What is the rationale for RP in high-risk or very high-risk prostate Ca?

[evilbooyaa]

I've read this thread in detail: http://forums.studentdoctor.net/thr...py-for-prostate-cancer.1187999/#post-17568561

As a tl;dr, it initially began as a protons vs IMRT (vs urologists), with a little bit of SBRT vs Resection for lung Ca sprinkled in, along with a bunch of CSBs about mediastinal LN staging, ending with a urologist coming in and inflaming all of the rad onc's with some BS about why he does RPs.

I'm interested in the opposite side. One of our own has already tried this in the urology forum(came up in similar threads): http://forums.studentdoctor.net/threads/prostate-high-risk.1191962/

And of course got an answer that says a lot of words but doesn't answer the question at hand (although it is funny to see him/her mention the protecT trial as his wild card). Granted, the OP seemed quite inflammatory in her initial line of question.

But, getting back to the point - What is the evidence for RP in high-risk or very high-risk Prostate Cancer? I don't really want to discuss low-risk or intermediate risk although who knows what this will devolve into.

I mean, it's in the NCCN guidelines (page 11, as the 4th option for both) so urologists here have a field day routinely resecting Gleason 8 or 9s/T3a, then getting positive margins/positive nodes and sending the med-oncs and rad-oncs to try to clean up their mess with ADT +/- salvage RT.

Everything I have read so far suggests that RT + ADT is better than RP. What about RP + ADT?

The other threads I posted have a lot of flaming, but I am truly interested in the data behind this thought process - I imagine if there was NO data at all, this option wouldn't be in NCCN.

Having a RP, even with PLND be an acceptable starting option for high-risk or VHR Prostate cancer, to me, is almost the equivalent of an upfront radical hysterectomy + PLND being an acceptable treatment modality (at least by NCCN) for cT2b+ Cervical cancer.

Is this because Cervical NCCN has no surgeons on its board? And the Urology NCCN is nearly 50% (13/30) Urologists? That's just speculation.

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[radtothebone]

I think a lot of it comes from the Urology mantra of "get the bulk of it out". Many patients I see also have the predetermined notion that getting the cancer out is a vital step for management. Of course that leaves me with the guy who I am currently treating that had RP at 76 year of age leading to a post-operative PSA that was detectable and "watched" for a bit. Now he can't fill his bladder more than 75 cc without leaking and his bladder dosimetry is quite sub-optimal.

Regarding data to support our cause, I think this recent paper from European Urology offers excellent support. Personally between this and ASCENDE-RT, I am convinced that a brachy boost is the best treatment option for high risk patients that are eligible.

https://www.ncbi.nlm.nih.gov/pubmed/27452951

 

[DebtRising]

What is the rationale? The rationale is that the urologist does not get reimbursed if the patient doesn't get an RP.

To fully evaluate the question a trial of RP /w ADT, EBRT /w ADT, or PLANNED RP+EBRT in a RCT to answer the question of the role of maximal local therapy, though clearly the QoL would be terrible. There is already tremendous amounts of data relating to the risk of EPE and basically periprostatic disease based on biopsy factors. Once you cross that threshold with a reasonable certainty then the utility of a local only procedure, like surgery, is nil.* There are always reports out there, retrospective, that treating the primary and all metastatic sites improves survival and one can extrapolate then that maximal local therapy has some survival benefit. The same story started in breast cancer however and then failed to be proven in randomized trials, though I believe some are still ongoing.

The fact that it is on the NCCN guidelines is very simple - the guidelines are professional opinion, and a recent JAMA article showed how much those authors were paid. Read the discussion section about the role of surgery in high risk disease and let me know all the articles you find.

