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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 →

Trials discussed

NRG/RTOG 9601NRG/RTOG 0534NRG-GU006NRG GU-009

Why it mattersRadiation oncology

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.

Monday clinic

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

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 settingDecipherPCSM benefit at 15 yr
Early salvage>0.6>5%
Late salvageAny>5%
Early salvageLow (≤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.

post-prostatectomy pts receiving salvage prostate bed RT with a decision about adding hormone therapy
Does not represent the intact-prostate definitive setting or the decision about pelvic nodal RT.

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
📄 PAPER · UroToday
Genomic Biomarkers to Guide Hormone Therapy With Salvage Radiation: Decipher and PAM50 in NRG/RTOG 9601 and 0534 - Krishnan Patel & Shuang (George) Zhao
Abstract
UroToday - GU OncToday brings coverage of the clinically relevant content needed to stay at the forefront of the dynamic field of GU oncology and urology.
📝 https://www.urotoday.com/video-lectures/genomic-classifier-in-prostate-cancer-post-radical-prostatectomy/video/5950-pam50-molecular-subtypes-in-prostate-cancer-trials-krishnan-patel-george-zhao.html?mtm_campaign=Patel_Zhao_SocialVideo_ID5950
Early signal

PE-PE NCT05578664

ForOligometastatic RCC, ≤3 mets within 5y of prior nephrectomy, MDT-eligible

Relapse-free survival surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

post-nephrectomy omRCC with ≤3 metastases within 5 years, all sites treatable by SABR or surgery
Does not represent pts with >3 metastases, no prior nephrectomy, or relapse beyond 5 years.

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.

EndpointP+MDT (n=56)MDT alone (n=29)Effect
Median RFS25.4 mo11.0 moHR 0.47 (95% CI 0.24-0.92), p=0.024
RFS events191635 total
Any AE80%21%n/a
G3 AE7%3%n/a
CONSORT flow
Randomized85
↓
P+MDT
allocated 56
mRFS 25.4 mo
MDT alone
allocated 29
mRFS 11.0 mo

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
📄 PAPER Roberto Iacovelli · ESMO Congress 2026 (2026-10)
PErioperative PEmbrolizumab (P) plus metastasis-directed therapy (MDT) versus MDT alone in patients (pts) with oligometastatic renal cell carcinoma (omRCC): The randomized phase II PE-PE trial
Abstract
ESMO Congress 2026 abstract LBA88 · Proffered paper 2: Genitourinary tumours, renal and urothelial · 2026-10-25 · presented by Roberto Iacovelli (Rome, Italy) · NCT05578664<br/><br/>Background: Adjuvant P is the standard of care for pts with intermediate-high/high risk of relapse after nephrectomy (Nx), as well as for those with M1NED within 1y of previous Nx. Although omRCC pts may receive anti-PD-1-based combos, the optimal management of those eligible for MDT remains uncertain.<br/>Methods: The PE-PE trial (NCT05578664) is a randomized, open-label, multicenter phase II study evaluating the efficacy of P in delaying tumor progression for omRCC pts candidates for MDT, including surgery or SABR to all metastatic sites. Eligible pts had undergone prior Nx and presented with ≤3 metastases within 5 years of Nx or previous metastasectomy. Pts were randomized 2:1 to receive P 400 mg every 6 weeks for 9 cycles (1 year) plus MDT (P+MDT) or MDT alone. The first dose of P was administered before MDT. The primary endpoint was relapse-free survival (RFS), while others included distant RFS, local relapse, OS, and safety.<br/>Results: 85 pts were randomized between March 2023 and February 2026: 56 to the P+MDT arm and 29 to the MDT-alone arm. Baseline characteristics were well balanced between treatment groups. SABR was selected in 73% vs. 72% of pts, while surgery was performed in 23% vs. 28%, respectively. The median number of P cycles administered was 6.6. The most frequent reasons for P discontinuation were disease progression (11 pts) and adverse events (AE, 4 pts). After a median follow-up of 17.5 mos, 35 RFS events were observed (19 vs.16), with two deaths (one in each arm). Median RFS was 25.4 mos in the P+MDT arm vs. 11.0 mos in the MDT-alone arm (HR 0.47; 95% CI, 0.24-0.92; p=0.024). Regarding safety, 80% vs. 21% of pts experienced at least one AE, while G3 AEs occurred in 7% vs. 3% of pts in the P+MDT and MDT-alone arms, respectively. P-related AEs of any G occurred in 59%, the most common being hypothyroidism (23%), fatigue (18%), and diarrhea (16%). Two pts experienced G3 toxicity without G4 or 5.<br/>Conclusions: The PE-PE trial supports the use of 1 year of perioperative P in pts with omRCC eligible for MDT, demonstrating a statistically significant and clinically meaningful improvement in RFS with a manageable and consistent safety profile.<br/>Clinical trial identification: NCT05578664.
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

cT3-4 or N+ rectal adenocarcinoma ≤10 cm from the anal verge treated with curative-intent TNT
Does not represent upper rectal tumors beyond 10 cm, watch-and-wait candidates, or settings without camrelizumab.

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.

EndpointSCRT + camrelizumab + CAPOXLCCRT + CAPOXEffect
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 TRAE51.3% (59/115)48.2% (54/112)n/a
Median f/u36.8 mo (34.8-37.8)35.6 mo (34.3-36.9)n/a
CONSORT flow
Randomized231
↓
SCRT + camrelizumab + CAPOX
allocated 113
LCCRT + CAPOX (SOC)
allocated 118

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.

📚 Sources · 📄 1 paper
📄 PAPER Zhen Yu Lin · ESMO Congress 2026 (2026-10)
Neoadjuvant short-course radiotherapy followed by camrelizumab and chemotherapy in locally advanced rectal cancer (LARC): The phase 3 UNION trial
Abstract
ESMO Congress 2026 abstract 3530O · Proffered paper: Gastrointestinal tumours, lower digestive · 2026-10-25 · presented by Zhen Yu Lin (Wuhan, China) · NCT04928807<br/><br/>Background: Despite the use of neoadjuvant chemoradiotherapy, recurrence and distant metastasis remain common in LARC. Effective immunotherapy-based strategies for the predominantly proficient mismatch repair/microsatellite-stable population remain limited. UNION is the first phase 3 trial to evaluate a neoadjuvant strategy incorporating radiotherapy, immunotherapy, and chemotherapy in LARC. Here we present the prespecified event-free survival (EFS) analysis.<br/>Methods: Patients with cT3-4 or N+ rectal adenocarcinoma (tumor located ≤10 cm from the anal verge) were randomly assigned (1:1) to receive short-course radiotherapy (SCRT; 25 Gy/5f; experimental group) or long-course chemoradiotherapy (50.4 Gy/28f with concurrent capecitabine 825 mg/m2 twice daily; standard of care group) followed by 2 neoadjuvant cycles and 6 adjuvant cycles of capecitabine and oxaliplatin (CAPOX). The experimental group additionally received neoadjuvant and adjuvant camrelizumab (200 mg, day 1) since CAPOX treatment for up to 17 cycles. The primary endpoint was blinded independent review committee (BIRC)-assessed pathological complete response rate. Key secondary endpoints with prespecified α allocation were investigator-assessed EFS and overall survival.<br/>Results: Between July 2021 and March 2023, 231 patients were randomized to the experimental group (n=113) and standard of care group (n=118). As of October 1, 2025, the median follow-up duration was 36.8 months (95% CI, 34.8-37.8) and 35.6 months (95% CI, 34.3-36.9), respectively. The 3-year EFS rate was significantly higher in the experimental group compared with standard of care (91.3% [95% CI, 83.9-95.4] vs 77.4% [95% CI, 67.9-84.4], hazard ratio=0.33 [95% CI, 0.15-0.71], P=0.0029). BIRC-assessed EFS consistently favored the experimental group. During the whole treatment period, the incidence of grade ≥3 treatment-related adverse events was 51.3% (59/115) and 48.2% (54/112), respectively.<br/>Conclusions: UNION is the first phase 3 trial to demonstrate a significant improvement in EFS with an immunotherapy-based regimen in LARC. This neoadjuvant strategy represents a new standard of care.<br/>Clinical trial identification: NCT04928807.
Confirmatory

KEYNOTE-975 NCT04210115

ForUntreated unresectable locally advanced ESCC/EAC/GEJ, dCRT candidates

Event-free survival (PD-L1 CPS ≥10) surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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 + dCRTPbo + dCRTHR (95% CI), P
Median EFS (investigator)15.2 mo14.7 mo0.97 (0.77-1.23), P=0.3994; boundary 0.0193
Median OS32.2 mo35.0 mo1.00 (0.77-1.30), nominal P=0.5003
AEPembro + dCRTPbo + dCRT
Grade ≥3100%100%
Grade 544 (13%)37 (10%)
Discontinuation for any AE117 (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.

untreated unresectable locally advanced esophageal/GEJ cancer treated with concurrent pembro and 50-60 Gy dCRT
Does not represent consolidation-only IO after dCRT or resectable trimodality pts.

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
Randomized703
↓
Pembro + dCRT
allocated 349
Pbo + dCRT
allocated 354

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
📄 PAPER Manish A. Shah · ESMO Congress 2026 (2026-10)
Pembrolizumab or placebo plus concurrent definitive chemoradiotherapy in esophageal and gastroesophageal junction (GEJ) cancer: The phase 3 randomized KEYNOTE-975 study
Abstract
ESMO Congress 2026 abstract 2875O · Proffered paper 1: Gastrointestinal tumour, upper digestive · 2026-10-23 · presented by Manish A. Shah (New York, United States of America) · NCT04210115<br/><br/>Background: The role of immunotherapy in participants (pts) with locally advanced, esophageal cancer (EC) treated with definitive chemoradiotherapy (dCRT) is not established. KEYNOTE-975 (NCT04210115) is an international phase 3, randomized, double-blind, placebo (pbo) controlled multicenter study that examines dCRT ± pembro in pts with previously untreated locally advanced unresectable esophageal and GEJ cancer. We report results from the second interim analysis (IA2).<br/>Methods: Eligible pts with histologically confirmed cTX N+ M0 or cT2-T4a NX M0 esophageal squamous cell cancer (ESCC) or adenocarcinoma (EAC) or GEJ cancer, or cTX N+ M1 cervical or upper thoracic EC with supraclavicular lymph node metastases only, ECOG PS 0-1, and who were ineligible for curative surgery but suitable for dCRT, were randomized 1:1 to 200 mg pembro or pbo Q3W for 8 cycles then 400 mg pembro or pbo Q6W for 5 cycles + site choice of dCRT (5-fluorouracil + cisplatin [FP] with radiotherapy [RT] 50 Gy or 60 Gy, or FOLFOX with RT 50 Gy). Dual-primary endpoints were event-free survival (EFS) by investigator and OS in pts with PD-L1 combined positive score (CPS) ≥10, CPS ≥1, and all pts. Data cut-off was Jan 21, 2026.<br/>Results: A total of 703 pts were randomized (349 pembro + dCRT; 354 pbo + dCRT). Median follow-up was 47.1 mo (range, 21.7-70.2) in all pts. At IA2, in pts with PD-L1 CPS ≥10, EFS was not improved with pembro + dCRT vs pbo + dCRT (median 15.2 vs 14.7 mo; HR 0.97; 95% CI, 0.77-1.23 [P=0.3994; P-value boundary for significance 0.0193). In pts with PD-L1 CPS ≥10, median OS was 32.2 mo vs 35.0 mo (HR 1.00; 95% CI, 0.77-1.30 [nominal P-value 0.5003]). As EFS was not positive in PD-L1 CPS ≥10, EFS in PD-L1 CPS ≥1 and all pts, and OS were not tested for statistical significance, and the study was stopped. Grade ≥3 AEs occurred in 100% of pts in each arm, with grade 5 AEs in 44 (13%) vs 37 (10%) pts. Discontinuation due to any AE occurred in 117 (34%) vs 97 (27%) pts.<br/>Conclusions: Pembrolizumab + dCRT vs pbo + dCRT did not significantly improve EFS in untreated unresectable esophageal or GEJ cancer with PD-L1 CPS ≥10. No new safety signals were observed.<br/>Clinical trial identification: NCT04210115.
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

Bladder preservation after neoadjuvant/perioperative therapy in MIBC (reTURBT cohort)
Group24-mo EFS24-mo OS
reTURBT pCR87.6%96.7%
reTURBT vs RC, pCR (HR)1.96 (0.53-7.27)0.90 (0.10-8.40)
reTURBT non-pCR19.3%50.4%
RC non-pCR67.8%82.5%
+2 more figures
reTURBT group (N=53): 36-mo EFS 66.7% (95% CI 54.5-81.7); MFS 65.9% (50.9-85.4); 36-mo OS 82.7% (95% CI 72.4-94.6).
reTURBT group (N=53): 36-mo EFS 66.7% (95% CI 54.5-81.7); MFS 65.9% (50.9-85.4); 36-mo OS 82.7% (95% CI 72.4-94.6).
N = 279 enrolled 02/2017-07/2025: RC n = 213 (76.4%), reTURBT n = 54 (19.3%), no surgery n = 12 (4.3%).
N = 279 enrolled 02/2017-07/2025: RC n = 213 (76.4%), reTURBT n = 54 (19.3%), no surgery n = 12 (4.3%).
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.

MIBC pts with ypT0 at reTURBT after neoadjuvant IO- or ADC-based therapy who decline RC
Does not represent pts with residual disease at reTURBT, node-positive disease, or non-urothelial-predominant histology.

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.

📚 Sources · 🐦 1 tweet

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).

Trials discussed

STAMPEDEENZARADPROTEUSDASL

Why it mattersRadiation oncology

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.

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
Caveats dominate

PROTEUS Substudy

ForHR LPC/LAPC, conventionally staged M0, planned RP + PLND

Event-free survival surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

Also covered Aug 29 May 31

PROTEUS Substudy
ArmMedianRate (95% CI)
APA + ADTNot reached63.0% (52.2-71.9)
RP + PLND alone19.1 months41.4% (35.6-47.1)
HR 0.38 (95% CI 0.26-0.55)p<0.0001n/a
+3 more figures
PROTEUS Substudy
Metastasis detection method, n (%)APA + ADTRP + PLND
PSMA PET9 (8.8)50 (16.3)
Conventional imaging1 (1.0)6 (2.0)
MFS HR 0.49 (95% CI 0.26-0.90)nominal p=0.0193n/a
PROTEUS Substudy
ArmMedian time to first subsequent therapy
APA + ADT46.0 months
RP + PLND alone12.3 months
HR 0.29 (95% CI 0.20-0.43), nominal p<0.0001n/a
PROTEUS Substudy
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.

conventionally staged M0 HR LPC/LAPC treated with RP + PLND
Does not represent PSMA PET-staged pts or men treated with definitive RT.

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
Randomized408
↓
APA + ADT + RP + PLND
allocated 102
EFS median not reached
RP + PLND alone
allocated 306
EFS median 19.1 months

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.

📚 Sources · 🐦 2 tweets
Confirmatory

PORTEC-3 NCT00411138

ForHigh-risk endometrial cancer, FIGO 2009 stage I-III, post-hysterectomy

Overall survival (co-primary with failure-free survival)

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).

