Prostate health

[scarbrtj]

1) incidence of prostate cancer is significantly declining
2) “Many [proton center] business plans require treating men diagnosed with prostate cancer in order to make the proforma financially viable”
3) The NCDB covers about 70% of all newly diagnosed patients nationwide
4) From Emory U and NCDB data: 276,880 men received EBRT for T1-3N0 prostate cancer 2004-2015; ∴ 23,000/year
5) From Cornell and NCDB: 104,635 men with high risk T3/4 prostate cancer received EBRT 2004-2016 (and surgery incidence went from 23% to 41% in that timeframe); ∴ 8000/year
6) Assume ~50% overlap between #4 and #5, so add 50% of the yearly of #5 to #4: 23,000+4,000 = ∴ 27,000/year T1-4 prostates getting EBRT (or brachy or protons).... let's round to 30,000... and multiply by NCDB correction factor (1/0.7)...

Therefore 42,000 men, out of 191,000 newly diagnosed per year, getting radiation of some form for prostate cancer. I can recall when nearly a quarter million CaP were dx/year, when the population was smaller. (And again, this 42K/year is possibly a bit over-estimated.)

This is the second or third most common cancer, in theory, that should be being treated in radiation centers. And it works out to less than 8 prostate patients per rad onc per year? This is a utilization rate of 22% for prostate external beam. As stark as the numbers are they make sense because of previously quoted utilization rates falling and decreasing resident GU experience (24% decline last decade or so).

A number quoted as counter to 42K/year is 60K/year. If true, this would mean about 12 definitive prostate patients per year per rad onc instead of the eight I calc'd. Regardless, if a significant portion of radiation business relies on this very common cancer (which it does) which is becoming less commonly common and irradiated (which it is), the national profit margins for rad onc are getting thin and/or fragile. And APM will not help.

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[RickyScott]

 

[Phantom1]

Yeah but we are also treating node positive disease now and even some men with low volume metastatic disease referred for prostate directed radiation.

Surgeons love to operate even on high risk patients where they leave positive margins, or on node positive where surgery may be just adding morbidity.. we all need to be present and stand up in tumor board to increase referrals.

 

[scarbrtj]

Yeah but we are also treating node positive disease now and even some men with low volume metastatic disease referred for prostate directed radiation.

Surgeons love to operate even on high risk patients where they leave positive margins, or on node positive where surgery may be just adding morbidity.. we all need to be present and stand up in tumor board to increase referrals.

Ok. Wildly and optimistically boost from 42K or 60K/year to 100K/year. We are treating half of all newly diagnosed prostates in other words. We ain't. But what if. Well, that's 20 new patients per rad onc per year. And this is the 2nd or 3rd most common cancer we treat? And it comprises 20 new patient visits per annum for America's rad oncs... if we stand up in tumor board... and maybe assassinate a few thousand urologists. This is a problem I think.

 

[Palex80]

We should expect "stage migration" to his us here as well. However it's going to be less bad that it's going to be for the surgeons.

Once PSMA-PET-CT becomes s.o.c. for baseline staging (I'd say in around 3-5 years from now), we should expect many patients to be upstaged to M1 with lesions being picked up that conventional staging failed to detect.
We do have STAMPEDE to back up EBRT to the prostate in low-metastatic burden cases, but at some point these data are going to be challenged since the vast majority of STAMPEDE-patients in the EBRT comparison got only ADT. Noone knows if the effect of EBRT to the prostate in low-metastatic M1 HSPC still exists if you add for instance Enzalutamide on top of ADT.
I presume around 30% of all cT3, GS>7 cases would actually turn up as M1 with PSMA-PET-CT. The surgeons are going to lose all those patients (since they failed to successfully carry out a trial addressing the role of surgery in M1 disease) and we are certainly going to lose some in the short term and maybe more in the long term.

 

[Chartreuse Wombat]

We should expect "stage migration" to his us here as well. However it's going to be less bad that it's going to be for the surgeons.

Once PSMA-PET-CT becomes s.o.c. for baseline staging (I'd say in around 3-5 years from now), we should expect many patients to be upstaged to M1 with lesions being picked up that conventional staging failed to detect.
We do have STAMPEDE to back up EBRT to the prostate in low-metastatic burden cases, but at some point these data are going to be challenged since the vast majority of STAMPEDE-patients in the EBRT comparison got only ADT. Noone knows if the effect of EBRT to the prostate in low-metastatic M1 HSPC still exists if you add for instance Enzalutamide on top of ADT.
I presume around 30% of all cT3, GS>7 cases would actually turn up as M1 with PSMA-PET-CT. The surgeons are going to lose all those patients (since they failed to successfully carry out a trial addressing the role of surgery in M1 disease) and we are certainly going to lose some in the short term and maybe more in the long term.

There is an ongoing trial addressing the role of surgery in M1 (link below)

S1802 | SWOG

www.swog.org

More than 230 patients accrued

I doubt surgeons will decline to operate in low volume M1 even if the trial is not completed.

