onc brain

About · curated by Nick Boehling, MD · @nb2276

2026-05-30 ASCO Annual Meeting 2026

digest generated 2026-08-11

Neo-CRAG: preop 45Gy/25fx added to periop XELOX lifts 3yr DFS 55.6% vs 42.4% (HR 0.750) and halves LRR, 9.4% vs 18.3%.
RT owned the day's positive randomised signals: Neo-CRAG is the first phase 3 to make preop chemoRT pay in node-heavy gastric/EGJ where CRITICS and TOPGEAR were null, and ROADS puts surgical-bed recurrence at 1% with GammaTile vs 12% post-op SRS. Prostate carried the biomarker news (TALAPRO-3, ENZAMET-Decipher), all systemic.

Bladder

Trimodality is being pressured from both sides: RAD-IO adds durvalumab to 55Gy/20fr chemoRT with RT delivery intact, while EV-309 puts chemoradiation in the control arm against an EV-only bladder-sparing pathway.

Early signal

RAD-IO

ForMIBC cT2-T3 (13% N+), bladder-preservation intent, 75% prior neoadjuvant chemo

TL;DR12-mo DFS 40/50 (80%, 95% CI 0.67-0.89) with durvalumab added to 5FU/MMC chemoRT, clearing the pre-set GO bar (≥75%).

Why it mattersRadiation oncology

The RT is unchanged from standard UK practice (55Gy/20fr bladder, 46Gy/20fr nodes when N+), so nothing here alters target volume or dose. What is new is that durvalumab was delivered neoadjuvant, synchronous AND adjuvant around that backbone, and only 61% completed it, which is the number gating any future randomised trial design.

Monday clinic

In cT2-T3 MIBC pts choosing bladder preservation with 5FU/MMC chemoRT, this supports enrolling on a checkpoint-inhibitor chemoRT trial rather than adding durvalumab off protocol; it does not extend to cisplatin-ineligible pts having RT alone or to those with extensive nodal disease.

The longer read
RAD-IO
+3 more figures
GO/NO-GO framework, 12-mo DFS: GO ≥75%, contextual 60-75%, NO-GO <60%.
GO/NO-GO framework, 12-mo DFS: GO ≥75%, contextual 60-75%, NO-GO <60%.
RAD-IO
Treatment statusN = 54%
Completed planned treatment3361
Discontinued early2139
RAD-IO
BaselineNumber%
Age, median (IQR)6962-76
Female1018
Male4582
Prior neoadjuvant chemo, yes4175
cT24480
cT31120
N+713
10 details

Single-arm multi-stage feasibility and safety trial of durvalumab added to 5-fluorouracil/mitomycin C chemoradiotherapy in muscle-invasive bladder cancer. N=55 enrolled, 54 treated. A stage 1 expansion opened to node-positive pts, the first 6 with N+ disease.

Median age 69 (IQR 62-76), 45 (82%) male. cT2 in 44 (80%), cT3 in 11 (20%), N+ in 7 (13%) (N1 4, N2 3). 41 (75%) had prior neoadjuvant chemotherapy, so this is largely a post-NAC bladder-preservation population.

Durvalumab before, during and for 12 months after chemoRT, with 5-fluorouracil and mitomycin C as the radiosensitising backbone. 33/54 (61%) completed planned treatment; 21/54 (39%) discontinued early.

55Gy in 20 fractions to bladder; node-positive pts received 46Gy in 20 fractions to nodes alongside the bladder dose. This is the standard UK hypofractionated schedule, not an escalated or de-escalated variant.

Primary: disease-free survival rate at 12 months post chemoRT, read against a prespecified GO/NO-GO framework (GO ≥75%, contextual 60-75%, NO-GO <60%).

40/50 (80%) disease free at 12 months, 95% CI 0.67 to 0.89, clearing the GO threshold. 2 pts pending and 3 not evaluable. Investigators report very high bladder preservation and survival versus their previous trial data; those comparator figures are not given in the source.

The benchmark is the team's own BC2001 trial (James, JCO 2016), whose chemotherapy randomisation gave DFS HR 0.78 (0.60-1.02), stratified logrank p=0.07 on the slide shown. Comparison is to that historic control experience, not to a contemporaneous arm.

cT2-T3 MIBC pts fit for 5FU/MMC chemoRT with bladder-preservation intent, most post-neoadjuvant chemotherapy
Does not represent cisplatin-ineligible pts managed with RT alone, extensive nodal disease beyond the 7 N+ pts enrolled, or anyone in whom cystectomy is preferred.

A 12-month DFS read is short for a preservation strategy where salvage cystectomy and late nodal relapse both fall outside the window. The evaluable denominator dropped from 55 to 50, and with 2 still pending the point estimate can move relative to a 75% threshold it clears by 5 points.

This clears a feasibility gate, not an efficacy one: the design question it answers is whether a randomised trial of durvalumab plus chemoRT is worth running, and the answer is yes. The 39% early discontinuation is the finding that should shape that trial, since a 12-month adjuvant tail that four in ten pts do not finish may not be the schedule worth randomising.

Single-arm feasibility/safety trial, N=55, 12-mo endpoint benchmarked against historic in-house CRT data. No randomised comparator; hard maturity gate applies.

  • Which durvalumab component (neoadjuvant, synchronous, adjuvant) drives benefit
  • Whether 80% 12-mo DFS survives a randomised comparator
  • Drivers of the 39% early discontinuation

Sourced from @katy_beckermann, @nataliagandur, @dralvaropinto

📚 Sources · 🐦 3 tweets

Management After pCR in MIBC (Panel)

TL;DRPanel review: sandwich immunotherapy regimens continue planned adjuvant therapy regardless of pCR, with de-escalation still unanswered.

Trials discussed

SWOG 8710ABACUSCHECKMATE-274KEYNOTE-905VOLGANIAGARAVESPERKEYNOTE-B15

Monday clinic

In MIBC pts who reach pT0N0 at cystectomy on a sandwich regimen, this supports completing planned adjuvant therapy rather than stopping on pathologic response; after cisplatin-based chemo alone, surveillance remains the presented standard.

Management post-pCR: continue or stop. NIAGARA regimen resumes durvalumab for another 8 months post-cystectomy.
Management post-pCR: continue or stop. NIAGARA regimen resumes durvalumab for another 8 months post-cystectomy.
+2 more figures
Management After pCR in MIBC (Panel)
SettingTrialReported outcome
Cisplatin-ineligibleKEYNOTE-905Periop EVP now standard
Cisplatin-ineligibleVOLGAEV + durva/treme improved EFS (press release)
Cisplatin-eligibleNIAGARA24-mo OS 82.2% vs 75.2%
Cisplatin-eligibleVESPER5-yr OS 66% vs 57%, ddMVAC > gem/cis
Cisplatin-eligibleKEYNOTE-B15OS improved vs gem/cis, under FDA review
Management After pCR in MIBC (Panel)
11 details

ASCO 2026 GU education session, not a trial. Synthesizes SWOG 8710, NIAGARA, VESPER, KEYNOTE-905, KEYNOTE-B15 and VOLGA into a position on what to do after pCR.

The practice answer presented is continue: resume durvalumab for 8 months post-cystectomy on the NIAGARA regimen, resume EVP post-cystectomy on perioperative EVP. Surveillance after pCR is standard only for cisplatin-based chemo alone.

MIBC pts reaching pT0N0 at cystectomy after a perioperative systemic regimen
Does not represent bladder-preservation / trimodality pts, whose post-treatment response assessment is clinical rather than pathologic.

The continue-vs-stop question has never been randomized. Not all pts in the source trials completed adjuvant therapy, often for toxicity, so the observed benefit reflects a mixed delivered dose rather than the full planned course.

The session names the two open questions itself: the relative contribution of the pre- versus postoperative components, and whether adjuvant therapy can be de-escalated on pCR or another biomarker. Neither is answerable from an intention-to-treat perioperative design.

