7 fractions, meh...howsabout 5

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Everyone is going to get SBRT for prostate cancer in the future. It’s a no brainer.

Urologists are shook
 
medgator said:
Assuming so called "shook" urologists actually send you the referrals....
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Haha yeah I mean I agree. I do think patients are getting smarter and smarter and becoming more of their own advocate. In the future as SBRT becomes the radiation SOC, most people will know about the ‘five days of treatment’ option
 
Krukenberg said:
Anyone outsourcing fiducials and spaceOAR to urology to keep them involved in the referrals?
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I’ve tried. Of the three urology groups in my town, two of three thoroughly uninterested. The urorads-sort of group seems more interested but they obviously don’t refer much to me.

It’s a pain for me to do it and I was hoping they’d do it but it’s been a no go for me.

Depending upon how the billing is done it’s just not a big money maker and if they’re not the ones doing the xrt there’s just not a lot of “skin in the game” so to speak for them.
 
Space OAR is a money loser. If you do it in ASC it’s like 1700 if you do it in office then it’s like 3300 or something last time I checked. The stuff isn’t cheap either.

If you do both the fidicials and Soace our together then you are subject to MPR so 50% reduction in payment for the subsequent procedure. Making even more of a waste.

Admittedly I was excited at first but I have lost my interest now.
 
RadsWFA1900 said:
Space OAR is a money loser. If you do it in ASC it’s like 1700 if you do it in office then it’s like 3300 or something last time I checked. The stuff isn’t cheap either.

If you do both the fidicials and Soace our together then you are subject to MPR so 50% reduction in payment for the subsequent procedure. Making even more of a waste.

Admittedly I was excited at first but I have lost my interest now.
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Yep financially makes sense only in the office, but if you do enough of them, you can make money on it based on how much you are paying for the ultrasound ownership/rental etc
 
medgator said:
Yep financially makes sense only in the office, but if you do enough of them, you can make money on it based on how much you are paying for the ultrasound ownership/rental etc
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Not worth the time or
Frustration.
 
RadsWFA1900 said:
Not worth the time or
Frustration.
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I agree. It's being marketed super aggressively in my area with reps telling the uros it reimburses 4000+. What they don't reveal is the kit costs 3,000+ and you have to have special u/s equipment (which I've been told costs 60,000) to even do it. I also find most of my uros can't instill the gel symetrically anyway, so in many cases it just delays treatment without offering any benefit. In theory, it's a great idea, but practically it has been a waste of time for me.
 
Reaganite said:
I agree. It's being marketed super aggressively in my area with reps telling the uros it reimburses 4000+. What they don't reveal is the kit costs 3,000+ and you have to have special u/s equipment (which I've been told costs 60,000) to even do it. I also find most of my uros can't instill the gel symetrically anyway, so in many cases it just delays treatment without offering any benefit. In theory, it's a great idea, but practically it has been a waste of time for me.
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Yeah it’s totally horse****. I asked thebreps straight up how much the kit costs and then how much it reimburses and of course they just look at me like I have 10 heads and can’t do simple math.
 
RadsWFA1900 said:
Yeah it’s totally horse****. I asked thebreps straight up how much the kit costs and then how much it reimburses and of course they just look at me like I have 10 heads and can’t do simple math.
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Financials are tough but the data is solid that it improves patient bowel QOL
 
Krukenberg said:
Financials are tough but the data is solid that it improves patient bowel QOL
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Was the bowel toxicity really that bad before spaceOAR for conventional fx? I mean honestly most of us were probably quoting low single digits for radiation proctitis for years now. When was the last time any of you had real problems with rectal toxicity on a prostate pt?

Where I see the real advantage to it is in hypofx and sbrt. Given the data and CMS coverage, no reason it shouldn't be done for any 5fx pt. Financially, it is a big PITA if you don't already have the appropriate US to do it though and a standard TRUS won't cut it
 
I think it’s basically a must for SBRT

Don’t think it matters past that
 
RadsWFA1900 said:
Literally the short bus of oncology is Rad Onc. If this is all we can offer hen our days are really numbered.
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Yeah - safe, effective, convenient, cost-effective curative therapy for one of the most common cancers that is poised to be the most attractive option for patients in the coming decades.

what a joke dude.
 
RadsWFA1900 said:
Literally the short bus of oncology is Rad Onc. If this is all we can offer hen our days are really numbered.
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Still not really sure I understand this perspective. What exactly are surgeons studying to advance cancer treatment? Their days are numbered? Figuring out the best way to use our scalpel seems like something we should be doing.
 
