High risk prostate fractionation

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elementaryschooleconomics said:
*sigh*

*puts on linen shirt, grabs crystal necklace, lights incense*

Counter to what feels like, well, everyone else in RadOnc does (especially oral boards), I try to never discuss actual trial numbers with patients.

Obviously, if really pressed and the person seems like they have the "health literacy" to understand what the numbers mean, I'll do it.

But the human brain does not natively understand the abstract concept of a population-level statistics. If that were true, no one would ever play Powerball. Additionally, people will absolutely latch onto a number if a doctor says it. A couple of weeks ago, I had a consult where a guy told me he only had 7 months left to live, and asked why he should get radiation if he was going to die so soon. On trying to figure out how he arrived at that belief, it sounds like someone in MedOnc gave him an estimate on what would happen if he elected to not receive any treatment, and by the time he got to me, he figured he should be ordering a casket.

I phrase things in various ways:

"How long do I have left to live" is discussed with the "hours to days, days to weeks, weeks to months, months to years" timeline.

"Are you going to cure my cancer" is discussed more organically, but I often say things such as "very good chance, good chance, 50/50, maybe 50/50 but it's worth a shot", etc (I modify this based on the literacy of the person I'm talking to).

For side effects, I go with "best case scenario, worst case scenario, and most likely scenario".

So, with that hippie context, when I get to the side effects portion of the consult, after discussing the more common side effects, I truthfully tell them that the most likely scenario is that guys tell me they feel a little tired, and that they have some more urinary urgency/frequency and/or difficulty starting to urinate, but get through from start to finish without severe issues (I don't know about y'all, but that's how my prostate courses usually go...even though I refuse to use the beloved SpaceOAR, I don't see much in the way of GI toxicity - sorry Boston Scientific).

After telling them the "most likely" scenario, I then tell them (again, truthfully) that the guys who do the shorter course regimen generally experience slightly more urgency/frequency earlier than the longer course patients, but they also have no trouble getting through. I then reiterate/summarize with something like "that's the choice, both options should have an equally excellent chance at controlling the cancer, and the tradeoff for being done faster is a slightly increased chance of some urinary side effects showing up earlier and maybe being a little more bothersome". I often make a stupid joke like "can't get anything for free in this world, right?" and then the three of us laugh (because there's usually a wife in the room).

That's all I say. No numbers, no doom and gloom. I'm absolutely CERTAIN that if I tried this in a department in a downtown metro area with someone driving in from the suburbs, I would have almost no one picking conventional, haha.

On my end, as I've said on SDN before: I vastly prefer conventional fractionation for psych/mental health reasons. Prostate patients are a nervous bunch. You get these older men who grew up in an era when men weren't supposed to show emotion, so they don't have great coping mechanisms. They're often generally healthy, so this is their first "real" big health issue. You can see the terror in their eyes, but they're trying to hold it in.

So you take someone like that, and you start them on a treatment they don't understand. Eventually, the treatment becomes "routine" for them, and the anxiety lessens.

EXCEPT if urinary side effects show up in Week 2, which is not uncommon in my experience (and consistent with the literature). Then it's just week after week of trying to dial in Flomax or whatever, and the anxiety is always lurking.

With conventional, if urinary side effects show up, it's usually in the final 10-14 days. By that point, guys have already "settled in" and it's MUCH easier to manage.

So...yeah. I'm a secret super hippie and like to use phrases such as "most likely" a lot. But I've had this conversation, and offered this choice, to a couple hundred prostate patients. None of these things I've observed are easily quantifiable, of course. But I hope the eviCores and AIMs of the world don't completely take away my ability to conventionally fractionate before I publish this in The Journal of New Age Chakra Radiation Doctors n' Stuff.
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You're counseling patients on increased rate of acute GU toxicity with mod hypofx? Besides the anecdotes presented here, data for that with 70/28 or 60/20 regimens? Acute GI toxicity, yes, I counsel based on ASTRO Prostate HypoFx guidelines.... but what's your evidence for worse acute GU toxicity?
 
