Combined
Decipher and PAM50 in NRG/RTOG 9601 and 0534
TL;DRASTRO 2026 secondary analyses: Decipher prognostic in 9601 but not formally predictive; PAM50 luminal-B predicted STADT benefit with salvage RT in 0534.
Reported via UroToday →
NRG/RTOG 9601NRG/RTOG 0534NRG-GU006NRG GU-009
The actionable split is early salvage with low Decipher: no significant 15-yr PCSM benefit from bicalutamide, while late salvage benefited regardless of score. PAM50 luminal-B status, reported on the Decipher grid, adds a predictive read for STADT. The PLNRT-by-subtype MFS trend is exploratory and should not yet move pelvic nodal coverage decisions.
In a post-RP pt with early salvage PSA and Decipher ≤0.6, this questions the PCSM value of adding hormone therapy to salvage RT; it does not extend to late salvage pts, who benefited regardless of score. The longer read
For salvage prostate bed RT, low-Decipher early salvage pts showed no significant PCSM gain from adding bicalutamide, while late salvage benefited regardless. A PAM50 luminal-B trend toward PLNRT benefit on MFS appeared in 0534 but is exploratory and does not support changing nodal fields.
PAM50 luminal-B predicted benefit from STADT in 0534 (significant interaction), matching NRG-GU006 with apalutamide, which suggests the effect does not depend on the agent. Decipher stayed prognostic but did not meet the predictive criterion, so it refines absolute risk rather than identifying who responds to ADT.
11 details
Two ASTRO 2026 secondary biomarker analyses of randomized salvage trials, discussed in a UroToday interview. RTOG 9601: salvage RT ± bicalutamide 24 mo. RTOG 0534: PBRT vs PBRT + STADT vs PBRT + STADT + PLNRT, PAM50 on a subset.
Post-prostatectomy salvage pts. 9601 enrolled PSA 0.2 to 4.0, early and late salvage. The 0534 PAM50 subset showed no significant baseline differences across arms.
Decipher was prognostic for OS, PCSM and DM, including early salvage, but not predictive by the statistical criterion. In 0534, luminal-B pts gained a large FFP benefit from STADT vs much less in non-luminal-B, with a significant interaction p.
| Salvage setting | Decipher | PCSM benefit at 15 yr |
|---|---|---|
| Early salvage | >0.6 | >5% |
| Late salvage | Any | >5% |
| Early salvage | Low (≤0.6) | No significant benefit |
The PAM50 finding matches NRG-GU006, where luminal-B tumors benefited from apalutamide, so the signal holds across bicalutamide, leuprolide-based STADT and an ARPI. NRG GU-009/010 used a Decipher cut of 0.85 in the intact setting, vs 0.6 here post-op.
No HRs, interaction p-values or absolute rates are given in the source interview. The PSA threshold separating early from late salvage is not stated. Decipher and PAM50 can be discordant, and the source offers no data on how to resolve that.
Presenters frame both tests as one input to shared decision-making with pts, not a gate. Decipher reports PAM50 subtype on the same grid, so a single order yields both.
- Does PAM50 luminal-B status predict benefit from pelvic nodal RT?
- How to act on discordant Decipher and PAM50 results
- Optimal Decipher cut point for de-intensifying ADT in early salvage
📚 Sources · 📄 1 paper
Abstract
PE-PE NCT05578664
ForOligometastatic RCC, ≤3 mets within 5y of prior nephrectomy, MDT-eligible
HR 0.47
95% CI 0.24-0.92, p=0.024; mRFS 25.4 vs 11.0 mo
TL;DRmRFS 25.4 vs 11.0 mo, HR 0.47 (0.24-0.92), p=0.024, adding 1y perioperative pembrolizumab to SABR/surgery MDT in omRCC.
SABR was the MDT in 73% vs 72% of pts, so this is mostly pembrolizumab plus SABR vs SABR alone. Dose/fractionation and the local relapse secondary aren't in the abstract, so it can't yet show whether P changes in-field control or only cuts distant events. The decision it moves is whether SABR to all sites goes ahead with or without IO.
In post-nephrectomy omRCC with ≤3 mets within 5y planned for SABR or metastasectomy, this supports discussing 1y of perioperative pembrolizumab with MDT; it does not extend to >3 mets or relapse beyond 5y of nephrectomy. The longer read
SABR was the MDT in 73% vs 72%, so this tests IO on top of SABR to all sites. Dose and the local relapse secondary are unreported, so whether P improves in-field control or only distant events is unknown, and SABR technique itself is unchanged.
One year of pembrolizumab, started before MDT, gave HR 0.47 for RFS beyond the M1NED-within-1y adjuvant setting. G3 AEs were 7% and hypothyroidism 23%, and with 2 deaths there is no OS read to weigh against deferring IO until relapse.
10 details
Randomized 2:1, open-label, multicenter phase II, N=85 (56 P+MDT, 29 MDT alone). Median follow-up 17.5 mo.
omRCC after prior nephrectomy, ≤3 metastases within 5 years of Nx or prior metastasectomy, candidates for MDT to all metastatic sites. Baseline characteristics reported as balanced.
Pembrolizumab 400 mg q6w × 9 cycles (1 year), first dose before MDT. Median cycles delivered 6.6.
MDT was SABR in 73% vs 72% and surgery in 23% vs 28%. Dose, fractionation and target definition not reported in source.
Primary: relapse-free survival. Secondary: distant RFS, local relapse, OS, safety; only safety secondaries are reported in the abstract.
Any AE 80% vs 21%, G3 7% vs 3%. P-related AEs 59%, led by hypothyroidism 23%; no G4/5.
KEYNOTE-564 established adjuvant pembrolizumab after Nx and for M1NED within 1 year of Nx. PE-PE moves that into unresected oligomets ablated by SABR or surgery, including relapse up to 5 years out.
No local vs distant relapse split, so the site of benefit is unknown. RFS assessor blinding not stated in an open-label trial, and 2 of the 9 planned cycles went undelivered at the median.
The RFS gain is large but rests on 35 events, with a CI upper bound of 0.92. It does not settle whether IO at MDT beats IO deferred to relapse, which is the comparison that decides treatment-free intervals.
| Endpoint | P+MDT (n=56) | MDT alone (n=29) | Effect |
|---|---|---|---|
| Median RFS | 25.4 mo | 11.0 mo | HR 0.47 (95% CI 0.24-0.92), p=0.024 |
| RFS events | 19 | 16 | 35 total |
| Any AE | 80% | 21% | n/a |
| G3 AE | 7% | 3% | n/a |
CONSORT flow
Randomized phase II met its RFS primary, but N=85 with a 29-pt control arm, 17.5-mo median f/u, open-label, and only 2 deaths; abstract-only.
- Local vs distant relapse split: where does pembrolizumab add benefit?
- OS benefit vs deferring IO until relapse after MDT
- SABR dose/fractionation interaction with perioperative IO
📚 Sources · 📄 1 paper
Abstract
UNION NCT04928807
ForcT3-4 or N+ rectal adenocarcinoma ≤10 cm from anal verge
TL;DR3-yr EFS 91.3% vs 77.4%, HR 0.33 (0.15-0.71), P=0.0029: SCRT → camrelizumab + CAPOX vs long-course CRT → CAPOX in LARC.
The control is long-course CRT, so the EFS gain (HR 0.33) comes with a switch to 25 Gy/5f. That makes SCRT the RT backbone for an IO-containing TNT, not a compromise. Because RT schedule and camrelizumab were changed together, the trial cannot say whether SCRT itself is what lets IO work in largely pMMR disease.
In cT3-4 or node-positive low/mid rectal adenocarcinoma, this supports SCRT followed by PD-1 inhibitor plus CAPOX as an evidence-backed TNT option. It does not settle IO use when no PD-1 agent equivalent to camrelizumab is available, or questions of organ preservation. The longer read
The experimental arm swapped 50.4 Gy/28f chemoRT for 25 Gy/5f and still improved 3-yr EFS (91.3% vs 77.4%). That puts SCRT forward as the RT platform for IO consolidation. Whether SCRT is synergistic or just interchangeable cannot be separated from the camrelizumab effect.
Adding camrelizumab across neoadjuvant and adjuvant CAPOX (up to 17 cycles) gave EFS HR 0.33 with G≥3 TRAE 51.3% vs 48.2%. It is a signal for PD-1 blockade beyond dMMR in LARC, though the MMR breakdown and OS are not in source, and camrelizumab availability outside China limits how far it transfers.
8 details 2 trials watching
Phase 3, randomized 1:1, N=231 (113 vs 118), accrued July 2021 to March 2023. Median follow-up 36.8 vs 35.6 mo at the October 1, 2025 cutoff.
cT3-4 or N+ rectal adenocarcinoma, tumor ≤10 cm from the anal verge. MMR/MSI composition of the enrolled cohort is not reported in source.
Experimental: SCRT 25 Gy/5f. Control: 50.4 Gy/28f with concurrent capecitabine 825 mg/m2 BID. Target volumes are not reported in source.
Both arms: 2 neoadjuvant + 6 adjuvant cycles of CAPOX. Experimental adds camrelizumab 200 mg d1 given alongside CAPOX for up to 17 cycles.
Primary: BIRC-assessed pCR rate (result not in source). Key secondary endpoints with prespecified α: investigator-assessed EFS and OS.
G≥3 TRAE over the whole treatment period 51.3% (59/115) vs 48.2% (54/112). The RT-attributable split is not reported.
RAPIDO set SCRT followed by consolidation chemo as a TNT option, and PRODIGE 23 did the same for an LCCRT-based approach. UNION is the first phase 3 to layer a PD-1 inhibitor onto SCRT in LARC, building on earlier SCRT + IO phase 2 signals such as TORCH.
The safety population (115 vs 112) does not match randomization (113 vs 118), so some pts received the other arm's treatment. Neoadjuvant CAPOX was only 2 cycles in the control arm, lighter than full TNT backbones. OS and surgical or organ-preservation outcomes are absent.
The EFS effect is large and was tested under alpha control, but it comes from a two-variable comparison. It supports the whole package and does not establish what SCRT or camrelizumab contributes individually.
| Endpoint | SCRT + camrelizumab + CAPOX | LCCRT + CAPOX | Effect |
|---|---|---|---|
| 3-yr EFS (investigator) | 91.3% (83.9-95.4) | 77.4% (67.9-84.4) | HR 0.33 (0.15-0.71), P=0.0029 |
| G≥3 TRAE | 51.3% (59/115) | 48.2% (54/112) | n/a |
| Median f/u | 36.8 mo (34.8-37.8) | 35.6 mo (34.3-36.9) | n/a |
CONSORT flow
Randomized phase 3, but the primary pCR result is not in source and EFS is secondary. SCRT and camrelizumab change together, so the benefit cannot be attributed to either.
- Does SCRT, versus long-course CRT, drive the immunotherapy benefit?
- Unreported pCR primary result and OS
- Benefit in confirmed pMMR/MSS pts specifically recruiting Neoadjuvant CAPOX With or Without Pucotenlimab Plus Selective Radiotherapy for Locally Advanced Rectal Cancer Phase 3n=556 · primary completion 2032-04 · phase 3 CAPOX ± pucotenlimab, pMMR/MSS LARCn=612 · primary completion 2032-12 · phase 3 SCRT+PD-1 iTNT vs LCRT TNT, MSS/pMMR only
📚 Sources · 📄 1 paper
Abstract
KEYNOTE-975 NCT04210115
ForUntreated unresectable locally advanced ESCC/EAC/GEJ, dCRT candidates
HR 0.97
95% CI 0.77-1.23, P=0.3994; not met (boundary 0.0193)
TL;DREFS HR 0.97 (95% CI 0.77-1.23), median 15.2 vs 14.7 mo in PD-L1 CPS ≥10: no EFS gain adding concurrent pembro to dCRT in unresectable esophageal/GEJ cancer.
The trial failed in the enriched PD-L1 CPS ≥10 group, where IO was most likely to help, and the curves sat on top of each other (EFS HR 0.97, OS HR 1.00) at 47.1 mo median f/u. Grade 5 AEs ran 13% vs 10%, so concurrent pembro with 50-60 Gy dCRT adds toxicity without benefit. This leaves dCRT alone as the backbone.
In untreated unresectable esophageal or GEJ cancer going to dCRT, including PD-L1 CPS ≥10, this does not support concurrent pembrolizumab; it does not address consolidation-only IO after dCRT or the resectable trimodality setting. The longer read
Concurrent pembro with 50-60 Gy dCRT did not move EFS (HR 0.97) or OS (HR 1.00) in CPS ≥10 pts, and grade 5 AEs rose to 13% vs 10%. No local control or dose-stratified data in source, so the RT backbone stays dCRT alone with no IO-driven change to dose or volume.
PD-L1 CPS ≥10 enrichment did not rescue concurrent pembro (EFS HR 0.97, OS HR 1.00), and AE discontinuation rose to 34% vs 27%. Biomarker selection does not justify adding PD-1 blockade to dCRT; consolidation-only timing remains untested by this trial.
9 details
International phase 3, randomized 1:1, double-blind, placebo-controlled, multicenter; N=703. Results are from the second interim analysis (IA2), after which the study was stopped. Median follow-up 47.1 mo.
Previously untreated locally advanced unresectable ESCC, EAC or GEJ cancer (cTX N+ M0 or cT2-T4a NX M0), or cervical/upper thoracic EC with supraclavicular nodal M1 only. ECOG 0-1, ineligible for curative surgery but suitable for dCRT.
Pembro 200 mg or placebo Q3W for 8 cycles, then 400 mg or placebo Q6W for 5 cycles, concurrent with dCRT. Chemo backbone FP or FOLFOX by site choice.
50 Gy or 60 Gy with FP, or 50 Gy with FOLFOX, by site choice. Fractionation, technique and target volume not reported in source.
Dual primary: investigator-assessed EFS and OS, tested hierarchically in PD-L1 CPS ≥10, CPS ≥1, then all pts.
EFS not improved in CPS ≥10 (arm-level numbers in table), so every downstream comparison went untested and the study was stopped.
| Endpoint (CPS ≥10) | Pembro + dCRT | Pbo + dCRT | HR (95% CI), P |
|---|---|---|---|
| Median EFS (investigator) | 15.2 mo | 14.7 mo | 0.97 (0.77-1.23), P=0.3994; boundary 0.0193 |
| Median OS | 32.2 mo | 35.0 mo | 1.00 (0.77-1.30), nominal P=0.5003 |
| AE | Pembro + dCRT | Pbo + dCRT |
|---|---|---|
| Grade ≥3 | 100% | 100% |
| Grade 5 | 44 (13%) | 37 (10%) |
| Discontinuation for any AE | 117 (34%) | 97 (27%) |
Grade ≥3 AEs in 100% of both arms. Grade 5 AEs 44 (13%) vs 37 (10%), AE discontinuation 117 (34%) vs 97 (27%). Authors report no new safety signals.
Joins KUNLUN (durvalumab + dCRT) as a negative concurrent IO-dCRT trial in esophageal cancer. Adjuvant nivolumab per CheckMate 577 belongs to the resected trimodality setting and is untouched by this result.
RT dose and chemo backbone by site choice with no outcome breakdown, pooled histologies, and no local control or failure-pattern data in source to show whether IO changed in-field control.
A flat EFS and OS in the PD-L1-enriched group argues against a hidden benefit in the untested CPS ≥1 or all-comer groups. Whether timing (consolidation vs concurrent) or histology matters stays open.
CONSORT flow
Double-blind phase 3 stopped at IA2 after the gatekeeper EFS endpoint failed in the enriched CPS ≥10 group; reaffirms dCRT alone as standard. Downstream populations formally untested.
- Would consolidation-only IO after dCRT differ from concurrent dosing?
- Histology-specific EFS in ESCC vs EAC/GEJ
- Did pembro alter local control or failure patterns?
📚 Sources · 📄 1 paper
Abstract
Bladder preservation after neoadjuvant/perioperative therapy in MIBC (reTURBT cohort)
ForMIBC cT2-4N0M0 urothelial, post-neoadjuvant IO/ADC, declining RC
TL;DRypT0Nx at reTURBT after neoadjuvant therapy: 24-mo EFS 87.6%, OS 96.7% in MIBC pts declining RC (n=54); non-pCR pts fared far worse.
Chemo-RT here was only salvage for residual tumor or recurrence, so this tests a bladder-sparing route that skips upfront RT. The split is stark: non-pCR at reTURBT gave 24-mo OS 50.4% vs 82.5% after RC, so residual disease at reTURBT is the point where definitive local therapy (RC or chemoRT) should be on the table.
In an MIBC pt with ypT0 at reTURBT plus negative MRI and cytology after IO-based neoadjuvant therapy who declines RC, this supports surveillance as a discussable option; it does not extend to pts with any residual disease at reTURBT. The longer read
Chemo-RT was used only as salvage for residual tumor or recurrence, so this tests bladder sparing without upfront RT. Non-pCR at reTURBT gave 24-mo OS 50.4% vs 82.5% after RC, marking residual disease as the point where definitive local therapy, including chemoRT, belongs.
Response at reTURBT after pembrolizumab-, SG- or nivolumab-based neoadjuvant therapy separated outcomes sharply: 24-mo EFS 87.6% with ypT0 vs 19.3% with residual disease. Depth of response to the systemic regimen, not the regimen label, drove eligibility for surveillance.
ypT0 at reTURBT pts who declined RC had 24-mo OS 96.7%, but EFS HR 1.96 (0.53-7.27) vs RC pCR is too imprecise to call equivalence. Residual disease at reTURBT tracked with far worse outcomes than RC, keeping cystectomy the default for incomplete responders.
| Group | 24-mo EFS | 24-mo OS |
|---|---|---|
| reTURBT pCR | 87.6% | 96.7% |
| reTURBT vs RC, pCR (HR) | 1.96 (0.53-7.27) | 0.90 (0.10-8.40) |
| reTURBT non-pCR | 19.3% | 50.4% |
| RC non-pCR | 67.8% | 82.5% |
+2 more figures
13 details 3 trials watching
Pooled cohort from four neoadjuvant/perioperative trials (PURE-01, SURE-01, SURE-02, NURE-Combo), N=279 enrolled 02/2017-07/2025. Bladder preservation was pt choice, not a randomized allocation.
MIBC cT2-4N0M0, pure/predominant (≥50%) urothelial carcinoma. The reTURBT group (n=54) declined RC and required negative imaging, biopsy and cytology.
Pembrolizumab, sacituzumab govitecan, SG + pembrolizumab, or nivolumab + nab-paclitaxel, restaged with CT + multiparametric bladder MRI. Adjuvant/maintenance per protocol; deferred RC or chemo-RT only for residual tumor or recurrence.
Whole reTURBT group: 36-mo EFS 66.7%, 36-mo OS 82.7%; 19% recurred, 13% distantly. Outcomes split sharply by response at reTURBT (Fig 2).
The comparator is the trials' own RC cohort, not a randomized arm. Trimodality therapy, the established bladder-sparing alternative, was not a planned arm here; chemo-RT appears only as salvage.
Four different regimens pooled into one small cohort. The tweet's comparison claim is truncated, and the 30/54 (56%) vs 43/213 (20%) schema figure carries no endpoint label in the source.
The pCR stratum looks good, but HRs vs RC of 1.96 (0.53-7.27) for EFS and 0.90 (0.10-8.40) for OS are too imprecise to call equivalence. Non-pCR at reTURBT is the clear failure mode and argues for definitive local therapy rather than continued surveillance.
Pts self-selected by declining RC; RC comparison non-randomized, pCR-stratum HR CIs span 1, reTURBT n=54 pooled across four heterogeneous phase 2 regimens.
- Durability of ypT0 at reTURBT beyond 36 months without cystectomy active Stage II-IIIa Urothelial Cancer Randomizing Pre-operative Nivolumab With or Without Relatlimab Phase 2n=90 · primary completion 2026-12 · bladder preservation in responders to nivo±relatlimabactive A Study of Risk Enabled Therapy After Neoadjuvant Immunochemotherapy for Bladder Cancer Phase 2n=81 · primary completion 2027-05 · cCR after AMVAC+nivo then active surveillance
- Would planned chemoRT rescue non-pCR pts at reTURBT? n=20 · primary completion 2027-09 · systemic tx response + genomics assign chemoRT vs RC
- Can ctDNA or MRI better select pts for surveillance?
📚 Sources · 🐦 1 tweet
Bladder preservation after neoadjuvant/perioperative therapy in 🇮🇹 MIBC pts who declined RC and underwent reTURBT (n=54)
— Rashid K. Sayyid (@RKSayyid) October 25, 2026
📌Negative imaging, biopsy & cytology
🔹19% recurred; 13% developed distant recurrence
🔹 ypT0Nx at reTURBT → 24-mo EFS 88%; MFS & OS >95%, comparable with… pic.twitter.com/2I402Cwxa9
STAMPEDE, ENZARAD, PROTEUS and DASL in context
TL;DRESMO26 round-up of four intensification trials. STAMPEDE Decipher update suggests differential abiraterone benefit in cN0 disease (interaction P=.01).
STAMPEDEENZARADPROTEUSDASL
The RT-relevant read is that STAMPEDE's abiraterone benefit was reported as predominantly in pts receiving RT, and the ESMO26 Decipher data suggest the abiraterone benefit differs in cN0 disease (interaction P=.01). Subgroup HRs are not reported in source text, so this flags, rather than settles, genomic selection of who gets abiraterone added to RT.
STAMPEDE's abiraterone benefit was reported as predominantly with RT, so the intensification question sits on the RT backbone. The ESMO26 Decipher interaction in cN0 (P=.01) hints at genomic selection for adding abiraterone to RT; subgroup magnitudes are not in the source.
The Decipher update suggests abiraterone benefit is not uniform in cN0 disease (interaction P=.01), raising biomarker-gated intensification. No subgroup HRs are reported in source, and the ENZARAD, PROTEUS and DASL updates are not described in the truncated tweet.
Also covered Jul 15
7 details
- 🔍 Trade-press-style round-up tweet placing STAMPEDE, ENZARAD, PROTEUS and DASL against #ESMO26 updates
- 🔍 Disease state and RT dose/fractionation not stated in source
- 📊 STAMPEDE: abiraterone-based intensification improved MFS and OS, predominantly with RT, per source
- 📊 New #ESMO26 Decipher data: differential abiraterone benefit in cN0 disease, interaction P=.01
- ⚠️ No effect size reported in source tweet for MFS, OS, or the Decipher subgroups
- ⚠️ Decipher interaction is a biomarker subgroup analysis; hypothesis-generating until validated
- ⚠️ Tweet is truncated; ENZARAD, PROTEUS and DASL updates are not described in the source text
- Does Decipher score select cN0 pts for abiraterone with RT?
- Where do ENZARAD, PROTEUS and DASL fit relative to STAMPEDE?
📚 Sources · 🐦 1 tweet
Putting STAMPEDE, ENZARAD, PROTEUS & DASL into context with the latest #ESMO26 updates:
— Himanshu Nagar (@HimanshuNagarMD) October 24, 2026
STAMPEDE: Abiraterone-based intensification improved MFS AND OS, predominantly with RT. New #ESMO26 Decipher data suggests differential abi benefit in cN0 disease (interaction P=.01); using…
PROTEUS Substudy
ForHR LPC/LAPC, conventionally staged M0, planned RP + PLND
HR 0.38
95% CI 0.26-0.55, p<0.0001
TL;DREFS HR 0.38 (95% CI 0.26-0.55) with perioperative apalutamide + ADT around RP + PLND in HR LPC/LAPC; MFS HR 0.49, nominal p only.
The testosterone curve is the hidden read: T recovery to ≥200 ng/dL took a median 20.7 mo (~9 mo from EOT), so much of the EFS window is BCF assessed under residual castration. TTST medians of 46.0 vs 12.3 mo carry ~20 mo of lead-time, which leaves the durable-benefit question with MFS and its nominal p=0.0193.
In conventionally staged HR LPC/LAPC headed for RP + PLND, this supports perioperative APA + ADT as an EFS-delaying option under discussion; it does not extend to PSMA PET-staged pts or to men treated with definitive RT. The longer read
Testosterone recovery took a median 20.7 mo (~9 mo from EOT), so the EFS gain is partly measured during residual castration. MFS HR 0.49 with nominal p=0.0193 is the endpoint that will decide whether perioperative APA + ADT changes disease course or only delays PSA events.
The surgical backbone was unchanged (RP + PLND in both arms), and the control arm's adjuvant management was left to physician discretion. Without baseline PSMA PET, some conventionally staged M0 candidates may have had occult disease, which matters when selecting HR LPC/LAPC pts for RP.
| Arm | Median | Rate (95% CI) |
|---|---|---|
| APA + ADT | Not reached | 63.0% (52.2-71.9) |
| RP + PLND alone | 19.1 months | 41.4% (35.6-47.1) |
| HR 0.38 (95% CI 0.26-0.55) | p<0.0001 | n/a |
+3 more figures
| Metastasis detection method, n (%) | APA + ADT | RP + PLND |
|---|---|---|
| PSMA PET | 9 (8.8) | 50 (16.3) |
| Conventional imaging | 1 (1.0) | 6 (2.0) |
| MFS HR 0.49 (95% CI 0.26-0.90) | nominal p=0.0193 | n/a |
| Arm | Median time to first subsequent therapy |
|---|---|
| APA + ADT | 46.0 months |
| RP + PLND alone | 12.3 months |
| HR 0.29 (95% CI 0.20-0.43), nominal p<0.0001 | n/a |
11 details 1 trial watching
Randomized 1:3, open-label, N=408, accrual July 2022 to October 2023. Stratified by cN0 vs cN1, Gleason 7 vs 8-10, and region. Phase not stated in source.
HR LPC/LAPC, conventionally staged M0 (CT + bone scan). No baseline PSMA PET.
APA 240 mg QD + ADT for 6 cycles neoadjuvant, RP + PLND, then 6 cycles adjuvant. Control: RP + PLND with local or systemic adjuvant tx at physician discretion.
Primary: EFS, time to first BCF (PSA progression), LRR, DM or death. Secondary/exploratory: MFS, time to first subsequent therapy.
EFS HR 0.38 (0.26-0.55), p<0.0001; MFS HR 0.49 (0.26-0.90), nominal p=0.0193; TTST HR 0.29 (0.20-0.43), nominal. Per-arm values in the figure captions.
proPSMA showed PSMA PET staging accuracy of 92% vs 65% for CT + bone scan, and EAU/ESMO advise PSMA PET/CT for high-risk disease where available. PROTEUS staged without it, so its M0 population differs from a modern PSMA-staged cohort.
1:3 allocation leaves 102 pts in the experimental arm. The control adjuvant strategy was at physician discretion, so the comparator is heterogeneous. Safety magnitudes were truncated in the source.
Lead-time from treatment exposure and slow testosterone recovery inflate the early-window endpoints. Whether metastatic progression is truly delayed, rather than PSMA-avid disease being detected later, is not settled without baseline PSMA PET.
CONSORT flow
Randomized, EFS met, but EFS leans on PSA failure during slow testosterone recovery; MFS nominal and PSMA-detection driven; TTST lead-time biased; no baseline PSMA PET.
- Does the EFS benefit hold in PSMA PET-staged M0 pts?
- Will MFS reach non-nominal significance with longer follow-up? n=2517 · primary completion 2026-12 · phase 3 parent RCT, MFS 1° EP vs placebo + ADT
- Does any benefit persist after testosterone recovery?
📚 Sources · 🐦 2 tweets
PROTEUS Substudy: Periop Apa + ADT with RP+PLND vs RP+PLND in HR PCa @urotoday #ESMO26
— Zach Klaassen (@zklaassen_md) October 24, 2026
Periop APA + ADT (+ RP+PLND; n= 102) vs RP+PLND alone (n=306)
🚨EFS: HR 0.38, 95% CI 0.26–0.55
🚨MFS: HR 0.49, 95% CI 0.26–0.90
🚨TT 1st Sub Rx: HR 0.29, 95% CI 0.20–0.43
🚨All Gr Hot Flush:… pic.twitter.com/v7zhSfLzrR
#ESMO26 PROTEUS discussion by Nicholas van As
— Alan Tan (@alantanmd) October 24, 2026
• No baseline PSMA PET; enrolled conventionally staged M0
• MFS events: true progression or delayed detection? Most were PSMA PET-detected (8.8% vs 16.3%)
• TTST HR 0.29, but ~20-mo lead-time bias#ProstateCancer pic.twitter.com/FfugtpcYwU
PORTEC-3 NCT00411138
ForHigh-risk endometrial cancer, FIGO 2009 stage I-III, post-hysterectomy
HR 0.76
95% CI 0.54–1.06, p=0.11, OS not met; co-primary FFS HR 0.71, p=0.022
TL;DR5y FFS 75.5% vs 68.6% (HR 0.71, p=0.022) with CRT over pelvic RT alone; co-primary 5y OS 81.8% vs 76.7% not met (HR 0.76, p=0.11).
Pelvic control was 91% with RT alone, so chemotherapy is not buying locoregional control here; 48.6 Gy pelvic EBRT (plus brachy boost in 47%, balanced by arm) stays the backbone in both arms. The RT question left open is whether pelvic RT can be dropped once chemo is given, which GOG-258 tests and its abstract suggests costs vaginal and nodal control.
In stage III high-risk endometrial cancer, this supports discussing concurrent cisplatin plus adjuvant carboplatin/paclitaxel with pelvic RT for failure-free survival; in stage I-II disease the FFS estimate (HR 0.85, p=0.47) does not clearly justify the added toxicity. The longer read
Pelvic control was 91% with RT alone, so chemo adds nothing locoregionally and 48.6 Gy pelvic EBRT plus indicated brachy boost stays the backbone. The RT decision this trial leaves open is omission of pelvic RT once chemo is given, where GOG-249 and the GOG-258 abstract both show more pelvic and nodal failure without it.
