PracticeUpdate: Oncology - Winter 2018

EXPERT OPINIONS 22

Top 3 Advances in Radiation Oncology From ASCO 2018

Interview with Helen A Shih MD, MS, MPH by Farzanna S Haffizulla MD, FACP, FAMWA

Dr. Haffizulla: Let’s talk a little bit about radiation oncology here at ASCO 2018. What are three most important studies in the radiation oncology arena that you’d like to highlight for our viewership. Dr. Shih: Well, there are several studies, but I think 3 particularly stood out to me. There was one in endometrial cancer led by the NRG Oncology, which is a study on high-risk, ear- ly-stage endometrial cancer. These patients are standardly treated with upfront surgery, total abdominal hysterectomy, bilateral salpingo-oophorectomy and then following that, there’s adjuvant treatment. But there isn’t consensus, should they get external beam pel- vic radiation, or vaginal cuff brachytherapy with chemotherapy, carboplatin and paclitaxel. This study randomized adjuvant treatment and was first presented in ASTRO 2017, showing that the 3-year survival rate was the same in both arms, as well as the distance recur- rence rate, which is the same as 18%. So, overall survival is roughly 90% in both arms. But what was notably different was that the rate of local regional nodal occurrence, pelvic para-aortic nodal recurrence in the pelvic radiation arm was lower, approximately half, 4.4% as compared to 9.2% in those patients who got brachytherapy and chemotherapy. That was pretty striking in support of pelvic radiation. What’s new here in ASCO 2018 is looking at quality of life which, to the patient, they vary…of course, they want to know that we have the best treatment possible in controlling their disease, but they want qual- ity of life. And here, in terms of quality of life differences between the arm, we’re seeing that with the patients who get pelvic radiation, they do have a higher incidence of gas- trointestinal symptoms. We’re talking about diarrhea, loose stools, incontinence, but in the arm that gets brachytherapy and chemotherapy we’re seeing much more instances of fatigue and neuropathy from the chemotherapy. Patients who have baseline higher number of comorbidities also seem to do worse in terms of quality of life. Many of these things were intuitive, but it is unique to be able to see in this prospect of randomized fashion, and I think will help guide patients and their providers in selecting best care, which I would say, on average, will be pelvic radiation therapy. Dr. Haffizulla: Fantastic. Go ahead. Dr. Shih: Another study that I think is worth highlighting – in locally advanced rectal cancer from our colleagues in China – is the multicenter FORWARC study. Traditionally, these patients are treated with upfront chemo radiation, 5-FU with radiation therapy preopera- tively before surgery, but in this study there were 2 additional study arms of comparing. Instead of just 5-FU, FOLFOX with radiation, or just chemotherapy alone with the FOLFOX, a modified FOLFOX regimen. This was also previously presented at ASCO 3 years ago, and at that time, the initial data that they saw was that the pathologic complete response with FOLFOX and radiation was much higher, 31% as compared to the standard of care, 5-FU radiation, which was just 12.5%, and this was also higher than the FOLFOX alone, which is 7.4%.

Dr. Shih is Director of the Central Nervous System & Eye Services in the Department of Radiation Oncology at Massachusetts General Hospital in Boston, Massachusetts.

PRACTICEUPDATE ONCOLOGY