evilbooyaa said:
You're counseling patients on increased rate of acute GU toxicity with mod hypofx? Besides the anecdotes presented here, data for that with 70/28 or 60/20 regimens? Acute GI toxicity, yes, I counsel based on ASTRO Prostate HypoFx guidelines.... but what's your evidence for worse acute GU toxicity?
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I think late toxicity is reasonably well estimated with alpha/beta calcs. As is cell kill. However a simple alpha/beta calc leaves much to be desired when estimating acute toxicity differences between 9 week and 1 week regimens that on paper are supposedly isotoxic. And actually, on paper, every single hypfractionated regimen is supposed to have LESS acute toxicity than normofract regimens (calculated with alpha/beta=10 eg). On paper is different than in clinic (of course one could say with a sufficiently correct model, paper would match clinic!). Ignoring time and really understanding how significantly manipulating it affects radiation therapy outcomes is too unexamined.
 
TheWallnerus said:
I think late toxicity is reasonably well estimated with alpha/beta calcs. As is cell kill. However a simple alpha/beta calc leaves much to be desired when estimating acute toxicity differences between 9 week and 1 week regimens that on paper are supposedly isotoxic. And actually, on paper, every single hypfractionated regimen is supposed to have LESS acute toxicity than normofract regimens (calculated with alpha/beta=10 eg). On paper is different than in clinic (of course one could say with a sufficiently correct model, paper would match clinic!). Ignoring time and really understanding how significantly manipulating it affects radiation therapy outcomes is too unexamined.
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Forget a/b for a second. Where in clinical data (like in real patients) with recommended mod hypofx regimens (NOT HYPRO regimen) are we seeing acute GU toxicity at higher rates than conventional fx?

I've posted extensively about mod hypo fx for prostate in the past, and have done multiple deep dives into the literature, and I just want to know if there is evidence behind an increase in acute GU toxicity- I already counsel on increase in acute GI toxicity. Because if it's there evidence there then I want to mention it. And if it's just dogmatic anecdotal voodoo that flies in the face of pretty much all the major prostate hypofx trials then I'd be interested in that as well.
 
evilbooyaa said:
Forget a/b for a second. Where in clinical data (like in real patients) with recommended mod hypofx regimens (NOT HYPRO regimen) are we seeing acute GU toxicity at higher rates than conventional fx?

I've posted extensively about mod hypo fx for prostate in the past, and have done multiple deep dives into the literature, and I just want to know if there is evidence behind an increase in acute GU toxicity- I already counsel on increase in acute GI toxicity. Because if it's there evidence there then I want to mention it. And if it's just dogmatic anecdotal voodoo that flies in the face of pretty much all the major prostate hypofx trials then I'd be interested in that as well.
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Actually (maybe it wasn’t clear) I’m saying a/b would say: less acute tox with hypofx. Like, a lot less potentially. However, anecdotally, I almost always see a brisker and quicker acute toxicity peak as the package treatment time compresses. YMMV.
 
I've done lots of 28 fx prostate treatments. GI and GU acute toxicity is minimal. I've personally noticed no difference compared to conventional. I also use the updated constraints from Duke, so they are more stringent than those from the original rtog trial.
 
evilbooyaa said:
You're counseling patients on increased rate of acute GU toxicity with mod hypofx? Besides the anecdotes presented here, data for that with 70/28 or 60/20 regimens? Acute GI toxicity, yes, I counsel based on ASTRO Prostate HypoFx guidelines.... but what's your evidence for worse acute GU toxicity?
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Figure 4B from CHHiP?

1660968608985.png


I don't mean "statistically significant overall increase in acute GU toxicity in a Phase III RCT".

I mean exactly what is shown at Week 2 from CHHiP.

As I said before here and elsewhere:

1) A lot of guys have high anxiety at consult and beginning of treatment.
- no, I don't have a trial to cite for "a lot"
2) I try to be very consistent with the "relatively full bladder" instructions.
- this is something most people have never been asked to do in their lives and adds more stress
3) Acute GU toxicity shows up earlier in mod hypo.

I forgot about the CHHiP supplement (p18, B):

1660969327118.png


I am absolutely not a "mod hypo hater" - the publications on my CV would be ironic, if that were the case.

When I talk about this to patients (or in general) - I am intentionally using colloquial language such as "a little more bothersome" precisely because I am not reciting trial data.