The regimen is demanding: all 4 carboplatin and paclitaxel cycles were completed by 79% and 71%, G3+ AEs ran 60% vs 12%, and G2+ neuropathy persisted at 3y in 8%. The FFS gain concentrates in stage III, and the authors flag a larger benefit in women over 70 and at least as much benefit in serous or clear cell histology.
10 details 4 trials watching
Open-label, international, randomised phase 3 at 103 centres across six GCIG groups; 1:1 by biased-coin minimisation, stratified by centre, lymphadenectomy, stage and histology. 686 enrolled, 660 in the ITT analysis; median follow-up 60.2 mo.
High-risk endometrial cancer, FIGO 2009: stage IA EEC grade 3 with LVSI, IB EEC grade 3, EEC stage II or III, or serous / clear cell stage IA (with invasion) to III. WHO PS 0-2, no upper age limit; median age 62, stage III in 46% vs 43%.
Experimental arm added cisplatin 50 mg/m² x2 concurrent, then 4 cycles carboplatin AUC5 + paclitaxel 175 mg/m². Both cisplatin cycles completed by 92%; all 4 carboplatin and paclitaxel cycles by 79% and 71%.
Pelvic EBRT 48.6 Gy in 1.8 Gy fractions in both arms; 45.0-50.4 Gy delivered in 100% vs 98%. Vaginal brachy boost for cervical invasion, given in 46% vs 48%.
Co-primary: overall survival and failure-free survival, ITT, Cox-adjusted for stratification factors.
G3+ AEs during treatment 60% vs 12% (p<0.0001). G2+ neuropathy persisted at 3y in 8% vs 1%.
Direction matches the pooled NSGO-EC-9501/EORTC-55991 + ManGO Iliade analysis (PFS 78% vs 69%, OS trend 82% vs 75%), here in a larger trial with concurrent plus adjuvant chemo. GOG-249 found chemo + VBT no better than pelvic EBRT in stage I-II with more pelvic and para-aortic recurrence; the GOG-258 abstract reported no OS/RFS gain for CRT over chemo alone but more vaginal and nodal failures without RT.
Final analysis was time-based, with OS events at 69% of the number required, so a 5% OS difference was below what the trial could detect. RT plan QA outside ANZGOG was still pending, and the stage and age subgroup reads are exploratory.
CRT buys FFS, not OS, at 5y, at the price of a fivefold G3+ toxicity rate and persistent neuropathy. The authors read the stage I-II FFS gain as not outweighing toxicity, so the combined regimen fits individual counselling, mainly in stage III.
| Endpoint | CRT | RT alone | Effect |
|---|---|---|---|
| 5y OS | 81.8% (77.5–86.2) | 76.7% (72.1–81.6) | HR 0.76 (0.54–1.06), p=0.11 |
| 5y FFS | 75.5% (70.3–79.9) | 68.6% (63.1–73.4) | HR 0.71 (0.53–0.95), p=0.022 |
| Stage III 5y OS | 78.7% | 69.8% | HR 0.71 (0.45–1.11), adjusted p=0.074 |
| Stage III 5y FFS | 69.3% | 58.0% | HR 0.66 (0.45–0.97), adjusted p=0.014 |
| Stage I–II 5y FFS | 80.8% | 76.6% | HR 0.85 (0.54–1.33), p=0.47 |
| G3+ AEs during treatment | 198 (60%) | 41 (12%) | p<0.0001 |
| G2+ neuropathy at 3y | 20 (8%) | 1 (1%) | p<0.0001 |
CONSORT flow
Randomised phase 3 met co-primary FFS but missed OS with only 69% of required OS events; direction matches pooled NSGO-EC-9501/ManGO data. Toxicity cost tempers adoption.
- Does the OS difference emerge with longer follow-up?
- Is pelvic RT still needed in stage III when chemotherapy is given? not yet Chemotherapy vs Chemoradiotherapy for Post-operative Endometrial Cancer Patients With P53-mutation Phase 2/3n=294 · primary completion 2028-08 · randomizes chemo alone vs CRT, p53abn stage I-IVA
- Can stage I-II pts be spared chemotherapy toxicity safely? n=590 · primary completion 2026-12 · molecular profile assigns CRT vs RT, stage I-IIn=316 · primary completion 2030-01 · RT + durvalumab vs RT ± chemo in MMRd ECn=600 · primary completion 2030-12 · RT + progestin vs RT + chemo, high-risk NSMP
📚 Sources · 📄 1 paper
Gomez LCT oligometastatic NSCLC (long-term results)
ForStage IV NSCLC, ≤3 mets, no progression after front-line systemic therapy
14.2 vs 4.4 mo
median PFS, 95% CI 7.4-23.1 vs 2.2-8.3, P = .022
TL;DRmOS 41.2 vs 17.0 mo (P=.017) and mPFS 14.2 vs 4.4 mo favoring LCT over maintenance/observation in oligometastatic NSCLC after front-line therapy.
The OS gap tracks survival after progression, 37.6 vs 9.4 mo: only 15 of 39 progressors (41%) got LCT at progression, and in the MT/O arm 7 were blocked by polymetastatic progression. That argues for consolidating every site while disease is still oligometastatic, not holding RT for progression. Dose and fractionation are not in source text.
In stage IV NSCLC with ≤3 metastases and no progression after front-line platinum doublet, EGFR TKI or crizotinib, this supports consolidating all sites over maintenance alone; it does not extend to IO-treated pts, >3 metastases, or disease progressing on first-line therapy. The longer read
The OS gap tracks survival after progression, 37.6 vs 9.4 mo, and 7 MT/O progressors lost LCT eligibility to polymetastatic progression. That argues for consolidating every site while still oligometastatic rather than reserving RT for progression; dose and fractionation are not in source text.
Maintenance or observation was the comparator, and adding LCT gave mOS 41.2 vs 17.0 mo on a pre-IO backbone of platinum doublet, EGFR TKI or crizotinib. Whether the gap persists with IO maintenance, absent from this trial, is the open regimen question.
10 details 5 trials watching
Randomized phase II, 1:1, 3 institutions (MD Anderson, London Health Sciences Center, University of Colorado); unmasked. Closed early by DSMB after 49 of 74 enrolled pts were randomized (94 planned). Median follow-up 38.8 mo (28.3-61.4).
Stage IV NSCLC, ≤3 metastases (primary not counted), ECOG ≤2, no progression after front-line therapy: ≥4 cycles platinum doublet, or ≥3 mo EGFR TKI or crizotinib. Randomization dynamically balanced on met number, response, CNS mets, N stage and EGFR/ALK status.
LCT was RT, surgery or both to all active disease sites, modality chosen by MDT; concurrent chemoRT allowed for primary and regional nodes. Dose and fractionation not reported in source text (Appendix Table A1).
Primary: PFS from randomization. Secondary: OS, toxicity, time to new lesions. Powered (90%) for PFS 4 to 7 mo, HR 0.57; P<.10 deemed significant.
PFS, OS and survival-after-progression gains in the arm table above. Late LCT at progression correlated with OS in a multivariable model, HR 0.44 (0.18-1.06), P=.064; initial LCT HR 0.30 (0.12-0.75).
| Endpoint | LCT (n=25) | MT/O (n=24) | P |
|---|---|---|---|
| Median PFS (1° EP) | 14.2 mo (7.4-23.1) | 4.4 mo (2.2-8.3) | .022 |
| Median OS | 41.2 mo (18.9-NR) | 17.0 mo (10.1-39.8) | .017 |
| Survival after progression | 37.6 mo | 9.4 mo | .034 |
| Time to new lesions | 14.2 mo (5.7-24.3) | 6.0 mo (4.4-8.3) | 0.11 |
| Deaths | 11 of 25 | 18 of 24 | n/a |
No additional grade ≥3 toxicity beyond events reported in the initial publication.
The authors state no prior randomized trial had shown an OS benefit from LCT in lung cancer. They align their proposed oligometastatic definition (0-3 metastases, unconstrained by molecular profile) with most pts enrolled on SABR-COMET and the UT Southwestern randomized phase II trial, and point to NRG-LU002 as the phase III test.
Unmasked with heterogeneous physician-chosen maintenance. Post-progression and late-LCT analyses are exploratory, post-randomization, and exclude 3 MT/O pts who crossed over before progression. EGFR/ALK cohort n=8, too small to read.
The OS gain is carried by survival after progression, consistent with a window in which all sites are still treatable. Whether the effect survives IO maintenance and a full-size trial is unsettled.
CONSORT flow
Randomised phase II closed early for PFS benefit at 49 of 94 planned pts; OS is secondary and tested at P<.10. Needs phase III confirmation (e.g. NRG-LU002).
- Does the OS benefit hold with IO-era maintenance? active Nivolumab and Ipilimumab With or Without Local Consolidation Therapy in Treating Patients With Stage IV Non-Small Cell Lung Cancer Phase 3n=339 · primary completion 2027-03 · phase III nivo/ipi ± LCT, stage IV NSCLCrecruiting First-line Immunotherapy-based Standard of Care and Local Ablative Treatments for Oligometastatic Non-small Cell Lung Cancer Patients. Phase 3n=124 · primary completion 2030-02 · phase III 1L IO-based SoC ± local ablative tx
- Does LCT add OS in EGFR/ALK-driven oligometastatic NSCLC? recruiting Local Consolidative Radiation Therapy Plus TKI Versus TKI Alone in Driver Mutated OM-NSCLC Phase 2n=106 · primary completion 2026-11 · randomized TKI ± LCRT, EGFR/ALK/ROS oligometrecruiting Osimertinib With or Without Primary Lung Tumor Resection for EGFR-Mutant Oligometastatic Non-Small Cell Lung Cancer Phase 3n=154 · primary completion 2031-08 · phase III osimertinib ± primary resection, EGFR
- Does a phase III trial confirm the OS benefit? recruiting Standard Maintenance Therapy (SMT) vs Local Consolidative Radiation Therapy and SMT in OM-NSCLC Phase 3n=190 · primary completion 2026-04 · phase III maintenance ± LCRT, 1-5 mets
📚 Sources · 📄 1 paper
Abstract
RTOG 9601 NCT00002874
ForpN0 pT2 R1/pT3 post-RP, detectable PSA 0.2-4.0 ng/ml, salvage RT
HR 0.77
95% CI 0.59-0.99, P=0.04; 12-yr OS 76.3% vs 71.3%
TL;DR12-yr OS 76.3% vs 71.3%, HR 0.77 (0.59-0.99), adding 24mo bicalutamide 150mg to salvage RT in pN0 post-RP pts with PSA 0.2-4.0.
The benefit follows pre-SRT PSA: 12-yr OS HR 0.45 (0.25-0.81) above 1.5 ng/ml and 0.61 at 0.7-1.5, but HR 1.13 (0.77-1.65) below 0.7, where the median entry PSA of 0.6 sat. RT was prostate bed only, 64.8 Gy/36 fx, so this informs hormone addition separately from the pelvic nodal coverage decision.
In a pN0 man after RP heading to salvage RT with PSA above 0.7 ng/ml, this supports adding hormone therapy to bed RT; it does not extend to PSA below 0.7 ng/ml, where the post hoc OS HR was 1.13. The longer read
Entry PSA gates the hormone add-on to prostate-bed salvage RT: OS HR 0.45 above 1.5 ng/ml, 0.61 at 0.7-1.5, 1.13 below 0.7. RT was 64.8 Gy/36 fx with nodes omitted in pN0 pts, so the trial leaves the elective pelvic nodal question open.
The drug tested, bicalutamide 150 mg for 24 months, is no longer standard, and gynecomastia reached 69.7% without prophylaxis. Whether GnRH-agonist ADT or a shorter course reproduces the OS HR 0.77 was not tested; the benefit concentrates at entry PSA ≥0.7 ng/ml.
11 details 1 trial watching
Randomized, double-blind, placebo-controlled NRG/RTOG trial; 840 randomized 1998-2003, 760 eligible analyzed (384 vs 376). Median follow-up 13 years among survivors.
Post-RP with lymphadenectomy, pT2 with positive margin or pT3, pN0, detectable PSA 0.2-4.0 ng/ml at least 8 weeks after surgery. No prior RT or chemo; prior hormones limited to short preoperative courses (6.4%). Staging by CT and bone scan.
Bicalutamide 150 mg daily for 24 months vs placebo, starting with RT. Adherence ≥18 months was 69.8% vs 74.7%.
64.8 Gy in 36 fractions of 1.8 Gy to the prostatic bed and membranous urethra, 6-10 MV photons, 2D or 3D planning. Pelvic nodes omitted because all dissections were negative. QA: 64.8% per protocol, 4.4% unacceptable variation.
Primary: overall survival. Secondary: disease-specific death, distant metastases, local progression, non-disease-specific death, second biochemical recurrence, AEs.
Primary met; every disease-control endpoint favored bicalutamide (table). The OS gain is concentrated at entry PSA ≥0.7 ng/ml in post hoc subgroups.
| Endpoint | RT + bicalutamide | RT + placebo | HR (95% CI), P |
|---|---|---|---|
| OS (1° EP) | 76.3% | 71.3% | 0.77 (0.59-0.99), P=0.04 |
| Death from PCa | 5.8% | 13.4% | 0.49 (0.32-0.74), P<0.001 |
| Metastatic PCa | 14.5% | 23.0% | 0.63 (0.46-0.87), P=0.005 |
| 2nd biochemical recurrence | 44.0% | 67.9% | 0.48 (0.40-0.58), P<0.001 |
| PSA at entry | n (%) | Bicalutamide | Placebo | HR (95% CI), P |
|---|---|---|---|---|
| <0.7 ng/ml | 405 (53.3) | 76.8% | 80.7% | 1.13 (0.77-1.65), 0.53 |
| 0.7-1.5 ng/ml | 237 (31.2) | 77.0% | 67.5% | 0.61 (0.39-0.95), 0.03 |
| >1.5 ng/ml | 118 (15.5) | 73.5% | 48.9% | 0.45 (0.25-0.81), 0.007 |
Gynecomastia 69.7% vs 10.9%. Late GU G3 7.0% vs 6.0%; no excess early bladder, bowel or hematologic toxicity, and no excess non-disease-specific death.
SPPORT and RADICALS-HD tested GnRH-based ADT with salvage RT, but neither used a placebo-controlled OS design. The Early Prostate Cancer Program trials of the same drug and dose reported a matching gynecomastia signal (68% vs 8%).
Post-randomization exclusion of 79 ineligible pts departs from strict ITT. Cardiac events were captured only as reported AEs, which risks ascertainment bias. Pre-PSMA staging leaves occult extra-field disease in the cohort.
OS benefit is real but risk-adapted: below PSA 0.7 the subgroup trended the other way. The open questions are whether a modern GnRH agonist reproduces the effect and which duration is enough.
CONSORT flow
Double-blind placebo-controlled RCT, OS primary met at 13y median f/u. Benefit concentrated at PSA ≥0.7 (post hoc); bicalutamide 150mg since superseded by GnRH agonists.
- Does GnRH-agonist ADT reproduce the bicalutamide OS benefit?
- Optimal hormone duration with salvage RT at low PSA active Comparison of HT Concomitant With RT vs RT Alone in Patients With a Detectable PSA After Prostatectomy Phase 2n=120 · primary completion 2022-03 · short degarelix + SRT vs SRT alone, pN0, PSA ≥0.2
- Does PSMA PET staging change who benefits from added hormones?
📚 Sources · 📄 1 paper
AUA 2026: Consolidative local therapy after EV+pembro response (surgery vs radiation vs surveillance)
TL;DRRT-based preservation, cystectomy and surveillance each argued for cCR after neoadjuvant EV+pembro in MIBC; no randomized data compare the three options.
Reported via UroToday →
This point-counterpoint session asked how to manage the bladder in MIBC after cCR on neoadjuvant EV+pembro. The RT case held that clinical restaging misses residual disease, and that RT-based preservation keeps the bladder with better sexual function and body image than cystectomy. The surgical case held that all level 1 EV+pembro data include cystectomy, and that cCR predicts pCR only 51% of the time. The surveillance case shifted the question from pCR to MFS. It rested on a 97% PPV of cCR for 2-year MFS and on local recurrence coming before metastasis, which would allow salvage. ctDNA was presented as promising but not yet able to select pts.
- No data were shown on RT consolidation after EV+pembro; the RT case rests on chemo-era cohorts and observational TMT vs RC QOL comparisons, where pts chose their modality.
- The 97% PPV comes from GC + nivo in HCRN GU16-257; applying it to EV+pembro assumes a cCR means the same thing under a different regimen.
- The 51% cCR-pCR concordance measures residual pathology, not whether that residual changes MFS once surveillance and salvage are in place, so the surgical case treats pCR as if it were an outcome.
- RETAIN-1 vs RETAIN-2 is a cross-trial comparison in small surveillance cohorts (N=22 in RETAIN-2) after AMVAC-based therapy, not EV+pembro, and no trial compares RT, cystectomy and surveillance head to head.
KEYNOTE-905/EV-303KEYNOTE-B15/EV-304SWOG 0219RETAIN-1RETAIN-2HCRN GU16-257ARCHERBRIGHT
For RT, the key observation is the failure pattern: in RETAIN-2, no pt developed mets without a prior local recurrence, which is the premise behind both salvage RT and surveillance. BRIGHT (55 Gy/20 fx whole bladder, then pembro) is the trial that will test whether RT consolidation after cT0–T1 response adds bladder control beyond surveillance. No EV-era RT data exist yet.
In MIBC with cCR after neoadjuvant EV+pembro, the evidence leaves cystectomy, RT-based preservation and surveillance all open, each supported only by non-randomized or chemo-era data. It does not apply to pts with residual MIBC on restaging TURBT. The longer read
No EV-era data support RT consolidation after cCR yet. BRIGHT (55 Gy/20 fx whole bladder, then pembro for 12 mo) is the test. The local-before-metastatic failure pattern in RETAIN is what makes salvage RT a credible backstop for pts on surveillance.
Both phase III EV+pembro trials mandated cystectomy, and pooled cCR-pCR concordance is 51%, so omitting RC means leaving level 1 evidence behind. ctDNA negativity does not rule out ≥pT2 disease (67% residual), so a negative test cannot yet justify skipping surgery.
11 details 4 trials watching
AUA 2026 point-counterpoint session with three advocates (RT, cystectomy, surveillance), reported in a UroToday write-up. It argues across published and presented data and reports no new trial result.
MIBC (cT2–T4aN0M0 in the cited trials) with clinical complete response after neoadjuvant EV+pembro, i.e. the population treated per KEYNOTE-905/EV-303 and KEYNOTE-B15/EV-304.
The slide shows the BRIGHT schema: RT 55 Gy/20 fx to the whole bladder, then pembro 200 mg q21 days for 12 months, in pts with a cT0–T1 response confirmed by TURBT with systematic biopsies after ≥3 cycles of NAT. The ARCHER arm regimens were not legible on the slide.
In EV-303 and EV-304, every pt was planned for cystectomy, so the EFS and OS benefits (EV-303 EFS HR 0.40, OS HR 0.50) reflect EV+pembro plus RC. Organ-sparing evidence comes from RETAIN-1/2 and HCRN GU16-257, which used chemo or chemo-IO backbones, not EV+pembro.
The disagreement comes down to which endpoint cCR has to predict. Against pCR, cCR fails often (51% concordance); against MFS, it looked accurate in one GC + nivo trial (PPV 97%). If local failure reliably comes before metastasis, salvage keeps that miss from costing a cure, but this has not been shown after EV+pembro.
The trial IDs for ARCHER and BRIGHT differ between the write-up and the slide. The QOL comparison mixes TMT cohorts where pts chose their modality, and it shows worse pain and emotional functioning with TMT.
| Option | Core argument | Evidence cited |
|---|---|---|
| Bladder-preserving RT | cCR does not guarantee eradication; RT gives durable bladder control with a QOL advantage | SWOG 0219, RETAIN-2, TMT vs RC patient-reported outcomes |
| Radical cystectomy | Cystectomy is the backbone of all level 1 EV+pembro data; cCR is not pCR | KEYNOTE-905/EV-303, KEYNOTE-B15/EV-304, Roessler meta-analysis, RETAIN ctDNA |
| Surveillance | Most pts had pCR at cystectomy anyway; the real question is whether cCR predicts MFS | HCRN GU16-257, RETAIN failure patterns, ctDNA (Epstein, ASCO GU 2026) |
| Outcome | RETAIN-1 | RETAIN-2 |
|---|---|---|
| Local recurrence | 62% | 36% |
| Metastatic recurrence | 36% | 14% |
| MFS with intact non-irradiated bladder | 48% | 68% |
- Does cCR after EV+pembro predict MFS as it did after GC + nivo? not yet A Phase 2 Study Evaluating Bladder Preservation With Enfortumab Vedotin Plus Pembrolizumab in Patients With Muscle-Invasive Urothelial Cancer Phase 2n=25 · primary completion 2034-11 · EV+P clinical response-based sparing, no RC or RT
- Does RT consolidation improve bladder control over surveillance after cCR? recruiting Enfortumab Vedotin in Combination With Pembrolizumab vs. Concurrent Chemoradiotherapy (cCRT) in People With Muscle Invasive Bladder Cancer (EV-309) Phase 3n=390 · primary completion 2030-03 · phase 3 EV+P alone vs chemoRT for bladder preservationn=56 · primary completion 2031-04 · response-adapted EV+P induction, then RT, CRT or RC
- Can ctDNA select pts to safely omit cystectomy? recruiting NEO-BLAST: Neoadjuvant Therapy for Bladder Cancer Followed by Active Surveillance vs Treatment Phase 2/3n=688 · primary completion 2028-12 · ctDNA/MRI-selected surveillance vs definitive therapy
📚 Sources · 📄 1 paper
Abstract
TRIDENT NCT04471844
ForndGBM (WHO 2016), post maximal safe resection or biopsy, pre-RT/TMZ
HR 0.953
95% CI 0.82-1.10, p=0.52; mOS 17.7 vs 17.5 m, not met
TL;DRNo OS gain starting TTFields with RT/TMZ vs at maintenance TMZ in ndGBM: mOS 17.7 vs 17.5 m, HR 0.953, p=0.52.
The RT read is toxicity without payoff: wearing TTFields through RT/TMZ raised device-related AEs to 76.2% vs 59.2% (mostly grade 1-2 skin) with no OS, PFS or ORR difference. RT dose, fractionation and array handling during RT are not reported in source, so the trial gives no reason to build arrays into the chemoRT course.
In ndGBM pts about to begin RT/TMZ after maximal safe resection or biopsy, this does not support moving TTFields start forward from maintenance TMZ; it does not extend to selecting MGMT-methylated pts for early start, which rests on a post hoc subset. The longer read
Wearing TTFields through RT/TMZ raised device-related AEs to 76.2% vs 59.2% (mostly grade 1-2 skin) with no OS, PFS or ORR difference. RT dose, fractionation and array handling during RT are not reported in source, so nothing here argues for building arrays into the chemoRT course.
Sequencing stays as is: TTFields with adjuvant TMZ gave mOS 17.5 m vs 17.7 m with early start (HR 0.953, p=0.52). The MGMT-methylated signal (HR 0.683, p=0.03) comes from a post hoc per-protocol-usage subset with no n reported, so MGMT status is not yet a selector for earlier start.
7 details
Randomized, open-label, global phase 3, 1:1, randomized before RT/TMZ. N=981, accrued Dec 2020 to Jan 2024. Stratified by MGMT promoter methylation status and extent of resection.
Adults with ndGBM (WHO 2016 classification), recovered from maximal safe resection (biopsy allowed), KPS threshold 70 (inequality sign not rendered in source), RT/TMZ planned <8 weeks after surgery. Median age 60 (22-86), 65.1% male, 38.9% MGMT methylated, 5.4% IDH mutant.
TTFields (200 kHz) started concurrently with RT/TMZ (Early Start, n=492) or with adjuvant TMZ (Maintenance Start, n=489). TTFields recommended until second disease progression in both arms. Median device use 7.7 m vs 6.1 m.
RT with TMZ in both arms. Dose, fractionation, target volume and array management during RT are not reported in source.
Primary: overall survival. Secondary: PFS, 1-, 2- and 3-year survival rate, ORR, safety. Kaplan-Meier with stratified log-rank test.
Primary not met in ITT (see table). PFS and ORR not different between arms, values not reported in source.
| Endpoint | Early Start (with RT/TMZ) | Maintenance Start (with adjuvant TMZ) | Effect |
|---|---|---|---|
| mOS (95% CI) | 17.7 m (16.0-18.8) | 17.5 m (15.9-19.0) | HR 0.953 (95% CI 0.82-1.10), p=0.52 |
| 1-year survival | 70.9% | 72.0% | NS |
| 2-year survival | 33.9% | 31.6% | NS |
| 3-year survival | 22.5% | 18.4% | NS |
| Device-related AEs | 76.2% | 59.2% | mostly grade 1-2 skin |
| Median TTFields duration (range) | 7.7 m (0-49) | 6.1 m (0-43) | not reported |
Device-related AEs 76.2% Early Start vs 59.2% Maintenance Start, mostly grade 1-2 skin-related. Grade 3+ rates and RT interruption not reported in source.
EF-14 established TTFields added to maintenance TMZ after chemoRT, which the source names as current standard and which is the control arm here. TRIDENT asks only whether starting earlier adds to that, and in ITT it does not.
The between-arm exposure contrast is small (median use 7.7 m vs 6.1 m) and ~25% never started maintenance, which dilutes a timing effect. The MGMT signal conditions on device usage after randomization, with no subgroup n, interaction test or ITT MGMT-methylated result in source.
A timing-null result, not a device-null one. The post hoc MGMT-methylated finding (HR 0.683, p=0.03) is a hypothesis for a prospective trial, and the abstract's "clinically meaningful" framing outruns a per-protocol-usage subset.
CONSORT flow
Randomized phase 3 with prespecified OS primary not met, so maintenance-start TTFields stands. MGMT-methylated benefit is post hoc in a per-protocol-usage subset, not grounds for change.
- Does early TTFields improve OS in MGMT-methylated ndGBM when tested prospectively?
- Scalp dose and RT interruption with arrays worn during RT/TMZ
📚 Sources · 📄 1 paper
Abstract
NRG/RTOG 9601 (transcriptomic analysis)
ForProstate cancer, salvage RT ± high-dose bicalutamide, GC score available
TL;DRSecondary analysis, n=352, 18.2y median f/u: GC per 0.1 prognostic for PCSM, sHR 1.34 (1.17-1.54); AAT benefit by GC showed no significant interaction.
The sRT decision in play is hormone omission at low pre-sRT PSA: at PSA <0.7, 15y PCSM benefit from AAT was -2% with GC <0.6 vs 16% with GC ≥0.6. At PSA ≥0.7 the gradient reverses (12% vs 6%), so GC here ranks risk more reliably than it selects for hormones.
In sRT candidates with pre-sRT PSA <0.7 and GC <0.6, this informs the discussion of sRT without hormone therapy as hypothesis-level evidence (15y PCSM benefit with AAT -2%); it does not extend to contemporary ADT, which this trial did not test. The longer read
The sRT decision in play is hormone omission at low pre-sRT PSA: at PSA <0.7, 15y PCSM benefit from AAT was -2% with GC <0.6 vs 16% with GC ≥0.6. At PSA ≥0.7 the gradient reverses (12% vs 6%), so GC ranks risk more reliably than it selects for hormones. RT dose and volume not reported.
11 details
Secondary analysis of NRG/RTOG 9601, a phase 3 trial of sRT ± high-dose bicalutamide, using GC scores (Veracyte) from a prior translational project. GC-available cohort n=352, median follow-up 18.2 years. Multivariable Cox or Fine-Gray models, adjusted (s)HR with 95% CI.
Pts treated with sRT on NRG/RTOG 9601 who had a GC score. Median GC 0.59 (Q1-Q3 0.42-0.76); 29%, 23%, 38% and 11% were low, intermediate, high and very high risk. Other baseline features not reported in source.
sRT with or without high-dose bicalutamide (AAT). Bicalutamide dose and duration not reported in source.
Salvage RT in both arms. Dose, fractionation and target volume not reported in source.
Primary objective: prognostic impact of GC (per 0.1) on PCSM. Secondary: OS, MFS, DM. Additional: PCSM and OS by pre-defined GC strata, and PCSM benefit of AAT by GC (<0.6 vs ≥0.6) within pre-sRT PSA subgroup (<0.7 vs ≥0.7).
GC was independently prognostic for every profiled endpoint (tables above). The AAT-by-GC estimates are absolute 15-year PCSM differences with no significant interaction in either PSA stratum.
| Endpoint | Adjusted (s)HR | 95% CI |
|---|---|---|
| PCSM (primary objective) | sHR 1.34 | 1.17-1.54 |
| OS | HR 1.18 | 1.09-1.27 |
| MFS | HR 1.16 | 1.08-1.25 |
| DM | sHR 1.20 | 1.07-1.35 |
| Endpoint at 15 years | Low GC | Very high GC | Difference |
|---|---|---|---|
| PCSM | 4% | 52% | 48% |
| OS | 75% | 25% | 50% |
| Pre-sRT PSA | GC <0.6 | GC ≥0.6 |
|---|---|---|
| <0.7 | -2% | 16% |
| ≥0.7 | 12% | 6% |
Extends the earlier GC validation in this same trial with final outcomes, and layers GC onto the prior 9601 finding that pre-sRT PSA predicts AAT benefit. GETUG-AFU 16, NRG/RTOG 0534 (SPPORT) and RADICALS-HD tested ADT with post-prostatectomy RT; none is addressed in this source.