 

[Palex80]

There is an ongoing trial addressing the role of surgery in M1 (link below)

S1802 | SWOG

www.swog.org

More than 230 patients accrued

I doubt surgeons will decline to operate in low volume M1 even if the trial is not completed.

The Germans have tested this question too. Their trial was called G-RAMPP, carried out in the Martini Clinic in Hamburg.

The Martini-Klinik – Prostate Cancer Centre in Germany

www.martini-klinik.de

More than 2.200 radical prostatectomies are carried out there per year. This is practically a factory...

The G-RAMPP trial was shut down after failing to recruit enough patients and after STAMPEDE results became public. It was deemed unethical to continue randomizing patients to no local therapy, when STAMPEDE had shown a benefit in the low-burden metastatic group.

 

[ramsesthenice]

We should expect "stage migration" to his us here as well. However it's going to be less bad that it's going to be for the surgeons.

Once PSMA-PET-CT becomes s.o.c. for baseline staging (I'd say in around 3-5 years from now), we should expect many patients to be upstaged to M1 with lesions being picked up that conventional staging failed to detect.
We do have STAMPEDE to back up EBRT to the prostate in low-metastatic burden cases, but at some point these data are going to be challenged since the vast majority of STAMPEDE-patients in the EBRT comparison got only ADT. Noone knows if the effect of EBRT to the prostate in low-metastatic M1 HSPC still exists if you add for instance Enzalutamide on top of ADT.
I presume around 30% of all cT3, GS>7 cases would actually turn up as M1 with PSMA-PET-CT. The surgeons are going to lose all those patients (since they failed to successfully carry out a trial addressing the role of surgery in M1 disease) and we are certainly going to lose some in the short term and maybe more in the long term.

PSMA PETs have been a boon for us. Our urologists are doing them for every patient with biochemical recurrence (they have some kind of cost-recovery service to keep it going since our trial completed accrual). They are astoundingly good at detecting tiny lesions with pretty low PSAs (as in the 0.1-0.2 range). The notion of, well, we will just watch these guys and see how it goes is completely gone.

I agree with you that once we are able to use these in the preop setting stage migration will play into our favor as well.

@chartreusewombat: I think at some (probably many) places that will be the case. I know a couple of our surgeons are inclined to proceed with surgery even if they know a patient probably has a small number of involved nodes. However, they are largely kept in check by our GU medical oncologists (and to a lesser extent me) who force the issue at TB.

 

[FrostyHammer]

We should expect "stage migration" to his us here as well. However it's going to be less bad that it's going to be for the surgeons.

Once PSMA-PET-CT becomes s.o.c. for baseline staging (I'd say in around 3-5 years from now), we should expect many patients to be upstaged to M1 with lesions being picked up that conventional staging failed to detect.
We do have STAMPEDE to back up EBRT to the prostate in low-metastatic burden cases, but at some point these data are going to be challenged since the vast majority of STAMPEDE-patients in the EBRT comparison got only ADT. Noone knows if the effect of EBRT to the prostate in low-metastatic M1 HSPC still exists if you add for instance Enzalutamide on top of ADT.
I presume around 30% of all cT3, GS>7 cases would actually turn up as M1 with PSMA-PET-CT. The surgeons are going to lose all those patients (since they failed to successfully carry out a trial addressing the role of surgery in M1 disease) and we are certainly going to lose some in the short term and maybe more in the long term.

Totally agree with you, but I never underestimate the ability of most American urologists to A) cut without data, B) misinterpret/misuse existing data, and/or C) assume that if RT was beneficial in any trial then surgery would naturally be better by extrapolation. They are awful and the worst IMHO of all surgeons.

 

[ramsesthenice]

Totally agree with you, but I never underestimate the ability of most American urologists to A) cut without data, B) misinterpret/misuse existing data, and/or C) assume that if RT was beneficial in any trial then surgery would naturally be better by extrapolation. They are awful and the worst IMHO of all surgeons.

I want to disagree with you but I can’t

Some of the community guys in our state still put people with biochemical recurrences on ADT sans radiation. I get their palliative referrals as inpatients when they are admitted with urosepsis and give SP caths. I will say though that the younger crop of guys I have worked with in the Midwest and east coast seem to be much more data oriented and good about considering when surgery may not be the best idea. Hopefully things will improve but as a field there is still a looooooong way to go.

 

[scarbrtj]

Positive takes and attempts at some good spin. Yet none of it matters.
There is a FALLING incidence (and prevalence) of this disease. (Both in the disease itself, and a rising incidence of surgery "robbing" RT incidence. But the falling overall disease incidence alone is enough...)
And a RISING incidence in the MDs (us rad oncs) to treat that disease.
And for the aforementioned MDs, it's one of their main diseases to treat.
It's like trying to fill a swimming pool at 100 gal/min that's draining at 105 gal/min.
Simple to see. Cut the drain back to <100 gal/min.
It appears what the urologists have done is turn the flow up way past 105, metaphorically, to compensate.
Rad oncs have almost zero control on the inflow. We can control the outflow though.

