Rad Onc Twitter

[deleted941485]

Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.

Always got pushback for BID from Ins and also the staff. So Im still doing 60/30 for SCLC and telling residents what to say to the friendly oral examiner for an exam that shouldn't even exist.

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[medgator]

Always got pushback for BID from Ins and also the staff. So Im still doing 60/30 for SCLC and telling residents what to say to the friendly oral examiner for an exam that shouldn't even exist.

It's unrealistic to do bid in situations, esp low volume clinics where you are trying to give 4-6 hours between fractions, not to mention it pretty much makes it impossible for the patient to continue to work through tx

 

[Lamount]

Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.

I would consider in highly selected patients with favorable distribution of dz. That’s a pretty toxic tx if a lot of the esophagus overlaps with PTV (acute > chronic)

 

[RickyScott]

I would consider in highly selected patients with favorable distribution of dz. That’s a pretty toxic tx if a lot of the esophagus overlaps with PTV (acute > chronic)

At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.

 

[deleted941485]

At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.

Thank god ENI was not a thing in my time, and I can just focus on the uptake on the PET scan.

 

[TheWallnerus]

It's unrealistic to do bid in situations, esp low volume clinics where you are trying to give 4-6 hours between fractions, not to mention it pretty much makes it impossible for the patient to continue to work through tx

When it comes to BID I am in low volume centers and just have to “suck it up” schedule wise when they appear. I have done a lot of BID and almost never have logistic problems per se. I agree it is impossible to work during BID. But being able to continue work during chemo radiation for locally advanced lung cancer is not safe bet even for once a day RT. I have FOMOS (fear of missing overall survival) when people or insurance companies attack BID. The worst financial toxicity and the most effective way to miss work is death. (Yes that’s hyperbolic.)

 

[metallica81788]

At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.

Subtle brag that all of your stage III lungs don't have fat level 7 nodes

 

[TheWallnerus]

At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.

On paper we all know 45/30 has a bit less acute radiobiological punch than 45/25 (the study that said 45/30 had worse esophageal toxicity) so it truly is a chronological area under the curve phenomenon. That said, in the Intergroup study, CT based planning happened for exactly zero patients. An esophageal DVH would have been a Martian to those investigators. I don’t even think the word “DVH” had been invented when the study started accruing. Now we are giving 60/15 to large volumes in the chest. That’s certainly got more acute RBE (on the esophagus) than 45/30.

Accelerated Hypofractionated Image-Guided vs Conventional Radiotherapy for Patients With Stage II/III Non-Small Cell Lung Cancer and Poor Performance Status: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT01459497.

pubmed.ncbi.nlm.nih.gov

 

[Burt Radnolds]

So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **

 

[Mandelin Rain]

Evicore “did their own research” and concluded that small cell lung cancer doesn’t even exist.

 

[thecarbonionangle]

Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.

In other words, BID is the nickelback of bands. Sadly my patients never agree to it

 

[jondunn]

BID is great/fine, that's not the issue, though I agree that most patients will choose another option.

the issue is 30 fraction BID vs 40 BID. I feel like this gentleman academic from Vanderbilt is the first person I've seen say that they want to offer it. When this first came out, on twitter, mednet, etc, most lung disease site academics said that they were not going to offer it, given the murkiness of the data. In this case it's not just Evicore, but the general tenor of the field. Med Onc has intense regulatory processes (for better or worse). Our version of this is a general consensus opinion from academics, lol.

 

[jondunn]

 

[Mandelin Rain]

They obviously ran a 10 patient Protons + chemo vs hospice trial.

Because otherwise, protons are the single greatest intervention in lung cancer since surgery.

 

[Palex80]

So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **

I seriously doubt that anyone will look into this in the future in a randomized Phase III design. The CALGB trial had to shut down the CCB-arm due to higher toxicity, if I recall correctly, and that CCB-arm would have produced an effect partially similar to what 60/1.5 bid did.
I will be offering 60/1.5 in fit patients, if I can meet constraints.
"Stong metastastic phenotype" is an argument, but we know (even from the Intergroup trial) that local progression is a major issue in these patients.
And I give almost all my LD-SCLC patients PCI. I believe in PCI.

 

[TheWallnerus]

So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **

Do you drag the patients in for more than 15 or 20 days?

 

[TheWallnerus]

I seriously doubt that anyone will look into this in the future in a randomized Phase III design. The CALGB trial had to shut down the CCB-arm due to higher toxicity, if I recall correctly, and that CCB-arm would have produced an effect partially similar to what 60/1.5 bid did.
I will be offering 60/1.5 in fit patients, if I can meet constraints.
"Stong metastastic phenotype" is an argument, but we know (even from the Intergroup trial) that local progression is a major issue in these patients.
And I give almost all my LD-SCLC patients PCI. I believe in PCI.

was sclc one of the first disease sites where a local radiotherapy in metastatic patients improved survival. ‘‘Twas controversial, hard to believe, etc. In SCLC, rad oncs could hold more sway. The med oncs don’t want us to though, and rad oncs seem to get taught in residency by the rad oncs they look up to that things like BID and PCI are almost being cruel to patients. You must be a mean guy if you want patients to come in twice a day.

Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial - PubMed

Dutch Cancer Society (CKTO), Dutch Lung Cancer Research Group, Cancer Research UK, Manchester Academic Health Science Centre Trials Coordination Unit, and the UK National Cancer Research Network.

pubmed.ncbi.nlm.nih.gov

 

[TheWallnerus]

When this first came out, on twitter, mednet, etc, most lung disease site academics said that they were not going to offer it, given the murkiness of the data

Will bet a 2019 dollar that those same academics were not offering 45/30 already. In relationship to its primacy and standard of care-ness, it (45/30) is the most underutilized thing of that nature in all of rad onc. If you already kind of staked your rep on being Mr QD (because I’m a good and smart doc) in SCLC, of course this data is “murky.”

 

[medgator]

Will bet a 2019 dollar that those same academics were not offering 45/30 already. In relationship to its primacy and standard of care-ness, it (45/30) is the most underutilized thing of that nature in all of rad onc. If you already kind of staked your rep on being Mr QD (because I’m a good and smart doc) in SCLC, of course this data is “murky.”

Prob should up the dose a bit to 70 if you're going to do QD but otherwise, there should be no problem compared to bid and we now have data to support that

https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.15_suppl.8505

 

[TheWallnerus]

Prob should up the dose a bit to 70 if you're going to do QD but otherwise, there should be no problem compared to bid and we now have data to support that

https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.15_suppl.8505

In the midst of this debate here will be the most true (dosimetric) statement for the day.

For a given thoracic PTV, the 20 Gy isovolume for a 70/35 plan is significantly greater in size than for a 45/30 plan, p→1/∞

 

[Palex80]

Prob should up the dose a bit to 70 if you're going to do QD but otherwise, there should be no problem compared to bid and we now have data to support that

https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.15_suppl.8505

I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.

 

[medgator]

I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.

That doesn't seem to be the case here.... 70/35 looks perfectly fine as an alternative imo

 

[TheWallnerus]

I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.

That doesn't seem to be the case here.... 70/35 looks perfectly fine as an alternative imo

Again on paper alpha beta wise what a huge jump in RBE from 45/30 to 66 or 70 qd. And they yielded bupkis. And then we do one dose escalation trial of bid and it’s positive. It’s almost like the SCLC data is trying to tell us BID works. If you have a plan where cord or lung or heart constraints can’t be met with 70 Gy RX dose, 45 Gy is such a friend.

 

[elementaryschooleconomics]

Come for the memes, stay for the alpha/beta calculations!

 

[TheWallnerus]

Come for the memes, stay for the alpha/beta calculations!

The longer you stay the more you have to correct for time in the calc

 

[Lamount]

Again on paper alpha beta wise what a huge jump in RBE from 45/30 to 66 or 70 qd. And they yielded bupkis. And then we do one dose escalation trial of bid and it’s positive. It’s almost like the SCLC data is trying to tell us BID works. If you have a plan where cord or lung or heart constraints can’t be met with 70 Gy RX dose, 45 Gy is such a friend.

I interpret this to be a matter of acceleration combating repopulation. For the most part, I BID all of my patients... but I am at a big academic center that treats for 12 hours a day on many machines, so it isn't a logistical hurdle for us (other than having two OTVs/week). From what patient's tell me, both 6-7 weeks QD vs. 3 weeks BID both kinda suck equally. If they are coming in from out-of-town, BID is actually better for them.

I am not against 60/40 BID... but we put most of our SCLC on LU005... and those who aren't on trial are usually too sick for enrollment, so aren't great candidates for the 4-weeks-from-hell approach

 

[TheWallnerus]

I interpret this to be a matter of acceleration combating repopulation.

Highlighted are radiotherapy theories from the 1980s, theories that haven't been invalidated yet.

 

[Lamount]

Highlighted are radiotherapy theories from the 1980s, theories that haven't been invalidated yet.

Great reference!

This certainly seems like it is part of it. If you subscribe to the linear quadratic model (which I do), SCLC has a very high a/b ratio, which means that fractionation really doesn't matter that much... meaning total dose = total dose (much like fractionation doesn't change the impact of heavy ions).

Where the BID is probably HELPFUL, is that you are getting in 3 Gy each day rather than 2 Gy, but not paying the price in terms of long term tox because of the benefits of hyperfractionation. Short term toxicity is another story... but esophagitis heals.

