Top Line: Is it safe to deliver radiation with immune checkpoint inhibitors, VEGF inhibitors, or multitarget TKIs?
The Study: A new ESMO-ESTRO consensus statement tackles one of the murkiest topics in radiation oncology practice: radiation in the setting of targeted systemic therapy agents. They systematically reviewed over 150 reports to develop 74 safety statements across drug glasses and anatomic sites. Sections for each drug category are broken down by risks and recommendations for specific irradiated areas of the body. In general, the immune checkpoint inhibitors (especially PD-1 and PD-L1 inhibitors) usually play nice with radiation, with minor or no RT adaptations required across most sites. It was not so for the VEGF inhibitors and TKIs with major adaptation recommended across most sites. It was also recommended to not combine RT and VEGF inhibitors or TKIs for ultracentral targets in the chest and to not combine sorafenib with high dose RT to the liver. Toxicities of concern included hemorrhage, fistula, and mucosal and GI injury. The only green lights were for low dose palliative or musculoskeletal RT. The authors note that simply holding these drugs during RT may not eliminate risk given long half-lives and ongoing vascular effects. Hence the recommendations for “major adaptation” of radiation regimens, consideration of anatomic doses, and clinical necessity rather than just simply holding the drug in question.
TBL: Integrating radiation with an ever-growing list of targeted systemic therapies remains a challenge outside the low-dose palliative context. This ESMO-ESTRO framework provides a helpful roadmap for navigating this space. | van Aken, Ann Oncol 2025
The Study: A new ESMO-ESTRO consensus statement tackles one of the murkiest topics in radiation oncology practice: radiation in the setting of targeted systemic therapy agents. They systematically reviewed over 150 reports to develop 74 safety statements across drug glasses and anatomic sites. Sections for each drug category are broken down by risks and recommendations for specific irradiated areas of the body. In general, the immune checkpoint inhibitors (especially PD-1 and PD-L1 inhibitors) usually play nice with radiation, with minor or no RT adaptations required across most sites. It was not so for the VEGF inhibitors and TKIs with major adaptation recommended across most sites. It was also recommended to not combine RT and VEGF inhibitors or TKIs for ultracentral targets in the chest and to not combine sorafenib with high dose RT to the liver. Toxicities of concern included hemorrhage, fistula, and mucosal and GI injury. The only green lights were for low dose palliative or musculoskeletal RT. The authors note that simply holding these drugs during RT may not eliminate risk given long half-lives and ongoing vascular effects. Hence the recommendations for “major adaptation” of radiation regimens, consideration of anatomic doses, and clinical necessity rather than just simply holding the drug in question.
TBL: Integrating radiation with an ever-growing list of targeted systemic therapies remains a challenge outside the low-dose palliative context. This ESMO-ESTRO framework provides a helpful roadmap for navigating this space. | van Aken, Ann Oncol 2025