ASTRO 2022: Interesting presentations

[OTN]

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A few months back we were arguing about this very thing here (hypofractionation in high-risk PCA). Thoughts?

Glad ASTRO is giving us more and more ammo which suggests acute toxicity is higher for hypofractionated RT for prostate than conventional, with no benefit in terms of disease control.

I will continue to present the data to my patients, and most (not all, note, but most) will continue to select the less-toxic treatment as they have been doing for years now. As I would do. Because I'm a laggard instead of a neophile, I guess.

With all due respect to our European colleagues, "We need to make your treatment a little more toxic because we want it to be cheaper for other people to able to be treated" is a dog that would not hunt over here in the colonies.

 

[grenz]

Glad ASTRO is giving us more and more ammo which suggests acute toxicity is higher for hypofractionated RT for prostate than conventional, with no benefit in terms of disease control.

I will continue to present the data to my patients, and most (not all, note, but most) will continue to select the less-toxic treatment as they have been doing for years now. As I would do. Because I'm a laggard instead of a neophile, I guess.

With all due respect to our European colleagues, "We need to make your treatment a little more toxic because we want it to be cheaper for other people to able to be treated" is a dog that would not hunt over here in the colonies.

Agree. The choice should be the patients. In certain populations they will take you up on the higher acute to increase convenience. But I have plenty of retirees who live nearby and say “I’ve got nothing better to do” and choose conventional. It would be non-patient centered to just deny them that choice and offer hypofrac only.

 

[deleted1111261]

Glad ASTRO is giving us more and more ammo which suggests acute toxicity is higher for hypofractionated RT for prostate than conventional, with no benefit in terms of disease control.

I will continue to present the data to my patients, and most (not all, note, but most) will continue to select the less-toxic treatment as they have been doing for years now. As I would do. Because I'm a laggard instead of a neophile, I guess.

With all due respect to our European colleagues, "We need to make your treatment a little more toxic because we want it to be cheaper for other people to able to be treated" is a dog that would not hunt over here in the colonies.

Laggard
What a$$holes

 

[Gfunk6]

I'm tossing around 20 Gy x 1 to the prostate in guys who drive ICE's. If I get one millenial on the jury I'm good.

This is pure genius. Not only does it reduce carbon footprint by virtue of minimum patient transport and electric utilization on the linac, but you can also compost the patient's body afterwards. Think of how many trees and plants can grow from that!

 

[Ray D. Ayshun]

This is pure genius. Not only does it reduce carbon footprint by virtue of minimum patient transport and electric utilization on the linac, but you can also compost the patient's body afterwards. Think of how many trees and plants can grow from that!

how about thermal ablation? Hook the patient up to a Tesla 3 PR and fully discharge the battery into his prostate.

COI: I own Tesla stock

 

[TheWallnerus]

This is pure genius. Not only does it reduce carbon footprint by virtue of minimum patient transport and electric utilization on the linac, but you can also compost the patient's body afterwards. Think of how many trees and plants can grow from that!

99.99% of a plant’s (or fruit’s or green bean’s etc) mass is CO2 from air and water from the soil. Very very little from compost (but it can help plant health). Carry on.

Video: Van Helmont's experiments on plant growth - Revise: Growth and development: Video playlist - BBC Bitesize

How Jan Baptist van Helmont showed that plants did not use soil to grow.

www.bbc.co.uk

 

[RadOncDoc21]

99.99% of a plant’s (or fruit’s or green bean’s etc) mass is CO2 from air and water from the soil. Very very little from compost (but it can help plant health). Carry on.

Video: Van Helmont's experiments on plant growth - Revise: Growth and development: Video playlist - BBC Bitesize

How Jan Baptist van Helmont showed that plants did not use soil to grow.

www.bbc.co.uk

It’s true, I learn something new everyday. I guess I’ve been wasting my time using compost from the mafia.

 

[Ray D. Ayshun]

99.99% of a plant’s (or fruit’s or green bean’s etc) mass is CO2 from air and water from the soil. Very very little from compost (but it can help plant health). Carry on.

Video: Van Helmont's experiments on plant growth - Revise: Growth and development: Video playlist - BBC Bitesize

How Jan Baptist van Helmont showed that plants did not use soil to grow.

www.bbc.co.uk

 

[TheWallnerus]

View attachment 361212

Not a plant!