  • Relative contribution of pre- vs postoperative components
  • Can adjuvant therapy be de-escalated based on pCR or biomarkers

Sourced from @nataliagandur

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Living Longer, Living Better (GU Discussant)

TL;DRASCO 2026 GU discussant on curing more while preserving organ, bladder, and kidney function across MIBC, RCC, and ctDNA selection.

Trials discussed

EV209EV309RAMPART

Why it mattersRadiation oncology

For an RT reader the delivery slide is the actionable part: full 55 Gy in 20 fractions was given in 54 (100) with no extension or delay in 47 (87) alongside durvalumab, so the immunotherapy did not cost RT intensity. EV-309 then places chemoradiation as the randomised comparator, meaning the bladder-preservation standard is now the control arm.

Monday clinic

In cT2-4a N0 MIBC being counselled for bladder preservation, this supports discussing chemoradiation plus checkpoint blockade as deliverable and trials of EV-based sparing as open questions; it does not extend to node-positive or metastatic disease.

The longer read
Living Longer, Living Better (GU Discussant)
+2 more figures
Treatment delivery: full 55 Gy in 20 fractions 54 (100), no extension or delay 47 (87), chemo discontinued early 12 (22), durvalumab completed 33 (61).
Treatment delivery: full 55 Gy in 20 fractions 54 (100), no extension or delay 47 (87), chemo discontinued early 12 (22), durvalumab completed 33 (61).
Living Longer, Living Better (GU Discussant)
9 details 4 trials watching

Discussant presentation, not an original trial. Brian Rini, MD, FASCO discusses ASCO 2026 GU data spanning MIBC bladder preservation, adjuvant RCC, and ctDNA-based selection.

The chemoradiation regimen under discussion is 55 Gy in 20 fractions with mitomycin C and 5-FU. All 54 (100) received the full dose and 47 (87) had no extension or delay, so adding durvalumab did not erode RT delivery.

Concurrent mitomycin C plus 5-FU with durvalumab. Mitomycin C dose reduced in 4 (7), 5-FU Week 1 dose reduced in 9 (17), chemotherapy discontinued early in 12 (22). Durvalumab completed in 33 (61), discontinued early in 21 (39) for toxicity and progression.

The EV platform reframes the comparison: EV-309 randomises cystectomy-ineligible or refusing cT2-4a N0 pts (N=390) against chemoradiotherapy for BIEFS and OS, while EV-209 (N=240) tests EV plus pembrolizumab in cystectomy-eligible pts with cCR and 2yr BIEFS. In adjuvant RCC the discussant's read is that adjuvant IO has no proven benefit in non-clear cell disease, with RAMPART non-clear cell subgroups too small to resolve it.

Selection, not intensification, is the through-line. Pathologic features are called a crude selection tool, and the ctDNA-stratified adjuvant RCC curves separate far more than pathology does (ctDNA-negative 24-mo DFS 79.9% on pembrolizumab and 72.9% on placebo, versus 38.8% and 18.3% in ctDNA-positive pts). The same logic sits under bladder preservation, where the unanswered question is which pt keeps their bladder, not whether the regimen can be delivered.

Everything here is second-hand from a discussant slide deck, so denominators, CIs and per-arm attributions are partial. The RAMPART non-clear cell forest plot arrived with row association uncertain in OCR, and its point estimates are not attributed to specific histologies. Central pathology review is still ongoing.

ComponentOutcomeNumber (%)
RadiotherapyReceived full 55 Gy in 20 fractions54 (100)
RadiotherapyNo extension or delay47 (87)
ChemotherapyMitomycin C dose reduced4 (7)
Chemotherapy5-FU Week 1 dose reduced9 (17)
ChemotherapyChemotherapy discontinued early12 (22)
DurvalumabCompleted33 (61)
DurvalumabDiscontinued early21 (39)

Sourced from @nataliagandur

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Prostate

A biomarker-heavy day (Decipher, 22-gene GC, HRR) where RT+ADT is the assumed backbone and only the systemic intensification varies; A-DREAM tests stopping ADT+ARPI outright.

Early signal

A-DREAM

FormHSPC, PSA <0.2 after 18-24mo ADT + ≥12mo ARPI

Treatment-free with eugonadal testosterone at 18 months surrogate

41.0% (32/78)

80% CI 33.1-48.9%, one-sided p 0.0249

TL;DR41% treatment-free with eugonadal T at 18mo after stopping ADT+ARPI in responding mHSPC (80% CI 33.1-48.9%, one-sided p 0.0249).

Why it mattersRadiation oncology

The RT-relevant detail is baseline burden: 51.3% had prostate RT and 29.5% had RT to metastatic sites, so the cohort that tolerated interruption was heavily locally treated, and 4 pts (5.1%) took RT as their non-protocol next step off ADT. Metastasis-directed RT is not tested here, but this is the population where a de-intensification question meets it.

Monday clinic

In mHSPC with PSA under 0.2 after 18-24 months of ADT plus at least 12 months of ARPI, this supports discussing a protocolized interruption with PSA and testosterone monitoring; it does not extend to pts with persistent PSA or to unselected metastatic disease.

The longer read
A-DREAM
+3 more figures
rPFS 15/78 events, median NE. OS 4/78 events, median NE.
rPFS 15/78 events, median NE. OS 4/78 events, median NE.
Primary endpoint: treatment-free with eugonadal T (≥150 ng/dL) at 18 months. Re-initiation triggers PSA ≥5 ng/mL, PCWG3 radiographic change, PrCa-related sx.
Primary endpoint: treatment-free with eugonadal T (≥150 ng/dL) at 18 months. Re-initiation triggers PSA ≥5 ng/mL, PCWG3 radiographic change, PrCa-related sx.
A-DREAM
CharacteristicValue
Median age70 (49-90)
High volume (CHAARTED)27 (35.1%)
Low volume (CHAARTED)50 (64.9%)
Prostate RT as local therapy40 (51.3%)
RT to metastatic sites23 (29.5%)
11 details 5 trials watching

Alliance single-arm phase 2, N=75 planned, 78 eligible enrolled 07/2022-03/2024. Median follow-up 26.9 months. Monitoring PSA and testosterone q3mo, scans at least q6mo (q3mo with rising PSA), QOL q6mo.

mHSPC on ADT + ARPI with PSA <0.2 stable or falling after 18-24 months of ADT and at least 12 months of ARPI. Median age 70 (49-90), 84.6% White, 64.9% low volume by CHAARTED, 35.1% high volume. Median PSA prior to starting ADT+ARPI 18.99 ng/mL.

Not an intervention, but the cohort was RT-heavy at baseline: 40 (51.3%) had radiation as local therapy, 31 (39.7%) had no local therapy, 7 (9.0%) prostatectomy +/- RT. 23 (29.5%) had radiation to metastatic sites. Dose and fractionation not reported in source.

Primary: treatment-free with eugonadal testosterone (T ≥150 ng/dL) at 18 months. Secondary: time to eugonadal T, duration off treatment, QOL. Exploratory: rPFS, TTNT, OS (CSS/NCSS), cost. Re-initiation triggered by PSA ≥5 ng/mL, PCWG3 radiographic change, or prostate-cancer-related symptoms.

Primary endpoint met: 32/78 (41.0%), 80% CI 33.1-48.9%, one-sided p 0.0249. Testosterone recovered in 52 (66.7%) by 18 months with median time to eugonadal T 9.0 months (95% CI 8.4-12.4); 45 (57.7%) stayed treatment-free for 18 months. rPFS 15/78 events, median NE; OS 4/78 events, median NE.

mHSPC pts with a deep, durable PSA response (<0.2) after 18-24 months of ADT plus at least 12 months of ARPI, predominantly low-volume
Does not represent pts with detectable or rising PSA on ARPI, shorter treatment duration, or de novo high-volume disease still in early response.

The 18-month primary readout is short for a de-intensification question whose real risk is late: 4 of 29 pts who resumed per protocol later progressed and discontinued the original ARPI, so re-treatment did not uniformly restore control. Deaths (4) included non-prostate causes (myelodysplastic syndrome, influenza, myocardial infarction), and with no continuous-treatment arm the OS curve carries no comparative information.