 

[ramsesthenice]

Positive takes and attempts at some good spin. Yet none of it matters.
There is a FALLING incidence (and prevalence) of this disease. (Both in the disease itself, and a rising incidence of surgery "robbing" RT incidence. But the falling overall disease incidence alone is enough...)
And a RISING incidence in the MDs (us rad oncs) to treat that disease.
And for the aforementioned MDs, it's one of their main diseases to treat.
It's like trying to fill a swimming pool at 100 gal/min that's draining at 105 gal/min.
Simple to see. Cut the drain back to <100 gal/min.
It appears what the urologists have done is turn the flow up way past 105, metaphorically, to compensate.
Rad oncs have almost zero control on the inflow. We can control the outflow though.

I am not disputing that there are some scary trends out there. But I think dismissing my (and other) experiences as positive spin is a bit of an over reach. In our little bubble of the country, practice patterns have shifted such that we are treating close to double the fraction of patients we were capturing prior to the last 3-5 years. Will that translate into a national trend? I have no idea. Prostate cancer is and always will be a bit of a liability for us because they have to go through specialists with competing financial interests. But still, there is impetuous for data driven practice pattern changes that if followed have the potential to more than offset the aforementioned issues.

And Scar, you don't need to retort. I'll do it for you.

Scar: "Ramses, you are comparing hypothetical future changes to real trends that are already affecting people. Reality trumps hyperbole."

Me: "Fair point. I just think there are more moving parts than you are accounting for."

We hug it out and everyone has a wonderful day.

 

[scarbrtj]

I am not disputing that there are some scary trends out there. But I think dismissing my (and other) experiences as positive spin is a bit of an over reach. In our little bubble of the country, practice patterns have shifted such that we are treating close to double the fraction of patients we were capturing prior to the last 3-5 years. Will that translate into a national trend? I have no idea. Prostate cancer is and always will be a bit of a liability for us because they have to go through specialists with competing financial interests. But still, there is impetuous for data driven practice pattern changes that if followed have the potential to more than offset the aforementioned issues.

And Scar, you don't need to retort. I'll do it for you.

Scar: "Ramses, you are comparing hypothetical future changes to real trends that are already affecting people. Reality trumps hyperbole."

Me: "Fair point. I just think there are more moving parts than you are accounting for."

We hug it out and everyone has a wonderful day.

Haha no retort. You're just an outlier. A true kung-fu Master.

 

[theradiator]

Positive takes and attempts at some good spin. Yet none of it matters.
There is a FALLING incidence (and prevalence) of this disease. (Both in the disease itself, and a rising incidence of surgery "robbing" RT incidence. But the falling overall disease incidence alone is enough...)
And a RISING incidence in the MDs (us rad oncs) to treat that disease.
And for the aforementioned MDs, it's one of their main diseases to treat.
It's like trying to fill a swimming pool at 100 gal/min that's draining at 105 gal/min.
Simple to see. Cut the drain back to <100 gal/min.
It appears what the urologists have done is turn the flow up way past 105, metaphorically, to compensate.
Rad oncs have almost zero control on the inflow. We can control the outflow though.

And don't forget that the rad oncs will be fighting more viciously for that smaller pie.

 

[evilbooyaa]

I am not disputing that there are some scary trends out there. But I think dismissing my (and other) experiences as positive spin is a bit of an over reach. In our little bubble of the country, practice patterns have shifted such that we are treating close to double the fraction of patients we were capturing prior to the last 3-5 years. Will that translate into a national trend? I have no idea. Prostate cancer is and always will be a bit of a liability for us because they have to go through specialists with competing financial interests. But still, there is impetuous for data driven practice pattern changes that if followed have the potential to more than offset the aforementioned issues.

And Scar, you don't need to retort. I'll do it for you.

Scar: "Ramses, you are comparing hypothetical future changes to real trends that are already affecting people. Reality trumps hyperbole."

Me: "Fair point. I just think there are more moving parts than you are accounting for."

We hug it out and everyone has a wonderful day.

How much of that do you think is, as somebody who works in academics, with the advent of hypofrac schedules, you are able to keep a higher percentage of out of town patients for treatment away from community practices? I'm not saying whether this is bad or not, I'm just commenting on another potential reason you are seeing a relative increase in number of patients.

Are you otherwise suggesting that the blossoming rates of RP for high-risk disease (per NCDB studies) is not affecting your neck of the woods?

 

[communitydoc13]

What do you think is driving the incidence numbers here? I'm guessing UPSTF and particularly AAFP recommendations against all prostate screening? Amazing that UPSTF recommended against all screening at age 70 when this is essentially the median age of pts enrolled in radiation prostate trials. AAFP clarified things by explicitly coming out against all prostate screening. In small communities, you can fight this to some degree with outreach, which I recommend.

 

[scarbrtj]

What do you think is driving the incidence numbers here? I'm guessing UPSTF and particularly AAFP recommendations against all prostate screening?

Playing a LARGE part. With negative consequences. There could be now a "wash-out" period occurring long after an initial burst of newly diagnosed cases of a non-lethal-relative-to-other-cancers illness (see end of graph 2009-11... sorry Oz is all I could find).