I mean that the way patients "perceive" acute GU toxicity is very different on Week 2 vs Week 5. In my experience, it will take guys the first 5 days or so (Week 1) to really dial in the routine in terms of bladder filling and adjusting to "the process". For even the highly anxious guys, if we can make it to the third OTV without side effects, they are noticeably more relaxed.

But anxious guys with bladder filling instructions noticing even mild GU symptoms on Week 2? That's definitely "more bothersome" than the guy hanging out with the staff on Week 6 telling me he "made it this far, it's not that bad".

Of course, I would absolutely take the guy who shows up in my office with a printout of some mod hypo article telling me he wants 60/20 any day of the week. The motivated guys who have already mentally committed to it are a breeze.

I'm not aware of data on this, no. This is not easy to measure, because we're really bad about this "soft" stuff. We're great at spitting out p-values from big trials with physician-graded toxicity scales. But quantifying the emotional duress of a 72-year-old guy who was taught that "real men don't cry" and thinks cancer only happens to people who don't "live right" as it pertains to the type, timing, and severity of side effects...there's no CTCAE scale for that.
 
elementaryschooleconomics said:
Figure 4B from CHHiP?

View attachment 358637

I don't mean "statistically significant overall increase in acute GU toxicity in a Phase III RCT".

I mean exactly what is shown at Week 2 from CHHiP.

As I said before here and elsewhere:

1) A lot of guys have high anxiety at consult and beginning of treatment.
- no, I don't have a trial to cite for "a lot"
2) I try to be very consistent with the "relatively full bladder" instructions.
- this is something most people have never been asked to do in their lives and adds more stress
3) Acute GU toxicity shows up earlier in mod hypo.

I forgot about the CHHiP supplement (p18, B):

View attachment 358638

I am absolutely not a "mod hypo hater" - the publications on my CV would be ironic, if that were the case.

When I talk about this to patients (or in general) - I am intentionally using colloquial language such as "a little more bothersome" precisely because I am not reciting trial data.

I mean that the way patients "perceive" acute GU toxicity is very different on Week 2 vs Week 5. In my experience, it will take guys the first 5 days or so (Week 1) to really dial in the routine in terms of bladder filling and adjusting to "the process". For even the highly anxious guys, if we can make it to the third OTV without side effects, they are noticeably more relaxed.

But anxious guys with bladder filling instructions noticing even mild GU symptoms on Week 2? That's definitely "more bothersome" than the guy hanging out with the staff on Week 6 telling me he "made it this far, it's not that bad".

Of course, I would absolutely take the guy who shows up in my office with a printout of some mod hypo article telling me he wants 60/20 any day of the week. The motivated guys who have already mentally committed to it are a breeze.

I'm not aware of data on this, no. This is not easy to measure, because we're really bad about this "soft" stuff. We're great at spitting out p-values from big trials with physician-graded toxicity scales. But quantifying the emotional duress of a 72-year-old guy who was taught that "real men don't cry" and thinks cancer only happens to people who don't "live right" as it pertains to the type, timing, and severity of side effects...there's no CTCAE scale for that.
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1661005972036.png

Pay me now or pay me later
 
What matters is the area under the curve, when it comes to how many symptoms normofractionated or hypofractionated treatment causes.
And the AUC looks about the same, the distribution over time is what differs.
 
elementaryschooleconomics said:
Figure 4B from CHHiP?
*snip*
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Here is the part of your post I previously bolded, and what I have left bolded you still have not shown evidence of:

"shorter course regimen generally experience slightly more urgency/frequency earlier than the longer course patients, but they also have no trouble getting through. I then reiterate/summarize with something like "that's the choice, both options should have an equally excellent chance at controlling the cancer, and the tradeoff for being done faster is a slightly increased chance of some urinary side effects showing up earlier and maybe being a little more bothersome"

There is no difference in severity of acute GU toxicity during radiation. There is no difference in the peak (as is seen with acute GI toxicity), and there is no difference in the area under the curve.

You want to say that patients get toxicities earlier, fine so be it.