Intermittent ADT has been tested before in metastatic disease (SWOG 9346 could not exclude an OS decrement with intermittent therapy in mHSPC), but A-DREAM asks the question in the modern ARPI-intensified era with a molecularly deeper response gate, which is why the cohort's off-treatment rate looks better than the older intermittent literature suggests. That comparison is a rationale, not a result: A-DREAM has no randomised arm.

The number that matters clinically is not 41% but its two components: testosterone recovery is the rate limiter (66.7% recovered, median 9.0 months), while disease control off treatment was more common (57.7% treatment-free at 18 months). A trial that de-intensifies successfully on disease grounds can still miss its endpoint on gonadal recovery in an older cohort, and that distinction determines who to counsel.

Single-arm phase 2, no continuous-treatment control, 18mo primary readout in a deeply selected responder cohort. Interruption safety needs a randomised comparator.

Sourced from @mjuanfi81

📚 Sources · 🐦 1 tweet

Precision Oncology: New Biomarkers in GU Practice (Panel)

TL;DRDiscussant session on biomarker readiness in prostate cancer; discordance between Decipher and clinical risk emerged in 24% of events.

Trials discussed

ENZAMETCHARTED

Why it mattersRadiation oncology

The transferable point for an RT reader is the training-context caveat: the Decipher-type classifiers cited were developed in cohorts that did not use ARPIs, and only 427 of 3816 pts had tissue. A genomic score used to escalate or omit RT intensification carries that generalizability gap into the clinic.

Decipher vs clinical risk, ≥high-risk prostate: 49% / 15% / 9% / 27%. Discordance in 24% of events. Tissue n=427 vs trial n=3816.
Decipher vs clinical risk, ≥high-risk prostate: 49% / 15% / 9% / 27%. Discordance in 24% of events. Tissue n=427 vs trial n=3816.
+3 more figures
ENZAMET biomarker flow: enrolled 1,125 → consented 1,071 → GEP 764 → final cohort 634; ADT+enza+docetaxel 320 (56% of enrolled).
ENZAMET biomarker flow: enrolled 1,125 → consented 1,071 → GEP 764 → final cohort 634; ADT+enza+docetaxel 320 (56% of enrolled).
Precision Oncology: New Biomarkers in GU Practice (Panel)
Treatment landscape 2026: PARP inhibitors ~10-20%, Lu-177 PSMA ~90%, pembrolizumab ~3%.
Treatment landscape 2026: PARP inhibitors ~10-20%, Lu-177 PSMA ~90%, pembrolizumab ~3%.
11 details

Discussant / education session at ASCO 2026 (Joshua Lang, MD, MS), reviewing biomarker evidence across GU practice rather than reporting a new trial. Slides cover the 2026 treatment landscape, a Decipher-vs-clinical-risk multivariable analysis, and the ENZAMET biomarker sub-analysis.

Decipher and clinical risk disagreed in 24% of patient events, with 15% biomarker-high/clinical-low and 9% biomarker-low/clinical-high. In the ENZAMET DPMC ≤0.85 group, ADT + enza + docetaxel showed worse OS than ADT + enza; no hazard ratio is legible in the source OCR.

The discussant's own caveats are the substance: tissue was available for 427 of 3816 pts, the source trials did not use ARPIs, and the ENZAMET docetaxel comparison was not randomised (docetaxel added by protocol amendment after 88 pts accrued). The worse-OS signal is confounded by more high-volume disease and older age in the docetaxel group.

The unifying claim is that a classifier's context of use is part of its validity: a model trained on pre-ARPI therapy and on the minority of pts with banked tissue should not be read as calibrated to today's ADT + ARPI backbone. Genomics is framed as distinct from germline genetics, with HRR and tumor-suppressor tissue panels held as current SOC.

  • Do pre-ARPI-trained genomic classifiers stay calibrated on ADT+ARPI backbones?
  • Does tissue-availability dropout bias biomarker cohort conclusions?

Sourced from @nataliagandur

📚 Sources · 🐦 1 tweet
Caveats dominate

ENZAMET + Decipher

FormHSPC on ADT + enzalutamide, Decipher score available

TL;DRDecipher >0.85 predicts docetaxel benefit in mHSPC on ADT+enza: HR(OS) 0.75 (0.43-1.33) vs 1.94 (0.95-3.96) if ≤0.85, interaction p=0.04.

Monday clinic

In mHSPC starting ADT + enzalutamide with a Decipher score available, this offers hypothesis-level support for weighing docetaxel intensification above the 0.85 cut and for questioning it below; it does not extend to patients on other ARSIs or to those without genomic testing.

The longer read
ENZAMET + Decipher
AnalysisLower Decipher (≤0.85)Higher Decipher (>0.85)Interaction p
Unweighted HR (95% CI)2.78 (1.49, 5.21)1.13 (0.71, 1.79)0.02
Unweighted p-value0.0010.60
IPTW weighted HR (95% CI)1.94 (0.95, 3.96)0.75 (0.43, 1.33)0.04
IPTW weighted p-value0.070.33
+2 more figures
ADT + ENZA + docetaxel cohort, N=320. OS HR 3.02 (1.50-5.76) and 1.08 (0.60-1.71), p=0.73.
ADT + ENZA + docetaxel cohort, N=320. OS HR 3.02 (1.50-5.76) and 1.08 (0.60-1.71), p=0.73.
ENZAMET + Decipher
8 details

Post-hoc genomic-classifier analysis of the ENZAMET ADT + enzalutamide cohort, N=320, testing whether Decipher (DPMC) predicts docetaxel benefit. Docetaxel receipt was investigator-elected, not randomised, so a propensity-score IPTW model carries the comparison.

mHSPC on an ADT + enzalutamide backbone with an evaluable Decipher score, split at the prespecified 0.85 cut. A separate panel restricts to low-volume disease.

Overall survival, read two ways: prognostic (Decipher stratum on ADT + enza) and predictive (docetaxel-by-Decipher interaction).

Prognostic signal is the cleanest number on the slide deck: HR 3.02 (1.50-5.76) for DPMC >0.85 on ADT + enza. The predictive claim rests on the interaction, p=0.02 unweighted and p=0.04 after IPTW, not on either stratum reaching significance.

mHSPC pts on ADT + enzalutamide with a Decipher score in hand
Does not represent pts on an ARSI other than enzalutamide, or anyone whose docetaxel decision was made without genomic testing available.

Docetaxel was not randomised within this cohort, so IPTW is doing the causal work and the authors concede residual imbalance after propensity scoring. Low-volume panel numbers are small (n at risk 14 and 13 in the reported strata) with a CI of 1.70 (0.32, 8.06), wide enough to be uninformative.

Presented as level 1B evidence consistent with CHAARTED and STAMPEDE, where docetaxel benefit concentrated in high-volume disease. This analysis proposes a genomic rather than volumetric selector for the same decision.

The strongest defensible claim is the prognostic one: DPMC >0.85 marks worse OS on ADT + enza. The predictive claim (add docetaxel above 0.85, omit it below) is directionally consistent across unweighted and weighted models but is not established by a single non-randomised interaction.

Post-hoc biomarker subgroup with non-randomised docetaxel use; both stratum HRs non-significant after weighting, residual imbalance conceded. Read rests on an interaction p=0.04.

  • Prospective validation of Decipher-guided docetaxel selection in mHSPC
  • Does the 0.85 cut hold on ARSI backbones other than enzalutamide
  • Whether low Decipher predicts docetaxel harm or only absent benefit

Sourced from @nataliagandur

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Confirmatory

ARACOG (AFT-47)

ForAdvanced prostate cancer (mHSPC, nmCRPC, mCRPC) starting an ARSI

Maximally Changed Cognitive Domain (CANTAB) at 24 weeks safety

daro -15.8 vs enza -36.1

median % change in MCCD at 24 wks, P=0.009

TL;DREnzalutamide MCCD decline -36.1 vs -15.8 for darolutamide at 24wks (P=0.009) in randomized phase 2, N=111.

