Rad Onc Twitter

About the Ads

thecarbonionangle

Full Member
7+ Year Member
Aug 23, 2014
2,290
3,815
  1. Attending Physician

    “Even in fabled Atlantis, the night that the ocean engulfed it,The drowning still cried out for their slaves. “

    Yea folks we have many questions. Many questions, indeed! the field is sinking. The Chairs are ignoring truth in their fake Dubai-esque parody of reality. As the final parts of the atlantis sink, the chairs are still thirsty for warm bodies. Medical students please don’t leave! Who will do my work? Who will write my stupid retrospective reviews? Who will wipe my chin when i drool? Who will boost my ego after i look in the mirror in the morning?

    Many questions into the sinking, a silent harmonious answer to our fabled end as the haggard daylight steers toward a deep monotone.

    RIP
     
    Last edited:
    • Like
    • Love
    • Haha
    Reactions: 4 users

    RealSimulD

    Full Member
    Jul 16, 2021
    222
    695
    1. Attending Physician
      Is it really good data, though? A 90-person, single-arm, single-institution trial? Is that even remotely good enough to move the field? Sure, it's hypothesis-generating, but I would say that's about it.
      Rapido study had many patients that didn’t undergo surgery for whatever reason, and their outcome mirrors other non-operative management studies. There is a study running at WashU I think for non-operative with short course as the RT component.

      25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.

      We tend to do SCRT for most rectal cases, with caveat being for those who “need heroic downstaging” being considered for long course. And we do for non-operative, but the data doesn’t isn’t better one way than the other. People tend to mood affiliate and lean towards long or short depending on their priors.

      Which, at the end of the day, is completely fine! Both lead to great outcomes. Modern treatment of rectal cancer is fantastic and continues to improve.
       
      • Like
      Reactions: 3 users

      elementaryschooleconomics

      Liberator of Flattening Filters
      Silver Member
      Nov 2, 2019
      1,470
      6,118
      1. Attending Physician
        25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.
        For me, in my community, it's more about managing expectations of the referring docs. I'm currently trying to get everyone who has been practicing for 20 years on the TNT train, I shudder to think about trying to convince them that 25/5 is OK.

        On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it. Obviously this is just local politics for me, and my experience might not be generalizable to the rest of you.
         
        • Like
        Reactions: 1 users

        RickyScott

        Full Member
        2+ Year Member
        Oct 4, 2017
        2,663
        4,695
        1. Attending Physician
          Rapido study had many patients that didn’t undergo surgery for whatever reason, and their outcome mirrors other non-operative management studies. There is a study running at WashU I think for non-operative with short course as the RT component.

          25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.

          We tend to do SCRT for most rectal cases, with caveat being for those who “need heroic downstaging” being considered for long course. And we do for non-operative, but the data doesn’t isn’t better one way than the other. People tend to mood affiliate and lean towards long or short depending on their priors.

          Which, at the end of the day, is completely fine! Both lead to great outcomes. Modern treatment of rectal cancer is fantastic and continues to improve.
          For radiation, GI is the new lymphoma/seminoma
           
          • Like
          Reactions: 2 users

          RealSimulD

          Full Member
          Jul 16, 2021
          222
          695
          1. Attending Physician
            For me, in my community, it's more about managing expectations of the referring docs. I'm currently trying to get everyone who has been practicing for 20 years on the TNT train, I shudder to think about trying to convince them that 25/5 is OK.

            On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it. Obviously this is just local politics for me, and my experience might not be generalizable to the rest of you.
            I led a group meeting of all members that would be treating rectal cancer in the area, which included my private practice RO competitors (who are wonderful - every region needs hospital folks and private folks - it’s better for the community). The data spoke to the group. It was actually really helpful to go through it detail with the multi D team. It made sense for our patients.
             

            TheWallnerus

            e^(iπ) + 1 = 0
            2+ Year Member
            Gold Member
            Apr 3, 2019
            1,062
            2,604
            1. Attending Physician
              25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.

