RadOnc Is Still The Best Field in Medicine

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Seems silly to treat with immunotherapy alone in melanoma with brain metastases considering the responses to immunotherapy alone in melanoma brain metastases are much worse than the responses to EGFR inhibitors in mutant NSCLC.
You are absolutely right, but I can also tell you that we have a seen a very sharp fall off in melanoma/brain pts over the last 6 months.

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Seems silly to treat with immunotherapy alone in melanoma with brain metastases considering the responses to immunotherapy alone in melanoma brain metastases are much worse than the responses to EGFR inhibitors in mutant NSCLC.

Not to oncologic idiots, unfortunately. And there's quite a few of those running around in my local med onc department at the given moment.
 
Not to oncologic idiots, unfortunately. And there's quite a few of those running around in my local med onc department at the given moment.
That kind of stuff doesn't happen in my neck of the woods, in community practice, yet.

Probably because the MOs out in the wild consider it borderline malpractice not to at least refer to RO upfront for a consult
 
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No one is more into intracranial SRS than me. NO ONE.

BUT - you guys are being blind if you don't see the importance of stuff like the Tawbi NEJM paper. I agree that rad onc should be super involved up front and be following patients for salvage or for identifying mets that should be treated up front rather than followed with immune checkpoint inhibitors. but these high response rates are real and are an important part of the management for these patients.

ALSO - the Amundson paper was based on Tarceva, not Osi, which has a much higher intracranial response rate.

If you're going to be a good CNS rad onc in 2018, you better be aware.

calling upfront observation on ICI for very select patients with brain mets 'oncologic idiocy' only makes you the idiot.

with good up front involvement, we're still going to be treating PLENTY of brain mets, maybe more for some patients.

however - definitely agree that some med oncs don't know what they're doing with these patients. They need us desperately.
 
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No one is more into intracranial SRS than me. NO ONE.

BUT - you guys are being blind if you don't see the importance of stuff like the Tawbi NEJM paper. I agree that rad onc should be super involved up front and be following patients for salvage or for identifying mets that should be treated up front rather than followed with immune checkpoint inhibitors. but these high response rates are real and are an important part of the management for these patients.

ALSO - the Amundson paper was based on Tarceva, not Osi, which has a much higher intracranial response rate.

If you're going to be a good CNS rad onc in 2018, you better be aware.

calling upfront observation on ICI for very select patients with brain mets 'oncologic idiocy' only makes you the idiot.

with good up front involvement, we're still going to be treating PLENTY of brain mets, maybe more for some patients.

however - definitely agree that some med oncs don't know what they're doing with these patients. They need us desperately.

I would only recommend systemic therapy and "observation" if the patient was going to be spared whole brain as a result of it. This is equal for TKI (even with tagrisso instead of tarceva) and ipi/nivo. Then at earliest sign of progression, if not an explosion of disease, I would SRS the growing lesions. If you have any data to refute any of that besides just hearsay, hyperbole, and personal attacks (bolded) then I'm all ears.

If a patient is a candidate for upfront SRS, treatment with immunotherapy alone should NOT be the recommended option. It can be an alternative you discuss with the patient and then the patient decides they want to give it a try, but I would tell them the standard of care for their intracranial disease is SRS.

Med-oncs who don't refer to radiation oncology for patients with brain metastases and instead unilaterally put them on systemic therapy are not acting in the best interests of their patient.

This is nothing against Ipi/Nivo itself - in the recurrent setting after whole brain, SRS, maybe surgery, maybe repeat SRS, having systemic therapy that can have an effect in the brain isn't a bad thing. Of course they'll have already become resistant to ipi/nivo, but that's not the discussion point.

Only in Radiation Oncology do we have people tripping over themselves to poo poo the excellent control rates we see with SRS, and try to convince other people that a 50-60% ORR is worth avoiding a treatment that has a 90-95% ORR.
 
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Our leadership and certification organizations want us to fail (see the last big post here)
We wrote a letter that was probably trashed by them
For every radonc job in a desirable location, there are tens of internal medicine jobs waiting there; and with the declining reimbursements, we aren't making that much more

Keep it real guys...keep it real
 
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At a fraction of the cost.


Except these patients are going to be on these therapies anyways for their extracranial disease? because....there's a survival benefit and it's first line for metastatic patients?


and no one is poo-pooing SRS or Radiation at all? you're accusing me of poo-pooing radiation in the thread I started where I'm talking about how awesome Rad Onc is....which has been derailed multiple times.