 

[Ray D. Ayshun]

Not a plant!

Don't be a laggard!

 

[thesauce]

Hypofract serves interests of large centers trying to draw pts away from the community to much more expensive centers.

This is 100% the reason for it. Why people can’t see this is beyond me.

 

[BobbyHeenan]

I know it's like sacrilegious, but we may wanna check those alpha beta calcs on prostate cancer. If those alpha beta calcs are correct we should have seen some form of cancer outcome benefit from all this hypofrac, no?

 

[Ray D. Ayshun]

I know it's like sacrilegious, but we may wanna check those alpha beta calcs on prostate cancer. If those alpha beta calcs are correct we should have seen some form of cancer outcome benefit from all this hypofrac, no?

a/b calcs only pan out when you compare 40/15 to 27/5 to 26/5 in early breast, and only wrt normal tissue toxicity. I suspect if we had a 79.2/44 vs 70/28 vs 70.5/28 vs 71/28 vs 71.5/28 vs 72/28 vs 72.5/28 vs 73/28 we'd see a BRFS benefit with hypofx.

 

[ramsesthenice]

This is 100% the reason for it. Why people can’t see this is beyond me.

"The greatest trick the devil ever pulled was convincing the world he didn't exist." Verbal Kent/Keyser Soze/ASTRO

 

[evilbooyaa]

Hey! I am reading on some interesting presentations at ASTRO this year, mostly from Twitter.

I thought I'd make a thread to discuss on those.

Here's the first one:


Interesting findings, although not practice changing, in my humble opinion.
It will however make me feel more comfortable irradiating asymptomatic bone mets with more than just a gut feeling to back it up.

It will be interesting to see the breakdown of the SREs in the control arm, i.e. is there a true benefit for the patients or are we merely introducing RT earlier on but not changing any other endpoints (fractures, hospitalizations, surgeries).

I would not overemphasize the overall survival benefit. KPS was also significant in the MVA and there was an imbalance in the trial with the intervention arm having more patients in excellent KPS than the control arm, something which is not uncommon in Phase II trials.



The protocol of the trial has been published before, for those of you that may have protocol-relevant questions:

Early palliative radiation versus observation for high-risk asymptomatic or minimally symptomatic bone metastases: study protocol for a randomized controlled trial - BMC Cancer

Background In patients with metastatic cancer, the bone is the third-most common site of involvement. Radiation to painful bone metastases results in high rates of pain control and is an integral part of bone metastases management. Up to one-third of inpatient consults are requested for painful...

bmccancer.biomedcentral.com

Interesting point: They randomized 93 patients, although they had "planned" to randomize only 74 per protocol. The incidence of SREs in the trial appears to have been lower that what they had thought?

DISCUSS!

I was initially worried about the SRE being driven by "well they have pain without getting RT so it's not a big deal" but with a difference in major SRE of 6 vs 0 and that being significant as well.... I think I may recommend it going forward to those high-risk patients who are at risk of impending fx, even if not acutely symptomatic. Especially when it's minimal toxicity

 

[Palex80]

I was initially worried about the SRE being driven by "well they have pain without getting RT so it's not a big deal" but with a difference in major SRE of 6 vs 0 and that being significant as well.... I think I may recommend it going forward to those high-risk patients who are at risk of impending fx, even if not acutely symptomatic. Especially when it's minimal toxicity

True, it appears to be 6 in 48 non-irradiated patients, so that would be 8 number need to treat to prevent one major SRE?

 

[evilbooyaa]

True, it appears to be 6 in 48 non-irradiated patients, so that would be 8 number need to treat to prevent one major SRE?

Given the toxicity of 8/1, 20/5, or 30/10 to a bony met is usually zero or minimal, especially in locations like femoral neck, comparing NNT vs NNH seems like a pretty decent no-brainer....

 

[Palex80]

This is 100% the reason for it. Why people can’t see this is beyond me.

Well, the counter-argument may be that if the community centers provided hypofractionation as often as the major academic centers do, then there wouldn't be any incentive for the patients to go to the major academic centers. But the issue may be, that if all community centers switched to only hypofractionation for the most common curative indications (breast & prostate) - and by that I mean for the majority of the breast and prostate cancer patients - there may not be the need for so many community centers or some of those community centers would not be profitable any longer?