It's not that urologists are bad people inherently, there actually are too many urologists / too limited in scope of practice. If you take the RP away then this country needs half of the urologists it currently has, and salary goes down. And if you think that is cynical then simply reflect on this - in 30 seconds you can plug in someones numbers and find out the approximate chances of prostate localized disease. With NO randomized evidence suggesting a benefit of maximal local therapy when the disease is not purely organ confined, and an easy alternative that offers equal local control and can treat the periprostatic tissues and lymph nodes, how do you justify RP in that patient outside of financial interests?

 

[medgator]

What is the rationale? The rationale is that the urologist does not get reimbursed if the patient doesn't get an RP.

Pretty much. Replace RP with cryo or hifu once you get in the community far removed from academia and the above still holds true.

Why should an unaffiliated urologist send you a patient for imrt or brachy when they can make $$ doing whichever local therapy instead.

Hifu apparently just got FDA approved in this country last fall, though more for the general indication of "ablation", but don't put it past urologists to start using it for cancer treatment instead of sending for xrt in patients they can't operate on. Many have already been doing cryo inappropriately on that population for years

 

[Chartreuse Wombat]

Initial surgery for high risk disease is more expensive, more toxic and no more effective than ADT + XRT (brachy in there somewhere). As pointed out the rationale is that urologists do biopsies and need to pay for their mortgage/college for kids/boat just like every other highly paid professional. We will see if the "move to value" changes anything.

 

[Krukenberg]

Pretty much. Replace RP with cryo or hifu once you get in the community far removed from academia and the above still holds true.

Why should an unaffiliated urologist send you a patient for imrt or brachy when they can make $$ doing whichever local therapy instead.

Hifu apparently just got FDA approved in this country last fall, though more for the general indication of "ablation", but don't put it past urologists to start using it for cancer treatment instead of sending for xrt in patients they can't operate on. Many have already been doing cryo inappropriately on that population for years

I saw a billboard just last month of a urologist specifically advertising HIFU.


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[Palex80]

In my opinion the rationale is that "you should use as many weapons as possible in prostate cancer".

There is data showing that the combination RP + adjuvant or salvage RT is superior to EBRT + ADT.
https://www.ncbi.nlm.nih.gov/pubmed/24574496
https://www.ncbi.nlm.nih.gov/pubmed/25742020
However these data are often flawed by the fact, that the RT doses in the definite setting were quite low in the past.

Although I am a supporter of EBRT + ADT for high-risk prostate cancer, I am not certain if it's the best option for all patients.
Many radiation oncologists say that EBRT + ADT is less toxic than surgery, which is indeed true concerning bladder control, however one must not forget that optimal EBRT + ADT for high-risk prostate cancer nowadays means 2-3 years of ADT plus taxanes, which may very well become standard of care in the next couple of years based on RTOG 0521 & Stampede. That's quite a lot of treatment, if you ask me...

What disturbes me the most is when elder patients with high-risk disease get pushed for RP by the urologists. That's something I do not fully grasp. These patients recover often miserably after RP and even if the RP may provide a small survival benefit, this is probably neligible if the patient is already 75 years old or so.

I am for myself however not certain what I would do, if I was diagnosed with GS9 tumor 10-15 years from now. In my late 40s early 50s, I would seriously consider RP followed by adjuvant RT +/- ADT to be honest.
It would be more toxic certainly than primary EBRT + ADT. But I do believe that the local control would be better. And being in my early 50s then, I would strive for a primary treatment or treatment-combo that would be able to keep me recurrence free for as long as possible.

Another attractive option would be some sort of local dose escalation, perhaps with HDR-brachy. But strict 80 Gy IMRT + 3 years of ADT would be too risky for me.

 

[MegaVoltagePhoton]

In my opinion the rationale is that "you should use as many weapons as possible in prostate cancer".

There is data showing that the combination RP + adjuvant or salvage RT is superior to EBRT + ADT.
https://www.ncbi.nlm.nih.gov/pubmed/24574496
https://www.ncbi.nlm.nih.gov/pubmed/25742020
However these data are often flawed by the fact, that the RT doses in the definite setting were quite low in the past.