With ablative doses we are tighter with margins for a reason right? We do things like on-board imaging etc. If i can keep the anterior wall of the rectum from getting 40 Gy in 5 fractions, I will. I'm not as worried about the anterior rectum getting high doses in conventional frac. Timmerman's SBRT studies show this with lower GI endoscopy demonstrating ulcers along the anterior rectal wall when getting full dose.
 
xrthopeful said:
Yeah - safe, effective, convenient, cost-effective curative therapy for one of the most common cancers that is poised to be the most attractive option for patients in the coming decades.

what a joke dude.
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Lol not really bro RPs ain’t going anywhere.
 
medgator said:
When was the last time any of you had real problems with rectal toxicity on a prostate pt?
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Early last decade. You know, the antediluvian non-IGRT Dark Ages.
xrthopeful said:
I think it’s basically a must for SBRT

Don’t think it matters past that
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It is *definitely* not a "must." Completely optional/dealer's choice thing.
Ray D. Ayshun said:
Still not really sure I understand this perspective. What exactly are surgeons studying to advance cancer treatment? Their days are numbered? Figuring out the best way to use our scalpel seems like something we should be doing.
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Best way to use scalpel ≠ using scalpel much less
xrthopeful said:
With ablative doses we are tighter with margins for a reason right? We do things like on-board imaging etc. If i can keep the anterior wall of the rectum from getting 40 Gy in 5 fractions, I will. I'm not as worried about the anterior rectum getting high doses in conventional frac.
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Whatever your worry level is in either scenario, theoretically it should be equal in either scenario à la PACE-B as mentioned...

36.25*(1+7.25/3)=124 Gy3
81*(1+1.8/3)=130 Gy3

... or pretty close levels of worry...

40*(1+8/3)=147 Gy3
81*(1+1.8/3)=130 Gy3
86.4*(1+1.8/3)=138 Gy3
 
Ray D. Ayshun said:
Still not really sure I understand this perspective. What exactly are surgeons studying to advance cancer treatment? Their days are numbered? Figuring out the best way to use our scalpel seems like something we should be doing.
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Despite knocking surgery their utilization really hasn’t changed all that much and held up better than us over the last 20 years.
 
medgator said:
What's the rate of XRT proctitis at 10 or 20 years out from SBRT?
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SBRT prostate has been around for over 10 years now and I have not seen any hint of unexpected late toxicity in the available literature. (0.4% at 7 years here with likely minimal spaceoar use). Can you describe a parallel situation in radiation oncology where there was an unexpected surge in late radiation toxicity 10+ years out? I'm not trying to be a punk just genuinely curious as I hear this argument not infrequently.
 
A lot of the earlier studies that didn’t use spacer used a rectal balloon. I agree with you that SBRT is very safe and has good long term data

I guess my point is I favor it for SBRT, but I don’t see the point of fiducials or spacers otherwise
 
Also can I just say that comparing SBRT doses to conventional doses with BED is a fool’s errand.

We don’t understand what’s going on with BED with SBRT doses really at all.

Also are you guys all doing 36.25/5 for high intermediate and high risk or are you dose escalating
 
medgator said:
Was the bowel toxicity really that bad before spaceOAR for conventional fx? I mean honestly most of us were probably quoting low single digits for radiation proctitis for years now. When was the last time any of you had real problems with rectal toxicity on a prostate pt?

Where I see the real advantage to it is in hypofx and sbrt. Given the data and CMS coverage, no reason it shouldn't be done for any 5fx pt. Financially, it is a big PITA if you don't already have the appropriate US to do it though and a standard TRUS won't cut it
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You may consider that study after study shows that physician assessed toxicity is much lower than patient reported. In the RCT the % of patients with decline in bowel QOL was 14% vs 41% in favor of the spacer.
 
radmonckey said:
SBRT prostate has been around for over 10 years now and I have not seen any hint of unexpected late toxicity in the available literature. (0.4% at 7 years here with likely minimal spaceoar use). Can you describe a parallel situation in radiation oncology where there was an unexpected surge in late radiation toxicity 10+ years out? I'm not trying to be a punk just genuinely curious as I hear this argument not infrequently.
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Outside of second malignancy, probably not much. Maybe ED, related more to the vasculature. My bigger issue is having a treatment that works with minimal morbidity and then seeing stuff like this come out, granted it's a few years old:


Nonetheless, imo the bar for avoiding any adverse outcome is far higher in the community
 