 

[Palex80]

Given the toxicity of 8/1, 20/5, or 30/10 to a bony met is usually zero or minimal, especially in locations like femoral neck, comparing NNT vs NNH seems like a pretty decent no-brainer....

There are some med oncs out there that will hate you if you tell them you want to irradiate half of the sacrum for an asymptomatic bone met based on a Phase II study, if the patient is scheduled to start Carbo/Pem/Pem. Frying the bone marrow in the pelvis can aggrevate cytopenia.

 

[deleted1111261]

Well, the counter-argument may be that if the community centers provided hypofractionation as often as the major academic centers do, then there wouldn't be any incentive for the patients to go to the major academic centers. But the issue may be, that if all community centers switched to only hypofractionation for the most common curative indications (breast & prostate) - and by that I mean for the majority of the breast and prostate cancer patients - there may not be the need for so many community centers or some of those community centers would not be profitable any longer?

Yes. That is correct.

Unless the reimbursement model changes dramatically.

If everyone goes to 5 fx for everything, then a lot of centers will close.

 

[communitydoc13]

There are some med oncs out there that will hate you if you tell them you want to irradiate half of the sacrum for an asymptomatic bone met based on a Phase II study

I think most of us wouldn't do that. Femoral neck with cortical involvement, sure. High volume, asymptomatic pelvic disease? We're probably leaving that alone. It would be very rare for us to treat large portions of the pelvis based on the criteria of high risk given in the study.

then there wouldn't be any incentive for the patients to go to the major academic centers

The incentive to go to major centers is the belief that the care is better. It has very little to do with hypofractionation and many community practices hypofractionate within reason. In my experience, many academic centers are the most resistant to shortening treatment courses.

Now, very short courses (5 or fewer tx) do allow tertiary centers to retain patients that otherwise would not be willing to make the travel or time away from home commitment.

 

[RadOncDoc21]

I think most of us wouldn't do that. Femoral neck with cortical involvement, sure. High volume, asymptomatic pelvic disease? We're probably leaving that alone. It would be very rare for us to treat large portions of the pelvis based on the criteria of high risk given in the study.


The incentive to go to major centers is the belief that the care is better. It has very little to do with hypofractionation and many community practices hypofractionate within reason. In my experience, many academic centers are the most resistant to shortening treatment courses.

Now, very short courses (5 or fewer tx) do allow tertiary centers to retain patients that otherwise would not be willing to make the travel or time away from home commitment.

Actually had a few horror stories from a top name academic center. Let’s just say they got a little too fancy for something that could have been treated better if they would have just done the standard of care. Instead of needing one modality, the patient ended up needing three. Instead of owning up to their mistake, they double down even harder.

Of course the patient has no idea because in their mind, this center is going “above and beyond,”‘which in reality they are right… they went way above and beyond what is considered reasonable and necessary.

I understand hindsight is 20/20 and I have made my share of mistakes, but this center never owns up to anything. I would share a story or an example but I would definitely be doxing myself. Let’s just say this center has all the greatest modalities and will treat anyone using anything.

 

[thesauce]

Well, the counter-argument may be that if the community centers provided hypofractionation as often as the major academic centers do, then there wouldn't be any incentive for the patients to go to the major academic centers.

It is a very rare patient that goes to an academic center after a consult at mine. They go there first. If they can talk them into treatment there, I’ll never see them. Maybe they’ll send them back to me for follow-up.

Patients are much easier to talk into treatment if the treatment courses are short. Far and away, the most common reason I hear for them coming to me is that the proposed course of treatment at the academic center was too long.

 

[thesauce]

Actually had a few horror stories from a top name academic center. Let’s just say they got a little too fancy for something that could have been treated better if they would have just done the standard of care. Instead of needing one modality, the patient ended up needing three.

Sounds like a TORS resection for early stage H&N and they left a positive margin. I’ve seen it.

 

[thecarbonionangle]

Sounds like a TORS resection for early stage H&N and they left a positive margin. I’ve seen it.

I hate tors. Recently saw a t1N1 p16+, would have done amazingly with ipsi radiation. Positive margin. Now needs chemo xrt. Surgeon sure helped them! another day, another surgeon hack job.

 

[deleted1111261]

I hate tors. Recently saw a t1N1 p16+, would have done amazingly with ipsi radiation. Positive margin. Now needs chemo xrt. Surgeon sure helped them! another day, another surgeon hack job.

