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Happy to share our recent publication on the use of quantum technology for machine learning to differentiate between brain metastases and high-grade gliomas on MRI. 1/3
doi.org/10.1007/s10278…
doi.org/10.1007/s10278…
Tony Felefly
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Radiation Oncologist | MSc Physics | PhD AI & Quantum Computing / Oncologic Imaging | Views are my own
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Thank you Sean for this stellar comment!!
Can't agree more!
As @TylerSbrt mentioned, PSMA-PET remains the elephant in the room, and I totally agree that DASL-HiCaP sheds some light on this, as ~55% had a baseline PET. Eagerly waiting for the full manuscript!
While CI-M0 / miM1 were eligible, I think the vast majority of physicians wouldn't offer it to these patients. This is particularly important because many people believed that intensification benefit was perhaps driven by occult M1 on CI. The absence of HTE by PSMA-PET in DASL-HiCaP makes this very unlikely.
On another note as we're discussing the PSMA-PET dilemma, patients with small pelvic PET+ nodes that otherwise don't meet the criteria for STAMPEDE / DASL-HiCaP weren't included in either trials.
Are you intensifying with ARPI for these patients? If yes, are you using 2 years of intensification?
I personally think these patients may benefit from some sort of intensification, but I believe the total duration could be lowered.
Eager to know what do you and other colleagues think about this.
@DrSpratticus @Soum_Roy_RadOnc @seanmmcbride @TylerSbrt @alison_tree @PCaParker @ChrisSweens1 @Prof_Nick_James @Prof_IanD @5_utr @adib_elio @jryckman3 @GrattonMatthieu @dr_coops @ChapinMD @brookmans76 @VedangMurthy @docpriyamvada @cpeedell @dr_alimuhammad @WallisCJD @piet_ost @PaulSargos @GiuliaMarvaso84 @alongi_filippo
Can't agree more!
As @TylerSbrt mentioned, PSMA-PET remains the elephant in the room, and I totally agree that DASL-HiCaP sheds some light on this, as ~55% had a baseline PET. Eagerly waiting for the full manuscript!
While CI-M0 / miM1 were eligible, I think the vast majority of physicians wouldn't offer it to these patients. This is particularly important because many people believed that intensification benefit was perhaps driven by occult M1 on CI. The absence of HTE by PSMA-PET in DASL-HiCaP makes this very unlikely.
On another note as we're discussing the PSMA-PET dilemma, patients with small pelvic PET+ nodes that otherwise don't meet the criteria for STAMPEDE / DASL-HiCaP weren't included in either trials.
Are you intensifying with ARPI for these patients? If yes, are you using 2 years of intensification?
I personally think these patients may benefit from some sort of intensification, but I believe the total duration could be lowered.
Eager to know what do you and other colleagues think about this.
@DrSpratticus @Soum_Roy_RadOnc @seanmmcbride @TylerSbrt @alison_tree @PCaParker @ChrisSweens1 @Prof_Nick_James @Prof_IanD @5_utr @adib_elio @jryckman3 @GrattonMatthieu @dr_coops @ChapinMD @brookmans76 @VedangMurthy @docpriyamvada @cpeedell @dr_alimuhammad @WallisCJD @piet_ost @PaulSargos @GiuliaMarvaso84 @alongi_filippo
Very much agree with you, Tony. For DASL Very High Risk N0 patients, the MFS-CI benefit is substantial and very robust (and a surrogate for OS). In addition to a group more enriched in Gleason 9-10 than Enzarad, our patients were enrolled in era replete with PSMA PET. How does that impact the enrolled group (even though it was not formally included in eligibility)?View quoted post on X
There are two putatively localized settings where pts may not experience a significant MFS benefit from fixed duration ARPI intensification: 1) localized lower risk disease where metastatic potential is constrained and 2) localized by conventional imaging disease where PSMA PET reveals already extant mets. In the former, the metastatic cat may never get out of the bag; in the latter, it already is.