 

[RickyScott]

Will sometimes give 45/15 depending on volume

 

[thecarbonionangle]

Will sometimes give 45/15 depending on volume

Canadians do this and works fantastique!

 

[TheWallnerus]

In other words, BID is the nickelback of bands. Sadly my patients never agree to it

Canadians do this and works fantastique!

We Asked Canadians Why They Hate Nickelback So Much And The Responses Are Hilariously Savage

 

[medgator]

Will sometimes give 45/15 depending on volume

My go to es sclc consolidation dose

 

[Ray D. Ayshun]

We Asked Canadians Why They Hate Nickelback So Much And The Responses Are Hilariously Savage

Just a bunch of anonymous aholes complaining on the internet? I've heard that one before.

 

[Ray D. Ayshun]

Will sometimes give 45/15 depending on volume

Been wondering if we could get away with 45 in 14.

In other news, on my way back from lunch I was wondering if gen surg has considered a trial of using restraints and a leather strap to bite down on in lieu of anesthesia. Slightly more acute toxicity but less financial toxicity I bet.

*Constraints changed to restraints..

 

[elementaryschooleconomics]

Been wondering if we could get away with 45 in 14.

In other news, on my way back from lunch I was wondering if gen surg has considered a trial of using constraints and a leather strap to bite down on in lieu of anesthesia. Slightly more acute toxicity but less financial toxicity I bet.

I heard GenSurg is running a non-inferiority trial reducing the number of sutures they use to close an incision. By using less Vicryl, they're not only reducing financial toxicity but also their carbon footprint. Do you really need more than two or three stiches to close an ex-lap? Seems wasteful.

That reminds me - why aren't we trying to reduce our carbon footprint? Is penumbra really that important? Less flash/smaller field sizes means less electricity, which means we can save the polar bears. I'll start writing up the protocol, I'll name it something cute like POSTAGE-STAMP PORTAL 2112.

 

[evilbooyaa]

Prob should up the dose a bit to 70 if you're going to do QD but otherwise, there should be no problem compared to bid and we now have data to support that

https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.15_suppl.8505

I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.

Taking two trials testing superiority of a BED-escalated daily regimen, having that fail the primary end point, then saying "well it looks to be similar" is fair. Offering it as an alternative to patients who can't/won't come for 45/30 BID is fair.

Taking it a step further and suggesting that once daily should be the preferred regimen or that it looks non-inferior is a statistical leap that I believe speaks to the biases of the posters in question more than it does in regards to the data.

There was once a phase II randomized trial improved OS. We (mostly) all treat oligomets now.

Now a phase II randomized trial also improved OS by tacking on 10 extra treatments. When it was presented last year, it didn't make sense because the PFS looked identical and OS was better - how did that happen, many (including myself) asked? But, there was an update in the paper. PFS improvement in 60/40 is numerically there, but P-value is like 0.13 or 0.067. They're underpowered for PFS. Somehow the median time from progression until death was longer in the 60Gy group. Unclear how that happened. But, they were (or at least seem to have been) powered for OS. P-value 0.012 on KM curves, with a goal of p < 0.1.
Better than P-value of 0.09 for OS in SABR-COMET KM curves, which was "statistically" significant because the goal was p < 0.20.

 

[radiation]

Highlighted are radiotherapy theories from the 1980s, theories that haven't been invalidated yet.

for all the hate on radbio, it still amazes me to this day that this trial exists and was completed. Same dose once or twice a day is the most pure radbio experiment you could do and there was an OS difference. Imagine doing the equivalent med onc trial of a drug dose once or twice a day. I can think of no other pure radiation question in the field that has a phase III trial showing a survival benefit for a primary endpoint. Every other major trial has used chemo or hormones to get a survival benefit

 

[TheWallnerus]

for all the hate on radbio, it still amazes me to this day that this trial exists and was completed. Same dose once or twice a day is the most pure radbio experiment you could do and there was an OS difference. Imagine doing the equivalent med onc trial of a drug dose once or twice a day. I can think of no other pure radiation question in the field that has a phase III trial showing a survival benefit for a primary endpoint. Every other major trial has used chemo or hormones to get a survival benefit

Conceived by med onc turned rad onc Turrisi no less.

 

[Mandelin Rain]

Taking two trials testing superiority of a BED-escalated daily regimen, having that fail the primary end point, then saying "well it looks to be similar" is fair.

Taking it a step further and suggesting that once daily should be the preferred regimen or that it looks non-inferior is a statistical leap that I believe speaks to the biases of the posters in question more than it does in regards to the data.

If you're RTOG and Kian Ang (RIP), you take that data and make the failed regimen the standard arm for head and neck cancer for all future trials. See: RTOG 0129.

The right way. The wrong way. And the MD Anderson way.