You'e the one calling people oncologic idiots

what you should instead be focusing on is thinking about how to time your SRS with or around the ICI in order to maximize response and decrease chance for toxicity, because whether or not you like it, metastatic RCC, Melanoma, Lung (probably soon to be breast as well with some of the early Atezo data) are GOING TO BE ON ICI therapies

If you're old and about to be leaving the game, then yes, feel free to ignore

If you're just starting your career - this is the reality.
 
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what you should instead be focusing on is thinking about how to time your SRS with or around the ICI in order to maximize response and decrease chance for toxicity.
Probably more important to know the data regarding response rates with and without brain srs and sharing said data with your med oncs.

Can't really time anything if you aren't getting the referral
 
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Sure. Assuming they have that. We all know plenty of patients who are essentially oligometastatic only ft the brain. Esp in lung


I'd love to see you convince a med-onc not to start a patient with de novo brain metastasis who happens to be a super high PD-L1 expressor (or even not super high expressor on the new combo chemo/immune therapy trial that just came out) on immunotherapy.

in fact, i would love to see you look at that patient in the face and tell him he shouldnt be started on immune therapy.

You can't talk about treating now with SRS before disease explodes if you're going to say that metastatic or 'oligometastatic' patients shouldnt be on immune therapy. come on.
 
Probably more important to know the data regarding response rates with and without brain srs and sharing said data with your med oncs.

Can't really time anything if you aren't getting the referral


I hundred percent agree we should be getting the referrals and that we should be involved up-front.
 
I'd love to see you convince a med-onc not to start a patient with de novo brain metastasis who happens to be a super high PD-L1 expressor (or even not super high expressor on the new combo chemo/immune therapy trial that just came out) on immunotherapy.

in fact, i would love to see you look at that patient in the face and tell him he shouldnt be started on immune therapy.

You can't talk about treating now with SRS before disease explodes if you're going to say that metastatic or 'oligometastatic' patients shouldnt be on immune therapy. come on.
I would ask them why? My guys would probably refer for xrt and then observe. Pts with brain only metastatic never got conventional chemo after brain xrt. Not sure how immunotherapy is any different.

The cost to the system is immense for putting these patients on lifelong five figure monthly therapy
 
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I agree that sometimes a rationale for oligomet tx is to delay initiation of chemo or ADT - however given the improved therapeutic ratio for many patients with immune therapy (works better, tolerated better) I would think there would be less of a desire to hold therapy for a high PD1 expressor.
 
I honestly think that making it an either or discussion is needlessly polemical.
 
Slightly off (the new) topic ((way off the original topic))...

Anyone seeing more radiographic/symptomatic necrosis now that everyone gets immunotherapy? Anecdotally, I've seen a bunch, particularly in longer-term (>2 years) survivors. Use a linac based platform FWIW.
 
Slightly off (the new) topic ((way off the original topic))...

Anyone seeing more radiographic/symptomatic necrosis now that everyone gets immunotherapy? Anecdotally, I've seen a bunch, particularly in longer-term (>2 years) survivors. Use a linac based platform FWIW.

I've seen a few more myself with patients that were on durvalumab.
 
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Slightly off (the new) topic ((way off the original topic))...

Anyone seeing more radiographic/symptomatic necrosis now that everyone gets immunotherapy? Anecdotally, I've seen a bunch, particularly in longer-term (>2 years) survivors. Use a linac based platform FWIW.

Part of it likely because these patients are living longer and RN in the brain can be partially time dependent.

Part of it likely due to interaction between IT and SRS, given prevalence of pseudoprogression.

There's a retrospective series from Colaco et al in SRS patients getting IT that said if you developed necrosis you lived longer which is postulated as better response due to combination, but is likely more dependent on time (for both factors) as it wasn't a Kaplan Meier analysis.
 
ALERT: timely brain mets discussion here. "Perhaps the largest question is how the improvements in targeted and immunologic therapies for NSCLC will affect the natural history of CNS disease." I can reasonably and likely predict that targeted/immunologic therapy effectiveness and metachronous CNS progression are inversely correlated; I can also further reasonably and likely predict that targeted/immunologic therapies are increasing in effectiveness over time.
 
ALERT: timely brain mets discussion here. "Perhaps the largest question is how the improvements in targeted and immunologic therapies for NSCLC will affect the natural history of CNS disease." I can reasonably and likely predict that targeted/immunologic therapy effectiveness and metachronous CNS progression are inversely correlated; I can also further reasonably and likely predict that targeted/immunologic therapies are increasing in effectiveness over time.

These sentences makes zero sense to me. Am I the only one?

