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Moonbeams said:
I'd also wonder about the feasibility of doing a sequential boost with a replan after 30. Carve dose out of the esophagus heart and take the reduced volume gross dz only to 60. I'm hesitant to make up stuff, but the concern with going to 60/40 is esophageal toxicity. That way you at least deliver the 45/30 standard of care, and if there really is a benefit of 10 more fractions, you are at least getting some of it this way with hopefully an acceptable toxicity tradeoff until there is a clearer answer. I haven't done this yet, but the concept is appealing. I struggle with esophageal toxicity enough with 30 fractions.

The scandinavians took the same volume all the way through to 60, correct? I don't have the study.
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No excess tox w/ 60/40

There should be in theory more acute tox w/ 60/40 bid vs 60/30 qd but I don’t think we should overly fret over the former (verboten?) vs the latter (std of care in NSCLC)
 
Moonbeams said:
So you just circle (on the 4D scan) the gross tumor, gross nodes, add a PTV margin and treat all the way through like that? I was trained to add a CTV expansion and include the rest of the nodal station at the levels the CTV expanded to, and I usually do a tad bit of electivsh expansion beyond that. Yes, I could see where toxicity would be a lot better that way.
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Disease you can see plus 7mm is the optimized (ie PTV) volume… for me
 
sirspamalot said:
Does -anyone- actually do BID for SCLC in the real world community practice?

And, if you do, do you go to the "higher dose" ie beyond 45?

I cannot recall last time I did BID..
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Yes, all the time. I have a lot of patients who travel quite a bit and they all liked the BID.

It actually works well with chemotherapy.
 
udrag14 said:
Yes, all the time. I have a lot of patients who travel quite a bit and they all liked the BID.

It actually works well with chemotherapy.
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When sirspamalot asked “Does anyone actually do bid in real world community practice” it is just another way of asking “Does anyone actually do the proven-best standard of care regimen in real world community practice.” When anyone says “rad onc is SO evidence based” I can’t help but murmur “for some things” under my breath.

BID for small cell is more discriminated against in rad onc than minorities are.
 
I don't see a ton of SCLC, maybe 5-10 cases a year but the majority tend to choose BID. I've only had one patient in the last year choose QD. I do discuss both options with them but say I recommend BID if they're able to tolerate the logistics. I haven't tried 60/40 yet but I plan to recommend for the next case I see.
 
TheWallnerus said:
“Does anyone actually do the proven-best standard of care regimen in real world community practice.”
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Not really true post calgb/rtog results:

favorable outcomes on the QD arm provide the most robust evidence available supporting high dose once-daily TRT as an acceptable option in LSCLC
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medgator said:
Not really true post calgb/rtog results:
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It was a negative trial!

This is like saying b/c of ACT study, cisplatin is standard of care for anal cancer.

It’s fine to do qD. Completely legit. It just rankles me to hear things like “in the real world, patients don’t want to do it”. My first practice - one of the locations was considered rural access, and I never did one qD.

I’ve worked in very challenging locales and those patients will do what we say, if there is a reason for it. Just because you were taught it was inconvenient or feel that way doesn’t mean “that’s the real world”
 
RealSimulD said:
It was a negative trial!

This is like saying b/c of ACT study, cisplatin is standard of care for anal cancer.

It’s fine to do qD. Completely legit. It just rankles me to hear things like “in the real world, patients don’t want to do it”. My first practice - one of the locations was considered rural access, and I never did one qD.

I’ve worked in very challenging locales and those patients will do what we say, if there is a reason for it. Just because you were taught it was inconvenient or feel that way doesn’t mean “that’s the real world”
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I’ll go one further. In 20 years and multiple practice locales I’ve never treated a single LS small cell patient QD (because I don’t discuss QD).
apocalypse now horror GIF by Maudit
 
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RealSimulD said:
It was a negative trial!

This is like saying b/c of ACT study, cisplatin is standard of care for anal cancer.

It’s fine to do qD. Completely legit. It just rankles me to hear things like “in the real world, patients don’t want to do it”. My first practice - one of the locations was considered rural access, and I never did one qD.