Why not pretend they never got the hack?
Then they can still just get RT !

But for real, if they were a candidate for RT and would have done amazingly, the surgery didn’t make their disease worse and warrant RT.

 

[medgator]

Why not pretend they never got the hack?
Then they can still just get RT !

But for real, if they were a candidate for RT and would have done amazingly, the surgery didn’t make their disease worse and warrant RT.

Toxicity goes up with trimodality, that's why and then we get blamed since we were the last to treat the patient.

Hot potato!

 

[medgator]

I hate that increased gi tox with equal efficacy defaults to "New SOC" without more discussion

.

ASTRO towing the big rad Onc line....

 

[deleted1111261]

Toxicity goes up with trimodality, that's why and then we get blamed since we were the last to treat the patient.

Hot potato!

I think you misunderstood the post

 

[Ray D. Ayshun]

I think you misunderstood the post

Fwiw, I think the end of your sentence was meant to be chemo and not rt.

 

[medgator]

Fwiw, I think the end of your sentence was meant to be chemo and not rt.

Even then.... We have data from the orator study and it's clear to me it is being ignored across the country

Randomized Trial of Radiotherapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Long-Term Results of the ORATOR Trial | Journal of Clinical Oncology

PURPOSE The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has risen rapidly, because of an epidemic of human papillomavirus infection. The optimal management of early-stage OPSCC with surgery or radiation continues to be a clinical controversy. Long-term randomized data comparing...

ascopubs.org

 

[thecarbonionangle]

Even then.... We have data from the orator study and it's clear to me it is being ignored across the country

Randomized Trial of Radiotherapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Long-Term Results of the ORATOR Trial | Journal of Clinical Oncology

PURPOSE The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has risen rapidly, because of an epidemic of human papillomavirus infection. The optimal management of early-stage OPSCC with surgery or radiation continues to be a clinical controversy. Long-term randomized data comparing...

ascopubs.org

When orator2 was presented at last year’s ASTRO, there was a presentation on same day by mayo on their de-escalation TORs protocol results and they basically said (coming from a rad onc) that their experience did not reflect this. So not only are surgeons ignoring orator1 and 2 but also some rad oncs.

 

[medgator]

When orator2 was presented at last year’s ASTRO, there was a presentation on same day by mayo on their de-escalation TORs protocol results and they basically said (coming from a rad onc) that their experience did not reflect this. So not only are surgeons ignoring orator1 and 2 but also some rad oncs.

My real world experience has been c/w orator

Mayo ROs:

 

[Ray D. Ayshun]

Even then.... We have data from the orator study and it's clear to me it is being ignored across the country

Randomized Trial of Radiotherapy Versus Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma: Long-Term Results of the ORATOR Trial | Journal of Clinical Oncology

PURPOSE The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has risen rapidly, because of an epidemic of human papillomavirus infection. The optimal management of early-stage OPSCC with surgery or radiation continues to be a clinical controversy. Long-term randomized data comparing...

ascopubs.org

I think simul was asking the same question I often ask. If we're willing to treat this population with RT alone sans op, why do we add chemo for a positive margin?

 

[medgator]

I think simul was asking the same question I often ask. If we're willing to treat this population with RT alone sans op, why do we add chemo for a positive margin?

The traditional eortc/rtog post op data back then that we use now was p16/HPV agnostic. No real data in the post op HPV+ population so it's all we have to go on.

The surgeons around me will argue that the only thing we know is that it adds toxicity without a defined benefit.

The best situation is when they never get tors at all

 

[gmsquid]

Why not pretend they never got the hack?
Then they can still just get RT !

But for real, if they were a candidate for RT and would have done amazingly, the surgery didn’t make their disease worse and warrant RT.

To be devils advocate, It could be patient selection. This could be one of the 8% of patients who would’ve failed primary rt. It’s possible that the surgery potentially correctly staged this person as more aggressive disease. I hate tors for the most part too, but just saying that sometimes positive margins aren’t cause the surgeon didn’t cut enough but reflective of more infiltrativs disease

 

[deleted1111261]

I agree with over use of TORS

I just don’t get the logic

If you’re cT1N1 and can get RT alone, after a TORS + ipsi neck, you’re still cT1N1, despite what path says.

Why add chemo?