I really think reassuring a prostate patient getting mod hypofx that he's going to be OK in terms of his GU toxicities (when he gets them at week 2 or 3) is the real answer here. And really, the OTV is "well might be a little bit because of RT, can offer you flomax if you want it" and the patients will realize the bother is not so much that it warrants medications (which is the definition of a CTCAE G1 GU toxicity)

I don't personally think, that instead of simply managing a patient's expectations, we should simply give him 50% more treatments, which, oh by the way, wink wink, helps us to be paid more. If a patient is choosing prostate RT w/ conventional fractionation, I would want them to know the severity of their urinary side effects will be the same. Their chances at acute GI toxicity and severity will be less. The downside (for the patient) is that they have to come in more times.

I've met a ton of 'anxious' prostate patients who just need hand holding and reassurance.
 
evilbooyaa said:
I really think reassuring a prostate patient getting mod hypofx that he's going to be OK in terms of his GU toxicities (when he gets them at week 2 or 3) is the real answer here.
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Evil…

Sometimes I need as much reassurance as the patient needs as selfish as that is
 
TheWallnerus said:
I'm too solipsistic for that I guess
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My (seemingly) monthly google of a term that Wallnerus used, to help all those like myself who do not have the english vocabulary wielded, sharper than a sword, by Wallnerus.

Definition of solipsistic​

adjective
of or characterized by solipsism, or the theory that only the self exists, or can be proved to exist:Her treatment philosophy dealt with madness as a complete, self-contained, solipsistic world that sane people are not able to enter.
 
theradiator said:
I vote for SneakerBooger for SDN poster of the year for promoting arthritis treatment and now leading the 'resistance' against the ridiculous NCCN and ASTRO crusade against effective and safe conventionally fractionated radiation for prostate cancer. In addition to the compelling evidence presented, I would add that conventionally fractionated radiation to 74 Gy in 37 fractions was shown in the ProtecT trial to be equally effective and less toxic compared to radical prostatectomy with 10 year follow-up.

I 'wonder' why NCCN and ASTRO would so aggressively promote a treatment which is certainly not more effective than the previous standard of care and is possibly more toxic.
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@scarbrtj deserves all the credit for introducing SDN to the greatest thing since sliced bread for rad onc - arthritis! But thank you anyway.

NCCN and ASTRO (and I would add NRG) may not be here entirely for the betterment of rad oncs or our patients. See post on socialized medicine in Canada (Oh Canada, here we come...? Evicore leading the way...)
 
theradiator said:
I vote for SneakerBooger for SDN poster of the year for promoting arthritis treatment and now leading the 'resistance' against the ridiculous NCCN and ASTRO crusade against effective and safe conventionally fractionated radiation for prostate cancer. In addition to the compelling evidence presented, I would add that conventionally fractionated radiation to 74 Gy in 37 fractions was shown in the ProtecT trial to be equally effective and less toxic compared to radical prostatectomy with 10 year follow-up.
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medgator said:
Shorter fractionation schemes benefit academic centers that are often seeing and potentially treating out of towners, higher costs are never an issue in these studies and it's easier to be blissfully ignorant about the elephant in the room.
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SneakyBooger said:
NCCN and ASTRO (and I would add NRG) may not be here entirely for the betterment of rad oncs or our patients.
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Pro tip on Medicare Advantage patients who may get standard fractionatation for their prostate cancer denied by benefit managers on the front end... have the member appeal the decision, and have them print out the NCCN guideline which shows 45 fractions for all stages as acceptable (yes it shows eg 28 fraction preferred etc etc but std fx is acceptable for all stages per NCCN) to send in with the appeal. The denial will be overturned every time.
 
TheWallnerus said:
Pro tip on Medicare Advantage patients who may get standard fractionatation for their prostate cancer denied by benefit managers on the front end... have the member appeal the decision, and have them print out the NCCN guideline which shows 45 fractions for all stages as acceptable (yes it shows eg 28 fraction preferred etc etc but std fx is acceptable for all stages per NCCN) to send in with the appeal. The denial will be overturned every time.
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I would add that conventional fractionation is also designated as "Preferred":



1662134696072.jpeg


Also, I am a very much "the glass is half full" kind of person, but have I mentioned that I harbor exceptional feelings for any rad onc that ever worked for Evicore?
 