I’ve worked in very challenging locales and those patients will do what we say, if there is a reason for it. Just because you were taught it was inconvenient or feel that way doesn’t mean “that’s the real world”
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95% of my LS-SCLC get BID... in fact, I struggle to think of the last person who got qday
 
You can also give your LD-SCLC higher fractions. The Canadians do it alot, just give 2.75 Gy/d.
It's the acceleration that counts, not the hyperfractionation.
 
Bunch of b.i.d virtue signaling on here! Bidches.

I usually do daily and very occasionally bid.

I don't believe bid is preferable for all patients. Elderly with large mediastinal disease, community hospital setting, I'm not doing bid. You get the pt through and the patient gets admitted. Admission can be a bear and you are not managing it. Patients do sometimes die acutely in this setting.

Palex80 said:
You know that you can simply QD your LD-SCLC, just give them higher fractions. The Canadians do it alot, just give 2.75 Gy/d.
It's the acceleration that counts, not the hyperfractionation.
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I don't know about this.

There may be something real and biologic about bid being slightly better. I believe the Norwegians (who for some reason have done various fractionation scheme studies) looked at hypofractionation and didn't see improved outcomes, whereas they did with hyperfractionation.

Reassortment? Radiation induced chemosensitization? Who knows. Maybe not real at all. Lots of small trials here and could be rando.

However, there is this...and CALGB was a big trial...and cancer outcomes were equivalent. I don't believe there was a QOL improvement in ACT.

 
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communitydoc13 said:
Bunch of b.i.d virtue signaling on here! Bidches.
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LOL, I just dont get why team BID cant accept equivalence! I wish we spent more time focusing on the politics of trial design.

I present them as equal and let people pick. For patients who are interested, I tell the history of the studies and explain how, despite their intense passion, the Bidches have never been able to show that it is better. At my last job, it was the "institutional" standard. So I structured the discussion to favor BID and I just said that in our group it was preferred.

Really, it is better to put your energy into enrolling to LU 005, which lets you do either. It is maybe a little easier to be protocol compliant on dosimetry with BID.

Anecdotally, maybe 30% picked BID. Many just couldn't swing it.
 
NotMattSpraker said:
I wish we spent more time focusing on the politics of trial design.
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Yeah!

So as someone who doesn't know. Does pharma or pharma providing a drug for trial make a difference?

Thinking about trials like NRG GU_008. They added Abiraterone and Apalutamide to the experimental arm, whereas the benefit of any additional systemic therapeutic to ADT in this setting is unknown.
 
Lol not virtue signaling

I think it may be equal.

But I think faster is great.

And, my only gripe is that people are saying it’s patient preference and that they won’t do it and BID is too hard. It has not been true for me in any setting I’ve worked in. It is okay to have your own biases - if you think qD is equal or better, then that’s fine. You’ll note I am not having a debate on efficacy.

I am sure 45/15 or 50/20 would be good, too.

Queen BIDtch
 
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I don't think Convert showed equivalence if you read that trial honestly. I think it's a bit much to say that BID is outright stupid based on it though.
Especially with the 60/40 scandinavian data and radiobiologic basis for BID, I still believe BID is SOC and recommend it but don't fault those who recommend daily instead.

Additionally, there are situations where I think BID clearly is better, namely when the patient is already well into or past the 2nd cycle. It's pretty clear that you need to get the patient to 45 Gy asap at that point. I have been in this situation where the med onc referred the patient late, then talked the patient out of BID. I was not pleased.

Speaking of which, when med onc sends a patient late and the primary has disappeared on your CT sim, do you all
1) Treat the original primary volume on the pre-chemo scan
2) Treat where the original was with a smaller volume
3) Treat mediastinum/hilar nodes only.
 
A quick 2 cents about ACTII since it gets mentioned here and there...

Cisplatin is likely equivalent to MMC and is probably less toxic. ACT2 showed them as dead even in terms of disease control outcome and was a huge well done trial. However it was not a non inferiority study so primary endpoints not met.

MMC has much more hematologic toxicity which was confirmed in the trial, but OVERALL rates of toxicity were the same cause everyone gets banged up by the radiation.

