High risk Prostate MedOnc referrals

[xrt123]

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Just wandering how people are practicing in terms of sending high risk prostate to medonc for discussion of more than just Lupron. Seems like there is some conflicting data from STAMPEDE and recent RTOG trial for docetaxel. Seems like abiraterone also is not getting covered unless node positive in my experience despite FFS benefit in nonmetastatic patients on STAMPEDE.

THANKS

 

[medgator]

Nccn recently took out the footnote for offering 6 cycles of adjuvant taxotere in high risk localized prostate CA. I think the problem was that the European trials weren't as pure in terms of including only truly high risk patients.

It's a shame because the really aggressive disease pts do likely obtain an OS benefit from it.

For now, I've stopped sending unless it's really aggressive looking.... I've got a guy with G9 in every core and a psa of 30 getting treated now. I'll probably send him and see what they say

 

[Gfunk6]

Evicore is planning to deny SBRT for oligomets and/or XRT to primary in cases of oligometastatic prostate cancer despite the mounting evidence against such a policy.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/radiation-oncology/evicore_radiation-therapy-guidelines_redline_v202019_eff070119_pub030119.pdf

Pages 233-234

 

[medgator]

Evicore is planning to deny SBRT for oligomets and/or XRT to primary in cases of oligometastatic prostate cancer despite the mounting evidence against such a policy.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/radiation-oncology/evicore_radiation-therapy-guidelines_redline_v202019_eff070119_pub030119.pdf

Pages 233-234

Sounds like another reason for smart patients to avoid medicare advantage/HMO plans and stick with traditional Medicare

 

[GapCalc]

Sounds like another reason for smart patients to avoid medicare advantage/HMO plans and stick with traditional Medicare

Sounds like another reason Evicore needs to be systematically dismantled.

 

[evilbooyaa]

Evicore is planning to deny SBRT for oligomets and/or XRT to primary in cases of oligometastatic prostate cancer despite the mounting evidence against such a policy.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/radiation-oncology/evicore_radiation-therapy-guidelines_redline_v202019_eff070119_pub030119.pdf

Pages 233-234

Evicore pulling standard insurance company non-sense. We don't know how prostate RT in metastatic prostate cancer will affect survival if patients get ADT AND Docetaxel/Abiraterone, so obviously it's better to just not cover the treatment! Who cares that ADT + Docetaxel/Abiraterone leads to better SYSTEMIC control, improving the importance of local control! Let's completely ignore that and just say "there is not a phase III randomized trial confirming the benefit of prostate RT in the patient population that receives both ADT with docetaxel or abiraterone. We look forward to the PEACE1 trial that, by the time there is 10-year follow-up, we will have moved on from ADT and docetaxel/abiraterone as upfront systemic management, and thus will continue to move the goalposts in regards to RT to the prostate in the oligometastatic prostate cancer setting. As long as subset analyses allow us to refuse treatment, we will allow them. See refusal of adjuvant Durvalumab for PD-L1 < 1% in Stage III NSCLC. If subset analyses would force us to allow certain treatments, we will deny it. See prostate RT or metastases SBRT in metastatic prostate cancer or refusal of IMRT in stage III NSCLC.

 

[evilbooyaa]

But in practice med-oncs are giving ADT anyways - up to specific med-onc preference if they want to add-on docetaxel/abiraterone. In regards to evidence, would favor those therapies being reserved for the highest-risk patients.

 

[Neuronix]

Evicore is planning to deny SBRT for oligomets and/or XRT to primary in cases of oligometastatic prostate cancer despite the mounting evidence against such a policy.

https://www.evicore.com/-/media/files/evicore/clinical-guidelines/solution/radiation-oncology/evicore_radiation-therapy-guidelines_redline_v202019_eff070119_pub030119.pdf

Pages 233-234

Oh lord they even cited me just a few pages away from there to make some conclusions that I don't agree with.

I saw someone call them EVILcore on the rad onc twitter. 👍 At least we can all agree on that

 

[medgator]

Oh lord they even cited me just a few pages away from there to make some conclusions that I don't agree with.

I saw someone call them EVILcore on the rad onc twitter. 👍 At least we can all agree on that

No choice if you're stuck with crappy commercial insurers like Cigna and Humana, but I absolutely tell my Medicare patients to avoid Medicare advantage/HMO plans like plague to avoid the delays in care they will invariably see with these evil companies

 

[Burt Radnolds]

No choice if you're stuck with crappy commercial insurers like Cigna and Humana, but I absolutely tell my Medicare patients to avoid Medicare advantage/HMO plans like plague to avoid the delays in care they will invariably see with these evil companies

When I want to do some progressive and data supported SBRT for patients and their insurance tab shows Medicare, I definitely jump for joy.

However, my eyes have recently been opened to the extreme out of pocket costs Medicare patients can incur if they don't have secondary insurance or a managed plan, in the order of 20% out of pocket. I would keep this in mind when advising patients about such things.

 

[medgator]

When I want to do some progressive and data supported SBRT for patients and their insurance tab shows Medicare, I definitely jump for joy.

However, my eyes have recently been opened to the extreme out of pocket costs Medicare patients can incur if they don't have secondary insurance or a managed plan, in the order of 20% out of pocket. I would keep this in mind when advising patients about such things.

Fair point, but in my experience, the co insurance for many of these Medicare advantage plans may end up ~20% of the treatment cost, not much different than what the medigap supplement will have to pay, with the added delay of now having to deal with Evicore/AIM/health help to get prior auth

 

[SneakyBooger]

Sounds like another reason for smart patients to avoid medicare advantage/HMO plans and stick with traditional Medicare

Thanks medgator! I did not know that!