TheWallnerus said:
Pro tip on Medicare Advantage patients who may get standard fractionatation for their prostate cancer denied by benefit managers on the front end... have the member appeal the decision, and have them print out the NCCN guideline which shows 45 fractions for all stages as acceptable (yes it shows eg 28 fraction preferred etc etc but std fx is acceptable for all stages per NCCN) to send in with the appeal. The denial will be overturned every time.
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Send in aua Astro fx guidelines as well.

Evilcore hasn't denied a conventional fx case for me in awhile. Some payors will only approve 40 rather than 45 fx though
 
SneakyBooger said:
All my prostates get 180.

One of my friends across town treats with everything that they can, including spacer and SBRT.

Yet I continue to see more prostates than any other rad onc in the region. Maybe it is just that I have been here a long time and built up a lot of trust.

The urologists have many times commented that they see more toxicity when their patients are treated elsewhere.

It would be imprudent to change that.

Buy who knows, maybe things will change - every dog has their day.

@RickyScott, I do believe you when you say you see more toxicity with 200.

I am pretty sure I have a paper looking at 180 vs 200 - let me see if I can find it.
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To add to this thread another little bit of insight to the world of rad onc...

This morning I got a call from the senior doc at another (smaller) urology group in town today complaining about all the post RT bladder problems they are seeing. He states that all of problems come from one rad onc, the hypofractionator. He requests that I see all of his prostate pts and no one else in town. I inform him I will get them in as soon as I possibly can.

The problem for the hypofractionator is once that bridge is burned it is very very hard to rebuild.
 
SneakyBooger said:
To add to this thread another little bit of insight to the world of rad onc...

This morning I got a call from the senior doc at another (smaller) urology group in town today complaining about all the post RT bladder problems they are seeing. He states that all of problems come from one rad onc, the hypofractionator. He requests that I see all of his prostate pts and no one else in town. I inform him I will get them in as soon as I possibly can.

The problem for the hypofractionator is once that bridge is burned it is very very hard to rebuild.
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Hypofractionators.
choices GIF
 
50% increase in Grade 2 toxicity at 5 years with hypofractionation to prostate only, but something tells me that's not going to be the takeaway from the trial:

 
OTN said:
50% increase in Grade 2 toxicity at 5 years with hypofractionation to prostate only, but something tells me that's not going to be the takeaway from the trial:

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One of the most important developments in the uptake of hypofractionation for prostate cancer in radiation oncology was the intentional ignoring of the differing rates of grade 0/1/2 toxicity in patients treated with hypofract vs std fract; it was the deciding advancement in GU in rad onc in the last 20y imho
 
TheWallnerus said:
One of the most important developments in the uptake of hypofractionation for prostate cancer in radiation oncology was the intentional ignoring of the differing rates of grade 0/1/2 toxicity in patients treated with hypofract vs std fract; it was the deciding advancement in GU in rad onc in the last 20y imho
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I think the increasing recognition of how flawed "physician-judged toxicity" is as a metric will change practice patterns for many specialties in the coming decades. I had "moderate hypofrac is the moral highroad" shoved down my throat for years. I've obviously planted my flag several times in this thread so I won't beat the drum again, but I would choose conventional frac for myself.

The drum worth beating, in my opinion, is continued caution against comparing hypofrac regimens between different disease sites. While I would personally choose conventional for prostate, I think hypofrac for breast is amazing and basically exclusively use it. I have never found a compelling reason to use conventional for intact breasts, and have never used it in my practice.

My boomer partners are a different story. Every time I cover their breast OTVs, my decision to never use conventional for breast is affirmed.
 
TheWallnerus said:
One of the most important developments in the uptake of hypofractionation for prostate cancer in radiation oncology was the intentional ignoring of the differing rates of grade 0/1/2 toxicity in patients treated with hypofract vs std fract; it was the deciding advancement in GU in rad onc in the last 20y imho
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There is also the effect of comparing treatments in stepwise fashion. 20 fractions is compared to standard with higher tox but meets the non-inferiority threshold. 5 is compared to 20 with higher tox but meets the non-inferiority threshold. And so on with 1 or 3 to 5. But no one compares 5 to conventional or 1/3 to conventional. Just keep boiling the frog.
 