Although I am a supporter of EBRT + ADT for high-risk prostate cancer, I am not certain if it's the best option for all patients.
Many radiation oncologists say that EBRT + ADT is less toxic than surgery, which is indeed true concerning bladder control, however one must not forget that optimal EBRT + ADT for high-risk prostate cancer nowadays means 2-3 years of ADT plus taxanes, which may very well become standard of care in the next couple of years based on RTOG 0521 & Stampede. That's quite a lot of treatment, if you ask me...

What disturbes me the most is when elder patients with high-risk disease get pushed for RP by the urologists. That's something I do not fully grasp. These patients recover often miserably after RP and even if the RP may provide a small survival benefit, this is probably neligible if the patient is already 75 years old or so.

I am for myself however not certain what I would do, if I was diagnosed with GS9 tumor 10-15 years from now. In my late 40s early 50s, I would seriously consider RP followed by adjuvant RT +/- ADT to be honest.
It would be more toxic certainly than primary EBRT + ADT. But I do believe that the local control would be better. And being in my early 50s then, I would strive for a primary treatment or treatment-combo that would be able to keep me recurrence free for as long as possible.

Another attractive option would be some sort of local dose escalation, perhaps with HDR-brachy. But strict 80 Gy IMRT + 3 years of ADT would be too risky for me.

With all due respect Palex, I think you're wrong. While there definitely are data showing RP is superior to RT, in almost all studies the authors included folks who got low dose radiation/maybe not full duration ADT with patients. Surgery protocols have probably improved too but I am not aware of paradigm changing findings in the surgical management of prostate cancer on the order of using long duration ADT and high dose RT. Moreover patients getting RT are usually almost a decade older and sicker -- obviously OS (unadjusted) is going to be worse.

I actually think thats a major strength of that paper by Kishan et al. in European Urology recently that was mentioned above. They showed no difference in PCSM and only included patients treated after 2000 where most had high dose RT or ADT. Obviously the caveat is shorter followup but I could buy the authors argument that clinical events are happening faster with Gleason 9/10 patients. Also I think the best outcomes were found in the brachy boost group, and those folks didnt have long duration ADT, and other folks are randomizing to shorter versus longer duration ADT, like the PCS trial, to find out whether long term ADT is needed.

I don't disagree with you that RP + adjuvant RT (or early salvage) is a viable option, but I certainly am skeptical of a survival advantage.

 

[seper]

I'd add that "planned tri-modality" approach (RP+EBRT+ADT) that somehow crept into practice for high risk PCa, is very toxic compared to traditional 80 Gy + ADT.
Ultra-high risk localized PCa is IMHO different, with no value of local therapy of any kind.

 

[evilbooyaa]

Here's my issue with your trials, Palex, as I'm sure you noted as well.

Second trial says this:

Notably 88.2% of patients treated with primary radiotherapy also had concurrent androgen deprivation therapy though we were not able to determine the duration of ADT or radiotherapy dose.

Same issue in the first trial - who knows what the RT dose was in that age?

Appreciate the input from everybody else; however, I maintain that there has to be more to this than just "Urologists just need money for their yachts". Glad to see I'm not completely off-base, however.

 

[Palex80]

I'd add that "planned tri-modality" approach (RP+EBRT+ADT) that somehow crept into practice for high risk PCa, is very toxic compared to traditional 80 Gy + ADT.
Ultra-high risk localized PCa is IMHO different, with no value of local therapy of any kind.

Tbeproblem ishowever that the "traditional 80Gy + ADT" are now or soon will become "80 Gy + 3 years of ADT + Docetaxel upfront". That's quite toxic too.

And I fully agree, as I already stated above, that eT doses were lower in those retrospective trials. Just as ADT was not given to all patients and probably not long enough. Yet we must also consider that our QoL data are based on trials just like that comparing them to QoL after surgery. "More" treatment means "more" efficacy, but also more side effects.

