Yikes. What a depressing list. "Please tell me that you have something more, Lieutenant."
It depends what you mean by academics.
Evicore says otherwise LOL: "For an individual with oligoprogression (progression of a limited number ofmetastatic sites while other metastatic disease sites remain controlled), SBRT is considered not medically necessary."
Medonc progress is incremental (as is almost all "real" progress) but it is remarkable. Many new therapies offer a median PFS benefit on the order of 12 weeks or so, but the total change in outcomes is still notable. Also, median does not adequately describe the progress regarding a highly variable outcome (PFS or even OS). If you are markedly improving outcomes in 20% of patients, you are doing a remarkable thing. The median survival of men with newly diagnosed metastatic prostate cancer may be approaching 6 years now...how many long term (as in more than 5 years) survivors have you encountered in the past 10 years who were diagnosed with metastatic ER+ or Her2+ breast cancer, renal cell carcinoma, endometrial or ovarian cancer, melanoma...not to mention what MM has become.
I think io + sbrt trials are out there. Lot of promise moving sbrt to the forefront in definitive early inoperable lung and liver imo (maybe even rcc eventually).
The data is everywhere
www.nature.com
forums.studentdoctor.net
Metastatic melanoma and nsclc are completely different diseases now compared to the pre IO era. And I'm not just talking about the outliers
The data is everywhere
Overall Survival Approaching 5 Years for Metastatic Renal Cell Carcinoma
In an interview with Targeted Oncology, James Brugarolas, MD, PhD discussed promising updated survival data in metastatic renal cell carcinoma and investigational biomarkers to further advanced the field.www.targetedonc.com
Survival improvement for patients with metastatic colorectal cancer over twenty years - npj Precision Oncology
Over the past two decades of successive clinical trials in metastatic colorectal cancer (CRC), the median overall survival of both control and experimental arms has steadily improved. However, the incremental change in survival for metastatic CRC patients not treated on trial has not yet been...
Just a couple examples.
Regarding radonc, certainly our days of being included almost reflexively under the mantra of "multidisciplinary care" for locally advanced solid malignancy has gone by the wayside.
I see more consults (due to demographics), more very old patients (@Palex80 's grey wave), more metastatic patients and treat fewer patients overall with shorter courses than 10 years ago (by a lot). Probably would have 2x number on beam if practice patterns were circa 2012.
I don‘t know man… look at kidney cancer, look at melanoma, look at Her2-positive breast cancer. I am seeing patients, I never imagined would be alive.
Fair point, but think of:
Saying ‘things haven’t changed except for immunotherapy’ is like saying biden’s presidential campaign in 2024 was a success ‘except for the debate thing’
I agree that we aren't going to disappear and will continue to have a role, sometimes our role will become more prominent in certain clinical circumstances. My contention is that our role is more likely to be dictated by the progressive tools and culture of medical oncology than it is by any technological improvements within our own field.
Great examples! We no longer routinely treat RP sarcoma due to clinical trial outcomes. Gastric (routinely for years) and esophageal adenocarcinoma (emergently) are now preferentially being treated with dual modality instead of tri-modality therapy in many places (clinical trial outcomes). We treat pancreatic less frequently in the adjuvant setting (typically at exhaustion of systemic therapy in my experience) and I offer PCI less often in my small cell patients in the setting of an older population (I don't like radiating 75+ year old whole brains).
I have over $2M in industry funding for drug + RT trials. What we need are more rad oncs that understand pharma's priorities and the general approval pathway to present concepts that get them engaged. For example, unless a drug was intentionally engineered as a radiotherapy adjuvant, it is extremely unlikely anyone is going to let their unapproved drug come out and play in a radiotherapy trial. Too much risk something bad could happen and affect a subsequent NDA review. Many, many IST concepts are DOA for overlooking this simple reality.
"According to 4 simulation models, breast cancer screening and treatment in 2019 were associated with a 58% reduction in US breast cancer mortality compared with interventions in 1975. Simulations suggested that treatment for stage I to III breast cancer was associated with approximately 47% of the mortality reduction, whereas treatment for metastatic breast cancer was associated with 29% and screening with 25% of the reduction."
As the kids say, "💯"
I would say, the most common ones have been successful. EGFR is the most common one and results have been overwhelming there.
Sunitinib was the first TKI with a proven OS in RCC.
I am seeing more and more patients being referred for RT prior to CAR-T treatment to "debulk" residual lymphomas.
CDK4/6-inhibitors demonstrate quite an effect.
Well, many patients receive Docetaxel upfront nowadays for mHSPC (at least in Europe), mostly through medoncs.
a) I do not see any decline of RT in SCLC, apart from PCI.
IMO we should very rarely be treating LR prostate patients period. We overwhelmingly overtreat favorable IR prostate cancer presently.
Oh I wasn't saying we compete for LR. I was trying to say because LR patients are "off the market", surgeons are now competing for what we had traditionally treated more (UIR and HR). So we have to compete now against surgeons, moreso than before, and short courses are more appealing to patients.
If med onc is really increasingly anti RT we are eff’d
That has not been my experience with the younger non-boomer crowd. Absolutely the case with the 60-70+ y/o's
I’m not trying to pick, but you just made my point. Pharma isn’t interested in large, practice changing trials. They are interested in doing the smallest trials possible to get a new indication. Whether you are a med Onc or rad onc, they don’t want to hear about something that’s going to take 1000 patients for a drug they can already market.
We are on the same page with this but perhaps have different disease/indications in mind. I am not thinking about radiosensitization but trials that are, for example, FLOT vs. immunoFLOT... and therefore leading to exclusion of chemoRT as future indication since a FLOT vs. immunoFLOT vs. chemoimmunoRT trial is not being run since there is not support for the RT arm on a trial like this. This is a real example from astrazeneca.
I agree and this is where my frustration with our cooperative groups comes in. This has been obvious for many years but we keep getting pigeon holed in proton vs photon and fractionation trials and we are now playing from behind. Regarding sensitization trials, I mostly agree but it didn’t have to be that way. If you look at ESOPEC, FLOT barely beat out CROSS. We had 15 years to find something to even modestly improve OS and put all of our eggs into protons and dose escalation approaches with no measurable return. I am absolutely convinced a CROSS backbone can be at least as good as FLOT with less toxicity but we will never know now.