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

high-risk endometrial cancer, FIGO 2009 stage I-III after hysterectomy, fit for platinum doublet, with stage III carrying the FFS gain
Does not represent stage IV disease or settings comparing CRT against chemotherapy alone.

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.

EndpointCRTRT aloneEffect
5y OS81.8% (77.5–86.2)76.7% (72.1–81.6)HR 0.76 (0.54–1.06), p=0.11
5y FFS75.5% (70.3–79.9)68.6% (63.1–73.4)HR 0.71 (0.53–0.95), p=0.022
Stage III 5y OS78.7%69.8%HR 0.71 (0.45–1.11), adjusted p=0.074
Stage III 5y FFS69.3%58.0%HR 0.66 (0.45–0.97), adjusted p=0.014
Stage I–II 5y FFS80.8%76.6%HR 0.85 (0.54–1.33), p=0.47
G3+ AEs during treatment198 (60%)41 (12%)p<0.0001
G2+ neuropathy at 3y20 (8%)1 (1%)p<0.0001
CONSORT flow
Assessed / enrolled 686
↓
Randomized686
↓
Chemoradiotherapy
allocated 343
analyzed 330
5yr OS 81.8%
Radiotherapy alone
allocated 343
analyzed 330
5yr OS 76.7%

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.

📚 Sources · 📄 1 paper
📄 PAPER de Boer, Stephanie M; Powell, Melanie E; Mileshkin, Linda et al. · The Lancet Oncology (2018-03)
Adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): final results of an international, open-label, multicentre, randomised, phase 3 trial
Early signal

Gomez LCT oligometastatic NSCLC (long-term results)

ForStage IV NSCLC, ≤3 mets, no progression after front-line systemic therapy

Progression-free survival surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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).

EndpointLCT (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 OS41.2 mo (18.9-NR)17.0 mo (10.1-39.8).017
Survival after progression37.6 mo9.4 mo.034
Time to new lesions14.2 mo (5.7-24.3)6.0 mo (4.4-8.3)0.11
Deaths11 of 2518 of 24n/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.

stage IV NSCLC with ≤3 metastases that did not progress after platinum doublet or first-line EGFR/ALK TKI
Does not represent IO-treated pts, higher metastatic burden, or disease progressing on front-line therapy.

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
Assessed / enrolled 74
↓
Randomized49
↓
LCT
allocated 25
mPFS 14.2 mo
MT/O
allocated 24
mPFS 4.4 mo

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).

📚 Sources · 📄 1 paper
📄 PAPER Gomez, Daniel R.; Tang, Chad; Zhang, Jianjun et al. · Journal of Clinical Oncology (2019-06)
Local Consolidative Therapy Vs. Maintenance Therapy or Observation for Patients With Oligometastatic Non–Small-Cell Lung Cancer: Long-Term Results of a Multi-Institutional, Phase II, Randomized Study
Abstract
PURPOSE Our previously published findings reported that local consolidative therapy (LCT) with radiotherapy or surgery improved progression-free survival (PFS) and delayed new disease in patients with oligometastatic non–small-cell lung cancer (NSCLC) that did not progress after front-line systemic therapy. Herein, we present the longer-term overall survival (OS) results accompanied by additional secondary end points. PATIENTS AND METHODS This multicenter, randomized, phase II trial enrolled patients with stage IV NSCLC, three or fewer metastases, and no progression at 3 or more months after front-line systemic therapy. Patients were randomly assigned (1:1) to maintenance therapy or observation (MT/O) or to LCT to all active disease sites. The primary end point was PFS; secondary end points were OS, toxicity, and the appearance of new lesions. All analyses were two sided, and P values less than .10 were deemed significant. RESULTS The Data Safety and Monitoring Board recommended early trial closure after 49 patients were randomly assigned because of a significant PFS benefit in the LCT arm. With an updated median follow-up time of 38.8 months (range, 28.3 to 61.4 months), the PFS benefit was durable (median, 14.2 months [95% CI, 7.4 to 23.1 months] with LCT v 4.4 months [95% CI, 2.2 to 8.3 months] with MT/O; P = .022). We also found an OS benefit in the LCT arm (median, 41.2 months [95% CI, 18.9 months to not reached] with LCT v 17.0 months [95% CI, 10.1 to 39.8 months] with MT/O; P = .017). No additional grade 3 or greater toxicities were observed. Survival after progression was longer in the LCT group (37.6 months with LCT v 9.4 months with MT/O; P = .034). Of the 20 patients who experienced progression in the MT/O arm, nine received LCT to all lesions after progression, and the median OS was 17 months (95% CI, 7.8 months to not reached). CONCLUSION In patients with oligometastatic NSCLC that did not progress after front-line systemic therapy, LCT prolonged PFS and OS relative to MT/O.
Confirmatory

RTOG 9601 NCT00002874

ForpN0 pT2 R1/pT3 post-RP, detectable PSA 0.2-4.0 ng/ml, salvage RT

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointRT + bicalutamideRT + placeboHR (95% CI), P
OS (1° EP)76.3%71.3%0.77 (0.59-0.99), P=0.04
Death from PCa5.8%13.4%0.49 (0.32-0.74), P<0.001
Metastatic PCa14.5%23.0%0.63 (0.46-0.87), P=0.005
2nd biochemical recurrence44.0%67.9%0.48 (0.40-0.58), P<0.001
PSA at entryn (%)BicalutamidePlaceboHR (95% CI), P
<0.7 ng/ml405 (53.3)76.8%80.7%1.13 (0.77-1.65), 0.53
0.7-1.5 ng/ml237 (31.2)77.0%67.5%0.61 (0.39-0.95), 0.03
>1.5 ng/ml118 (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%).

pN0 men after RP with a detectable PSA up to 4.0 ng/ml receiving prostate-bed salvage RT
Does not represent PSMA-staged, node-positive, or very-low-PSA early salvage pts, or GnRH-agonist regimens.

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
Randomized840
↓
RT + bicalutamide
allocated 419
analyzed 384
12-yr OS 76.3%
RT + placebo
allocated 421
analyzed 376
12-yr OS 71.3%

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.

📚 Sources · 📄 1 paper
📄 PAPER Shipley, William U.; Seiferheld, Wendy; Lukka, Himanshu R. et al. · New England Journal of Medicine (2017-02)
Radiation with or without Antiandrogen Therapy in Recurrent Prostate Cancer

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 →

Presentation

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.

Adversarial read
  • 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.
Trials cited

KEYNOTE-905/EV-303KEYNOTE-B15/EV-304SWOG 0219RETAIN-1RETAIN-2HCRN GU16-257ARCHERBRIGHT

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

MIBC pts with cCR after neoadjuvant EV+pembro who are deciding on consolidation
Does not represent pts with residual disease on restaging, or those treated with other neoadjuvant regimens without a matching cCR definition.

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.

OptionCore argumentEvidence cited
Bladder-preserving RTcCR does not guarantee eradication; RT gives durable bladder control with a QOL advantageSWOG 0219, RETAIN-2, TMT vs RC patient-reported outcomes
Radical cystectomyCystectomy is the backbone of all level 1 EV+pembro data; cCR is not pCRKEYNOTE-905/EV-303, KEYNOTE-B15/EV-304, Roessler meta-analysis, RETAIN ctDNA
SurveillanceMost pts had pCR at cystectomy anyway; the real question is whether cCR predicts MFSHCRN GU16-257, RETAIN failure patterns, ctDNA (Epstein, ASCO GU 2026)
OutcomeRETAIN-1RETAIN-2
Local recurrence62%36%
Metastatic recurrence36%14%
MFS with intact non-irradiated bladder48%68%
📚 Sources · 📄 1 paper
📄 PAPER · UroToday
AUA 2026: Consolidative Local Therapy After Enfortumab Vedotin + Pembrolizumab Response: Surgery, Radiation, or Surveillance?
Abstract
AUA 2026, muscle-invasive bladder cancer (MIBC), KEYNOTE-905/EV-303 trials, KEYNOTE-B15/EV-304 trials, Enfortumab Vedotin + Pembrolizumab, RETAIN trials.
📝 https://www.urotoday.com/conference-highlights/aua-2026/aua-2026-bladder-cancer/169111-aua-2026-consolidative-local-therapy-after-enfortumab-vedotin-pembrolizumab-response-surgery-radiation-or-surveillance.html
Confirmatory

TRIDENT NCT04471844

ForndGBM (WHO 2016), post maximal safe resection or biopsy, pre-RT/TMZ

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointEarly 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 survival70.9%72.0%NS
2-year survival33.9%31.6%NS
3-year survival22.5%18.4%NS
Device-related AEs76.2%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.

adults with ndGBM (WHO 2016) after maximal safe resection or biopsy who are planned for RT/TMZ and TTFields
Does not represent pts not receiving TTFields at all, since both arms used the device.

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
Randomized981
↓
Early Start (TTFields with RT/TMZ)
allocated 492
mOS 17.7 m
Maintenance Start (TTFields with adjuvant TMZ)
allocated 489
mOS 17.5 m

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
📄 PAPER W. Shi; M. Glas; S. Lapointe et al. · ASTRO 2026 Annual Meeting (2026-09)
TRIDENT: Phase 3 Trial of Tumor Treating Fields (TTFields) Therapy Concurrent with Temozolomide (TMZ) Radiochemotherapy Followed by Maintenance TMZ and TTFields for Newly Diagnosed Glioblastoma (ndGBM)
Abstract
ASTRO 2026 abstract LBA 04 · LBA 01 - Late-breaking Abstract Session · 2026-09-29 · presented by Wenyin Shi, MD, PhD<br/><br/>Purpose/Objective(s): Standard treatment for newly diagnosed glioblastoma (ndGBM) is maximal safe resection followed by radiotherapy (RT) with temozolomide (TMZ) then maintenance TMZ and TTFields therapy. TRIDENT evaluated whether earlier initiation of TTFields therapy concurrently with RT/TMZ improves survival compared with current utilization.<br/>Materials/Methods: TRIDENT (NCT04471844) was a randomized, open-label, global phase 3 clinical trial. Adults with ndGBM (WHO 2016 classification) were randomized 1:1 prior to RT/TMZ to receive TTFields (200 kHz) initiated concurrently with RT/TMZ (Early Start arm) or with adjuvant TMZ (Maintenance Start arm). Patients (pts) were stratified by MGMT promoter methylation status and extent of resection. TTFields were recommended until second disease progression in both arms. Key inclusion criteria: recovered from maximal safe resection (biopsy allowed); KPS =70; and planned initiation of RT/TMZ <8 weeks after surgery. Primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), 1-, 2-, and 3-year survival rate, overall response rate (ORR), and safety. Survival data were compared using the Kaplan-Meier method and a stratified log-rank test.<br/>Results: A total of 981 pts were randomized Dec 2020–Jan 2024 globally to the Early Start (n=492) or Maintenance Start (n=489) arms. Baseline characteristics were balanced (overall: median age 60 [22–86] years, 65.1% male, 38.4% KPS =80, 38.9% MGMT methylated, 5.4% IDH mutant). ~25% of pts did not initiate the maintenance phase across both arms. Median duration of TTFields use was 7.7 months (m) (0-49) and 6.1 m (0-43) with Early and Maintenance Start, respectively. In the intention to treat (ITT) population, there was no significant difference in median OS (mOS). mOS (95% CI) was 17.7 m (16.0–18.8 ) with Early Start vs 17.5 m (15.9–19.0 ) with Maintenance Start, (HR 0.953 [95% CI 0.82–1.10]; p=0.52). 1, 2, and 3-year survival rates were 70.9% vs 72.0%, 33.9% vs 31.6%, and 22.5% vs 18.4%, respectively (all NS). PFS and ORR were not significantly different between arms. Device-related adverse events (AEs) occurred in 76.2% of Early Start pts vs. 59.2% of Maintenance Start pts but remained mostly grade 1-2 skin-related. In post hoc analysis of pts with per protocol device usage during RT/TMZ, pts with MGMT-methylated tumors showed a significant survival benefit with Early Start (mOS of 33.8 m vs 23.8 m; HR 0.683 [95% CI 0.484–0.963]; p=0.03).<br/>Conclusion: TTFields concurrent with RT/TMZ was feasible and safe. Although earlier TTFields initiation did not improve survival in the ITT population, durable long-term survival was observed regardless of TTFields start time. Post hoc analyses identified a clinically meaningful survival benefit from early TTFields initiation in pts with MGMT-methylated tumors.
📝 https://amportal.astro.org/sessions/lba-01-22916/trident-phase-3-trial-of-tumor-treating-fields-ttfields-therapy-concurrent-with-temozolomide-113296 10.1016/j.ijrobp.2026.06.2464
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointAdjusted (s)HR95% CI
PCSM (primary objective)sHR 1.341.17-1.54
OSHR 1.181.09-1.27
MFSHR 1.161.08-1.25
DMsHR 1.201.07-1.35
Endpoint at 15 yearsLow GCVery high GCDifference
PCSM4%52%48%
OS75%25%50%
Pre-sRT PSAGC <0.6GC ≥0.6
<0.7-2%16%
≥0.712%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.

pts given sRT ± high-dose bicalutamide on NRG/RTOG 9601 with a GC score available (n=352)
Does not represent pts receiving contemporary ADT with sRT, which this analysis did not test.