DoctwoB said:
There is also the effect of comparing treatments in stepwise fashion. 20 fractions is compared to standard with higher tox but meets the non-inferiority threshold. 5 is compared to 20 with higher tox but meets the non-inferiority threshold. And so on with 1 or 3 to 5. But no one compares 5 to conventional or 1/3 to conventional. Just keep boiling the frog.
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What's your take from clinical experience? We all have our biases but few of us follow prostates more than 2-5 years out if they have Urology on board. Have you seen a different late side effect profile going from 44-28-20-5?
 
communitydoc13 said:
What's your take from clinical experience? We all have our biases but few of us follow prostates more than 2-5 years out if they have Urology on board. Have you seen a different late side effect profile going from 44-28-20-5?
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Small N, but definitely see more irritative GU side effects from SBRT. Hard to compare conventional to 20 fractions since not many get conventional and there is a lot of brachy monotherapy or brachy boost for higher risk in my region.
 
DoctwoB said:
There is also the effect of comparing treatments in stepwise fashion. 20 fractions is compared to standard with higher tox but meets the non-inferiority threshold. 5 is compared to 20 with higher tox but meets the non-inferiority threshold. And so on with 1 or 3 to 5. But no one compares 5 to conventional or 1/3 to conventional. Just keep boiling the frog.
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Preach. It's like the 501(k) device approval pathway at the FDA.
 
DoctwoB said:
There is also the effect of comparing treatments in stepwise fashion. 20 fractions is compared to standard with higher tox but meets the non-inferiority threshold. 5 is compared to 20 with higher tox but meets the non-inferiority threshold. And so on with 1 or 3 to 5. But no one compares 5 to conventional or 1/3 to conventional. Just keep boiling the frog.
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Biocreep...
 
TheWallnerus said:
Pro tip on Medicare Advantage patients who may get standard fractionatation for their prostate cancer denied by benefit managers on the front end... have the member appeal the decision, and have them print out the NCCN guideline which shows 45 fractions for all stages as acceptable (yes it shows eg 28 fraction preferred etc etc but std fx is acceptable for all stages per NCCN) to send in with the appeal. The denial will be overturned every time.
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Anybody else notice that conventional is suddenly no longer listed as an option for low and FIR prostate cancer? For UIR and high risk it's listed with the star (not a typical option). So UHC will let you treat 45 fractions only if you are doing nodes for very high risk is how this is going to go.

So, I suspect denials will no longer be overturned every time by citing NCCN on appeal. I knew this was coming eventually (based on nothing) but it's a real kick in the teeth with the recent CMS beat down on top of it. Why is a treatment that works just as well as the others with lower toxicity no longer even an option? Meanwhile urology is out there freezing focal tumors and IR is doing god knows what in the gland. I will continue to repeat that every single case of late rectal bleeding I have had to send to GI occurred in patients who received 70 Gy in 28 fractions.
 
alwaysbeIMRTing said:
Anybody else notice that conventional is suddenly no longer listed as an option for low and FIR prostate cancer? For UIR and high risk it's listed with the star (not a typical option). So UHC will let you treat 45 fractions only if you are doing nodes for very high risk is how this is going to go.

So, I suspect denials will no longer be overturned every time by citing NCCN on appeal. I knew this was coming eventually (based on nothing) but it's a real kick in the teeth with the recent CMS beat down on top of it. Why is a treatment that works just as well as the others with lower toxicity no longer even an option? Meanwhile urology is out there freezing focal tumors and IR is doing god knows what in the gland. I will continue to repeat that every single case of late rectal bleeding I have had to send to GI occurred in patients who received 70 Gy in 28 fractions.
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I have to be honest, I treat prostate with a decent amount of SBRT, follow all my prostate cancer patients for at least 15 years after treatment, and I really haven't seen that much rectal bleeding at all. Certainly not enough to justify The Goo.
 
I see both sides of the frustration. On one hand, many in our field don’t want to move toward capitation. On the other, many of the same voices are dismayed by the shift from conventional → moderate → ultra-hypofractionation. The tension is real.


Still, the trend lines are hard to ignore. Payors and CMS are pushing shorter regimens, and I don’t think that trajectory is reversible. We can either adapt to it — clinically, financially, and operationally — or continue to fight battles with UHC/benefit managers knowing where the system is headed.


