David Sher
@DavidSherMD
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"Ultimately, the secret of quality is love. You have to love your patient, you to have to love your profession, you have to love your G-d." Avedis Donabedian
Dallas, TX
Joined April 2019
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I would like to recognize the professionalism and bravery of all of the radiation therapists treating patients despite the constant risks of
#COVID19
exposure. They are under-appreciated heroes!
@UTSW_RadOnc
@E_T_TweetHome
@ASTRO_org
@subatomicdoc
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Thrilled to see our INRT-AIR trial out in press!
In this phase II study, we **eliminated** elective nodal irradiation for patients with HSNCC treated with definitive RT/CRT.
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Absolutely remarkable RCT on weekly adaptive radiotherapy in oropharynx, showing *no* difference between the arms.
Weekly Adaptive Radiotherapy vs Standard Intensity-Modulated Radiotherapy for Head and Neck Cancer
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Performed a H&N adaptive fraction today using our new HyperSight on Ethos...
The CBCT is effectively indistinguishable from the simulation CT...
Success of adaptive radiotherapy hinges on visualization of the targets and OARs.
Impressive!
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So disappointing that weather prevented our presentation of the
@UTSW_RadOnc
phase II LT-SABR trial (yes, pronounced "light saber") for early-stage glottic larynx cancer at
#HNCS22
. Below are the slides!
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H&N contouring tip. There are no lymph nodes inside the submandibular gland (in contrast to the parotid). So when contouring level IB, do not include the gland in your volume. It will unnecessarily increase your oral cavity dose (for non-oral cavity primaries).
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This rental car was meant for me! (a little H&N rad onc humor…)
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We had a very exciting week here
@UTSW_RadOnc
as we finished treating our last patient on the H&N DARTBOARD trial!
This randomized ph II study is comparing daily adaptive RT and near-marginless treatment (1 mm PTV) with standard IGRT using CBCT-based ART (Ethos) for H&N SqCC.
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Perhaps I’m tipping over a sacred (H&N contouring) cow, but…
Why do we need 5 mm around the GTV for CTV70?
Let’s have PTV70 = GTV70 plus setup error.
Use a lower dose CTV for microscopic dz.
Why?
Almost all recurrences are directly in-field (1/2)
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My 9 yo asked “what is saliva?” and got more than he bargained for. Now he has a healthy respect for the submandibular glands and is finally ready to contour some OARs.
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This trial is insane in every good way imaginable.
Insanely innovative, insanely different from standard-of-care, insanely successful.
A few thoughts below.
Practice changing clinical trial by
@imrtlee
@xrtGenomics
@MSK_RadOnc
@MSKCancerCenter
and the entire HN group. Results from this study again demonstrated the importance of biology driven de-escalation. One size does not fit all.
@DavidSherMD
@DanielMaMD
@henson_md
@YaoCMKL
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How can it be 2021 and I need to write a letter of medical necessity to use IMRT for postop oropharynx?
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Very happy for
@DominicMoonMD
to see his HYPORT study out in
@IJROBP
.
@UTSW_RadOnc
phase I trial of hypofractionated adjuvant RT for resected HNSCC: 3 weeks of treatment!
46.5 Gy/15 fx then 44.4 Gy/12 fx. 6 pts/cohort.
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We are hiring a H&N radiation oncologist!
Our facility has fantastic technologies that are ideal for H&N neck radiotherapy (CBCT- and MRI-based adaptive radiotherapy, MRI and soon-to-be PET sim, PET-linac etc etc), and we have a culture that encourages innovation. (1/2)
We are seeking clinical radiation oncologists to join our GU, H&N, and GYN disease-oriented teams!
To apply, scan the QR code below or visit direct link:
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Interested in people’s thoughts on my rule of 35 for H&N IMRT.
Keep max spinal cord and brainstem dose <= 35 Gy.
Why?
For cord, a few years ago, I was frustrated by Lhermitte’s. Not devastating to patients, but annoying.
Moved to 35 Gy max, haven’t seen it in years.
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Some thoughts on the fantastic DARS trial.