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
📄 PAPER K. Patel; E. Feng; E. Walker et al. · ASTRO 2026 Annual Meeting (2026-09)
Long-Term Transcriptomic Analysis of NRG/RTOG 9601: A Phase 3 Study of Salvage Radiotherapy for Prostate Cancer with or without Anti-Androgen Therapy
Abstract
ASTRO 2026 abstract 315 · SS 36 - Predicting Benefit and Toxicity: Biomarkers in Prostate Radiotherapy · 2026-09-29 · presented by Krishnan Patel, MD<br/><br/>Purpose/Objective(s): The prognostic utility of a genomic classifier (GC) on overall survival (OS), prostate cancer-specific mortality (PCSM), and distant metastasis (DM) after salvage radiotherapy (sRT) was previously validated in NRG/RTOG 9601, a phase 3 trial of sRT ± high-dose bicalutamide [anti-androgen therapy (AAT)]. A separate analysis of NRG/RTOG 9601 showed that AAT may increase cardiovascular mortality and that pre-sRT PSA was predictive of the benefit from AAT. Here, we update the prior work with final outcomes data from NRG/RTOG 9601 to characterize the clinical utility of modern clinico-transcriptomic risk stratification.<br/>Materials/Methods: This is a secondary analysis of NRG/RTOG 9601 with GC scores (Veracyte; San Diego, CA) from a prior National Clinical Institute-translational science project. The primary objective was to estimate the prognostic impact of GC score (per 0.1) on PCSM, and secondarily on OS, metastasis-free survival (MFS), and DM. Additional objectives were the estimation of PCSM and OS by pre-defined GC strata [low (=0.4), intermediate (0.4-0.6), high (0.6-0.85), and very high (>0.85)] and the estimation of the PCSM benefit of AAT by GC (<0.6 vs =0.6) within pre-sRT PSA subgroup (<0.7 vs =0.7). PCSM was selected as the primary endpoint in this secondary analysis to evaluate disease-specific prognosis and AAT treatment effect, given the suggestion of increased other-cause mortality with high-dose bicalutamide, which may not occur with contemporary androgen deprivation therapy (ADT). Multivariable Cox or Fine-Gray models were fit and adjusted (subdistribution) hazard ratios [(s)HR] were reported with 95% confidence intervals.<br/>Results: A total of 352 patients were included in the GC-available cohort with a median follow-up of 18.2 years. The median GC score was 0.59 (Q1-Q3: 0.42-0.76), and 29%, 23%, 38%, and 11% had low, intermediate, high, and very high GC risk scores, respectively. GC was independently prognostic for all profiled endpoints [sHR PCSM 1.34 (1.17-1.54); HR OS 1.18 (1.09-1.27); HR MFS 1.16 (1.08-1.25); sHR DM 1.20 (1.07-1.35); all p=0.002]. Furthermore, there was a clinically meaningful difference in prognosis between the low and very high GC subgroup at 15 years: ?PCSM 15-Year of 48% (4% vs. 52%) and ?OS 15-Year of 50% (75% vs. 25%). Within the high pre-sRT PSA (=0.7) subgroup, the absolute improvement in 15 year PCSM with AAT was clinically meaningful across GC risk (GC<0.6: 12%; GC=0.6: 6%), whereas in the low pre-sRT PSA (<0.7) subgroup, only the high GC risk patients derived a clinically meaningful 15-year PCSM benefit (GC<0.6: -2%; GC=0.6: 16%). However, there was no significant interaction between GC and AAT effect within either PSA strata (both p>0.05) likely due to limited power.<br/>Conclusion: With the long-term update of NRG/RTOG 9601, GC score continues to provide clinically meaningful prognostic information beyond clinical data. These analyses support the hypothesis that GC may have clinical utility in selecting early sRT candidates for modern ADT.
📝 https://amportal.astro.org/sessions/ss-36-22888/long-term-transcriptomic-analysis-of-nrg-rtog-9601-a-phase-3-study-of-salvage-radiotherapy-fo-112073 10.1016/j.ijrobp.2026.06.227
Confirmatory

NRG-HN009 (p16-negative phase II toxicity)

Forp16-negative locoregionally advanced SCCHN, 70 Gy RT + concurrent cisplatin

Acute toxicity T-score ratio (weekly/Q3) safety

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointQ1 Cis (weekly)Q3 CisEffect
Mean T-score2.48 (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 failure9.6%4.6%Absolute difference 5.0% (95% CI 1.0, 8.9)
AE termQ3 CisQ1 Cis
Nausea124
WBC decreased1428
Dehydration91
Hypomagnesemia28
Acute kidney injury113

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.

p16-negative locoregionally advanced SCCHN, larynx-dominant with heavy smoking history, treated with 70 Gy RT and concurrent cisplatin
Does not represent the p16-positive cohort (241 pts, reported separately) or settings other than 70 Gy RT with concurrent cisplatin.

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
Randomized234
↓
Q3 Cis 100 mg/m2 + 70 Gy
allocated 118
Mean T-score 2.23
Q1 weekly Cis 40 mg/m2 + 70 Gy
allocated 116
Mean T-score 2.48

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
📄 PAPER P. M. Harari; K. Attwood; F. Siddiqui et al. · ASTRO 2026 Annual Meeting (2026-09)
NRG-HN009 Randomized Phase II/III Trial of RT + Cisplatin Q3 Weeks vs RT + Cisplatin Weekly for Patients with Locoregionally Advanced SCCHN: p16-Negative Phase II Toxicity Results
Abstract
ASTRO 2026 abstract LBA 06 · LBA 01 - Late-breaking Abstract Session · 2026-09-29 · presented by Paul Harari, MD, FASTRO<br/><br/>Purpose/Objective(s): To provide first report of phase II acute toxicity results for the p16-negative cohort of 234 patients from NRG-HN009. The phase II acute toxicity results for the p16-positive cohort of 241 patients were presented at the Multidisciplinary HNC Symposium in Feb 2026.<br/>Materials/Methods: Eligible patients with p16-negative SCCHN were randomly assigned to receive 70 Gy RT + Cis at 100 mg/m2 Q3 weeks (Q3) vs 70 Gy RT + Cis weekly at 40 mg/m2 (Q1). Acute toxicity was measured by T-score, defined as the number of all treatment-related grade 3-4 adverse events during treatment or within six months. To proceed to phase III, the mean T-score ratio (Q1/Q3) from negative binomial regression must be significantly (1-sided p<0.1) < 1 ( i.e. , Q1 toxicity < Q3 toxicity) and the difference in 6-month locoregional failure estimates (Q1-Q3) must be = 8% (absolute difference). Quality assurance modality reviews for a random sample of cases were performed for radiation and chemotherapy delivery quality.<br/>Results: Between Oct 2021-Sept 2025, 234 patients were randomized, 118 patients to Q3 and 116 to Q1. 91% of patients completed all follow-up up to 6 months. Median age was 60 years; 76% male; 80% white; 58% Zubrod 0; 87% former or current smokers; 70% >10 pack-years smoking history; 57% larynx, 28% oropharynx, 15% hypopharynx; 83% T1-3 tumors and 74% node-positive disease. Mean T-score ratio was 1.11 (90% upper confidence bound 1.33; p=0.77) with mean T-scores of 2.23 (95% confidence interval 1.81, 2.65) for Q3 and 2.48 (95% CI 1.97, 2.99) for Q1. There were absolute differences in acute grade 3-4 rates between arms of = 5% in the following terms as shown in Table 1. The Q3 Cis arm showed higher acute grade 3-4 toxicity rates of nausea, dehydration and acute kidney injury, whereas the Q1 Cis arm showed higher rates of WBC and magnesium decrease. The 6-month locoregional failure rates were 4.6% for Q3 and 9.6% for Q1 [absolute difference 5.0% (95% CI 1.0, 8.9)]. RT reviews were completed for 91% of sampled patients with overall score per protocol or acceptable variation in 81% on Q3 and 94% on Q1. Chemotherapy reviews were completed for 100% of sampled patients with overall score per protocol or acceptable variation in 80% on Q3 and 98% on Q1.<br/>Conclusion: The phase II toxicity results for the p16-negative cohort of NRG-HN009 did not meet criteria for continuing to phase III. Acute grade 3-4 AE rates between arms with = 5% difference varied across the Q3 and Q1 Cis treatment arms as depicted in Table 1. The overall acute toxicity and locoregional control results at 6 months for all 475 patients enrolled on the NRG-HN009 phase II study (p16+ and p16-) will be summarized at presentation. Treatment-Related Grade 3-4 Acute AE Rate (%) Nausea WBC decreased Dehydration Hypomagnesemia Acute kidney injury Q3 Cis 12 14 9 2 11 Q1 Cis 4 28 1 8 3
📝 https://amportal.astro.org/sessions/lba-01-22916/nrg-hn009-randomized-phase-ii-iii-trial-of-rt-cisplatin-q3-weeks-vs-rt-cisplatin-weekly-for-p-113301 10.1016/j.ijrobp.2026.06.2466
Early signal

TORCH-iTNT NCT06281405

ForpMMR LARC, T3-4/N+ M0, 96.6% with at least one high-risk feature

Complete response rate (pCR + cCR) surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

pMMR LARC (T3-4/N+ M0) carrying at least one high-risk feature such as low tumor location, cT4, cN2, MRF+ or EMVI+
Does not represent dMMR rectal cancer or pts treated with long-course chemoradiotherapy.

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.

📚 Sources · 📄 1 paper
📄 PAPER Y. Wang; L. Shen; J. Wan et al. · ASTRO 2026 Annual Meeting (2026-09)
Immunotherapy Based Total Neoadjuvant Therapy with or without Short-Course Radiotherapy for Locally Advanced Rectal Cancer: Initial Results of TORCH-iTNT
Abstract
ASTRO 2026 abstract 168 · SS 14 - Now Is a STELLAR Time to TORCH Colorectal Cancer · 2026-09-28 · presented by Fan Xia, MD, PhD<br/><br/>Purpose/Objective(s): For patients with proficient mismatch repair (pMMR) locally advanced rectal cancer (LARC), combining PD-1 inhibitors with total neoadjuvant chemoradiotherapy (iTNT) has shown significant potential to improve complete response (CR) rates and facilitate organ preservation. However, the combination of radiotherapy and surgery often results in greater functional impairment compared to using either treatment alone. Meanwhile, the synergy between chemotherapy and PD-1 inhibitors has been observed to enhance tumor downstaging, facilitating sphincter-preserving surgery and reducing radiation-related damage. This trial aims to assess the efficacy and functional outcomes of two iTNT regimens: CAPOX combined with PD-1 inhibitor, either with or without short-course radiotherapy (SCRT), in the neoadjuvant treatment of pMMR LARC patients.<br/>Materials/Methods: The TORCH-iTNT trial is a multicenter phase II randomized trial which enrolled 192 pMMR LARC (T3-4/N+M0) patients. Patients were assigned to either Group A, receiving 6 cycles of CAPOX plus Toripalimab, or Group B, undergoing SCRT (25Gy/5Fx) followed by 6 cycles of CAPOX plus Toripalimab. Patients with clinical complete response (cCR) were offered an option of watch-and-wait (W&W) approach, while non-cCR patients were recommended for surgery. In Group A, adjuvant chemoradiotherapy was administered to patients with positive circumferential margins. The primary endpoint was the complete response (CR) rate, defined as the combination of pathological complete response (pCR) and cCR. Secondary endpoints encompassed organ preservation rate, anorectal function, adverse events, and survival outcomes.<br/>Results: By January 31, 2026, a total of 192 patients were enrolled, with 148 completing the treatment (70 in Group A and 78 in Group B). Baseline characteristics were well-balanced, and 96.6% (143/148) of patients presented with at least one high-risk feature, including low tumor location (=5 cm), cT4, cN2, MRF+, or EMVI+. Seven patients in Group A and 25 patients in Group B achieved cCR and adopted W&W strategy. Among the 58 and 52 patients in Group A and Group B who received surgery, pCR rates were 32.8% (19/58) and 44.2% (23/52), respectively. Four non-cCR patients in Group A either declined surgery or were still undergoing further treatment. Disease progression was recorded in one patient from each group. The overall CR rates were 37.1% (26/70) in Group A and 61.5% (48/78) in Group B. Thrombocytopenia was the most common grade 3-4 adverse event, occurring in 12.9% of Group A and 14.1% of Group B patients.<br/>Conclusion: This study is the first comparative analysis of two iTNT regimens in LARC. Unprecedentedly, the neoadjuvant combination of CAPOX and PD-1 inhibitor showed an encouraging CR rate in pMMR LARC patients, and this CR rate can be further enhanced with the addition of SCRT prior to immunochemotherapy. Extended follow-up is essential to evaluate long-term therapeutic efficacy and functional outcomes. (NCT06281405)
📝 https://amportal.astro.org/sessions/ss-14-22849/immunotherapy-based-total-neoadjuvant-therapy-with-or-without-short-course-radiotherapy-for-l-113721 10.1016/j.ijrobp.2026.06.081
Early signal

STELLAR II NCT05484024

ForMid-to-low pMMR LARC; T3-4 94.9%, node-positive 92.9%

Complete response rate (phase 2 primary) surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointiTNT (SCRT + CAPOX + sintilimab)TNT (SCRT + CAPOX)P
Overall CR51.9% (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 toxicity27.7%19.9%not reported
4-cycle chemo completion92.9%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.

mid-to-low pMMR LARC, mostly T3-4 and node-positive, treated with SCRT-based TNT
Does not represent dMMR disease, upper rectal tumors, or long-course CRT-based TNT.

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
Randomized588
↓
iTNT (SCRT + CAPOX + sintilimab)
allocated 296
Overall CR 51.9%
TNT (SCRT + CAPOX)
allocated 292
Overall CR 26.8%

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.

📚 Sources · 📄 1 paper
📄 PAPER H. Li; L. Wei; W. Zhang et al. · ASTRO 2026 Annual Meeting (2026-09)
Short-Course Radiotherapy-Based Total Neoadjuvant Therapy with or without a PD-1 Inhibitor in pMMR Locally Advanced Rectal Cancer: Short-Term Results from a Randomized Phase 3 Trial (STELLAR II)
Abstract
ASTRO 2026 abstract 165 · SS 14 - Now Is a STELLAR Time to TORCH Colorectal Cancer · 2026-09-28 · presented by Yuan Tang, MD<br/><br/>Purpose/Objective(s): Total neoadjuvant therapy (TNT) is the standard of care for proficient mismatch repair (pMMR) locally advanced rectal cancer (LARC). While several phase II studies have suggested that adding immunotherapy to TNT can increase the complete response (CR) rate, phase 3 trials directly comparing TNT with versus without immunotherapy are lacking. The STELLAR II trial (NCT05484024) was therefore designed to conduct a head-to-head comparison, evaluating whether short-course radiotherapy (SCRT)-based TNT combined with a PD-1 inhibitor (iTNT) can safely improve the CR rate and survivals.<br/>Materials/Methods: This was a multicenter, randomized, phase 2/3 trial involving patients with mid-to-low pMMR LARC. Eligible patients were randomly assigned to iTNT or TNT group . The iTNT group received SCRT (5 Gy x5) followed by 4 cycles of CAPOX and sintilimab. The TNT group received the same regimen without sintilimab. After neoadjuvant therapy, treatment strategy either resection or watch-and-wait (W&W) was determined based on evaluation, followed by 2 additional cycles of same prior regimen. Primary endpoints were the CR rate for phase 2 and 3-year DFS for phase 3. Interim phase II results were previously reported at ESTRO 2025; here, we present the short-term efficacy and safety data from the fully accrual of trial.<br/>Results: From August 2022 to August 2025, 658 patients were screened and 588 were randomized, with 296 assigned to the iTNT group and 292 to the TNT group. Median age was 59 years, and 71.1% were male. Most patients had T3–4 (94.9%), node-positive (92.9%), and lower tumors (71.3%). 48.8% of patients had MRF+ disease and 45.4% had EMVI. All patients completed SCRT. Completion rates for 4-cycle of chemotherapy were 92.9% in the iTNT group and 94.1% in the TNT group. In the iTNT group, 254 patients (86.1%) received at least 4 cycles of sintilimab. Grade 3-4 toxicities occurred in 27.7% (iTNT) and 19.9% (TNT) of patients, and grade 3-5 immune-related adverse events occurred in 3.4% of patients. As of February 6, 2026, 458 patients had undergone surgery, with 8 awaiting surgery. Pathological complete response (pCR) was achieved in 41.7% (88/211) of the iTNT group versus 19.4% (48/247) of the TNT group. Ninety-two patients (15.6%) adopted a W&W strategy after clinical complete response (cCR). The overall CR rate was 51.9% (150/289) in the iTNT group, significantly higher than the 26.8% (78/291) in the TNT group ( P <0.001). Short-term efficacy and survival outcomes continue to be followed.<br/>Conclusion: This study provides the first substantial and reliable short-term efficacy and safety data for SCRT-based TNT combined with a PD-1 inhibitor in pMMR LARC. The significantly improved CR rate with iTNT offers a promising new option for organ preservation. Further 3-year survival outcomes are eagerly awaited.
📝 https://amportal.astro.org/sessions/ss-14-22849/short-course-radiotherapy-based-total-neoadjuvant-therapy-with-or-without-a-pd-1-inhibitor-in-113668 10.1016/j.ijrobp.2026.06.078
Caveats dominate

NRG/RTOG 0815 Decipher GC

ForIntermediate-risk prostate cancer, dose-escalated RT, biopsy Decipher GC available

Distant metastasis (GC-STAD interaction) surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

NRG/RTOG 0815 Decipher GC
GC groupAbsolute 10-yr DM benefit from adding STAD
Int/High GC8%
Low GC1%
+1 more figure
Predicted 10-yr DM across continuous GC score, RT + STAD vs RT alone.
Predicted 10-yr DM across continuous GC score, RT + STAD vs RT alone.
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.

