can we talk about urorad?

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Problem with all those studies is that the salvage policy wasn't well defined and it was not an era of ultra sensitive psa. Definitely controversial and there is level 1 evidence to treat, but those studies don't reflect modern practice, specifically that when psa is 0.2, can salvage pretty easily.

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Problem with all those studies is that the salvage policy wasn't well defined and it was not an era of ultra sensitive psa. Definitely controversial and there is level 1 evidence to treat.

Generally, the presence of level 1 evidence is not considered controversial. That is to say, unless there is competing level 1 evidence to the contrary.
 
Generally, the presence of level 1 evidence is not considered controversial. That is to say, unless there is competing level 1 evidence to the contrary.

Level 1 evidence has to apply to your patient group. This is where the controversy lies. In the SWOG 8794 adjuvant vs. salvage study, the median PSA at time of salvage was 1.0. We know from other data (http://forums.studentdoctor.net/showpost.php?p=14372354&postcount=7) that the salvage rate depends on the PSA at the time of salvage. With frequent PSA and "ultra-sensitive" tests, patients should be getting treated now at about the 0.2-0.5 level based on ASTRO/AUA consensus guidelines.

So the question becomes: does SWOG 8794 apply to modern practice? i.e. the patients who were "salvaged" with a PSA >0.5 were likely setup to fail, where they don't necessarily need to be. We have to ignore some other factors that would push you to treat immediately, such as patient compliance or urologists not doing the right thing in your community. Knowing that PSA <0.5 is much more salvageable, will randomization of patients to salvage ONLY if the PSA is <0.5 vs. adjuvant for high risk factors (SVI, T3b, positive margin) make a difference in survival?

There is evidence for equivalence of adjuvant and salvage radiation only when salvage is performed in a timely fashion: http://www.sciencedirect.com/science/article/pii/S009042959900299X (edit: also http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2010.09447.x/full). This also may be a reason why the SWOG found a survival and distant metastasis free benefit, while the German and EORTC studies did not. Also, the EORTC only found a benefit for positive margins on subset analysis (http://jco.ascopubs.org/content/25/27/4178.long) which could be the most important factor. Though I don't know what the median PSA at time of salvage were for those studies.

So in the end, it's still reasonable to only give adjuvant radiation for positive margins, or to be dogmatic about the SWOG study and recommend adjuvant radiation for all high risk features until more trial data becomes available.
 
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So giving preference to German Study over SWOG study is quite interesting given the German and EORTC followup is 10 years vs Swog 15 years, given the natural history of prostate cancer. Note as well German trial was not powered to show OS difference. Swanson et al., JCO, 25(16):2225-9 also shows differences for differences to median time to failure, local failure, and distant mets for <= 0.2 ng/ml, >2 and <=1 ng/ml, and > 1ng/mL. As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)
 
Level 1 evidence has to apply to your patient group. This is where the controversy lies. In the SWOG 8794 adjuvant vs. salvage study, the median PSA at time of salvage was 1.0. We know from other data (http://forums.studentdoctor.net/showpost.php?p=14372354&postcount=7) that the salvage rate depends on the PSA at the time of salvage. With frequent PSA and "ultra-sensitive" tests, patients should be getting treated now at about the 0.2-0.5 level based on ASTRO/AUA consensus guidelines.

So the question becomes: does SWOG 8794 apply to modern practice? i.e. the patients who were "salvaged" with a PSA >0.5 were likely setup to fail, where they don't necessarily need to be. We have to ignore some other factors that would push you to treat immediately, such as patient compliance or urologists not doing the right thing in your community. Knowing that PSA <0.5 is much more salvageable, will randomization of patients to salvage ONLY if the PSA is <0.5 vs. adjuvant for high risk factors (SVI, T3b, positive margin) make a difference in survival?

There is evidence for equivalence of adjuvant and salvage radiation only when salvage is performed in a timely fashion: http://www.sciencedirect.com/science/article/pii/S009042959900299X. This also may be a reason why the SWOG found a survival and distant metastasis free benefit, while the German and EORTC studies did not. Also, the EORTC only found a benefit for positive margins on subset analysis (http://jco.ascopubs.org/content/25/27/4178.long) which could be the most important factor. Though I don't know what the median PSA at time of salvage were for those studies.

So in the end, it's still reasonable to only give adjuvant radiation for positive margins, or to be dogmatic about the SWOG study and recommend adjuvant radiation for all high risk features until more trial data becomes available.

I have a very hard time leaving off radiation in the adjuvant setting for patients that met the criteria for SWOG. That trial has got to be one of the biggest homeruns for radiation that I've seen across all disease sites. NNT of <10 to save a life! For prostate cancer!! There is even an improvement in QOL!

While early salvage may be just as good, you are relying on the system to get them regular PSAs and timely followups to the appropriate physicians. I can't tell you how many times I've had a patient come in with a PSA >3.0 post-prostatectomy because they moved or otherwise stopped following up with a Urologist and the only provider they were seeing is their PCP who didn't know post-op PSAs should be treated differently. Now with some PCPs not even drawing PSAs...

However, I do agree with Neuronix that you have to know your patient base.
 
So giving preference to German Study over SWOG study is quite interesting given the German and EORTC followup is 10 years vs Swog 15 years, given the natural history of prostate cancer. Note as well German trial was not powered to show OS difference. Swanson et al., JCO, 25(16):2225-9 also shows differences for differences to median time to failure, local failure, and distant mets for <= 0.2 ng/ml, >2 and <=1 ng/ml, and > 1ng/mL. As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)

To be fair to simul, this is a level 2a recommendation despite the level I evidence likely owing to the controversy that still exists and, as such, observation is still offered as an alternative.
 