If you’re saying you would, then RT alone was undertreatment and you should thank surgeon for pointing out chemo was needed

 

[medgator]

I agree with over use of TORS

I just don’t get the logic

If you’re cT1N1 and can get RT alone, after a TORS + ipsi neck, you’re still cT1N1, despite what path says.

Why add chemo?

If you’re saying you would, then RT alone was undertreatment and you should thank surgeon for pointing out chemo was needed

Or maybe the surgeon didn't get it all? And RT would have? Or it could be a situation like @gmsquid pointed out

 

[deleted1111261]

Radiation research rules

1. First, always drop some fractions

2. Bio markers. I don’t know what this means, but say it.

3. Create new toxicity or ways to analyze cost to benefit your outcome

4. Never pick a side. Just look for not inferior.

5. If not positive, say “appears to correlate, but not powered yo show this”

6. If you can show something that is expensive is worse in someway, do so

7. If any major institutions are involved, ignore 6

8. Diversity (unless viewpoints), inclusion (except those that disagree), equity (except for senior academic faculty) are desirable

9. Protons good; MRL good; imrt very very bad

10. You can always take off another fraction !

 

[deleted1111261]

Or maybe the surgeon didn't get it all? And RT would have?

Yes but why chemo?
If surgeon didn’t get it all, it’s just a big biopsy

 

[medgator]

Yes but why chemo?

Traditional risk factors for needing chemo post op have been +margin or ece. Even though the data that is derived from wasn't a pure HPV/p16+ population

 

[gmsquid]

I agree with over use of TORS

I just don’t get the logic

If you’re cT1N1 and can get RT alone, after a TORS + ipsi neck, you’re still cT1N1, despite what path says.

Why add chemo?

If you’re saying you would, then RT alone was undertreatment and you should thank surgeon for pointing out chemo was needed

It’s pre test vs post test probability. After the surgery you now have more info about that particular patient. Why give chemo at all to anybody in the definitive setting? It only helps 10-15 percent of patients and you don’t know which ones. The more info you have changes your ultimate treatment decision

 

[medgator]

Radiation research rules

1. First, always drop some fractions

2. Bio markers. I don’t know what this means, but say it.

3. Create new toxicity or ways to analyze cost to benefit your outcome

4. Never pick a side. Just look for not inferior.

5. If not positive, say “appears to correlate, but not powered yo show this”

6. If you can show something that is expensive is worse in someway, do so

7. If any major institutions are involved, ignore 6

8. Diversity (unless viewpoints), inclusion (except those that disagree), equity (except for senior academic faculty) are desirable

9. Protons good; MRL good; imrt very very bad

10. You can always take off another fraction !

!!!!!!! Hopefully someone can tag ASTRO and the ROI with that

 

[deleted1111261]

It’s pre test vs post test probability. After the surgery you now have more info about that particular patient. Why give chemo at all to anybody in the definitive setting? It only helps 10-15 percent of patients and you don’t know which ones. The more info you have changes your ultimate treatment decision

I’m just saying that it is contradictory to say “surgeon bought them radiation”

No, they didn’t. The c stage is same. You’re mixing studies. They did buy them RT, but that’s bc a gross positive margin means tumor is still there.

The reflexive chemo is inconsistent. Either be happy you know they need it or don’t give it.

 

[TheWallnerus]

I’m just saying that it is contradictory to say “surgeon bought them radiation”

No, they didn’t. The c stage is same. You’re mixing studies. They did buy them RT, but that’s bc a gross positive margin means tumor is still there.

The reflexive chemo is inconsistent. Either be happy you know they need it or don’t give it.

I think once the surgeon operates on a neck even if it’s early stage tonsil, for me, they “bought” the patient contralateral neck RT. So it would feel like a bit of a therapeutic snafu.

 

[communitydoc13]

Yes but why chemo?
If surgeon didn’t get it all, it’s just a big biopsy

I think not all positive margins are the same.

In the absence of radical tonsillectomy, primary margins are often close/positive. I don't think this should reflexively buy you chemo in an HPV positive tonsillar cancer unless the surgeon is telling you they saw something bad (deeply infiltrative, much more extensive than on imaging, etc). In my experience, ENTs often err on the side of being conservative with their tonsillectomies (thank goodness, they are painful AF in a 70 yo anyway).