 

[elementaryschooleconomics]

I heard GenSurg is running a non-inferiority trial reducing the number of sutures they use to close an incision. By using less Vicryl, they're not only reducing financial toxicity but also their carbon footprint. Do you really need more than two or three stiches to close an ex-lap? Seems wasteful.

That reminds me - why aren't we trying to reduce our carbon footprint? Is penumbra really that important? Less flash/smaller field sizes means less electricity, which means we can save the polar bears. I'll start writing up the protocol, I'll name it something cute like POSTAGE-STAMP PORTAL 2112.

Look, guys, I was joking, no need to go this far:

 

[Ray D. Ayshun]

Look, guys, I was joking, no need to go this far:


View attachment 345954

View attachment 345956

Good way of picking a treatment. Another way of reducing CO2 emissions would be picking a regimen with a worse OS.

 

[Gfunk6]

Good way of picking a treatment. Another way of reducing CO2 emissions would be picking a regimen with a worse OS.

Ah ha! Now we know that RO-APM was really an attempt to reduce America's carbon footprint.

 

[deleted941485]

I guess you want to go from probationary status to banned? Hey when you can't fight the facts, ad-hominem! Is that you, KO?

Here's another gem, completely divorced from the reality of clinical practice:

Yeah the best research in the field affected the only reason I get up in the morning and put up with the bull**** that I do. Oh only a minor point in Kens mind.

 

[elementaryschooleconomics]

This is an absolute gem of a statement.

"[Hypofractionation] doesn't change the need for RadOnc, just the reimbursement." - Kenneth Olivier

In the context of "we're not training too many Radiation Oncologists". Man, I think one or two things have changed since March 12th, 2019. I don't want to pile on the other folks in that series of Tweets, so I'll just say that reading everything there is like opening a time capsule...and that wasn't even three years ago!

 

[medgator]

View attachment 345967

This is an absolute gem of a statement.

"[Hypofractionation] doesn't change the need for RadOnc, just the reimbursement." - Kenneth Olivier

In the context of "we're not training too many Radiation Oncologists". Man, I think one or two things have changed since March 12th, 2019. I don't want to pile on the other folks in that series of Tweets, so I'll just say that reading everything there is like opening a time capsule...and that wasn't even three years ago!

The same guy that hired an extender so he could get more Twitter time. I'm guessing he's salaried at Mayo, so hypofx is a win win for him for getting extra time with the bird.

*He* still has to staff that consult and sign a plan, but now he has less patient visits to deal with and more time to write inane tweets

 

[jondunn]

Taking two trials testing superiority of a BED-escalated daily regimen, having that fail the primary end point, then saying "well it looks to be similar" is fair. Offering it as an alternative to patients who can't/won't come for 45/30 BID is fair.

Taking it a step further and suggesting that once daily should be the preferred regimen or that it looks non-inferior is a statistical leap that I believe speaks to the biases of the posters in question more than it does in regards to the data.

There was once a phase II randomized trial improved OS. We (mostly) all treat oligomets now.

Now a phase II randomized trial also improved OS by tacking on 10 extra treatments. When it was presented last year, it didn't make sense because the PFS looked identical and OS was better - how did that happen, many (including myself) asked? But, there was an update in the paper. PFS improvement in 60/40 is numerically there, but P-value is like 0.13 or 0.067. They're underpowered for PFS. Somehow the median time from progression until death was longer in the 60Gy group. Unclear how that happened. But, they were (or at least seem to have been) powered for OS. P-value 0.012 on KM curves, with a goal of p < 0.1.
Better than P-value of 0.09 for OS in SABR-COMET KM curves, which was "statistically" significant because the goal was p < 0.20.

How can you be underpowered for PFS, when it is a more commonly occurring event than seen with OS? That doesn’t make sense.

Am I incorrect in my understanding?

 

[jondunn]

Canadians do this and works fantastique!

45/15 is great. all things being considered I think that’s what makes the most sense, in many ways.

 

[Lamount]

How can you be underpowered for PFS, when it is a more commonly occurring event than seen with OS? That doesn’t make sense.

Am I incorrect in my understanding?

Maybe it’s that SCLC spreads the same regardless, but kills people slower with better thoracic control… or perhaps more RT improves non-cancer mortality 🤣

 

[jondunn]

Maybe it’s that SCLC spreads the same regardless, but kills people slower with better thoracic control… or perhaps more RT improves non-cancer mortality 🤣

Well that is a reasonable idea about how OS can improve without PFS or local control improving, which is what was seen in the trial, and to me doesn’t pass the smell test and deserves to be further explored to see if there is some mechanism here.

However my question was about the study being underpowered for PFS, which doesn’t make sense and is simply untrue based on my understanding of statistics.

 

[jondunn]

It’s much more likely that there’s a biologic imbalance in the arms, in my opinion.