Since anecdotes have been shared, I’ll add mine: I’ve been treating prostate with SBRT for many years now. With careful planning and consistent use of spacers, I haven’t yet seen a case of rectal bleeding toxicity in my own practice. That’s just my experience, but it’s shaped why I’m more comfortable embracing these newer approaches.

Edited for maximum diplomacy
 
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I also don't have many problems with SBRT and typically use spaceOAR. Based on anecdotal experience, I now push for spaceOAR with 28 fractions. I also have not had many problems with the 20 fraction regimen but haven't used it a lot. So I suspect I will be doing a lot more spaceOAR implants, which I'm not exactly thrilled about. I never did it for conventional unless the patient came in demanding it, which was rare.
 
TheWallnerus said:
I guess prostate HDR never caught on because of lack of SpaceOAR in that distant era…
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Prostate HDR is great but you really need to be a high-volume site to do it effecively. Many academic med centers or places like Kaiser have a dedidcated vault, anesthesia team, specially trained nursing staff, etc. etc. Not to mention the administrative hassle and cost of handling potentially weaponizable radioactive sources.

Besides with SBRT and FLAME sytle IMRT you can approach HDR dosing without the need for the dedicated infastructure.
 
alwaysbeIMRTing said:
Anybody else notice that conventional is suddenly no longer listed as an option for low and FIR prostate cancer? For UIR and high risk it's listed with the star (not a typical option). So UHC will let you treat 45 fractions only if you are doing nodes for very high risk is how this is going to go.

So, I suspect denials will no longer be overturned every time by citing NCCN on appeal. I knew this was coming eventually (based on nothing) but it's a real kick in the teeth with the recent CMS beat down on top of it. Why is a treatment that works just as well as the others with lower toxicity no longer even an option? Meanwhile urology is out there freezing focal tumors and IR is doing god knows what in the gland. I will continue to repeat that every single case of late rectal bleeding I have had to send to GI occurred in patients who received 70 Gy in 28 fractions.
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Never used nccn to get it approved. The aua Astro guidelines discuss the increase in gi toxicity with hypo regimens

Most pts still pick hypo in my experience but I've never had a problem getting conventional fractionation approved citing those guidelines, they will also allow for high risk as others have stated or high aua scores/big ass glands
 
Thanks, this is helpful. It too easy though to just say "so you're going to deny a treatment in the NCCN guidelines." Now that evicore douche (you know the one) is going to flip the script and scold me for trying to treat with something not in the guidelines.
 
Gfunk6 said:
Prostate HDR is great but you really need to be a high-volume site to do it effecively. Many academic med centers or places like Kaiser have a dedidcated vault, anesthesia team, specially trained nursing staff, etc. etc. Not to mention the administrative hassle and cost of handling potentially weaponizable radioactive sources.

Besides with SBRT and FLAME sytle IMRT you can approach HDR dosing without the need for the dedicated infastructure.
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Completely agree. Volume matters as much if not more for the physics team as it does you. We do 5-6 implants per week and are usually right at 2-2.5 hr start to finish. That’s easily half of what it is when multiple members of the team are not immediately familiar with the processes and equipment. My partner puts a Barigel in all of his HDR patients. I honestly don’t know why. I’ve done hundreds of primary and boost cases over the last 8 years and seen exactly 0 cases of rectal bleeding after HDR. I’ve seen a couple where I couldn’t get good anterior placement because someone put in a thick spacer for EBRT.

I do more FLAME or SBRT than 70/28 when only doing EBRT these days but Ive honestly had very few issues with rectal bleeding with any fractionation schemes for intact prostate. The vast majority of cases I have seen that needed intervention were salvage with conventional. Which makes sense to me based on the volumes. I know of people putting in spacers for salvage. There is enough scaring that it technically works. However, I’m not convinced that moving the posterior edge of the CTV to the spacer is a good idea. It brings the rectal dose down, but I’ve seen plenty of posterior recurrences that may well be posterior to the spacer and missed with this approach. I will need to see a lot of follow up to convince myself it’s a good idea. Would love to be wrong.

I also agree that NCCN probably doesn’t matter much. Payers arbitrarily decide what they will follow or not. It isn’t helping, but probably unlikely to hurt.