I would however like to hear how you would treat yourself if you were in the following situation:
You are in your early 50s, PSA 23, 6/10 cores positive GS 4+5, staging negative for lymph nodes or distant disease.

 

[evilbooyaa]

Tbeproblem ishowever that the "traditional 80Gy + ADT" are now or soon will become "80 Gy + 3 years of ADT + Docetaxel upfront". That's quite toxic too.

And I fully agree, as I already stated above, that eT doses were lower in those retrospective trials. Just as ADT was not given to all patients and probably not long enough. Yet we must also consider that our QoL data are based on trials just like that comparing them to QoL after surgery. "More" treatment means "more" efficacy, but also more side effects.

I would however like to hear how you would treat yourself if you were in the following situation:
You are in your early 50s, PSA 23, 6/10 cores positive GS 4+5, staging negative for lymph nodes or distant disease.

Partin calculator (assuming I have cT1c disease) says I would have a 23% chance of organ-confined disease, 33% EPE, 25% SV, 18% LN involvement (Partin table underestimates extra-organ disease).
If I have a positive surgical margin or LN involvement I may need RT and hormones down the line anyways. I agree with others in previous threads that OS is not the most important time point to me, but rather metastasis-free survival, as metastatic prostate cancer SUCKS.

Honestly, knowing what I know about dose escalation and it's benefit for prostate Ca, I'd probably want to find a place that would do IMRT-based EBRT + BT (either LDR or HDR, high-volume center either way) + ADT. If it was myself going through the process, I'd probably shoot for 3-months of ADT.

I get that people may have varying opinions on their personal care, but I don't think RP + PLND alone is an acceptable treatment for high-risk prostate Ca.

 

[evilbooyaa]

The fact that it is on the NCCN guidelines is very simple - the guidelines are professional opinion, and a recent JAMA article showed how much those authors were paid. Read the discussion section about the role of surgery in high risk disease and let me know all the articles you find.

So here's the paragraph, from NCCN, verbatim:

Some patients at high or very high risk may benefit from radical prostatectomy. In an analysis of 842 men with Gleason scores 8 to 10 at biopsy who underwent radical prostatectomy, predictors of unfavorable outcome included PSA level over 10ng/mL, clinical stage T2b or higher, Gleason score 9 or 10, higher number of biopsy cores with high-grade cancer, and over 50% core involvement. (130) Patients without these characteristics showed higher 10-year biochemical-free and disease-specific survival after radical prostatectomy compared to those with unfavorable findings (31% vs 4% and 75% vs 52%, respectively). Radical prostatectomy is an option for men with high-risk disease and in select patients with very high-risk disease

Here's reference # 130 which was quoted - https://www.ncbi.nlm.nih.gov/pubmed/22373045

The Institutional Review Board-approved institutional RP database (1982-2010) was analysed for men with high-Gleason prostate cancer on biopsy; 842 men were identified. The 10-year biochemical-free (BFS), metastasis-free (MFS) and prostate cancer-specific survival (CSS) were calculated using the Kaplan-Meier method to verify favourable pathology as men with Gleason <8 at RP or ≤ pT3a compared with men with unfavourable pathology with Gleason 8-10 and pT3b or N1. Preoperative characteristics were compared using appropriate comparative tests. Logistic regression determined preoperative predictors of unfavourable pathology.

RESULTS:
There was favourable pathology in 656 (77.9%) men. The 10-year BFS, MFS and CSS were 31.0%, 60.9% and 74.8%, respectively. In contrast, men with unfavourable pathological findings had significantly worse 10-year BFS, MFS and CSS, at 4.3%, 29.1% and 52.3%, respectively (all P < 0.001).

I've actually reviewed that study briefly before. It's not a bad study at face value. It gives prognostic factors as to adverse features at time of RP to assist with distinction between those with high-risk vs those with very high-risk cancer..
However, if I went through that study at my journal club and came to the conclusion that NCCN came to (bolded) I'd get laughed out of the room.