"What then should we make of the success of deferred SRS in this trial? Of the patients randomly assigned to SRS, approximately one sixth needed more than one course of SRS, and more than one third required WBRT, implying that in a large proportion of patients, delayed SRS at time of salvage does not work as well as desired, given that in the definitive setting, it produces > 90% local control"

When you SRS a lesion you usually have to SRS them again (at some point) because of distant brain failure. That is inherent whether it is salvage or post-op SRS. The issue is not local recurrence.

It's the same question as is in post-prostatectomy prostate cancer - is there a difference between adjuvant and early salvage.

In post-op brain mets, is there a difference in local progression between observation and adjuvant? Yes, as expected, given the Mahajan trial results. However, is there a difference in survival between observation (and early salvage as necessary) and adjuvant? No, per the Mahajan paper again (although it's not powered to look at OS, the median OS was 18 and 17 months for the two groups).

Should we routinely be post-op WBRTing? I'd argue not if they're otherwise candidates for SRS. That's what the trial (for which the above article is an editorial) is essentially saying (http://ascopubs.org/doi/full/10.1200/JCO.2018.78.6186). Japan runs SRS trials with weird comparative arms, IMO.

I would probably still favor post-op SRS for the local recurrence prevention (like in Mahajan) but salvage SRS is an option as well. Clinically, it's driven if I'm doing SRS at that moment in time anyways (for definitive lesions) - if I'm in there anyways I'd rather just radiate the post-op cavity too. Arguably, if it was a solitary brain met I'd want to radiate that. If it's one brain met but extensive extracranial disease then maybe I can have a discussion with the patient about treating now vs at salvage.
 
I have heard through the grapevine that there is very exciting news coming when COMET results are presented.

FWIW, just got my ASTRO abstract book and saw these results: SBRT improved OS (41 months vs 28 months) and PFS (12 months vs 6 months) vs SoC for patients with 1-5 mets and controlled primary. 99 patients, randomized phase II study. Game changer? Talk amongst yourselves.
 
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FWIW, just got my ASTRO abstract book and saw these results: SBRT improved OS (41 months vs 28 months) and PFS (12 months vs 6 months) vs SoC for patients with 1-5 mets and controlled primary. 99 patients, randomized phase II study. Game changer? Talk amongst yourselves.
while it is certainly promising, it is not a game changer. To me, game changers are phase III trials published in the NEJM that make it into NCCN guidelines as high level evidence. My guess is that those medoncs who are skeptical/ "oppositional" - to radiation- are not going to be convinced by this study. It most likely needs to be followed by a larger trial, but I certainly will push it in the meantime and hope to offer it to patients.
 
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I disagree re: game-changer. I would have liked to have seen more patients in the study, but a 13 month increase in median survival (more than a year!) is huge. Doubling of PFS is also huge. I can't see how a medonc could justify not offering SBRT to his or her patients, based on this data. If I were a patient it's what I would want for sure.

Edit: Just noticed this wasn't even for patients going on/receiving immunotx, just "chemotherapy" - I can imagine the immunotx results may be even better, once we get that data.
 
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Most of the big developments in RT are unfortunately pretty Meh compared over the last 15years compared to Med Onc trials which have changed the game considerably ie Pacific trial. The best we can hope for in RT is a local control/PFS benefit.
 
while it is certainly promising, it is not a game changer. To me, game changers are phase III trials published in the NEJM that make it into NCCN guidelines as high level evidence. My guess is that those medoncs who are skeptical/ "oppositional" - to radiation- are not going to be convinced by this study. It most likely needs to be followed by a larger trial, but I certainly will push it in the meantime and hope to offer it to patients.

LU-002 currently enrolling to prove it based on Gomez/Iyengar data in a phase III setting for NSCLC.

Med-oncs treat based on phase II trials all the time.

Immunotherapy is a huge relatively recent advancement that began in the metastatic setting, and right now, adding immunotherapy to standard of care treatment in the nonmetastatic setting is going to very in-vogue and a very easy study to get funded. Start with one of the most common cancers with poor outcomes in definitive locally advanced tx - NSCLC. There's H&N trials adding immunotherapy concurrently. Wonder when NSCLC will get concurrent immunotherapy (instead of carbo/tax or cis/etop) with their RT?
 
Most of the big developments in RT are unfortunately pretty Meh compared over the last 15years compared to Med Onc trials which have changed the game considerably ie Pacific trial. The best we can hope for in RT is a local control/PFS benefit.
You posted this directly below a post showing an OS advantage to the addition of SBRT to standard of care systemic tx.
 