 

[ramsesthenice]

How much of that do you think is, as somebody who works in academics, with the advent of hypofrac schedules, you are able to keep a higher percentage of out of town patients for treatment away from community practices? I'm not saying whether this is bad or not, I'm just commenting on another potential reason you are seeing a relative increase in number of patients.

Are you otherwise suggesting that the blossoming rates of RP for high-risk disease (per NCDB studies) is not affecting your neck of the woods?

The latter. We are treating a lot more high risk patients than we use to. The hypofrac question is a good one but that’s not a huge contributor. Hypofrac is pretty prevalent around here (even in the community) so it doesn’t usually factor into where people get treated. In fact, there are a couple proton centers with a couple hundred miles and they siphon off a couple guys a month.

The key has been the MOG. Surgery would not get here on their own.

 

[Chartreuse Wombat]

The latter. We are treating a lot more high risk patients than we use to. The hypofrac question is a good one but that’s not a huge contributor. Hypofrac is pretty prevalent around here (even in the community) so it doesn’t usually factor into where people get treated. In fact, there are a couple proton centers with a couple hundred miles and they siphon off a couple guys a month.

The key has been the MOG. Surgery would not get here on their own.

MOG=?

 

[Palex80]

PSMA PETs have been a boon for us. Our urologists are doing them for every patient with biochemical recurrence (they have some kind of cost-recovery service to keep it going since our trial completed accrual). They are astoundingly good at detecting tiny lesions with pretty low PSAs (as in the 0.1-0.2 range). The notion of, well, we will just watch these guys and see how it goes is completely gone.

One thing I have learned from "positive" findings in PSMA-PET-CTs is that you need to verify them with some kind of additional examination if you are not sure they are "real".
I had a patient half a year ago, come in with a rather fast rising PSA of 0.6 ng/ml post radical prostatectomy. A PSMA-PET-CT was ordered by the urologist, it showed a) a local recurrence b) a pelvic bone lesion c) a lymph node in the supraclavicular fossa. The case was shown at the tumor board and the urologists & oncologists all cried out "He is metastatic, he doesn't need salvage RT, he needs ADT + whatever".
I persuaded them to work up these lesions. MRI of the pelvis verified the local recurrence (it was an R1 resection anyways), the PSMA-avid lesion in the bone did not show up on MRI. An ultrasound with fine needle biopsy of the avid lymph node (1cm short axis) came back negative.
I treated him with 66 Gy to the prostatic fossa and his PSA fell down to undetectable levels within a month after completion of RT.

 

[Mandelin Rain]

MOG=?

Montenegrin Oncology Group

 

[DoctwoB]

Totally agree with you, but I never underestimate the ability of most American urologists to A) cut without data, B) misinterpret/misuse existing data, and/or C) assume that if RT was beneficial in any trial then surgery would naturally be better by extrapolation. They are awful and the worst IMHO of all surgeons.

Never underestimate the ability of American Radiation Oncologists to hand wave away retrospective data showing surgical superiority

Imma just leave this here

Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer - PubMed. PROTECT also with slighly lower rates of BPFS with surgery vs. XRT in intermed/high risk

TBF I am also aware of a retrospective study showing XRT + brachy did better then surgery. Equipoise exists.

I'm not sure where this idea of Urologists being cowboys for treating high risk disease with surgery comes from. Some patients are just better candidates for surgery, especially those with pre-existing severe LUTS. I'd argue the bigger cowboys are the Radoncs treating high risk without brachy boost. Data (albeit poor quality data subject to bias) suggests outcomes are superior vs. XRT alone and equivalent to XRT + Brachy. All my high risk patients (all patients actually) are shown nomograms and are well aware of the risk of needing salvage XRT and in very high risk patients I tell them that it is multi-modal therapy.

 

[radOresident]

Retrospective data and $1.50 will buy you a coffee at Mcdonalds

 

[ramsesthenice]

MOG=?

Sorry, multidisciplinary oncology group. Med Onc support has been very helpful in this regard.

 

[MegaVoltagePhoton]

Never underestimate the ability of American Radiation Oncologists to hand wave away retrospective data showing surgical superiority

Imma just leave this here

Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer - PubMed. PROTECT also with slighly lower rates of BPFS with surgery vs. XRT in intermed/high risk

TBF I am also aware of a retrospective study showing XRT + brachy did better then surgery. Equipoise exists.

I'm not sure where this idea of Urologists being cowboys for treating high risk disease with surgery comes from. Some patients are just better candidates for surgery, especially those with pre-existing severe LUTS. I'd argue the bigger cowboys are the Radoncs treating high risk without brachy boost. Data (albeit poor quality data subject to bias) suggests outcomes are superior vs. XRT alone and equivalent to XRT + Brachy. All my high risk patients (all patients actually) are shown nomograms and are well aware of the risk of needing salvage XRT and in very high risk patients I tell them that it is multi-modal therapy.

that is just wrong. i followed your link, it is an ncdb paper which has no information on adt use and duration. this is pointed out in the letters to the editor about this paper. Re: Sebastian Berg, Alexander P. Cole, Marieke J. Krimphove, et al. Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer. Eur Urol 2019;75:552-5: Comparing Apples to Oranges: A Self-fulfilling Prophecy? - PubMed for instance outlines this well. in fact the retrospective paper that you are talking about, from kishan et al in jama, had real patient data and showed XRT and RP were the same, and brachy boost was better than both.