In the end, the Brits stuck with MMC because it was cheaper and is a 15 min infusion instead of 4 hours for cis with hydration. It's all about the bottom line for them.

I'd take the cisplatin if it were me.
 
RealSimulD said:
BID is too hard. It has not been true for me in any setting I’ve worked in.
Click to expand...

World's most toxic boss weighing in here...

I find the notion that BID is too hard on staff to be ridiculous. Specifically how? The patient gets 30 treatments either way. Practically it's just a second patient for the day. Sure, it's 15 minutes I guess they can't leave earlier for 3 weeks. But you're taking up 2 spots for 3 weeks versus 1 for 6 and half. Who's to say those last 3.5 weeks wouldn't be during a time when your machine happens to be coincidentally slammed. Also, I do not believe in adjusting my treatment plan based on what is convenient for staff. I make the plan on what is best for the patient, no exceptions, and then work around that.
 
communitydoc13 said:
Yeah!

So as someone who doesn't know. Does pharma or pharma providing a drug for trial make a difference?

Thinking about trials like NRG GU_008. They added Abiraterone and Apalutamide to the experimental arm, whereas the benefit of any additional systemic therapeutic to ADT in this setting is unknown.
Click to expand...

It is different, but I view it as a logistical difference not like one is inherently better or worse when it comes to design. Im not sure if you were implying this or not, but weird trial design seems to be just as likely to come from "pure academics" versus industry sponsored. The lymphoma trials and SCLC we are discussing here are great examples of areas where politics and biases seem to really influence the design and none of those are industry funded.

Within NRG, there is now the RTOG Foundation that focuses on industry collaborations. About Us

You can see who sponsors any trial at clinicaltrials.gov. As an example GU 008 is NCI funded whereas Pacific 4 (an RTOGF trial) is AZ funded.

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov
 
Moonbeams said:
World's most toxic boss weighing in here...

I find the notion that BID is too hard on staff to be ridiculous. Specifically how? The patient gets 30 treatments either way. Practically it's just a second patient for the day. Sure, it's 15 minutes I guess they can't leave earlier for 3 weeks. But you're taking up 2 spots for 3 weeks versus 1 for 6 and half. Who's to say those last 3.5 weeks wouldn't be during a time when your machine happens to be coincidentally slammed. Also, I do not believe in adjusting my treatment plan based on what is convenient for staff. I make the plan on what is best for the patient, no exceptions, and then work around that.
Click to expand...

Well, you might also consider that the behavior of the staff and the patient have a big impact on "what is best for the patient".

There is medicine in papers and the raging dumpster fire that is medicine in real life.
 
medgator said:
Except the data shows it isn't necessarily better for the patient outside of perhaps the theoretical scenarios you've posted
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Before calgb outcome, the rationale (and I’ve seen it on SDN) is that it is too inconvenient. This still keeps coming up. Once people say “it’s actually not, we do it all the time”. Then you hear about negative trial as justification- which is fine. I don’t think it’s wrong to say that qD seems fine.

But, it’s still a negative trial, the SOC remains BID (based on conclusion of paper).
 
RealSimulD said:
Before calgb outcome, the rationale (and I’ve seen it on SDN) is that it is too inconvenient. This still keeps coming up. Once people say “it’s actually not, we do it all the time”. Then you hear about negative trial as justification- which is fine. I don’t think it’s wrong to say that qD seems fine.

But, it’s still a negative trial, the SOC remains BID (based on conclusion of paper).
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Until you start looking at qol data....


Then it starts to make sense why the original paper came out and said high-dose qd is a clearly "acceptable" option. The esophagitis and convenience issues are nothing to sneeze at
 
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NotMattSpraker said:
LOL, I just dont get why team BID cant accept equivalence! I wish we spent more time focusing on the politics of trial design.

I present them as equal and let people pick. For patients who are interested, I tell the history of the studies and explain how, despite their intense passion, the Bidches have never been able to show that it is better. At my last job, it was the "institutional" standard. So I structured the discussion to favor BID and I just said that in our group it was preferred.

Really, it is better to put your energy into enrolling to LU 005, which lets you do either. It is maybe a little easier to be protocol compliant on dosimetry with BID.