As for spacers, Barigel is the way to go if you want to use one. It’s not as thick as space OAR and patients don’t have as many bothersome sensations. And, if you do get an infiltration, you can dissolve it with hyaluronidsse before it has time to cause severe complications. I’ve never had to do it, but I’ve seen the trainings. I’m still selective when I use any gel, but after years of using SpaceOAR, I’m much happier with Barigel.
 
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ramsesthenice said:
I also agree that NCCN probably doesn’t matter much. Payers arbitrarily decide what they will follow or not. It isn’t helping, but probably unlikely to hurt.
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You guys need to look up Maximus. Granted, there is a specific patient and appeal pathway with which to get familiar with them. This only matters when it matters, but when it matters it matters a lot.

Also, some payors (United eg) base all chemo coverage decisions on NCCN level 1/2a/2b recs. There may come a day when they do so for rad onc.
 
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alwaysbeIMRTing said:
Anybody else notice that conventional is suddenly no longer listed as an option for low and FIR prostate cancer? For UIR and high risk it's listed with the star (not a typical option). So UHC will let you treat 45 fractions only if you are doing nodes for very high risk is how this is going to go.

So, I suspect denials will no longer be overturned every time by citing NCCN on appeal. I knew this was coming eventually (based on nothing) but it's a real kick in the teeth with the recent CMS beat down on top of it. Why is a treatment that works just as well as the others with lower toxicity no longer even an option? Meanwhile urology is out there freezing focal tumors and IR is doing god knows what in the gland. I will continue to repeat that every single case of late rectal bleeding I have had to send to GI occurred in patients who received 70 Gy in 28 fractions.
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That changed several months ago. Maybe longer. NCCN is almost entirely academic institutions which of course have been trying to reduce fractions for years since most are CMS exempt centers that make an insane amount of money per course. All they really care about is getting a patient on beam and they know that will only happen if they offer shorter courses that patients will actually leave their home to travel for. They get paid (a lot) more for SBRT than a community center does for 45 fractions.

You are correct that there is no reason they would show preference for hypofractionation over standard fractionation since outcomes are certainly no better. Heck all hypofrac studies have been non-inferiority.

Their only theoretical argument would be patient convenience and financial considerations which they are not supposed to be taking into account. It’s an overreach and shows NCCN getting into the political realm of doing what’s best for them personally which was a jump the shark moment similar to the USPSTF. I reference both less and less now.
 
OTN said:
I have to be honest, I treat prostate with a decent amount of SBRT, follow all my prostate cancer patients for at least 15 years after treatment, and I really haven't seen that much rectal bleeding at all. Certainly not enough to justify The Goo.
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I have seen more cases of inflammation/sterile prostatitis with SBRT, particularly in diabetic patients who have a lot of urgency and inflammation for several months or more after the treatment.
 
ramsesthenice said:
.

As for spacers, Barigel is the way to go if you want to use one. It’s not as thick as space OAR and patients don’t have as many bothersome sensations. And, if you do get an infiltration, you can dissolve it with hyaluronidsse before it has time to cause severe complications. I’ve never had to do it, but I’ve seen the trainings. I’m still selective when I use any gel, but after years of using SpaceOAR, I’m much happier with Barigel.
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The barrigel reps i know know about the spaceoar toxicities and maude database and they mention where they think barrigel has improved in that regard

Theoretically sounds better but won't know for a few years right?
 
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medgator said:
The barrigel reps i know know about the spaceoar toxicities and maude database and they mention where they think barrigel has improved in that regard

Theoretically sounds better but won't know for a few years right?
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Im right there with you and notice I didn't say the long term complications or severe things are less. Need more time to know that and I bet even with Barigel, they are not entirely trivial which is why I am still selective in who gets any spacer.

What I can say for sure though is that they are night and day less bothersome shortly after they are put in. Most people say that can't feel them or barely feel them after about 24 hours. That was categorically not my experience with spaceOAR. That honestly felt like a solution that was worse than the initial problem most of the time IMO. Even when well placed and no rectal infiltration, a lot of people were still very bothered by them. Based on that alone, Im through with SpaceOAR.
 
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