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What I find fascinating about reading threads like this is the spectrum of opinions regarding the future of the field. We don't all have to agree regarding having inpatients, having the ability to give systemic therapy, but I don't see how anybody reasonable can disagree that it would not harm us to provide further avenues to allow the people who want to to these things within our specialty to do so. I like to use famility medicine as a specialty example for one that allows practitioners to to do other things by doing training (scopes, biopsies, vasectomies, tubal ligations, delivering babies, pain procedures, etc). We should be opening up pathways to allow people to have more training and expand the spectrum of our field. We will always be limited by being the keepers of a modality that is reaching technological and physical limitations. Med oncs will dismiss trials if they want to, it doesnt matter if <100 patient trial shows a survival benefit.
 
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med oncs may not like 'radiation' but they LOOOOOOVE SBRT.

you're drunk if you don't think they're going to start ramping up their SBRT referrals (in our department at least, we've had to tell the med oncs we weren't going to treat more than a few times, though now maybe we will be doing more)

'Treat the oligomet, silly rad onc monkey!'
 
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Well I hope I am wrong. I certainly believe the trial justifies treating oligomets and plan to adopt this. However, absent a phase III trial, docs who are skeptical of radiation- and there are plenty among medonc thought leaders in lung- are unlikely to send to us, which is why they are apparently performing a confirmatory phase III. Conceptually stage 4 lung cancer is not that different from stage 3, where 80-90% of patients have occult metastatic disease.
 
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Slightly off (the new) topic ((way off the original topic))...

Anyone seeing more radiographic/symptomatic necrosis now that everyone gets immunotherapy? Anecdotally, I've seen a bunch, particularly in longer-term (>2 years) survivors. Use a linac based platform FWIW.
You posted this directly below a post showing an OS advantage to the addition of SBRT to standard of care systemic tx.

Oh well in that case Pop open that champagne. Good times are hear again! 99 patients oh boy. Look out med onc. Larger point still stands...Med Onc achievements over the last 15 years are far more impressive than anything we have done in the same time frame. I’ll bet in the next 5 years pharma will have a new agent on the market and all the med oncs will want to try that before they send for SBRT. You know...to spare them that awful RT.
 
Oh well in that case Pop open that champagne. Good times are hear again! 99 patients oh boy. Look out med onc. Larger point still stands...Med Onc achievements over the last 15 years are far more impressive than anything we have done in the same time frame. I’ll bet in the next 5 years pharma will have a new agent on the market and all the med oncs will want to try that before they send for SBRT. You know...to spare them that awful RT.


I'm truly sorry that you hate your chosen field so much.

As for me? I would still pick rad onc 150 times out of a 100 over med onc. What we do is way cooler, our jobs are much more streamlined around oncology-focused and patient-centered things and Rad Oncs always look way happier in clinic or tumor boards! All I ever think is 'lol those poor med onc chaps.....'

I'll pray for you.
 
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Oh well in that case Pop open that champagne. Good times are hear again! 99 patients oh boy. Look out med onc. Larger point still stands...Med Onc achievements over the last 15 years are far more impressive than anything we have done in the same time frame. .
Except none of it is curative, at least in solid tumors. And it's far more expensive. Med oncs never cure anything outside of testicular or lymphoma, really.

Not sure how that's a recipe for self loathing....
 
As for me? I would still pick rad onc 150 times out of a 100 over med onc. What we do is way cooler, our jobs are much more streamlined around oncology-focused and patient-centered things and Rad Oncs always look way happier in clinic or tumor boards! All I ever think is 'lol those poor med onc chaps.....

The only time I get jealous of med oncs is their job market. In my state there are far, far more job options for med oncs. For new grads in my state the salaries are higher for med onc than rad onc. The fellows where I trained were looking at jobs that paid 50% or more higher than what I was being offered out of residency.

At the more malignant centers, the med oncs turn over frequently because they can easily leave for greener pastures. The rad oncs at these same places are "trapped" by a limited job market, easily replaceable by a desperate new grad. Even on the research side there are many more startup packages and much more industry money to fund research for med oncs.
 
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Since this thread is already way off topic and turned into a bit of med vs rad onc (or at least pros and cons or whatever) I'm curious if anybody knows about the current state and future prospects of surgical oncology? I would imagine that with SBRT and improvements in systemic therapy that on a national level thoracic surgeons are doing way less surgeries than 15-20 years ago and the same must be true for resection of oligo-metastatic liver lesions and more palliative cases. I assume this trend will continue but just curious if surgeons have found additional procedures or indications (talk about investment in years of education and then not finding a job in radiation oncology . . . I can't imagine committing years or even up to a decade in surgical residency and fellowship without a certain employment future!)