Why it mattersRadiation oncology

The comparison is between each pt's own worst-hit domain, and those differed by arm (PALFAM for daro, SWM for enza), so the read is how far the worst domain falls, not which one. Crossover before 24wks was scored at crossover inside the randomized arm, which attenuates rather than widens the gap. Moves ARSI selection when cognitive burden matters, not efficacy.

Monday clinic

In a man starting an ARSI for mHSPC or nmCRPC where cognitive burden is a live concern, this supports darolutamide over enzalutamide on measured cognition; it does not speak to disease control, which was never compared head-to-head.

The longer read
ARACOG (AFT-47)
MetricDarolutamide (N=48)Enzalutamide (N=47)
Maximally changed modulePALFAMSWM
DomainVisual memory / executive functionWorking memory / executive function
Median change, baseline to 24 wks-15.8-36.1
Between-arm PP=0.009P=0.009
+2 more figures
ARACOG (AFT-47)
Schema: N=111 with mCRPC, nmCRPC or mHSPC randomized to darolutamide (study-provided) vs enzalutamide (standard of care), stratified by age (<65, 65-80, >80); enrolled 8/17/2021 to 3/11/2025.
Schema: N=111 with mCRPC, nmCRPC or mHSPC randomized to darolutamide (study-provided) vs enzalutamide (standard of care), stratified by age (<65, 65-80, >80); enrolled 8/17/2021 to 3/11/2025.
8 details

Randomized open-label phase 2 from the Alliance for Clinical Trials in Oncology, N=111, stratified by age (<65, 65-80, >80). Enrolled 8/17/2021 to 3/11/2025, with CANTAB modules, PROMs and timed-up-and-go collected at 12 and 24 weeks.

Men with mCRPC, nmCRPC or mHSPC. Randomization was stratified by age across three bands (<65, 65-80, >80), so the design anticipated an older population. Baseline cognitive eligibility criteria not reported in source.

Darolutamide was provided by the study; enzalutamide was given through standard of care, so the two arms differed in drug supply as well as drug. Doses and concurrent ADT not reported in source.

Primary: % change from baseline to 24 weeks in the Maximally Changed Cognitive Domain (MCCD), drawn from 5 remotely delivered CANTAB modules (SWM, PALFAM, OTS, SSP, RVP) covering executive function, visual memory, attention and working memory. Blood for polygenic hazard score and AR testing, PROMs and timed-up-and-go were collected alongside.

Median MCCD change -15.8 with darolutamide (PALFAM) vs -36.1 with enzalutamide (SWM), P=0.009, across 48 and 47 pts in the primary analysis. No oncologic endpoint was reported in source.

The two drugs have never been compared head-to-head for efficacy, and cognition in ARAMIS and ARASENS (darolutamide) and PROSPER and ARCHES (enzalutamide) was captured as clinician-graded adverse events against placebo, not measured with a battery. Mild executive dysfunction is exactly the harm an AE table structurally misses.

men on darolutamide or enzalutamide across mHSPC, nmCRPC and mCRPC, tested to 24 weeks
Does not represent men on apalutamide or abiraterone, nor men followed beyond 24 weeks.

Pts crossing over before 24 weeks carried their crossover score into the randomized arm, which should attenuate the gap rather than widen it. CANTAB is a research battery, not a clinical diagnostic, and no link to function, falls or discontinuation is reported in source. 24 weeks says little about years of therapy.

This shifts an argument that has run on mechanism and on AE tables onto measured performance. Where the two drugs are treated as interchangeable for disease control, cognition becomes a defensible tiebreaker. What it does not settle is whether an MCCD gap of this size is felt by the pt.

Randomized, prespecified primary endpoint met against a named comparator; open-label design and the composite MCCD construct temper it. Consistent with darolutamide's known limited CNS penetration.

  • Whether the MCCD difference translates to function, falls, or discontinuation
  • Durability of cognitive divergence beyond 24 weeks
  • Whether apalutamide differs from enzalutamide on the same testing

Sourced from @nataliagandur, @katy_beckermann

📚 Sources · 🐦 2 tweets
Practice-changing

TALAPRO-3

ForHRR-deficient metastatic hormone-sensitive prostate cancer, enzalutamide/ADT candidates

Imaging-based radiographic progression-free survival surrogate

HR 0.48

95% CI 0.36-0.65, P<0.001; 3yr rPFS 77% vs 56%

TL;DR3yr rPFS 77% vs 56%, stratified HR 0.48 (0.36-0.65), p<0.001, adding talazoparib to enzalutamide in HRR-deficient mCSPC.

Monday clinic

In HRR-deficient metastatic prostate cancer starting enzalutamide plus ADT, this supports considering talazoparib upfront rather than reserving it, including for non-BRCA HRR alterations; it does not speak to HRR-proficient disease, which the trial excluded.

The longer read
TALAPRO-3
PanelArmEvents/NMedian rPFS (95% CI), moHR (95% CI)
A ITTTalazoparib+enzalutamide67/300NC (NC-NC)0.48 (0.36-0.65), P<0.001
A ITTPlacebo+enzalutamide126/29945.8 (37.7-NC)
B BRCATalazoparib+enzalutamide22/104NC (NC-NC)0.37 (0.22-0.61)
B BRCAPlacebo+enzalutamide49/10335.1 (18.6-NC)
C Non-BRCAPlacebo+enzalutamide77/196NC (40.5-NC)0.57 (0.39-0.82)
8 details 4 trials watching

Randomised, placebo-controlled phase 3 of talazoparib plus enzalutamide vs placebo plus enzalutamide, with ADT in both arms. ITT N=599 (300 vs 299), analysed as ITT with prespecified BRCA and non-BRCA subgroups.

HRR-deficient metastatic prostate cancer; the BRCA subgroup was 104 vs 103 and non-BRCA 196 vs 196, so BRCA carried roughly a third of the trial. Detailed eligibility and stratification factors are not reported in source.

Talazoparib added to an enzalutamide/ADT backbone that both arms received, so the comparison isolates the PARP inhibitor's contribution rather than the androgen-signaling backbone. Doses not reported in source.

Primary: imaging-based rPFS. Overall survival, safety and response endpoints are not reported in the source tweet or figure.

Landmark 3yr rPFS 77% vs 56%; median rPFS not reached in the talazoparib arm against 45.8 mo on placebo. Effect held in both molecular subgroups, numerically larger in BRCA (HR 0.37) than non-BRCA (HR 0.57).

PopulationEvents/N talazoparibEvents/N placeboMedian placebo armHR (95% CI)
ITT67/300126/29945.8 (37.7-NC)0.48 (0.36-0.65) stratified
BRCA22/10449/10335.1 (18.6-NC)0.37 (0.22-0.61) unstratified
Non-BRCA45/19677/196NC (40.5-NC)0.57 (0.39-0.82) unstratified
HRR-deficient metastatic prostate cancer starting enzalutamide plus ADT
Does not represent HRR-proficient disease, which this trial did not enroll.

TALAPRO-2 tested the same combination in first-line mCRPC across all comers; here the population is HRR-selected and the HR is numerically stronger. PROpel and MAGNITUDE established the PARP-plus-ARSI question in mCRPC, with MAGNITUDE's benefit confined to HRR-altered pts, which is the population this trial enrolled outright.

The talazoparib arm's median rPFS is NC (NC-NC) in both ITT and BRCA panels, so the absolute duration of benefit is unmeasured and the curves may still converge. No OS signal is available in source, and toxicity of the doublet (the practical cost of adding a PARP inhibitor to lifelong ARSI) is entirely absent from what was published in the thread.

The non-BRCA HR of 0.57 is the number that decides how wide this goes: if it holds, the case extends past BRCA to the broader HRR panel rather than collapsing to a BRCA-only result as earlier PARP trials did. What it does not settle is whether an rPFS gain of this size converts to survival, or whether the same result would follow sequential rather than upfront talazoparib.

