Hematologic

Time for a Boom-Boom? Long-Term Results of the FoRT Lymphoma Trial

With the COVID-19 pandemic, increasing healthcare costs, and a strained global oncology workforce, radiation oncologists worldwide and their health systems have moved towards more cost, time, and infection control-effective strategies including hypofractionation.  

For patients, this can be great news.  Who wouldn’t want 2 visits for their cancer treatments rather than 12? Especially for those with pre-existing barriers to accessing care such as transportation limitations, financial toxicity, or limited social supports, being offered less treatment may allow more patients to afford any cancer care through a patient-centered care approach. 


However, is less always more1 ?

In 2014, the first results of the FoRT trial were published.2 This landmark trial led by Dr. Peter Hoskin compared a 4Gy in 2 fraction regimen with the 24Gy in 12 fraction standard for indolent lymphoma. With a median follow-up of 26 months, the time to local progression with 4 Gy was worse than 24 Gy. The conclusion was that the 24 Gy standard was more effective and still the standard of care for the curative treatment of follicular and marginal zone lymphoma.   

Despite proven effectiveness in cancer cure or palliation, more evidence on unacceptably low levels of utilization, and integration into National Cancer Control Plans as a cost-effective strategy, radiation treatment remains underutilized by both LMICs and HICs.  This is especially true for lymphoma even in settings that have the most treatment resources. Even with more inclusive healthcare approaches, gaps in appropriate radiation treatment utilization haven’t changed much since 2014.


Recently, an update to FoRT was published. Long-term results at a median follow-up over six years followed similar trends in effectiveness and toxicity. However, with time has come technological advances, improved access to imaging, an increasing lymphoma burden, and shift to both person and people-centered care. FoRT’s interpretations in the modern context for the treatment of lymphoma may differ at the patient, provider, health system, and global levels.


Could or should this update change lymphoma practice or preference in the modern era?



Please consider joining the discussion this weekend for our #RadOnc #JC:

Hoskin, P., et al. (2021). “4 Gy versus 24 Gy radiotherapy for follicular and marginal zone lymphoma (FoRT): long-term follow-up of a multicentre, randomised, phase 3, non-inferiority trial.” The Lancet Oncology 22(3): 332-340.
We’ll be joined by experts: Drs. James Bates (@JamesBatesMD), Andrea R Filippi (@AndrearicFili) & others!

Also thanks to @TheLancetOncol for making the paper temporarily free to access with registration. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30686-0/fulltext

The chat begins 8 AM Central Standard Time (CST) on Saturday May 15th. It lives on throughout the weekend and concludes with a Live Hour at 10am CST (5pm Italy) on Sunday May 16th.

Guiding topics include:

T1.  Background: What is the rationale behind this trial? Why did we move to a lower and shorter radiation course to treat follicular and marginal zone lymphomas?


T2.  Methods: How were the endpoints, arms and other treatment details chosen for validity?

T3.  Results/Discussion: What are the benefits of a ‘Boom-Boom’ regimen? What is the take-home message? When would it be preferable to use 4 Gy in 2 fractions in our practice? What is your local practice?

T4. #PatientsIncluded:  What are some perspectives from patients on lymphoma treatment including the toxicities?  When could the risk of potentially less cancer control or the need for closer follow-up be acceptable?

T5.  Next Steps: Is more research needed to determine optimal treatment for indolent lymphoma? Any clinical trials open/pending? How can we improve access to quality lymphoma care? 

Tips to help participate more:

If you’re not ready, just lurk and tune in using #RadOnc #JC.

Suggestions? Leave a comment or tweet one @Rad_Nation.

We look forward to engaging with you!

Temporarily free to access with registration at The Lancet Oncology:

Hoskin, P., et al. (2021). “4 Gy versus 24 Gy radiotherapy for follicular and marginal zone lymphoma (FoRT): long-term follow-up of a multicentre, randomised, phase 3, non-inferiority trial.” The Lancet Oncology 22(3): 332-340. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30686-0/fulltext

Other selected references free to download:

Follicular Lymphoma Guidelines, Trials, & Other Studies

Dreyling, M., et al. (2021). “Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.” Annals of Oncology 32(3): 298-308. https://www.annalsofoncology.org/article/S0923-7534(20)43163-1/fulltext

Brady, J. L., et al. (2019). “Definitive radiotherapy for localized follicular lymphoma staged by 18F-FDG PET-CT: a collaborative study by ILROG.” Blood 133(3): 237-245. https://ashpublications.org/blood/article/133/3/237/261418/Definitive-radiotherapy-for-localized-follicular

Saleh, K., et al. (2020). “Repeated courses of low-dose 2 × 2 Gy radiation therapy in patients with indolent B-cell non-Hodgkin lymphomas.” Cancer medicine 9(11): 3725-3732. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286454/

#PatientsIncluded: General Follicular Lymphoma Reading for Everyone

Bennett C. Standard Radiotherapy Dose for Indolent Lymphoma Prevails in FoRT Trial. Feb 24 2021. https://www.cancertherapyadvisor.com/home/cancer-topics/lymphoma/lymphoma-fort-study-standard-radiotherapy-treatment/

QuadShot News. “Boom Boom.” February 5, 2021.  http://www.quadshotnews.com/2021/02/boom-boom.html

1 Lown Institute. Right Care Series in The Lancet. https://lowninstitute.org/projects/right-care-series-in-the-lancet/. Published 2017. Accessed.

Other References

2 Hoskin PJ, Kirkwood AA, Popova B, et al. 4 Gy versus 24 Gy radiotherapy for patients with indolent lymphoma (FORT): a randomised phase 3 non-inferiority trial. Lancet Oncol. 2014;15(4):457-463.

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