AAT benefit by GC is given as point estimates only: no CIs, no cell sizes. PCSM was chosen as primary for this secondary analysis because of suspected other-cause mortality with bicalutamide, which sets aside the endpoint where AAT harm would show. Whether the GC-available subset matches the full trial is not reported.
The prognostic claim is well supported at long follow-up. The predictive claim is not: the GC gradient runs in opposite directions in the two PSA strata. The authors frame GC-guided selection for modern ADT in early sRT as a hypothesis, which is the right ceiling.
Secondary biomarker analysis of a GC-available subset; predictive claim rests on non-significant interactions, and the hormone agent was high-dose bicalutamide, not contemporary ADT.
- Does GC predict benefit from contemporary ADT with early sRT?
- Do intermediate and high GC strata separate on 15-year PCSM and OS?
- Does the AAT-by-GC pattern hold for OS, not just PCSM?
📚 Sources · 📄 1 paper
Abstract
NRG-HN009 (p16-negative phase II toxicity)
Forp16-negative locoregionally advanced SCCHN, 70 Gy RT + concurrent cisplatin
T-score ratio 1.11
90% upper confidence bound 1.33, p=0.77 · phase III criteria not met
TL;DRT-score ratio (weekly/Q3) 1.11, p=0.77: weekly cisplatin not less toxic with 70 Gy in p16-negative locoregionally advanced SCCHN, no phase III.
6-mo LRF was 4.6% (Q3) vs 9.6% (weekly), absolute difference 5.0% (95% CI 1.0, 8.9), despite worse RT QA on Q3 (81% vs 94% per protocol or acceptable). RT quality does not explain the gap. With 70 Gy fixed, schedule choice rests on toxicity type, not total G3-4 burden.
In p16-negative locoregionally advanced SCCHN receiving 70 Gy with concurrent cisplatin, this questions choosing weekly 40 mg/m2 on tolerability grounds, since G3-4 event counts were not lower; it does not extend to the p16-positive cohort, reported separately. The longer read
6-mo LRF was 4.6% (Q3) vs 9.6% (weekly), absolute difference 5.0% (95% CI 1.0, 8.9), despite worse RT QA on Q3 (81% vs 94% per protocol or acceptable). RT quality does not explain the gap. With 70 Gy fixed, the concurrent schedule is the variable to weigh for locoregional control.
Weekly 40 mg/m2 traded toxicities instead of lowering them: G3-4 AKI 11% vs 3% and nausea 12% vs 4% on Q3, WBC decrease 28% vs 14% and hypomagnesemia 8% vs 2% on weekly. Chemotherapy delivery was per protocol or acceptable in 80% on Q3 vs 98% on weekly; cumulative dose not reported.
12 details 1 trial watching
Randomized phase II/III; this is the phase II acute toxicity report for the p16-negative cohort. 234 randomized (118 Q3, 116 Q1) between Oct 2021 and Sept 2025; 91% completed all follow-up up to 6 months. QA modality reviews were done on a random sample of cases.
p16-negative locoregionally advanced SCCHN. Median age 60; 76% male; 58% Zubrod 0; 87% former or current smokers, 70% >10 pack-years. 57% larynx, 28% oropharynx, 15% hypopharynx; 83% T1-3 and 74% node-positive.
Cisplatin 100 mg/m2 Q3 weeks (Q3) vs cisplatin 40 mg/m2 weekly (Q1), each with RT. Chemotherapy delivery scored per protocol or acceptable variation in 80% on Q3 vs 98% on Q1. Cumulative cisplatin dose delivered is not reported in source.
70 Gy in both arms; fractionation, technique and target volumes are not reported in source. RT reviews were completed for 91% of sampled pts, scored per protocol or acceptable variation in 81% on Q3 vs 94% on Q1.
acute toxicity by T-score, the number of all treatment-related grade 3-4 AEs during treatment or within six months. To proceed to phase III, the mean T-score ratio (Q1/Q3) had to be below 1 at 1-sided p<0.1, together with a 6-month locoregional failure difference criterion (printed as '= 8%' absolute in the portal text).
The cohort did not meet criteria for continuing to phase III; arm-level values are in the tables.
| Endpoint | Q1 Cis (weekly) | Q3 Cis | Effect |
|---|---|---|---|
| Mean T-score | 2.48 (95% CI 1.97, 2.99) | 2.23 (95% CI 1.81, 2.65) | Ratio 1.11 (90% upper bound 1.33), p=0.77 |
| 6-month locoregional failure | 9.6% | 4.6% | Absolute difference 5.0% (95% CI 1.0, 8.9) |
| AE term | Q3 Cis | Q1 Cis |
|---|---|---|
| Nausea | 12 | 4 |
| WBC decreased | 14 | 28 |
| Dehydration | 9 | 1 |
| Hypomagnesemia | 2 | 8 |
| Acute kidney injury | 11 | 3 |
Total G3-4 burden was similar, but the profile differed by schedule. Q3 carried more G3-4 nausea (12% vs 4%), dehydration (9% vs 1%) and acute kidney injury (11% vs 3%); weekly carried more WBC decrease (28% vs 14%) and hypomagnesemia (8% vs 2%). Late toxicity is not reported in source.
The Tata Memorial randomized trial (Noronha et al.) favored Q3 over a lower weekly dose for locoregional control in a mostly postoperative population, while JCOG1008 supported weekly dosing after surgery. This cohort tests the schedule question with 70 Gy RT in p16-negative disease and gives no toxicity support for weekly; the source draws no comparison to either trial.
The T-score weighs every G3-4 event equally, so marrow and renal events are interchangeable in the primary. QA was scored on a random sample, not all cases, and per-arm cumulative cisplatin dose is missing. The portal text has lost the inequality in the LRF criterion, so the abstract alone does not show whether that half of the rule passed.
The tolerability premise for weekly cisplatin did not hold here: toxicity was redistributed, not reduced. The LRF difference favors Q3 but rests on a 6-month read in a toxicity-driven phase II, so it is a direction, not an efficacy result. Pooled results for all 475 pts were deferred to the presentation.
CONSORT flow
Randomized, prespecified phase II go/no-go analysis; weekly failed its toxicity criterion, leaving Q3 as the reference schedule. Abstract only; 6-month LRF is immature and not an efficacy test.
- Does the 6-month LRF gap persist in longer-term locoregional control and survival?
- Do pooled p16+ and p16- results (475 pts) show the same toxicity pattern?
- Late toxicity and hearing outcomes by cisplatin schedule n=100 · primary completion 2028-09 · randomized weekly LD vs HD cisplatin CRT, p16-stratified
📚 Sources · 📄 1 paper
Abstract
TORCH-iTNT NCT06281405
ForpMMR LARC, T3-4/N+ M0, 96.6% with at least one high-risk feature
61.5% vs 37.1%
48/78 with SCRT vs 26/70 without; no p-value or CI reported
TL;DRCR (pCR + cCR) 61.5% with SCRT 25Gy/5Fx → CAPOX + toripalimab vs 37.1% without RT in pMMR LARC; no p-value reported.
The RT read sits in cCR, not pCR: 25 pts after SCRT 25Gy/5Fx vs 7 without RT reached cCR and went to W&W, so the short course is what opened the organ-preservation route. The no-RT arm still carried adjuvant chemoradiotherapy for positive circumferential margins, at a rate the source does not report.
In pMMR LARC (T3-4/N+ M0) with high-risk features where organ preservation is the aim, this supports retaining SCRT ahead of CAPOX plus PD-1 inhibitor; it does not extend to dMMR disease, and it does not show that omitting RT preserves function. The longer read
The RT read sits in cCR, not pCR: 25 pts after SCRT 25Gy/5Fx vs 7 without RT reached cCR and went to W&W, so the short course is what opened the organ-preservation route. The no-RT arm still carried adjuvant chemoradiotherapy for positive circumferential margins, at an unreported rate.
CAPOX plus toripalimab without RT gave a 37.1% (26/70) CR rate in pMMR LARC, but with no chemotherapy-alone arm the PD-1 inhibitor's contribution is unmeasured. G3-4 thrombocytopenia was similar across arms (12.9% vs 14.1%), so adding SCRT did not visibly cost hematologic tolerance of six cycles.
Omitting RT sent more pts to resection: 58 of 70 in the no-RT arm had surgery vs 52 of 78 after SCRT, with 7 vs 25 entering W&W. pCR among resected was 32.8% vs 44.2%. Margin status, sphincter preservation and anorectal function are not yet reported.
11 details 1 trial watching
Multicenter randomized phase II, 192 pMMR LARC pts enrolled. Initial results as of January 31, 2026 cover the 148 who completed treatment (70 in Group A, 78 in Group B). Allocation ratio, stratification and follow-up duration are not stated in source.
pMMR LARC, T3-4/N+ M0. Baseline characteristics described as balanced. 96.6% (143/148) had at least one high-risk feature: low tumor location, cT4, cN2, MRF+ or EMVI+.
Group A: 6 cycles of CAPOX plus toripalimab. Group B: SCRT followed by the same 6 cycles. cCR pts were offered W&W, non-cCR pts were recommended for surgery.
SCRT 25Gy/5Fx before immunochemotherapy in Group B. Group A received no neoadjuvant RT, with adjuvant chemoradiotherapy reserved for positive circumferential margins. Target volumes, technique and the interval from SCRT to response assessment are not reported in source.
Primary: complete response rate, defined as pCR plus cCR. Secondary: organ preservation rate, anorectal function, adverse events and survival outcomes.
Thrombocytopenia was the most common grade 3-4 AE, 12.9% in Group A and 14.1% in Group B. No other AE data, and no RT-attributable or surgical toxicity, are reported in source.
TORCH, the same group's predecessor, tested induction vs consolidation sequencing of SCRT with CAPOX and toripalimab; this trial asks instead whether SCRT can be dropped. UNION set SCRT followed by immunochemotherapy against long-course chemoradiotherapy. PROSPECT asked the RT-omission question with chemotherapy alone in a lower-risk population than the one enrolled here.
cCR criteria and the assessment timepoint are not stated, and cCR calls cannot be blinded to arm. The pCR denominator in Group B excludes the 25 cCR pts who went to W&W, so resected-only pCR is not a like-for-like comparison. No chemotherapy-alone arm, so toripalimab's contribution is unmeasured.
The gap in CR is carried mostly by clinical responses, which is the outcome that matters for W&W and also the softer of the two components. The rationale for the no-RT arm was functional sparing, yet 58 of 70 Group A pts went to surgery vs 52 of 78 in Group B, and anorectal function is not yet reported. Regrowth after W&W will decide whether the cCR advantage holds.
Initial results in 148 completers of 192 enrolled; no p-value or CI; CR is an early response endpoint, and organ preservation, function and survival readouts are pending.
- Local regrowth rate after W&W in each arm not yet the Efficacy of MR-guided Online Adaptive Radiotherapy for Locally Advanced Rectal Cancer Phase NAn=49 · primary completion 2026-12 · SCRT on MR-linac; W&W local recurrence rate endpoint
- Anorectal function with vs without SCRT
- Does toripalimab add to CAPOX alone in pMMR LARC without RT?
📚 Sources · 📄 1 paper
Abstract
STELLAR II NCT05484024
ForMid-to-low pMMR LARC; T3-4 94.9%, node-positive 92.9%
51.9% vs 26.8%
150/289 vs 78/291, P<0.001; phase 3 primary 3-year DFS not yet reported
TL;DROverall CR 51.9% vs 26.8% (P<0.001) adding sintilimab to SCRT (5 Gy x5) + CAPOX TNT in pMMR LARC; 3-year DFS pending.
The RT backbone is 5 Gy x5 with 100% completion, so the CR gain comes on a schedule any department can deliver. The surgical denominators (211 iTNT vs 247 TNT) show fewer iTNT pts reached the OR, though the per-arm split of the 92 W&W pts is not reported. The decision in play is SCRT-based TNT plus PD-1 blockade as an organ-preservation route.
In mid-to-low pMMR LARC planned for SCRT-based TNT where organ preservation is a goal, this supports sintilimab as a CR-raising addition at the cost of more grade 3-4 toxicity; it does not yet inform DFS and does not extend to long-course CRT-based TNT. The longer read
The RT backbone is 5 Gy x5 with 100% completion, so the CR gain comes on a schedule any department can deliver. Fewer iTNT pts reached surgery (211 vs 247 operated), though the per-arm W&W split is not reported. This informs SCRT-based TNT plus PD-1 blockade as an organ-preservation route; technique and target volumes are not in source.
Sintilimab was the only randomized variable on a fixed SCRT + CAPOX backbone, and 86.1% received at least 4 cycles without loss of chemo completion (92.9% vs 94.1%). The price is grade 3-4 toxicity of 27.7% vs 19.9%. This is a checkpoint-inhibitor signal in pMMR disease, with DFS still unreported.
pCR was 41.7% (88/211) vs 19.4% (48/247) among operated pts, and 92 pts (15.6%) entered W&W after cCR. In a cohort with 71.3% lower tumors, that bears on sphincter preservation. Regrowth rates, salvage outcomes and surgical morbidity are not reported in source.
9 details 4 trials watching
Multicenter, randomized, phase 2/3 trial. 658 screened and 588 randomized from August 2022 to August 2025 (296 iTNT, 292 TNT). Data as of February 6, 2026; blinding not stated in source.
Mid-to-low pMMR LARC. Median age 59, 71.1% male. T3-4 94.9%, node-positive 92.9%, lower tumors 71.3%, MRF+ 48.8%, EMVI 45.4%.
SCRT followed by 4 cycles of CAPOX with sintilimab (iTNT) or the same regimen without sintilimab (TNT). After evaluation, resection or W&W, then 2 additional cycles of the same prior regimen.
SCRT 5 Gy x5 in both arms, delivered first. All pts completed SCRT. Technique, target volumes and the interval to surgery are not reported in source.
Primary: CR rate for phase 2 and 3-year DFS for phase 3. This report covers short-term efficacy and safety only.
Arm-level CR, pCR, toxicity and compliance are in the table above. 92 pts (15.6%) adopted W&W after cCR, and 458 had undergone surgery with 8 awaiting.
| Endpoint | iTNT (SCRT + CAPOX + sintilimab) | TNT (SCRT + CAPOX) | P |
|---|---|---|---|
| Overall CR | 51.9% (150/289) | 26.8% (78/291) | P<0.001 |
| pCR (operated pts) | 41.7% (88/211) | 19.4% (48/247) | not reported |
| Grade 3-4 toxicity | 27.7% | 19.9% | not reported |
| 4-cycle chemo completion | 92.9% | 94.1% | not reported |
Grade 3-4 toxicities 27.7% (iTNT) vs 19.9% (TNT). Grade 3-5 immune-related AEs in 3.4% of pts. Chemotherapy completion was similar (92.9% vs 94.1%); surgical morbidity is not reported.
Per the source, several phase II studies suggested that adding immunotherapy to TNT raises CR, but phase 3 comparisons of TNT with vs without immunotherapy were lacking. RAPIDO and the original STELLAR trial established SCRT-based TNT, while UNION and TORCH tested SCRT plus checkpoint blockade without an otherwise-identical immunotherapy-free TNT control.
Overall CR pools pathological and clinical response, and whether cCR assessment was blinded is not stated. pCR is computed on operated pts only, with unequal denominators (211 vs 247). The per-arm W&W split is not reported.
The randomized variable is sintilimab alone, so the trial isolates the drug and says nothing about SCRT vs long-course CRT as its partner. A higher CR opens an organ-preservation route, but whether it converts to DFS in pMMR disease is unsettled until the phase 3 primary reads out.
CONSORT flow
Randomized and fully accrued, but this is a short-term CR readout; the phase 3 primary (3-year DFS) and W&W regrowth data are not yet reported.
- Does the higher CR rate translate into a 3-year DFS benefit?
- Regrowth rate and durability of W&W after iTNT recruiting CAPOX and PD-1 Antibody Combined With or Without Radiotherapy for MSS Locally Advanced Rectal Cancer Phase 2n=192 · primary completion 2026-06 · W&W for cCR after SCRT + toripalimab-CAPOX iTNTrecruiting Personalized Long-course Radiotherapy Plus Chemotherapy With or Without Immunotherapy for LARC: PALACE Study Phase 3n=184 · primary completion 2027-07 · CR endpoint requires cCR sustained over 1 year
- Does the PD-1 benefit hold with long-course CRT-based TNT? recruiting Personalized Long-course Radiotherapy Plus Chemotherapy With or Without Immunotherapy for LARC: PALACE Study Phase 3n=184 · primary completion 2027-07 · phase 3 long-course RT + chemo ± serplulimab, CR endpointrecruiting Neoadjuvant Chemoradiotherapy Followed by Chemotherapy With or Without Tislelizumab for Resectable Ultra-low Rectal Cancer: The RELIEVE-02 Study Phase 3n=196 · primary completion 2027-12 · phase 3 long-course CRT then CAPOX ± tislelizumab, pMMR
📚 Sources · 📄 1 paper
Abstract
NRG/RTOG 0815 Decipher GC
ForIntermediate-risk prostate cancer, dose-escalated RT, biopsy Decipher GC available
p-interaction <0.001
10-yr DM absolute benefit 11% high GC vs 1% low GC
TL;DR10-yr DM absolute benefit from adding STAD to dose-escalated RT: 11% in high GC vs 1% in low GC, p-interaction <0.001.
The omission read is the low-GC group: 44% of the cohort had GC <0.45 and a 10-yr DM absolute difference of 1% with STAD. The slide pools int/high GC at 8% while the abstract gives 11% for high GC alone, so where GC 0.45-0.6 falls is not resolved in source. RT dose and fractionation are not stated.
In intermediate-risk prostate cancer planned for dose-escalated RT, a low Decipher GC (<0.45) supports discussing STAD omission and a GC >0.6 argues against it; it does not settle the GC 0.45-0.6 group or pts outside intermediate-risk disease. The longer read
The omission read is the low-GC group: 44% of the cohort had GC <0.45 and a 10-yr DM absolute difference of 1% with STAD added to dose-escalated RT. Slide pools int/high GC at 8% vs 11% for high GC alone in the abstract, so GC 0.45-0.6 stays unresolved. RT dose and fractionation not stated in source.
| GC group | Absolute 10-yr DM benefit from adding STAD |
|---|---|
| Int/High GC | 8% |
| Low GC | 1% |
+1 more figure
12 details 2 trials watching
Ancillary study of NRG/RTOG 0815, a phase 3 randomized trial of dose-escalated RT with or without 6 months of STAD. Prespecified analysis plan with NCI approval, GC data linked to updated outcomes at 10.2 years median follow-up (IQR 8.4-11.4).
Intermediate-risk prostate cancer. GC scores were obtained for 395 pts of 856 with available tissue, with baseline characteristics balanced between arms. GC distribution: low (<0.45) 44%, intermediate (0.45-0.6) 24%, high (>0.6) 32%.
6 months of STAD added to dose-escalated RT vs RT alone. Agents not stated in source.
Dose-escalated RT in both arms. Dose, fractionation, modality mix and target volume are not stated in source, though RT modality was a covariate in the multivariable models.
Primary: distant metastasis. Secondary: biochemical failure, MFS, PCSM, OS. Cox and Fine-Gray competing risk MVA adjusted for age, race, clinical risk factors, comorbidity score and RT modality.
GC-STAD interaction for DM p<0.001 and for PCSM p-interaction <0.001. 10-yr DM absolute difference 1% in low GC vs absolute benefit 11% in high GC. Slide 2 shows predicted 10-yr DM rising with GC score after RT alone and staying low with RT + STAD.
| Endpoint | sHR (95% CI) | p |
|---|---|---|
| Biochemical failure | 2.19 (1.36-3.53) | <0.001 |
| Distant metastasis | 4.89 (0.98-24.3) | 0.05 |
The parent NRG/RTOG 0815 trial set the question of STAD with dose-escalated RT for intermediate-risk disease as a whole. Decipher has prior ancillary validation in NRG/RTOG 0126 and 9601. This analysis adds a treatment interaction inside a trial that randomized the therapy in question.
The slide and the abstract cut the cohort differently (int/high GC pooled at 8% vs high GC at 11%), leaving the GC 0.45-0.6 group unresolved. The prognostic DM estimate has a CI of 0.98-24.3. No favorable vs unfavorable intermediate-risk breakdown in source.
The predictive claim is for DM and PCSM, not OS or MFS, for which no interaction is reported in source. The low-GC finding is the clinically usable half, since it identifies a large group with no clear benefit from intensification. The authors themselves defer to NRG GU010 for prospective validation.
Ancillary biomarker analysis in the 395 pts with GC scores; interaction rests on 16 DM and 7 PCSM events. Prespecified plan, but prospective validation (NRG GU010) pending.
- Does GC-guided STAD omission hold prospectively in NRG GU010? n=2050 · primary completion 2026-11 · phase 3 Decipher-guided de-intensification in UIRn=222 · primary completion 2027-12 · phase 2 SBRT without ADT in UIR, Decipher-guided
- STAD benefit in intermediate GC (0.45-0.6) reported on its own?
- Does the interaction hold within favorable vs unfavorable intermediate-risk disease?
📚 Sources · 🐦 1 tweet · 📄 1 paper
🚨Decipher score predictive of ADT benefit for preventing metastasis in patients with intermediate-risk #ProstateCancer in secondary analysis of @NRGonc RTOG 0815 RCT@angela_jia_ @ASTRO_org #ASTRO26 pic.twitter.com/YokjDQVxKa
— Tyler Seibert MD PhD (@TylerSbrt) September 29, 2026
Abstract
NRG/RTOG 0534 PAM50
ForPost-RP salvage RT, PSA 0.1-2.0 ng/mL, pT2 or pT3 N0M0, Gleason ≤9
TL;DR5-y FFP benefit from adding ADT to post-RP salvage RT was 31% vs 10% by PAM50 Luminal B status (p-int=.01), secondary biomarker analysis.
The decision in play is ADT with salvage RT, not target volume. The FFP interaction (P=0.01) rests on pooled STADT arms vs PBRT alone, HR 0.34 (0.23-0.52) in one subtype panel. In the three-arm slide, Arm 3 vs 2 reads HR 0.64 (0.34-1.20), p=0.16, so what PLNRT adds within subtype is unresolved.
In men post-RP with PSA 0.1-2.0 ng/mL and pT2 or pT3 N0M0 disease heading to salvage RT, PAM50 Luminal B status supports the case for adding STADT; it does not establish that non-Luminal B men can omit ADT. The longer read
The decision in play is ADT with salvage RT, not target volume. The FFP interaction (P=0.01) rests on pooled STADT arms vs PBRT alone, HR 0.34 (0.23-0.52) in one subtype panel. In the three-arm slide, Arm 3 vs 2 reads HR 0.64 (0.34-1.20), p=0.16, so what PLNRT adds within subtype is unresolved.
For the ADT decision, PAM50 Luminal B is offered as a selection marker: 5-y FFP benefit 31% vs 10% (p-int=.01), with a weaker 10-y MFS interaction (p-int=.05). STADT duration and agent are not reported in source, and the non-Luminal B estimate is too imprecise to support omission.
+2 more figures
10 details
PAM50 molecular subtyping on biorepository tissue from NRG/RTOG 0534, a three-arm randomised trial of post-prostatectomy salvage RT. Analytic cohort n=709 from 1792 enrolled and evaluable. Phase, prespecification of this analysis and median follow-up are not stated in source.
Parent trial eligibility per slide: post-RP, PSA 0.1-2.0 ng/mL, pT2 or pT3 N0M0, Gleason ≤9. Of 1039 consented pts with samples, 3 had insufficient RNA, 120 failed cDNA QC and 207 failed microarray QC.
Arm 1 PBRT alone (n=215), Arm 2 PBRT + STADT (n=247), Arm 3 PBRT + STADT + PLNRT (n=247). Dose, fractionation, pelvic nodal volume and STADT duration are not reported in source tweets.
Reported: FFP at 5 y and MFS at 10 y, each tested for subtype-by-treatment interaction. The primary endpoint of this biomarker analysis is not stated in source.
Tweet: 5-y FFP benefit from postop ADT 31% vs 10% (p-int=.01) and 10-y MFS 20% vs -3% (p-int=.05). FFP slide: pooled STADT arms vs PBRT alone HR 0.34 (0.23-0.52), p<0.001 in one subtype panel; the other panel's HR is garbled in OCR with CI 0.43-1.00.
The parent trial (Pollack et al, Lancet Onc 2022) is the slide's stated reference for the unselected result. GETUG-AFU 16 and RADICALS-HD tested ADT with post-RP RT without molecular selection, and NRG GU006 used PAM50 subtype prospectively with salvage RT; none of their figures appear in source.
Subtype panel labels and one HR are not legible in OCR, so effect sizes by subtype rest partly on the tweet's framing. The MFS interaction sits at p-int=.05. No multiplicity handling, event counts or Luminal B prevalence in source.
A treatment-by-subtype interaction on FFP is the claim that would let PAM50 select for ADT; a prognostic signal alone would not. The MFS interaction is weaker and the three-arm comparisons are underpowered within subtype, so this reads as support for biomarker-directed ADT rather than a rule for omission.
Biomarker subset analysis of a completed randomised trial, prespecification not stated; analytic cohort is a tissue- and QC-selected fraction. Interaction on MFS is borderline.
- Does PAM50 Luminal B predict ADT benefit independent of entry PSA and grade?
- Can non-Luminal B men omit ADT with salvage RT?
- Does pelvic nodal RT benefit differ by PAM50 subtype?
📚 Sources · 🐦 1 tweet
New #ASTRO2026 data from @NRGOnc /RTOG 0534 SPPORT 🔬🧬 presented by Shuang (George) Zhao @UTMDAnderson. PAM50 Luminal B = both prognostic & predictive of benefit from postop ADT.
— Lauren Henke, MD, MSCI (@lauren_henke) September 27, 2026
📈 5-y FFP benefit: 31% vs 10% (p-int=.01)
🎯 10-y MFS: 20% vs -3% (p-int=.05)#Pcsm @Astro_org pic.twitter.com/BRJsYDWiQS
NRG/RTOG 0815
ForNon-metastatic intermediate-risk prostate cancer, GS 7 in 92%, median age 68
HR 0.87
95% CI 0.72-1.04, p=0.13 (ns); 14-y OS 53% vs 58%
TL;DR14-y OS 53% vs 58% (HR 0.87, p=0.13) adding 6 mo STAD to dose-escalated RT in intermediate-risk prostate cancer; PSA failure HR 0.60.
Dose escalation did not make STAD redundant: local failure still fell (HR 0.44) and the PSA-failure benefit held in single-risk-factor pts (HR 0.66). With 88% treated by EBRT alone to 79.2 Gy, the trial cannot say whether a brachytherapy boost substitutes for ADT. 422 of 446 deaths were non-prostate, which is why OS stayed flat.
In non-metastatic intermediate-risk prostate cancer planned for dose-escalated EBRT, this supports discussing 6 months of STAD as a disease-control gain (PSA failure, distant metastasis, salvage ADT) without a proven OS gain; it does not extend to pts with all 3 risk factors and ≥50% positive cores, who were ineligible. The longer read
Dose escalation did not make STAD redundant: local failure still fell (HR 0.44) and the PSA-failure benefit held in single-risk-factor pts (HR 0.66). With 88% treated by EBRT alone to 79.2 Gy, the trial cannot say whether a brachytherapy boost substitutes for ADT.
Six months of LHRH agonist/antagonist plus antiandrogen roughly halved later salvage ADT (15% vs 7% at 14 y) and cut distant metastasis (40 vs 14 events) without an OS gain. The cost is more grade ≥3 cardiac (26 vs 10) and metabolic (20 vs 4) events, though non-prostate mortality was not higher (HR 0.93).
| Arm | 10-yr OS | 14-yr OS | HR (95% CI) | p |
|---|---|---|---|---|
| RT Alone | 70% | 53% | Referent | n/a |
| RT + STAD | 74% | 58% | 0.87 (0.72, 1.04) | 0.13 |
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| Arm | 10-yr PSA failure | 14-yr PSA failure | HR (95% CI) | p |
|---|---|---|---|---|
| RT Alone | 25% | 34% | Referent | n/a |
| RT + STAD | 16% | 19% | 0.60 (0.48, 0.76) | < 0.001 |
10 details
Phase III prospective randomized trial, accrued 1538 pts 2009-2016, 1493 eligible for analysis (751 RT alone, 742 RT + STAD). Stratified by number of risk factors (1 vs 2-3), ACE-27 (≥2 vs <2), and RT modality. Median follow-up 9.4 years (10.3 years in survivors).
Non-metastatic intermediate-risk prostate cancer with ≥1 of: clinical stage T2b-T2c, Gleason score 7, PSA >10 but ≤20 ng/mL. Ineligible: all 3 risk factors with ≥50% positive cores. Median age 68, 67% single risk factor, 92% Gleason 7, median PSA 8.1 ng/mL, 67% ACE-27 <2.
STAD: LHRH agonist/antagonist plus oral antiandrogen for 6 months, added to dose-escalated RT. Protocol-compliant or acceptable variation in 91% for the LHRH component and 87% for the antiandrogen.
Physician's choice of EBRT alone to 79.2 Gy or EBRT 45 Gy plus LDR or HDR brachytherapy boost. EBRT alone in 88% (abstract) to 89% (slide). Over 90% of RT plans scored per protocol or variation acceptable for contours and dose.
Primary: overall survival, powered to detect 5-year OS 90% to 93% (HR 0.66) with 85% power. Secondary: biochemical failure, local failure, distant metastasis, prostate cancer death, initiation of salvage therapy, non-prostate cancer death.