It’s invigorating to see a randomized trial of radiation technique, which can have such an impact on the patient in the short- and long-term.
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Have any radiation oncology departments developed contingency plans for when a patient under treatment has been exposed to COVID-19?
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Insightful cost-effectiveness analysis here of SC24, the landmark randomized study of spine SBRT (24 Gy/2) versus conventional RT.
Bottom-line: in the Canadian healthcare system, SBRT is clearly, obviously, cost-effective.
@SahgalArjun
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As H&N RT continues to improve, chronic taste changes have become a more prominent symptom after treatment. Need better PROs to describe these side effects, which can be very frustrating.
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We are extremely excited to activate our *randomized* DARTBOARD trial of daily adaptive radiotherapy using near marginless planning.
@UTSW_RadOnc
is very enthusiastic about adaptive RT, and it is critical to prove its utility with prospective study.
DARTBOARD, a clinical trial led by Dr.
@DavidSherMD
, Chief of Head and Neck Radiation Oncology Service, studies daily adaptive radiotherapy on head and neck cancers using tumor targeting driven by an AI-drive algorithm.
Learn more in this week's MedBlog:
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Drama in the household. We knew this day would come (admittedly, we thought a few years ago…), but my 9 yo (yes, 9) figured out there is no Tooth Fairy. Picture is after he calmed down and became pensive, so only one tear left.
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@Marty_Shrkeli
People look at $ per
#radonc
MD and conclude, overpaid/too expensive. If reframed more appropriately, $ per patient treated, conclusion would be that radiotherapy is extremely cost-effective. Oligomet SBRT is an excellent example of this calculation.
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From a QoL perspective, I feel like taste is the Last Frontier of IMRT optimization. *So* important to patients but our understanding is limited. This nifty paper from MDACC &
@cd_fuller
takes a look:
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Very useful, large, study on ORN after extractions preceding H&N radiotherapy (n=879) from PMH.
Some comments:
1. Overall risk was quite low (n=16, 1.8% ORN out of entire cohort), about 1/3 successfully treated within 6 months. (1/n)
Although the timing of dental extractions affect osteoradionecrosis (ORN) development, most extractions performed within 14 days of the radiation therapy start date do not develop into ORN.
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Terrific work
@DanielMaMD
@DavidRoutmanMD
@BhishamCheraMD
!!
Could next step may be randomizing postop ctHPVDNA(-) patients to observation or PORT?
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I just successfully placed wax on my son’s insane orthodontic appliance and finally feel like being a head and neck radiation oncologist helped me at home.
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Fantastic lecture by Visiting Professor
@JJCaudell
@UTSW_RadOnc
on the past, present and future of H&N radiotherapy. Both biological insights and tech innovations are needed to revolutionize the therapeutic ratio.
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Near crisis-level sockopenia this morning, but
@IJROBP
came through big-time! It’s now his favorite journal: how young is too young for RePRT?
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Dear
@ABR_Radiology
, just took a rad onc MOC question in which the only difference between DVH lines was the color. Can you please help color-blind examinees and create a non-color mechanism (e.g. dots/dashes) to distinguish between answers? THANKS.
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This study truly shows the importance of rigorous phase I/II clinical trials of SAbR. Without prospective study of novel tx that otherwise “make sense,” we’ll never know their real impact. Kudos to my colleagues for publishing their hard work!
@UTSW_RadOnc
SABR is not a panacea - investigators
@utswcancer
show that SABR boost after pelvic
#radiotherapy
to advanced cervical cancers not suited to brachytherapy may be too risky. Avg. boost volume 139cc, 2 year cumulative grade ≥ 3 toxicity of 26.7%.
#radonc
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Really well-done paper from MDACC on failure patterns after IMRT for CUP. My question
@cd_fuller
: given very long times to the rare mucosal failure, were these recurrences or 2nd primaries?
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Superb summary of RTOG 1016 and De-ESCALaTE from the Red Journal Head and Neck Editors.
De-Escalation Strategies in HPV-Associated Oropharynx Cancer—Are we Putting the Cart Before the Horse?
