than PSP because, in addition to the opportunity for robust/LET-informed optimization, with IMPT SFO you can also conform to proximal edge of the target as well as lateral concavities (whereas you can’t do either with PSP).
 
temujim said:
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.
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Drugs only get approved after demonstrating a benefit in a phase 3 trial In some setting. Never been done for protons. If I had to objectively weigh clinical evidence, they are worse.
 
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RickyScott said:
Drugs only get approved after demonstrating a benefit in a phase 3 trial In some setting. Never been done for protons. If I had to objectively weigh clinical evidence, they are worse.
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Drugs get approved, but once they're out in the wild you can do anything you want with them. Perhaps you don't remember the saga of stem cell transplants in breast cancer. Or induction TPF in H&N. Etc etc.

Protons deposit dose -- we can model it, plan it, and QA it. So it follows a course of proton therapy can cure cancer. Maybe they're better, maybe worse, maybe no different. Technology marches on and new iterations should be tested. Don't care for the marketing, but hey, that's life.
 
temujim said:
Drugs get approved, but once they're out in the wild you can do anything you want with them. Perhaps you don't remember the saga of stem cell transplants in breast cancer. Or induction TPF in H&N. Etc etc.

Protons deposit dose -- we can model it, plan it, and QA it. So it follows a course of proton therapy can cure cancer. Maybe they're better, maybe worse, maybe no different. Technology marches on and new iterations should be tested. Don't care for the marketing, but hey, that's life.
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To get approved a drug has to show some benefit in some setting. It can then be used off label. In 30 years, protons have never shown a benefit in any setting.
 
Tsigolonco noitaidar said:
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.
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A guy goes and gets the words “I love you” tattooed on his… member. He comes home and his wife sees it and says “Stop trying to put words in my mouth.”

The equal sign has a very clear definition (I use it in my avatar’s signature). I took the symbol at its word. If you actually meant by using the equal sign that PSPT and 3D *WERE NOT* equal that’s a “you problem” not a “me problem,” and a bit misleading. (Arguing with someone who constantly eludes being held responsible for using the words they actually use is annoying.)
 
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TheWallnerus said:
A guy goes and gets the words “I love you” tattooed on his… member. He comes home and his wife sees it and says “Stop trying to put words in my mouth.”

The equal sign has a very clear definition (I use it in my avatar’s signature). I took the symbol at its word. If you actually meant by using the equal sign that PSPT and 3D *WERE NOT* equal that’s a “you problem” not a “me problem,” and a bit misleading. (Arguing with someone who constantly eludes being held responsible for using the words they actually use is annoying.)
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Sounds good dude. You seem like a nice guy.
 
Lamount said:
Agree… but would say that SFO is only 3D-ish. It is still better than PSP because, in addition to the opportunity for robust/LET-informed optimization, with IMPT SFO you can also conform to proximal edge of the target as well as lateral concavities (whereas you can’t do either with PSP).
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I hear the sound of all the anti-proton folks typing vigorously and googling "what is SFO" and "what is MFO"....
 
Was never a big lung PORT guy but would discuss/offer it in referred N2 cases. Recent evidence definitely making for even more nuanced consideration with even softer treatment recommendations for me, with many opting out.

However, if you look at the data, there is a DFS benefit and dramatic mediastinal control benefit. Our field offers many many "standard of care" therapies for similar benefits (breast, endometrial, rectal, etc). Should we be considering lung PORT more? Or should we be chopping even more indications elsewhere?
 
Tsigolonco noitaidar said:
Sounds good dude. You seem like a nice guy.
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I’m not nice, and I’m not not nice. But I feel like I’m getting gaslit. I can’t imagine how patients might feel… (I’m thinking of every single graphic showing a PSPT Bragg Peak versus an X-ray depth dose curve…)
 
Saying that there is a DFS benefit is certainly a stretch!
 
TheWallnerus said:
Yes and just as a reductio ad absurdum exercise, the DFS and “control” data look more compelling IMHO for PCI in NSCLC vs PORT, and there are attendant trends in OS too.
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Are you referring to the trial on folks with mut-driven NSCLC pre-Osi?
 