              On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it.
              But goshdangit galdarnit 25/5 is not "new" by a long shot, antedates IMRT, and was one of a vanishing few trials of the 20th century to show a survival advantage from radiotherapy application (and maybe unless I'm forgetting something one of the most significant p-value survival advantages from RT of all time). I like to quote this trial from time to time to hint that US docs don't read, or hate non-US data (they used to hate it very much so), and/or are hypocritical.

              AC8TBxK.png
               
              • Like
              • Haha
              Reactions: 2 users

              elementaryschooleconomics

              Liberator of Flattening Filters
              Silver Member
              Nov 2, 2019
              1,470
              6,118
              1. Attending Physician
                I led a group meeting of all members that would be treating rectal cancer in the area, which included my private practice RO competitors (who are wonderful - every region needs hospital folks and private folks - it’s better for the community). The data spoke to the group. It was actually really helpful to go through it detail with the multi D team. It made sense for our patients.
                That's a good idea. I feel like this is a "herding cats" situation for me right now, but I'm probably being unfairly pessimistic about it.
                 

                RealSimulD

                Full Member
                Jul 16, 2021
                222
                695
                1. Attending Physician
                  Honestly I am not sure why I've not shoved all in on 5 fraction rectal.

                  Oh I know why. When I send my patients back to the academic place for surgery the patient gets told I might have given them unsafe radiotherapy.

                  It’s really too bad academic centers work this way. I wonder if there would be a way to have an open conversation about this. Or @OTN and MDACC to have it out and listen at how damaging and one-sided the relationship feels. I felt that way with JHH when I worked in DC area, but UMaryland was an excellent partner. Truly collegial. In AZ, there was no academic center. Allegedly, we were “Banner University Medical Center” but not really academic.
                   
                  • Like
                  Reactions: 1 user
                  About the Ads

                  GI_RadOnc

                  Full Member
                  Nov 7, 2019
                  89
                  254
                  1. Academic Administration
                    I'm a huge fan of 25 / 5; and participated in the RAPIDO trial. Easier on the patient, good results; easier for the patient and the oncologists, and has level 1 evidence from at least TWO prospective, randomized studies that it's either better or not worse (RAPIDO, Polish-2). It does take different communication with the patient due to the proctitis happening after the radiation is complete...

                    This latest WashU report builds on a long WashU legacy to let people know that there isn't something magical about US rectal cancer patients as opposed to European ones! After doing SCRT -> immediate surgery for several years there, a nice prospective, phase II study with SC-TNT came out (Five fractions of radiation therapy followed by 4 cycles of FOLFOX chemotherapy as preoperative treatment for rectal cancer - PubMed)

                    I don't think the WashU report on it's own moves the needle; but it continues to investigate the regimen for organ preservation, and has patients with less advanced disease than RAPIDO. It includes the population that may be recommended for NO RADIATION after PROSPECT reports out. And it shows that this population may have good organ preservation with SC-TNT. That's going to keep radiation therapy involved in these 'bi-modality' patients; who may do equally well with RT+chemo; chemo+surgery; or maybe even RT+surgery.

                    The key trial for the organ preservation, of course, is going on in Europe in Germany. They are randomizing patients between long course chemoradiation + chemo VERSUS short course radiation + chemo; essentially OPRA vs RAPIDO with the endpoint of cCR. Short-course Radiotherapy Versus Chemoradiotherapy, Followed by Consolidation Chemotherapy, and Selective Organ Preservation for MRI-defined Intermediate and High-risk Rectal Cancer Patients - Full Text View - ClinicalTrials.gov.

                    With regards to changing practices... I brought short course radiation and TNT to our practice a few years ago; with many colleagues who had 20 years plus of experience. It took about 1 year to change the practice; and definitely to have some flexibility when starting out. I should collect our path outcomes both before and after the change; but anecdotally patients are doing quite similarly.