EndpointsHR (95% CI)p
Biochemical failure2.19 (1.36-3.53)<0.001
Distant metastasis4.89 (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.

intermediate-risk prostate cancer treated with dose-escalated RT with biopsy tissue yielding a Decipher GC score
Does not represent pts outside intermediate-risk disease or settings where RT dose and technique differ from the trial's, which the source does not specify.

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.

📚 Sources · 🐦 1 tweet · 📄 1 paper
📄 PAPER A. Y. Jia; M. Johnson; J. Proudfoot et al. · ASTRO 2026 Annual Meeting (2026-09)
Genomic Stratification of Benefit from Short-Term Androgen Deprivation with Dose-Escalated Radiotherapy in Intermediate-Risk Prostate Cancer: An Ancillary Study of NRG/RTOG 0815
Abstract
ASTRO 2026 abstract 312 · SS 36 - Predicting Benefit and Toxicity: Biomarkers in Prostate Radiotherapy · 2026-09-29 · presented by Angela Jia, MD, PhD<br/><br/>Purpose/Objective(s): NRG/RTOG 0815 is a phase 3 randomized trial of dose-escalated radiotherapy (RT) with or without 6 months of short-term androgen deprivation therapy (STAD). We aimed to validate the potential prognostic and predictive ability of the 22-gene genomic classifier (GC) on long-term outcomes in the NRG/RTOG 0815 trial.<br/>Materials/Methods: After National Cancer Institute approval of a prespecified analysis plan, archived prostate biopsy specimens from NRG/RTOG 0815 were profiled using a locked, clinical-grade Decipher GC assay (Veracyte, San Diego). Genomic risk was analyzed as a continuous variable and by prespecified score categories: low (GC < 0.45), intermediate (GC 0.45-0.6), and high (GC > 0.6). Linkage of GC data to updated clinical outcomes with extended follow-up was performed. The primary endpoint of this study was distant metastasis (DM). Secondary endpoints included biochemical failure (BF), metastasis-free survival (MFS), prostate cancer–specific mortality (PCSM), and overall survival (OS). Cox and Fine-Gray competing risk multivariable analysis (MVA) models adjusted for age, race, clinical risk factors, comorbidity score, and RT modality.<br/>Results: GC scores were successfully obtained for 395 patients of 856 patients with available tissue. Baseline characteristics were balanced between arms with 10.2 years (IQR 8.4-11.4) median follow-up. There were 91 BF, 139 MFS, 16 DM, 134 OS and 7 PCSM events. On MVA, a higher GC score (int/high vs low) was independently prognostic for BF (sHR 2.19, 95% CI 1.36-3.53, p<0.001) and for DM (sHR 4.89, 95% CI 0.98-24.3, p=0.05). A significant GC-STAD interaction was observed for DM (p-interaction <0.001) and PCSM (p-interaction <0.001). Patients with low-GC scores (44% of cohort) derived no clinically meaningful benefit from STAD (10-year DM absolute difference of 1%), whereas patients with high-GC (32% of cohort) scores had a significant DM reduction with STAD (10-year DM absolute benefit of 11%).<br/>Conclusion: In intermediate-risk prostate cancer treated with dose-escalated RT, the 22-gene GC is independently prognostic and predictive of DM benefit from STAD. Patients with low GC scores have favorable long-term outcomes with no clear benefit from treatment intensification with STAD. In contrast, patients with higher GC scores treated with RT alone had unacceptably high long-term DM rates, which were significantly improved with STAD. NRG GU010 will serve as prospective validation and build on these findings.
📝 https://amportal.astro.org/sessions/ss-36-22888/genomic-stratification-of-benefit-from-short-term-androgen-deprivation-with-dose-escalated-ra-112070 10.1016/j.ijrobp.2026.06.224
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

FFP by PAM50 subtype. Interaction P=0.01. One panel: HR 0.34 (95% CI 0.23-0.52), p<0.001.
FFP by PAM50 subtype. Interaction P=0.01. One panel: HR 0.34 (95% CI 0.23-0.52), p<0.001.
+2 more figures
NRG/RTOG 0534 PAM50
Enrolled and evaluable n=1792. Samples in biorepository n=1039. Analytic cohort n=709: PBRT alone n=215, PBRT + STADT n=247, PBRT + STADT + PLNRT n=247.
Enrolled and evaluable n=1792. Samples in biorepository n=1039. Analytic cohort n=709: PBRT alone n=215, PBRT + STADT n=247, PBRT + STADT + PLNRT n=247.
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.

men post-RP with PSA 0.1-2.0 ng/mL, pT2 or pT3 N0M0, Gleason ≤9 receiving salvage RT with tissue passing PAM50 assay QC
Does not represent node-positive disease, PSA above 2.0 ng/mL, or adjuvant RT.

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
Confirmatory

NRG/RTOG 0815

ForNon-metastatic intermediate-risk prostate cancer, GS 7 in 92%, median age 68

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

NRG/RTOG 0815
Arm10-yr OS14-yr OSHR (95% CI)p
RT Alone70%53%Referentn/a
RT + STAD74%58%0.87 (0.72, 1.04)0.13
+3 more figures
NRG/RTOG 0815
Arm10-yr PSA failure14-yr PSA failureHR (95% CI)p
RT Alone25%34%Referentn/a
RT + STAD16%19%0.60 (0.48, 0.76)< 0.001
Grade 3+ late AE incidence: HR 1.08. Arm 2 vs Arm 1: 20 vs 4 grade 3+ metabolic/lab, 71 vs 38 grade 3 sexual function, 26 vs 10 grade 3+ cardiac events.
Grade 3+ late AE incidence: HR 1.08. Arm 2 vs Arm 1: 20 vs 4 grade 3+ metabolic/lab, 71 vs 38 grade 3 sexual function, 26 vs 10 grade 3+ cardiac events.
NRG/RTOG 0815
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).

EndpointRT + STADRT aloneEffect size
MFS, 10-y72%67%n/a
MFS, 14-y57%50%HR 0.83 (0.69-0.99), p=0.042
Distant metastasis, events1440HR 0.35 (0.19-0.64), p<0.001
Prostate cancer deaths519HR 0.26 (0.10-0.70), p=0.004
PCSM, 10-y0.4%2.7%n/a
PCSM, 14-y2.1%3.3%n/a
Salvage ADT, 10-y7%13%n/a
Salvage ADT, 14-y7%15%HR 0.53 (0.38-0.75), p<0.001
Non-prostate cancer deaths202220HR 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.

non-metastatic intermediate-risk prostate cancer treated mostly with EBRT alone to 79.2 Gy, two-thirds with a single risk factor
Does not represent pts with all 3 risk factors and ≥50% positive cores, and has limited data for brachytherapy-boost pts.

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
Assessed / enrolled 1538
↓
Randomized
↓
RT alone
allocated 751
14-y OS 53%
RT + STAD
allocated 742
14-y OS 58%

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
📄 PAPER D. J. Krauss; T. G. Karrison; A. A. Martinez et al. · ASTRO 2026 Annual Meeting (2026-09)
Long-Term Follow-up Results for NRG/RTOG 0815: A Phase III Prospective Randomized Trial of Dose-Escalated Radiotherapy with or without Short-Term Androgen Deprivation Therapy for Patients with Intermediate-Risk Prostate Cancer
Abstract
ASTRO 2026 abstract 106 · SS 02 - Escalate, De-escalate, or Substitute? Trials Shaping Prostate Cancer Care · 2026-09-27 · presented by Daniel Krauss, MD, FASTRO<br/><br/>Purpose/Objective(s): Initial reported results of NRG/RTOG 0815 demonstrated reductions in rates of biochemical and local failure as well as distant metastases for patients receiving short-term androgen deprivation (STAD) in addition to dose-escalated radiotherapy (RT) compared to dose-escalated RT alone. However, the study did not demonstrate a significant benefit to adding STAD with respect to overall survival. Updated clinical results with extended follow-up are presented here.<br/>Materials/Methods: Eligible patients had intermediate risk prostate cancer defined by the presence of > 1 of the following features: clinical stage T2b-T2c, Gleason score 7, or baseline PSA > 10 and < 20 ng/mL. Patients were stratified by the presence of 1 vs. > 1 intermediate risk factor, baseline ACE-27 comorbidity score ( > 2 vs. < 2), and RT boost modality. Randomization was to dose-escalated RT alone (Arm 1) or combined with STAD consisting of LHRH agonist/antagonist plus oral anti-androgen for 6 months (Arm 2). RT was administered per the discretion of the treating physician and consisted of external beam RT (EBRT) alone to 79.2 Gy or EBRT (45 Gy) combined with LDR or HDR brachytherapy boost. The primary endpoint was overall survival.<br/>Results: The study accrued 1538 patients between 2009-2016 with 1493 eligible for analysis, 751 on Arm 1 and 742 on Arm 2. Baseline clinical characteristics were well-balanced between treatment arms. 88% of patients were treated with dose-escalated EBRT alone, 67% had a single intermediate risk factor, and 67% an ACE-27 score < 2. Median follow-up was 9.4 years (10.3 years for surviving patients). No differences in rates of late Grade > 3 adverse events were observed between treatment arms. 446 deaths occurred, 239 in Arm 1 and 207 in Arm 2, corresponding to 14-year overall survival rates of 53% vs. 58% (HR 0.87, 95% CI: 0.72-1.04, p = 0.13). Rates of biochemical failure (HR 0.60, p < 0.001) and local failure (HR 0.44, p < 0.001) were lower in Arm 2. 40 patients developed distant metastases on Arm 1 compared to 14 on Arm 2 (HR 0.35, p < 0.001). Metastasis-free survival at 14 years was 50% for Arm 1 vs. 57% for Arm 2 (HR 0.83, p = 0.042). 19 deaths were attributed to prostate cancer on Arm 1 compared to 5 on Arm 2 (HR 0.26, p = 0.004). No significant difference in non-prostate cancer-related mortality was observed.<br/>Conclusion: The addition of STAD to dose-escalated RT resulted in improvements in clinical failure rates, prostate cancer-specific mortality, and metastasis-free survival. No statistically significant benefit in overall survival was found.
📝 https://amportal.astro.org/sessions/ss-02-22885/long-term-follow-up-results-for-nrg-rtog-0815-a-phase-iii-prospective-randomized-trial-of-dos-112045 10.1016/j.ijrobp.2026.06.019
📄 PAPER · UroToday
ASTRO 2026: Long-Term Follow-up Results for NRG/RTOG 0815: A Phase III Prospective Randomized Trial of Dose-Escalated Radiotherapy with or without Short-Term Androgen Deprivation Therapy for Patients with Intermediate-Risk Prostate Cancer
Abstract
ASTRO 2026 NRG/RTOG 0815 trial, short-term androgen deprivation therapy (STAD) for patients with intermediate-risk prostate cancer.
📝 https://www.urotoday.com/conference-highlights/astro-2026/astro-2026-prostate-cancer/172102-astro-2026-long-term-follow-up-results-for-nrg-rtog-0815-a-phase-iii-prospective-randomized-trial-of-dose-escalated-radiotherapy-with-or-without-short-term-androgen-deprivation-therapy-for-patients-with-intermediate-risk-prostate-cancer.html?mtm_campaign=Krauss_SocialASTRO26_ID172102

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 →

Trials discussed

MARCAPPOSEIDONRTOG 9601RTOG 0534NRG GU002NRG GU006BALANCESYMPHONY

Why it mattersRadiation oncology

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.

Monday clinic

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

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
≤0.201.14 (0.83-1.57)0.42
0.21-0.500.94 (0.74-1.19)0.70
0.51-1.00.72 (0.54-0.96)0.02
>1.00.69 (0.48-0.98)0.03
EndpointLuminal B: apalutamide vs placeboLuminal B HRNon-luminal B: apalutamide vs placeboNon-luminal B HR
5-year bPFS72% 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 MFS95% 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-studyQuestionPlanned per armPlanned overall
SYMPHONY-PRESTOProstate bed SBRT: conventional 20-33 fraction vs 5-fraction474948
SYMPHONY-ADAGIONormal-dose vs reduced dose RT474948
SYMPHONY-CRESCENDOProstate bed RT alone vs added elective nodal RT435870
SYMPHONY-FULL-SCOREMDT vs added prostate-bed/nodal treatment in N+/M+240480

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.

men after radical prostatectomy with PSA 0.1-1.0 ng/mL and N0M0 disease being considered for salvage RT
Does not represent N+/M+ recurrence, which the planned SYMPHONY-FULL-SCORE addresses.

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.

📚 Sources · 📄 1 paper
📄 PAPER · UroToday
ASTRO 2026: Role of Biomarkers in the Post-operative Setting for Prostate Cancer
Abstract
ASTRO 2026 role of biomarkers in the post-operative setting for prostate cancer, digital rectal examination, MARCAP, POSEIDON individual patient data.
📝 https://www.urotoday.com/conference-highlights/astro-2026/astro-2026-prostate-cancer/172240-astro-2026-role-of-biomarkers-in-the-post-operative-setting-for-prostate-cancer.html?mtm_campaign=Spratt_SocialASTRO26_ID172240
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

LUNAR vs SATURN
ArmNMedian time to progressionProgression rate
SBRT alone186.0 mo (IQR 4.9-11.9)100% (18/18)
SBRT + RLT2019.4 mo (IQR 12.7-28.4)60% (12/20)
SBRT + AAT2521.7 mo (IQR 9.1-33.0)68% (17/25)
+2 more figures
LUNAR vs SATURN
CovariateHR (95% CI)p
PSADT (month)0.87 (0.77 - 0.98)0.018
PSA baseline1.02 (0.95 - 1.11)0.533
Age (years)0.95 (0.88 - 1.03)0.213
Prior hormone therapy1.31 (0.58 - 2.98)0.519
Prior MDT1.34 (0.49 - 3.63)0.568
Any Grade ≥3 AE: 10% (2) RLT (n=20) vs 20% (5) AAT (n=25), p = 0.357.
Any Grade ≥3 AE: 10% (2) RLT (n=20) vs 20% (5) AAT (n=25), p = 0.357.
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.