No mention about EBRT or how a 31% BFS for the "favourable" pathology is even worse than 70Gy alone (no hormones) for BFS from 1999 (6-year BFS w/ PSA <10 of 76%)
https://www.ncbi.nlm.nih.gov/pubmed/10386637?dopt=Abstract

 

[medgator]

.

The fact that it is on the NCCN guidelines is very simple - the guidelines are professional opinion, and a recent JAMA article showed how much those authors were paid. Read the discussion section about the role of surgery in high risk disease and let me know all the articles you find.

Even unpaid NCCN volunteer physicians are going to stick up for their specialty at the end of the day. Unless we're talking about pushing a specific drug or technology (like a category 1 rec for Da vinci robotic RP, or everyone should get calypso), I don't see how the fact they were paid has anything to do with recs.

It's a turf war, plain and simple.

 

[Palex80]

Even unpaid NCCN volunteer physicians are going to stick up for their specialty at the end of the day. Unless we're talking about pushing a specific drug or technology (like a category 1 rec for Da vinci robotic RP, or everyone should get calypso), I don't see how the fact they were paid has anything to do with recs.

It's a turf war, plain and simple.

Very true

https://www.ncbi.nlm.nih.gov/pubmed/24566445

 

[radiation]

Haven't seen this study mentioned, but one the earlier papers looking at this issue came from Zelefsky and Scardino published in JCO
https://www.ncbi.nlm.nih.gov/pubmed/20159826

As a caveat, MSKCC urologists are doing oncologic surgery for high-risk pts - eg full lymph node dissection (~20 nodes harvested)

 

[Palex80]

I get that people may have varying opinions on their personal care, but I don't think RP + PLND alone is an acceptable treatment for high-risk prostate Ca.

I fully agree. That's why I would opt for immediate adjuvant RT + ADT (although there is no data for adjuvant combo-therapy yet).

 

[evilbooyaa]

Haven't seen this study mentioned, but one the earlier papers looking at this issue came from Zelefsky and Scardino published in JCO
https://www.ncbi.nlm.nih.gov/pubmed/20159826

As a caveat, MSKCC urologists are doing oncologic surgery for high-risk pts - eg full lymph node dissection (~20 nodes harvested)

Interesting study. Shows that RP + "extensive" PLND (not sure how many lymph nodes were taken out) is better than dose-escalated RT (even up to 80+ Gy) in high-risk patients.

However, 56% of all comers for EBRT got ADT - What percentage of high-risk cancers got ADT? They make it sound like that was a main indication. If it was a lot, then maybe 3 to 6 months isn't enough. Maybe ENI would have helped?

Discussion remarks about how this was only two surgeons operative volume - maybe the skill of the surgeons is better. All of the surgical patients got OPEN RP; does that make a difference at all comopared to RALP? I don't think studies have shown any difference between the two approaches.

Salvage rates - 207 patients after EBRT with biochemical failure - only 88 (43%) got ADT? Salvage is easier if you do surgery first, but I wasn't expecting over 50% of those failing to not get hormones, while 76% of failed RPs got either RT or hormones/chemo
If you needed salvage after RP you needed it quickly (13 months to salvage for RP vs 69 months to salvage for EBRT, median)
I wonder what the median time to distant metastasis was between the two groups?

I'd like to hear other people's insights on this paper. Yes, it's retrospective, yes it's imbalanced in patient groups, but on MVA they maintain surgery is better than EBRT for metastatic-free survival in high-risk prostate patients.