                    And, it's interesting that the two NCCN centers in our area do not use short course radiation routinely! But none have the temerity to point out that the radiation I delivered was 'inappropriate'! Cause, you know, data.
                     
                    • Like
                    Reactions: 6 users

                    metallica81788

                    Keeper of the Llamaworm
                    Moderator Emeritus
                    10+ Year Member
                    Verified Expert
                    Jul 26, 2007
                    12,276
                    893
                    1. Attending Physician
                      I was converted by force to 25/5 by my institution upon arrival; they are very aggressive about it.

                      Initially I hated it, and the short term proctitis is real - generally worse than I see with long course. Seems like patients either do fantastic or terrible shortly after finishing. However, I strongly dislike treating any GI so it moves these patients along quicker and the (anecdotal) post-surgical outcomes have been fantastic. I also don't see too many rectal cancers so it doesn't make a huge impact on my practice metrics.

                      Our institutional protocol is 25/5 for all with exception of very low tumors or any consideration for watch/wait style. At least I don't have to worry about any surgeons accusing me of "inappropriate" care.
                       
                      • Like
                      Reactions: 2 users

                      TheWallnerus

                      e^(iπ) + 1 = 0
                      2+ Year Member
                      Gold Member
                      Apr 3, 2019
                      1,062
                      2,604
                      1. Attending Physician
                        To ruminate on RickyScott's point for those reading who aren't in rad onc...

                        1. 1970's seminoma paper from MDACC:
                        keC6HJl.png

                        2. Then we all just sort of decided chest RT for seminoma was a little much.
                        3. Then the dog leg got eliminated.
                        4. Then the RT dose got reduced.
                        5. Then a drug seemed to be better than the RT.
                        6. Then the options became surveil, risk-adapt w/ chemo, or, according to the NCCN, RT if the patient begs on his hands and knees for it but you have to tell him long-term side effects are greater.

                        As time went on we did less and less. How'd the B.A.L.L.S. initiative go @Gfunk6?
                         
                        • Like
                        Reactions: 1 user

                        RickyScott

                        Full Member
                        2+ Year Member
                        Oct 4, 2017
                        2,663
                        4,695
                        1. Attending Physician
                          For GI: 1)gastric xrt eliminated. 2) anal cancer will disappear in 2030s w/vaccine 3) pancreas XRT- large studies continue to disappoint. preop Esophageal XRT= FLOT (one drug away from being eliminated) Rectal cancer: In setting of LAR, absolute benefit of XRT is very low and again one drug away from being eliminated and most pts are now candidate for 5 fractions. Sure, xrt for non operative manangement of rectal cancer is promising, and can also be given in 5 fractions, but minority of rectal cases.
                           
                          Last edited:
                          • Like
                          Reactions: 1 user

                          BobbyHeenan

                          Full Member
                          7+ Year Member
                          Mar 20, 2013
                          1,149
                          1,615
                          1. Attending Physician
                            We have a surg onc that is really into watch and wait. So I've been very reluctant to use 5 fraction for these.

                            Maybe I need to revisit this?

                            I'm very comfortable with 5 fraction for patients surely going to surgery...but for these cases where surgeon is on board (and hoping) not to operate, I've stuck with long course.
                             
                            Last edited:
                            • Like
                            Reactions: 1 users

                            communitydoc13

                            Full Member
                            Jul 14, 2020
                            276
                            744
                            1. Attending Physician
                              I'm very comfortable with 5 fraction for patients surely going to surgery...but for these cases where surgeon is on board (and hoping) not to operate, I've stuck with long course.
                              Feel exactly the same way. One question I have is TNT with significant nodal disease. I remember Chris Crane on mednet discussing what is actually taken out with TME and noting that pelvic sidewall nodes and higher nodes near iliac bifurcation not typically removed. I like to dose escalate these nodes with standard fractionation close to 60 Gy (or some dose painted equivalent).