Primary OS not met (HR 0.87, p=0.13). Every disease-control secondary favored STAD, including local failure HR 0.44 (per-arm local failure rates not reported in source).
| Endpoint | RT + STAD | RT alone | Effect size |
|---|---|---|---|
| MFS, 10-y | 72% | 67% | n/a |
| MFS, 14-y | 57% | 50% | HR 0.83 (0.69-0.99), p=0.042 |
| Distant metastasis, events | 14 | 40 | HR 0.35 (0.19-0.64), p<0.001 |
| Prostate cancer deaths | 5 | 19 | HR 0.26 (0.10-0.70), p=0.004 |
| PCSM, 10-y | 0.4% | 2.7% | n/a |
| PCSM, 14-y | 2.1% | 3.3% | n/a |
| Salvage ADT, 10-y | 7% | 13% | n/a |
| Salvage ADT, 14-y | 7% | 15% | HR 0.53 (0.38-0.75), p<0.001 |
| Non-prostate cancer deaths | 202 | 220 | HR 0.93 (0.77-1.13) |
Overall late grade ≥3 AEs did not differ (HR 1.08, 95% CI 0.84-1.40). With STAD: grade ≥3 metabolic/lab 20 vs 4, grade 3 sexual function 71 vs 38, grade ≥3 cardiac 26 vs 10 (each p<0.01). EPIC hormone and sexual domains dropped early with STAD and largely converged by 60 months; urinary and bowel domains were similar.
The case for short-term ADT in intermediate-risk disease was built by RTOG 9408 and the D'Amico Dana-Farber trial with conventional-dose RT, leaving open whether dose escalation would erase the benefit. This trial tests that directly and finds the disease-control benefit persists with dose-escalated RT, in line with EORTC 22991.
Disease-control gains are secondary endpoints, and the source states no multiplicity adjustment. MFS (p=0.042) is driven mostly by deaths, with only 40 vs 14 distant metastasis events. Brachytherapy-boost strata are small, and subgroup HRs for OS and MFS are not reported in source.
STAD buys fewer PSA failures, fewer metastases, less salvage ADT and fewer prostate cancer deaths, not a demonstrated survival gain, in a cohort where 422 of 446 deaths were non-prostate. The investigators could not identify a subgroup without benefit for PSA failure and distant metastasis, so omission still rests on competing risk and toxicity tolerance rather than trial-defined selection.
CONSORT flow
Completed phase III with mature f/u; primary OS not met, but durable secondary disease-control gains align with existing STAD use. Powered for HR 0.66, so a smaller OS effect is unresolved.
- Does a brachytherapy boost remove the need for STAD in intermediate-risk disease?
- Can genomic classifiers or MMAI select intermediate-risk pts who can omit STAD?
📚 Sources · 🐦 1 tweet · 📄 2 papers
NRG/RTOG 0815: Ph 3 RCT of dose-escalated RT ± 6 mo STAD in IR PCa (n=1493; median f/u 10.3 y)
— Rashid K. Sayyid (@RKSayyid) September 28, 2026
🚨OS: 10-y 70% (RT alone) vs 74% (RT+STAD); 14-y 53% vs 58% (HR 0.87; p=0.13)
🔹PSA failure: 25% vs 16% at 10 y; 34% vs 19% at 14 y (HR 0.60; p<0.001)
🔹MFS: 67% vs 72% at 10 y; 50%… pic.twitter.com/G5qfgfc9CI
Abstract
Abstract
Biomarkers in Post-operative Prostate Cancer (Spratt)
TL;DR5y MFS 95% vs 82% (HR 0.27) with apalutamide + salvage RT in PAM50 luminal B, flat in non-luminal B (NRG GU006).
Reported via UroToday →
MARCAPPOSEIDONRTOG 9601RTOG 0534NRG GU002NRG GU006BALANCESYMPHONY
Pre-RT PSA, not pathology, sorted hormone therapy benefit in POSEIDON: OS HR 1.14 at PSA ≤0.20 ng/mL vs 0.72 at 0.51-1.0 and 0.69 above 1.0, while adverse feature count showed no interaction (p = 0.40). That weakens GG4-5 or SVI alone as the reason to add ADT to early salvage RT.
In post-RP men with PSA 0.1-1.0 ng/mL and N0M0 disease, a PAM50 luminal B result supports considering systemic intensification with salvage RT; non-luminal B showed no bPFS or MFS separation, and none of this extends to N+/M+ recurrence. The longer read
Pre-RT PSA, not pathology, sorted hormone therapy benefit in POSEIDON: OS HR 1.14 at PSA ≤0.20 ng/mL vs 0.72 at 0.51-1.0 and 0.69 above 1.0, while adverse feature count showed no interaction (p = 0.40). That weakens GG4-5 or SVI alone as the reason to add ADT to early salvage RT.
The systemic read is agent and duration: 24 months of ADT did not beat 4-6 months for OS (HR 0.96), and NRG GU006 tested 6 months of apalutamide, not ADT. Luminal B selected for benefit (5-year MFS 95% vs 82%); non-luminal B did not (90% vs 89%).
14 details 3 trials watching
Trade-press write-up of a single ASTRO 2026 talk (Spratt) covering the POSEIDON IPD meta-analysis (6 randomized trials, 6,057 pts, median f/u 9.0 years), an adverse-feature IPD meta-analysis, NRG GU006 (BALANCE), retrospective PAM50 work in RTOG 0534, and an MMAI digital pathology biomarker in NRG/RTOG 9601 and 0534.
NRG GU006: post-radical prostatectomy, PSA 0.1-1.0 ng/mL, N0M0, PAM50 subtyped before randomization. RTOG 0534: post-radical prostatectomy, PSA 0.1-2.0 ng/mL, N0M0.
GU006: blinded 1:1 randomization to salvage RT + 6 months of apalutamide vs RT + 6 months of placebo. RTOG 0534 arms included RT alone and RT with 6 months of ADT. POSEIDON compared short-term ADT of 4-6 months with long-term ADT of 24 months.
RT dose, fractionation and target volume for the reported trials are not stated in source. The planned SYMPHONY program tests the RT questions directly: 5-fraction vs conventional 20-33 fraction prostate bed SBRT, reduced vs normal dose, and added elective nodal RT.
Effect sizes are in the tables above. The pattern across datasets: hormone therapy benefit tracks pre-RT PSA above 0.50 ng/mL and PAM50 luminal B, and does not track adverse pathologic feature count.
| Pre-RT PSA (ng/mL) | OS HR (95% CI) | p |
|---|---|---|
| ≤0.20 | 1.14 (0.83-1.57) | 0.42 |
| 0.21-0.50 | 0.94 (0.74-1.19) | 0.70 |
| 0.51-1.0 | 0.72 (0.54-0.96) | 0.02 |
| >1.0 | 0.69 (0.48-0.98) | 0.03 |
| Endpoint | Luminal B: apalutamide vs placebo | Luminal B HR | Non-luminal B: apalutamide vs placebo | Non-luminal B HR |
|---|---|---|---|---|
| 5-year bPFS | 72% vs 54% | 0.45 (95% CI 0.24-0.86; p = 0.0062) | 70% vs 71% | 0.95 (80% CI 0.65-1.41; p = 0.44) |
| 5-year MFS | 95% vs 82% | 0.27 (95% CI 0.07-0.95; p = 0.029) | 90% vs 89% | 1.06 (95% CI 0.41-2.78; p = 0.90) |
| Sub-study | Question | Planned per arm | Planned overall |
|---|---|---|---|
| SYMPHONY-PRESTO | Prostate bed SBRT: conventional 20-33 fraction vs 5-fraction | 474 | 948 |
| SYMPHONY-ADAGIO | Normal-dose vs reduced dose RT | 474 | 948 |
| SYMPHONY-CRESCENDO | Prostate bed RT alone vs added elective nodal RT | 435 | 870 |
| SYMPHONY-FULL-SCORE | MDT vs added prostate-bed/nodal treatment in N+/M+ | 240 | 480 |
The talk frames PAM50 against Decipher, which the speaker's figure places at Simon level 1B via prospective-retrospective validation in randomized cohorts including RTOG 9601 and RTOG 0534. PAM50 is presented as a step past that, a level 1A predictive biomarker, because NRG GU006 stratified on it prospectively.
The RTOG 0534 PAM50 analysis is post-hoc and only one of three luminal B comparisons reached p = 0.004; the other two were p=0.10 and p = 0.16. MMAI figures are approximate curve reads. The write-up does not say how N0M0 was staged.
The case for intensification in luminal B is better supported than the case for omission in non-luminal B: the non-luminal B MFS estimate (HR 1.06, 95% CI 0.41-2.78) cannot exclude either benefit or harm. GU006 tested apalutamide, so it does not by itself answer whether PAM50 selects for ADT.
- Does PAM50 luminal B predict benefit from ADT, not only apalutamide, with salvage RT?
- Can non-luminal B pts safely omit systemic therapy with salvage RT?
- Does 5-fraction prostate bed SBRT match conventional fractionation after prostatectomy? recruiting Post-prostatectomy Radiation Therapy--Moderate Versus Ultra-hypofractionated (Also Known as Stereotactic Body Radiation Therapy [SBRT]) Phase 2n=136 · primary completion 2026-11 · randomized ultra- vs moderate hypofx post-RP, 2y QoLrecruiting Salvage Stereotactic Body Radiotherapy of the Prostate Bed for Biochemical Recurrence After Radical Prostatectomy. Phase NAn=284 · primary completion 2029-02 · randomized phase II/III salvage SBRT vs SOC RTn=206 · primary completion 2031-09 · phase 3: 5-fx bed SBRT vs mild hypofx, QoL non-inferiority
📚 Sources · 📄 1 paper
Abstract
LUNAR vs SATURN
ForM1 oligorecurrent PCa post-RP
TL;DRMedian time to progression 19.4 mo SBRT + RLT vs 21.7 mo SBRT + AAT vs 6.0 mo SBRT alone in M1 oligorecurrent PCa post-RP.
SBRT is the constant across all three groups, so the read is which systemic partner: every SBRT-alone pt progressed (18/18) at a median 6.0 mo. PSADT, not the partner, was the independent euPFS predictor (HR 0.87 per month, p=0.018). SBRT dose, fractionation and target volume are not reported in source.
In M1 oligorecurrent PCa post-RP headed for SBRT, this frames 177Lu-PNT2002 as a candidate alternative partner to 6 mo AAT with a numerically lower grade ≥3 AE rate; it does not establish equivalence and does not extend to pts without prior RP. The longer read
SBRT is the constant across all three groups, so the read is which systemic partner: every SBRT-alone pt progressed (18/18) at a median 6.0 mo. PSADT, not the partner, was the independent euPFS predictor (HR 0.87 per month, p=0.018). SBRT dose, fractionation and target volume are not reported in source.
The systemic question is 177Lu-PNT2002 vs 6 mo AAT alongside SBRT: adjusted euPFS HR 1.39 (95% CI 0.56-3.45), p=0.47, too wide to call equivalent. Grade ≥3 AEs were 10% (2) vs 20% (5), p=0.357, with lymphopenia on RLT and rash / hypertension and hepatic toxicity on AAT.
| Arm | N | Median time to progression | Progression rate |
|---|---|---|---|
| SBRT alone | 18 | 6.0 mo (IQR 4.9-11.9) | 100% (18/18) |
| SBRT + RLT | 20 | 19.4 mo (IQR 12.7-28.4) | 60% (12/20) |
| SBRT + AAT | 25 | 21.7 mo (IQR 9.1-33.0) | 68% (17/25) |
+2 more figures
| Covariate | HR (95% CI) | p |
|---|---|---|
| PSADT (month) | 0.87 (0.77 - 0.98) | 0.018 |
| PSA baseline | 1.02 (0.95 - 1.11) | 0.533 |
| Age (years) | 0.95 (0.88 - 1.03) | 0.213 |
| Prior hormone therapy | 1.31 (0.58 - 2.98) | 0.519 |
| Prior MDT | 1.34 (0.49 - 3.63) | 0.568 |
10 details
Cross-trial IPD comparison of LUNAR and SATURN, n=63, with an IPTW-adjusted primary comparison of RLT vs AAT. Not a randomised comparison between the two systemic partners. Median follow-up not reported in source.
M1 oligorecurrent PCa post-RP. Prior hormone therapy and prior MDT were both permitted, since each appears as a yes/no covariate in the model. Lesion number, imaging modality and other eligibility detail not reported in source.
SBRT + 177Lu-PNT2002 RLT (LUNAR, n=20) vs SBRT + 6 mo androgen annihilation therapy (SATURN, n=25), with an SBRT alone group (n=18). RLT activity, cycle number and AAT drug components not reported in source.
Eugonadal progression-free survival (euPFS), reported as median time to progression and progression rate per group, plus an IPTW-weighted multivariable Cox model. The euPFS event definition is not reported in source.
RLT vs AAT adjusted HR 1.39 (95% CI 0.56-3.45), p=0.47. PSADT was independently associated with euPFS, HR 0.87 per month (95% CI 0.77-0.98; p=0.018), with no PSADT difference among groups.
Grade ≥3 AEs 10% (2) with RLT vs 20% (5) with AAT, p=0.357. RLT events were lymphopenia, 2 (10%). AAT events were rash / hypertension 4 (16%) and hepatic toxicity 1 (4%).
ORIOLE and STOMP tested MDT against observation in oligometastatic PCa, and EXTEND and RADIOSA tested adding hormone therapy to MDT. This analysis asks the next question, whether a radioligand can stand in for the hormonal partner, without a randomised answer.
SBRT dose, fractionation and target volume are not reported, so RT comparability across the two trials cannot be checked. The euPFS definition, follow-up and staging imaging are also absent, and the KM p < 0.0001 is not tied to a named comparison.
The clear separation is SBRT alone vs either intensified group, not RLT vs AAT. The RLT vs AAT estimate is uninformative on equivalence. The PSADT association is prognostic only: no treatment-by-PSADT interaction is reported in source.
Non-randomised cross-trial comparison of 20 vs 25 pts; IPTW adjusts measured covariates only. The interval around the RLT vs AAT estimate cannot support a claim of similarity.
- Randomised comparison of SBRT + RLT vs SBRT + short-course AAT in oligorecurrent PCa
- Does PSADT select pts for SBRT alone vs intensified MDT?
- SBRT dose and target volume comparability between LUNAR and SATURN
📚 Sources · 🐦 1 tweet
LUNAR vs SATURN: cross-trial IPD comparison of SBRT + 177Lu-PNT2002 RLT vs SBRT + 6 mo androgen annhilation therapy (AAT) the in M1 oligorecurrent PCa post-RP (n=63)
— Rashid K. Sayyid (@RKSayyid) September 30, 2026
🔹Median time to progression: 19.4 mo RLT vs 21.7 mo AAT vs 6.0 mo SBRT alone
🔹Adjusted euPFS similar w/ RLT vs… pic.twitter.com/bn7sstnbvy
MARCAP Consortium
ForLocalized prostate cancer, NCCN intermediate to high risk, definitive RT
TL;DRIPD meta-analysis, 10,853 pts: ADT added to RT improved MFS HR 0.83 and OS HR 0.86; dose escalation improved bRFS only.
Reported via UroToday →
The dose-invariance result is the load-bearing one: ADT's benefit was identical at ≥74 Gy and <74 Gy (both HR 0.83), so escalating dose does not buy out the ADT decision. Adjuvant prolongation carries the benefit (MFS HR 0.84), neoadjuvant prolongation does not (HR 0.95), which moves sequencing, not just duration.
In NCCN intermediate- and high-risk localized prostate cancer receiving definitive RT, this supports adding and prolonging ADT on the adjuvant side rather than substituting dose escalation; it does not address node-positive or post-prostatectomy salvage settings. The longer read
ADT's benefit was identical at ≥74 Gy and <74 Gy (HR 0.83 both), so escalation does not buy out the hormone decision, and HEAT showed escalation to 79.2 Gy improved biochemical RFS but not MFS or OS. Adjuvant prolongation carries the survival benefit; neoadjuvant prolongation (HR 0.95) does not.
The duration and sequencing read: extending adjuvant ADT from 4-6 to 18-36 months gave MFS HR 0.84 and OS HR 0.85, while extending neoadjuvant ADT from 3-4 to 6-9 months gave HR 0.95 for both. Relative benefit held across NCCN groups, so risk stratification changes NNT, not effect size.
9 details 5 trials watching
Individual patient data meta-analysis from the MARCAP Consortium, 12 eligible trials, 10,853 patients, median follow-up 11.4 years (IQR 9.0-15.0). Three intensification questions analyzed separately: ADT use, neoadjuvant ADT prolongation, adjuvant ADT prolongation.
Localized prostate cancer treated with definitive radiotherapy, stratified by NCCN prognostic risk group. The RT ± ADT comparison ran 2,557 control vs 2,579 experimental (NCCN high 32.6% vs 32.8%, intermediate 47.6% vs 48.7%); the adjuvant-prolongation comparison was high-risk enriched at 71.5% vs 71.1% NCCN high across 1,900 vs 1,874 pts.
Dose was analyzed as a binary ≥74 Gy vs <74 Gy split, with the companion HEAT analysis using 64 to <74 Gy vs ≥74 Gy and escalation up to 79.2 Gy. Brachytherapy boost is discussed as an escalation route alongside external-beam dose.
ADT addition improved MFS HR 0.83 (0.77-0.89) and OS HR 0.86 (0.80-0.92). Adjuvant prolongation improved MFS HR 0.84 (0.78-0.91) and OS HR 0.85 (0.78-0.94); neoadjuvant prolongation did neither (MFS HR 0.95, OS HR 0.95). 10-yr MFS 61% (59-63) with ADT vs 52% (50-54) without; 10-yr OS 65% (63-67) vs 57% (55-59).
| Intervention | Intermediate risk | High risk |
|---|---|---|
| ADT addition | 18.0 | 8.4 |
| Adjuvant ADT prolongation | 16.1 | 10.4 |
The 2022 HEAT network meta-analysis (13 trials, 11,862 pts) found dose escalation improved biochemical RFS but not MFS or OS, and named high-dose RT plus long-term ADT the best strategy. PROG 05/09 and GETUG-18 are invoked to explain the gap: a 21% 5-year biochemical benefit in low risk where metastasis is rare, versus 3% in high risk where it is not.
The pooled trials span 30+ years of practice, so the RT technique behind the <74 Gy stratum is not the technique a reader delivers today. The stated optimal durations (closer to 12 months high risk, 24+ months very high risk) come from DHARMA, accepted but unpublished, so that specific number is not yet auditable.
The framing claim is that dose escalation and ADT are not interchangeable levers: escalation buys biochemical control, ADT buys metastasis-free and overall survival, and the two do not substitute. The dogma that dose escalation obviates ADT is named as widely repeated and never demonstrated.
IPD meta-analysis of randomised trials, large N, long f/u. Reinforces ADT intensification over dose escalation; no new randomisation, and duration guidance rests on unpublished DHARMA.
- Optimal adjuvant ADT duration by prognostic risk group active A Study of Shorter Course Hormone Therapy and Radiation for High-risk Prostate Cancer Phase 2n=50 · primary completion 2026-10 · shorter-course ADT with brachy + hypofx EBRT, high-riskrecruiting Artificial Intelligence Driven Personalisation of Radiotherapy and Concomitant Androgen Deprivation Therapy for Prostate Cancer Patients (the HypoPro Trial) Phase 2n=30 · primary completion 2026-10 · MMAI classifier individualises ADT duration, high-risk
- Does dose escalation change ADT benefit with modern brachytherapy boost active Comparative Study of Radiotherapy Treatments to Treat High Risk Prostate Cancer Patients Phase 3n=307 · primary completion 2028-12 · phase 3 HDR brachy boost vs dose-escalated RT + ADTrecruiting Androgen Suppression Combined With Nodal Irradiation and Dose Escalated Prostate Treatment Phase 3n=710 · primary completion 2032-10 · phase 3 SBRT vs EBRT + brachy boost, all on ADTrecruiting PRO-BOOST-LC: Whole-Gland Boost Strategies Versus SBRT Monotherapy in PSMA-Staged Localized and Locally Advanced Prostate Cancer Phase 2/3n=1000 · primary completion 2033-12 · randomised brachy or SBRT boost vs SBRT alone, + ADT
- Whether intermediate-risk subsets warrant long-term ADT
📚 Sources · 📄 1 paper
Abstract
STELLAR NCT02533271
ForDistal/middle-third rectal adeno, cT3-4 and/or cN+, age 18-70, ECOG 0-1
64.5% v 62.3%
HR 0.883, 1-sided 95% CI to 1.11, P<.001 for noninferiority
TL;DR3yr DFS 64.5% v 62.3% (HR 0.883, NI margin 1.43, P<.001 NI): 5x5Gy then CAPOX non-inferior to 50Gy/25f CRT in LARC.
Every pt got IMRT, unlike RAPIDO, Polish II or PRODIGE 23, and 3yr LRR was 8.4% v 11.0% with 25Gy/5fx to a full elective pelvic CTV, so the short-course arm did not trade local control for convenience. Compliance was the mechanism: 100% completed 5x5Gy with no dose reduction. This supports offering 5x5Gy over 50Gy/25f when the systemic phase is the priority.
In cT3-4 or node-positive mid/low rectal cancer where getting full-dose neoadjuvant chemo delivered is the constraint, this supports 25Gy/5fx followed by CAPOX instead of long-course chemoradiation; it does not extend to upper rectal tumors or pts over 70, both excluded. The longer read
All pts received IMRT with full elective pelvic CTV coverage, unlike RAPIDO, Polish II or PRODIGE 23, and 3yr LRR was 8.4% v 11.0% with 25Gy/5fx. Every TNT pt completed all five fractions with no dose reduction. This supports 5x5Gy over 50Gy/25f without conceding local control.
Moving CAPOX preoperatively raised full-dose preop completion of the systemic phase but cut it the other way on delivery overall, 74.8% v 93.2%. Four preop cycles produced no distant-metastasis benefit (3yr DM 22.8% v 24.7%), unlike the heavier RAPIDO and PRODIGE 23 programs, so cycle number may matter for distant control.
TME at 6-8 weeks after short-course RT plus chemotherapy gave R0 resection in 91.5% v 87.8% (P=.189) and grade III+ complications of 14.0% v 15.7% (P=.625), so the compressed schedule did not degrade the operation. Sustained cCR was higher after TNT (21.8% v 12.3% for pCR plus sustained cCR), enlarging the nonoperative-management pool to 9.4% v 3.4%.
12 details 5 trials watching
Multicenter open-label randomized phase III noninferiority trial, 16 hospitals across 11 provinces of China, accrual August 2015 to August 2018, N=599 randomly assigned 1:1 (TNT 302, CRT 297). Stratified by tumor location, clinical stage and MRF status; median follow-up 35.0 months (range 8.3-63.9).
Age 18-70, ECOG 0-1, rectal adenocarcinoma of the distal or middle third (0-10cm from anal verge), cT3-4 and/or node-positive, no distant metastases, no prior anticancer treatment. Arms were balanced: cT4 15.9% v 12.8%, MRF involvement 56.3% v 56.2%, clinical stage III 85.8% v 83.5%.
TNT arm received 25Gy in 5 fractions over one week; CRT arm 50Gy in 25 fractions over 5 weeks with concurrent capecitabine 825mg/m2 twice daily. All patients received IMRT, a departure from RAPIDO, Polish II and PRODIGE 23. CTV covered mesorectum, presacral space, internal iliac, obturator nodes and ischiorectal fossa; superior border at the sacral promontory, inferior 2-3cm distal to the tumor, external iliacs added only for cT4b; CTV-to-PTV expansion 0.5-1.0cm.
TNT arm: 4 cycles CAPOX (oxaliplatin 130mg/m2 day 1, capecitabine 1,000mg/m2 twice daily days 1-14) starting 7-14 days after radiotherapy, then TME, then 2 further cycles. CRT arm: concurrent capecitabine during radiotherapy, then TME, then 6 cycles CAPOX. Total mesorectal excision was scheduled 6-8 weeks after preoperative treatment in both arms; a watch-and-wait pathway was permitted for clinical complete responders.
Primary: 3-year disease-free survival, noninferiority claimed if the upper bound of the 95% CI of the HR was at or below 1.43 (an 11% absolute margin against an assumed 65% CRT rate). Secondary endpoints were overall survival, metastasis-free survival, locoregional recurrence and surgical complications. Target accrual 600 with at least 194 DFS events for 80% power at one-sided alpha 0.05.
Acute grade III-V toxicity during preoperative treatment was 26.5% with TNT versus 12.6% with CRT (P<.001), driven almost entirely by hematologic events (grade 3-4 15.8% v 2.0%, P<.001) rather than by anything the radiotherapy added. Radiotherapy delivery itself was cleaner in the short-course arm, with no dose reductions at all, and grade III+ surgical complications were comparable (14.0% v 15.7%, P=.625). Grade III-IV toxicity during adjuvant chemotherapy ran lower after TNT (3.3% v 11.8%, P=.003).
STELLAR is the third randomized trial of short-course radiotherapy plus neoadjuvant chemotherapy against long-course CRT, after Polish II and RAPIDO, with PRODIGE 23 addressing the adjacent question of chemotherapy sequencing around long-course CRT. Its 3-year LRR of 8.4% with TNT sits alongside RAPIDO and PRODIGE 23 (4%-8.3%) and well below Polish II (21%-22%), which enrolled a heavier fixed cT3/cT4 population. Unlike RAPIDO and PRODIGE 23, STELLAR showed no reduction in distant metastasis (3-year DM 22.8% v 24.7%), and its OS advantage mirrors the early Polish II signal that later disappeared at 8 years.
The 11% noninferiority margin is wide, and the authors concede in retrospect that a narrower margin or larger sample would have been defensible given how close the arms proved. Distant metastasis, the endpoint short-course TNT was designed to move, did not separate at all (22.8% v 24.7%), which weakens the mechanistic case for the OS difference. Adjuvant chemotherapy completion also differed between arms (60.0% v 48.3%, P=.009), so postoperative treatment intensity is not held constant across the comparison.
The defensible read is the primary endpoint: 25Gy in 5 fractions followed by CAPOX delivers the same 3-year DFS and the same locoregional control as 50Gy in 25 fractions, in one week of radiotherapy instead of five. The 11.4-point OS separation is the number that will be quoted and the one least supported, since neither MFS nor LRR moved and the same pattern in Polish II did not survive longer follow-up. What transfers most reliably is the technique: full elective pelvic coverage with IMRT at 5x5Gy, delivered without a single dose reduction.
| Endpoint (3yr) | TNT | CRT | Effect size |
|---|---|---|---|
| DFS (1°) | 64.5% (58.3-70.7) | 62.3% (56.1-68.5) | HR 0.883, 1-sided 95% CI to 1.11, P<.001 NI |
| OS | 86.5% (82.1-90.8) | 75.1% (69.4-80.8) | HR 0.67 (0.46-0.97), P=.033 |
| MFS | 77.1% (71.7-82.6) | 75.3% (70.0-80.7) | HR 0.88 (0.63-1.24), P=.475 |
| LRR | 8.4% (4.6-12.2) | 11.0% (6.5-15.5) | HR 0.80 (0.45-1.44), P=.461 |
| Subgroup | DFS HR (95% CI), P | OS HR (95% CI), P |
|---|---|---|
| cT4 | 0.621 (0.328 to 1.177), .144 | 0.362 (0.152 to 0.859), .021 |
| Distance to anal verge ≤5cm | 0.706 (0.485 to 1.028), .070 | 0.540 (0.318 to 0.916), .022 |
| cT2-3 | 0.916 (0.674 to 1.245), .575 | 0.752 (0.493 to 1.149), .187 |
| Distance >5cm | 1.120 (0.744 to 1.687), .587 | 0.808 (0.468 to 1.394), .443 |
CONSORT flow
Prespecified noninferiority met on 3yr DFS with adequate accrual, but open-label, 35mo follow-up only, and the OS gain is a secondary endpoint unsupported by MFS or LRR.
- Does the 3yr OS advantage survive 5-10 year follow-up active Short RT Versus RCT,Followed by Chemo.and Organ Preservation for Interm and High-risk Rectal Cancer Patients Phase 3n=702 · primary completion 2023-09 · ACO/ARO/AIO-18.1: 5x5Gy vs 54Gy CRT, n=702
- Optimal number of preoperative chemotherapy cycles with short-course RT n=42 · primary completion 2026-11 · 5x5Gy then 9 cycles mFOLFOX6, CR rate 1° EPactive Preoperative Sequential Short-course Radiation Therapy and FOLFOX for Locally Advanced Rectal Cancer Phase 2n=364 · primary completion 2028-12 · SCRT then 4 cycles FOLFOX vs CRT, n=364n=608 · primary completion 2029-12 · phase 3 SCRT+CAPOX vs SCRT+CAPOXIRI, n=608
- Late toxicity and quality of life, not yet reported recruiting Short Course Radiation Therapy and Combination Chemotherapy for the Treatment of Stage II-III Rectal Cancer Phase 1n=25 · primary completion 2026-10 · SCRT then chemo with QoL assessment as endpoint
📚 Sources · 📄 1 paper
Abstract
TNTCRT NCT03177382
ForHigh-risk stage II/III rectal cancer, cT4/cN2/MRF+/EMVI, age ≤70
HR 0.674
95% CI 0.489-0.929, P=.016; 3-year DFS 74.8% v 66.0%
TL;DR3-year DFS 74.8% v 66.0%, HR 0.674, for doublet CAPOX bracketing long-course chemoradiation vs conventional nCRT in high-risk LARC.
RT is fixed in both arms, so the RT read is what intensified chemo does around it: locoregional failure stayed 6.03% v 6.19% and the DFS gain is distant. The pCR jump (26.37% v 9.80%) is the lever for organ-preservation selection. LCRT dose and fractionation are not reported in source text.