 

[medicinewoman101]

Were these studies done with robotic? I have urologists doing robotics on high risk guys leaving them with terrible incontinence taking 2-3 nodes, literally the guy told me he took much wider margins bc of the high risk diagnosis which is why his incontinence is unilikely to improve. 6 months later still cant get an acceptable bladder DVH on this guy (hes on hormones)

Lets not mince words here. Urologist are oncologic idiots, plain and simple. They are the scum of oncologic medicine motivated by the $ sign. Someone needs to write an editorial on this to the new york times. NCCN is in the hands of the lobby which is why this is still listed as an option. Yes, I think a young patient is different, but F*CK NCCN for not making this more clear in their recommendations, they know exactly what they were doing. Ive seen many 65+ men going to that piece of **** Robot. Enough is enough.

 

[BobbyHeenan]

Obviously, I'm no fan of prostatectomy for high risk patients. Heck, I just saw a guy that had gleason 9 disease AND pre-op MRI evidence of extra prostatic spread that was taken to the OR anyway. Big surprise...positive margin, EPE, SV invasion and 2 nodes taken, both negative.

However, even at academic centers they're doing prostatectomies (saw a Hopkins Gleason 9 s/p prostatectomy patient last year with + margin). So if the "ivory tower" is doing it it's not going to stop any time soon.

What really irks me more than anything is when I ask one of these high risk patients:

"Did the urologist tell you you more than likely would need radiation after your prostatectomy?" The answer is almost universally some version of this: "no, he thought he could get it all with surgery, he seemed surprised. I guess if he would have told me that I maybe would have had just radiation anyway."

I can kind of understand the burning desire to cut on all cancer that urologists have, but the purposeful omission of a very important caveate is what grinds my gears.

 

[seper]

JHU is urology snake pit, worst of them all

 

[medgator]

."

I can kind of understand the burning desire to cut on all cancer that urologists have, but the purposeful omission of a very important caveate is what grinds my gears.

Don't worry... When the codes for RP get cut enough, they'll stop doing it, just like they stopped giving out Lupron like candy when that reimbursement got cut

 

[OTN]

Don't worry... When the codes for RP get cut enough, they'll stop doing it, just like they stopped giving Lupron out like candy when that reimbursement got cut

Without RP, though, do we really need even half as many urologists as we currently have?

 

[MegaVoltagePhoton]

Interesting study. Shows that RP + "extensive" PLND (not sure how many lymph nodes were taken out) is better than dose-escalated RT (even up to 80+ Gy) in high-risk patients.

However, 56% of all comers for EBRT got ADT - What percentage of high-risk cancers got ADT? They make it sound like that was a main indication. If it was a lot, then maybe 3 to 6 months isn't enough. Maybe ENI would have helped?

Discussion remarks about how this was only two surgeons operative volume - maybe the skill of the surgeons is better. All of the surgical patients got OPEN RP; does that make a difference at all comopared to RALP? I don't think studies have shown any difference between the two approaches.

Salvage rates - 207 patients after EBRT with biochemical failure - only 88 (43%) got ADT? Salvage is easier if you do surgery first, but I wasn't expecting over 50% of those failing to not get hormones, while 76% of failed RPs got either RT or hormones/chemo
If you needed salvage after RP you needed it quickly (13 months to salvage for RP vs 69 months to salvage for EBRT, median)
I wonder what the median time to distant metastasis was between the two groups?

I'd like to hear other people's insights on this paper. Yes, it's retrospective, yes it's imbalanced in patient groups, but on MVA they maintain surgery is better than EBRT for metastatic-free survival in high-risk prostate patients.

Yes, those are precisely the flaws of analyses like the MSKCC one. The thing is RT for prostate cancer has changed considerably over the past 20 years -- more data on ADT and dose, improved treatment delivery, changes in preop staging, etc. While surgical care has probably changed too, it's not even in the same ballpark. So when you compare RT patients from the 1980s to surgery patients from the 1980s, I'm sure surgery was better. Nowadays? Well, we have the PROTECT trial, but you're not going to get a trial looking at high-risk patients so you'll have to suffice for retrospective data. And the retrospective data that actually restrict to patients treated more or less by modern standards show at least equal effect of RT and RP.