 

[ramsesthenice]

Never underestimate the ability of American Radiation Oncologists to hand wave away retrospective data showing surgical superiority

Imma just leave this here

Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer - PubMed. PROTECT also with slighly lower rates of BPFS with surgery vs. XRT in intermed/high risk

TBF I am also aware of a retrospective study showing XRT + brachy did better then surgery. Equipoise exists.

I'm not sure where this idea of Urologists being cowboys for treating high risk disease with surgery comes from. Some patients are just better candidates for surgery, especially those with pre-existing severe LUTS. I'd argue the bigger cowboys are the Radoncs treating high risk without brachy boost. Data (albeit poor quality data subject to bias) suggests outcomes are superior vs. XRT alone and equivalent to XRT + Brachy. All my high risk patients (all patients actually) are shown nomograms and are well aware of the risk of needing salvage XRT and in very high risk patients I tell them that it is multi-modal therapy.

A major major weakness in NCDB is that it is notoriously horrible at catching information on adjuvant therapies. The cited article reported 15% of patient in the RP group got adjuvant/salvage RT but the real number is probably much higher. Its always going to be hard to know what to do with tiny (albeit statistically significant) differences in survival from messy data sets.

 

[OTN]

Positive takes and attempts at some good spin. Yet none of it matters.
There is a FALLING incidence (and prevalence) of this disease. (Both in the disease itself, and a rising incidence of surgery "robbing" RT incidence. But the falling overall disease incidence alone is enough...)
And a RISING incidence in the MDs (us rad oncs) to treat that disease.
And for the aforementioned MDs, it's one of their main diseases to treat.
It's like trying to fill a swimming pool at 100 gal/min that's draining at 105 gal/min.
Simple to see. Cut the drain back to <100 gal/min.
It appears what the urologists have done is turn the flow up way past 105, metaphorically, to compensate.
Rad oncs have almost zero control on the inflow. We can control the outflow though.

Just because we're training more radoncs doesn't mean they will get hired- breadlines, right? So, the incidence of radoncs to treat prostate cancer doesn't necessarily have to rise. I'm not going to hire another radonc just because academia keeps making them.

 

[Ray D. Ayshun]

Retrospective data and $1.50 will buy you a coffee at Mcdonalds

In other words, being an associate professor and having $1.50 will get you as much coffee as a professor with $1.50.

 

[Chartreuse Wombat]

In other words, being an associate professor and having $1.50 will get you as much coffee as a professor with $1.50.

Yes but you many need to work longer and harder as an associate professor for that $1.50.

 

[DoctwoB]

that is just wrong. i followed your link, it is an ncdb paper which has no information on adt use and duration. this is pointed out in the letters to the editor about this paper. Re: Sebastian Berg, Alexander P. Cole, Marieke J. Krimphove, et al. Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer. Eur Urol 2019;75:552-5: Comparing Apples to Oranges: A Self-fulfilling Prophecy? - PubMed for instance outlines this well. in fact the retrospective paper that you are talking about, from kishan et al in jama, had real patient data and showed XRT and RP were the same, and brachy boost was better than both.

You're right that's definitely a weakness, though if salvage XRT wasn't used optimally and surgery still did better that's a feather in the cap of surgery. And under or delayed utilization of salvage XRT is a known issue in the real world setting. And my point isn't to say that surgery is obviously superior, just that equipoise exists and it isn't unreasonable for Urologists to treat high risk patients with surgery (though they should be informed about the likelihood of needing salvage) any more then it is unreasonable to treat patients with XRT + brachy + ADT

My personal hope is that the pendulum is and will swing the other way on PSAs. ERSPC long term data shows the number needed to screen to save a life is down to the 500s, and the longest term cohorts with the least contamination (Rotterdam and Gothenborg) show NNS in the 200s. That is much better then the data for mammogram and colonoscopy, and a PSA is much easier/cheaper then both of them. So with a little luck (and better patient care) there will be more for all of us to treat.

 

[evilbooyaa]

Never underestimate the ability of American Radiation Oncologists to hand wave away retrospective data showing surgical superiority

Imma just leave this here

Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer - PubMed. PROTECT also with slighly lower rates of BPFS with surgery vs. XRT in intermed/high risk

TBF I am also aware of a retrospective study showing XRT + brachy did better then surgery. Equipoise exists.

I'm not sure where this idea of Urologists being cowboys for treating high risk disease with surgery comes from. Some patients are just better candidates for surgery, especially those with pre-existing severe LUTS. I'd argue the bigger cowboys are the Radoncs treating high risk without brachy boost. Data (albeit poor quality data subject to bias) suggests outcomes are superior vs. XRT alone and equivalent to XRT + Brachy. All my high risk patients (all patients actually) are shown nomograms and are well aware of the risk of needing salvage XRT and in very high risk patients I tell them that it is multi-modal therapy.