In MRI-defined high-risk stage II/III rectal cancer at or under age 70, this supports doublet CAPOX bracketing long-course chemoradiation over nCRT plus adjuvant chemo; it does not extend to pts over 70 or to short-course RT based TNT. The longer read
RT is identical in both arms, so the read is what intensified chemo does around a fixed LCRT backbone: locoregional failure held at 6.03% v 6.19%, and the DFS gain is distant. Dose, fractionation and target volume are not reported in source text.
The same doublet moved from postoperative to preoperative, with oxaliplatin added concurrent to RT. Grade ≥3 toxicity front-loads into the neoadjuvant phase (27.59% v 8.56%) but whole-course severe toxicity is comparable, so the decision this moves is sequencing, not drug choice.
Intensification did not degrade operability: major postoperative complications 3.98% v 2.94%, and roughly 87% v 90% reached total mesorectal excision. pCR 26.37% v 9.80% widens the pool for a nonoperative discussion, though watch-and-wait was not tested here.
8 details 5 trials watching
Multicenter randomized phase III, N=458, accrual June 6, 2017 to December 27, 2023, median follow-up 51 months. Primary endpoint: DFS. Blinding is not reported and the two regimens are not maskable.
Stage II/III LARC aged 18 to 70 with at least one MRI high-risk feature (cT4a-b, cN2, mesorectal fascia involvement, or cT3c-d with EMVI). Baseline burden was heavy: cT4 47.82%, cN2 75.98%, threatened MRF 70.96%, EMVI 54.80%.
Experimental: one cycle induction CAPOX, LCRT with two cycles concurrent CAPOX, three cycles consolidation CAPOX, then surgery, so all cytotoxic therapy precedes resection. Control: LCRT with concurrent capecitabine, surgery, then six cycles adjuvant CAPOX at 4 to 8 weeks.
Long-course RT in both arms, so RT is the fixed element and the randomized variable is chemotherapy timing plus oxaliplatin exposure. Dose, fractionation, technique and target volume are not reported in the source text, nor is whether concurrent doublet chemotherapy altered RT delivery.
Primary: DFS. Secondary results reported here: MFS, pCR, locoregional failure, overall survival, grade ≥3 adverse events, major postoperative complications.
Primary endpoint met, with MFS moving in step and pCR strongly favoring the experimental arm, while locoregional failure and 3-year OS did not separate. See the efficacy table.
| Endpoint | Doublet-LC TNT | nCRT | Effect size |
|---|---|---|---|
| 3-year DFS (primary) | 74.8% | 66.0% | HR 0.674 (0.489-0.929), P=.016 |
| 3-year MFS | 77.7% | 67.6% | HR 0.655 (0.469-0.915), P=.013 |
| pCR | 26.37% | 9.80% | P<.001 |
| Locoregional failure | 6.03% | 6.19% | P=.943 |
| 3-year OS | 90.2% | 87.5% | P=.167 |
| Measure | Doublet-LC TNT | nCRT | P |
|---|---|---|---|
| Grade ≥3 AE, neoadjuvant phase | 27.59% | 8.56% | <.001 |
| Severe toxicity, entire course | 28.02% | 24.32% | .371 |
| Major postoperative complications | 3.98% | 2.94% | .567 |
Grade ≥3 toxicity front-loads into the neoadjuvant phase with the doublet, but severe toxicity across the entire treatment course and major postoperative complications were comparable. Total mesorectal excision was performed in approximately 87% (TNT) and 90% (nCRT).
Sits alongside RAPIDO, PRODIGE-23 and STELLAR, the trials that established TNT, but keeps long-course chemoradiation as the RT backbone rather than short-course RT. Unlike RAPIDO's longer follow-up, intensification here did not increase locoregional failure.
Control-arm adjuvant CAPOX delivery and completion are not reported, and a TNT advantage partly reflects therapy planned but not received when postoperative chemotherapy under-delivers. Accrual spanned 2017 to 2023, during which TNT became routine, so control-arm contemporaneity drifted. Age was capped at 70.
The gain is distant, not local: MFS tracks DFS while locoregional failure is flat and low in both arms, which says long-course chemoradiation with a fluoropyrimidine is near its local ceiling in this population and the remaining room is systemic. The pCR tripling is the organ-preservation lever, but pCR is a resection-specimen endpoint and this trial did not test nonoperative management.
CONSORT flow
Randomized phase III, primary DFS met at 51mo median f/u, but TNT is already established by RAPIDO, PRODIGE-23, STELLAR; this refines regimen rather than the paradigm.
- Doublet long-course TNT versus short-course RT based TNT head to head active Short-Course Radiotherapy Followed by Neoadjuvant Chemotherapy and Camrelizumab in Locally Advanced Rectal Cancer (UNION) Phase 3n=231 · primary completion 2023-03 · randomised SCRT+CAPOX vs long-course CRT then CAPOX, pCRrecruiting Optimizing Immunotherapy Combined With Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer Phase 2n=228 · primary completion 2027-06 · SCRT vs long-course CRT with CAPOX in one TNT trialn=608 · primary completion 2029-12 · SCRT plus CAPOX arm, doublet vs triplet consolidation
- Benefit-risk of this intensified regimen above age 70 not yet CGA Guided Ultrafractionated RT and Systemic Treatment in Elderly or Frail Patients with Inoperable Localized CRC Phase 2n=124 · primary completion 2027-11 · CGA-guided RT plus systemic tx, enrols age 70 and over
- Whether the higher pCR converts to durable organ preservation recruiting Organ Preservation First Strategy and Intentional Watch and Wait for MRI Defined Low-risk Rectal Cancer Phase NAn=96 · primary completion 2025-09 · organ-preservation rate after IMRT plus consolidation CapeOX
📚 Sources · 📄 2 papers
Abstract
SIB-CRT vs Standard CRT for LARC (NCT02195141) NCT02195141
ForStage II/III rectal adenocarcinoma, neoadjuvant chemoRT candidates
15.2% vs 18.4%
P=0.695, primary endpoint not met
TL;DR9yr LC 87.1% vs 70.1% (HR 0.40, P=0.038) and OS 74.3% vs 48.9% (HR 0.43) favoring SIB dose escalation.
The boost was 56 Gy to PGTV and 60 Gy to involved lateral nodes on a 50 Gy/25 fx pelvic base, a deliverable prescription with acute G3 toxicity 14.5% vs 19.6%. LC 87.1% vs 70.1% is the mechanistically coherent signal; the OS and MFS separation on 106 pts is not, and gates any move to boost outside a trial.
In stage II/III LARC where perioperative chemotherapy is not planned or not tolerated, this supports testing an integrated boost to gross disease and involved lateral nodes; it gives no read on pts receiving modern TNT, where the subgroup showed no added benefit. The longer read
The prescription is deliverable and specified: 56 Gy to PGTV, 60 Gy to involved lateral nodes, on a 50 Gy/25 fx pelvic base, with acute G3 toxicity 14.5% vs 19.6% and no late toxicity reported. LC 87.1% vs 70.1% is the endpoint a boost can own; treat the OS and MFS separation as hypothesis-generating for a boost trial, not license to escalate off-protocol.
The benefit was confined to pts who did not receive perioperative chemotherapy (9yr DFS 70.8%, HR 0.343, P=.014), with no additional benefit in those who did, and chemo receipt was not randomized. Read as a signal about RT dose in chemotherapy-ineligible pts rather than any argument against systemic intensification.
9 details 5 trials watching
Prospective randomized phase 2, 1:1, N=106 (55 SIB-CRT, 51 CRT), accrued August 2013 to February 2015. Median follow-up 116.6 months, which is the study's real asset.
Stage II/III rectal adenocarcinoma. Radical surgery planned 6 to 8 weeks after chemoradiotherapy. Perioperative chemotherapy was not randomized, and its receipt defines the subgroup that carries the result.
Both arms received 50 Gy/25 fx to the pelvis. The experimental arm added a simultaneous integrated boost of 56 Gy to PGTV and 60 Gy to lateral metastatic nodes where present, so the escalation targets gross primary and involved lateral nodes rather than the elective volume.
Primary: pCR rate. Secondary: DFS, OS, MFS, LC, CSS and toxicity. Every result the conclusion rests on is secondary.
Acute grade 3 toxicity 14.5% (SIB-CRT) vs 19.6% (CRT), primarily radiation dermatitis. Late toxicity is not reported in the source, which matters most for a boost delivered near bowel and for pts followed nearly a decade.
Neoadjuvant dose escalation in LARC has repeatedly raised pCR without translating to survival; this trial reports the mirror image, a null pCR (15.2% vs 18.4%) with survival separation. The result also sits against the TNT era, where systemic intensification rather than RT dose is the current lever, and the chemo-receiving subgroup here showed no additional benefit.
The survival claim is a secondary-endpoint result from 51 vs 55 pts, so a handful of events moves each HR, and no confidence intervals are reported in the source. The driving subgroup is defined by non-randomized chemotherapy receipt, and the higher rate of curative treatment in the SIB arm (89.1% vs 78.4%) is itself a plausible route to the OS difference independent of dose.
A pelvic boost has a defensible mechanism for LC 87.1% vs 70.1% and essentially none for MFS 70.8% vs 47.2%. The authors attribute the distant benefit to intensified control of micrometastases; the simpler reading is that a small trial with a large curative-treatment imbalance produced correlated secondary endpoints.
| Endpoint | SIB-CRT | CRT | Effect |
|---|---|---|---|
| DFS | 70.8% | 47.4% | HR 0.46, P=0.013 |
| OS | 74.3% | 48.9% | HR 0.43, P=0.008 |
| MFS | 70.8% | 47.2% | HR 0.48, P=0.017 |
| LC | 87.1% | 70.1% | HR 0.40, P=0.038 |
| CSS | 77.4% | 57.2% | P=0.027 |
| pCR | 15.2% | 18.4% | P=0.695 |
CONSORT flow
Randomized phase 2, N=106, primary endpoint (pCR) missed; survival gains are secondary endpoints with wide implied precision and a non-randomized chemo subgroup driving them.
- Does SIB add anything on a total neoadjuvant therapy backbone n=37 · primary completion 2026-05 · SIB-SCRT plus CAPOX and PD-1 in high-risk LARCn=156 · primary completion 2026-12 · randomises GTV SIB 58.75 vs 50 Gy/25f for CRrecruiting THeragnostic Utilities for Neoplastic DisEases of the Rectum by MRI Guided Radiotherapy Phase NAn=179 · primary completion 2027-01 · RT dose escalation gated by early regression index
- Late GI and GU toxicity of the boost beyond 9 years active Safety of a Boost (CXB or EBRT) in Combination With Neoadjuvant Chemoradiotherapy for Early Rectal Adenocarcinoma Phase 3n=148 · primary completion 2023-06 · safety endpoint for CXB vs EBRT boost after nCRTrecruiting Standard Dose Versus High Dose of Radiotherapy in Rectal Preservation With Chemo-radiotherapy in Rectal Cancer Patients Phase 3n=162 · primary completion 2026-12 · 62 Gy vs 50.4 Gy phase 3, dose-escalation toxicity
- Whether the curative-treatment rate imbalance explains the OS gap
📚 Sources · 📄 1 paper
Abstract
POSEIDON
ForPost-RP prostate cancer receiving PORT, median pre-PORT PSA 0.3 ng/mL
HR 0.87
95% CI 0.76–1.01, p=0.06; not met
TL;DRIPD meta-analysis of 6 RCTs: adding HT to PORT did not improve OS (HR 0.87, 95% CI 0.76–1.01, p=0.06); benefit confined to pre-PORT PSA >0.5 ng/mL.
MFS improved (HR 0.79) but never cleared the ICECaP 0.81 surrogate threshold at any pre-PORT PSA, so the bPFS/MFS gains behind GETUG-AFU 16 and RTOG 0534 were not expected to translate to OS. Duration showed no interaction (p=0.17); long-term HT OS benefit on splines appears only at PSA ≥1.6 ng/mL, above most modern early salvage.
In PET-negative BCR after RP heading to early salvage PORT at PSA ≤0.5 ng/mL, this questions adding HT for survival; above 0.5 ng/mL it supports HT, with no OS evidence favoring 24 over 4–6 mo; it does not extend to PSMA PET-positive nodal disease. The longer read
For early salvage PORT at pre-PORT PSA ≤0.5 ng/mL, HT added no OS benefit, so RT alone is a defensible default in PET-negative BCR. Above 0.5 ng/mL the OS HR falls to 0.72 to 0.69; long-term HT OS benefit on splines appears only at PSA ≥1.6 ng/mL.
Duration showed no OS interaction (p=0.17) and prolonging short to long course did not improve OS (HR 0.89), so 4–6 mo carries the supported benefit. MFS gains did not clear the ICECaP threshold, weakening MFS as a basis for systemic intensification with PORT.
14 details 5 trials watching
IPD meta-analysis of six randomised phase 3 trials via the MARCAP consortium (PROSPERO CRD42019134376), one-stage Cox stratified by trial. 6057 pts, median follow-up 9.0y (IQR 7.2–10.7).
Men receiving PORT after radical prostatectomy for recurrent prostate cancer. Median pre-PORT PSA 0.3 ng/mL in the any-HT and short-term sets, 0.5 ng/mL in the long-term set. Race and ethnicity data not available.
Short-term HT 4–6 mo (GETUG-AFU 16, NRG/RTOG 0534, RADICALS-HD two-way and three-way), predominantly GnRH agonist. Long-term HT 24 mo (RADICALS three-way, RTOG 9601); RTOG 9601 used high-dose bicalutamide monotherapy.
Primary: overall survival. Secondary: MFS, event-free survival, biochemical recurrence; prespecified interaction tests for pre-PORT PSA and HT duration.
No OS benefit overall (HR 0.87, p=0.06) despite MFS gain (HR 0.79, p<0.001). OS benefit limited to pre-PORT PSA >0.5 ng/mL (interaction p=0.02), with NNT 22 at 0.51–1.00 and 12 at >1.00 ng/mL.
| Comparison | N | OS HR (95% CI) | MFS HR (95% CI) |
|---|---|---|---|
| Any HT + PORT vs PORT | 5026 | 0.87 (0.76–1.01), p=0.06 | 0.79 (0.70–0.89), p<0.001 |
| Short-term HT (4–6 mo) | 3938 | 0.93 (0.77–1.11) | 0.82 (0.71–0.95) |
| Long-term HT (24 mo) | 1088 | 0.79 (0.63–1.00), p=0.049 | 0.74 (0.60–0.91), p=0.004 |
| Short → long prolongation | 1523 | 0.89 (0.68–1.16), p=0.37 | 0.76 (0.61–0.95), p=0.02 |
| Pre-PORT PSA (ng/mL) | OS HR (95% CI) | 10y OS PORT vs PORT+HT | 10y NNT (death) |
|---|---|---|---|
| ≤0.20 | 1.14 (0.83–1.57) | 89.9% vs 87.4% | negative |
| 0.21–0.50 | 0.94 (0.74–1.19) | 84.9% vs 84.5% | negative |
| 0.51–1.00 | 0.72 (0.54–0.96) | 76.4% vs 80.9% | 22 |
| >1.00 | 0.69 (0.48–0.98) | 72.4% vs 80.5% | 12 |
GETUG-AFU 16 and RTOG 0534 established HT with salvage RT on biochemical endpoints; per the ASCO Post write-up only RTOG 9601, a late-salvage trial, had shown an OS benefit. POSEIDON pools these trials and finds the OS signal tracks pre-PORT PSA rather than HT duration.
Duration comparison is confounded: long-term HT trials enrolled higher-PSA, higher-risk pathology. The PSA interaction is model-dependent (continuous PSA: one-stage p=0.19, two-stage p=0.04) and no multiplicity correction was applied. RT dose and field detail not reported in source excerpt.
The trial-level MFS gains held but did not clear the ICECaP surrogate threshold, so the historical case for routine HT with low-PSA salvage rests on endpoints that do not predict OS here. Short-term HT may suffice where HT is used; NRG GU006 (PAM50, apalutamide) tests biomarker selection.
Pooled randomised IPD with prespecified OS primary not met, undercutting routine HT with low-PSA PORT. The PSA >0.5 benefit rests on subgroup interaction, not a primary comparison.
- Does PSMA PET staging change which pts benefit from HT with PORT?
- Can a genomic classifier outperform pre-PORT PSA for selecting HT?
- Does ARSI-based short-term HT change the OS read? active Radiation Therapy With or Without Apalutamide in Treating Patients With Recurrent Prostate Cancer, the BALANCE Trial Phase 2n=298 · primary completion 2025-03 · ph2 SRT ± apalutamide, placebo-controlled, post-RPn=586 · primary completion 2026-11 · ph3 apalutamide added to ADT + RT, pN+ post-RPactive Combined Apalutamide, Radiotherapy, and LHRH Agonist in Prostate Cancer Patients After Prostatectomy Phase 3n=490 · primary completion 2028-09 · ph3 apalutamide + SRT + LHRHa vs SRT + LHRHa post-RPactive A Study of Adding Apalutamide to Radiotherapy and LHRH Agonist in High-Risk Patients With Hormone-Sensitive Prostate Cancer Phase 3n=691 · primary completion 2029-08 · ph3 apalutamide + RT + LHRHa post-RP, PSMA-PET 1° EPrecruiting Treating Prostate Cancer That Has Come Back After Surgery With Apalutamide and Targeted Radiation Based on PET Imaging Phase 3n=804 · primary completion 2032-12 · ph3 apalutamide+abiraterone added to SRT + short ADT
📚 Sources · 📄 2 papers
Abstract
Consolidative TRT + Atezolizumab Maintenance in ES-SCLC NCT04462276
ForES-SCLC with ≥SD after carbo-etoposide-atezolizumab induction, unselected
6.7 vs 13.4 mo
HR 1.55 (95% CI 0.90-2.69), P = .34; primary end point not met
TL;DRPrimary EP missed: mOS 6.7 vs 13.4mo (HR 1.55, P=.34) with consolidative 30Gy/10fx; trial halted for fatal SAEs.
The failure is toxicity, not tumor control: PFS was identical (2.4 vs 2.6 mo) while fatal AEs hit 19.4% vs 3.0%, and TRT carried an AE HR of 2.47 (1.15-5.32). Dose was modest (30 Gy/10 fx, postinduction volumes, below OAR thresholds), so de-escalating the plan is not the obvious fix; baseline DLCO SB and radiation-induced lymphopenia are the selection levers.
In unselected ES-SCLC responding to chemoimmunotherapy, this argues against offering consolidative thoracic RT during atezolizumab maintenance off-trial, particularly with low baseline DLCO; it says nothing about limited-stage disease or thoracic RT given without concurrent IO maintenance. The longer read
The dose was already conservative (30 Gy/10 fx, postinduction volumes, below OAR thresholds) and no dosimetric parameter tracked with serious events, so de-escalating the plan is not an obvious mitigation. Concurrent vs sequential timing did not change AE risk either. Selection (baseline DLCO SB 45.3 vs 56.7 in fatal-AE pts) and lymphocyte-sparing planning are the live levers.
Arm B's mOS of 13.4 mo and 56.6% 1-yr OS beat the IMpower133 atezolizumab benchmark, so maintenance alone was performing normally and the detriment is attributable to the added modality. TRT carried an AE HR of 2.47 (1.15-5.32) while longer atezolizumab exposure did not, which supports continuing maintenance unmodified rather than adding thoracic RT off-trial.
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Multicenter open-label phase 2 randomized trial (TREASURE, AIO-TRK-0320) at 20 sites in Germany and Austria, accrual September 2020 to August 2022, follow-up to September 2024, database lock April 2025, post hoc OS update April 2026. Planned 104 randomized for 80% power on a 20% absolute 12-month OS improvement; halted at 68 on SMC recommendation.
ES-SCLC with at least stable disease after induction carboplatin-etoposide-atezolizumab. 34 per arm, mean age 63.3 vs 65.6 y, 63.2% male, ECOG 0-1, thoracic PR in 82.4% overall. Randomization stratified by brain metastases, induction response, and prophylactic cranial irradiation.
30 Gy in 10 fractions to the postinduction thoracic primary and involved lymph node volume. Doses and volumes sat within or below typical clinical ranges and below established organ-at-risk thresholds, and concurrent versus sequential delivery relative to atezolizumab made no difference to AE occurrence.
Primary: overall survival from randomization, by stratified log-rank and multivariable Cox in the ITT population. Secondary: PFS and frequency plus severity of AEs and SAEs. Sensitivity analyses in per-protocol and an adjusted ITT excluding fatal AEs.
SAEs 61.3% vs 18.2% (P < .001) and fatal AEs 19.4% vs 3.0% (P = .04), dominated by infection and respiratory events. Grade 3 or greater trAE rate in arm A (26%) exceeded published benchmarks for atezolizumab monotherapy and for consolidative TRT without immunotherapy, which is the argument for an interaction between the two modalities rather than either alone.
Arm B tracked or beat the IMpower133 atezolizumab benchmark (13.4 mo and 56.6% 1-yr vs 12.3 mo and 51.7%), so the control arm was not underperforming; arm A fell well below it. Prior prospective single-arm series of TRT added to chemoimmunotherapy reported no toxicity increase, while randomized PACIFIC-2 and CheckMate-73L in NSCLC both showed more fatal infections in the concurrent thoracic RT plus IO arms.
Early termination at 68 of 104 makes every efficacy estimate exploratory, and the OS confidence interval (0.90-2.69) crosses 1. Causal attribution of the deaths was contested: investigators called 4 of the arm A fatalities unrelated, the SMC reclassified 3 of those as possibly or probably related. Risk-factor analyses (DLCO SB, GTV, dosimetry) are small-N and post hoc.
The PFS/OS dissociation is the load-bearing observation. Identical PFS argues the RT did nothing systemically, so the OS gap most plausibly reflects treatment-related deaths rather than faster progression, a reading the adjusted-ITT sensitivity analysis complicates by remaining consistent after excluding fatal AEs.
| Endpoint | Arm A (+TRT) | Arm B | P |
|---|---|---|---|
| Any toxic effects | 30 (96.8%) | 25 (75.8%) | .02 |
| SAEs | 19 (61.3%) | 6 (18.2%) | <.001 |
| trAEs | 71.0% | 30.3% | .001 |
| trSAEs | 29.0% | 6.1% | .01 |
| Fatal AEs | 6 (19.4%) | 1 (3.0%) | .04 |
CONSORT flow
Randomized, prespecified OS primary, halted early for fatal SAEs; result contests the single-arm safety data that encouraged consolidative TRT in the IO era.
- Can DLCO or lymphocyte kinetics select pts who tolerate consolidative TRT active Thymus Dosimetric and Morphologic Predictors of Radiation-Induced Lymphopenia in Stage III NSCLCn=450 · primary completion 2027-12 · thymus dose + morphology as RT lymphopenia predictors
- Does lymphocyte-sparing planning mitigate the infection signal n=55 · primary completion 2023-05 · SBRT planning optimized to cut lymphocyte depletionn=212 · primary completion 2026-11 · randomises lymphocyte-sparing vs conventional thoracic RT
- Is the late 2-year OS crossover real or small-numbers noise recruiting Phase II Trial of Consolidative Thoracic Radiotherapy for ES-SCLC After Standard Care of Chemo-immunotherapy Phase NAn=104 · primary completion 2025-09 · consolidative TRT after chemo-IO, PD-L1 maintenancerecruiting Association of Thoraco-mediastinal Radiotherapy With Maintenance Immunotherapy Treatment With Atezolizumab Phase 2n=37 · primary completion 2026-12 · consolidative TRT + atezolizumab maintenance in ES-SCLC
📚 Sources · 📄 1 paper
Abstract
ARTO NCT03449719
ForOligometastatic CRPC, ≤3 sites, no prior systemic therapy for CRPC
TL;DRAdding SBRT to all met sites improved OS: median NR vs 50 mo, HR 0.55 (0.33-0.92), p=0.021 in omCRPC.
The prescription is the transferable part: 1-5 fractions at BED ≥100 Gy to ALL sites, not an index lesion, so this is ablative comprehensive MDT rather than debulking. That, plus a control arm on a modern ARSI backbone, is what separates ARTO from the hormone-sensitive MDT trials and moves the question from omission to comprehensive ablation in CRPC.
In mCRPC with three or fewer sites and no prior CRPC-directed systemic therapy, this supports discussing comprehensive ablative SBRT alongside starting abiraterone; it does not extend to polymetastatic disease or to pts already progressing through an ARSI. The longer read
The transferable parameter is the prescription: 1-5 fractions at BED ≥100 Gy to ALL sites, not an index lesion. If a lesion cannot reach that dose, the pt has not had the tested intervention. This moves comprehensive ablative MDT from PSA-directed to survival-directed intent in CRPC.
The abiraterone plus ADT backbone was identical in both arms, so the OS difference is not a systemic-therapy effect and does not change drug choice or sequencing. What changes is the referral: a pt starting abiraterone for CRPC with ≤3 sites is now a radiotherapy conversation, not systemic therapy alone.
Also covered Jun 12
9 details 5 trials watching
Multicentre phase 2 randomised open-label trial, 16 academic and community centres in Italy, 1:1 by random permuted blocks, stratified by centre, ECOG PS and number of metastases. Enrolment Jan 2, 2019 to Sept 7, 2022; median follow-up 53 months (IQR 43-60). ITT analysis.
Age ≥18 with prostate adenocarcinoma and metastatic castrate-resistant disease, no more than three metastatic sites, and no previous systemic therapy for the mCRPC state. N=157 (control 82, experimental 75). No race or ethnicity data collected.
Both arms received ADT plus oral abiraterone acetate 1000 mg daily. The experimental arm added SBRT; the systemic backbone was identical, so the contrast isolates the radiotherapy.
SBRT delivered to all sites of metastatic disease in one to five fractions at a biologically effective dose ≥100 Gy. Comprehensive ablative intent, not treatment of an index lesion.
Primary: 6-month biochemical response (PSA decline ≥50% from baseline), reported previously. After the primary was met the power calculation was updated post-hoc for overall survival, finalised before unmasking; this report is an unplanned long-term OS analysis.
Most common grade 3-4 events were infectious complications (five control, zero experimental) and cardiovascular disorders (three each). One treatment-related death, in the control group, from myocardial failure. No excess grade 3-4 toxicity attributable to SBRT in the reported events.
STOMP and ORIOLE established MDT in hormone-sensitive oligometastatic disease without a systemic backbone, and SABR-COMET tested SABR across mixed histologies. ARTO is the randomised test in castrate-resistant disease with an ARSI given to both arms, which is the setting those trials leave open.
Open-label with no sham, and the OS power calculation was revised after the primary read, so the alpha spent on this comparison is not the trial's original design. The experimental median is not reached, meaning the reported HR rests on a control-arm curve that is itself only partly mature at 53 months.
A survival signal from comprehensive ablation on top of a modern ARSI backbone is the strongest randomised argument yet that MDT in CRPC is doing more than delaying PSA progression. What it does not settle is whether the benefit tracks the ablative dose, the completeness of coverage, or simply the favourable biology of pts whose disease stayed oligometastatic into castration resistance.
See the OS figures above; per-arm event counts beyond the medians and HR are not reported in source.
CONSORT flow
Randomised phase 2, but the OS analysis is unplanned with post-hoc power revision and the primary endpoint was 6-month PSA response. N=157.
- Does the OS benefit hold in a prespecified phase 3? active Prostate-cancer Treatment Using Stereotactic Radiotherapy for Oligometastases Ablation in Hormone-sensitive Patients Phase 3n=550 · primary completion 2026-06 · randomised phase 3, SBRT to all mets in mHSPCrecruiting Veterans Affairs Seamless Phase II/III Randomized Trial of STAndard Systemic theRapy With or Without PET-directed Local Therapy for Oligometastatic pRosTate Cancer Phase 2/3n=464 · primary completion 2026-09 · phase 2/3 SST +/- PET-directed local therapyrecruiting Metastasis-directed Therapy in Oligoprogressive Castration-refractory Prostate Cancer Phase 3n=246 · primary completion 2029-01 · phase 3 MDT in oligoprogressive CRPC, n=246
- Is benefit dose-dependent or driven by completeness of ablation? recruiting HIghly MetAstatic Life Prolonging Therapy-Resistant Prostate Cancer: Role of Stereotactic Radiotherapy for Bone and Lymph Node Metastases (HIMARS) Phase NAn=18 · primary completion 2028-05 · volume-escalated SBRT, defines max tolerated volume
- Does MDT benefit persist with newer ARSIs or PSMA radioligand therapy? n=107 · primary completion 2030-10 · 225Ac vs 177Lu-PSMA-617 with MDT SBRT
📚 Sources · 📄 1 paper
Abstract
ENZARAD (ANZUP 1303)
ForHigh-risk localized/locally-advanced prostate, EBRT candidates, 2yr ADT
HR 0.88
95% CI 0.67-1.15, p=0.34; 8yr 74% vs 72%, did not meet 1° EP
TL;DR8yr MFS 74% vs 72%, HR 0.88 (0.67-1.15), p=0.34: enzalutamide added to 2yr ADT + RT missed its primary endpoint.
Reported via UroToday →
The signal tracks the pelvic field, not the drug: MFS HR 0.47 (0.29-0.76) with pelvic RT planned and 0.43 (0.20-0.92) in cN1, both declared before randomization. RT was 78Gy or 46Gy plus brachy boost with 46Gy elective nodes for cN1, so this transfers directly. It moves the intensification decision toward pts you were already covering nodally.