M1 oligorecurrent PCa post-RP treated with SBRT plus either 177Lu-PNT2002 or 6 mo AAT
Does not represent pts without prior RP or disease beyond the oligorecurrent state.

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
Confirmatory

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 →

Why it mattersRadiation oncology

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.

Monday clinic

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

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).

InterventionIntermediate riskHigh risk
ADT addition18.08.4
Adjuvant ADT prolongation16.110.4

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.

localized NCCN intermediate- and high-risk prostate cancer treated with definitive external-beam radiotherapy over a long follow-up era
Does not represent node-positive, metastatic, or post-prostatectomy salvage populations, all of which sit outside the pooled trials.

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.

📚 Sources · 📄 1 paper
📄 PAPER · UroToday
ASTRO 2025: Quantifying the Benefits of Adding Androgen Deprivation Therapy versus Dose-Escalation for Prostate Cancer
Abstract
Prostate Cancer, Adding Androgen Deprivation Therapy versus Dose-Escalation for Prostate Cancer, reatment intensification strategies with radiotherapy.
📝 https://www.urotoday.com/conference-highlights/astro-2025/astro-2025-prostate-cancer/163446-astro-2025-quantifying-the-benefits-of-adding-androgen-deprivation-therapy-versus-dose-escalation-for-prostate-cancer.html
Confirmatory

STELLAR NCT02533271

ForDistal/middle-third rectal adeno, cT3-4 and/or cN+, age 18-70, ECOG 0-1

3-year disease-free survival surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

cT3-4 or node-positive adenocarcinoma of the middle and lower rectum in patients aged 18-70 fit for oxaliplatin doublet chemotherapy and TME
Does not represent upper rectal tumors, patients over 70, MRF-negative early cT3 disease selected for chemotherapy alone, or the watch-and-wait population, since only 9.4% versus 3.4% went to nonoperative management.

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)TNTCRTEffect 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
OS86.5% (82.1-90.8)75.1% (69.4-80.8)HR 0.67 (0.46-0.97), P=.033
MFS77.1% (71.7-82.6)75.3% (70.0-80.7)HR 0.88 (0.63-1.24), P=.475
LRR8.4% (4.6-12.2)11.0% (6.5-15.5)HR 0.80 (0.45-1.44), P=.461
SubgroupDFS HR (95% CI), POS HR (95% CI), P
cT40.621 (0.328 to 1.177), .1440.362 (0.152 to 0.859), .021
Distance to anal verge ≤5cm0.706 (0.485 to 1.028), .0700.540 (0.318 to 0.916), .022
cT2-30.916 (0.674 to 1.245), .5750.752 (0.493 to 1.149), .187
Distance >5cm1.120 (0.744 to 1.687), .5870.808 (0.468 to 1.394), .443
CONSORT flow
Assessed / enrolled 629
↓ 30 excluded
Randomized599
↓
TNT (25Gy/5fx + CAPOX)
allocated 302
analyzed 302
3yr DFS 64.5%
CRT (50Gy/25f + capecitabine)
allocated 297
analyzed 297
3yr DFS 62.3%

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.

📚 Sources · 📄 1 paper
📄 PAPER Jin, Jing; Tang, Yuan; Hu, Chen et al. · Journal of Clinical Oncology (2022-05)
Multicenter, Randomized, Phase III Trial of Short-Term Radiotherapy Plus Chemotherapy Versus Long-Term Chemoradiotherapy in Locally Advanced Rectal Cancer (STELLAR)
Abstract
PURPOSE To ascertain if preoperative short-term radiotherapy followed by chemotherapy is not inferior to a standard schedule of long-term chemoradiotherapy in patients with locally advanced rectal cancer. MATERIALS AND METHODS Patients with distal or middle-third, clinical primary tumor stage 3-4 and/or regional lymph node–positive rectal cancer were randomly assigned (1:1) to short-term radiotherapy (25 Gy in five fractions over 1 week) followed by four cycles of chemotherapy (total neoadjuvant therapy [TNT]) or chemoradiotherapy (50 Gy in 25 fractions over 5 weeks, concurrently with capecitabine [chemoradiotherapy; CRT]). Total mesorectal excision was undertaken 6-8 weeks after preoperative treatment, with two additional cycles of CAPOX (intravenous oxaliplatin [130 mg/m 2 , once a day] on day 1 and capecitabine [1,000 mg/m 2 , twice a day] from days 1 to 14) in the TNT group and six cycles of CAPOX in the CRT group. The primary end point was 3-year disease-free survival (DFS). RESULTS Between August 2015 and August 2018, a total of 599 patients were randomly assigned to receive TNT (n = 302) or CRT (n = 297). At a median follow-up of 35.0 months, 3-year DFS was 64.5% and 62.3% in TNT and CRT groups, respectively (hazard ratio, 0.883; one-sided 95% CI, not applicable to 1.11; P &lt; .001 for noninferiority). There was no significant difference in metastasis-free survival or locoregional recurrence, but the TNT group had better 3-year overall survival than the CRT group (86.5% v 75.1%; P = .033). Treatment effects on DFS and overall survival were similar regardless of prognostic factors. The prevalence of acute grade III-V toxicities during preoperative treatment was 26.5% in the TNT group versus 12.6% in the CRT group ( P &lt; .001). CONCLUSION Short-term radiotherapy with preoperative chemotherapy followed by surgery was efficacious with acceptable toxicity and could be used as an alternative to CRT for locally advanced rectal cancer.
Confirmatory

TNTCRT NCT03177382

ForHigh-risk stage II/III rectal cancer, cT4/cN2/MRF+/EMVI, age ≤70

Disease-free survival surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

EndpointDoublet-LC TNTnCRTEffect size
3-year DFS (primary)74.8%66.0%HR 0.674 (0.489-0.929), P=.016
3-year MFS77.7%67.6%HR 0.655 (0.469-0.915), P=.013
pCR26.37%9.80%P<.001
Locoregional failure6.03%6.19%P=.943
3-year OS90.2%87.5%P=.167
MeasureDoublet-LC TNTnCRTP
Grade ≥3 AE, neoadjuvant phase27.59%8.56%<.001
Severe toxicity, entire course28.02%24.32%.371
Major postoperative complications3.98%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.

MRI-defined high-risk stage II/III rectal cancer with cT4, cN2, threatened MRF or EMVI, aged 70 or under, treated with long-course chemoradiation
Does not represent pts older than 70, stage II disease without a high-risk feature, or short-course RT based TNT.

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
Randomized458
↓
Doublet-LC TNT
allocated 232
3-year DFS 74.8%
nCRT
allocated 226
3-year DFS 66.0%

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.

📚 Sources · 📄 2 papers
📄 PAPER Wang, Xin; Tang, Yuanling; Lu, Junyang et al. · Journal of Clinical Oncology (2026-07)
Total Neoadjuvant Therapy With Long-Course Radiotherapy Versus Chemoradiotherapy in High-Risk Locally Advanced Rectal Cancer (TNTCRT): A Multicenter, Randomized, Phase III Trial
Abstract
PURPOSE High-risk locally advanced rectal cancer (LARC) carries a substantial risk of distant recurrence, which limits disease-free survival (DFS). We compared total neoadjuvant therapy (TNT) integrating long-course radiotherapy (LCRT) with uninterrupted doublet chemotherapy (doublet-LC TNT) versus conventional neoadjuvant chemoradiotherapy (nCRT). METHODS In this multicenter, randomized, phase III trial, patients with stage II/III LARC and at least 1 high-risk feature (cT4a-b, cN2, mesorectal fascia involvement, or cT3c-d with extramural vascular invasion) were enrolled. Patients were assigned to doublet-LC TNT (induction, concurrent, and consolidation capecitabine plus oxaliplatin with LCRT) before surgery or nCRT (capecitabine with LCRT) followed by surgery and adjuvant chemotherapy. The primary end point was DFS (ClinicalTrials.gov identifier: NCT03177382 ). RESULTS Between June 6, 2017, and December 27, 2023, 458 patients were randomly assigned to doublet-LC TNT (n = 232) or nCRT (n = 226). At a median follow-up of 51 months, doublet-LC TNT improved 3-year DFS (74.8% v 66.0%; hazard ratio [HR], 0.674 [95% CI, 0.489 to 0.929]; P = .016). Metastasis-free survival (MFS; 77.7% v 67.6%; HR, 0.655 [95% CI, 0.469 to 0.915]) and pathologic complete response rates (pCR; 26.37% v 9.80%; P &lt; .001) were higher with doublet-LC TNT, whereas locoregional failure remained low and comparable (6.03% v 6.19%; P = .943). Although grade ≥3 adverse events during the neoadjuvant phase were more frequent with doublet-LC TNT (27.59% v 8.56%; P &lt; .001), severe toxicities during the entire treatment course (28.02% v 24.32%; P = .371) and major postoperative complications (3.98% v 2.94%; P = .567) were comparable. CONCLUSION Compared with conventional nCRT, doublet-LC TNT improved DFS, MFS, and pCR rates with manageable toxicity. These findings support this intensified, doublet-based regimen as a standard option within the modern TNT paradigm. Further comparative studies are warranted to evaluate these results against other short-course radiotherapy‑based or nondoublet-concurrent TNT regimens.
📄 PAPER Wang X; Tang Y; Lu J · The ASCO Post (2026-07)
Total Neoadjuvant Therapy With Long-Course RT and Uninterrupted Doublet Chemo Offers Efficacy Benefits in High-Risk Locally Advanced Rectal Cancer
Early signal

SIB-CRT vs Standard CRT for LARC (NCT02195141) NCT02195141

ForStage II/III rectal adenocarcinoma, neoadjuvant chemoRT candidates

Pathological complete response surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

stage II/III rectal adenocarcinoma treated with long-course chemoRT and planned radical surgery in a single randomized phase 2 cohort accrued 2013 to 2015
Does not represent pts managed with modern total neoadjuvant therapy, in whom the source reports no additional benefit from SIB.

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.

EndpointSIB-CRTCRTEffect
DFS70.8%47.4%HR 0.46, P=0.013
OS74.3%48.9%HR 0.43, P=0.008
MFS70.8%47.2%HR 0.48, P=0.017
LC87.1%70.1%HR 0.40, P=0.038
CSS77.4%57.2%P=0.027
pCR15.2%18.4%P=0.695
CONSORT flow
Assessed / enrolled 106
↓
Randomized106
↓
SIB-CRT
allocated 55
pCR 15.2%
CRT
allocated 51
pCR 18.4%

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.

📚 Sources · 📄 1 paper
📄 PAPER Li; Wang; Xu et al. · International journal of radiation oncology, biology, physics (2026-07)
Dose-escalated versus Standard Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer: 9-year Results of a Randomized Phase 2 Trial.
Abstract
PURPOSE: To compare the safety and efficacy of preoperative simultaneous integrated boost chemoradiotherapy (SIB-CRT) versus standard chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC).<br/><br/>METHODS AND MATERIALS: This prospective, randomized phase II trial (NCT02195141) enrolled patients with stage II/III rectal adenocarcinoma. Patients were randomly assigned (1:1) to CRT (50 Gy/25 fx to pelvis) or SIB-CRT (50 Gy/25 fx to the pelvis with SIB of 56 Gy to PGTV and 60 Gy to lateral metastatic nodes if present). Radical surgery was planned 6-8 weeks after chemoradiotherapy. The primary endpoint was pathological complete response (pCR) rate; secondary endpoints were disease-free survival (DFS), overall survival (OS), metastasis-free survival (MFS), local control (LC), cancer-specific survival (CSS) and toxicity.<br/><br/>RESULTS: From August 2013 to February 2015, 106 patients were enrolled: 55 in the SIB-CRT group and 51 in the CRT group. Acute grade 3 toxicity occurred in 14.5% (SIB-CRT) and 19.6% (CRT) of patients, primarily manifested as radiation dermatitis. Curative treatment (radical surgery or watch-and-wait) was achieved in 89.1% (49/55) of SIB-CRT patients and 78.4% (40/51) of CRT patients (P=0.135). After a median follow-up of 116.6 months, the SIB-CRT group showed superior 9-year outcomes in the intention-to-treat (ITT) population: DFS (70.8% vs 47.4%; HR 0.46, P=0.013), OS (74.3% vs 48.9%; HR 0.43, P=0.008), MFS (70.8% vs 47.2%; HR 0.48, P=0.017), LC (87.1% vs 70.1%; HR 0.40, P=0.038) and CSS (77.4% vs 57.2%; P=0.027). Similar benefits were observed in the curative treatment cohort. The pCR rates were comparable (15.2% vs 18.4%; P=0.695). Exploratory subgroup analysis showed that the survival benefit of SIB-CRT was statistically significant in patients who did not receive perioperative chemotherapy (9-year DFS: 70.8%; HR=0.343, P&#x202f;=&#x202f;.014), whereas no additional benefit was observed in those receiving chemotherapy.<br/><br/>CONCLUSIONS: Dose escalation through SIB during neoadjuvant chemoradiotherapy translates into superior long-term survival outcomes. Despite comparable pCR rates, the intensified control of both local disease and micrometastases by SIB-CRT, coupled with its significant superiority within the chemotherapy-naive subgroup, likely contributed to these robust results. These findings establish dose escalation as a potent strategy for optimizing long-term cure in the modern management of LARC, particularly in chemotherapy-ineligible patients.
Challenges SOC

POSEIDON

ForPost-RP prostate cancer receiving PORT, median pre-PORT PSA 0.3 ng/mL

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

ComparisonNOS HR (95% CI)MFS HR (95% CI)
Any HT + PORT vs PORT50260.87 (0.76–1.01), p=0.060.79 (0.70–0.89), p<0.001
Short-term HT (4–6 mo)39380.93 (0.77–1.11)0.82 (0.71–0.95)
Long-term HT (24 mo)10880.79 (0.63–1.00), p=0.0490.74 (0.60–0.91), p=0.004
Short → long prolongation15230.89 (0.68–1.16), p=0.370.76 (0.61–0.95), p=0.02
Pre-PORT PSA (ng/mL)OS HR (95% CI)10y OS PORT vs PORT+HT10y NNT (death)
≤0.201.14 (0.83–1.57)89.9% vs 87.4%negative
0.21–0.500.94 (0.74–1.19)84.9% vs 84.5%negative
0.51–1.000.72 (0.54–0.96)76.4% vs 80.9%22
>1.000.69 (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.

PET-negative biochemical recurrence after RP treated with PORT, mostly early salvage
Does not represent PSMA PET-positive nodal or metastatic disease, or biomarker-selected (Decipher) decisions.

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.