                              Is there an equivalent strategy with 5 fxn treatment?
                               
                              • Like
                              Reactions: 1 users

                              w00tz

                              Full Member
                              10+ Year Member
                              Dec 16, 2006
                              434
                              720
                              1. Attending Physician
                                I am very skeptical of 25/5, especially for NOM. Based on what we know/believe about BED and alpha/beta, LC has significantly higher BED than SC. If SC does prove to be equivalent to LC for in NOM for big T3 tumors, I will have an existential crisis and throw my Hall book in a dumpster fire.
                                 
                                • Like
                                • Love
                                Reactions: 10 users

                                Gfunk6

                                And to think . . . I hesitated
                                Moderator Emeritus
                                Verified Expert
                                15+ Year Member
                                Gold Member
                                Apr 16, 2004
                                4,128
                                2,695
                                SF Bay Area
                                1. Attending Physician
                                  As time went on we did less and less. How'd the B.A.L.L.S. initiative go @Gfunk6?

                                  It's gone great! I have not treated a seminoma in 10 years. I can only assume this means that these insanely complex and high-dose treatments are being performed using IMPT on a registry trial at academic medical centers.
                                   
                                  • Haha
                                  Reactions: 2 users

                                  radoncftw

                                  Full Member
                                  5+ Year Member
                                  Apr 15, 2015
                                  48
                                  77
                                  1. Medical Student
                                    Feel exactly the same way. One question I have is TNT with significant nodal disease. I remember Chris Crane on mednet discussing what is actually taken out with TME and noting that pelvic sidewall nodes and higher nodes near iliac bifurcation not typically removed. I like to dose escalate these nodes with standard fractionation close to 60 Gy (or some dose painted equivalent).

                                    Is there an equivalent strategy with 5 fxn treatment?
                                    Yes

                                     
                                    • Like
                                    Reactions: 1 user
                                    About the Ads

                                    Doctorer

                                    Full Member
                                    2+ Year Member
                                    Jan 24, 2018
                                    103
                                    269
                                    1. Attending Physician
                                      It's gone great! I have not treated a seminoma in 10 years. I can only assume this means that these insanely complex and high-dose treatments are being performed using IMPT on a registry trial at academic medical centers.
                                      Please, don’t be ridiculous, hyperbole like this isn't helpful!

                                      They’re not on a registry.
                                       
                                      • Haha
                                      • Love
                                      • Like
                                      Reactions: 6 users

                                      Ray D. Ayshun

                                      Full Member
                                      7+ Year Member
                                      Bronze Member
                                    • Sep 7, 2014
                                      1,580
                                      2,183
                                        Findings from Rapido study:

                                        Probability at three years of distant metastasis and locoregional failure were, in the experimental and standard arms, 19.8% vs 26.6% (HR 0.69 [0.53 – 0.89]; p = 0.004) and 8.7% vs 6.0% (HR 1.45 [0.93 – 2.25]; p = 0.10), respectively.

                                        Reception of more systemic therapy in the exp arm may have also reduced LRF a little more as well. In any case, possibly a 3% improvement in LRF for an extra 4 weeks of RT.
                                         
                                        • Like
                                        • Okay...
                                        Reactions: 1 users

                                        RealSimulD

                                        Full Member
                                        Jul 16, 2021
                                        222
                                        695
                                        1. Attending Physician
                                          I’m no statistician, but I don’t think that’s how that works… two studies comparing long and short (non TNT) have shown no local control difference. I’m not sure an non-statistically significant absolute difference of 2.7% is the argument to hang your hat on.
                                           
                                          • Like
                                          Reactions: 2 users

                                          Ray D. Ayshun

                                          Full Member
                                          7+ Year Member
                                          Bronze Member
                                        • Sep 7, 2014
                                          1,580
                                          2,183
                                            I’m no statistician, but I don’t think that’s how that works… two studies comparing long and short (non TNT) have shown no local control difference. I’m not sure an non-statistically significant absolute difference of 2.7% is the argument to hang your hat on.
                                            Like I said, possibly. We are a specialty good at powering trials for one thing to conclude other things. Kinda like powering a trial comparing breast schemes for local control in order to conclude toxicity equivalence.
                                             