In cN1 or node-covered high-risk localized prostate going to 2yr ADT plus definitive EBRT, this supports adding enzalutamide; in cN0 prostate-only fields, including 'very high-risk' by Gleason and PSA, it does not. The longer read
The benefit tracks the field, not the risk label: MFS HR 0.47 (0.29-0.76) where pelvic RT was planned, versus 0.85 (0.64-1.13) in 'very high-risk' disease. RT was 78Gy or 46Gy plus brachy boost, with 46Gy elective nodes plus gross nodal boost for cN1, so it maps onto standard practice. It ties the intensification call to your nodal coverage decision.
Enzalutamide x24mo was tested against an active NSAA x6mo, not ADT alone, so the flat all-comer MFS HR 0.88 argues against routine ARSI substitution rather than against intensification in general. The cN1 MFS HR 0.43 (0.20-0.92) is where the drug earns its place. Sequencing and biomarker selection remain open.
11 details
International investigator-initiated phase 3, N=802 from 8 countries, accrued March 2014 to June 2018, median follow-up 8 years. Powered at 80% for an HR 0.67. Primary was changed from OS to MFS during the trial because deaths ran below projection.
High-risk clinically localized or locally-advanced disease suitable for EBRT: 90% Gleason 8-10, 36% PSA >20 ng/ml, 12% cN1 by conventional imaging. 40% planned for pelvic RT and 8% for a brachytherapy boost.
Experimental: enzalutamide 160 mg daily x 24 months plus LHRH agonist x24 months. Control: conventional NSAA x6 months plus LHRH agonist x24 months. The control is an active antiandrogen, not ADT alone.
Prostate to 78Gy, or 46Gy plus brachytherapy boost, starting 16 weeks after hormonal therapy. Pelvic nodal RT required for cN1 (46Gy elective nodes plus boost to gross nodes) and optional for cN0 but declared before randomization. QA was unusually tight: credentialing, benchmarking, real-time review of the first 5 plans per site, then 20% random sampling.
Primary: MFS. Secondary: OS, CSS, PSA PFS, clinical PFS, castration resistance, HRQoL, adverse events, cost-effectiveness. Main effects by unstratified log-rank at alpha=0.05, Cox HRs, all p-values nominal without multiplicity adjustment, five prespecified subgroups tested by interaction.
Primary MFS not met. PFS favored enzalutamide at a nominal p=0.044 and OS was flat; the subgroup detail sits in the table above.
| Subgroup | MFS HR (95% CI) | OS HR (95% CI) |
|---|---|---|
| cN1 (regional nodes) | 0.43 (0.20-0.92) | 0.46 (0.17-1.26) |
| Pelvic field RT planned | 0.47 (0.29-0.76) | 0.53 (0.30-0.95) |
| 'Very high-risk' | 0.85 (0.64-1.13) | 0.81 (0.57-1.13) |
STAMPEDE's abiraterone-based intensification in non-metastatic high-risk disease produced an MFS HR 0.53 against ENZARAD's 0.88, and the ENZARAD cN1 subgroup HR mirrors the STAMPEDE result. The gap plausibly reflects population, not drug: cN1 11% vs 39%, median PSA 14 vs 35 ng/ml, cT3-4 47% vs 92%.
The pelvic-RT subgroup is not a clean randomized comparison of pelvic coverage: it carried 28% N1 and 62% Gleason 9/10 against 0% N1 and 49% Gleason 9/10 in the no-pelvic-RT group, so risk enrichment and biological interaction are entangled. The presenter named both explanations and could separate neither.
Two prespecified subgroups moving together on MFS and OS, with OS HRs tracking MFS HRs as ICECaP surrogacy predicts, is more internally consistent than a lone subgroup blip. It still does not establish that enzalutamide works only when the pelvis is treated.
Adequately powered phase 3 missed its primary MFS endpoint against an active NSAA control; benefit rests on two prespecified subgroups with overlapping risk composition.
- Which pelvic-RT subgroups drive the enzalutamide benefit
- Biomarkers identifying who needs ARSI intensification
- Whether pooled ARPI trial data confirms the nodal signal
📚 Sources · 📄 1 paper
Abstract
ARS Appropriate Use Criteria: Locoregionally Recurrent Rectal Cancer
TL;DRUpdated ARS appropriate use criteria for LRRC, built on 116 references (10 randomized phase 2/3), reaffirming combined-modality therapy toward R0 resection.
The RT-relevant content sits in PICO question 4 (role of RT/reirradiation), but the excerpt stops before the appropriateness ratings, so dose, fractionation and reirradiation technique recommendations are not reported in source text. What is stated: preoperative RT, systemic therapy, or both are positioned as tools to raise the odds of an R0 resection, which frames RT as resectability-directed rather than definitive.
In a previously irradiated patient with pelvic sidewall or presacral recurrence being staged for salvage, this frames preoperative RT or chemoRT as a means to margin-negative resection; it does not settle reirradiation dose or the nonoperative alternative. The longer read
RT is framed as resectability-directed: preoperative RT, systemic therapy, or both to raise the odds of R0. The reirradiation question (PICO 4) is posed but its appropriateness ratings, dose and technique are not in the source excerpt, so the decision a previously irradiated pelvis actually turns on is not reportable here.
Preoperative systemic therapy sits alongside RT as a downsizing tool rather than a competing pathway, and immunotherapy is named within the PICO question on systemic therapy. Specific regimen and sequencing ratings are not in the source excerpt.
The document is explicitly resection-centered: margin-negative resection is called the ultimate determinant of survival and local control. Resectability assessment by compartment, sidewall, sacral and visceral involvement on MRI drives the operative approach, with everything preoperative judged by whether it makes R0 more likely.
10 details 5 trials watching
Literature-based systematic review plus RAND/UCLA modified Delphi appropriateness rating, run under the standing ARS AUC methodology with PICOTS framing and PRISMA 2020 assessment. Two rounds of voting; ratings collapse to usually not appropriate, may be appropriate, usually appropriate.
Locoregionally recurrent rectal cancer. Eligible evidence was prospective observational, phase 2/3, and retrospective series of at least 25 patients, published January 1, 2013 to July 16, 2025, English language, animal studies excluded.
There is no efficacy endpoint. The output is an appropriateness rating per treatment option across five PICO questions: surgery, preoperative/perioperative therapy, nonoperative management, RT/reirradiation, and systemic therapy.
116 references carried the evidence: 10 well-designed randomized phase 2/3, 29 moderately well designed, 76 retrospective, 1 meta-analysis. The committee's stated conclusion is that margin-negative resection is the ultimate determinant of survival and local control, with preoperative systemic therapy, RT, or both used to facilitate it.
| Study design | n |
|---|---|
| Well-designed (randomized phase 2 and phase 3) | 10 |
| Moderately well designed (matched cohort, phase 2) | 29 |
| Design limitations (retrospective) | 76 |
| Meta-analysis | 1 |
Two thirds of the evidence base (76 of 116) is retrospective, so a modified Delphi vote is doing work the trials cannot. The document is an executive summary: the per-scenario appropriateness grid, which is the part a reader would carry to tumor board, is not in the source excerpt available here.
The committee explicitly declines to move practice, framing the update as reassurance about combined-modality therapy rather than a new position. For a radiation oncologist the operative question is where RT sits relative to surgical resectability, and the summary answers it in one direction only: RT is a means to R0, not an alternative to it.
- Role of nonoperative management in LRRC recruiting Radiotherapy Dose Escalation for Non-operative Management of Unresectable Locally Recurrent Rectal Cancer (STEP-UP) Phase NAn=30 · primary completion 2029-12 · RT dose escalation for unresectable LRRC, no surgery
- Optimal reirradiation dose and technique in previously irradiated pelvis recruiting Pencil Beam Proton Therapy for Pelvic Recurrences in Rectal Cancer Patients Previously Treated With Radiotherapy Phase 2n=65 · primary completion 2025-10 · dose-escalated proton reRT, prior pelvic RT >30Gy EQD2n=31 · primary completion 2025-12 · carbon ion reRT 74Gy/20Fx, unresectable LRRCrecruiting Hypofractionated Radiotherapy Plus Immunotherapy Versus Conventional Radiotherapy in Locally Recurrent Rectal Cancer Phase 2n=221 · primary completion 2030-03 · randomised 15-30Gy/5Fx reRT vs conventional RT
- Preoperative chemoRT vs systemic therapy alone before salvage resection n=44 · primary completion 2028-12 · preop chemoRT + PD-1 then radical salvage surgery
📚 Sources · 📄 1 paper
Abstract
INDIBLADE
ForStage II/III cT2-4aN0-2 MIBC, bladder-preservation candidates
78% at 2yr
0.67-0.9
TL;DR2yr bladder-intact EFS 78% (0.67-0.9) after induction ipi/nivo then chemoRT in cT2-4aN0-2 MIBC; 2yr OS 96% (0.91-1).
The RT-relevant gap is technique: the source gives no dose, fractionation, radiosensitizer, or whether the pelvic nodes were covered, and the cohort explicitly includes N1-2 and cT4a, so elective nodal coverage is exactly the parameter a reader needs and does not get. Bladder-intact EFS 78% at 2yr is the endpoint that gates preservation counselling.
In cT2-4aN0-2 MIBC where bladder preservation is already on the table, this supports discussing induction ipi/nivo before chemoradiation as investigational sequencing; it does not extend to cystectomy-eligible pts choosing surgery, nor to cT4b or M1 disease.
Technique is the missing variable: no dose, fractionation, or target volume, and with cT4a and N1-2 admitted, whether the pelvic nodes were treated is the parameter that decides whether 78% bladder-intact EFS transfers. Until that is published, this changes counselling tone, not planning.
Dual checkpoint blockade as induction, not concurrent or adjuvant, is the sequencing question here, and pts still completed chemoradiation afterwards. Cycles and dosing are not in source, so the regimen is not yet reproducible; 2yr OS 96% argues the sequence is at least deliverable.
Bladder-intact EFS 78% at 2yr bears on which cT2-4aN0-2 pts get offered preservation instead of upfront radical cystectomy. Salvage cystectomy rate is not reported in source, so the number that matters most for surgical planning, how many came to the OR anyway, is missing.
9 details
Single-arm bladder-preservation study of induction ipilimumab plus nivolumab followed by chemoradiation. Phase, N, number of sites and median follow-up are not reported in the source tweet; results are read out at 2 years.
Stage II/III muscle-invasive bladder cancer, cT2-4aN0-2. That range admits both node-positive and cT4a disease, a broader population than many bladder-preservation series. No further eligibility, performance status or baseline detail in source.
Induction ipilimumab + nivolumab, then chemoradiation. Dosing, number of induction cycles, and the concurrent radiosensitizer are not reported in source.
The chemoradiation component is named but not specified: no total dose, fractionation, technique, or target volume. Whether the cT4a and N1-2 pts received elective pelvic nodal coverage is unstated, which is the parameter that most gates transfer to another practice.
Primary read: 2yr bladder-intact event-free survival, 78% (0.67-0.9). 2yr OS 96% (0.91-1). Whether the trial prespecified bladder-intact EFS as its primary endpoint is not stated in source.
The 96% 2yr OS sits well above what an unselected cT2-4aN0-2 population would predict, which points at selection; the source reports no eligibility filter to judge that against. With no cystectomy or pathologic-response denominator reported, bladder-intact EFS cannot be separated into pts who never needed salvage vs pts who declined it.
The claim on offer is that adding induction ipi/nivo raises the ceiling of trimodality therapy, but a single arm cannot isolate the immunotherapy's contribution from the chemoradiation backbone. What it does establish is feasibility: pts got through induction dual checkpoint blockade and still completed CRT, with 2yr OS 96%.
Single-arm induction immunotherapy plus CRT with 2yr follow-up and wide CI; no randomised comparator against standard chemoradiation or cystectomy.
- Salvage cystectomy rate and pathologic response not reported
- Immunotherapy contribution over chemoradiation alone unproven
- Nodal coverage and RT dose for cT4a/N1-2 pts unstated
📚 Sources · 🐦 1 tweet
‼️ INDIBLADE: stage II/III (cT2-4aN0-2) MIBC -> induction ipilimumab plus nivolumab -> CRT
— NonsparseOncologist (@5_utr) June 17, 2026
2-year bladder-intact event-free survival is 78% (0.67−0.9) 🤩
2-year overall survival was 96% (0.91−1)
Lots of bladders can be potentially spared!https://t.co/LzTe72GYHD
KEYNOTE-689 vs NIVOPOSTOP
TL;DREducational round-up contrasting perioperative pembro vs postoperative nivo in resectable LA-HNSCC; 3yr DFS ~63% vs 53% cited for NIVOPOSTOP.
KEYNOTE-689NIVOPOSTOP
RT is the constant in both frameworks, not the variable: cisplatin CRT stays the postoperative backbone and the question is only where IO is inserted around it. The source gives no dose, fractionation or target volume, and no in-field vs out-of-field failure data, so nothing here changes an RT plan.
Postoperative cisplatin CRT is unchanged in both designs; only the IO timing moves. With no dose, fractionation, target volume or locoregional failure data in the source, the radiation decision is untouched, though a neoadjuvant pembro window shifts the timing of adjuvant CRT initiation.
The two designs answer different sequencing questions: pembro started before surgery and continued through adjuvant CRT and maintenance, versus nivo added to postoperative CRT only in high-risk pathology. Only NIVOPOSTOP carries a number here, 3-year DFS approximately 63% vs 53%.
The perioperative design puts two cycles of pembrolizumab before resection, so the operation is delayed by a neoadjuvant window. The source reports no compromise in surgery completion but gives no numbers on delay, resectability, or margin status.
10 details 2 trials watching
- 🔍 Curator-shared teaching infographic (single-author X post), not a primary trial report or peer-reviewed review
- 🔍 Trial framing as presented in the graphic
Feature KEYNOTE-689 NIVOPOSTOP (GORTEC 2018-01) Drug Pembrolizumab Nivolumab Setting Perioperative (before + after surgery) Purely postoperative Population Resectable Stage III-IVA HNSCC High-risk resected HNSCC Control arm Surgery → RT/CRT Post-op CRT Primary endpoint Event-Free Survival (EFS) Disease-Free Survival (DFS) - 🔍 RT is fixed background in both: adjuvant cisplatin CRT in the KEYNOTE-689 experimental arm, postoperative cisplatin CRT in both NIVOPOSTOP arms
- 🔍 NIVOPOSTOP high-risk features listed
- Positive margins
- Extranodal extension (ENE)
- ≥4 involved nodes
- Extensive perineural invasion and other adverse pathological features
- 📊 NIVOPOSTOP: 3-year DFS approximately 63% vs 53% with standard CRT alone
- 📊 KEYNOTE-689: no effect size reported in source; graphic states only "significant improvement in EFS"
- ⚠️ No HR, CI, or p-value given for either trial in the source
- ⚠️ "3-year DFS approximately 63% vs 53%" is an approximation in the source, not a reported trial value
- ⚠️ No RT dose, fractionation, or target volume reported for either trial in source
- ⚠️ Graphic asserts higher PD-L1 CPS derives greater benefit with no supporting numbers
- Head-to-head of perioperative vs postoperative IO timing n=80 · primary completion 2029-02 · perioperative IO vs pembro + surgery + adjuvant RT
- Whether PD-L1 CPS should gate IO in resected HNSCC
- Locoregional failure patterns with IO added to postoperative CRT n=173 · primary completion 2025-11 · anti-PD-1 added to adjuvant CCRT, DFS primary
📚 Sources · 🐦 1 tweet
🧠 High-yield: KEYNOTE-689 vs NIVOPOSTOP
— Dr Rupam Manna MD (@DrRupamOncology) June 15, 2026
These two trials are redefining standards for resectable LA-HNSCC.
1/ KEYNOTE-689 (NEJM 2025)
Perioperative pembro → significant EFS benefit
First positive perioperative IO trial in >2 decades
2/ NIVOPOSTOP (ASCO 2025)
Post-op nivo +… pic.twitter.com/1mRQr9jmVX
ARTO NCT03449719
ForOligometastatic CRPC, ≤3 nonvisceral lesions, starting first-line abiraterone
92% v 68.3%
OR 5.34 (95% CI, 2.05 to 13.88; P = .001)
TL;DRAdding SBRT to abiraterone in oligometastatic CRPC: biochemical response 92% vs 68.3%, OR 5.34; PFS HR 0.35.
Surfaced from a review's discussed trials
The systemic backbone is fixed (AAP both arms), so the entire effect is RT-attributable: PFS HR 0.35 for ablating ≤3 nonvisceral lesions. That isolates the metastasis-directed question in castration-resistant disease, where prior randomized MDT data sit in the hormone-sensitive setting. Dose and fractionation are not in the source text, which limits direct transfer.
In castration-resistant pts with three or fewer nonvisceral metastases starting first-line abiraterone, this supports considering metastasis-directed SBRT concurrently; it does not extend to visceral, higher-volume, or hormone-sensitive metastatic disease. The longer read
The randomized contrast is SBRT alone, since AAP is fixed in both arms: PFS HR 0.35 (95% CI 0.21-0.57) for ablating ≤3 nonvisceral lesions. This moves the offer-MDT-at-castration-resistance decision, though dose, fractionation and target volume are absent from the source text, so technique transfer cannot be judged.
Systemic management is unchanged: both arms received first-line abiraterone and prednisone, so nothing here alters drug choice or sequencing. The read is whether to involve radiation oncology at the start of AAP in low-volume CRPC, with progression deferred (HR 0.35) but no survival endpoint reported.
Also covered Jul 7
8 details 5 trials watching
Multicenter randomized phase 2, 1:1 allocation, N=157 enrolled January 2019 to September 2022. Median follow-up not reported in source.
Oligometastatic castrate-resistant prostate cancer, defined as three or fewer nonvisceral metastatic lesions. Visceral disease excluded by definition.
Both arms received abiraterone acetate and prednisone (AAP). The experimental arm added concomitant SBRT, so AAP is a fixed backbone and the randomized contrast is radiotherapy alone.
SBRT to all sites of disease, delivered concomitantly with AAP. Dose, fractionation and target-volume detail are not reported in the source text, which gates how directly the result transfers to a given SBRT practice.
Primary: biochemical response, PSA decrease ≥50% from baseline at 6 months. Secondary: complete biochemical response (PSA <0.2 ng/mL at 6 months) and progression-free survival. No survival endpoint reported.
No toxicity reported in source, so the added burden of ablating up to three lesions is unquantified. PSA endpoints are mechanically sensitive to removing PSA-producing deposits, and the 6-month timepoint precedes any durability read.
STOMP and ORIOLE established the randomized signal for metastasis-directed therapy in hormone-sensitive oligometastatic disease. ARTO's addition is that the signal persists on an ARSI backbone in castration-resistant disease, a setting those trials did not test.
The PFS HR 0.35 is the more meaningful of the two results, since it is less mechanically coupled to ablating PSA-producing lesions than the primary endpoint. What remains unsettled is whether deferring progression on an ARSI translates into anything durable, which a phase 2 sized for a 6-month PSA readout cannot answer.
Randomized phase 2 with a 6-month PSA surrogate primary endpoint; no OS, no reported toxicity, and phase 3 confirmation in CRPC is absent.
- Does the PFS benefit translate to overall survival n=102 · primary completion 2027-04 · randomised SBRT in oligomet CRPC on ARSi backbonerecruiting Metastasis-directed Therapy in Oligoprogressive Castration-refractory Prostate Cancer Phase 3n=246 · primary completion 2029-01 · phase 3 MDT in castration-refractory, up to 5 lesions
- SBRT-attributable toxicity when ablating up to three sites recruiting SBRT Versus Hypofractionated Radiotherapy for Biochemically Recurrent or Oligometastatic Prostate Adenocarcinoma Phase 3n=118 · primary completion 2030-01 · phase 3 powered on SBRT toxicity vs hypofx RTrecruiting Fractionated Stereotactic Radiotherapy Plus Second-generation Antiandrogen for Oligometastatic Castration-resistant Prostate Cancer Patients. Phase 2n=51 · primary completion 2030-05 · SBRT + abiraterone/enza in mCRPC, safety endpoint
- Whether benefit holds beyond three lesions recruiting HIghly MetAstatic Life Prolonging Therapy-Resistant Prostate Cancer: Role of Stereotactic Radiotherapy for Bone and Lymph Node Metastases (HIMARS) Phase NAn=18 · primary completion 2028-05 · volume-escalated SRT in high-volume mets, MTV endpoint
📚 Sources · 📄 1 paper
Abstract
RADIOSA NCT03940235
ForMetachronous oligorecurrent hormone-sensitive prostate cancer, ≤3 lesions
TL;DRcPFS 32.2 vs 15.1 mo, HR 0.43, adding 6 months of ADT to ablative SBRT in metachronous oligorecurrence.
Surfaced from a review's discussed trials
The RT is nearly free here: one G3 event (left ureter stenosis) and no late toxicity across 105 pts treated to a stated BED >100 Gy, so the entire cost of this decision is 6 months of castration. SBRT alone still gave 15.1-mo cPFS, the benchmark for deferring systemic therapy in a selected pt.
In a man with metachronous oligorecurrence, three or fewer nodal or bone lesions after radical local treatment, this supports adding a short ADT course to ablative SBRT over SBRT alone; it does not extend to synchronous, higher-volume, or castration-resistant disease. The longer read
The RT side of the decision is nearly free: one G3 event (left ureter stenosis) and no late toxicity at a stated BED >100 Gy. The 15.1-mo SBRT-alone cPFS is the benchmark that ablative prescription buys, so a softer nodal dose is not this control arm.
The systemic question is duration, not agent: 6 months of LHRH started within a week of SBRT, 22 G1 events, all resolved. cPFS 32.2 vs 15.1 mo (HR 0.43) with no OS or castration-resistance readout leaves open whether this modifies disease or defers detection.
8 details 5 trials watching
Single-centre randomised open-label phase 2 at the European Institute of Oncology, Milan. 105 pts assigned 1:1 between Aug 1, 2019 and April 30, 2023; median follow-up 31 months (IQR 16-36). Modified intention-to-treat analysis, 3 pts lost to follow-up.
Metachronous oligorecurrent hormone-sensitive disease: biochemical progression after radical local treatment with ≤3 lesions (pelvic nodal, extra-regional nodal, or bone) on next-generation imaging, ECOG 0-1. Median age 70 (IQR 65-75). Stratified by doubling time (≤3 vs >3 mo), node vs bone, and PET vs MRI.
30 Gy in 3 fractions every other day to all oligometastatic sites, or equivalent regimens by site. Stated EQD2 98.6 Gy (α/β 1.5 Gy) and BED >100 Gy, an ablative prescription rather than a symptomatic one, which is the dose the control-arm result belongs to.
6 months of ADT with an LHRH analogue in the combination arm, begun within 1 week before SBRT; no ADT in the control arm. The RT backbone is fixed across arms, so the randomised variable is the short systemic course alone.
Primary: clinical progression-free survival, assessed in 51 pts per group. No overall survival, ADT-free survival, or castration-resistance readout is reported in source.
Radiation contributed one G1 GI event; the only G3 was a left ureter stenosis in the combination arm, with no late toxicity in either group. The 22 G1 events were ADT-attributed and had resolved by last follow-up, so the harm ledger sits with the systemic course, not the RT.
STOMP and ORIOLE established MDT against observation in metachronous oligorecurrence, partly on the strength of keeping men off systemic therapy. EXTEND tested the mirror-image addition, MDT layered onto hormone therapy. This is the first randomised trial in this setting to report improved cPFS for the combination.
Progression was assessed unmasked, and PSA suppression from the randomised ADT gates the restaging that defines the event. Median follow-up sits below the combination arm's median cPFS of 32.2 mo, so the tail after testosterone recovery is thin. No biomarker separates the pts who would do well on SBRT alone.
Local and systemic therapy read as additive here rather than redundant, but the trade is priced in cPFS only. Whether 6 months is the right duration, and for whom SBRT alone suffices, is exactly what the investigators leave to future biomarker work.
CONSORT flow
Randomised, prespecified primary cPFS hit (HR 0.43). Single-centre, N=105, surrogate composite endpoint, so it supports adding short ADT to MDT rather than establishing it.
- Optimal ADT duration alongside metastasis-directed SBRT active Testing the Addition of the Drug Relugolix to the Usual Radiation Therapy for Advanced-Stage Prostate Cancer, The NRG Promethean Study Phase 2n=194 · primary completion 2029-02 · SBRT +/- relugolix vs placebo in oligomet CSPCn=162 · primary completion 2031-04 · randomises RDT +/- ADT in radiorecurrent oligomet CSPC
- Biomarkers identifying pts who do well with SBRT alone active Immune Response Evaluation in Oligorecurrent and Oligoprogressive Prostate Cancer Patients Treated With SBRT Phase NAn=40 · primary completion 2026-07 · immune profiling of SBRT + ADT in oligorecurrence
- Whether cPFS benefit translates to OS or delayed castration resistance active Prostate-cancer Treatment Using Stereotactic Radiotherapy for Oligometastases Ablation in Hormone-sensitive Patients Phase 3n=550 · primary completion 2026-06 · phase 3, n=550, SBRT + SOC in oligomet HSPCrecruiting Metastasis Directed Stereotactic Body Radiotherapy for Oligo Metastatic Hormone Sensitive Prostate Cancer Phase NAn=118 · primary completion 2031-12 · phase 3 MD-SBRT vs standard tx, failure-free survival
📚 Sources · 📄 1 paper
Abstract
RTOG 0848 NCT01013649
ForResected pancreatic head adenocarcinoma, post 6 cycles adjuvant gemcitabine-based chemo
HR 0.96
90% CI 0.79-1.18, 1-sided P=.38; did not meet OS
TL;DRAdjuvant CXRT after 6 cycles gemcitabine-based chemo missed OS (HR 0.96), but node-negative pts gained: 5yr OS 48.1% vs 28.6%.
The whole RT read sits in 91 node-negative pts: 5yr OS 48.1% vs 28.6%, median OS 3.9 vs 3.0 yr, with interaction P=.022. Delivery was standard and QA'd (50.4 Gy/28 fx, tumor bed plus pancreatojejunostomy plus regional nodes, 81% IMRT), so the technique transfers directly. G4-5 toxicity was unchanged (6% v 5%).
In a resected pancreatic head adenocarcinoma pt who is node-negative and progression-free after adjuvant chemotherapy, this supports discussing CXRT; it does not extend to node-positive disease, where no treatment effect was seen, or to margin-positive pts (only 10 node-negative/margin-positive across both arms). The longer read
The RT signal is confined to 91 node-negative pts: 5yr OS 48.1% vs 28.6%, median OS 3.9 vs 3.0 yr, interaction P=.022. Technique transfers unchanged (50.4 Gy/28 fx, tumor bed plus pancreatojejunostomy plus regional nodes, 81% IMRT, real-time central review), and G4-5 toxicity was flat at 6% v 5%.
The systemic backbone dates the result: 67% got single-agent gemcitabine, 28% gemcitabine plus erlotinib, and no pt received FOLFIRINOX. Unselected CXRT after six cycles adds nothing (OS HR 0.96), so referral for adjuvant RT stays off the default path, though the grade 3 excess (38% v 19%) is GI and lymphopenic, not prohibitive.
10 details 2 trials watching
Prospective randomized phase IIR/III, two-step, multicenter (RTOG then NRG). Step 2 opened November 2009, closed October 2018, analyzed December 2023. Randomization 1:1, unmasked, stratified by nodal status, CA19-9, margins and adjuvant systemic treatment.
Curative-intent gross total resection of pancreatic head adenocarcinoma with documented microscopic margin status; body/tail excluded. Only pts without recurrence after five cycles of chemotherapy entered step 2: 546 entered step 1, 354 randomized (174 chemo, 180 chemo+CXRT). 74% node-positive, 17% margin-positive, 81% T3.
Step 1 was gemcitabine (67%), gemcitabine plus erlotinib (28%) or non-oxaliplatin gemcitabine combinations (5%); no pt received FOLFIRINOX. Both arms then took a sixth cycle; the experimental arm followed with CXRT within 21 days, sensitized by capecitabine (83%) or infusional 5-FU (15%).
50.4 Gy in 28 fractions to the postoperative tumor bed, pancreatojejunostomy and regional nodes; median delivered dose 50.4 Gy over 28 fractions and 38 days. 81% IMRT, 19% 3D conformal, 79% with no interruptions, 88% received ≥50 Gy. Centers were IROC-credentialed and every plan underwent real-time central review before start.
Primary: overall survival from second-step randomization. Secondary: DFS and adverse events (CTCAE v4.0). Final analysis triggered at the earlier of 316 OS events or 5 years of potential follow-up for all pts; it fired on the latter with 270 events, cutting power to 72%.
Grade 4 or 5 AEs were not increased (6% v 5%, P=.68), with one grade 5 in each arm (hepatic failure, sepsis). Grade 3 rose to 38% v 19% (P<.001), driven by GI events and decreased lymphocyte count; grade 3 nonhematologic 22% v 11% (P=.004).
ESPAC-1 reported adjuvant CXRT as detrimental, but accrued 1994-2000 with split-course lower-dose 2D planning, no postoperative imaging to exclude incomplete resection or early metastases, and no QA. RTOG 9704's post hoc analysis linked RT protocol deviations to worse survival, the specific failure mode 0848 designed its real-time review to prevent.
Accrual took almost 9 years and the OS event rate ran below projection, so the trial read out on a follow-up trigger at 270 of 316 planned events (power 72% for the hypothesized HR 0.76). The node-negative arms hold 42 and 49 pts, and the subgroup rests on an interaction P=.022 across nine tested subgroups.