A positive margin on a neck dissection? That tells you something. Much like ECE. But these are very rare. Fixed neck mass type scenarios and most ENTs know to avoid this situation anyway.

 

[deleted1111261]

I think not all positive margins are the same.

In the absence of radical tonsillectomy, primary margins are often close/positive. I don't think this should reflexively buy you chemo in an HPV positive tonsillar cancer unless the surgeon is telling you they saw something bad (deeply infiltrative, much more extensive than on imaging, etc). In my experience, ENTs often err on the side of being conservative with their tonsillectomies (thank goodness, they are painful AF in a 70 yo anyway).

A positive margin on a neck dissection? That tells you something. Much like ECE. But these are very rare. Fixed neck mass type scenarios and most ENTs know to avoid this situation anyway.

Bingo.

People taking TORS as same thing as radical tonsillectomy. Very different.

If it is cT1N0 before TORS and pT2N2bM0 with 2 nodes on ipsi side and a positive margin on primary, what makes you think that RT alone was enough but now you have "bought yourself chemo"? If you truly felt that it bought the patient chemo, then you should be thanking the surgeon, because you're saying RT alone would have been undertreatment.

I am not debating the inanity of it. I'm just saying we don't have to buy into it.

If you felt RT would have cured them before, then I don't understand why feeling "forced" to advise for chemo.

 

[RadOncDoc21]

Bingo.

People taking TORS as same thing as radical tonsillectomy. Very different.

If it is cT1N0 before TORS and pT2N2bM0 with 2 nodes on ipsi side and a positive margin on primary, what makes you think that RT alone was enough but now you have "bought yourself chemo"? If you truly felt that it bought the patient chemo, then you should be thanking the surgeon, because you're saying RT alone would have been undertreatment.

I am not debating the inanity of it. I'm just saying we don't have to buy into it.

If you felt RT would have cured them before, then I don't understand why feeling "forced" to advise for chemo.

Stop with your common sense arguments. This isn’t a place to question anything or anyone unless you kiss the ring of the big wigs. Now stay in your lane sir, last warning!

 

[gmsquid]

Bingo.

People taking TORS as same thing as radical tonsillectomy. Very different.

If it is cT1N0 before TORS and pT2N2bM0 with 2 nodes on ipsi side and a positive margin on primary, what makes you think that RT alone was enough but now you have "bought yourself chemo"? If you truly felt that it bought the patient chemo, then you should be thanking the surgeon, because you're saying RT alone would have been undertreatment.

I am not debating the inanity of it. I'm just saying we don't have to buy into it.

If you felt RT would have cured them before, then I don't understand why feeling "forced" to advise for chemo.

That’s not the issue here. Because rt alone may not have cured them and if you gave them rt alone they may have needed salvage surgery on the backend anyways . Pet staging has changed what you include to 70 Gy has it not? A ton of those patients may have got 63 to that neck or even 56. Your knowledge with the pet evolves how you treat two patients with similar ct findings. Two patients who were equivalently T1N0 by CT. One may get chemo and one may get RT alone. Surgery is no different. It didn’t buy the patient chemo you just have more a priori information about that patient after surgery. You can’t ignore it.

And yes there are probably levels to positive margins. Like a diagnostic tonsillectomy in a T1N1 single node patient with a positive margin would still merit rt alone. But in the setting of a a radical tonsillectomy/oncologic surgery a positive margin is different.

 

[communitydoc13]

Pet staging has changed what you include to 70 Gy has it not?

I think the question for me is to what degree does the extra information that we've obtained by surgery (or any new imaging technique) fit into to data that has historically driven the recommendation for adjuvant chemo/rt with positive margins and ECE.

The patients on those studies (Bernier, Cooper etc) are as different from your typical HPV positive OP cancer patient in the modern era as old school high risk prostate cancer patients are from the high risk prostate cancer patients of today (often one incidental core of Gleason 4+4 or higher). Comparing margin status from a TORs tonsillectomy to margins from radical OC surgery is difficult.

That being said, there are times where the surgery does tell you something, and there are HPV positive OP cancers that are bad actors. It's a judgement call. Things that scare me are still often clinical. Pain, trismus, deep seated or infiltrative tumor without much mucosal disease or haziness around the vascular bundle in the neck.

I'm also not sure that you need to treat a subcentimeter, PET avid node with 70. I do it, but....