                                            • Haha
                                            • Like
                                            Reactions: 1 users

                                            medgator

                                            Persona Non Grata
                                            15+ Year Member
                                            Gold Member
                                            Sep 20, 2004
                                            8,600
                                            6,952
                                            1. Attending Physician
                                              Findings from Rapido study:

                                              Probability at three years of distant metastasis and locoregional failure were, in the experimental and standard arms, 19.8% vs 26.6% (HR 0.69 [0.53 – 0.89]; p = 0.004) and 8.7% vs 6.0% (HR 1.45 [0.93 – 2.25]; p = 0.10), respectively.

                                              Reception of more systemic therapy in the exp arm may have also reduced LRF a little more as well. In any case, possibly a 3% improvement in LRF for an extra 4 weeks of RT.
                                              That's the big issue many of us have with that study, not a pure sc vs LC comparison. Hopefully data from those more recently accruing trials will clear things up
                                               
                                              • Like
                                              Reactions: 1 user

                                              OTN

                                              Member
                                              15+ Year Member
                                              Silver Member
                                              Nov 6, 2003
                                              1,530
                                              3,566
                                                I'm a huge fan of 25 / 5; and participated in the RAPIDO trial. Easier on the patient, good results; easier for the patient and the oncologists, and has level 1 evidence from at least TWO prospective, randomized studies that it's either better or not worse (RAPIDO, Polish-2). It does take different communication with the patient due to the proctitis happening after the radiation is complete...

                                                This latest WashU report builds on a long WashU legacy to let people know that there isn't something magical about US rectal cancer patients as opposed to European ones! After doing SCRT -> immediate surgery for several years there, a nice prospective, phase II study with SC-TNT came out (Five fractions of radiation therapy followed by 4 cycles of FOLFOX chemotherapy as preoperative treatment for rectal cancer - PubMed)

                                                I don't think the WashU report on it's own moves the needle; but it continues to investigate the regimen for organ preservation, and has patients with less advanced disease than RAPIDO. It includes the population that may be recommended for NO RADIATION after PROSPECT reports out. And it shows that this population may have good organ preservation with SC-TNT. That's going to keep radiation therapy involved in these 'bi-modality' patients; who may do equally well with RT+chemo; chemo+surgery; or maybe even RT+surgery.

                                                The key trial for the organ preservation, of course, is going on in Europe in Germany. They are randomizing patients between long course chemoradiation + chemo VERSUS short course radiation + chemo; essentially OPRA vs RAPIDO with the endpoint of cCR. Short-course Radiotherapy Versus Chemoradiotherapy, Followed by Consolidation Chemotherapy, and Selective Organ Preservation for MRI-defined Intermediate and High-risk Rectal Cancer Patients - Full Text View - ClinicalTrials.gov.

                                                With regards to changing practices... I brought short course radiation and TNT to our practice a few years ago; with many colleagues who had 20 years plus of experience. It took about 1 year to change the practice; and definitely to have some flexibility when starting out. I should collect our path outcomes both before and after the change; but anecdotally patients are doing quite similarly.

                                                And, it's interesting that the two NCCN centers in our area do not use short course radiation routinely! But none have the temerity to point out that the radiation I delivered was 'inappropriate'! Cause, you know, data.
                                                The European trial will, of course, tell us the answer. Do we even bother to try RCTs anymore in the US?
                                                 
                                                • Like
                                                Reactions: 3 users

                                                jondunn

                                                Account on Hold
                                                Account on Hold
                                              • Sep 13, 2021
                                                233
                                                286
                                                1. Attending Physician
                                                  I am very skeptical of 25/5, especially for NOM. Based on what we know/believe about BED and alpha/beta, LC has significantly higher BED than SC. If SC does prove to be equivalent to LC for in NOM for big T3 tumors, I will have an existential crisis and throw my Hall book in a dumpster fire.