In the DASL era, a patient with CI neg/PSMA PET pos disease probably wasn’t enrolled. Investigators might not have viewed the arms in equipoise in that setting. They may have thought such patients needed ARPI intensification as SOC for OS purposes. We thus removed a patient population unlikely to realize an MFS benefit, since they already had Mets. This, in combination with enrolling higher grade gleasons, really enriched for the N0 population most likely to benefit. That’s why I would argue that in our PSMA PET era, DASL should have controlling weight in decision making regarding adding an ARPI in the N0 setting.
And for the RadOncs out there, with its favorable side effect profile, you might feel more comfortable take the initiative on prescribing Daro. #radonc
I think it depends on the risk in N0.
In STAMPEDE and DASL-HiCaP, nodal status was a stratification factor, and prespecified subgroup analysis didn't show any sign of HTE (photos below). So N0 clearly benefited from intensification.
In ENZARAD, they included more favorable high-risk patients. Those who got pelvic nodal RT derived a benefit as per their subgroup analysis. Although the characteristics of these patients weren't reported, most of them were N0, and my guess is that they were on the higher-risk end, as physicians felt they would benefit from pelvic ENI. I'm not aware of any interaction between nodal RT and hormonal therapy that would explain the results.
Curious to know how others interpret these results, and if they would intensify with ARPI for some N0 patients.
@DrSpratticus @Soum_Roy_RadOnc @seanmmcbride @TylerSbrt @alison_tree @PCaParker @ChrisSweens1 @Prof_Nick_James @Prof_IanD @5_utr @adib_elio @jryckman3 @GrattonMatthieu @dr_coops @ChapinMD @brookmans76 @VedangMurthy @docpriyamvada @cpeedell @dr_alimuhammad @WallisCJD
In STAMPEDE and DASL-HiCaP, nodal status was a stratification factor, and prespecified subgroup analysis didn't show any sign of HTE (photos below). So N0 clearly benefited from intensification.
In ENZARAD, they included more favorable high-risk patients. Those who got pelvic nodal RT derived a benefit as per their subgroup analysis. Although the characteristics of these patients weren't reported, most of them were N0, and my guess is that they were on the higher-risk end, as physicians felt they would benefit from pelvic ENI. I'm not aware of any interaction between nodal RT and hormonal therapy that would explain the results.
Curious to know how others interpret these results, and if they would intensify with ARPI for some N0 patients.
@DrSpratticus @Soum_Roy_RadOnc @seanmmcbride @TylerSbrt @alison_tree @PCaParker @ChrisSweens1 @Prof_Nick_James @Prof_IanD @5_utr @adib_elio @jryckman3 @GrattonMatthieu @dr_coops @ChapinMD @brookmans76 @VedangMurthy @docpriyamvada @cpeedell @dr_alimuhammad @WallisCJD
Thanks @TylerSbrt. The N1 signal consistently holds up across all 3 RT-based studies with impressive HRs. For most N0 disease, the data simply aren't there (yet)View quoted post on X
Not sure we can compare EFS for inoperable patients here with operable (more fit, less comorbid) patients in the neoadjuvant CT-IO trials, particularly when we look at DSS curves below. @SalmaJabbour1
EFS here is mostly driven by deaths unrelated to the disease or AEs.
VALOR will ultimately settle this question @drewmoghanaki
EFS here is mostly driven by deaths unrelated to the disease or AEs.
VALOR will ultimately settle this question @drewmoghanaki
Remarkable results from SBRT +/- immunotherapy for unresected stage I-II NSCLC. No benefit from addingView quoted post on X
IO & surgery remains standard of care for fit pts w stage I-II, EFS of ~30m w SBRT vs 46-65m for much more advanced disease in trials of neoadj IO #lcsm ascopubs.org/doi/10.1200/JC…
Of note, the Surrogate Threshold Effect for MFS in ICECaP-2 was 0.81. So basically even if we buy into the PSMA-PET MFS in PROTEUS, HR was 0.8 (95%CI 0.67-0.96). Consequently, this MFS HR does not predict an OS benefit by surrogacy, as the CI upper limit is way above the surrogate threshold.
Actual OS data are needed in this context.
Actual OS data are needed in this context.
🚨 Two major ARPI trials in high-risk localized prostate cancer, each adding a drug to standard local therapy 🧵 #ProstateCancer #RadOnc #pcsmView quoted post on X