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Microscopic dz is only 5 to rarely 10 mm from GTV (even less around nodes), and that does *not* need full dose. It's microscopic.
Such margins markedly increase the irradiated high-dose volume.
Volume reduction is a great de-escalation paradigm, for all disease sites. (2/2)
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Extremely important data in this study.
Immunotherapy is incredible and revolutionary, but even monotherapy has sig toxicity and a non-trivial grade 5 risk.
Its use in non-approved clinical settings (esp high-risk, non-met cancer) should be reserved for clinical trials.
Aggregate safety data for pembrolizumab monotherapy across trials in European Journal of Cancer with Dr.
@JulieBrahmer
et al (n=8937). G3+ AEs in 51% of pts, discontinuation from AE in 13%, fatal AEs 6%. Median time to immune-mediated AE was 85d.
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So proud of our
@UTSW_RadOnc
Precision Rad Onc fellow
@DanaKeilty
for presenting our long-term data on 5 fraction RT for paraganglioma.
At
@the_RSS
2023,
@DanaKeilty
presents
@UTSW_RadOnc
outcomes using 25Gy/5 Rx to median 60.5% IDL for h&n paragangliomas, showing excellent LC, median ⬇️40% size, improved symptoms, and favorable tox profile ⚡
@DavidSherMD
#radonc
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@drmattmc
A related question is why the perceived acute and late side effects of endocrine therapy are perceived to be so much better than a course (often short) of radiotherapy (now often small volume). Automatic perception of RT as more toxic is problematic.
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Extremely exciting to see ECOG 3311 published. Important study and impressive team effort to complete a complex multi-disciplinary trial. (1/4)
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Very large multi-institutional experience of postoperative management of low- and intermediate-grade salivary gland cancers.
Bottom-line(s): (1/2)
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@xrtGenomics
Disappointing but consistent with H&N data. Results highlight that draining lymph node irradiation is likely not the only reason CRT+IO has failed. Rather concurrent I/O + CRT may be changing the TME in ways that are counterproductive. Very interesting and lots of work needed.
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Hey
@NEJM
, shouldn't the 1,000 patient RCT be a bit more prominent than the 60 patient uncontrolled cohort study?
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Absolutely masterful lectures on prostate cancer by
@ndesai2005
@DrMikeFolkert
@ChadTangMD
at
#TRS2020
@TxRadSociety
. Prostate cancer doesn’t stand a chance in Texas!
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Dose calculation directly on the CBCT is an absolute game-changer.
Cannot wait to bring this to clinic!
Lina Åström doing amazing work as usual, sharing Ethos 2.0 updates from the Herlev team! Direct plan calculation on CBCT for online adaptive (HU accuracy confirmed by
@JamesRobar
et al). Makes sim-free (“One stop!”) tx so easy to do on a broader scale! Love this for the clinic!
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Parenting tip: if you give your child a hand-me-down computer, first sign out from Amazon
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My stage I HPV+ tonsil patient was offered pembro alone (no RT!) by an outside med onc. A bit in shock. Treatment de-escalation will = SUCCESS de-escalation if not properly studied and implemented.
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Adaptive radiotherapy is a team sport!
Today two of our physicists, Drs. David Chiu and Frances Su, hosted the first Unity MRI contour training workshop to train therapists to contour in Monaco TPS for MR-guided adaptive therapy.
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Incredible resolution on breath-hold HyperSight (LEFT scan, anterior lesion) to see development of internal necrosis after one fraction of SAbR. Daily ART can be useful to treat two lesions with one iso.
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It was terrific seeing my colleague
@aguilera_md
discuss his paradigm-breaking work at the
@eaonc
Fall Meeting. Incredible seeing the potential impact of SAbR in metastatic pancreatic cancer.
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Heard some rad oncs discussing the challenges of getting VALOR open
@DrewMoghanaki
then heard 3 great talks on how NCDB studies have fatal flaws. Patient outcomes can’t be improved unless we aggressively and creatively pursue RCTs.
#ASTRO2019
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I recently saw a young patient in follow-up soon after a restaging PET-CT.