                                                  I understand the sentiment, but the data is the data.

                                                  Alpha beta doesn’t seem to be telling the whole story
                                                   
                                                  • Like
                                                  Reactions: 1 user

                                                  TheWallnerus

                                                  e^(iπ) + 1 = 0
                                                  2+ Year Member
                                                  Gold Member
                                                  Apr 3, 2019
                                                  1,062
                                                  2,604
                                                  1. Attending Physician
                                                    I understand the sentiment, but the data is the data.

                                                    Alpha beta doesn’t seem to be telling the whole story
                                                    I would marry alpha beta if I could! It always tells the whole story, if you use the right alpha beta. The BED of 25/5 is bigger than 50.4/28... with the right alpha beta.*† (And sometimes all the cells in the same tumor refuse to tell the same alpha beta story.)

                                                    * and time correction factors
                                                    † α/β≤~3.8 (with ~0.5 per day BED-lessening correction factor), α/β≤~1.3 (with no time correction)
                                                     
                                                    Last edited:
                                                    • Like
                                                    Reactions: 2 users

                                                    RickyScott

                                                    Full Member
                                                    2+ Year Member
                                                    Oct 4, 2017
                                                    2,663
                                                    4,695
                                                    1. Attending Physician
                                                      I would marry alpha beta if I could! It always tells the whole story, if you use the right alpha beta. The BED of 25/5 is bigger than 50.4/28... with the right alpha beta.* (And sometimes all the cells in the same tumor refuse to tell the same alpha beta story.)

                                                      * and time correction factors
                                                      And maybe short course is less immunosuppressive
                                                       
                                                      • Like
                                                      Reactions: 2 users
                                                      About the Ads

                                                      evilbooyaa

                                                      Full Member
                                                      Staff member
                                                      Volunteer Staff
                                                      10+ Year Member
                                                      Verified Expert
                                                      Oct 10, 2011
                                                      7,295
                                                      7,911
                                                      1. Attending Physician
                                                        As a not very common user of 25/5, the Wash U study is interesting to me.

                                                        RAPIDO told me that TNT is probably better than ChemoRT/SC RT alone --> Surgery --> Chemo in an unselected population.

                                                        I agree with @elementaryschooleconomics that trying to get non-academic CRS on TNT can be a struggle on it's own.

                                                        Historically, my concern with watch and wait was whether LC was better than SC. I'd be intersted in seeing OPRA results compared to this Wash U paper.

                                                        @OTN , It's not the highest quality data to suggest that short course for non-op management is MANDATORY, but it does provide data (at least to me) that it's a reasonable tx paradigm.

                                                        As APM approaches closer and closer for the general population, we should all be ready to be willing to pivot to a shorter, equal fractionation. Not mandatory, but an option.
                                                         
                                                        • Like
                                                        Reactions: 4 users

                                                        GI_RadOnc

                                                        Full Member
                                                        Nov 7, 2019
                                                        89
                                                        254
                                                        1. Academic Administration
                                                          I've been using short course TNT for just about everyone with locally advanced rectal cancer, including W&W since 2014... helps that my job has a Polish med onc; so he's totally on-board! But I do support the equipoise that we don't know for sure in the W&W setting the SC-TNT vs the LC-TNT.

                                                          The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.

                                                          The better argument for long course rectal cancer chemoradiation is the lack of W&W data; and lack of integration of SC-TNT with the rest of your treatment team (med onc, surgery).