To be fair to simul, this is a level 2a recommendation despite the level I evidence likely owing to the controversy that still exists and, as such, observation is still offered as an alternative.

So level 2a recs from NCCN are controversial? NCCN offers few cat 1 recs across all disease sites, which by your rationale, would make almost all cancer care controversial. I think you are confusing level 1 data with level 1 recommendation.
 
As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)

I'm just giving the other side of the argument here. For a lengthier and more eloquent version, see:

http://www.sciencedirect.com/science/article/pii/S0022534713043656

Adjuvant Versus Salvage Post-Prostatectomy Radiation Therapy: A Critical Review of the Evidence
Anthony V. D'Amico, MD, PhD August 2013

"Therefore, while awaiting the results of the RADICALS and RAVES trials, discussing PSA surveillance and delaying RT until PSA failure (confirmed PSA level of more than 0.2 ng/ml) for men with Gleason score 7 or less and pT3aR0 or pT2R1 disease warrants consideration.


As for the NCCN discussion, I would agree with their category 2A recommendation.

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

As I stated previously, I think it would be appropriate to treat or only treat for positive margins. But they do state RT OR Observation in their guidelines, both as category 2A evidence. There is no (RT Preferred) as they sometimes do. This is a complicated issue.
 
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So level 2a recs from NCCN are controversial? NCCN offers few cat 1 recs across all disease sites, which by your rationale, would make almost all cancer care controversial. I think you are confusing level 1 data with level 1 recommendation.

Controversial enough that they allow for observation as the alternative.

Their level I recommendations are based on "high-level evidence" which AFAIK would be a cooperative group RCT like SWOG, EORTC etc which is level I evidence. Despite having that level I evidence, NCCN saw fit to make the recommendation "2A"

Contrast this the situation in H&N Ca, where we have level I evidence for a benefit in post-op Tx of ECE and +margin. There, the NCCN clearly states a "Category 1" recommendation for adjuvant chemo/RT in that situation, based on Level I evidence. They don't say observation. They don't say post-op RT alone.
 
Right. What everyone else said :)

It is controversial. I don't take much things as "the word", but if Tony D'Amico says something, I do take it as "the word". He's a brilliant collater and synthesizer of data, and he recognizes that logical people can disagree. Do I think that it's wrong to use SWOG criteria? Absolutely not. But, in my practice, I don't argue with the urologists because that study doesn't represent modern medicine, and tweaking practice towards reality isn't a bad thing.

Back to the beach...
 
Fair enough, although I still think discussants are confusing level data with category recommendation. Again, there are only a handful of cat 1 recs in NCCN.
 
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How is ASTRO ensuring that any anti-loophole law that is passed doesn't prevent radiation oncologists themselves from owning treatment centers? It seems like that is a risk of their efforts.
By definition we can't self refer. Radiologists don't send orders for scans to their own machines.

Rad oncs don't diagnose prostate ca and make referrals. Urologists do
 
"In 2013, the U.S. Government Accountability Office found that more than half of the nearly $1.3 billion paid by Medicare for IMRT therapy went to radiation centers that treat prostate cancer."

More than half? I had no idea it was that bad...
 
"In 2013, the U.S. Government Accountability Office found that more than half of the nearly $1.3 billion paid by Medicare for IMRT therapy went to radiation centers that treat prostate cancer."

More than half? I had no idea it was that bad...

I could see it.... the big 3 we treat are lung, breast and prostate. Urorads by far has been the biggest abuse out of those 3 sites IMO. Still not quite as big as the 80% of medicare proton spending going to prostate, but still it's a disheartening number.
 
sI agree with ASTRO in principle regarding self-referring Urorads centers. However, I believe that their approach is wrong. If you simply ban physicians (e.g. ALL non-Rad Oncs) who own linear accelerator from self-referring then you have gone down a slippery slope. As I mentioned in other threads, it is essentially impossible for the vast majority of Rad Oncs to purchase their own accelerator. The expense and risk are too high. You need buy-in from other physicians. If you simply ban self-referral, then you are hastening the death of physician-owned practices and accelerating MDs into employment models.

A more intelligent way to go about this would be on the physician payment reform end. The ONLY reason self referral exists is $$$. If you create capitated reimbursement models or case rates then I guarantee you that utilization will drop. Of course, this means that all the members of ASTRO Executive Team in large academic centers who invested in protons will eat it financially.
 
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Sorry to bump an old thread but curious to see what the status is with the UroRads centers. Any progress made by ASTRO to fight these centers? Seems like the discussion of these places has disappeared
 
Sorry to bump an old thread but curious to see what the status is with the UroRads centers.

They still exist.

Any progress made by ASTRO to fight these centers? Seems like the discussion of these places has disappeared
ASTRO let that ship sail well before they tried to fight it. Unfortunately their efforts essentially hurt many in the freestanding/pp community as collateral damage. They likely realized:

1) how many physicians they were alienating in the process and

2) how futile such a fight was likely to be going forward

And have likely moved on
 
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Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume
 
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I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?
 
I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?
Agree it's dumb to open one now, but for existing ones that have already paid off a machine and/or vault, many are likely aware of where things are going. Many urorads centers offer brachy/sbrt etc already
 
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Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume
Well, that is the urologists' speciality... draining things.
 
I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?
From ASTRO Website July 11, 2019. Of course this is the proposed rule, not the final rule.

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Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume
Partner with your own group of urologists. Multi-specialty groups are the future of RO outside of academics. Or offer things like HDR, sbrt, hypofx etc if they aren't
 
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Anybody know about the reno NV job? Whats the deal? PM me if u want
 
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