CONSORT flow
Randomized 599
Talazoparib+enzalutamide
allocated 300
3yr rPFS 77%
Placebo+enzalutamide
allocated 299
3yr rPFS 56%

Randomised double-blind phase 3, prespecified 1° rPFS hit with HR 0.48 in a biomarker-defined population, consistent across BRCA and non-BRCA. OS immature.

Sourced from @DrChoueiri

📚 Sources · 🐦 1 tweet
Caveats dominate

Clinico-transcriptomic Risk Stratification (Abstract 5000)

ForNCCN high-risk / very-high-risk localized prostate, definitive RT + ADT

TL;DR~¼ of NCCN ≥HR pts carry discordant clinical vs biomarker risk; 22-gene GC independently prognostic for MFS, DM, OS.

Why it mattersRadiation oncology

The de-escalation cell is where the risk sits: 9% of NCCN ≥HR pts read clinically high but biomarker low, and the framework withholds AAP from them. The 15% running the other way is the easier sell. What moves is whether GC gets ordered at consult, not any planning parameter.

Monday clinic

In NCCN high-risk or very-high-risk localized prostate headed for definitive RT + ADT, this supports ordering a 22-gene GC before the abiraterone decision; it does not speak to post-prostatectomy salvage, node-positive, or metastatic disease.

The longer read
MFS and OS: NRG Risk ≤ 2 (CT HR) and NRG Risk ≥ 3 (CT VHR) vs STAMPEDE RT+ADT reference.
MFS and OS: NRG Risk ≤ 2 (CT HR) and NRG Risk ≥ 3 (CT VHR) vs STAMPEDE RT+ADT reference.
+3 more figures
Clinico-transcriptomic Risk Stratification (Abstract 5000)
Clinico-transcriptomic Risk Stratification (Abstract 5000)
Clinical risk↓ Biomarker↑ Biomarker
↓ Clinical49%15%
↑ Clinical9%27%
Clinico-transcriptomic Risk Stratification (Abstract 5000)
8 details

Clinico-transcriptomic analysis of NRG cohorts modeling the 22-gene GC as a continuous variable (per 0.1 unit) alongside clinical covariates, with treatment carried as a covariate. Contributing trials, N, and follow-up duration are not reported in the source.

NCCN ≥ high-risk localized prostate, spanning NCCN HR and VHR. Baseline age, PSA, and grade distributions are not reported in the source.

Every branch of the framework keeps RT + ADT. No dose, fractionation, target volume, or ADT duration is reported, so RT enters as a fixed backbone rather than a variable under test.

Prognostic performance assessed on MFS, distant metastasis, and OS. No single primary endpoint is stated, and the framework itself is not compared against a randomized alternative.

GC was independently prognostic for all three endpoints (p<0.001); the row-level hazard ratios are not legible in the source slide. Approximately ¼ of the ≥HR population carries discordant clinical vs biomarker risk.

Score (NCCN + GC)CT riskRecommendation
≤ 2 pointsCT HRRT + ADT
≥ 3 pointsCT VHRRT + ADT + AAP

STAMPEDE M0 (Attard, Lancet 2022) is the external yardstick: the CT HR and CT VHR curves are overlaid on that trial's RT + ADT arm rather than on a randomized internal control. Eligibility, staging era, and ADT duration differ between cohorts, so the vertical gap carries trial effects alongside risk-group effects.

NCCN high-risk and very-high-risk localized prostate treated with definitive RT + ADT
Does not represent post-prostatectomy salvage, node-positive or metastatic disease, or men managed with surgery alone.

The GC term's hazard ratios and confidence intervals are not legible in the source, so the size of the increment over clinical variables cannot be checked. The 9% clinically-high / biomarker-low cell is where the framework withholds intensification, and its outcomes are the ones a reader most needs before acting.

The contribution is a parsimonious integer score computable at the consult desk, extending Spratt et al. (JCO 2018) to the modern VHR population. What it does not settle is whether the signal separating these curves also identifies who benefits from AAP: a prognostic split widens absolute benefit for a uniformly effective drug without any interaction, and none is reported here.

Retrospective pooled analysis; GC shown prognostic, not predictive. Intensification threshold benchmarked against STAMPEDE across trials, not randomized within cohort; no treatment-by-GC interaction in source.

  • Does GC predict abiraterone benefit or only prognosis?
  • Prospective validation of the ≥3-point intensification threshold
  • Whether NCCN VHR pts with GC < 0.6 can omit AAP

Sourced from @nataliagandur, @chavarriagaj

📚 Sources · 🐦 2 tweets

Breast

PREPEC favours pre-pectoral reconstruction on patient-reported chest well-being but reports no RT stratification and no capsular contracture data, leaving the post-mastectomy RT question open.

Challenges SOC

PREPEC

ForSkin- or nipple-sparing mastectomy, therapeutic or risk-reducing, implant reconstruction

Physical well-being (chest), BREAST-Q, 24 months surrogate

79.2 vs 74.3

Difference 4.8 (95% CI 1.0-8.7), p=0.01

TL;DRPre-pectoral implant improved 24-mo BREAST-Q physical well-being (chest) by 4.8 points, but implant loss 21.1% vs 14.5%.

Why it mattersRadiation oncology

The 4.8-point BREAST-Q gain (1.0 to 8.7) sits against a 5.7-point higher implant loss rate (-2.4 to 13.8), so this is a trade-off, not a win. Source reports no post-mastectomy RT stratification or irradiated subgroup, so whether pre-pectoral holds up under PMRT is untested here.

Monday clinic

In women planned for skin- or nipple-sparing mastectomy with implant reconstruction, this supports pre-pectoral placement for patient-reported chest well-being while flagging higher device loss; it does not address women who will need post-mastectomy radiotherapy.

The longer read
PREPEC
IBBR assignmentN24-mo LS mean (95% CI)
Pre-pectoral IBBR19179.2 (75.5 - 82.8)
Sub-pectoral IBBR18974.3 (70.7 - 78.0)
Difference4.8 (1.0 - 8.7), p=0.01
+2 more figures
PREPEC
Actual IBBR positioningUnplanned loss/replacement at 24 mo, crude % (n/N)
Pre-pectoral IBBR21.1% (41 / 194)
Sub-pectoral IBBR14.5% (27 / 186)
Adjusted difference (95% CI)5.7 (-2.4 to 13.8)
PREPEC
9 details

International randomized trial (PREPEC / OPBC-02) of pre-pectoral versus sub-pectoral implant-based breast reconstruction after skin-sparing or nipple-sparing mastectomy. Follow-up to 24 months, with 6 post-randomization patient-reported timepoints.

Women undergoing nipple-sparing or skin-sparing mastectomy in either the therapeutic or risk-reduction setting. Primary analysis included 191 pre-pectoral and 189 sub-pectoral; safety was analysed by actual positioning (194 versus 186).

Primary: long-term patient-reported physical well-being (chest) on BREAST-Q, scored 0 to 100 with higher better. Main secondary safety endpoint: unplanned loss or replacement of expander or implant.

Primary endpoint met; the safety endpoint moved against pre-pectoral placement. See the endpoint tables above.

Unplanned implant or expander loss or replacement at 24 months was 21.1% (41/194) pre-pectoral versus 14.5% (27/186) sub-pectoral, adjusted difference 5.7% (-2.4 to 13.8), which the investigators call inconsistent with the non-inferiority hypothesis.

women having skin-sparing or nipple-sparing mastectomy with implant-based reconstruction, therapeutic or risk-reducing
Does not represent autologous reconstruction, delayed reconstruction, or, on the evidence in this source, women planned for post-mastectomy radiotherapy.

Longitudinal completion ranged 83-95% and the primary estimate rests on multiple imputation with imputed baseline values, so the 4.8-point difference carries missing-data assumptions on top of its confidence interval. Surgeon and patient blinding is not feasible for a positioning trial, which cuts directly at a patient-reported primary endpoint.

The trial answers the PRO question it asked and simultaneously undercuts the assumption that pre-pectoral placement is device-safe. Whether a 4.8-point BREAST-Q gain is worth a 5.7-point absolute rise in unplanned reoperation is a preference-sensitive decision, not one the trial resolves.

