RTOG 0848 forest plot (Fig 3): RT*chemo interaction p=0.414. Gem alone, gem combos, gem erlotinib — all consistent. Zero evidence RT benefit varies by chemotherapy backbone. Calling for a new FOLFIRINOX trial before using RT in pN0 patients inverts the burden of proof.

RTOG 0848: neg overall, but benefit in pN0 (adj chemoRT improved OS 5yr 48% v 29%). Caveats: small N0 subgroup (N=91), gem chemo, pre neoadj era. My main takeaway: RT has role in (select) resectable PDAC & future trials need to focus on biologically favorable subset. @OncoAlert

Definitive Radiotherapy to the Primary Tumor in Stage IV NSCLC: A Consensus Statement From the International Association for the Study of Lung Cancer Advanced Radiation Technology Subcommittee - Journal of Thoracic Oncology jto.org/article/S1556-0864(2…

Also, the use of Dotatate PET scan in addition to MRI is really useful in meningiomas. I’ve been taking some of these “bad actor” meningiomas to 66-70 Gy.

FIRESTORM: improved PFS with dose-escalated postop RT >= 66Gy/33fr for high-risk meningiomas redjournal.org/article/S0360… @Raj_Singh_MD @joshuapalmermd @PDBrownOnc

No, 30/5 is the default unless we can’t meet brain minus CTV V30<10.5 cc then consider dropping the 27.5 or rarely 25/5. If 25/5 with residual tumor then boost on GK with an additional ~5/1

This is our approach at Sunnybrook with excellent LC

At @DukeRadOnc we did 27.5 Gy in 5 fx to PTV. 2mm margins from cavity to PTV.

I typically use 27 in three. For large lesions I’ll use either 30 in five or 32.5. I was impressed with their results with such a relatively lower dose. What do you typically use?

This is what we do at @pmcancercentre and SIB to 30Gy for any gross tumor

Is 25Gy/5 to post-op cavity after resection brain met effective? Yes, according to this study ~90% LC at 1 and 4 years Symptomatic Radiation Necrosis 3%

Among the thousands of abstracts presented at #ASCO26, one that generated a lot of attention was by an amazing team I'm fortunate to work with at the Los Angeles and St. Louis VA medical centers. Not only did our work get an oral presentation, but we also got an ASCO Daily News highlight. Likely because of the scale and fidelity of the analysis on a 1 million patient cohort with structured smoking history. @BrendanHeiden dailynews.ascopubs.org/do/ne…

Omission of ALND in #breastcancer with 1-2 sentinel nodes macrometastases - OS from SENOMAC trial - Jana de Boniface #ASCO26 Recommendation should be viewed in the context of postoperative locoregional #radiotherapy @OncoAlert #OncoAlert

Maybe cite our data - we have the largest series! pubmed.ncbi.nlm.nih.gov/3557…. It’s a made up criterion to help get urologists to buy into referral by making them do extra stuff. No proven benefit and possible harm eg perforation.

OK so some of my thoughts about #PROTEUS, presented at Plenary session during #ASCO26 💠This was a tough trial to do, congratulations to the team for getting this done! 💪 🔷I think this is going to muddy the waters, esp for us rad oncs who get sent pts post-prostatectomy 1/n

To clarify a few things about this thread ⬇️ 🔸Not only do we need think about this in the context of upfront tx considerations for men with HR PCa... 🔸Inevitably, there are going to be pts tx'd this way. What I am referring to is, what do we (rad oncs) do after? 1/n

🚨 PROTEUS: perioperative apalutamide moves into high-risk localized #prostatecancer Just out in @NEJM 🧬 2109 men w/ high-risk localized or locally advanced PCa randomized to ADT apalutamide vs ADT placebo around radical prostatectomy. 🎯 Both stated primary endpoints met. ⚠️ But the trial deserves nuance. Thread 🧵 #ASCO26 @ASCO @PCF_Science

Trials in localized prostate cancer are incredibly difficult to pull off, especially given the rapidly changing imaging and therapeutic landscape, so major congrats to the investigators. For me, top line results: small MFS benefit when MFS is defined by either conventional imaging or PSMA PET. No MFS benefit by conventional imaging. Critically, there were significant differences in PSMA PET utilization. Post hoc analysis showed that 686 patients (64.9%) in the apalutamide group and 755 patients (71.8%) in the placebo group underwent PSMA PET at least once. That difference is greater than the absolute MFS benefit (when MFS is defined by either conventional or PSMA imaging) and may mean that the MFS benefit is confounded by the differential use of PSMA PET at biochemical recurrence. The extent of that confounding will depend on the comparative probability of detecting Mets at BCR using PET vs conventional imaging in the trial cohort. Would be interested in that data. Does PROTEUS change practice? Given the above, I'm not sure the argument is there to go from RP alone (the current standard) to RP ADT ARPI. Will be interested in the substudy results. #ASCO26 #radonc #medtwitter #pcsm nejm.org/doi/full/10.1056/NE…

The real question is the Enzarad data, which is not a subgroup analysis like STAMPEDE. STAMPEDE is hands down my favorite trial ever, but important to note that the M0 analysis was a subgroup analysis and not all patients even had local therapy. Some patients had PSAs in the 1000s. Enzarad a bit more relevant where MFS and OS were not significantly improved in N0M0 patients. Just like PROTEUS MFS and OS were not improved by conventional imaging. Given we now often get PSMA PET/CT upfront for staging, ARPIs in N0M0 patients have no proven role.

#ASCO26 Talk about real-time updates. NEJM paper now online and my predictions and inferences appear true. Majority of MFS events were by PET not conventional imaging. "Most distant metastases were identified by PSMA PET (53.0% of those in the apalutamide group and 60.7% in the placebo group)" VERY IMPORTANTLY: "No significant between-group difference was observed in metastasis-free survival assessed with conventional imaging alone (hazard ratio, 0.84; 95% CI, 0.67 to 1.07)" Not only does MFS cross 1, but the HR also crosses the surrogate threshold effect (0.81). @urotoday @PCF_select @US_FDA