She learned of her brutal prognosis on her phone, from the MyChart test release mandated by the CARES act.
The
@OncLive
HTIBM files: Me and Gerber. The recent USA law requiring immediate release of medical results to patient portals created panic scenarios. Facts forced on patients without context. But you can’t change the law, right? Enter Gerber.
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I have a whole new respect for Apple: the new iPhone update screens Evicore calls as "Spam Risk."
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Very high-yield study, as the group was able to look at long-term dysphagia following H&N radiation (median > 8 years from treatment) and correlate with dose.
Most notable finding is the high burden of chronic dysphagia (31%), recognizing this was a x-sectional study. 1/5
New article (Vol 190)
Radiation-induced long-term dysphagia in survivors of head and neck cancer and association with dose-volume parameters
Thuy-Tien Maria Huynh et al.
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There are "known unknown" and "unknown unknown" p16+ squamous cell carcinomas of the head & neck.
For patients with HPV+ SqCC of the upper neck, it is an oropharynx primary unless proven otherwise, with mucosal coverage as indicated (can debate NP coverage too)... (1/3)
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Several prospective and retrospective studies have shown the safety and improved QoL’s with dropping the ENI dose to 40 Gy or below, including work from MSKCC (
@CJTsaiMDPhD
@seanmmcbride
@imrtlee
), Belgium (RCT!), Coastal Carolina, and UTSW.
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Absolute MasterClass summaries of radiotherapy for early-stage breast cancer
@TxRadSociety
Annual Meeting by
@BenSmithMD
and my colleague Dr. Asal Rahimi
@UTSW_RadOnc
. Breast cancer doesn't stand a chance in Texas!
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I’m thrilled to report that CIPHER, our international phase III randomized trial of carbon ion RT versus IMRT for unresectable pancreatic cancer, is open! LET’S DO THIS!
@PanCAN
@letswinpc
@NiuSanford
@ShaalanBeg
@UTSW_RadOnc
@utswcancer
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Thrilled to have Dr. Badiyan join our faculty!
Welcome to our newest faculty member, Dr.
@BadiyanMD
! Dr. Badiyan joins both our gastrointestinal and lung disease-oriented teams. He will also serve as our department's Director of Clinical Adaptive Therapy.
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Congratulations team! Extremely impressive work.
@DrMikeFolkert
@ndesai2005
@seanmmcbride
A Multi-Institutional Phase II Trial of High-Dose SAbR for Prostate Cancer Using Rectal Spacer
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Honestly, I'm too busy drawing my cord blocks to deal with this stuff.
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Fascinating RCT on PET-based adaptive SIB boost for high-risk HNSCC in
@IJROBP
Dose-escalation in two phases. Escalation in fx 1-10 based on pre-RT PET. Escalation in fx 11-20 based on PET after fx 8. Fx 21-30 was not escalated.
Standard arm 69.12/32 fx
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On this Presidents’ Day, I would like to celebrate the President of the larynx: the humble arytenoid.
It contributes to voice and closure of the larynx before swallowing, crucial functions that can be compromised by RT. (1/2)
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I saw a cool post last week about a surprisingly great clinical result & wanted to reciprocate.
64 yo man with T4N2 p16+, HPV- BOT SqCC treated with CRT in 2017.
3 months after CRT, restaging showed a new rounded lung nodule, biopsied as p16+, HPV- treated with SBRT in 2017...
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I think that the clinical utility of the Unity MRL is really just beginning.
The passion of the ViewRay users speaks to the importance of MR-guided motion-mgmt to moving targets. No comparison to gating on the target versus a surrogate.
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I could not agree more with this description!
"AI as co-pilot" is a terrific metaphor.
In addition to teaching AI how to fly the plane, we can also teach it when to ask for help, which will make the pilot more efficient in finishing the flight.
Important review & discussion of
#artificalintelligence
at
#HNCS24
by
@BenjaminKannMD
. Now widely used for normals but good review of literature for target identification- especially LN by
@DavidSherMD
. AI as copilot but unlikely to stand on its own✈️
@ASTRO_org
@AHNSinfo
@ASCO
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@JAMAOto
The paper is well-written, but I would strongly caution anyone from using NCDB data to make treatment decisions. Far too much unknown confounding and lack of detail.