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medgator said:
Outside of second malignancy, probably not much. Maybe ED, related more to the vasculature. My bigger issue is having a treatment that works with minimal morbidity and then seeing stuff like this come out, granted it's a few years old:


Nonetheless, imo the bar for avoiding any adverse outcome is far higher in the community
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I think that's completely valid. Prostate sbrt is nothing to rush into. I do think evidence is mounting that it's efficacious and well tolerated. It will likely eventually be the standard of care in my opinion but we aren't quite there. NCCN has recently modified their language to allow it in all risk groups, but for unfavorable intermediate and high risk it is only recommended if other fractionations present an unnecessary burden to the patient.
 
xrthopeful said:
Also can I just say that comparing SBRT doses to conventional doses with BED is a fool’s errand.

We don’t understand what’s going on with BED with SBRT doses really at all.

Also are you guys all doing 36.25/5 for high intermediate and high risk or are you dose escalating
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If so, all those fools attempted to make their SBRT regimens late tissue toxicity BED-normoequivalent (and simultaneously oncologically BED superior, unique to CaP) to conventional fractionation as first predicted by Hall. (Except in those days it was called hypofractionation instead of stereotactic ablative radiation therapy. Foolish!) The SBRT doses chosen were from derivation, not afflatus.
 
A couple years ago, the reps came to me telling me that I'm likely experiencing 15% proctitis. I disagreed, telling them that in 7-8 years I'd never had a rectal bleed. They refused to believe this and pressed on. They told me my V70 was likely >20%. Again, I disagreed and showed them a couple DVHs. They pressed on. I completely tuned out on SpaceOAR when the reps showed me the data that it also improved dosimetry, bladder toxicity, and erectile function. The stuff literally shoves the prostate into the bladder, and yet there was less toxicity and better DVHs. It should have next to no effect on erectile function, but there it was. Like 40% impotence vs 15%. I laughed at the slide and told them I now believe none of their data. Haven't looked back.


Still, the most bothersome thing to me about SpaceOAR is.... If you have a guy with a TRUS in his butt, his legs in the air, a needle through his perineum, and foreign bodies being implanted in the prostate/pelvis; why not just put a few more needles in and drop a few more foreign bodies and be done with it?

5 rectal balloons. No risk. Less inconvenience/cost. Less discomfort. No need for MRI. No long term worry about WTF is an irradiated hydrogel matrix going to do in a pelvis in 20 years.
 
Just FYI - I enroll on NRG GU-005 (basically PACE B), and spaceOAR is not mandated.

I offer it but don’t incist on it.

I too think the spaceOAR trial data is a tad suspect (as I recall margins are not published) but have seen it help a DVH.
 
Yeah if you’re doing a balloon no need for spacer then. My bias is just to use one of them for SBRT.
 
Mandelin Rain said:
A couple years ago, the reps came to me telling me that I'm likely experiencing 15% proctitis. I disagreed, telling them that in 7-8 years I'd never had a rectal bleed. They refused to believe this and pressed on. They told me my V70 was likely >20%. Again, I disagreed and showed them a couple DVHs. They pressed on. I completely tuned out on SpaceOAR when the reps showed me the data that it also improved dosimetry, bladder toxicity, and erectile function. The stuff literally shoves the prostate into the bladder, and yet there was less toxicity and better DVHs. It should have next to no effect on erectile function, but there it was. Like 40% impotence vs 15%. I laughed at the slide and told them I now believe none of their data. Haven't looked back.


Still, the most bothersome thing to me about SpaceOAR is.... If you have a guy with a TRUS in his butt, his legs in the air, a needle through his perineum, and foreign bodies being implanted in the prostate/pelvis; why not just put a few more needles in and drop a few more foreign bodies and be done with it?

5 rectal balloons. No risk. Less inconvenience/cost. Less discomfort. No need for MRI. No long term worry about WTF is an irradiated hydrogel matrix going to do in a pelvis in 20 years.
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Indeed. Now to the SpaceOAR folks' credit, I am sure that they have seen many rectal V70s >20%. This results from a PTV margin >5mm in all three dimensions. Using a PTV of this size with daily IGRT is not a PTV, it's a mistake. But the SpaceOAR reps are not rad oncs, they only can report what they've seen, etc. If you're a wide-marginist, one of the only ways to fix that clinical error is to manipulate the patient's anatomy with SpaceOAR. Usually I try to keep the 50% iso ~1cm or less from the posterior prostate, V70s usually <<10%. (Below is one of my more mediocre plans but acceptable; rectum, brown line.) I agree with Marcel the Margin King: reducing margins is a next frontier/unexplored frontier of lowering radiotherapy toxicity. Treat something with big margins with protons vs small margins w/XRT, XRT will have less toxicity. Going from 1cm to 0.5cm margins on a 4cm prostate reduces treatment volume by a whopping ~40%, and PTV size/volume correlates closely with toxicity.