Anecdotally, maybe 30% picked BID. Many just couldn't swing it.
Click to expand...
I am not against qday, and I present both.

I do feel like BID is a little easier to make lung constraints with bulky mediastinal disease.
 
RealSimulD said:
Before calgb outcome, the rationale (and I’ve seen it on SDN) is that it is too inconvenient. This still keeps coming up. Once people say “it’s actually not, we do it all the time”. Then you hear about negative trial as justification- which is fine. I don’t think it’s wrong to say that qD seems fine.

But, it’s still a negative trial, the SOC remains BID (based on conclusion of paper).
Click to expand...

The negative trial does not justify that argument, they are taking you for a ride! The correct conclusion is that daily is not superior to BID, that was the question asked. If you dive in to the stats, they actually designed it so daily had to be a lot superior to be positive... almost 9% better on OS! Its funny, people abuse non-inferiority like crazy. Here I think it actually makes sense and we didnt get that.

As far as I know, every modern study has not been able to show a difference. That is what I tell patients.

1668700859357.png
 
NotMattSpraker said:
Well, you might also consider that the behavior of the staff and the patient have a big impact on "what is best for the patient".

There is medicine in papers and the raging dumpster fire that is medicine in real life.
Click to expand...
My experience is that is has not been a problem.
6.5 weeks gives more time for there to be issues, something to come up to cause the patient to quit. the esophagitis happens more on treatment than post-treatment, etc. In a disease where time is of the essence, I believe in just getting the dose in as quickly as possible. I don't shame people who prefer daily, but there seems to be a lot of shaming the other way around. Can't we all get along?
 
Nobody has asked the question as to which pays more… I’m assuming qday. Logistically better for qday if that’s the case since you are doing technically the same amount of work. I know we can’t talk about financials here as admins dictate everything we do, so please carry on another senseless debate. I’ll add this to the breast is worst pile!
 
I treat a very diverse population of patients, across two very different systems- and treat BID. Have actually yet to have a patient not be ok with it- and for most of our patients getting it done in 3 weeks instead of daily for 6-7 weeks, is really appreciated.

In residency was told that no one wants to be treated with BID radiation.
Once I had to make my own decisions, had a hard time getting decent V20's with large tumors to 66 Gy on older equipment. Amazing what dropping the dose to 45 Gy did for those OARs.

Since then I'm all in on the BID bandwagon.
Have yet to treat 60 Gy in 40 fractions though...
 
communitydoc13 said:
Yeah!

So as someone who doesn't know. Does pharma or pharma providing a drug for trial make a difference?

Thinking about trials like NRG GU_008. They added Abiraterone and Apalutamide to the experimental arm, whereas the benefit of any additional systemic therapeutic to ADT in this setting is unknown.
Click to expand...
GU008 has been amended. Apalutamide no abiraterone

1668702166656.png
 
communitydoc13 said:
I don't believe bid is preferable for all patients. Elderly with large mediastinal disease, community hospital setting, I'm not doing bid. You get the pt through and the patient gets admitted. Admission can be a bear and you are not managing it. Patients do sometimes die acutely in this setting.
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On paper, 45/30 should have significantly less acute and long-term side effects than 60/30 or more. OAR constraints can be certainly be more easily met trying to take "large mediastinal disease" to 45 Gy total dose versus 60 Gy or more. Patients do die acutely getting 60/30 chemoRT too. The 45/30 esophageal toxicity rates from the 1990s when the Intergroup SCLC BID trial was conceived and accrued (and when ENI was a thing) can't be expected to be as high in the IMRT (ISRT)/PET era.
rymd said:
Once I had to make my own decisions, had a hard time getting decent V20's with large tumors to 66 Gy on older equipment. Amazing what dropping the dose to 45 Gy did for those OARs.
Click to expand...
ditto
 
RadOncDoc21 said:
Nobody has asked the question as to which pays more… I’m assuming qday. Logistically better for qday if that’s the case since you are doing technically the same amount of work. I know we can’t talk about financials here as admins dictate everything we do, so please carry on another senseless debate. I’ll add this to the breast is worst pile!
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Charge per fx and every 5 gets an otv, so not really a difference unless you are giving more than 30 fx qd which you should be per trial in which case qd wins by a smidge.