STAHP.

Another NCDB looking at comparitive effectiveness between a surgical and non-surgical treatment. C'MON man! At this point this **** is just bad, bad science. There are ALWAYS co-morbidity factors that are not accounted for properly in NCDB between a surgical and non-surgical treatment, that confound any results of cross-modality comparisons. Same for laryngectomy vs chemoRT in larynx cancer. Same for surgery vs SBRT in NSCLC. Literally every single NCDB study comparing modalities of radiation vs surgery (in any disease site) will pretty much ALWAYS show an advantage to surgery.

Listen, if you can round up all the Urologists and you can agree that Surgery in high-risk prostate cancer will need salvage RT ~50% of the time, then GO for it. Of course you get the toxicity of both therapies and the oncologic equivelance to patients just treated with one local modality. But the amount of patients that see me for salvage 6 months after prostatectomy (for salvage) that are completely surprised at why they're in my clinic b/c "surgeon said he was gon' get it all, doc!" is TOO damn high. This is from academic urologists as well, NOT just community folks.

WHY do surgery if you think they're going to need RT as well? Just do the damn RT + ADT and call it a day. All you're doing is buying these patients more toxicity with trimodality therapy with zero benefit. Adding brachy boost in HR is not the ONLY SOC because there is a subset of folks who poo-poo that ASCENDE-RT "only" showed a bPFS benefit, with no DMFS or OS benefit (yet).

Urologists (in general, maybe not you, DoctwoB) are the original oncologic idiots. Signing somebody up for two local modalities (and the associated urinary incontinence and erectile dysfunction of surgery AND urinary irritation and rectal side effects of RT) when one would suffice in terms of oncologic outcomes is stupid.

ENTs are starting to climb up there with TORS nonsense (followed by adjuvant RT, or god forbid chemoRT, anyways like 80% of the time) for an exquisitely radiosensitive phenotype like p16+ OPhx, but I'll save that full rant for another thread.

 

[DoctwoB]

STAHP.

Another NCDB looking at comparitive effectiveness between a surgical and non-surgical treatment. C'MON man! At this point this **** is just bad, bad science. There are ALWAYS co-morbidity factors that are not accounted for properly in NCDB between a surgical and non-surgical treatment, that confound any results of cross-modality comparisons. Same for laryngectomy vs chemoRT in larynx cancer. Same for surgery vs SBRT in NSCLC. Literally every single NCDB study comparing modalities of radiation vs surgery (in any disease site) will pretty much ALWAYS show an advantage to surgery.

Listen, if you can round up all the Urologists and you can agree that Surgery in high-risk prostate cancer will need salvage RT ~50% of the time, then GO for it. Of course you get the toxicity of both therapies and the oncologic equivelance to patients just treated with one local modality. But the amount of patients that see me for salvage 6 months after prostatectomy (for salvage) that are completely surprised at why they're in my clinic b/c "surgeon said he was gon' get it all, doc!" is TOO damn high. This is from academic urologists as well, NOT just community folks.

WHY do surgery if you think they're going to need RT as well? Just do the damn RT + ADT and call it a day. All you're doing is buying these patients more toxicity with trimodality therapy with zero benefit. Adding brachy boost in HR is not the ONLY SOC because there is a subset of folks who poo-poo that ASCENDE-RT "only" showed a bPFS benefit, with no DMFS or OS benefit (yet).

Urologists (in general, maybe not you, DoctwoB) are the original oncologic idiots. Signing somebody up for two local modalities (and the associated urinary incontinence and erectile dysfunction of surgery AND urinary irritation and rectal side effects of RT) when one would suffice in terms of oncologic outcomes is stupid.

ENTs are starting to climb up there with TORS nonsense (followed by adjuvant RT, or god forbid chemoRT, anyways like 80% of the time) for an exquisitely radiosensitive phenotype like p16+ OPhx, but I'll save that full rant for another thread.

Retrospective data is bad, but when its all you have its what you use understanding its' limitations.

I'm sure there are abuses in the community (or academia) of Urologists overselling the efficacy of RP or underselling the side effects. Trust my when I tell you the same can be said of your colleagues. "He didn't tell me the radiation could affect my bladder" or "how could this be from radiation, that was years ago." are common phrases in my clinic. FWIW I've seen more fatalities from XRT for prostate cancer (5) then surgery (1).

To your other points the multi-modality of therapy should be stressed. What's worse? To undergo Surgery with 50-70% chance of XRT (maybe years down the road)? To undergo XRT + 2-3 years of ADT + brachy? I would argue we're talking about different toxicity profiles and know many men who would opt for the former. There is no excuse on either side for not providing accurate data or getting real informed consent. The combined data from ASCENDE + retrospective studies would give me SIGNIFICANT pause about offering XRT without brachy to high risk prostate cancer. I wouldn't want it for my father and I doubt you would either.