Randomised, prespecified PRO primary endpoint met, but the safety co-read failed its non-inferiority hypothesis, so the trade-off, not the win, is the finding.

  • Does pre-pectoral placement hold up under post-mastectomy radiotherapy
  • Capsular contracture rates by implant plane
  • Durability of the well-being advantage beyond 24 months

Sourced from @to_be_elizabeth

📚 Sources · 🐦 1 tweet

CNS

ROADS moves the resected-cavity question from post-op SRS timing to intraoperative brachytherapy, with an OS gap wider than bed control alone explains and an LMD signal running the other way.

Challenges SOC

ROADS

ForResected brain metastasis >2 cm, post-op cavity radiation candidates

Time to surgical bed recurrence local control

NR vs 17 mo

GammaTile vs SRS; no HR, CI, or p reported in source

TL;DRSurgical bed recurrence 1% with GammaTile brachytherapy vs 12% post-op SRS in resected brain mets >2cm, N=230.

Why it mattersRadiation oncology

The RT read is the bed-control mechanism: GammaTile puts dose in the cavity at resection, closing the gap where post-op SRS fails in cavities >2 cm, with median time to bed recurrence not reached vs 17 mo. LMD was 10% GT vs 3% SRS, so the trade is bed control against meningeal seeding when picking the cavity strategy.

Monday clinic

In a resected brain metastasis larger than 2 cm being planned for cavity radiation, this questions post-op SRS as the default bed strategy; it does not extend to intact metastases, cavities under 2 cm, or pts already carrying leptomeningeal disease.

The longer read
ROADS
EndpointGammaTileSRS
Time to surg bed recurNR17 mo
Surg bed recur FSNR11 mo
2 yr OS62%36%
10 details

Randomized trial of GammaTile brachytherapy vs post-op SRS after resection of a brain metastasis, N=230, reported as final results at ASCO 2026 (Weinberg). Randomization ratio, number of sites, and follow-up duration not reported in source.

Resected brain metastasis >2 cm, the size band where post-op cavity SRS control is weakest. Histology mix, number of brain metastases allowed, systemic disease status, and performance status not reported in source.

Experimental arm is GammaTile, a Cs-131 collagen tile implanted in the cavity at the time of resection, so dose starts without the post-op delay. SRS dose, fractionation, cavity margin, and time from surgery to SRS are not reported in source, and those are exactly the parameters that decide whether the control arm reflects the reader's own practice.

Primary I: time to surgical bed recurrence. Primary II: surgical bed recurrence-free survival. 2 yr OS is reported alongside them; the source does not state whether OS was a prespecified secondary.

Both primaries favor GammaTile with medians not reached vs 17 mo and 11 mo. No HR, confidence interval, or p-value appears in the source.

Radiation necrosis 7% SRS vs 8% GT, essentially flat. Leptomeningeal disease 3% SRS vs 10% GT is the signal that cuts against the arm winning on bed control; timing and denominators not reported in source.

Post-op cavity SRS became standard on N107C/CEC.3 and the MDACC randomized trial, both of which traded whole-brain neurocognitive toxicity for weaker bed control, with failure concentrated in larger cavities. ROADS attacks that residual failure directly rather than re-litigating whole-brain RT.

resected brain metastases larger than 2 cm going on to cavity-directed radiation
Does not represent intact metastases treated with SRS alone, small cavities, or pts with established leptomeningeal disease.

The 2 yr OS separation, 62% vs 36%, is far larger than bed recurrence alone (12% vs 1%) would mechanistically support, which points at arm imbalance, differential salvage, or systemic therapy that the source does not report. The trial is also inherently unblinded, and the LMD excess in the GammaTile arm has no reported timing to judge whether it is procedure-related seeding.

If the bed-control numbers hold in the full report, the cavity strategy for a large resected met becomes a surgical-planning decision made before the operation rather than a radiation-planning decision made after it. The OS claim should wait for the manuscript.

Randomized, both primaries reported, final analysis. Verdict held below practice-changing: conference-slide source with no HR, CI, or p-value, and unexplained LMD excess.

  • Is the 2yr OS separation confirmed with hazard ratios and cause of death?
  • Does the leptomeningeal excess with GammaTile reflect seeding or longer survival?
  • Does the benefit hold against fractionated post-op SRS rather than single fraction?

Sourced from @PDBrownOnc

📚 Sources · 🐦 1 tweet

Thoracic / Lung

All systemic 1L data; ESAONA's intracranial iORR 95.5% vs 79.6% is the one with an RT bearing, since better CNS control shifts the threshold for upfront brain radiotherapy.

Early signal

CHRYSALIS-2

ForTreatment-naive advanced NSCLC with atypical (uncommon) EGFR mutation

TL;DRMedian OS 41.0 mo (95% CI 27.7-NE) with 1L amivantamab + lazertinib in atypical EGFR-mutant NSCLC, single-arm n=49.

Monday clinic

In treatment-naive advanced NSCLC with an atypical EGFR mutation, this supports amivantamab plus lazertinib as a prospectively benchmarked option where none is established; it does not extend to classical exon 19del/L858R disease or exon 20 insertions.

The longer read
Overall survival, 1L ami + laz. Median OS 41.0 mo (95% CI 27.7-NE). Median follow-up 31.3 mo. n at risk 49 at baseline.
Overall survival, 1L ami + laz. Median OS 41.0 mo (95% CI 27.7-NE). Median follow-up 31.3 mo. n at risk 49 at baseline.
+1 more figure
Time on treatment. Median duration 13.3 mo (range <0.1-53.2); 39% on treatment >2 yrs.
Time on treatment. Median duration 13.3 mo (range <0.1-53.2); 39% on treatment >2 yrs.
8 details 3 trials watching

Single-arm expansion cohort of the CHRYSALIS-2 program, n=49, 1L atypical EGFR-mutated advanced NSCLC. Median follow-up 31.3 mo. No randomised comparator arm.

Treatment-naive advanced NSCLC harbouring an atypical (uncommon) EGFR mutation. Baseline strata shown on the swimmer plot include age ≥65y, Asian ancestry and CNS involvement; per-stratum counts are not reported in source.

IV amivantamab (EGFR/MET bispecific) plus lazertinib (third-generation EGFR TKI). No chemotherapy backbone. Median duration of treatment 13.3 months (range <0.1-53.2), with 39% of 1L participants still on treatment beyond 2 years.

Median OS 41.0 mo (95% CI 27.7-NE), described by the presenters as roughly 3.5 years. The upper CI bound is not estimable, so the point estimate is anchored on the lower bound of 27.7 mo.

Reported only as consistent with prior reports, no new safety signals with longer follow-up. No grade 3+ rates, infusion-reaction rates or dermatologic AE rates appear in the source.

treatment-naive advanced NSCLC with an atypical EGFR mutation, fit for a bispecific plus TKI doublet
Does not represent classical exon 19del/L858R disease, exon 20 insertions treated as a separate class, or pretreated patients.

The atypical EGFR label pools biologically distinct alterations (G719X, S768I, L861Q and compound variants) whose single-agent TKI sensitivity differs; n=49 cannot resolve per-variant benefit, and the curator's read of no variant-outcome association is an absence of signal in a small cohort, not evidence of uniformity. No comparator, so the 41.0 mo median cannot be positioned against afatinib or osimertinib series in the same population.

Atypical EGFR is the part of the EGFR-mutant space where no regimen is settled, so a 41.0 mo median in 49 pts is meaningful as a benchmark even without randomisation. The practical question this leaves open is whether the bispecific's added toxicity and IV schedule are justified over an oral TKI alone, which this design cannot answer.

Single-arm n=49 expansion cohort, no randomised comparator against afatinib or osimertinib in atypical EGFR. Maturity gate: single-arm never reaches confirmatory.

Sourced from @chulkimMD

📚 Sources · 🐦 1 tweet
Early signal

ESAONA

For1L EGFR-mutant NSCLC with brain metastases

Intracranial ORR (BICR) surrogate

95.5% vs 79.6%

p = 0.0004

TL;DRiORR 95.5% vs 79.6% (p=0.0004) and intracranial PFS HR 0.46 favoring asandeutertinib in 1L EGFR-mutant NSCLC with brain mets.