Somebody is much more likely to be torn between medical and radiation oncology since surgery is a way different career path and animal but this just got me curious and I honestly don't personally know many fellowship trained surgical oncologists or even general surgeons with an interest or focus in oncology. Feel free to delete this if it's too off topic for this thread.
 
Since this thread is already way off topic and turned into a bit of med vs rad onc (or at least pros and cons or whatever) I'm curious if anybody knows about the current state and future prospects of surgical oncology? I would imagine that with SBRT and improvements in systemic therapy that on a national level thoracic surgeons are doing way less surgeries than 15-20 years ago and the same must be true for resection of oligo-metastatic liver lesions and more palliative cases. I assume this trend will continue but just curious if surgeons have found additional procedures or indications (talk about investment in years of education and then not finding a job in radiation oncology . . . I can't imagine committing years or even up to a decade in surgical residency and fellowship without a certain employment future!)

Somebody is much more likely to be torn between medical and radiation oncology since surgery is a way different career path and animal but this just got me curious and I honestly don't personally know many fellowship trained surgical oncologists or even general surgeons with an interest or focus in oncology. Feel free to delete this if it's too off topic for this thread.

Rad onc is a "one trick pony," Surgical oncologists (only 1-2 yr fellowship) can perform many non- oncological procedures. Ex: We have one is who also very well published in gastric bypasses and thoracic surgeons certainly dont have to focus on oncology, nor do fellowship trained colorectal surgeons.
 
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That's not the best way to look at it. Adjuvant chemo is curative (breast, colon). Concurrent chemo ups survival (cervix). MedOnc work has some bright sides.

Except none of it is curative, at least in solid tumors. And it's far more expensive. Med oncs never cure anything outside of testicular or lymphoma, really.

Not sure how that's a recipe for self loathing....
 
Oh well in that case Pop open that champagne. Good times are hear again! 99 patients oh boy. Look out med onc. Larger point still stands...Med Onc achievements over the last 15 years are far more impressive than anything we have done in the same time frame. I’ll bet in the next 5 years pharma will have a new agent on the market and all the med oncs will want to try that before they send for SBRT. You know...to spare them that awful RT.
MedOnc has had better gains because 10 years ago, when I was in training, their systemic agents were crap. Complete crap. I for one am glad systemic options have improved, as it has noticeably increased my patient numbers, as I have been treating oligomets for several years now with SBRT.

A lot of this discussion seems to center around relationships with med onc colleagues. Maybe it's the particular practice I'm in, but we all have the "cancer is the enemy, not the other doc" attitude, so when I told several of my medonc colleagues yesterday about the COMET data, they were excited to be able to offer a treatment which will potentially extend the survival of their patients.
 
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That's not the best way to look at it. Adjuvant chemo is curative (breast, colon). Concurrent chemo ups survival (cervix). MedOnc work has some bright sides.
Agreed, I'm just speaking from a mono therapy perspective which is what the post I was responding to seem to imply
 
This hits the nail on the head. None of us are going to disagree that the practice of radiation oncology is better than other fields. Its just that future jobs outlook overcome the inherent positives here. I enjoy the practice of radiation, but enough to work in the job in Irvine, CA, salina KS, or even as a satellite *** for MDACC (where rumor has it, Houston must give final electronic approval on plans of pts on the other side of the country. )?

This is the first I'm hearing of a job in Irvine, CA. Salina KS and Rhinelander WI are the mainstays. What's the Irvine job that's so not wanted it is falling into RadOnc lore?
 
This is the first I'm hearing of a job in Irvine, CA. Salina KS and Rhinelander WI are the mainstays. What's the Irvine job that's so not wanted it is falling into RadOnc lore?

It’s been posted yearly or so for at least the last 2 years. They’re a churn-and-burn practice, from what I’ve heard. Buyer beware.
 
That Salina, KS job has been available for as long as I can remember. I guess there will always be at least one job available in the future.
 
Watch out for late breaking abstracts in this years ESMO 2018 conference starting on October 19th in Munich.
I've heard of some very promising data on RT, especially for one very common indication...
 
Watch out for late breaking abstracts in this years ESMO 2018 conference starting on October 19th in Munich.
I've heard of some very promising data on RT, especially for one very common indication...
Go on, no need to tease
 
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Go on, no need to tease
400px-Merfeld%2C_Wildpferdefang_--_2014_--_0685.jpg


It's only rumors though... And I am not saying anything more.
 
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Guys with node positive disease + RT did as well as locally advanced + RT, and/or substantially better than those who did not get RT?
 
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