📚 Sources · 📄 2 papers
📄 PAPER Kishan, Amar U; Sun, Yilun; Parker, Christopher C et al. · The Lancet (2026-03)
Hormone therapy use and duration with postoperative radiotherapy for recurrent prostate cancer: an individual patient data meta-analysis
📄 PAPER · The ASCO Post
For Most Men With Prostate Cancer, Hormone Therapy With Postprostatectomy Radiotherapy Confers No Survival Benefit
Abstract
Adding hormone therapy to postprostatectomy radiotherapy may provide little survival benefit for most men with prostate cancer, especially those with very low prostate-specific antigen (PSA) levels be...
📝 https://ascopost.com/issues/march-25-2026/for-most-men-with-prostate-cancer-hormone-therapy-with-postprostatectomy-radiotherapy-confers-no-survival-benefit/
Challenges SOC

Consolidative TRT + Atezolizumab Maintenance in ES-SCLC NCT04462276

ForES-SCLC with ≥SD after carbo-etoposide-atezolizumab induction, unselected

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

12 details 5 trials watching

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.

unselected ES-SCLC pts responding to first-line chemoimmunotherapy who are candidates for consolidative thoracic RT during maintenance
Does not represent limited-stage SCLC, pts with preexisting interstitial lung disease (an exclusion criterion), or thoracic RT delivered without concurrent checkpoint maintenance.

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.

EndpointArm A (+TRT)Arm BP
Any toxic effects30 (96.8%)25 (75.8%).02
SAEs19 (61.3%)6 (18.2%)<.001
trAEs71.0%30.3%.001
trSAEs29.0%6.1%.01
Fatal AEs6 (19.4%)1 (3.0%).04
CONSORT flow
Assessed / enrolled 96
↓
Randomized68
↓
Atezolizumab + TRT (arm A)
allocated 34
mOS 6.7 mo
Atezolizumab only (arm B)
allocated 34
mOS 13.4 mo

Randomized, prespecified OS primary, halted early for fatal SAEs; result contests the single-arm safety data that encouraged consolidative TRT in the IO era.

📚 Sources · 📄 1 paper
📄 PAPER Bozorgmehr, Farastuk; Chung, Inn; Behnisch, Rouven et al. · JAMA Oncology (2026-07)
Consolidative Thoracic Radiotherapy With Atezolizumab Maintenance in Extensive-Stage Small Cell Lung Cancer
Abstract
Importance Chemoimmunotherapy followed by immunotherapy maintenance is the standard first-line treatment for extensive-stage small cell lung cancer (ES-SCLC), yet data regarding efficacy and safety of consolidative thoracic radiotherapy (TRT) are lacking. Objective To determine whether combining consolidative TRT with immunotherapy maintenance in ES-SCLC is safe and improves patients’ overall survival (OS) and progression-free survival (PFS). Design, Settings, and Participants This was a multicenter open-label phase 2 randomized clinical trial recruiting patients from September 2020 to August 2022 in Germany and Austria, with the last follow-up visit in September 2024. Eligible patients had ES-SCLC with at least stable disease after induction chemoimmunotherapy (carboplatin−etoposide−atezolizumab). Although the database was locked in April 2025, a post hoc survival update was performed in April 2026. Data were analyzed from April 2025 to April 2026. Interventions Randomized (1:1) to either atezolizumab maintenance combined with consolidative TRT (30 Gy in 10 fractions) (arm A) or atezolizumab maintenance alone (arm B). Main Outcome and Measure OS (time from randomization to death due to any cause). Results Of 96 patients assessed for eligibility, 68 patients were randomized; recruitment was prematurely terminated due to safety concerns. Median OS in the combination arm was numerically shorter compared to atezolizumab only (6.7 months [95% CI, 5.1-9.0] vs 13.4 months [95% CI, 10.7-17.5]; HR, 1.55 [95% CI, 0.90-2.69]; P = .34), while median PFS was similar (2.4 months [95% CI, 1.3-3.9] vs 2.6 months [95% CI, 1.2-3.9]; HR, 0.92 [95% CI, 0.54-1.55]; P = .85). TRT plus atezolizumab was accompanied by higher frequency of severe adverse events (SAEs) (19 patients [61.3%] vs 6 patients [18.2%]; P &amp;amp;lt; .001) and fatal outcomes (6 patients [19.4%] vs 1 patient [3.0%]; P = .04). Safety analysis revealed predominance of infection and respiratory disorder−related SAEs, possibly facilitated by a depletion of lymphocytes observed specifically in patients after TRT, and by a lower single breath diffuse capacity of the lungs for carbon monoxide in patients with fatal AEs in arm A. No further risk factors were identified, given that baseline characteristics were well balanced between both arms and between patients with and without SAEs, including fatal SAEs. Conclusions and Relevance In this randomized clinical trial, TRT combined with immunotherapy increased toxic effects in unselected patients with ES-SCLC without survival benefit, presumably due to radiation-induced lymphocyte depletion facilitating infections. Cautious patient selection and further investigation to identify those who may benefit without undue risk are required. Trial Registration ClinicalTrials.gov Identifier: NCT04462276
Early signal

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

oligometastatic CRPC with three or fewer sites, systemic-therapy-naive for the CRPC state, treated with abiraterone plus ADT and comprehensive ablative SBRT
Does not represent polymetastatic CRPC, pts already progressing on an ARSI, or those in whom fewer than all lesions can be ablated to BED ≥100 Gy.

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
Randomized157
↓
AA/ADT alone (control)
allocated 82
mOS 50 mo
SBRT + AA/ADT
allocated 75
mOS not reached

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.

📚 Sources · 📄 1 paper
📄 PAPER Francolini; Di Cataldo; Caini et al. · The Lancet. Oncology (2026-07)
SBRT plus abiraterone acetate and ADT versus abiraterone acetate and ADT in oligometastatic castrate-resistant prostate cancer (ARTO): long-term, unplanned overall survival analysis of an open-label, randomised, phase 2 trial.
Abstract
BACKGROUND: The ARTO trial showed improved early clinical outcomes by adding metastasis-directed therapy (MDT), through stereotactic body radiotherapy (SBRT), to abiraterone acetate and ADT in oligometastatic castrate-resistant prostate cancer. The aim of this analysis is to explore the long-term impact of MDT on overall survival.<br/><br/>METHODS: ARTO was a multicentre, phase 2, randomised trial conducted in 16 academic and community centres across Italy. All patients included were aged 18 years or older and had a diagnosis of prostate adenocarcinoma with metastatic castrate-resistant prostate cancer, no more than three metastatic sites, and no previous systemic therapy for metastatic castrate-resistant prostate cancer status. Patients were randomly assigned (1:1, using random permuted blocks; stratified by treating centre, Eastern Cooperative Oncology Group performance status, and number of metastases) in an open-label design to androgen deprivation therapy plus oral abiraterone acetate 1000 mg daily with or without SBRT to all sites of metastatic disease (one to five fractions providing a biologically effective dose &#x2265;100 Gy). The primary endpoint was 6-month biochemical response (PSA decrease of &#x2265;50% compared with baseline) and has been reported previously. After meeting its primary endpoint, the power calculation was updated post-hoc to assess overall survival, finalised before data unmasking. We present an unplanned long-term follow-up focusing on overall survival. All analyses were performed on an intention-to-treat basis. The trial is registered on ClinicalTrials.gov (NCT03449719) and is now closed.<br/><br/>FINDINGS: Between Jan 2, 2019, and Sept 7, 2022, 157 patients were randomly assigned to the control (n=82) and experimental (n=75) groups. No data about race or ethnicity were collected. After a median follow up of 53 months (IQR 43-60), median overall survival was 50 months (95% CI 36-not reached [NR]) in the control group versus NR (55-NR) in the experimental group (HR 0&#xb7;55, 95% CI 0&#xb7;33-0&#xb7;92, p=0&#xb7;021). Most common grade 3-4 adverse events recorded were infectious complications (five in the control group vs zero in the experimental group) and cardiovascular disorders (three in the control group vs three in the experimental group). One treatment-related death occurred in the control group due to myocardial failure.<br/><br/>INTERPRETATION: The ARTO trial showed significant benefit in overall survival with the addition of MDT to systemic therapy versus systemic therapy alone.<br/><br/>FUNDING: Fondazione Radioterapia Oncologica.
Confirmatory

ENZARAD (ANZUP 1303)

ForHigh-risk localized/locally-advanced prostate, EBRT candidates, 2yr ADT

Metastasis-free survival surrogate

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 →

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

SubgroupMFS 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 planned0.47 (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%.

high-risk clinically localized or locally-advanced prostate cancer treated with high-dose EBRT and 2 years of LHRH agonist, mostly Gleason 8-10 and node-negative
Does not represent metastatic disease, pts managed with radical prostatectomy, or ADT-alone comparisons without an active antiandrogen control.

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
📄 PAPER · UroToday
ESMO 2025: Randomized Phase III Trial of Androgen Deprivation Therapy (ADT) with Radiation Therapy with or without Enzalutamide for High Risk, Clinically Localized Prostate Cancer: ENZARAD (ANZUP 1303)
Abstract
ESMO 2025 ENZARAD (ANZUP 1303), randomized phase II trial of ADT + radiation therapy +/- enzalutamide, localized prostate cancer.
📝 https://www.urotoday.com/conference-highlights/esmo-2025/esmo-2025-prostate-cancer/164090-esmo-2025-randomized-phase-iii-trial-of-androgen-deprivation-therapy-adt-with-radiation-therapy-with-or-without-enzalutamide-for-high-risk-clinically-localized-prostate-cancer-enzarad-anzup-1303.html

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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 designn
Well-designed (randomized phase 2 and phase 3)10
Moderately well designed (matched cohort, phase 2)29
Design limitations (retrospective)76
Meta-analysis1
patients with locoregionally recurrent rectal cancer under multidisciplinary evaluation for salvage
Does not represent primary rectal cancer, or patients whose recurrence is managed for distant metastatic disease rather than pelvic control.

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.

📚 Sources · 📄 1 paper
📄 PAPER Miller, Eric D.; Jethwa, Krishan R.; Dozois, Eric et al. · Cancer (2026-06)
Executive summary of American Radium Society Appropriate Use Criteria for the treatment of locoregionally recurrent rectal cancer
Abstract
Abstract This literature‐based systematic review and associated guidelines provide evidence‐based paradigms for the management of locoregionally recurrent rectal cancer (LRRC). This multispecialty committee included gastrointestinal radiation and medical oncology, gastroenterology, radiology, and colorectal surgery. As is the standard, the previously described American Radium Society Appropriate Use Criteria methodology for this project was followed rigorously, with the Population, Intervention, Comparator, Outcome, Timing, and Study Design framework and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses methodology to assess the evidence. RAND/University of California Los Angeles consensus methodology (modified Delphi) was used to rate the appropriateness of treatment options. Published between January 1, 2013, and July 16, 2025, 116 peer‐reviewed trials provided the evidence: 10 were well‐designed randomized phase 2/3 trials, 29 were moderately well designed trials that accounted for most common biases (matched cohort and phase 2), 76 trials had design limitations (retrospective), and one was a meta‐analysis. Clinical cases were created as examples to illustrate current acceptable management of LRRC. Treatment and prognosis are influenced by prior therapy and the site(s) and extent of LRRC. The ability to achieve a margin‐negative surgical resection is the ultimate determinant of survival and local control. Preoperative systemic therapy, radiation therapy, or a combination of the two can facilitate tumor downsizing and improve the likelihood of a margin‐negative resection. An individualized multidisciplinary approach is required to ensure the best outcome. Although this review does not suggest a major alteration of current practice, it provides reassuring evidence of the importance of combined‐modality therapy.
📝 https://doi.org/10.1002/cncr.70464
Early signal

INDIBLADE

ForStage II/III cT2-4aN0-2 MIBC, bladder-preservation candidates

Bladder-intact event-free survival surrogate

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).

Why it mattersRadiation oncology

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.

Monday clinic

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.

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.

cT2-4aN0-2 MIBC pts pursuing bladder preservation with induction checkpoint blockade before chemoradiation
Does not represent cT4b, M1, or pts for whom upfront radical cystectomy is the chosen path.

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

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.

Trials discussed

KEYNOTE-689NIVOPOSTOP

Why it mattersRadiation oncology

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.

KEYNOTE-689 vs NIVOPOSTOP
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
    FeatureKEYNOTE-689NIVOPOSTOP (GORTEC 2018-01)
    DrugPembrolizumabNivolumab
    SettingPerioperative (before + after surgery)Purely postoperative
    PopulationResectable Stage III-IVA HNSCCHigh-risk resected HNSCC
    Control armSurgery → RT/CRTPost-op CRT
    Primary endpointEvent-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
📚 Sources · 🐦 1 tweet
Early signal

ARTO NCT03449719

ForOligometastatic CRPC, ≤3 nonvisceral lesions, starting first-line abiraterone

Biochemical response (PSA decrease ≥50% at 6 months) surrogate

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

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

castration-resistant pts with three or fewer nonvisceral metastases beginning first-line abiraterone
Does not represent visceral, higher-volume, or hormone-sensitive metastatic disease.

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.

📚 Sources · 📄 1 paper
📄 PAPER Francolini; Allegra; Detti et al. · Journal of clinical oncology : official journal of the American Society of Clinical Oncology (2023-12)
Stereotactic Body Radiation Therapy and Abiraterone Acetate for Patients Affected by Oligometastatic Castrate-Resistant Prostate Cancer: A Randomized Phase II Trial (ARTO).
Abstract
PURPOSE: ARTO (ClinicalTrials.gov identifier: NCT03449719) is a multicenter, phase II randomized clinical trial testing the benefit of adding stereotactic body radiation therapy (SBRT) to abiraterone acetate and prednisone (AAP) in patients with oligometastatic castrate-resistant prostate cancer (CRPC).<br/><br/>MATERIALS AND METHODS: All patients were affected by oligometastatic CRPC as defined as three or less nonvisceral metastatic lesions. Patients were randomly assigned 1:1 to receive either AAP alone (control arm) or AAP with concomitant SBRT to all the sites of disease (experimental arm). Primary end point was the rate of biochemical response (BR), defined as a prostate-specific antigen (PSA) decrease &#x2265;50% from baseline measured at 6 months from treatment start. Complete BR (CBR), defined as PSA < 0.2 ng/mL at 6 months from treatment, and progression-free survival (PFS) were secondary end points.<br/><br/>RESULTS: One hundred and fifty-seven patients were enrolled between January 2019 and September 2022. BR was detected in 79.6% of patients (92% v 68.3% in the experimental v control arm, respectively), with an odds ratio (OR) of 5.34 (95% CI, 2.05 to 13.88; P = .001) in favor of the experimental arm. CBR was detected in 38.8% of patients (56% v 23.2% in the experimental v control arm, respectively), with an OR of 4.22 (95% CI, 2.12 to 8.38; P < .001). SBRT yielded a significant PFS improvement, with a hazard ratio for progression of 0.35 (95% CI, 0.21 to 0.57; P < .001) in the experimental versus control arm.<br/><br/>CONCLUSION: The trial reached its primary end point of biochemical control and PFS, suggesting a clinical advantage for SBRT in addition to first-line AAP treatment in patients with metastatic castration-resistant prostate cancer.
📝 Auto-resolved from a review's discussed trials (ARTO).
Confirmatory

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

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

metachronous oligorecurrent hormone-sensitive prostate cancer, ≤3 nodal or bone lesions after radical local treatment, ECOG 0-1, treated at a single high-volume centre
Does not represent synchronous or de novo oligometastatic disease, more than three lesions, or castration-resistant recurrence.

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
Assessed / enrolled 218
↓ 113 excluded
Randomized105
↓
SBRT + 6mo ADT
allocated 53
analyzed 51
median cPFS 32.2 mo
SBRT alone
allocated 52
analyzed 51
median cPFS 15.1 mo

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.