The negative primary settles that unselected adjuvant CXRT adds nothing after gemcitabine-based chemotherapy, while the safety profile removes the ESPAC-1-era objection that RT here is harmful. What stays open is whether the node-negative signal reflects a real locoregional benefit in pts with lower competing distant risk, and whether it survives a modern FOLFIRINOX backbone.
| Endpoint | Chemo (n=42) | Chemo+CXRT (n=49) |
|---|---|---|
| 5yr OS (95% CI) | 28.6 (14.9-42.2) | 48.1 (33.3-62.9) |
| Median OS, yr (95% CI) | 3.0 (2.2-4.0) | 3.9 (2.5-NR) |
| Median DFS, yr (95% CI) | 1.5 (0.8-2.7) | 2.3 (1.4-NR) |
CONSORT flow
Prespecified stratified phase III, primary OS endpoint negative overall. Node-negative benefit rests on a subgroup interaction (P=.022) in 91 pts, hypothesis-generating not definitive.
- Does the node-negative CXRT benefit hold on a FOLFIRINOX backbone?
- Can SBRT substitute for conventional CXRT in this setting? active mFOLFIRINOX With or Without Stereotactic Body Radiotherapy in Locally Advanced Pancreatic Adenocarcinoma Phase 2n=92 · primary completion 2025-01 · candidate match
- How to select for RT benefit when nodal status follows neoadjuvant therapy? active Carboplatin, Nab-Paclitaxel, Durvalumab Before Surgery and Adjuvant Therapy in Head and Neck Squamous Cell Carcinoma Phase 2n=39 · primary completion 2022-02 · candidate match
📚 Sources · 📄 1 paper
MROQC ADT Practice Patterns
ForIntact high-risk M0, N0-1 prostate cancer, definitive RT
TL;DRGuideline-concordant ≥18mo ADT intended in 67.0% of high-risk M0/N0-1 pts receiving definitive RT; ARPI recommended in 23.2% of STAMPEDE-eligible pts post-publication.
Facility-level variability in ≥18mo ADT recommendations persisted after adjusting for cN1, grade group and PSA (P<.0001), so treating site, not only tumor features, shapes duration. Among STAMPEDE M0-eligible pts, ARPI recommendations reached only 23.2% after publication, a gap a department can audit directly in its own high-risk RT cohort. The longer read
Grade group drove concordant ADT recommendations most (GG5 OR 9.45, GG4 OR 6.23), and site-level variability survived adjustment (P<.0001). For an RT department the benchmark is concrete: 67.0% intended ≥18mo ADT and 23.2% ARPI uptake in STAMPEDE M0-eligible pts after publication.
9 details
Prospective statewide quality-consortium data (MROQC), N=553 across 26 centers, June 2020 to November 2024. Multivariable analysis of predictors, a mixed-effects model with treatment site as random intercept, and ARPI adoption compared before vs after STAMPEDE M0 publication.
Intact high-risk M0, N0-1 prostate cancer treated with definitive RT: cT3/4 13.3%, cN1 19.9%, GG 4-5 75.0%, PSA ≥20 ng/mL 40.0%. 27.9% met STAMPEDE M0 criteria (≥2 of cT3/T4, GG 4-5, PSA ≥40 ng/mL, or cN1).
Primary: intended guideline-concordant ADT (GC-ADT, ≥18 months) per 2022 AUA/ASTRO. Also assessed: ARPI recommendation in STAMPEDE-eligible pts and facility-level variability.
91.3% recommended any ADT, 67.0% guideline-concordant. ARPI recommendations in STAMPEDE-eligible pts rose from 0% to 23.2% after publication; facility variability persisted on MVA (P<.0001).
| Factor | OR (95% CI) |
|---|---|
| cN1 | 2.94 (1.44-5.99) |
| GG4 | 6.23 (2.85-13.62) |
| GG5 | 9.45 (4.46-20.06) |
| PSA ≥40 ng/mL | 3.64 (1.22-10.87) |
Benchmarks practice against the 2022 AUA/ASTRO 18-36 month recommendation and STAMPEDE M0 ARPI intensification criteria. Single-state data, and the source offers no comparison with other practice settings.
The abstract gives no reasons for sub-18mo recommendations (comorbidity, pt preference, toxicity), so non-concordance is not necessarily poor care. The ARPI comparison is an uncontrolled before-after design, and no OR is reported for cT3/4.
The strongest predictors of a concordant recommendation were grade group (GG5 OR 9.45) and cN1, consistent with shorter courses being offered when high-risk status rests on other features. Residual site variability points to local norms beyond the modelled case mix, though unmeasured covariates could contribute.
Practice-patterns study of intended ADT recommendations; no efficacy or outcome endpoint, so nothing here confirms or challenges SOC.
- Delivered vs intended ADT duration in routine definitive RT practice
- Drivers of facility-level variation in ADT duration recommendations
- Barriers to ARPI intensification in STAMPEDE M0-eligible pts
📚 Sources · 📄 1 paper
Abstract
mRCAT-III NCT06507371
ForpMMR/MSS cT3-4N0/+M0 rectal adenoCa, ≤10cm from anal verge, no lateral node
61.0% vs 28.6%
P<0.0001, blinded independent central review
TL;DRpCR 61.0% vs 28.6% (P<0.0001) when elective nodal RT was omitted and tislelizumab added in pMMR/MSS LARC.
The RT variable here is target volume, not dose: both arms got 5Gy x 5d, and the experimental target was tumor bed alone with tumor-draining nodes deliberately spared. That inverts the usual de-escalation logic (smaller field proposed to IMPROVE efficacy by preserving nodal immunity), but tislelizumab moves with it, so the pCR gain cannot be assigned to the field change.
In pMMR/MSS cT3-4 rectal cancer ≤10cm from the verge with no positive lateral node, this raises the question of elective nodal omission with PD-1 blockade but does not yet support dropping nodal coverage outside a trial, and says nothing about dMMR/MSI-H disease. The longer read
The only RT variable is target volume: 5Gy x 5d in both arms, tumor bed alone versus conventional fields including the tumor-draining nodes. Elective nodal omission is being proposed to improve efficacy rather than reduce toxicity, but with no recurrence data reported, the coverage decision stays unchanged outside a trial.
Tislelizumab was added to an unchanged CAPOX backbone in a pMMR/MSS population, where checkpoint blockade has generally underperformed. The 61.0% vs 28.6% pCR is the sequencing signal, though the concurrent field reduction means the drug's independent contribution is not isolated.
All patients proceeded to TME, so the higher pCR (61.0% vs 28.6%) and MPR (77.9% vs 50.6%) bear on the depth of response at resection and, via the unreported organ-preservation secondary, on which patients might avoid it. Nodal yield and recurrence after unirradiated draining nodes are not reported.
| Endpoint (ITT) | Experimental (N=77) | Control (N=77) | P |
|---|---|---|---|
| pCR rate | 61.0 (47/77) | 28.6 (22/77) | <0.001 |
| MPR rate | 77.9 (60/77) | 50.6 (39/77) | <0.001 |
+1 more figure
10 details 5 trials watching
Multicenter, open-label, randomized phase 3 across 17 hospitals in China (NCT06507371). 1:1 allocation, n=77 per arm, stratified by clinical N stage (cN0 vs cN+). Pathologic response read by blinded independent central review.
Rectal adenocarcinoma with lower edge ≤10 cm from the anal verge, cT3-4 N0/+ M0, MSS/pMMR, age 18-75, ECOG PS 0-1. No positive lateral lymph node permitted, which excludes the population where lateral nodal management is itself contested.
Both arms received 5Gy x 5 days. The experimental arm's modification was target volume only: radiation to the tumor bed without tumor-draining lymph nodes, against conventional short-course fields in the control. Dose and fractionation were held constant, so the field is the only RT variable.
Experimental: tislelizumab 200 mg IV d1 plus oxaliplatin 130 mg/m² IV d1 and capecitabine 1000 mg/m² PO d1-14. Control: the same CAPOX backbone without tislelizumab. Both followed by TME, then adjuvant therapy and follow-up.
Primary: pCR rate in the ITT population. Secondary: MPR rate, TRG, organ preservation rate, EFS, OS and AEs. Only pCR and MPR are reported in the source; the time-to-event secondaries are not.
The presentation states the experimental approach reduced the incidence of severe gastrointestinal adverse events, consistent with a smaller irradiated volume, but no grade-specific rates are reported in source.
The control arm's 28.6% pCR sits above what short-course RT with consolidation chemotherapy has historically produced in pMMR disease, so the comparator is not obviously weak. The experimental result approaches the response depth usually reserved for dMMR/MSI-H disease, where checkpoint blockade already produces high complete-response rates; extending that to MSS is the claim being made.
Nodal recurrence is the outcome that decides whether sparing the tumor-draining nodes is safe, and no recurrence, EFS or OS data appear in the source. A pCR advantage at TME cannot answer it, and the cN+ stratum is where a nodal-omission failure would show first.
The trial's mechanistic premise, that irradiating draining nodes depletes the lymphocyte reservoir a PD-1 agent needs, is testable but not tested here: the field change and the checkpoint inhibitor were introduced together. A three-arm design (node-sparing RT + CAPOX, conventional RT + CAPOX + tislelizumab) would be needed to separate them.
CONSORT flow
Randomised phase 3, 1° EP met by central review, but confounds nodal-target omission with PD-1 addition and reports no recurrence or survival data.
- Nodal recurrence risk after sparing tumor-draining lymph nodes recruiting Nodal-Region Sparing Short-Course RT With Chemo-PD-1/Bevacizumab vs. Short-Course RT With Chemotherapy as TNT in pMMR/MSS Locally Advanced Rectal Cancer Phase 2n=76 · primary completion 2029-06 · nodal-sparing vs standard SCRT TNT in pMMR/MSSrecruiting Node-Sparing Short-Course Radiotherapy Sequential Chemotherapy and PD-1 Inhibitor for Mid/Low pMMR/MSS Rectal Cancer (MODIFI-RC-II) Phase 2/3n=430 · primary completion 2030-12 · randomised node-sparing vs conventional field, n=430
- Whether tislelizumab or field reduction drives the pCR gain recruiting Neoadjuvant Long-course Chemoradiation Plus PD-1 Blockade for Mid-low Locally Advanced Rectal Cancer Phase 2n=186 · primary completion 2024-03 · CRT ± tislelizumab, fixed field: isolates the PD-1 armnot yet Neoadjuvant Chemoradiotherapy Followed by Chemotherapy With or Without Tislelizumab for Resectable Ultra-low Rectal Cancer: The RELIEVE-02 Study Phase 3n=154 · primary completion 2027-12 · phase 3 CRT+chemo ± tislelizumab, ultra-low pMMR/MSS
- Organ preservation and EFS with node-sparing short-course RT recruiting Nodes-sparing Short-course Radiation Combined With CAPOX and Tislelizumab for MSS Middle and Low Rectal Cancer Phase 2n=32 · primary completion 2024-08 · node-sparing SCRT + CAPOX/tisle, organ preservation 2° EP
📚 Sources · 🐦 1 tweet
One of most interesting rectal ca studies at #ASCO26
— Dr. Nina Niu Sanford (@NiuSanford) June 2, 2026
P3 RCT in pMMR LARC: Node-sparing short-course RT + CAPOX + tislelizumab doubled pCR v conventional SCRT + CAPOX (61 v 29%)
Hypothesis = sparing elective node RT preserves antitumor immunity & improves PD1 response @OncoAlert pic.twitter.com/6xvA6ne0mg
LBA8005: Concurrent Thoracic RT + Chemoimmunotherapy in ES-SCLC
ForTreatment-naive ES-SCLC on durvalumab/platinum/etoposide, ECOG 0-1, thoracic lesion
10.0 vs 11.8 mo
HR 1.14, 95% CI 0.84-1.56, p=0.40 (primary endpoint not met)
TL;DRmOS 10.0 vs 11.8 mo, HR 1.14 (0.84-1.56), p=0.40: adding 30Gy/10fx consolidative TRT to chemo-IO did not improve survival.
The consolidative-TRT habit carried over from CREST does not survive an IO backbone: OS HR 1.14, and both landmark subgroups (completers HR 1.02, no brain/liver mets HR 1.10) sit on or above 1.0, so there is no population here in which 30Gy/10fx earned its place. Source gives no local control or toxicity numbers, so the mechanism stays open.
In treatment-naive ES-SCLC starting durvalumab plus platinum/etoposide, this argues against routinely adding 30Gy/10fx thoracic RT during cycles 2-4; it does not address consolidative TRT after IO completion, nor PCI, which was permitted in both arms. The longer read
The 30Gy/10fx schedule that CREST validated does not hold up on an IO backbone (HR 1.14), and enriching for the fitter patient did not help: completers HR 1.02, no brain/liver mets HR 1.10. Note this tested CONCURRENT RT at day 21-28, not post-induction consolidation, so that decision is still open.
The systemic regimen was identical in both arms, so this is a clean read that thoracic RT adds nothing to durvalumab plus carboplatin/etoposide, not a comment on the backbone itself. PFS was flat (5.1 vs 5.0 mo), and referral for concurrent thoracic RT during cycles 2-4 is not supported.
| Arm | Median OS | 95% CI | HR (95% CI), p |
|---|---|---|---|
| Chemoimmunotherapy plus TRT | 10.0 months | 8.3 - 11.7 | 1.14 (0.84 - 1.56), p=0.40 |
| Chemoimmunotherapy | 11.8 months | 10.0 - 13.6 | reference |
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| Arm | Median PFS | 95% CI | HR (95% CI), p |
|---|---|---|---|
| Chemoimmunotherapy plus TRT | 5.1 months | 4.7 - 5.4 | 1.10 (0.84 - 1.45), p=0.49 |
| Chemoimmunotherapy | 5.0 months | 4.6 - 5.4 | reference |
9 details 5 trials watching
Randomized phase III, 1:1, N=228 (115 TRT vs 113 control). Stratified by liver metastases and brain metastases. Primary: overall survival; key secondary ORR, PFS, toxicity.
Treatment-naive confirmed SCLC, stage IV or stage III ineligible for curative chemoradiation, ECOG PS 0-1, at least one measurable thoracic lesion. Asymptomatic or stable brain metastases allowed.
Both arms: 4 cycles durvalumab 1500 mg + carboplatin AUC=5 + etoposide 100 mg/m2 IV d1 with d2-3 IV or 200 mg/m2 PO d2-4, Q3W, then durvalumab 1500 mg Q4W until progression, toxicity, or patient choice.
30 Gy in 10 fractions starting day 21-28, so delivered concurrently with the later chemoimmunotherapy cycles rather than as post-chemo consolidation. PCI 25-30 Gy to responders and WBRT 20-30 Gy for brain metastases were optional per local routine in both arms. Target volume, technique, and dose constraints not reported in source.
Primary endpoint not met. PFS was likewise flat (5.1 vs 5.0 mo, HR 1.10, p=0.49), and neither landmark subgroup shifted the estimate below 1.0.
| Population | TRT median OS | Control median OS | HR (95% CI), p |
|---|---|---|---|
| Completed all 4 chemo-IO courses | 11.9 mo (9.7-14.1) | 12.1 mo (9.4-14.8) | 1.02 (0.72-1.44), p=0.92 |
| No brain or liver mets | 11.9 mo (6.2-17.7) | 13.2 mo (10.4-16.1) | 1.10 (0.65-1.87), p=0.72 |
CREST (Slotman, Lancet 2015) established the same 30 Gy/10 fx schedule as consolidative TRT after chemotherapy alone and showed a 2-year OS gain. This trial asks the schedule against a durvalumab-containing backbone and finds nothing, which is the relevant question now that chemo-IO is standard first line.
Toxicity was a key secondary but no AE data appear in the source slides, so a harm-versus-local-benefit tradeoff cannot be assessed. No local control or pattern-of-failure endpoint is shown, and permitted PCI plus WBRT in both arms further blurs the RT contrast between arms.
The timing choice matters for how far the null generalizes: day 21-28 puts RT alongside active chemo-IO, not after it, so this tests concurrent thoracic RT rather than the CREST consolidation paradigm. What it does not settle is whether the null reflects absent local benefit or a benefit cancelled by added toxicity.
CONSORT flow
Randomised phase III, primary OS endpoint, prespecified stratification; result diverges from CREST-era practice of consolidative TRT. Design internally valid for the null claim.
- Does consolidative TRT after completing chemo-IO still help? n=150 · primary completion 2025-03 · RT to all residual lesions post chemo-IO in ES-SCLCrecruiting Phase II Trial of Consolidative Thoracic Radiotherapy for ES-SCLC After Standard Care of Chemo-immunotherapy Phase NAn=104 · primary completion 2025-09 · ph2 TRT after chemo-IO then PD-1/L1 maintenancenot yet Addition of Thoracic Consolidation Radiotherapy to the Maintenance Immunotherapy for ES-SCLC (STONE-001) Phase 3n=182 · primary completion 2028-12 · randomised TRT added to IO maintenance after inductionn=165 · primary completion 2028-12 · consolidative RT to residual disease during IO
- Did concurrent TRT add toxicity that offset local benefit? active Chemotherapy and Immunotherapy in Extensive-Stage Small-Cell Lung Cancer With Thoracic Radiotherapy Phase 2n=35 · primary completion 2027-09 · safety/feasibility of concurrent TRT with chemo-durva
- Local control and pattern-of-failure outcomes unreported
📚 Sources · 🐦 1 tweet
🚨 #ASCO26 | #️⃣LBA8005⁰☢️ Concurrent thoracic radiotherapy + chemoimmunotherapy in ES-SCLC
— Masahiro TORASAWA, MD. PhD. (@M_Torasawa) June 2, 2026
👥 ES-SCLC⁰Durvalumab + platinum/etoposide⁰± concurrent thoracic radiotherapy⁰TRT: 30 Gy / 10 fractions, starting day 21–28
📊 Randomized phase III⁰ChemoIO + TRT: n=115⁰ChemoIO… pic.twitter.com/TDA5amz59e
RT + Systemic Therapy: What to Continue vs Hold (Speers)
TL;DRASCO 2026 education session slides triaging concurrent systemic agents with breast/CW + RNI into continue, caution, and hold/sequence.
HERANCCTG N9831APHINITYKATHERINEATEMPTDESTINY-Breast05COMBARTKEYNOTE-522
The operational content is the PK column: talazoparib 5t½ 19 days and pembrolizumab 5t½ ~110 days mean a brief hold buys nothing, so the mitigation is field size, lung dose and monitoring rather than a washout. Field size, not agent class, gates the CDK4/6i and olaparib calls.
In a pt starting breast/CW + RNI while on T-DXd, this supports concurrent treatment with lung-dose scrutiny rather than a hold; it does not extend to baseline ILD or active pulmonary disease, where sequencing is advised. The longer read
Plan geometry, not the drug name, does the deciding: large lung volumes, IMN coverage, bolus and reconstruction move T-DM1 into caution, high lung-dose plans move T-DXd, and field size gates CDK4/6i and olaparib. Where 5t½ is long (pembrolizumab ~110 days, T-DXd 30 days) a hold is unavailable, so the lever is dose constraints and surveillance.
The washout column tells you what a hold actually costs: capecitabine 4 hrs and veliparib 1 day are free to interrupt, talazoparib 19 days and T-DXd 30 days are not. Olaparib is asked to start 2-12 wks after RT completes on the OlympiA paradigm, which is a sequencing constraint on adjuvant planning, not a toxicity call.
+3 more figures
14 details 4 trials watching
ASCO 2026 education session slide set from Corey W. Speers, adapted from Wong, Speers, Schaverien, ASCO Educational Book 2026, Table 5. It is an allocation framework, not a trial: agents are sorted into continue, caution, and hold/sequence for concurrent use with breast/chest wall + RNI.
The RT context throughout is breast/CW + regional nodal irradiation. The modifiers that move an agent between buckets are plan-level, not drug-level: large lung volumes, IMN coverage, bolus, reconstruction, CNS SRS for T-DM1, high lung-dose plans and thoracic/lung RT for T-DXd, and field size for CDK4/6 inhibitors and olaparib.
Each agent is anchored to its half-life and five-half-life washout: olaparib 15 hr / 3 days, veliparib 5.5 hr / 1 day, talazoparib 90 hr / 19 days, capecitabine ~45 min / 4 hrs, palbociclib 28.8 hr / 6 days, abemaciclib-ribociclib 24-55 hr / 5-11 days, T-DM1 4 days / 20 days, T-DXd 6 days / 30 days, pembrolizumab 22 days / ~110 days. The stated default outside protocol is PK-based washout → RT → resume.
T-DXd's dominant toxicity is ILD: ~12% at 5.4 mg/kg with ~0.9% fatal, and 9.6% vs 1.6% for T-DM1 in DESTINY-Breast05; RT timing within the T-DXd arm showed 10.7% sequential vs 9.6% concurrent. Veliparib carries dose-limiting moist desquamation and fibrosis with concurrent RT (TBCRC 024). T-DM1 signals are dermatitis (possibly underreported), a small pneumonitis signal, and CNS radionecrosis with SRS.
The HER2 mAb call rests on trial precedent rather than new data: HERA started trastuzumab after chemotherapy and XRT, NCCTG N9831 gave XRT concurrently with trastuzumab, and APHINITY gave trastuzumab plus pertuzumab concurrently with RT. The immunotherapy call rests on KEYNOTE-522, whose V1 protocol required restarting pembrolizumab ≥2 wks post-RT and whose V2 amendment permitted concurrency; the post-hoc of 1,174 pts (715 irradiated) found numerically fewer G3-5 and immune AEs in the concurrent group.
The evidence tiers behind the buckets are uneven and the slide says so: the KEYNOTE-522 concurrency read is post-hoc with no adjustment for why pts were irradiated concurrently versus sequentially, and the CDK4/6i call rests on limited prospective data, most evidence retrospective, with a single trial cited (NCT05996107). P-RAD's endpoint is a biomarker (T-cell infiltration, tertiary lymphoid structures), not a clinical outcome.
The organizing logic is that PK sets whether a hold is even available, and plan geometry sets whether it is needed. Where 5t½ is short (capecitabine 4 hrs, veliparib 1 day, olaparib 3 days) the framework holds because it costs almost nothing; where 5t½ is long (talazoparib 19 days, T-DXd 30 days, pembrolizumab ~110 days) it concedes that a hold is theatre and shifts to lung dose, field size and surveillance. The unresolved item it flags rather than settles is T-DM1 vs T-DXd, where the mAbs are described as settled and the ADCs are not.
| Agent | Call | Basis given |
|---|---|---|
| Endocrine therapy | Continue | Minimal radiosensitization |
| Trastuzumab ± pertuzumab | Continue | Generally safe; modern heart-sparing |
| T-DM1 | Continue | Dermatitis + pneumonitis vigilance; caution with CNS SRS |
| Pembrolizumab | Continue | Pneumonitis vigilance + immune-toxicity workflows |
| T-DXd | Caution | Sequence/hold for high lung-dose or active pulmonary disease |
| CDK4/6 inhibitors | Caution | Usually hold for large fields; concurrent only in protocol |
| Olaparib | Caution | Reasonable with limited fields; protocol settings only |
| Cytotoxic chemo (anthracycline/taxane/platinum) | Hold / sequence | Sequence, do not give concurrently |
| Capecitabine | Hold / sequence | Adjuvant paradigm non-concurrent |
| Veliparib / talazoparib | Hold / sequence | Veliparib + RT severe acute/late tox |
| mTOR / PI3K agents | Hold / sequence | Mucosal, skin, metabolic, inflammatory risk; ESMO-ESTRO advises caution |
- T-DM1 vs T-DXd concurrency with locoregional RT
- Prospective CDK4/6i concurrent RT safety data recruiting Safety Assessment of Concurrent Radiotherapy and Novel Systemic Therapy for Breast Cancer Phase NAn=148 · primary completion 2026-01 · CDK4/6i during breast/CW ± nodal RT, n=148 safetyn=15 · primary completion 2026-09 · phase 1b abemaciclib + letrozole concurrent preop RT
- Whether short-course preop RT priming translates to outcomes n=120 · primary completion 2025-12 · randomised no/low/high dose preop RT boost + pembrorecruiting Preoperative Immunotherapy Combined With Stereotactic Radiation Therapy Boost in the Treatment of HER2-negative Breast Cancer Phase 2n=78 · primary completion 2028-02 · preop RT boost + randomised pembro vs placebo, HER2-neg
📚 Sources · 🐦 1 tweet
#ASCO26
— Yakup Ergün (@dr_yakupergun) June 1, 2026
Which treatments should continue with RT, and which should be held?
From the Great presentation by Dr. Corey W. Speers pic.twitter.com/9B7e0HePDZ
MIRACLE-2
For1L MSS rectal cancer ≤10 cm from AV, synchronous unresectable mets
TL;DRORR 68.0%, mOS 23.2 mo, 18% NED with HFRT/SBRT then chemo-biologic + tislelizumab in 1L MSS rectal cancer with synchronous unresectable mets.
HFRT went to the primary and HFRT or SBRT to metastases before PD-1, but no dose, fractionation or target volume is reported, so the RT component cannot be reproduced. G3/4 lymphopenia 36.7% (all-grade 95.9%) is worth weighing when multisite RT precedes PD-1 blockade. Upfront RT to all sites in MSS disease stays investigational.
Every pt got HFRT to the primary and HFRT or SBRT to metastases before PD-1, but no dose, fractionation or target volume is reported, so the RT schedule cannot be reproduced. G3/4 lymphopenia 36.7% is worth weighing when multisite RT precedes PD-1 blockade.
The backbone was RAS/BRAF-selected: FOLFOX-bevacizumab for mutant, FOLFIRI-cetuximab for wild-type, each with tislelizumab. Short durability (mPFS 9.3 mo, 1-yr DOR rate 20%) tempers the claim that adding RT and PD-1 overcomes MSS immune resistance, and first-line regimen choice is unchanged.
| Best overall response | n (%) | 95% CI |
|---|---|---|
| CR | 1 (2.0%) | n/a |
| PR | 33 (66.0%) | n/a |
| SD | 10 (20.0%) | n/a |
| PD | 6 (12.0%) | n/a |
| ORR | 34 (68.0%) | 53.6%-80.0% |
| DCR | 44 (88.0%) | 76.0%-95.2% |
| ETS rate | 38 (76.0%) | 62.4%-86.8% |
10 details 1 trial watching
Prospective, single-arm, phase I. Efficacy data for N=50 as of December 31, 2025; median follow-up 19.9 mo (95% CI 16.4-23.4). Reassessment every 8 weeks.
MSS rectal cancer, primary ≤10 cm from anal verge on MRI, with synchronous unresectable metastases, first-line. 76.0% male, median age 57 (range 30-73); liver mets 52.0%, lung 8.0%, both 40.0%; RAS/BRAF mutant 56.0%.
HFRT to the primary and HFRT or SBRT to metastases, delivered before systemic therapy. Dose, fractionation and target volumes not reported in source.
RAS/BRAF-mutant: FOLFOX-bevacizumab-tislelizumab; wild-type: FOLFIRI-cetuximab-tislelizumab, tislelizumab 200mg Q2W per flowchart. Median 8 courses (range 3-12). Resectable disease went to primary resection plus metastasectomy/local ablation; watch-and-wait considered for primary cCR when the sphincter could not be preserved.
Primary: ETS rate (≥20% target lesion reduction at 8 wks after systemic start). Secondary: DCR, DOR, OS, PFS, safety.
18% (9/50) reached NED; how many got there via resection, ablation or watch-and-wait is not reported.
| Endpoint | Median (95% CI) | 1-yr rate |
|---|---|---|
| PFS | 9.3 mo (7.1-11.5) | 33.4% |
| OS | 23.2 mo (15.1-31.3) | 93.3% |
| DOR (34 CR/PR) | 8.0 mo (5.2-10.8) | 20% |
No grade 5 TRAEs. G3/4: lymphopenia 36.7%, neutropenia 26.5%, leukopenia 20.4%. All-grade lymphopenia 95.9%, anemia 91.8%.
PD-1 benefit in mCRC rests on MSI-H/dMMR disease (KEYNOTE-177), not MSS. This single arm cannot show RT converts MSS IO resistance, because the doublet plus bevacizumab or cetuximab backbone is itself active first-line.
Median OS 23.2 mo carries a wide CI (15.1-31.3) at 19.9 mo median follow-up. Primary endpoint ETS is an 8-week shrinkage measure, not a durable outcome.
High early shrinkage (ETS 76.0%, ORR 68.0%) sits against short durability (1-yr PFS 33.4%, 1-yr DOR rate 20%), so durable immune conversion is not yet shown. The testable claim, that RT to all disease sites sensitizes MSS tumors to PD-1 blockade, needs a randomised design and biomarker selection, which the authors flag as a priority.
Single-arm phase I, N=50, surrogate primary (ETS); no RT-free or IO-free control, so neither RT nor tislelizumab contribution is isolated.
- RT contribution vs systemic therapy + PD-1 alone in MSS rectal cancer
- Predictive biomarkers for RT + PD-1 response in MSS disease n=497 · primary completion 2028-10 · ctDNA methylation response tracking, RT ± PD-1 in mCRC
- Optimal RT dose/fractionation to prime PD-1 response
📚 Sources · 🐦 1 tweet
MIRACLE-2: RT to primary/mets -> chemo + tislelizumab in MSS unresectable met rectal ca (N=50): 68% ORR & median OS 23 mo.
— Dr. Nina Niu Sanford (@NiuSanford) May 31, 2026
Early, single-arm data, but ~1 in 5 pts reached NED.
Suggests RT + systemic + PD1 blockade could overcome immune resistance in MSS mCRC. #ASCO26 @OncoAlert pic.twitter.com/sjnUW8x7f3
CAN-2409 NCT01436968
ForIntermediate or high-risk localised prostate cancer, EBRT candidates, ECOG 0-2
HR 0.70
95% CI 0.52-0.94, p=0.016; median NR vs 86.1 mo
TL;DRDFS HR 0.70 (0.52-0.94), 2y biopsy persistence/recurrence 19.6% vs 36.4%, adding intraprostatic aglatimagene to EBRT in intermediate/high-risk localised prostate cancer.