Example: in NCDB, true margin width/status is unknown.
Can't interpret any PORT results without such data.
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Much more work needs to be done on this paradigm, and we will open up an RCT next year: INRT vs. ENI. BUT this study shows that this concept is viable and potentially a *big* improvement over standard neck treatment. It may also synergize with IO, as
@KaramLab
work has suggested.
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@SyedAAhmad5
With all due respect, I would argue that a manuscript should stand (or fall) on its own, independent of authorship. A reason why I believe in blinding the authors and institutions of a submission prior to peer review. This info can bias the review.
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It’s time to make a *revolutionary improvement* in radiation for unresectable pancreatic cancer! Randomized studies are essential to prove that technology can meaningful impact outcome:
@PanCAN
@letswinpc
@NiuSanford
@ShaalanBeg
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Preliminary analysis by
@DominicMoonMD
has shown only modest benefit to adaptive radiotherapy for postoperative H&N radiotherapy. There is typically not enough anatomic change to warrant the effort.
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Wonderful work published here on risk factors for DM following local therapy for oral cavity carcinoma, including outcomes from four centers in two countries (Canada and Brazil). Even apart from the predictive index, very nice read to understand patterns-of-failure in OC SqCC.
🌟 Our research on risk prediction of distant mets in oral cavity ca is in print
@JNCI_Now
@Dr_AliHosni
🔍 2749 OCC pts from 4 centres 🇨🇦 🇧🇷
📈 Score for DM based on: pT3-4, pN+, LVI, G3
🎯 Outperforms AJCC 8th in predicting DM (c-index 0.75 v 0.69)
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Terrific summary of trial considerations for SAbR in oligometastatic GI disease. These concepts apply across primary sites.
A few points:
1. Pt selection is crucial, and it's imperative trial sponsors support blood, tissue and imaging studies to refine the optimal SAbR cohort.
Here is our take on RCTs for RT in oligometastatic GI cancers.
Many have attributed negative trials to patient selection. We suggest other reasons studies may not meet endpts: large hypothesized OS benefits, crossover, & more
w
@whallradonc
,
@TedHong9
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Has anyone observed that with improving late toxicities over time, more patients are commenting on neck spasms as their main concern? Other than Botox, any secrets?
#hncsm
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Profound thanks go out to the H&N rad oncs
@DominicMoonMD
@VladAvkshtol
, incredible physics team, skilled adaptive therapists, tireless research coordinators, and most of all, the patients.
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Put aside FMISO and 30 Gy to gross disease, these ENI outcomes are an incredible result and again highlight that “standard” elective neck doses for HPV+ OPC are almost certainly too high.
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Great work Miranda!
New research: Medicaid expansion associated with decreased mortality among newly diagnosed breast, colorectal and lung cancer patients: via
@JAMANetworkOpen
@mirandalammd
@ashishkjha
@BrighamWomens
@HarvardChanSPH
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Question I didn’t expect to hear from my 8 year-old: “Did you watch Squid Game yet?”
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One quick tip for the HN scans: tell patients not to swallow and also to hold their breath at a comfortable resting position. Eliminates the hyoid and thyroid cartilage artifact from respiratory motion (and obviously swallowing). The CBCT is so quick (6s) they can all do it.
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Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your G-d. If you have love, you can then work backward to monitor and improve the system. (3)
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I am very grateful to have been invited and participate in this symposium. My colleagues in
@UTSWDerm
@UTSW_Surgery
@utswcancer
are world-class; I learned a tremendous amount!
Great talk by my
@UTSW_RadOnc
colleague
@DavidSherMD
summarizing the role and data for RT in high-risk skin cancers at the multidisciplinary UT Southwestern Skin Cancer Symposium! Need more events like this this to bring together all the different disciplines
@utswcancer
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@ezrahahn
@CJTsaiMDPhD
@seanmmcbride
@xrtGenomics
@imrtlee
@Dr_AliHosni
@yaoyu_md
@DrJohndeAlmeida
@YaoCMKL
@lillian_siu
@ScottBratman
@henson_md
@HNSurgeon
@cd_fuller
@Lawson_Eng
Totally agree that independent of this surprising result, reducing elective neck dose and volume appears to be a lower-risk and effective de-escalation strategy.