Why it mattersRadiation oncology

The RT-relevant number is intracranial PFS: median not reached vs 17.5 mo, HR 0.46. If a first-line TKI holds CNS disease that long, the deferral-of-brain-RT window widens, but the source reports no prior-RT stratification, no CNS-RT use by arm, and no lesion size or symptom criteria, so this cannot yet gate an SRS-versus-defer decision.

Monday clinic

In treatment-naive EGFR-mutant NSCLC with asymptomatic brain metastases, this supports the case for TKI-first CNS control as a hypothesis, not a change in practice; it says nothing about symptomatic or large lesions where local therapy is already indicated.

ESAONA
EndpointAsandeutertinib (n=111)Osimertinib (n=113)Effect
Intracranial ORR (BICR)95.5% (89.8-98.5)79.6% (71.0-86.6)p = 0.0004
Intracranial PFS (BICR)Median not reached17.5 mo (15.18-NA)HR 0.46, p = 0.0020
Overall PFS (BICR)Median not reached17.2 mo (15.18-19.55)HR 0.64, p = 0.0473
Any TRAE99.1%95.6%n/a
Serious TRAE10.8%7.1%n/a
7 details 4 trials watching

Randomised phase II, N=224, asandeutertinib (n=111) vs osimertinib (n=113). Endpoints read by BICR. Follow-up duration, stratification factors and alpha allocation are not reported in the source slide.

First-line EGFR-mutated NSCLC with brain metastases. The source does not state lesion number, size, symptom status, or whether prior CNS radiotherapy was permitted, which is the eligibility gate an RT reader needs.

Intracranial ORR by BICR is the headline, with intracranial PFS and overall PFS reported alongside. No overall survival data in source.

Any TRAE 99.1% vs 95.6%; serious TRAE 10.8% vs 7.1%. The excess serious-event rate is small in absolute terms but sits on a phase II denominator, and no organ-level breakdown is given in source.

treatment-naive EGFR-mutant NSCLC with brain metastases enrolled on trial
Does not represent symptomatic or large CNS lesions requiring immediate local therapy, prior-TKI-exposed disease, or leptomeningeal involvement.

The intracranial separation (HR 0.46) is larger than the systemic one (HR 0.64), which points at CNS penetration rather than a general potency gain as the mechanism. For radiation oncology the question is whether that CNS margin is durable enough to defer SRS in asymptomatic pts; a phase II with unreached medians and no OS cannot answer it.

CONSORT flow
Randomized 224
Asandeutertinib
allocated 111
iORR 95.5%
Osimertinib
allocated 113
iORR 79.6%

Phase II, conference-slide source only; no OS, borderline overall-PFS p, and no reported CNS-RT or prior-RT stratification. Needs phase III before displacing osimertinib.

Sourced from @DrRishabhOnco

📚 Sources · 🐦 1 tweet
Early signal

OptiTROP-Lung05 NCT06448312

For1L stage IIIB-IV NSCLC, PD-L1 TPS ≥1%, EGFR/ALK wild-type, ECOG 0-1

Progression-free survival (BICR) surrogate

HR 0.35

95% CI 0.26-0.47, p<0.0001; NR vs 5.7 mo

TL;DRmPFS NR vs 5.7mo, HR 0.35 (0.26-0.47) for sac-TMT + pembro in 1L PD-L1+ NSCLC.

Monday clinic

In treatment-naive PD-L1 TPS ≥1% advanced NSCLC without EGFR/ALK alteration, this supports a TROP2 ADC plus pembro as a chemo-free option worth watching; it does not address pts already committed to pembro plus platinum chemo, nor PD-L1-negative disease.

The longer read
OptiTROP-Lung05
ArmPFS events, n (%)Median PFS, mo (95% CI)HR (95% CI)
Sac-TMT + Pembro (n=208)66 (31.7)NR (13.6, NE)0.35 (0.26, 0.47), p<0.0001
Pembro (n=205)128 (62.4)5.7 (4.3, 7.0)n/a
+3 more figures
OptiTROP-Lung05
PD-L1 stratumSac-TMT + Pembro median, moPembro median, moHR (95% CI)
TPS ≥50%NR (NE, NE)9.5 (6.9, 13.8)0.47 (0.29, 0.77)
TPS 1-49%NR (11.1, NE)4.3 (2.9, 5.5)0.28 (0.19, 0.41)
OptiTROP-Lung05
ArmOS events, n (%)Median OS, mo (95% CI)HR (95% CI)
Sac-TMT + Pembro (n=208)33 (15.9)NR (NE, NE)0.55 (0.36, 0.85)
Pembro (n=205)54 (26.3)NR (NE, NE)n/a
OptiTROP-Lung05
13 details 3 trials watching

Randomized, multicenter, open-label phase 3 (NCT06448312), 1:1, N=413. Stratified by histology (squamous vs non-squamous), PD-L1 TPS (1-49% vs ≥50%), and ECOG (0 vs 1). Median follow-up 10.5 months at this analysis.

Locally advanced stage IIIB/IIIC or metastatic stage IV NSCLC with no prior systemic antitumor therapy. Required PD-L1 TPS ≥1% by IHC 22C3 central lab, no sensitizing EGFR or ALK alteration, ECOG 0 or 1.

Sac-TMT 4 mg/kg Q2W plus pembrolizumab 400 mg versus pembrolizumab 400 mg Q6W alone, until progression or unacceptable toxicity. Pembro was capped at a maximum of 18 cycles in both arms. One pt in the pembro group never received assigned treatment.

Primary: PFS by BICR. Key secondary: OS. Other secondary: investigator-assessed PFS, ORR, DCR, DOR, safety. The updated efficacy boundary at the actual 194 PFS events was 0.0174 (2-sided).

PFS crossed its boundary at p<0.0001. OS was descriptive at the PFS interim, HR 0.55 (0.36, 0.85) with both medians not reached and only 33 vs 54 deaths.

The pembro-alone control performed as expected for an all-comers TPS ≥1% population, with the TPS ≥50% arm reaching 9.5 mo and the TPS 1-49% arm 4.3 mo, consistent with the KEYNOTE-042 signal that low-expressors gain least from single-agent IO. This is the setting where chemo-IO has historically been chosen, so the trial tests whether an ADC can occupy that slot instead of platinum doublet chemotherapy.

treatment-naive PD-L1-positive advanced NSCLC, EGFR/ALK wild-type, ECOG 0-1, enrolled at a predominantly Chinese trial network
Does not represent PD-L1-negative disease, driver-mutant NSCLC, ECOG ≥2, or pts for whom pembro plus platinum chemo is the intended comparator.

No toxicity data in the source, which is the decisive missing piece for a doublet whose entire premise is avoiding chemotherapy. The comparator is pembro monotherapy rather than the chemo-IO most oncologists actually give at TPS 1-49%, so the PFS gap partly measures a weak control rather than a strong experimental arm.

An HR of 0.35 with a median not reached is a large PFS effect, and the OS point estimate moves in the same direction, but neither settles whether sac-TMT plus pembro beats the regimen it would actually replace. The larger effect in TPS 1-49% (HR 0.28) than TPS ≥50% (HR 0.47) is the expected pattern when the control arm is weakest in the low-expressors, not evidence of a biomarker-selected ADC effect.

CONSORT flow
Randomized 413
Sac-TMT + Pembro
allocated 208
mPFS NR (13.6, NE)
Pembro
allocated 205
mPFS 5.7 mo (4.3, 7.0)

PFS interim of an open-label phase 3; OS descriptive at 10.5 mo f/u with both medians NR. No safety data in source, and no comparison vs pembro + chemo.

Sourced from @dr_yakupergun, @HHorinouchi

📚 Sources · 🐦 2 tweets

GI Upper

Neo-CRAG revives preoperative chemoRT in gastric/EGJ by restricting to cT3N2+ on a D2 backbone, though the comparator is XELOX, not FLOT.