Tsigolonco noitaidar said:
I hear the sound of all the anti-proton folks typing vigorously and googling "what is SFO" and "what is MFO"....
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In the Seattle proton prostate experience (w rectal balloons/space oar) it didn’t seem to matter if single vs multifield treatment. About 10% still had their rectums cauterized. 75% PBS. Noticed Matt spraker was an author. (He seems like he has integrity unlike Nancy Mendenhall who reported close to 0 toxicity with passive scatter) but who knows, if mendenhall and Uf are to belived, perhaps modern proton therapy delivers more toxicity than the 20 year old techniques.
pubmed.ncbi.nlm.nih.gov

Analysis of Gastrointestinal Toxicity in Patients Receiving Proton Beam Therapy for Prostate Cancer: A Single-Institution Experience - PubMed

PBT was associated with acceptable rates of GR2+ transient GI toxicity, mostly in the form of RB, which correlated with anticoagulation use. High EPIC bowel domain quality of life was maintained in the 2 years after treatment.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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Penn (and others) need to keep those proton treatments flowing. 3D and IMRT are not going to pay for 75 inch OLEDs in every patient room. Protons are "too big to fail" and "immune to data driven decision making." Even if randomized data shows no benefit for protons whatsoever, remember that dosimetry still shows a lower mean heart dose with protons. As we all know dosimetry >> randomized clinical outcomes.

www.beckershospitalreview.com

Penn Medicine opens $1.6B hospital - Becker's Hospital Review | Healthcare News & Analysis

Philadelphia-based Penn Medicine opened its 17-story, $1.6 billion hospital, the Pavilion, Oct. 30, the University of Pennsylvania's largest capital project and the biggest hospital project in the Philadelphia area, according to the health system.
www.beckershospitalreview.com www.beckershospitalreview.com
 
Lamount said:
Are you referring to the trial on folks with mut-driven NSCLC pre-Osi?
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That and others and the RTOG. Overall survival aside, am I totally off my rocker to think there's more robust/mathematically-convincing data to support DFS improvements with NSCLC PCI vs NSCLC PORT?
 
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TheWallnerus said:
That and others and the RTOG. Overall survival aside, am I totally off my rocker to think there's more robust/mathematically-convincing data to support DFS improvements with NSCLC PCI vs NSCLC PORT?
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The data supports PCI far more than it supports PORT. I’d still do neither 🙂 though in residency, had a very educated man (I think a college professor) and his understanding of the literature was that it was worth decreasing brain Mets even if it didn’t improve his survival.
 
TheWallnerus said:
That and others and the RTOG. Overall survival aside, am I totally off my rocker to think there's more robust/mathematically-convincing data to support DFS improvements with NSCLC PCI vs NSCLC PORT?
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In the specific circumstance where a highly effective CNS-penetrating TKI is unavailable, PCI for “high risk” NSCLC is well supported by the data 🙂
 
RealSimulD said:
The data supports PCI far more than it supports PORT. I’d still do neither 🙂 though in residency, had a very educated man (I think a college professor) and his understanding of the literature was that it was worth decreasing brain Mets even if it didn’t improve his survival.
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So you don’t routinely do PORT for incidentally discovered multistation pN2? If you don’t, did your practice change recently after lungART or was it something you didn’t do much of before then? (Just curious)
 
Lamount said:
So you don’t routinely do PORT for incidentally discovered multistation pN2? If you don’t, did your practice change recently after lungART or was it something you didn’t do much of before then? (Just curious)
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I did, because I was using Lally/ANITA retrospective data in lieu of any prospective data. Seemed to be the right answer for oral exams and NCCN said so,

Now, with two negative trials, I don’t see evidence to do it. I can’t honestly come up with one thing that I do with such limited data. Plus, I rely less on NCCN to catch up with modern evidence.
 
RealSimulD said:
I did, because I was using Lally/ANITA retrospective data in lieu of any prospective data. Seemed to be the right answer for oral exams and NCCN said so,

Now, with two negative trials, I don’t see evidence to do it. I can’t honestly come up with one thing that I do with such limited data. Plus, I rely less on NCCN to catch up with modern evidence.
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RT for pancreatic ca, SRS to sclc brain mets… but I see your point. I think it comes down to what one considers the SOC to begin with. You ask whether the current level of evidence justifies giving PORT, and I ask if it justifies omitting it.

The question I have is why did those 26% of people on the RT arm “refuse”. If they were doing perfectly fine and simply refused it, the per protocol and as treated analyses are reasonable to consider. If they were too sick, then one could ask if the per protocol analysis is artificially omitting the sickest patients in the RT arm, which would mean the ITT is a better comparison. The fact that they used the word “refused” and this was after randomization makes me think it was just preference… but would be interested to see why they refused.
 
Lamount said:
RT for pancreatic ca, SRS to sclc brain mets… but I see your point. I think it comes down to what one considers the SOC to begin with. You ask whether the current level of evidence justifies giving PORT, and I ask if it justifies omitting it.