 

[FistLength]

Curious why triple therapy is not discussed as frequently for high risk disease, brachy + external beam + ADT?

 

[MegaVoltagePhoton]

Curious why triple therapy is not discussed as frequently for high risk disease, brachy + external beam + ADT?

The Eur Urol paper from this year (Kishan et al, looking at Gleason 9 or 10) did include some of those triple therapy pts. I think it's probably just that there aren't too many center doing Brachy boost for these types of cases.

 

[medgator]

The Eur Urol paper from this year (Kishan et al, looking at Gleason 9 or 10) did include some of those triple therapy pts. I think it's probably just that there aren't too many center doing Brachy boost for these types of cases.

On the whole, brachy use for prostate ca has gone down in utilization the last several years in the U.S.

The data in high risk pCa and potential changes in reimbursement coming in the future may swing the pendulum back though

 

[Krukenberg]

The Eur Urol paper from this year (Kishan et al, looking at Gleason 9 or 10) did include some of those triple therapy pts. I think it's probably just that there aren't too many center doing Brachy boost for these types of cases.

Is the learning curve for HDR easier than LDR? If it starts to come back in popularity I wonder if everyone will start learning HDR


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[evilbooyaa]

Is the learning curve for HDR easier than LDR? If it starts to come back in popularity I wonder if everyone will start learning HDR


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Haven't done any prostate HDR but having something adjustable if its placed poorly seems easier to pick up and do compared to LDR. Like if you perf the uterus on cervical HDR, you can avoid treating the top of the tandem. I imagine that if you stick a needle into the bladder you can avoid treating that needle (not sure if each needle has multiple stations similar to tandem/ovoids). Can't make that same save if you stick a I-125 seed into the bladder.

 

[Chartreuse Wombat]

Curious why triple therapy is not discussed as frequently for high risk disease, brachy + external beam + ADT?

Cynicism alert....
Abundant evidence that brachytherapy is declining, despite growing evidence of improved efficacy vis-a-vis dose-escalated external beam (e.g. ASCENDE-RT). Why would this be?
1) Brachytherapy requires procedural expertise which is decreasing in training programs https://www.ncbi.nlm.nih.gov/pubmed/23973187
2) Increasing "physical presence" requirements makes it more difficult for practices to "allow" physicians to spend time in the OR away from machines that perform SBRT, IGRT, etc
3) The deck is stacked in favor of 9 weeks of IMRT from a reimbursement perspective...for the time being...if we ever get to a true "value" model then 1.8 Gy/day vanishes

If we ever get to the "value" model then watch for the rush to SBRT; it has started already https://www.ncbi.nlm.nih.gov/pubmed/27171855

 

[FistLength]

Cynicism alert....
Abundant evidence that brachytherapy is declining, despite growing evidence of improved efficacy vis-a-vis dose-escalated external beam (e.g. ASCENDE-RT). Why would this be?
1) Brachytherapy requires procedural expertise which is decreasing in training programs https://www.ncbi.nlm.nih.gov/pubmed/23973187
2) Increasing "physical presence" requirements makes it more difficult for practices to "allow" physicians to spend time in the OR away from machines that perform SBRT, IGRT, etc
3) The deck is stacked in favor of 9 weeks of IMRT from a reimbursement perspective...for the time being...if we ever get to a true "value" model then 1.8 Gy/day vanishes

If we ever get to the "value" model then watch for the rush to SBRT; it has started already https://www.ncbi.nlm.nih.gov/pubmed/27171855

That's too bad. Someone close to me was diagnosed with gleason 9 prostate cancer. After doing a lot of research we went with triple therapy with a rad onc who specializes in brachytherapy, he has done over 2500 cases. So far treatment has been excellent. I am still a medical student, so didn't make sense why we do not use brachy more often. Thanks for the explanation.