 

[ramsesthenice]

Retrospective data is bad, but when its all you have its what you use understanding its' limitations.

I'm sure there are abuses in the community (or academia) of Urologists overselling the efficacy of RP or underselling the side effects. Trust my when I tell you the same can be said of your colleagues. "He didn't tell me the radiation could affect my bladder" or "how could this be from radiation, that was years ago." are common phrases in my clinic. FWIW I've seen more fatalities from XRT for prostate cancer (5) then surgery (1).

To your other points the multi-modality of therapy should be stressed. What's worse? To undergo Surgery with 50-70% chance of XRT (maybe years down the road)? To undergo XRT + 2-3 years of ADT + brachy? I would argue we're talking about different toxicity profiles and know many men who would opt for the former. There is no excuse on either side for not providing accurate data or getting real informed consent. The combined data from ASCENDE + retrospective studies would give me SIGNIFICANT pause about offering XRT without brachy to high risk prostate cancer. I wouldn't want it for my father and I doubt you would either.

I am a huge proponent of brachytherapy and even I have to tell you to slow down a bit there. Ascend is intriguing but to it’s not clear to me everyone should be using a Brachy boost yet. GU tox was clearly worse on trial and it’s a huge overstatement to say we should broadly adopt a more toxic treatment for improved bRFS. I would absolutely not tell my dad to let just anyone do this to him.

 

[Chartreuse Wombat]

I am a huge proponent of brachytherapy and even I have to tell you to slow down a bit there. Ascend is intriguing but to it’s not clear to me everyone should be using a Brachy boost yet. GU tox was clearly worse on trial and it’s a huge overstatement to say we should broadly adopt a more toxic treatment for improved bRFS. I would absolutely not tell my dad to let just anyone do this to him.

Brachy boost=improved bRFS no difference in other efficacy endpoints but more toxicity
79 Gy vs 70 Gy=improved bRFS no difference in other efficacy endpoints but more toxicity
Goose...gander?

 

[seper]

Well, what's going on there? We don't understand this disease yet?

Goose...gander

 

[medgator]

Brachy boost=improved bRFS no difference in other efficacy endpoints but more toxicity
79 Gy vs 70 Gy=improved bRFS no difference in other efficacy endpoints but more toxicity
Goose...gander?

Toxicity difference between 70 and 79.2 isn't same as toxicity difference between brachy and no brachy boost

 

[Mandelin Rain]

Who is doing 79.2 anymore?

How do you integrate a brachy boost into 5 or 20 fractions? Answer: you don't. Moving on.

 

[OTN]

Who is doing 79.2 anymore?

How do you integrate a brachy boost into 5 or 20 fractions? Answer: you don't. Moving on.

Every patient treated at the local urorads facility (they have 35-45 on treatment)

Edit: I realized I made an error. Heavens, I don't want to misrepresent what they're doing! They actually treat to 81 Gy in 45 fx.

 

[Chartreuse Wombat]

Who is doing 79.2 anymore?

How do you integrate a brachy boost into 5 or 20 fractions? Answer: you don't. Moving on.

90% of the examinees at ORal Boards in 2017 and 2018

 

[Mandelin Rain]

90% of the examinees at ORal Boards in 2017 and 2018

Now that ASTRO has blessed it, I bet that number will flip for the next oral boards.

The goal going into any oral boards segment is to avoid anything remotely controversial that you have to defend. In the past two years, it's probably become more controverial to continue standard fractionation.

 

[radiation]

Never underestimate the ability of American Radiation Oncologists to hand wave away retrospective data showing surgical superiority

Imma just leave this here

Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer - PubMed. PROTECT also with slighly lower rates of BPFS with surgery vs. XRT in intermed/high risk

TBF I am also aware of a retrospective study showing XRT + brachy did better then surgery. Equipoise exists.

I'm not sure where this idea of Urologists being cowboys for treating high risk disease with surgery comes from. Some patients are just better candidates for surgery, especially those with pre-existing severe LUTS. I'd argue the bigger cowboys are the Radoncs treating high risk without brachy boost. Data (albeit poor quality data subject to bias) suggests outcomes are superior vs. XRT alone and equivalent to XRT + Brachy. All my high risk patients (all patients actually) are shown nomograms and are well aware of the risk of needing salvage XRT and in very high risk patients I tell them that it is multi-modal therapy.

Great thread on how patient selection drives differences in outcomes. Huge survival differences in patients getting surgery with no differences in prostate cancer control

 

[Mandelin Rain]

Radical prostatectomy improves your cardiopulmonary health, clearly. No other explanation.

 

[ramsesthenice]

Who is doing 79.2 anymore?

How do you integrate a brachy boost into 5 or 20 fractions? Answer: you don't. Moving on.

Stoney Brook does. They have been doing 15 fraction hypofractionated treatment with a brachy boost for a long time.

 

[evilbooyaa]

Retrospective data is bad, but when its all you have its what you use understanding its' limitations.

