The present of radiation oncology

[RadOnc10000]

Instead of always talking about the future, why don't we talk about the present?

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Adding Radiation Therapy to Chemotherapy Improves Survival in Patients With High-Risk Breast Cancer

Journal of the National Cancer Institute

For patients with high-risk breast cancer treated with radical mastectomy and adjuvant chemotherapy, the addition of radiation therapy leads to better survival outcomes with few long-term toxic effects, according to a 20-year follow-up of a randomized trial, which appears in the January 19 issue of the Journal of the National Cancer Institute....

(http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15657341)

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This paper addresses a controversial issue in breast cancer (and many other solid tumors): does loco-regional therapy improve survival in the setting of chemotherapy? The resounding answer is: yes. These authors demonstrate an ~20% ABSOLUTE risk reduction in breast cancer recurrence (local and distant) and a 15% absolute improvement in OVERALL survival in patients who received XRT in addition to chemotherapy after mastectomy. Long-term toxicity (including cardiac) was minimal in both groups. Caveats include that the chemotherapy regimen was less aggressive than that used today and that the radiotherapy techniques have changed (i.e. improved) since these patients were treated. Overall, these data underscore the remarkable effectiveness of radiotherapy, as the survival gains made by adding adjuvant chemotherapy in breast cancer are often around 5% (and at that level are felt to be worth the risk of side effects.) They also indicate that local therapy makes a major contribution to cure, even in cases of advanced cancer.

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[stephew]

this gets back to the faq and other posts on how as chemo improves survival for systemic issues, radonc and local control will become more important.
steph

 

[RadOnc10000]

this gets back to the faq and other posts on how as chemo improves survival for systemic issues, radonc and local control will become more important.
steph

Agreed. Beyond just dealing with regional effects of tumors, local therapy will play an ever increasing role in improving survival (by eliminating residual disease that could serve as a future source of metastases.)

 

[SunnyS81]

Feel free to point out how nieve I am, but I've repeatedly been instructed that surgical resection is preferred over radiation for localized disease. Except in a few areas where surgical resection is anatomically difficult, how do the two compared. Chemo vs radiation debate seems to like beating a dead horse.......if radiation is predominately for localized disease, shouldn't the debate be comparing surgery?

 

[Gfunk6]

Feel free to point out how nieve I am, but I've repeatedly been instructed that surgical resection is preferred over radiation for localized disease.

Generally, this is true but there are important exceptions such as anal cancer, where radiation alone has proven to be more efficiacious than surgery alone in clinical trials.

Also radiation is frequently used before surgery to "down-stage" a tumor, particularly in anatomically sensitive locations.

 

[cdf95cro]

IMHO,

I've heard variations on "surgical resection is preferred over radiation for localized disease," mostly as a statement of position from junior surgery residents and I like to ask, in reply "what kind of localized disease?" I mean are we talking clear CRM in rectal, or grossly negative margins in GBM (which are never really negative), regional node postive ER-/PR- breast, or positive margins on a Whipple? Localized disease with or without lyphatics? Surgery + chemo vs chemo rads or definitive surgery vs radiation montherapy? A skilled surgical oncologist from MSKCC or a hack who does lap choles 99% of the time vs IMRT at Anderson or Cobalt in Mexico?

The fact is, even a cursory look at the literature will tell you that there are specific cytological, anatomical, and therapeutic differences that make reductio ad absurdum statements like this as useful as "There are two kinds of people in the world, those who believe there are two kinds of people in the world and those who don't."

Trying to use such simple ideas and syllogisms will get you in trouble in real life when the truth is more complex ( and interesting). I'm still puzzling over the ESPAC data for instance...
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15028824

 

[stephew]

you nkow what? in some cases its better for total resection. in some cases (like prostate) no reason to think so.

 

[radiaterMike]

I would not fret too much over ESPAC (other than trying to figure out why the NEJM and Lancet accepted it for publication. The trial has major flaws. According to the data, RT increases disease recurrence, equating to worse survival, which makes absolutely no sense. For a list of the flaws, check out the editorial that accompanies the article. These editorials often give more insight than the trial itself.

- Mike

IMHO,

I've heard variations on "surgical resection is preferred over radiation for localized disease," mostly as a statement of position from junior surgery residents and I like to ask, in reply "what kind of localized disease?" I mean are we talking clear CRM in rectal, or grossly negative margins in GBM (which are never really negative), regional node postive ER-/PR- breast, or positive margins on a Whipple? Localized disease with or without lyphatics? Surgery + chemo vs chemo rads or definitive surgery vs radiation montherapy? A skilled surgical oncologist from MSKCC or a hack who does lap choles 99% of the time vs IMRT at Anderson or Cobalt in Mexico?

The fact is, even a cursory look at the literature will tell you that there are specific cytological, anatomical, and therapeutic differences that make reductio ad absurdum statements like this as useful as "There are two kinds of people in the world, those who believe there are two kinds of people in the world and those who don't."

Trying to use such simple ideas and syllogisms will get you in trouble in real life when the truth is more complex ( and interesting). I'm still puzzling over the ESPAC data for instance...
http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15028824

 

[RadOnc10000]

Feel free to point out how nieve I am, but I've repeatedly been instructed that surgical resection is preferred over radiation for localized disease. Except in a few areas where surgical resection is anatomically difficult, how do the two compared. Chemo vs radiation debate seems to like beating a dead horse.......if radiation is predominately for localized disease, shouldn't the debate be comparing surgery?

I'm not sure that I understand your question. What is the "chemo vs. radiation debate"? As far as whether surgical resection or radiation is preferred, that answer is very much disease and patient specific and cannot be answered with a blanket statement. Additionally, most often it is not "either/or" but "both" that is best for the patient.

However, to take you up on your blanket statement, I think it is not hard to imagine that as chemotherapy, biologically-based therapies, and radiotherapy improve, the combination of these could do just as well as (or even better than) surgery for local disease. There are already examples of this, such as in the case of laryngeal cancer, where concurrent chemoradiotherapy allows preservation of the larynx (i.e. no laryngectomy) in a large fraction of patients, at no cost in overall survival (http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=14645636). This is obviously a special case, but who is to say it can't become more of the norm rather than the exception in the future?

 

[cdf95cro]

I would not fret too much over ESPAC (other than trying to figure out why the NEJM and Lancet accepted it for publication. The trial has major flaws. According to the data, RT increases disease recurrence, equating to worse survival, which makes absolutely no sense. For a list of the flaws, check out the editorial that accompanies the article. These editorials often give more insight than the trial itself.

- Mike

Mike- I totally agree; it does however illustrate that major methodological concerns can impair even large trials and that simple models of disease behavior and therapeutic response may be more difficult to tease out than blanket statements suggest. The optimum utility of surgery/chemo/rads has yet to be optimized in many scenarios ( for the record, I think that the fact that the study is controversial and numerically large is one reason NEJM jumped on it, and that the domestic data coming out next year will match the earlier GITSG data).

It is just a pet peeve that we not respond to simplistic questions like "surgical resection is preferred over radiation for localized disease" or "biologic chemo means we won't have burn patients with radiation" with equally inane statements, rather than acknowledging the limiatations of our current knowledge, and elevating the debate...

 

[stephew]

perhaps the NEJM and Lancet should publish these erudite critiques of their work.