The question I have is why did those 26% of people on the RT arm “refuse”. If they were doing perfectly fine and simply refused it, the per protocol and as treated analyses are reasonable to consider. If they were too sick, then one could ask if the per protocol analysis is artificially omitting the sickest patients in the RT arm, which would mean the ITT is a better comparison. The fact that they used the word “refused” and this was after randomization makes me think it was just preference… but would be interested to see why they refused.
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So how would you give adjuvant lung xrt? Prior to io or concurrent with it?
 
RealSimulD said:
I did, because I was using Lally/ANITA retrospective data in lieu of any prospective data. Seemed to be the right answer for oral exams and NCCN said so,

Now, with two negative trials, I don’t see evidence to do it. I can’t honestly come up with one thing that I do with such limited data. Plus, I rely less on NCCN to catch up with modern evidence.
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Still might do it in the setting of macroscopic ene vs close radiographic surveillance
 
RickyScott said:
So how would you give adjuvant lung xrt? Prior to io or concurrent with it?
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The question of adjuvant IO has come up recently and our group is certainly considering it. Our med oncs are awaiting the full publication of IMpower10. I would support them if they wanted to utilize this on PDL-1 >1, IIIA NSCLC. Truth is, many/most of our adjuvant patients end up having N3 or T3 disease anyway, and a lot are PDL-1 negative. If IO was planned for a given patient, I am not sure that I would give any RT.
 
Lamount said:
So you don’t routinely do PORT for incidentally discovered multistation pN2?
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RealSimulD said:
Now, with two negative trials, I don’t see evidence to do it.
Click to expand...

I, like many of us I imagine, can only do RT on a patient referred to me. I can't do RT on patients I never get to see. I get to see PORT patients much, much less often than I used to in the past. Referring docs see that evidence/data too.
 
cancerletter.com

No longer “experimental”—Prostate cancer patients should have access to proton therapy - The Cancer Letter

Proton therapy is an ultra-precise form of radiation that spares patients excess radiation to the heathy tissues and organs surrounding their tumor. It has been shown to be effective in reducing short- and long-term side effects and improving health outcomes for adults and children with a wide...
cancerletter.com cancerletter.com

Take a swig for every dishonest statement, usually a good publication…
 
TheWallnerus said:
I, like many of us I imagine, can only do RT on a patient referred to me. I can't do RT on patients I never get to see. I get to see PORT patients much, much less often than I used to in the past. Referring docs see that evidence/data too.
Click to expand...
TheWallnerus said:
I, like many of us I imagine, can only do RT on a patient referred to me. I can't do RT on patients I never get to see. I get to see PORT patients much, much less often than I used to in the past. Referring docs see that evidence/data too.
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I haven’t seen a single postop pt since this came out.
 
goodkerma said:
cancerletter.com

No longer “experimental”—Prostate cancer patients should have access to proton therapy - The Cancer Letter

Proton therapy is an ultra-precise form of radiation that spares patients excess radiation to the heathy tissues and organs surrounding their tumor. It has been shown to be effective in reducing short- and long-term side effects and improving health outcomes for adults and children with a wide...
cancerletter.com cancerletter.com

Take a swig for every dishonest statement, usually a good publication…
Click to expand...
Very precise folks!
 
goodkerma said:
cancerletter.com

No longer “experimental”—Prostate cancer patients should have access to proton therapy - The Cancer Letter

Proton therapy is an ultra-precise form of radiation that spares patients excess radiation to the heathy tissues and organs surrounding their tumor. It has been shown to be effective in reducing short- and long-term side effects and improving health outcomes for adults and children with a wide...
cancerletter.com cancerletter.com

From the linked article:
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“[Question]
We know proton therapy is an effective treatment for prostate cancer, but the real question is can it deliver better results than conventional radiotherapy?

[Anawer]
Randomized evidence in other disease sites report reduced side-effects with protons compared with traditional radiation therapy, leading to improved quality of life with proton therapy, but those metrics are complicated to measure and require more dedicated and detailed studies to make definitive claims about superior efficacy. “

This answer is the most roundabout, tortured way of simply writing “no it cannot” that I’ve read.
 
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'Dr. Spaceman/Hasan is it true that protons are better than photons'


'We have no way of knowing as the powerful PHOTON lobby keeps blocking our research!'
 
Just to stir the pot:

1636637233217.png
 
elementaryschooleconomics said:
Just to stir the pot:

View attachment 345579
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I am not a statistician but I think "OR, 15.3" is pretty high??

In all seriousness the proton data keep telling us that one can not simply take a Gy and prescribe a cobalt gray equivalent and expect to see less side effects. And more importantly: the radiobiology of protons is sometimes really, really different than photons. It's almost like protons are experimental (gasp).
 
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