                                                          Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
                                                           
                                                          • Like
                                                          • Love
                                                          Reactions: 2 users

                                                          elementaryschooleconomics

                                                          Liberator of Flattening Filters
                                                          Silver Member
                                                          Nov 2, 2019
                                                          1,470
                                                          6,118
                                                          1. Attending Physician
                                                            The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.
                                                            I have a dream,

                                                            that one day future residents will practice in a specialty,

                                                            where they are not tested on their ability to memorize and regurgitate irrelevant trivia,

                                                            but on their ability to practice compassionate and and effective medicine.
                                                             
                                                            • Like
                                                            Reactions: 5 users

                                                            RealSimulD

                                                            Full Member
                                                            Jul 16, 2021
                                                            222
                                                            695
                                                            1. Attending Physician
                                                              I've been using short course TNT for just about everyone with locally advanced rectal cancer, including W&W since 2014... helps that my job has a Polish med onc; so he's totally on-board! But I do support the equipoise that we don't know for sure in the W&W setting the SC-TNT vs the LC-TNT.

                                                              The alpha/beta arguments and the non-statistically significant difference in local control are boomer arguments! That Hall textbook is about as relevant as the decay curve of a Co-60 teletherapy unit by now; and should be limited to the ABR board hazing only! And to not offer a patient 4 weeks of their life back for a numerical difference in local control that has a p=.10 is also silly.

                                                              The better argument for long course rectal cancer chemoradiation is the lack of W&W data; and lack of integration of SC-TNT with the rest of your treatment team (med onc, surgery).

                                                              Has anyone tried the FOLFOXIRI -> long course in the French study? I don't have the cajones to do it for locally advanced rectal cancer; but have seen some young patients with metastatic disease with a good response who have been referred in for the radiation...
                                                              Is that Prodige?
                                                               

                                                              Ray D. Ayshun

                                                              Full Member
                                                              7+ Year Member
                                                              Bronze Member
                                                            • Sep 7, 2014
                                                              1,580
                                                              2,183
                                                                The issue I have with 5 x 5 in w&w is that sometimes it works, and in this setting, that's good enough, because there's always surgery. Not much pressure to do any more than work every now and then. Is 54-56 gy plus xeloda more likely to cure rectal cancer than 5x5? I'll do a side bet for a really expensive bourbon at the next astro I attend.
                                                                 

                                                                jondunn

                                                                Account on Hold
                                                                Account on Hold
                                                              • Sep 13, 2021
                                                                233
                                                                286
                                                                1. Attending Physician
                                                                  The issue I have with 5 x 5 in w&w is that sometimes it works, and in this setting, that's good enough, because there's always surgery. Not much pressure to do any more than work every now and then. Is 54-56 gy plus xeloda more likely to cure rectal cancer than 5x5? I'll do a side bet for a really expensive bourbon at the next astro I attend.

                                                                  Sometimes it works? Why do you say sometimes?

                                                                  Your baseline belief is that 25/5 is ‘less than’ in terms of efficacy. As long as you have that bias, the rest of the conversation is hard to have
                                                                   

                                                                  RickyScott

                                                                  Full Member
                                                                  2+ Year Member
                                                                  Oct 4, 2017
                                                                  2,663
                                                                  4,695
                                                                  1. Attending Physician
                                                                    I have a dream,

                                                                    that one day future residents will practice in a specialty,

                                                                    where they are not tested on their ability to memorize and regurgitate irrelevant trivia,

                                                                    but on their ability to practice compassionate and and effective medicine.
                                                                    ..so if you don’t rate, just overcompensate …
                                                                     
                                                                    • Haha
                                                                    Reactions: 1 user

                                                                    Ray D. Ayshun

                                                                    Full Member
                                                                    7+ Year Member
                                                                    Bronze Member
                                                                  • Sep 7, 2014
                                                                    1,580
                                                                    2,183
                                                                      Sometimes it works? Why do you say sometimes?