Challenges SOC

Neo-CRAG

ForcT3N2-3M0 / cT4 gastric or Siewert II-III EGJ adenocarcinoma, D2-resectable

Disease-free survival surrogate

HR 0.750

95% CI 0.607-0.928, P=0.008; 3yr DFS 55.6% vs 42.4%

TL;DRAdding preop 45Gy/25fx to periop XELOX raised 3yr DFS 55.6% vs 42.4%, HR 0.750; mOS 67.5 vs 37.6mo.

Why it mattersRadiation oncology

The RT case here rests on locoregional control: LRR after R0 fell to 9.4% from 18.3%, tracking the ypN0 (56.1% vs 36.4%) and pCR gains, which is the mechanistic chain CRITICS and TOPGEAR never produced. Dose was conventional 45Gy/25fx preoperatively, and G3+ postop complications stayed flat (9.0% vs 7.6%), so the deliverability objection to preop RT before D2 loses force.

Monday clinic

In node-heavy cT3N2+ or cT4 gastric/Siewert II-III disease heading to D2 resection, this supports revisiting preoperative chemoRT rather than chemo alone; it does not speak to cT2N0-N1 disease or to pts already committed to a FLOT backbone.

The longer read
Neo-CRAG
EndpointCRTCTEffect size
3yr DFS55.6% (50.1-61.1)42.4% (36.9-47.9)HR 0.750 (0.607-0.928), P=0.008
Median DFS52.7 mo24.4 mon/a
5yr OS50.1%44.2%HR 0.781 (0.628-0.970), P=0.025
Median OS67.5 mo37.6 mon/a
9 details

Randomised, multicenter, phase 3 trial, N=620 (310 per group), 13 referral hospitals in China, accrual 2013-2022. Follow-up on the DFS curve extends past 120 months.

High-risk locally advanced gastric or EGJ adenocarcinoma: cT3N2-3M0, cT4aN+M0, or cT4bNanyM0, Siewert II/III permitted. 225 (36.3%) had an EGJ primary, and every pt was intended for standardized D2 resection.

Both arms: 3 cycles preoperative XELOX (oxaliplatin 130 mg/m² D1, capecitabine 1000 mg/m² BID D1-14, Q3W) then D2 gastrectomy then 3 adjuvant XELOX cycles.

CRT arm added concurrent 45 Gy / 25 fractions after cycle 1 of preoperative chemo, with attenuated concurrent dosing (oxaliplatin 100 mg/m², capecitabine 825 mg/m²). Target volume not specified in source.

Primary: disease-free survival, from randomization to progression, relapse, or death. Secondary: overall survival, pCR, R0 resection, safety.

Primary endpoint met. The locoregional read is the one an RT reader needs: LRR 9.4% vs 18.3% among R0-resected pts.

G3+ haematologic toxicity 14.6% vs 10.3%, the expected cost of concurrent chemoRT. G3+ postoperative complications were comparable, 9.0% vs 7.6%, so preoperative RT did not measurably worsen D2 surgical morbidity.

CRITICS (postoperative chemoRT after D1+ surgery) and TOPGEAR (preoperative chemoRT with ECF/FLOT) both failed to show a survival gain for radiotherapy in this disease. Neo-CRAG differs on three axes at once: RT given preoperatively, D2 resection mandated, and enrolment restricted to node-heavy cT3N2+ or cT4 disease.

high-risk cT3N2-3 / cT4 gastric and Siewert II-III EGJ adenocarcinoma treated with D2 gastrectomy and a doublet backbone
Does not represent cT2 or node-negative disease, Siewert I tumours, or pts planned for perioperative FLOT.

The 2013-2022 accrual window means the control arm reflects a doublet era; a 37.6 mo median OS in the control group is short against contemporary FLOT-treated series. Single-country enrolment with uniformly high-quality D2 surgery also caps generalisability to centres with variable nodal dissection.

The pCR, downstaging, ypN0 and LRR gradient forms a coherent mechanistic chain from RT to the DFS separation, which is what earlier negative trials lacked. What it does not settle is whether that chain survives a stronger systemic backbone, since much of FLOT's advantage over a doublet is itself locoregional.

CONSORT flow
Randomized 620
CRT (chemoRT + XELOX)
allocated 310
3yr DFS 55.6%
CT (XELOX alone)
allocated 310
3yr DFS 42.4%

Randomised ph3, prespecified DFS met with OS support, but the chemo backbone is XELOX not FLOT, so it contests RT omission without settling it.

  • Does preoperative chemoRT still add benefit on a FLOT backbone?
  • Generalizability outside high-volume D2 centers
  • Optimal target volume and elective nodal coverage not reported in source

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Supportive / QoL

SPIN scores who responds to celiac plexus SRS, derived and validated in the same 90 pts.

Caveats dominate

SPIN Score (Celiac Plexus Radiosurgery) NCT03323489

ForPancreatic cancer with retroperitoneal pain considered for celiac plexus SRS

TL;DRPost-hoc predictors of pain response after celiac SRS: response 32% / 53% / 89% by 0 / 1 / 2 SPIN points.

Why it mattersRadiation oncology

The actionable RT read is timing, not technique: neurotoxic chemo exposure carried OR 5.1 (p=0.009) against response, so the referral decision moves earlier in the disease course, before oxaliplatin or taxane neuropathy. Celiac SRS is NCCN-listed and single-fraction, so the gate is who you irradiate and when, not dose.

Monday clinic

In pancreatic cancer pts with retroperitoneal pain scoring above 6 and no prior neurotoxic chemo, this supports considering celiac SRS earlier rather than after systemic lines; it does not tell you what to do for the chemo-exposed, low-pain pt, where response was 32%.

The longer read
SPIN Score (Celiac Plexus Radiosurgery)
SPIN scorenPain response
03132%
14053%
21989%
10 details

Post-hoc analysis of the pivotal single-arm phase 2 celiac plexus radiosurgery trial (NCT03323489), n=90 evaluable. Candidate baseline predictors screened by univariate then multivariate logistic regression, with only multivariate-significant variables carried into the score. Internal validation by bootstrap resampling, 500 iterations, for an optimism-corrected AUC.

Pain response per parent protocol: a ≥2-point reduction in average pain on the Brief Pain Inventory-Short Form, baseline to three weeks. Parent-trial response was 53% (95% CI 42-64%).

Only neurotoxic chemotherapy exposure (OR 5.1, p=0.009) and baseline pain intensity (OR 1.8, p=0.003) survived multivariate analysis; age and therapy line dropped out to collinearity. The resulting 2-point score separated response into 32% / 53% / 89%, with AUC 0.716 apparent, 0.714 optimism-corrected.

PredictorUnivariateMultivariate
Neurotoxic chemo exposureOR 5.33 (2.13-13.4), p<0.001OR 5.1, p=0.009
Baseline pain intensityOR 1.73, p=0.003OR 1.8, p=0.003
AgeOR 1.06, p=0.014lost significance
Therapy lineOR 0.65, p=0.04lost significance
pancreatic cancer pts with retroperitoneal pain enrolled on the phase 2 celiac SRS trial
Does not represent pts outside that trial's eligibility, or celiac pain from non-pancreatic primaries.

The score was derived and internally validated in the same 90 pts, so the bootstrap corrects optimism from resampling but not from the variable-selection step that preceded it. The 2-point stratum is n=19, and the dichotomy at pain >6 was picked from the same data that shows steeper response above 7 and 8.

The neurotoxic-chemo term is the interesting one because it is a timing variable a clinician controls, not a fixed patient trait: it implies referral for celiac SRS competes with the systemic sequence rather than following it. Whether that reflects true nerve injury blunting an ablative pain response, or confounding by later-line disease biology, the post-hoc design cannot separate.

Post-hoc derivation on the parent trial's own 90 pts; internal bootstrap only, no external cohort. Design dominates the read regardless of effect size.

  • External validation of the SPIN score in an independent cohort
  • Is neurotoxic chemo effect causal or a proxy for later-line disease
  • Durability of pain response beyond the 3-week endpoint

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