📚 Sources · 📄 1 paper
📄 PAPER Marvaso; Corrao; Zaffaroni et al. · The Lancet. Oncology (2025-03)
ADT with SBRT versus SBRT alone for hormone-sensitive oligorecurrent prostate cancer (RADIOSA): a randomised, open-label, phase 2 clinical trial.
Abstract
BACKGROUND: Metastasis-directed therapy by stereotactic body radiotherapy (SBRT) has been shown to improve clinical outcomes in the oligometastatic prostate cancer setting. We aimed to investigate whether short-course androgen deprivation therapy (ADT) and SBRT at all oligometastatic sites versus SBRT alone improves clinical progression-free survival in men with metachronous oligorecurrent hormone-sensitive prostate cancer.<br/><br/>METHODS: The RADIOSA study was a single-centre, randomised, open-label, controlled phase 2 trial done in the European Institute of Oncology, IRCCS, Milan, Italy. Key eligibility criteria were histologically proven initial diagnosis of adenocarcinoma of the prostate, biochemical progression after radical local prostate treatment, nodal relapse in the pelvis, extra-regional nodal relapse, bone metastases at next-generation imaging with a maximum of three lesions, Eastern Cooperative Oncology Group (ECOG) performance status 0-1, and age 18 years or older. Participants were stratified according to prostate-specific membrane antigen doubling time (&#x2264;3 vs >3 months), metastases localisation (node vs bone), and diagnostic imaging (positron emission tomography vs MRI) and were randomly assigned (1:1) using a computer-generated random number to SBRT alone or SBRT in combination with 6 months of ADT. For SBRT treatment, a schedule of 30 Gy in three fractions every other day (with the equivalent dose in 2 Gy fractions being 98&#xb7;6 Gy, considering &#x3b1;/&#x3b2; ratio of 1&#xb7;5 Gy and biologically effective dose of >100 Gy), or equivalent regimens depending on disease site location, was administered. Patients in the SBRT with ADT group received 6 months of ADT with a luteinising hormone-releasing hormone analogue within 1 week before the start of SBRT. The allocated treatment was not masked. The primary outcome measure was clinical progression-free survival. All analyses followed a modified intention-to-treat principle, consisting of all patients assigned to a treatment group who had available data. The trial is registered at ClinicalTrials.gov, NCT02680587, and is complete.<br/><br/>FINDINGS: Between Aug 1, 2019, and April 30, 2023, 218 patients were assessed for eligibility, 113 were excluded, and 105 were enrolled and randomly assigned to an intervention (52 to SBRT only and 53 to SBRT with ADT). Three patients were lost to follow-up and 51 patients in each group were assessed for the primary outcome. The median age at study enrolment was 70 years (IQR 65-75); data on race and ethnicity were not collected. With a median follow-up of 31 months (IQR 16-36) for both groups, the median clinical progression-free survival was 15&#xb7;1 months (95% CI 12&#xb7;4-22&#xb7;8) for the SBRT group versus 32&#xb7;2 months (22&#xb7;4-not reached) for the SBRT with ADT group (hazard ratio 0&#xb7;43 [95% CI 0&#xb7;26-0&#xb7;72], p=0&#xb7;0010]). One gastrointestinal grade 1 adverse event (SBRT group) and one genitourinary grade 3 adverse event (left ureter stenosis, SBRT with ADT group) were reported, with no late toxicities observed. 22 grade 1 ADT-related adverse events were reported, all of which had resolved at the last follow-up. No treatment-related deaths were recorded.<br/><br/>INTERPRETATION: To our knowledge, the RADIOSA trial represents the first randomised trial in the metachronous oligometastatic hormone-sensitive prostate cancer setting to report improved clinical progression-free survival with the combination of SBRT and a short course of ADT, although carefully selected patients might still benefit from SBRT alone. By demonstrating improved clinical progression-free survival, the RADIOSA trial reinforces the role of metastasis-directed therapy in delaying systemic treatment escalation. Additionally, it underscores the need for further studies to determine the optimal duration of ADT and identify biomarkers predicting response to SBRT alone.<br/><br/>FUNDING: Italian Association of Cancer Research.
📝 Auto-resolved from a review's discussed trials (RADIOSA).
Challenges SOC

RTOG 0848 NCT01013649

ForResected pancreatic head adenocarcinoma, post 6 cycles adjuvant gemcitabine-based chemo

Overall survival

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%.

Why it mattersRadiation oncology

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%).

Monday clinic

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

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.

resected pancreatic head adenocarcinoma, progression-free after five cycles of gemcitabine-based adjuvant chemotherapy
Does not represent body/tail primaries, pts treated with FOLFIRINOX or neoadjuvant therapy, or margin-positive node-negative pts (10 total, five per arm).

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.

EndpointChemo (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
Randomized354
↓
Chemo
allocated 174
analyzed 174
5yr OS 23.1%
Chemo+CXRT
allocated 180
analyzed 180
5yr OS 27.9%

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.

📚 Sources · 📄 1 paper
📄 PAPER Ross A Abrams; Kathryn A Winter; Karyn A Goodman et al. · Journal of Clinical Oncology (2026-06)
Adjuvant Chemotherapy +/- Chemoradiotherapy for Adenocarcinoma of The Pancreatic Head: Results of The Radiotherapy Randomization of NRG Oncology/RTOG 0848
Unclear

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.

Why it mattersRadiation oncology

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

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).

FactorOR (95% CI)
cN12.94 (1.44-5.99)
GG46.23 (2.85-13.62)
GG59.45 (4.46-20.06)
PSA ≥40 ng/mL3.64 (1.22-10.87)
intact high-risk M0/N0-1 prostate cancer treated with definitive RT
Does not represent post-prostatectomy, intermediate-risk, or metastatic pts, or the ADT duration actually delivered.

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
📄 PAPER Dykstra, Michael P.; Regan, Samuel N.; Yin, Huiying (Maggie) et al. · JCO Oncology Practice (2025-09)
Androgen Deprivation Therapy Practice Patterns in High-Risk Prostate Cancer Treated With Definitive Radiotherapy: Prospective Results From a Statewide Quality Consortium
Abstract
PURPOSE The 2022 AUA/ASTRO guidelines recommend 18-36 months of androgen deprivation therapy (ADT) with definitive radiotherapy for localized, high-risk prostate cancer. The STAMPEDE M0 trial supports intensification with androgen receptor pathway inhibitors (ARPIs) for patients with ≥2 cT3/T4, Grade Group [GG] 4-5, prostate-specific antigen (PSA) ≥40 ng/mL, or cN1. Given advances in imaging, risk stratification, and treatment delivery, we characterized contemporary practice patterns using prospective data from the Michigan Radiation Oncology Quality Consortium (MROQC). METHODS Patients enrolled in MROQC with intact, high-risk M0/N0-1 prostate cancer were included. Clinical information, including intended ADT duration and ARPI use, was prospectively collected. The primary outcome was intended guideline-concordant ADT (GC-ADT, ≥18 months). Multivariable analyses (MVA) assessed associations between clinical factors and GC-ADT recommendations. We compared the adoption of ARPI with standard therapies before and after the publication of STAMPEDE M0. Facility-level variability was evaluated using a mixed-effects model, with the treatment site as a random intercept. RESULTS Between June 2020 and November 2024, 553 patients across 26 centers were included: cT3/4 (13.3%), cN1 (19.9%), GG 4-5 (75.0%), and PSA ≥20 ng/mL (40.0%). Overall, 91.3% were recommended ADT, with 67.0% being guideline-concordant. On MVA, GC-ADT was significantly associated with cN1 (odds ratio [OR], 2.94 [95% CI, 1.44 to 5.99]), GG (GG4 OR, 6.23 [95% CI, 2.85 to 13.62]; GG5 OR, 9.45 [95% CI, 4.46 to 20.06]), and PSA ≥40 (OR, 3.64 [95% CI, 1.22–10.87]). Facility-level variability persisted in the MVA ( P &lt; .0001). Among the 27.9% who met meeting STAMPEDE criteria, ARPI recommendations increased from 0% prepublication to 23.2% afterward. CONCLUSION Within a statewide quality consortium, guideline-concordant ADT recommendations occurred in two thirds of patients, with ARPI intensification in under 25% among STAMPEDE-eligible patients. These findings highlight the need for individualized ADT strategies and collaborative efforts to standardize high-quality care.
Challenges SOC

mRCAT-III NCT06507371

ForpMMR/MSS cT3-4N0/+M0 rectal adenoCa, ≤10cm from anal verge, no lateral node

pCR rate (ITT) surrogate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

mRCAT-III
Endpoint (ITT)Experimental (N=77)Control (N=77)P
pCR rate61.0 (47/77)28.6 (22/77)<0.001
MPR rate77.9 (60/77)50.6 (39/77)<0.001
+1 more figure
Study design: 5Gy x 5d both arms, n=77 per group, NCT06507371
Study design: 5Gy x 5d both arms, n=77 per group, NCT06507371
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.

pMMR/MSS cT3-4 N0/+ M0 rectal adenocarcinoma within 10 cm of the anal verge, without lateral nodal involvement
Does not represent dMMR/MSI-H tumors, patients with positive lateral lymph nodes, or upper rectal and rectosigmoid primaries.

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
Randomized154
↓
Node-sparing SCRT + CAPOX + tislelizumab
allocated 77
pCR 61.0%
Conventional SCRT + CAPOX
allocated 77
pCR 28.6%

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.

📚 Sources · 🐦 1 tweet
Challenges SOC

LBA8005: Concurrent Thoracic RT + Chemoimmunotherapy in ES-SCLC

ForTreatment-naive ES-SCLC on durvalumab/platinum/etoposide, ECOG 0-1, thoracic lesion

Overall survival

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

LBA8005: Concurrent Thoracic RT + Chemoimmunotherapy in ES-SCLC
ArmMedian OS95% CIHR (95% CI), p
Chemoimmunotherapy plus TRT10.0 months8.3 - 11.71.14 (0.84 - 1.56), p=0.40
Chemoimmunotherapy11.8 months10.0 - 13.6reference
+2 more figures
LBA8005: Concurrent Thoracic RT + Chemoimmunotherapy in ES-SCLC
ArmMedian PFS95% CIHR (95% CI), p
Chemoimmunotherapy plus TRT5.1 months4.7 - 5.41.10 (0.84 - 1.45), p=0.49
Chemoimmunotherapy5.0 months4.6 - 5.4reference
Study design. TRT 30 Gy/10 fractions starting day 21-28. Durvalumab 1500 mg, carboplatin AUC=5, etoposide 100 mg/m BSA. PCI 25-30 Gy to responders.
Study design. TRT 30 Gy/10 fractions starting day 21-28. Durvalumab 1500 mg, carboplatin AUC=5, etoposide 100 mg/m BSA. PCI 25-30 Gy to responders.
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.

PopulationTRT median OSControl median OSHR (95% CI), p
Completed all 4 chemo-IO courses11.9 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 mets11.9 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.

treatment-naive ES-SCLC, ECOG 0-1, with measurable thoracic disease, receiving durvalumab plus platinum/etoposide
Does not represent limited-stage SCLC, patients selected for consolidative TRT only after completing induction, or symptomatic brain metastases.

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
Randomized228
↓
Chemoimmunotherapy plus TRT
allocated 115
mOS 10.0 mo
Chemoimmunotherapy
allocated 113
mOS 11.8 mo

Randomised phase III, primary OS endpoint, prespecified stratification; result diverges from CREST-era practice of consolidative TRT. Design internally valid for the null claim.

📚 Sources · 🐦 1 tweet

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.

Trials discussed

HERANCCTG N9831APHINITYKATHERINEATEMPTDESTINY-Breast05COMBARTKEYNOTE-522

Why it mattersRadiation oncology

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.

Monday clinic

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

RT + Systemic Therapy: What to Continue vs Hold (Speers)
+3 more figures
RT + Systemic Therapy: What to Continue vs Hold (Speers)
T-DXd ILD ~12% at 5.4 mg/kg, fatal ~0.9%. DESTINY-Breast05 ILD 9.6% T-DXd vs 1.6% T-DM1. RT timing 10.7% seq vs 9.6% concurrent. COMBART 40 pts, acute tox 20%.
T-DXd ILD ~12% at 5.4 mg/kg, fatal ~0.9%. DESTINY-Breast05 ILD 9.6% T-DXd vs 1.6% T-DM1. RT timing 10.7% seq vs 9.6% concurrent. COMBART 40 pts, acute tox 20%.
KEYNOTE-522 post-hoc: 1,174 pts, 715 received RT. Pembrolizumab t½ 22 days, 5t½ ~110 days. P-RAD preop RT 0 / 9 / 24 Gy.
KEYNOTE-522 post-hoc: 1,174 pts, 715 received RT. Pembrolizumab t½ 22 days, 5t½ ~110 days. P-RAD preop RT 0 / 9 / 24 Gy.
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.

pts receiving breast/chest wall plus regional nodal irradiation while on concurrent systemic therapy
Does not represent other disease sites, definitive thoracic RT, or the CNS SRS setting except as a named caution.

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.

AgentCallBasis given
Endocrine therapyContinueMinimal radiosensitization
Trastuzumab ± pertuzumabContinueGenerally safe; modern heart-sparing
T-DM1ContinueDermatitis + pneumonitis vigilance; caution with CNS SRS
PembrolizumabContinuePneumonitis vigilance + immune-toxicity workflows
T-DXdCautionSequence/hold for high lung-dose or active pulmonary disease
CDK4/6 inhibitorsCautionUsually hold for large fields; concurrent only in protocol
OlaparibCautionReasonable with limited fields; protocol settings only
Cytotoxic chemo (anthracycline/taxane/platinum)Hold / sequenceSequence, do not give concurrently
CapecitabineHold / sequenceAdjuvant paradigm non-concurrent
Veliparib / talazoparibHold / sequenceVeliparib + RT severe acute/late tox
mTOR / PI3K agentsHold / sequenceMucosal, skin, metabolic, inflammatory risk; ESMO-ESTRO advises caution
📚 Sources · 🐦 1 tweet
Early signal

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.

Why it mattersRadiation oncology

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.

MIRACLE-2
Best overall responsen (%)95% CI
CR1 (2.0%)n/a
PR33 (66.0%)n/a
SD10 (20.0%)n/a
PD6 (12.0%)n/a
ORR34 (68.0%)53.6%-80.0%
DCR44 (88.0%)76.0%-95.2%
ETS rate38 (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.

EndpointMedian (95% CI)1-yr rate
PFS9.3 mo (7.1-11.5)33.4%
OS23.2 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.

first-line MSS rectal cancer with synchronous unresectable liver and/or lung metastases, primary ≤10 cm from the anal verge
Does not represent MSI-H/dMMR disease, colon primaries, or metachronous or resectable metastatic presentations.

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.

📚 Sources · 🐦 1 tweet
Confirmatory

CAN-2409 NCT01436968

ForIntermediate or high-risk localised prostate cancer, EBRT candidates, ECOG 0-2

Disease-free survival surrogate

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.

Why it mattersRadiation oncology

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%.