                                                                      Your baseline belief is that 25/5 is ‘less than’ in terms of efficacy. As long as you have that bias, the rest of the conversation is hard to have
                                                                      Because sometimes it does. Sometimes long course dose too. Only an rct will determine which does it better, and one rct hints that a lower dose long course regimen (50.4 vs 54-56) is slightly better at controlling residual microscopic disease than short course. The idea that a five fx regimen thats barely more aggressive than a 5 fx palliative regimen would be used in the definitive setting seems weird. I'll trust the data, and buy the bourbon, if I'm wrong.
                                                                       

                                                                      RealSimulD

                                                                      Full Member
                                                                      Jul 16, 2021
                                                                      222
                                                                      695
                                                                      1. Attending Physician
                                                                        Because sometimes it does. Sometimes long course dose too. Only an rct will determine which does it better, and one rct hints that a lower dose long course regimen (50.4 vs 54-56) is slightly better at controlling residual microscopic disease than short course. The idea that a five fx regimen thats barely more aggressive than a 5 fx palliative regimen would be used in the definitive setting seems weird. I'll trust the data, and buy the bourbon, if I'm wrong.
                                                                        This is mood affiliation in action. The pCr rate in rapido trial is impressive, amongst highest reported. As the honorable alligator asks, is it the chemotherapy or the SCRT? I answer - “yes”.

                                                                        Give it a try. But beware the pelvic and abdominal spasms in week 1-2 after treatment. We have a handout made for this, with some people pre writing RXs

                                                                        It’s not bad to do LCRT, I’m not judging anybody. I think the problem, personally, is this is an advance for patients but we get punished to do it. This is a big problem in RO, in general.
                                                                         
                                                                        • Like
                                                                        Reactions: 2 users

                                                                        jondunn

                                                                        Account on Hold
                                                                        Account on Hold
                                                                      • Sep 13, 2021
                                                                        233
                                                                        286
                                                                        1. Attending Physician
                                                                          sometimes I think about what I would/will want as a patient. changes from time to time. how I feel right now:

                                                                          I would actively demand/want 5 fraction partial breast

                                                                          would want prostate sbrt

                                                                          I would lean towards wanting 25/5 but would be fine with either. 5.5 weeks is a long time to deal with the worsening acute toxicity, having to be on the table with it, etc

                                                                          I would be fine with any of 1,5,or 10 fraction for my bone mets. would prob pick 5, but that's not data based, just a little bit of wishful thinking.

                                                                          I would prefer 54/3 or 50/5 over 34/1 for my stage 1 lung cancer.
                                                                           
                                                                          • Like
                                                                          Reactions: 1 users

                                                                          Ray D. Ayshun

                                                                          Full Member
                                                                          7+ Year Member
                                                                          Bronze Member
                                                                        • Sep 7, 2014
                                                                          1,580
                                                                          2,183
                                                                            This is mood affiliation in action. The pCr rate in rapido trial is impressive, amongst highest reported. As the honorable alligator asks, is it the chemotherapy or the SCRT? I answer - “yes”.

                                                                            Give it a try. But beware the pelvic and abdominal spasms in week 1-2 after treatment. We have a handout made for this, with some people pre writing RXs

                                                                            It’s not bad to do LCRT, I’m not judging anybody. I think the problem, personally, is this is an advance for patients but we get punished to do it. This is a big problem in RO, in general.
                                                                            Pcr in SC double lc, 27% vs 13%, yet somehow trending towards worse lrf, or equivalent... In any case, using the results of a trial comparing the short course regimen to a long course regimen nobody uses in the definitive setting doesn't seem right.
                                                                             
                                                                            • Like
                                                                            Reactions: 1 user
                                                                            About the Ads

                                                                            Your message may be considered spam for the following reasons:

                                                                            1. Your new thread title is very short, and likely is unhelpful.
                                                                            2. Your reply is very short and likely does not add anything to the thread.
                                                                            3. Your reply is very long and likely does not add anything to the thread.
                                                                            4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
                                                                            5. Your message is mostly quotes or spoilers.
                                                                            6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
                                                                            7. This thread is locked.