The effect is local: 2y post-treatment biopsy persistence/recurrence 19.6% vs 36.4% (p=0.0015), while OS and PCSM were not different (1 PCSM event per arm). That places it beside ADT, SIB and brachy boost as a local-intensification option; the discussant's RTOG 9408 benchmark, 4mo ADT added to 66.6 Gy, showed 2y positive biopsy 40% vs 20%.
In intermediate or high-risk localised prostate cancer planned for 78 Gy in 2 Gy, 60 Gy in 3 Gy or 70 Gy in 2.5 Gy fractions, this supports intraprostatic aglatimagene as a DFS-improving addition; it does not extend to pts whose EBRT includes a brachytherapy or SIB boost. The longer read
Local control is the RT read: 2y biopsy persistence/recurrence 19.6% vs 36.4% (p=0.0015) on 78 Gy or hypofractionated EBRT, with OS and PCSM not different. It sits beside ADT, SIB and brachy boost as local intensification, none of which was tested with it here.
| Trial | Arms | Local endpoint | Control vs intensified |
|---|---|---|---|
| RTOG 9408 | RT 66.6Gy vs + 4m ADT | 2yr post-Rx biopsy positive | 40% vs 20% |
| ASCENDE-RT | 46Gy + DE-EBRT 23Gy vs 46Gy + LDR-BT | 10y local failure | 7.1% vs 1.5% |
| FLAME | RT 77Gy vs + SIB 95Gy | Crude local failure | 7.7% vs 2.7% |
| CAN-2409 | RT 78Gy + placebo vs + CAN-2409 | 2yr post-Rx biopsy positive | 36.4% vs 19.6% |
8 details
Phase 3, randomised 2:1, double-blind, placebo-controlled at 51 US and Puerto Rico centres (26 community, 25 institutional or military). Accrual Feb 2012 to Sept 2021; median follow-up 50.3 mo (IQR 35.2-63.3).
Intermediate or high-risk localised prostate cancer planned for EBRT, age ≥18, ECOG 0-2. N=745 (496 vs 249); 591 (79%) White, 121 (16%) Black.
Three courses of intraprostatic aglatimagene (5 × 10^11 viral particles) plus valacyclovir vs placebo plus valacyclovir. Stratified by risk category and ADT use; ADT optional.
78 Gy in 2 Gy fractions, or hypofractionated 60 Gy in 3 Gy or 70 Gy in 2.5 Gy fractions. No boost regimen described in source.
Primary: DFS, time from randomisation to prostate cancer recurrence or death, ITT. Safety in all pts receiving ≥1 injection.
Per the discussant, the DFS gain was driven mainly by 2y post-treatment biopsy pCR; OS and PCSM not significantly different.
| Endpoint | Aglatimagene + valacyclovir | Placebo + valacyclovir | Effect |
|---|---|---|---|
| Median DFS | NR (95% CI 121.78-NR) | 86.1 mo | HR 0.70 (0.52-0.94), p=0.016 |
| 2y post-Rx biopsy pCR | 80.4% | 63.6% | not stated |
| 2y biopsy persistence/recurrence | 19.6% | 36.4% | p=0.0015 |
G3+ TEAEs 8% vs 7%; most common G3+ event AKI (2% each). SAEs 6% vs 7%, treatment-related SAEs 2% each. No treatment-related deaths.
The discussant set it against established local-intensification strategies: ADT in RTOG 9408, LDR brachy boost in ASCENDE-RT and focal SIB in FLAME. None was tested head-to-head or in combination with aglatimagene.
Long accrual (Feb 2012 to Sept 2021). Safety population (479 and 232) smaller than randomised arms (496 and 249). MFS and biochemical recurrence not presented; funded by Candel Therapeutics and NIH.
A positive blinded phase 3 of an oncolytic-viral agent with RT and no toxicity penalty, but the benefit currently rests on biopsy-defined local persistence. Whether that converts to MFS or PCSM, and whether it holds against boost-level dose intensification, is unsettled.
CONSORT flow
Blinded phase 3 met DFS at 50.3mo, but gain driven by 2y biopsy persistence; OS/PCSM not different, and no boost-level dose intensification in control.
- Does the biopsy-driven DFS gain translate into MFS or PCSM benefit?
- Added value over brachytherapy boost or focal SIB dose intensification
- Interaction with ADT use and duration
📚 Sources · 🐦 1 tweet · 📄 1 paper
🗣️Prostate Oral Abstract #ASCO25
— Michael Serzan, MD (@MikeSerzanMD) June 3, 2025
👉Dr @angela_jia_ discusses "Better Treatments, Better Selection: Improving Patient Outcomes in Localized Prostate Cancer"
🔑 KEY TAKE AWAYS
- #CAN2409 improves DFS and 2yr PathCR however PCSM and OS remain immature.
❓How to integrate with… pic.twitter.com/WamsneYBI1
Abstract
OCEANUS
ForAdvanced NSCLC receiving RT with ICI, newly diagnosed or ICI-refractory
TL;DRSequential RT+ICI mOS 20.3 vs 16.0 mo for concurrent, aHR 0.68 (0.47-0.99), in newly diagnosed advanced NSCLC; retrospective registry.
The RT-relevant gap is the exposure itself: the source text neither defines the sequential window nor reports dose, fractionation or target, so the timing signal cannot yet guide SBRT versus palliative-course scheduling around ICI. In refractory disease, continuing ICI after RT gave 11.2 vs 6.7 mo rwOS (P=.20), limited to 90-day survivors.
In newly diagnosed advanced NSCLC starting ICI with an RT indication, this adds observational support for sequencing RT rather than overlapping it; it does not extend to unresectable locally advanced disease, and in ICI-refractory disease the maintenance signal is non-significant. The longer read
Timing is the RT variable: sequencing RT around ICI rather than overlapping it tracked with longer rwOS in newly diagnosed advanced disease. Dose, fractionation, target and the sequential window are not reported in source text, so the signal cannot yet separate SBRT from palliative-course scheduling.
In ICI-refractory NSCLC, ICI maintenance after RT gave 11.2 vs 6.7 mo rwOS (P=.20), non-significant and limited to 90-day survivors. Chemotherapy tracked with longer rwOS only in newly diagnosed disease, magnitude not reported in source, so the systemic partner question stays open.
9 details 2 trials watching
Territory-wide retrospective cohort from the Hong Kong Hospital Authority CDARS database (more than 90% population coverage), NSCLC diagnosed 2010 to 2021. Overlap weighting was the primary propensity method, IPTW the sensitivity analysis; RMST was specified where proportional hazards failed.
Of 3522 ICI-treated pts, 335 received RT: 155 newly diagnosed advanced and 180 refractory NSCLC. 247 (73.7%) male, median age 64 (range 34-90).
RT dose, fractionation, modality, target site and the interval separating sequential from concurrent delivery are not reported in source text.
Primary: real-world OS after landmark, via weighted Kaplan-Meier and Cox models. Exposures: sequential vs concurrent RT+ICI (newly diagnosed), RT with vs without ICI maintenance (refractory), and receipt of chemotherapy.
Chemotherapy tracked with longer rwOS in newly diagnosed disease but not in refractory disease; no chemotherapy effect size in source text. IPTW estimates were similar to the primary analysis.
| Cohort | Exposure arm | Reference arm | Effect |
|---|---|---|---|
| Newly diagnosed advanced (n=155) | Sequential RT+ICI: 20.3 mo (13.3-NR) | Concurrent RT+ICI: 16.0 mo (8.3-30.0) | aHR 0.68 (0.47-0.99), P=.045 |
| Refractory (n=180) | RT + ICI maintenance: 11.2 mo (7.9-20.6) | RT without ICI maintenance: 6.7 mo (4.4-17.4) | P=.20 |
The source notes randomized data on RT+ICI sequencing are limited. PEMBRO-RT tested SBRT before pembrolizumab in advanced NSCLC, and PACIFIC placed ICI after concurrent chemoRT in unresectable locally advanced disease; neither randomized timing as this cohort compares it.
Undefined timing window and unreported RT parameters make the exposure heterogeneous, possibly mixing consolidative and palliative courses. The 2010 to 2021 window spans shifting first-line ICI practice, and any RMST estimates are not reported in source text.
A sequential advantage cuts against the common assumption that overlap maximises RT-ICI interaction, but urgent symptomatic RT given during ICI could explain it equally well. Whether continuing ICI after RT helps refractory disease remains open.
Retrospective propensity-weighted registry cohort; residual confounding by indication likely, upper CI bound 0.99 in n=155, and authors frame it as hypothesis generating.
- Does sequential vs concurrent RT+ICI timing change OS when randomized?
- Does continuing ICI after RT benefit refractory NSCLC? recruiting A Study Evaluating The Combination of Immunotherapy With Radiotherapy in Non-Small Cell Lung Cancer Phase 2n=39 · primary completion 2030-06 · post-IO progression, ICI + ablative hypofractionated RT
- Which RT dose and target drive any timing effect? n=366 · primary completion 2027-06 · abscopal control across RT fractionation arms + ICI
📚 Sources · 📄 1 paper
Abstract
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%).
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.
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
The RT is unchanged: 55Gy/20fr bladder, 46Gy/20fr to nodes in the N+ expansion, standard UK practice, so no target-volume or dose decision moves. The trial's value for an RT reader is that a 12-month adjuvant IO tail can be run around that backbone at all, though only 61% completed it.
Durvalumab was given in all three positions (neoadjuvant, synchronous, adjuvant 12 months) on a 5FU/MMC backbone, and 39% discontinued early. That delivery figure, not the 80% DFS, is what constrains which durvalumab schedule is worth randomising in bladder preservation.
+3 more figures
| Treatment status | N = 54 | % |
|---|---|---|
| Completed planned treatment | 33 | 61 |
| Discontinued early | 21 | 39 |
| Baseline | Number | % |
|---|---|---|
| Age, median (IQR) | 69 | 62-76 |
| Female | 10 | 18 |
| Male | 45 | 82 |
| Prior neoadjuvant chemo, yes | 41 | 75 |
| cT2 | 44 | 80 |
| cT3 | 11 | 20 |
| N+ | 7 | 13 |
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.
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
📚 Sources · 🐦 3 tweets
RAD-IO at #ASCO26: durvalumab added to chemoradiation in muscle-invasive bladder cancer cleared its efficacy bar in a bladder-preservation approach. Single-arm, benchmarked against prior CRT data.
— Katy Beckermann (@katy_beckermann) May 30, 2026
Durvalumab given before, during, and 12 months after chemoRT (55Gy/20Fr +… pic.twitter.com/UXxwoZzaMC
#ASCO26 🔬 Abstract 4504 | RAD-IO
— Dra. María Natalia Gandur Quiroga (@nataliagandur) May 30, 2026
Durvalumab + chemoradiotherapy in muscle-invasive bladder cancer
Presented by Nicholas D. James, PhD, MBBS, FRCP@OncoAlert@ASCO
Bladder preservation in MIBC remains one of the most important curative-intent questions in GU oncology.
The key… pic.twitter.com/W6JqzTVsJ3
RAD-IO: chemoradiation (5FU+MMC) + Durva in MIBC. #ASCO26 pic.twitter.com/yTyhkdjCox
— Álvaro Pinto (@dralvaropinto) May 30, 2026
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.
EV209EV309RAMPART
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.
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
The delivery slide is the actionable part: full 55 Gy in 20 fractions in 54 (100) with no extension or delay in 47 (87) while durvalumab ran concurrently, so RT intensity survived the combination. EV-309 then makes chemoradiotherapy the randomised control arm for a drug-only bladder-sparing strategy.
Systemic components absorbed the attrition: chemotherapy discontinued early in 12 (22) and durvalumab in 21 (39). In adjuvant RCC the discussant's position is that adjuvant IO has no proven benefit in non-clear cell disease, while ctDNA separates 24-mo DFS far better than pathology (79.9% vs 38.8% on pembrolizumab).
EV-209 keeps cystectomy as the fallback for non-clinical-CR pts in cystectomy-eligible cT2-4a N0 MIBC (N=240), and EV-309 (N=390) enrols only pts ineligible for or refusing cystectomy. Bladder-intact event-free survival counts cystectomy as an event, so the trials are structured around deferring surgery, not replacing it outright.
+2 more figures
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.
| Component | Outcome | Number (%) |
|---|---|---|
| Radiotherapy | Received full 55 Gy in 20 fractions | 54 (100) |
| Radiotherapy | No extension or delay | 47 (87) |
| Chemotherapy | Mitomycin C dose reduced | 4 (7) |
| Chemotherapy | 5-FU Week 1 dose reduced | 9 (17) |
| Chemotherapy | Chemotherapy discontinued early | 12 (22) |
| Durvalumab | Completed | 33 (61) |
| Durvalumab | Discontinued early | 21 (39) |
- Long-term bladder preservation, function and QoL after chemoradiation plus durvalumab n=11 · primary completion 2026-02 · chemoRT +/- durvalumab, node-positive bladder
- Whether EV-based bladder sparing beats chemoradiotherapy on BIEFS and OS recruiting A Study to Find Out if Enfortumab Vedotin Given With Pembrolizumab Helps People With Muscle-invasive Bladder Cancer Keep Their Bladder Phase 2n=240 · primary completion 2027-11 · phase 2 EV+pembro bladder-sparing, n=240recruiting Enfortumab Vedotin in Combination With Pembrolizumab vs. Concurrent Chemoradiotherapy (cCRT) in People With Muscle Invasive Bladder Cancer (EV-309) Phase 3n=390 · primary completion 2030-03 · phase 3 EV+pembro vs cCRT, bladder preservationn=56 · primary completion 2031-04 · response-adapted EVP induction, cCRT or RC on failure
- Whether ctDNA-guided selection changes adjuvant RCC outcomes
📚 Sources · 🐦 1 tweet
#ASCO26 GU Oncology Spotlight 🚨
— Dra. María Natalia Gandur Quiroga (@nataliagandur) May 30, 2026
🔬 Living Longer, Living Better: Can We Have It All?
Discussant: Brian I. Rini, MD, FASCO@OncoAlert@ASCO
This GU session captured one of the central tensions in curative-intent oncology:
Can we improve cure rates while preserving quality of… pic.twitter.com/AMwrRZZM2Q
Neo-CRAG
ForcT3N2-3M0 / cT4 gastric or Siewert II-III EGJ adenocarcinoma, D2-resectable
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.
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.
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
Conventional 45Gy/25fx delivered preoperatively, after cycle 1 of chemo, halved locoregional recurrence after R0 resection (9.4% vs 18.3%) with no excess G3+ postoperative complications (9.0% vs 7.6%). That combination, a local-control gain without a surgical-morbidity cost, is what the omission decision in node-heavy cT3N2+ disease has been waiting for.
The systemic backbone was XELOX in both arms, so the DFS gain is attributable to radiotherapy rather than to the regimen, but the control arm's 37.6 mo median OS is the caveat: this does not tell you whether radiotherapy still adds on top of FLOT, whose own advantage is partly locoregional. Sequencing of RT after cycle 1 with attenuated dosing was deliverable.
Every pt was intended for standardized D2 resection, and preoperative chemoRT did not degrade it: G3+ postoperative complications were 9.0% vs 7.6%, and 448 of 620 randomised pts reached gastrectomy. ypN0 rose to 56.1% from 36.4%, which changes what the surgeon can expect to find in the nodal basin rather than the extent of dissection required.
| Endpoint | CRT | CT | Effect size |
|---|---|---|---|
| 3yr DFS | 55.6% (50.1-61.1) | 42.4% (36.9-47.9) | HR 0.750 (0.607-0.928), P=0.008 |
| Median DFS | 52.7 mo | 24.4 mo | n/a |
| 5yr OS | 50.1% | 44.2% | HR 0.781 (0.628-0.970), P=0.025 |
| Median OS | 67.5 mo | 37.6 mo | n/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.
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
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
📚 Sources · 🐦 1 tweet
Neo-CRAG: Ph3 RCT (n=620, gastric/GEJ) - adding neoadj chemoRT to peri-op XELOX improved OS (68 v 38 mo).
— Dr. Nina Niu Sanford (@NiuSanford) May 30, 2026
Limitation=non-FLOT, BUT still relevant IMO b/c:
1) DFS/OS benefit substantial.
2) Improvements in pCR, downstg, LRR supports plausible RT effect on OS. #ASCO26 @OncoAlert pic.twitter.com/eeM0Z8p20M
SWOG/NRG S1914 NCT04214262
ForT1-3N0M0 NSCLC ≤7cm, medically inoperable or declined surgery, ≥1 risk factor
HR 1.15
95% CI 0.65-2.01, p=0.63; primary endpoint not met
TL;DROS HR 1.15 (0.65-2.01), p=0.63: atezolizumab added to SBRT failed, with more local failures (13% vs 7%) and G≥3 AEs (12% vs 2%).
The RT read is that adding IO did not just fail to help, it tracked with MORE local failure (13% vs 7%), inside a BED ≥100 Gy 3-8 fraction regimen that is already delivering >90% in-field control. Central review of those events is pending, so treat the local signal as unconfirmed. This closes the question of routinely sequencing atezolizumab around definitive SBRT off-protocol.
In medically inoperable T1-3N0M0 NSCLC with high-risk features (size ≥2 cm, SUV ≥6.2, or poorly differentiated histology), this supports SBRT alone at BED ≥100 Gy without added checkpoint blockade; it does not address IO for node-positive or operable early-stage disease. The longer read
SBRT alone at BED ≥100 Gy in 3-8 fractions remains the standard, and adding atezolizumab tracked with MORE local failure (13% vs 7%) rather than better in-field durability. Central review of those events is pending. Regional (2% vs 3%) and distant (4% vs 5%) failure were unchanged, so the out-of-field rationale also went unrewarded.
Neoadjuvant/concurrent/adjuvant atezolizumab 1200 mg Q3W × 8 cycles bought no OS or PFS benefit and cost a six-fold rise in G≥3 AEs (12% vs 2%) including a G5 respiratory failure. This argues against porting PACIFIC-style consolidation logic into node-negative early-stage disease pending the PD-L1 analysis.
11 details
Randomized phase III SWOG/NRG cooperative-group trial, accrual 8/13/20 to 9/6/24, 417 randomized / 403 eligible (201 SBRT alone, 202 atezolizumab + SBRT) against an accrual goal of 432. Closed at the first interim analysis for futility on both OS and PFS. Median follow-up in living pts was 12 months (range 0.03-49).
T1-3N0M0 NSCLC ≤7 cm, medically inoperable or declined surgery, with ≥1 recurrence risk factor: tumor diameter ≥2 cm, ≥6.2 (SUV), or moderately/poorly/undifferentiated histology. Median age 73 (41-91), 89% ECOG 0-1, median tumor diameter 2.3 cm. Stratified by location (central vs peripheral), size (<4 vs ≥4 cm) and PS.
SBRT in 3-8 fractions to a BED ≥100 Gy in both arms, i.e. standard definitive dosing rather than a de-escalated backbone. In the experimental arm SBRT began with cycle 3, so radiation was delivered after two neoadjuvant atezolizumab cycles and concurrently with the third.
Atezolizumab 1200 mg IV Q3W for 8 cycles, given neoadjuvantly, concurrently and adjuvantly around SBRT. No protocol treatment was received by 6 pts on S and 8 on AS.
Primary: overall survival, compared by 1-sided stratified log-rank at the 2.5% level. Secondary: PFS, failure patterns, toxicity, QoL.
Neither OS nor PFS favored the IO arm, and local failure ran higher with atezolizumab. See the failure-pattern table and primary endpoint above.
| Failure site | SBRT alone | Atezo + SBRT |
|---|---|---|
| Local | 7% | 13% |
| Regional | 2% | 3% |
| Distant | 4% | 5% |
G≥3 AEs 12% on AS vs 2% on S (21 G3, 1 G4, and 1 G5 respiratory failure with atezolizumab; 3 G3 and 1 G4 with SBRT alone). A six-fold excess of high-grade toxicity with no efficacy return is the safety read.
The prior randomized phase II (PMID 37478883) suggested benefit from adding immunotherapy to SBRT; this larger phase III does not reproduce it. It also sits against PACIFIC-era logic, where consolidation IO helps after chemoRT for stage III, and shows that result does not port down to node-negative disease treated with ablative SBRT.
Follow-up is short (median 12 mo alive) and central review of local recurrence events is not complete, so the local-failure imbalance is provisional. The smoker subgroup harm signal was not multiplicity-controlled, and PD-L1 status, QoL and correlative blood/tissue analyses are all still pending.
A negative primary endpoint with a directionally worse PFS, worse local control and six-fold more high-grade toxicity is stronger than a null result: it argues against the abscopal/radiosensitization rationale in this setting. It does not exclude benefit in a biomarker-selected subset, which the pending PD-L1 analysis will test.
CONSORT flow
Phase III, primary OS endpoint not met, closed at interim for futility. Reaffirms SBRT alone as SoC and refutes the earlier phase II IO signal.
- Does a PD-L1-defined subset benefit from IO added to SBRT?
- Will central review confirm the excess local failures with atezolizumab?
- Is the worse outcome in former/never smokers real or chance?
📚 Sources · 📄 1 paper
Abstract
Bladder-preserving TMT multicenter analysis (URONCOR)
ForcT2-T4aN0M0 MIBC treated with definitive TMT, median age 76
TL;DRCLR 63.7% in a 369-pt Spanish TMT cohort; salvage cystectomy 9.7%, image-guidance quality and 5-FU-based CRT predicted local response.
The modifiable RT variable here is verification protocol: weekly portal imaging carried OR 0.35 (0.20-0.60) for complete local response, with VMAT trending favorable, across a 2010 to 2022 accrual. Dose, fractionation and target volume are not reported in source, so what transfers is the case for daily volumetric IGRT in a filling, moving organ.
In cT2-T4aN0M0 MIBC pts in their seventies weighing bladder preservation against cystectomy, this real-world series supports TMT delivered with modern image guidance and a 5-FU-based backbone; it does not inform node-positive or metastatic disease and carries no head-to-head against radical cystectomy. The longer read
Verification protocol is the modifiable variable: weekly portal imaging carried OR 0.35 (0.20-0.60) for complete local response, with VMAT trending favorable. Dose, fractionation and target volume are not reported in source, so what transfers is the case for daily volumetric IGRT and adaptive planning rather than a specific prescription.
The concurrent backbone mattered: 5-FU-based CRT carried OR 4.9 (1.1-22.1) for complete local response, though the CI leaves the magnitude open and comparator regimens are unnamed in source. Systemic failure at 10.7% ran at or above local-only failure at 10.1%, keeping perioperative systemic therapy questions live.
Salvage cystectomy was performed in 9.7% against 28.8% who progressed, so in a median-age-76 cohort most failures were not surgically rescued. With no in-cohort cystectomy comparator, this informs counseling on bladder preservation for cT2-T4aN0M0 disease without establishing equivalence to upfront radical cystectomy.
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Multicenter retrospective cohort, Spain, 2010 to 2022, N=369 treated with definitive trimodality therapy (maximal TURBT then concurrent chemoradiotherapy). Predictors of response identified by multivariable logistic regression. Follow-up duration not reported in source.
cT2-T4aN0M0 MIBC selected for bladder preservation. Median age 76, 85.1% male. Fitness for cystectomy and completeness of TURBT are not reported in source.
Concurrent chemoradiotherapy, regimen at each center's discretion. 5-FU-based CRT predicted higher complete local response (OR 4.9, 95% CI 1.1-22.1, p=0.038). The comparator regimens are not named in source.
Dose, fractionation and target volume are not reported in source. The only technique signals reported are verification frequency (weekly portal imaging, OR 0.35 for CLR) and a non-significant trend favoring VMAT.
complete local response (CLR). Secondary: OS, CSS, recurrence patterns, salvage cystectomy. No OS or CSS estimate appears in the source, so the survival half of the conclusion cannot be checked.
CLR 63.7%, salvage cystectomy 9.7%. Progression 28.8%, with systemic failure (10.7%) running at or above local-only failure (10.1%).
BC2001 established the locoregional-control gain from adding chemotherapy to bladder radiotherapy, and the pooled RTOG bladder-preservation experience set the complete-response benchmark; both were protocol populations. This adds European real-world multicenter data at a median age of 76, with no internal cystectomy comparator.
No follow-up duration, OS or CSS estimate is reported, so the durability behind the preservation claim cannot be judged. The 5-FU odds ratio spans 1.1 to 22.1, compatible with a marginal or a large effect, and in a retrospective series regimen choice tracks renal function and performance status.
Systemic failure at 10.7% running at or above local-only failure at 10.1% argues the ceiling in this population is micrometastatic disease rather than the bladder, which caps what further local intensification can buy. Read conservatively, the predictors favor modern image guidance and an active concurrent backbone, not any specific verification schedule.
Retrospective multicenter cohort with no cystectomy comparator; imaging and chemo predictors come from multivariable regression across a 2010-2022 era shift, so a causal reading is unsupported.
- Does daily volumetric IGRT improve complete local response vs weekly portal imaging?
- Which concurrent chemotherapy backbone maximizes complete local response in TMT?
- Long-term bladder-intact survival vs radical cystectomy in matched populations
📚 Sources · 🐦 1 tweet
📢 Presentamos en #ESTRO26 nuestro análisis multicéntrico sobre preservación vesical en cáncer vesical músculo-invasivo tratado con TMT.
— URONCOR (@URONCOR) May 19, 2026
🔎 En 369 pacientes, la respuesta completa clínica se asoció a menor recurrencia local y mejor supervivencia!@fcounago #NicoFeltes pic.twitter.com/aQjjkcHGP4
OPERA
ForRectal cancer on watch-and-wait pathway after neoadjuvant therapy
TL;DRW14 clinical response (DRE+rectoscopy) identified 76% good responders; 5yr organ preservation 75% A vs 83% B, p=0.24.
The transferable read is timing: response can be called at W14, one month after NAT ends, on DRE plus rectoscopy, with MRI TRG1-2 concordance of 98% (80/82). nCR at W14 preserved organs as well as cCR (77% vs 81%), so a near-complete response reflecting radiation effect does not by itself send a patient to TME.
In rectal pts on a watch-and-wait pathway, this supports assessing response at W14 rather than deferring to W24 and reassessing nCR rather than treating it as failure; it does not address pts never eligible for organ preservation. The longer read
Response can be called at W14, one month after NAT ends, on DRE plus rectoscopy, with MRI TRG1-2 concordance of 98% (80/82). nCR at that point preserved organs as well as cCR (77% vs 81%), so a near-complete response reflecting radiation effect does not itself justify TME.
The surgical decision this moves is when to abandon watch-and-wait. A W14 nCR reached 5yr organ preservation of 77% versus 81% for cCR, so early near-complete response is not evidence for proceeding to TME. Regrowth and salvage counts are not reported in source.
| Endpoint | Arm A | Arm B | Overall |
|---|---|---|---|
| W14 good response (cCR+nCR) | 65% | 88% | 76% |
| W14 partial response | n/a | n/a | 24% |
| 5yr organ preservation | 75% | 83% | p=0.24 |
| CTRE performed at W14 | n/a | n/a | 122/141 (87%) |
+2 more figures
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Post-hoc analysis of the randomised OPERA trial (two arms, A and B), reporting 5-year organ-preservation outcomes. The parent trial assessed response at week 24 with a three-modality triad (DRE, rectoscopy, MRI); this analysis asks whether the week 14 read is good enough.
Week-14 clinical tumor response evaluation (CTRE) by DRE and rectoscopy, categorised CR / nCR / PR, with cCR + nCR counted as a "good" clinical response. MRI graded by TRG. CTRE was correlated with relapse and 5-year organ-preservation rates.
Both arms received neoadjuvant therapy with organ preservation as the goal, and good responders at W14 either proceeded to organ preservation or were reassessed at W24. Dose, fractionation, and the content distinguishing Arm A from Arm B are not reported in source, which limits how far the arm difference transfers.
CTRE was obtainable in 122/141 (87%) at W14. MRI confirmed TRG1-2 in 98% (80/82) of clinical CR pts, and 5-year organ preservation did not differ by arm (p=0.24) or by response depth (cCR 81% vs nCR 77%).
Watch-and-wait practice has largely settled on later response assessment, with the OPRA framing of consolidation timing and the registry experience both anchoring the decision point well beyond three months. This analysis argues the clinical exam carries most of that information a month after NAT ends, which is earlier than the field currently commits.
The 19 pts without CTRE at W14 (141 minus 122) are unaccounted for in source, and selective assessability would bias the 76% good-response figure upward. The arm difference (88% vs 65%, p=0.004) is uninterpretable here because the randomised contrast is not described.
The clinically useful claim is that nCR is a radiation effect, not residual tumor, and the 5-year organ-preservation parity between cCR and nCR (81% vs 77%) is the evidence for it. What the source does not settle is regrowth: organ preservation at 5 years is a net figure that can absorb salvage, so equal preservation does not establish equal local control.
Post-hoc timepoint analysis of 141 pts; W14 vs W24 assessment was never randomised, and no relapse or regrowth data reported in source.
- Regrowth and salvage rates behind the 5yr organ preservation figures
- What distinguished Arm A from Arm B
- Outcomes of the 19 pts without W14 CTRE
📚 Sources · 🐦 1 tweet
Day FOUR of #ESTRO26 Coverage by OncoAlert 🚨
— OncoAlert (@OncoAlert) May 18, 2026
Five-year Results of the OPERA Trial: When and How to Assess Tumor Response to Guide Rectal Preservation Presented by Syrine Ben Dhia 🇫🇷 #RadOnc ☢️
This post-hoc analysis of the OPERA trial evaluated early tumor response… pic.twitter.com/KUanFTxeFh