Edit: 40 fx given bid will win out if you feel comfortable doing that off a European abstract
 
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RadOncDoc21 said:
Nobody has asked the question as to which pays more… I’m assuming qday. Logistically better for qday if that’s the case since you are doing technically the same amount of work. I know we can’t talk about financials here as admins dictate everything we do, so please carry on another senseless debate. I’ll add this to the breast is worst pile!
Click to expand...
I would assume that would be the 40 fraction BID plan. You can bill a special treatment procedure code 77470 for BID, but you get that with chemo anyway.
Although with BID, it's easier to miss charges since you're doing OTVs and image review twice as often.
 
Thanks for the responses. I guess I’m just tired of hearing all the arguments we make in our field when at the end we’re dealing with small cell. Once a day isn’t better or worst then twice a day but in the end, they all die. We continue to argue. If only we used this energy to argue why we need to stop seeing declines in reimbursements and stop expanding residency programs. I know we can have more then one conversation but I swear we are the only field in medicine that can truly justify anything in things that don’t matter… that’s all I’m saying.
 
communitydoc13 said:
Yeah, and my question now is why did they stick with Apa and not Abi (which is a cheap drug now with excellent evidence of benefit in the very high risk and metastatic setting).
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Good question. I don't know the answer. I wasn't in the room.

I do know that the reason RTOG 9601 used bicalutamide 150mg in lieu of GNRH was that the company provided drug and placebo.
 
RadOncDoc21 said:
Thanks for the responses. I guess I’m just tired of hearing all the arguments we make in our field when at the end we’re dealing with small cell. Once a day isn’t better or worst then twice a day but in the end, they all die. We continue to argue. If only we used this energy to argue why we need to stop seeing declines in reimbursements and stop expanding residency programs. I know we can have more then one conversation but I swear we are the only field in medicine that can truly justify anything in things that don’t matter… that’s all I’m saying.
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Ha! They don’t all die. Stage III SCLC had better long term survival probabilities than Stage III NSCLC in the anteimmunotherapy era. Even in the NEJM paper 5y OS was 26 percent at 5y; 74% is way less than all. And 5y OS with 60/40 appears to be ~40%.

I am convinced most modern rad onc trainees are trained to think:
*BID is unethically inconvenient
*BID is equivalent to QD for OS
*BID melts esophaguses
*it’s ok to be nihilistic about SCLC
 
Rankle away. My patients are often poor, poorly educated, have difficulty paying or even obtaining transportation (20% use the free rideservice, whose reliability is hardly perfect even at qD) and then of course, you have just regular ole' patient compliance. Half my patients keep smoking thru treatment.

Hate the game, not the playa
 
RadOncDoc21 said:
For the record I’m pro Qday because I don’t want my patient showing up at 5.
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This is an acceptable answer. Also, as someone texted me, it is inconvenient for staff and doc, so they don't like to do it. That's fine. It reimburses a little less, and that's an acceptable answer, too.

I just don't buy that all patients are refusing to do something the doctor says for a few particular docs, but happen to be very obedient for the rest of us.
 
RealSimulD said:
I just don't buy that all patients are refusing to do something the doctor says for a few particular docs, but happen to be very obedient for the rest of us.
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Yes, many patients are obedient. Many want to be, but for reasons.. aren't. At least 10% in my world aren't on any given week. Perhaps you are tooting your horn to imply you have 100% compliance and heavens to betsy forbid, some of us don't have that in our patient population. It must be the doctor! Ridiculous.

I don't know where you practice, or where you are in your career arc, but your holier than thou attitude won't serve you well... unless of course, you're at one of our fine fine ivory tower institutions.
 
sirspamalot said:
I don't know where you practice, or where you are in your career arc, but your holier than thou attitude won't serve you well... unless of course, you're at one of our fine fine ivory tower institutions.
Click to expand...

Bruh, no offense but this is legit hilarious that you're saying this to Simul (someone who's practice and career arc seem to have been discussed ad nauseum here)
 
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