I'm sure there are abuses in the community (or academia) of Urologists overselling the efficacy of RP or underselling the side effects. Trust my when I tell you the same can be said of your colleagues. "He didn't tell me the radiation could affect my bladder" or "how could this be from radiation, that was years ago." are common phrases in my clinic. FWIW I've seen more fatalities from XRT for prostate cancer (5) then surgery (1).

To your other points the multi-modality of therapy should be stressed. What's worse? To undergo Surgery with 50-70% chance of XRT (maybe years down the road)? To undergo XRT + 2-3 years of ADT + brachy? I would argue we're talking about different toxicity profiles and know many men who would opt for the former. There is no excuse on either side for not providing accurate data or getting real informed consent. The combined data from ASCENDE + retrospective studies would give me SIGNIFICANT pause about offering XRT without brachy to high risk prostate cancer. I wouldn't want it for my father and I doubt you would either.

Radiation oncologists that don't counsel on potential long-term toxicities are bad too. Of course patients may forget that they had a discussion of long-term side effects if it's been years since hteir RT.

The toxicity profile of adding brachy is not insignificant, but at least it's the same RT toxicities (urinary irritation) and NOT urinary incontinence or ED seen at the levels of post-prostatectomy patients.

I'm with you on the brachy boost component but I do see the value of those who talk about a 13% absolute increase in risk of 5-year cumulative incidence of G3+ toxicity with brachy boost compared to EBRT alone for a ~20% bPFS benefit at 9-years. It's not DMFS or OS, so for some rad oncs, the extra toxicity is not warranted.

ASCENDE-RT: An Analysis of Treatment-Related Morbidity for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost with a Dose-Escalated External Beam Boost for High- and Intermediate-Risk Prostate Cancer - PubMed

The incidence of acute and late GU morbidity was higher after LDR-PB boost, and there was a nonsignificant trend for worse GI morbidity. No differences in the frequency of erectile dysfunction were observed.

pubmed.ncbi.nlm.nih.gov

Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy (the ASCENDE-RT Trial): An Analysis of Survival Endpoints for a Randomized Trial Comparing a Low-Dose-Rate Brachytherapy Boost to a Dose-Escalated External Beam Bo

Compared with 78 Gy EBRT, men randomized to the LDR-PB boost were twice as likely to be free of biochemical failure at a median follow-up of 6.5 years.

pubmed.ncbi.nlm.nih.gov

 

[Chartreuse Wombat]

20% bPFS benefit at 9-years in ASCENDE-RT
15% bPFS benefit at 8-years with 0126 (79.2 Gy)

 

[evilbooyaa]

20% bPFS benefit at 9-years in ASCENDE-RT
15% bPFS benefit at 8-years with 0126 (79.2 Gy)

Rates of G3+ GU toxicity with addition of BT in ASCENDE-RT- 18.4 vs 5.2%
Rates of G3+ GU toxicity with dose escalation in 0126 - ~4% w/ 79.2 vs 2% w/ 70.2

Standard vs Dose-Escalated Radiotherapy in Medium-Risk Prostate Cancer

This randomized clinical trial assesses whether dose-escalated radiation therapy vs standard dose improves survival for men with intermediate-risk prostate cancer.

jamanetwork.com

I think seeing a similar bPFS benefit to initial dose escalation studies with a 6.5-fold increase in toxicity difference (2% difference vs 13% difference) makes it reasonable for people to have concerns about making this the only SOC for patients.

 

[Mandelin Rain]

I'm not sure about you guys, but the guys I see who don't have surgery aren't exactly prime candidates for brachy. Blood thinners, lung disease, heart disease, terrible diabetes, whatever. There's a reason they aren't in the OR. Far be it for me to take them there.

 

[seper]

I still wonder why we are not demostrating OS, metastatic-free survival improvement, or decreased need for hormones.

 

[Chartreuse Wombat]

I still wonder why we are not demostrating OS, metastatic-free survival improvement, or decreased need for hormones.

Competing co-morbidities. Especially in the XRT cohort

 

[ramsesthenice]

I'm not sure about you guys, but the guys I see who don't have surgery aren't exactly prime candidates for brachy. Blood thinners, lung disease, heart disease, terrible diabetes, whatever. There's a reason they aren't in the OR. Far be it for me to take them there.

In places that only treat (I hate this word but) surgical throw aways brachy is a non-issue for the reasons you stated.

FWIW, I do offer HDR brachy boosts for patients with reasonably sized prostates, no T3 disease (on MRI), and no or minimal obstructive symptoms at baseline. I personally have not seen the added toxicity that I remember from all the boost patients treated with LDR where I trained. HDR is more time intensive but I do feel like I get better control over urethral dosing. The Canadians have some (not going to call it robust or great) data showing less GU tox with HDR compared to LDR. Could also be patient selection. My point is, I think in the right patients there probably is a role for brachy boost, but I think it is a very big stretch to say it should be the standard treatment for high risk patients.

As eluded to above, the fraction of patients opting for a boost now that basically everyone is getting hypofractionation is noticeably lower. The convenience factor just isn't there anymore and I don't oversell the possible clinical benefits.