Monday clinic

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

CAN-2409
TrialArmsLocal endpointControl vs intensified
RTOG 9408RT 66.6Gy vs + 4m ADT2yr post-Rx biopsy positive40% vs 20%
ASCENDE-RT46Gy + DE-EBRT 23Gy vs 46Gy + LDR-BT10y local failure7.1% vs 1.5%
FLAMERT 77Gy vs + SIB 95GyCrude local failure7.7% vs 2.7%
CAN-2409RT 78Gy + placebo vs + CAN-24092yr post-Rx biopsy positive36.4% 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.

EndpointAglatimagene + valacyclovirPlacebo + valacyclovirEffect
Median DFSNR (95% CI 121.78-NR)86.1 moHR 0.70 (0.52-0.94), p=0.016
2y post-Rx biopsy pCR80.4%63.6%not stated
2y biopsy persistence/recurrence19.6%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.

intermediate or high-risk localised prostate cancer receiving 78 Gy or hypofractionated EBRT with optional ADT
Does not represent pts treated with brachytherapy or SIB boost regimens.

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
Randomized745
↓
Aglatimagene + valacyclovir
allocated 496
analyzed 496
mDFS not reached
Placebo + valacyclovir
allocated 249
analyzed 249
mDFS 86.1 mo

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
📄 PAPER DeWeese, Theodore L; Manzanera, Andrea; Sylvester, John et al. · The Lancet Oncology (2026-06)
Aglatimagene besadenovec (CAN-2409) with radiotherapy for patients with localised prostate cancer: a phase 3, multicentre, randomised, double-blind, placebo-controlled trial
Abstract
Background About 30% of men with localised prostate cancer undergoing radiotherapy with curative intent have disease recurrence associated with progression-related symptoms and substantial toxicity of salvage therapies. Previous studies with aglatimagene besadenovec (CAN-2409, hereafter referred to as aglatimagene) showed synergy with radiation and immune-mediated cytotoxicity in patients with prostate cancer. We aimed to assess whether addition of aglatimagene plus prodrug (valacyclovir) to standard-of-care external beam radiation therapy (EBRT) could improve disease-free survival in this population. Methods We conducted a phase 3, randomised, double-blind, placebo-controlled trial at 51 medical centres (26 community and 25 institutional or military) across the USA and Puerto Rico in patients with intermediate or high-risk prostate cancer. Patients aged at least 18 years who were planning to undergo EBRT and with an Eastern Cooperative Oncology Group score of 0-2 were eligible. Patients were randomly assigned (2:1) via central block-randomisation to receive either three courses of intraprostatic aglatimagene (5 × 10 11 viral particles) plus valacyclovir or placebo plus valacyclovir, with randomisation stratified by risk category and androgen deprivation therapy (ADT) use. Patients received standard-of-care EBRT (78 Gy in 2 Gy fractions) or hypofractionated EBRT (60 Gy in 3 Gy fractions or 70 Gy in 2·5 Gy fractions) with optional ADT. The primary endpoint was disease-free survival, defined as time-from-randomisation to prostate cancer recurrence or death in the intent-to-treat population (all randomly assigned patients). Safety was assessed in all individuals who received at least one injection. The trial is registered at ClinicalTrials.gov, NCT01436968, and long-term follow-up is ongoing. Findings Between Feb 21, 2012, and Sept 9, 2021, 745 men (591 [79%] White, 121 [16%] Black) were randomly assigned to receive aglatimagene plus valacyclovir (n=496) or placebo plus valacyclovir (n=249). After a median follow-up of 50·3 months (IQR 35·2-63·3), median disease-free survival was not reached (95% CI 121·78 to not reached) in the aglatimagene plus valacyclovir group versus 86·1 (IQR 29·7-143·0) months in the placebo plus valacyclovir group (hazard ratio 0·70, 95% CI 0·52-0·94; p=0·016). Treatment-emergent adverse events (TEAEs) of grade 3 or worse occurred in 40 (8%) of 479 patients in the aglatimagene group and 17 (7%)of 232 patients in the placebo group. The most common TEAE of grade 3 or worse was acute kidney injury in both the aglatimagene group (nine [2%] of 479 patients) and the placebo group (four [2%] of 232 patients). Serious adverse events occurred in 28 (6%) of 479 patients in the aglatimagene group and 17 (7%) of 232 in the placebo group. Treatment-related serious adverse events occurred in eight (2%) patients in the aglatimagene group (four acute kidney injury, two pyrexia, and one each influenza-like symptoms and urinary retention) and five (2%) in the placebo group (four acute kidney injury, and one each increased creatinine levels and skin rash; one patient reported two serious adverse events). No treatment-related deaths were reported. Interpretation Aglatimagene plus valacyclovir was associated with longer disease-free survival than placebo plus valacyclovir when added to standard of radiotherapy for the treatment of localised prostate cancer, offering a meaningful benefit without increasing clinically significant toxicity. Funding Candel Therapeutics and US National Institutes of Health.
📝 https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(26)00071-9/fulltext
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

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.

CohortExposure armReference armEffect
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.

advanced or ICI-refractory NSCLC receiving RT alongside ICI in a Hong Kong public-system population
Does not represent unresectable locally advanced disease treated with curative chemoRT, or refractory pts who died within 90 days.

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.

📚 Sources · 📄 1 paper
📄 PAPER Zhou; Wang; Lee et al. · JAMA oncology (2026-05)
Combination of Radiotherapy and Immunotherapy in Advanced Non-Small Cell Lung Cancer.
Abstract
IMPORTANCE: The optimal sequencing of radiotherapy (RT) combined with immunotherapy (iRT) and the value of chemotherapy remain undefined for advanced non-small cell lung cancer (NSCLC), where randomized data are limited.<br/><br/>OBJECTIVE: To compare real-world overall survival (OS) between sequential and concurrent iRT in newly diagnosed advanced NSCLC, assess the effect of immune checkpoint inhibitor (ICI) maintenance after RT in refractory disease, and evaluate the association of chemotherapy with survival.<br/><br/>DESIGN, SETTING, AND PARTICIPANTS: This is a territory-wide study (OCEANUS) based on the Hong Kong Hospital Authority Clinical Data Analysis and Reporting System (more than 90% population coverage). Patients with NSCLC diagnosed from January 1, 2010, to December 31, 2021, who subsequently received iRT for advanced or refractory disease were included. Overlap weighting was the primary propensity score-weighted method, with inverse probability of treatment weighting used for sensitivity analysis. Data were analyzed from December 2024 to April 2025.<br/><br/>EXPOSURES: Sequential vs concurrent iRT for newly diagnosed advanced NSCLC; RT with vs without ICI maintenance for refractory NSCLC; receipt of chemotherapy.<br/><br/>MAIN OUTCOMES AND MEASURES: The primary outcome was real-world OS after landmark, estimated with weighted Kaplan-Meier and Cox models. When proportional hazards were violated (per Schoenfeld residuals), treatment effects were summarized using restricted mean survival time.<br/><br/>RESULTS: Of 3522 patients who received ICIs, 335 received RT, including 155 with newly diagnosed advanced and 180 with refractory NSCLC. Of these, 247 (73.7%) were male, and the median (range) age was 64 (34-90) years. In newly diagnosed NSCLC, patients treated with sequential iRT had significant longer real-world OS than those treated with concurrent iRT (median, 20.3 months [95% CI, 13.3 to not reached] vs 16.0 months [95% CI, 8.3-30.0]; adjusted hazard ratio, 0.68; 95% CI, 0.47-0.99; P&#x2009;=&#x2009;.045). Chemotherapy was also associated with longer survival in patients with newly diagnosed advanced NSCLC. In refractory NSCLC, RT with ICI maintenance was associated with a numerically longer median real-world OS (11.2 months [95% CI, 7.9-20.6] vs 6.7 months [95% CI, 4.4-17.4]; P&#x2009;=&#x2009;.20). Addition of chemotherapy was not significant for real-world OS. Inverse probability of treatment weighting analyses produced similar estimates.<br/><br/>CONCLUSIONS AND RELEVANCE: In this cohort study, sequential iRT was associated with longer survival than concurrent iRT in patients with newly diagnosed advanced NSCLC, and chemotherapy was associated with longer survival. In patients with refractory NSCLC who survived at least 90 days, RT with ICI maintenance resulted in nonsignificantly longer survival and an unclear association with chemotherapy. These findings are hypothesis generating and support prospective randomized studies to define optimal sequencing of iRT and use of systemic treatment partners.
📝 https://jamanetwork.com/journals/jamaoncology/fullarticle/2847148?guestAccessKey=6284363c-f1dd-46da-aa0e-8528e5ecca06&utm_source=twitter&utm_medium=social_jamaonc&utm_term=20674463146&utm_campaign=article_alert&linkId=952727864
Early signal

RAD-IO

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

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

Why it mattersRadiation oncology

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

Monday clinic

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Which durvalumab component (neoadjuvant, synchronous, adjuvant) drives benefit
  • Whether 80% 12-mo DFS survives a randomised comparator
  • Drivers of the 39% early discontinuation
📚 Sources · 🐦 3 tweets

Living Longer, Living Better (GU Discussant)

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

Trials discussed

EV209EV309RAMPART

Why it mattersRadiation oncology

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

Monday clinic

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

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

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

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

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

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

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

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

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

Neo-CRAG

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

Disease-free survival surrogate

HR 0.750

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

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

Why it mattersRadiation oncology

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

Monday clinic

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

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

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

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

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

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

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

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

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

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

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

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

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

CONSORT flow
Randomized620
↓
CRT (chemoRT + XELOX)
allocated 310
3yr DFS 55.6%
CT (XELOX alone)
allocated 310
3yr DFS 42.4%

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

  • Does preoperative chemoRT still add benefit on a FLOT backbone?
  • Generalizability outside high-volume D2 centers
  • Optimal target volume and elective nodal coverage not reported in source
📚 Sources · 🐦 1 tweet
Confirmatory

SWOG/NRG S1914 NCT04214262

ForT1-3N0M0 NSCLC ≤7cm, medically inoperable or declined surgery, ≥1 risk factor

Overall survival

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%).

Why it mattersRadiation oncology

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.

Monday clinic

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

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 siteSBRT aloneAtezo + SBRT
Local7%13%
Regional2%3%
Distant4%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.

medically inoperable or surgery-declining T1-3N0M0 NSCLC ≤7 cm with high-risk features treated to BED ≥100 Gy
Does not represent node-positive, operable, or post-operative early-stage pts, nor other checkpoint inhibitors or SBRT sequencing schedules.

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
Randomized417
↓
SBRT alone (S)
allocated 201
2yr OS 82%
Atezolizumab + SBRT (AS)
allocated 202
2yr OS 80%

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
📄 PAPER Simone, Charles B.; Daly, Megan Eileen; Redman, Mary Weber et al. · Journal of Clinical Oncology (2025-06)
SWOG/NRG S1914: Randomized phase III trial of induction/consolidation atezolizumab + SBRT versus SBRT alone in high risk, early-stage NSCLC.
Abstract
8003 Background: Stereotactic body radiation therapy (SBRT) is the standard of care (SoC) for early stage, medically inoperable non-small cell lung cancer (NSCLC). While rates of in-field control exceed 90%, regional and distant control after SBRT remain suboptimal. A prior phase II randomized trial suggested a benefit to adding immunotherapy (PMID 37478883). SWOG/NRG S1914 (NCT#04214262) is a randomized phase III trial evaluating neoadjuvant, concurrent and adjuvant atezolizumab plus SBRT for early-stage NSCLC vs SoC. Methods: Eligible patients (pts) had T1-3N0M0 NSCLC ≤7cm, were medically inoperable or declined surgery, and had ≥1 risk factor for increased recurrence: tumor diameter ≥2 cm, ≥6.2, moderately/poorly/undifferentiated histology. Randomization was to SoC SBRT (S [3-8 fractions, biologically effective dose ≥100 Gy]) or neoadjuvant, concurrent and adjuvant atezolizumab (AS [1200 mg IV Q3 week, 8 cycles]) with SBRT initiated with cycle 3, stratifying by tumor location (central vs peripheral), size (&lt;4 cm vs ≥4cm) and ECOG performance status (PS, 0-1 vs 2). The primary objective was to compare overall survival (OS) between the arms. Secondary objectives included comparisons of progression free survival (PFS), failure patterns, toxicity and quality of life (QoL). OS and PFS were compared using a 1-sided stratified log-rank test at the 2.5% level, confidence intervals (CI) are 95%. The accrual goal was 432 eligible pts. Results: From 8/13/20 - 9/6/24, 417 pts were randomized, 403 met eligibility [201 to S, 202 to AS]. Accrual closed at the first interim analysis for futility based on OS and PFS per design. Median follow-up for pts still alive was 12 (range: 0.03-49) months. Median age was 73 (41-91) years and 89% had PS 0-1. Median tumor diameter was 2.3 cm. No protocol treatment was received for 6 pts on S and 8 on AS. With 49 deaths, OS was not different between the arms (HR (CI): 1.15(0.65-2.01), p=0.63; 2-year OS: 82% S vs 80% AS). With 88 events, PFS was not better with AS (HR (CI): 1.35(0.89-2.06), p=0.16); 2-year PFS was 71% on S vs 60% on AS. Regional (2% vs 3%) and distant (4% vs 5%) failures were not different; there were more local failures with AS (13% vs 7%). Among former (53%)/never (3%) smokers, AS had worse OS and PFS than S (HR(CI): 2.50 (1.11-5.59), p=0.03); HR(CI): 2.16(1.15-4.04), p=0.01), respectively. Grade (G) ≥3 adverse event (AE) rates were 12% on AS (N=21 G3, 1 G4, 1 G5 respiratory failure) vs 2% on S (N=3 G3, 1 G4). Conclusions: In the first reported phase III trial to assess immunotherapy (IO) added to SBRT in early-stage NSCLC, IO failed to improve survival. More G ≥3 adverse events were reported with AS. Central review of local recurrence events is ongoing. Additional investigation into subgroups, PD-L1 status, QoL and blood/tissue are pending to determine whether there are subsets who can benefit from this combination and shed further insights into these findings. Clinical trial information: NCT04214262 .
📝 https://ascopubs.org/doi/10.1200/JCO.2025.43.16_suppl.8003
Caveats dominate

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

Bladder-preserving TMT multicenter analysis (URONCOR)
10 details

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.

cT2-T4aN0M0 MIBC pts selected for definitive TMT in routine European practice, median age 76
Does not represent node-positive or metastatic disease, nor pts triaged to upfront radical cystectomy.

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
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Early signal

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.

Why it mattersRadiation oncology

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.

Monday clinic

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

OPERA
EndpointArm AArm BOverall
W14 good response (cCR+nCR)65%88%76%
W14 partial responsen/an/a24%
5yr organ preservation75%83%p=0.24
CTRE performed at W14n/an/a122/141 (87%)
+2 more figures
OPERA
OPERA
10 details

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%).

rectal cancer pts treated with neoadjuvant therapy under an organ-preservation intent and assessed clinically after NAT
Does not represent pts with obstructing or clinically progressive disease for whom watch-and-wait was never on the table.

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
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