Prostates, hormones and dose

[bcl2]

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Intermediate disease: Do we really believe the D'Amico hormone benefit given that we now know the dose was suboptimal?

High risk: Same question, all suboptimal doses. Any thoughts?

 

[Gfunk6]

Nobody knows, only retrospective data is available.

For intermediate, results of RTOG 0815 should help answer the question.

For high, results of 0815 will probably be extrapolated. Until then there is good retrospective data available.

 

[JumpingFrenchmn]

Intermediate disease: Do we really believe the D'Amico hormone benefit given that we now know the dose was suboptimal?

High risk: Same question, all suboptimal doses. Any thoughts?

for the ignoramicus extremicus, could you clarify what you're referring to?

 

[deleted4401]

Low risk - high dose RT alone, based on proton dose escalation trial
Int risk - high dose RT + 2/2/2 ADT based on D'Amico + I won't tx int risk to a lower dose than high risk, and also MDACC/Dutch dose escalation
High risk - high dose RT + 2/2/2 ADT + adjuvant ADT 2-3 years based on EORTC + I won't tx high risk to lower dose than low risk, and also MDACC/Dutch dose escalation

All - Most patients don't need treating, but 0 Gy is a failing answer for most situations except Very Low Risk with <20 year life expectancy. Not only failing, but perhaps also a buying yourself needless litigation strategy.

For personal enjoyment: a famous person reacting to radiology oral boards - http://www.youtube.com/watch?v=DQBkMtukCPw

-S

 

[medgator]

Simul,

Just curious...for intermediate risk is that your boards answer or what you would truly do? Most people getting treated at various institutions for int. risk off protocol that I know of are getting dose escalation (75-80 Gy) without HT.

Int risk - high dose RT + 2/2/2 ADT based on D'Amico + I won't tx int risk to a lower dose than high risk, and also MDACC/Dutch dose escalation

-S

Im curious about that as well, especially with the side effects of ADT. D'Amico has published extensively on that as well, with particular concerns to patients with underlying coronary disease

http://jama.ama-assn.org/content/302/8/866.abstract

 

[deleted4401]

It's both what I actually do and board answer. I can't justify in my head dropping the dose for a higher risk patient, knowing that there is a documented dose response. NCCN says for intermediate risk, consider 78 - 80 Gy for intermediate/high risk, +/- 6 months ADT, +/- pelvic nodal irradiation, +/- brachy boost. Sort of a free for all. Hmm - I'm surprised, I thought treating that way was the way everybody did.

As far as CAD mortality ... hopefully the vasculopath with 3 MIs isn't getting PSA screening, but if he does, then it gets complicated.

-S

 

[deleted4401]

Pelvis only if I'm treating with long term hormones... There is a thread on this and a review on it in Red Journal this month. Written by Roach though, so hardly unbiased.

Also, I don't remember where I saw it, but in one of the recent RTOG dose escalation studies, a significant portion of the patients got the 6 months of hormones, and a subset or two benefited (intermediate, maybe?). I really can't remember, looked at the usual suspects but couldn't find the article.

-S

 

[medgator]

Yea, we don't drop the dose for intermediate, all intermediate and high risk get 79.2 Gy (unless constraints become an issue). In terms of NCCN, you hit the nail on the head as it's kind of a do what you want and I think a lof of it is institution dependent. We dont' offer 6 months for intermediate (but I can certainly see why you do) but do ofter the 2/2/2 + 2-3 years for high risk. I don't really know about pelvis, there's data both ways but I tend to be against using pelvic treatment unless the risk of LN is 20-25%. Do you guys/gals use pelvic more or less frequently?

Didn't realize there was a push for intermediate pts getting 79.2 I had typically treated them with 77.4, but looking through RTOG 0815, they pretty much want you to use 79.2 on everyone unless you can't meet constraints (which are pretty generous to begin with --- rectum 70 Gy/25%, 60 Gy/50% --- I am generally stricter than that in practice).