DJyaF51.png
 
Thanks, SneakyBlogger. More invasive interventions = more AE's.
For those who switched to 5 fx "SBRT" on an LINAC, do you do anything different? Urethral avoidance? Enemas?
 
seper said:
Thanks, SneakyBlogger. More invasive interventions = more AE's.
For those who switched to 5 fx "SBRT" on an LINAC, do you do anything different? Urethral avoidance? Enemas?
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To be the devil's advocate, transperineal spaceOAR and fiducial placement is a lot less "dirty" than the traditional transrectal approach many use for biopsies and fiducials
 
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I've been doing 5-fraction SBRT for 2 years now. MRI for planning and fiducials placed by the referring urologist. 3mm PTV margins. CBCT before each arc with fiducial imaging in between. Full bladder and empty rectum, though I don't have the patient do enemas. All patients treated to either 36.25 or 40 in 5. No urethral avoidance except for keeping hot spots away.

I've treated about 8-10 now, and all have done well with minimal grade 2 urinary toxicity in the first 1-2 months after treatment. None have any residual GU or GI toxicity. All are NED. Combination of low- and low-intermediate risk. We have a very, very large urorads group in town, so I don't see that much prostate, which is why my patient numbers aren't too high. As the urorads group treats everyone in 45 fractions, we thought, once we were comfortable with the data, offering SBRT would help recapture some of the market, and that has happened a bit. Not much, but they're building a new urology office (no XRT) right next to ours, so up will go a billboard letting those patients know there's a potential 5-fraction option nearby.

I do not believe the SpaceOAR does anything for long-term GI toxicity, doesn't do much for acute toxicity, and I'd rather avoid possible clinical and financial toxicity from its placement, so I avoid it. If 50 in 5 works for high-risk disease the SpaceOAR would make that possible, though. I've yet to see data.
 
thanks.. I wonder if additional "in-fraction" CBCT actually increases error by adding treatment time. What kind of shifts are you seeing?
 
seper said:
thanks.. I wonder if additional "in-fraction" CBCT actually increases error by adding treatment time. What kind of shifts are you seeing?
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The data shows that it can cause a bit of drift, but I feel more comfortable making sure rectal/bladder filling are consistent. Shifts are 3mm or less.
 
OTN said:
I've been doing 5-fraction SBRT for 2 years now. MRI for planning and fiducials placed by the referring urologist. 3mm PTV margins. CBCT before each arc with fiducial imaging in between. Full bladder and empty rectum, though I don't have the patient do enemas. All patients treated to either 36.25 or 40 in 5. No urethral avoidance except for keeping hot spots away.

I've treated about 8-10 now, and all have done well with minimal grade 2 urinary toxicity in the first 1-2 months after treatment. None have any residual GU or GI toxicity. All are NED. Combination of low- and low-intermediate risk. We have a very, very large urorads group in town, so I don't see that much prostate, which is why my patient numbers aren't too high. As the urorads group treats everyone in 45 fractions, we thought, once we were comfortable with the data, offering SBRT would help recapture some of the market, and that has happened a bit. Not much, but they're building a new urology office (no XRT) right next to ours, so up will go a billboard letting those patients know there's a potential 5-fraction option nearby.

I do not believe the SpaceOAR does anything for long-term GI toxicity, doesn't do much for acute toxicity, and I'd rather avoid possible clinical and financial toxicity from its placement, so I avoid it. If 50 in 5 works for high-risk disease the SpaceOAR would make that possible, though. I've yet to see data.
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very nice
 
OTN said:
I've been doing 5-fraction SBRT for 2 years now. MRI for planning and fiducials placed by the referring urologist. 3mm PTV margins. CBCT before each arc with fiducial imaging in between. Full bladder and empty rectum, though I don't have the patient do enemas. All patients treated to either 36.25 or 40 in 5. No urethral avoidance except for keeping hot spots away.
Click to expand...

I do ours very similar to this except I only do one CBCT and do intrafraction real time fiducial tracking on a truebeam.

I don't use rectal balloons either. I don't demand spaceOAR but for whatever reason I have patients asking for it.
 
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