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Please join us in Dallas on Friday, September 22, for this X-Ray-Guided Online Adaptive Radiotherapy Symposium. The symposium features a dynamic group of speakers who will discuss the present and future uses of online ART. Should be great!!
Join us Sept. 22 for the X-Ray-Guided Online Adaptive Radiotherapy Symposium in Dallas! This symposium will provide a full day of presentations and interactive sessions with leading experts in adaptive radiotherapy.
For more information and registration:
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The amount of work that goes into such a trial cannot be understated: truly in-the-trenches type stuff given all of the replannings. Kudos to the entire team.
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@ShaunaRadOnc
@cd_fuller
@drdavidpalma
@ShlomoKoyfmanMD
@sueyom
@ajuloorimd
@ASTRO_org
Option 5: contralateral elective neck dissection, spare C/L RT in a young woman if that side pN0.
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I feel safer in my hospital clinic than a Dallas supermarket. Kudos to
@JudgeClayJ
for mandating masks in Dallas County businesses.
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Very proud of
@UTSW_RadOnc
to achieve this milestone. It takes a whole team, working side-by-side from start-to-finish. Physicists, therapists (contouring!), MDs making the extra effort every day to deliver personalized care. (1/2)
Our amazing team of physicians, physicists and radiation therapists hit a HUGE milestone this week...
Since we started using the Ethos in June 2021, we have delivered 6,000 total treatments - over 2,000 of which were CBCT-based online adaptive treatments!
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@NiuSanford
Thanks so much
@NiuSanford
. The authors have been absolutely phenomenal and passionate about their topics, and it shows in their work. Several more are in the pipeline. For those who have new ideas/topics (esp statisticians!), please contact me!
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@xrtGenomics
@imrtlee
@sueyom
@CJTsaiMDPhD
@seanmmcbride
Definitely requires caution, but before we lose faith… the concept here was that IO can take care of all occult nodal disease, which is obviously questionable…
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@DrMLChua
@xrtGenomics
@CJTsaiMDPhD
@DanielMaMD
FWIW, implicit assumption in that paradigm is that one cannot identify suspicious lymph nodes harboring occult metastatic disease, so induction is needed to sterilize them.
With proper imaging and AI, I think we can eliminate ENI.
Lots more work of course needs to be done.
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Special and heartfelt shout out and thank you to all H&N radiation nurses during Nat’l Nurse’s Week. It takes a special clinician & person to care for this challenging population, both in terms of clinical skills and compassion.
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@Rad_Nation
@cd_fuller
@DanielMaMD
@BhishamCheraMD
@xrtGenomics
@sueyom
@BarbaraBurtness
@SJFrankMD
@imrtlee
@rbryanbell
I would add elective neck de-escalation, both in terms of dose and *volume*. Less eye-popping but meaningful! HN005 has this concept built into the control arm, and the EVADER trial is investigating it prospectively.
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@duvvuri_md
@MCWardMD
@RajasekaranMD
@Penn_ENT
@PennMedicine
@DrNeilGross
@HNSurgeon
@TopfHNS
@VinPaleri
@KatieVanAbelMD
I don't think that such an extensive elective volume would be considered standard.
Older IMRT studies used huge expansions for microscopic disease, but the modern CTV is much more tailored.
That's one reason PROs from older studies don't apply to modern high-quality IMRT.
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Fascinating!! An elegant biological rationale for the observed association b/n marijuana use and HPV-positive OPC.
Cannabinoids promote progression of HPV positive head and neck squamous cell carcinoma via p38 MAPK activation
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Just at the supermarket, maybe only 30-40% of people wearing some sort of mask; no cashiers. Younger people seemed less likely to have a mask. Unless we realize we are in this *together*, we will be here *forever*!
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