Here's one of the first pages in my most recent New Yorker
My main beef is what to do with nodes. Not enough good quality data on 5x5 or other approaches. I have no problems with those "lower" high risk cases where nodal risk is lower, but would I really want to omit nodes for a 5+4 cT3b cancer?
Even a urologist is going to sample them (many of them are skipping lymphadenectomy now in low/int risk cases)
Urologists come in all shapes and forms, like a beautiful tamarind. Some do a “lympadenectomy” and take out 3 nodes. Some take out 40-60, you just never know!!!
The imagery is fantastic. Well played!
Now all academic centers are Gil Lederman at a much higher price. Academic centers are visionaries with their PROMISE service lines. Gil Lederman a quack.That's been the case for decades 😉 This guy had some great radio ads back in the day ...
Gil Lederman's Dubious Career - Nymag
When the notorious cancer doctor Gil Lederman cadged an autograph from a dying George Harrison, the world was appalled.But as Lederman scrambles to salvage his reputation, the very nature of his experimental practice has come under attack.nymag.com
What do you make of the ASCENDE RT data then, which was barely significant but with inadequate ADT duration in the high risk patients, so unclear overall?
Not sure yet. My main interest is local control. Local failures can be disastrous and with better systemic options it will probably continue to become more important. I struggle to rationalize why a higher BED in the primary would give better distant control. I mean, people argue that primary failures lead to distant failures so there should be a correlation. It’s not immediately clear to me how valid that argument is as local only failures after RT are the exception and not the rule. At this point I am not convinced HDR (or SBRT) boosts will give better systemic control. But I do think you get better in gland control with no to minimal increased toxicity with HDR (as opposed to LDR).
No more than 1 cm
Extent of almost all sv invasion is within .3cm of prostate. Sbrt may very well be legit for high risk prostate, but it will mean that almost all prostate can be treated in 5 fractions and that many pts can travel to large centers for treatment, centralizing treatment to some extent. Sheer hypocrisy to push prostate sbrt and residency expansion.
Wait wait wait. Are you implying you don’t think the big centers will disclose that SBRT isn’t going to be any more effective, that it could actually be done at many community centers, and that on the whole traveling far away for 5 treatments might actually take more time than a hypofrac course locally?
Closing the sale at big centers involves subtlety implying that local center is not sophisticated enough to deliver 5 fractions (and do you really want to be treated by someone who is not on the cutting edge) or that local center is greedy and incentivized to fractionate for $.
HDR when active surveillance preferred treatment? Overkill?
Everyone gets AS as an option (and preference if life expectancy considerations) and most people pick it. We are only talking about people who refuse AS.
We literally get almost zero low risk patients referred
We don’t get many. Almost all of the older patients opt for AS with urology and that is that. We mostly get younger patients who refuse surgery or people who want treatment and know someone who either had a good experience with RT or a bad experience with surgery. Typically they had a dad or uncle who got “seed treatment” and had no trouble. Or they had surgery and piss a little every time they swing too hard with the driver ☹️
Sorry my question was more how do you treat these low riskers. HDR alone or EBRT + HDR boost
Ohhhh. Mono therapy only. No boost for these guys. I only boost patients with high volume UFIR or HR disease.
Thanks. Makes sense.
Sadly, if I were the unscrupulous type, I could probably get away with it. I have little to no competition in the immediate vicinity and have the advantage of being at the state institution. Fortunately I am not an @ss. Well, at least not that kind of @ss 🙃
There is a bit of a logic flaw here with the weight given to the use of PSMA PETs in this study. You are arguing the key is their improved sensitivity to rule out patients with occult distant Mets who are unlikely to benefit from regional therapy. I can get behind you so far. Here is where it gets tricky. If regional nodal RT affords you a profound improvement over Prostate only RT in men who are N0 after PET staging, we have to conclude PETs are not good at detecting occult regional disease. If they were, regional RT wouldn’t be able to add much. So are we to conclude PSMAs are simultaneously great at detecting occult distant disease but crappy at detecting occult regional disease?
PSMA is able to detect regional and metastatic disease far better than bone scan and CT, so it would weed out patients with regional and distant disease (who otherwise would have been enrolled and failed without PSMA). The patients enrolled likely had microscopic disease and benefited from ENI. Some extra bonus points for treating to L4/L5 instead of L5/S1, but the money is in the PSMA.
PSMA PET is a great leap, but it’s not a panacea. Sensitivity of around 40% for staging in this recent study from Hopkins. But to your point that may be why pelvic RT helps here.
pubmed.ncbi.nlm.nih.gov
I think I need a lesson on the significance of PSMA-PET.
Werner Bezwoda says: “You ask too many questions.”
Of course not! But they are happy to mandate when we should do RT or not in plenty of other situations. I was implying at least this is a situation where either side of the fence is ok on that end.
Excellent points. I don't typically follow the SABR-COMET approach no but there are a lot of issues there that are pretty distinct from POP-RT. I think a more relevant comparison to POP-RT is probably ASCEND-RT. I do believe in using a brachy boost for people with high volume high risk disease and I do it. But not because of the trial. I am still a bit skeptical there will be a significant improvement in distant disease control or survival with longer follow up. But, I do think you get better in gland control and as long as you are using HDR toxicity really is not an issue. Since in gland failures can be fairly disastrous there is a clinical rationale to do it even if longer term oncologic outcomes don't pan out. Note the calculation: risk/benefit. I can easily understand who people who have only done LDR or have not done much brachy would look at the data and reach a different conclusion.
Despite what is clearly stated in ASTROs guidelines about moderate hypofx vs conventional in terms of acute toxicity... I actually was able to get conventional approved (pt requested) through a third party appeal via the payor when evicore only approved hypofx and i sent those guidelines in as part of it
Well, I'm not sure I believe even the bPFS benefit in high risk patients... The p value was barely significant, and the ADT was inadequate for high risk patients. Would it still have been significant if adequate ADT would be given? That's the unresolved question.
By assaults you mean multiple negative trials?
All said and done, sounds like we practice more or less the same. You are always very thoughtful and well spoken on your practice and the literature. Nothing but love 🙂
I treat with ENI in high risk patients. I'd probably offer ENI to the vast majority of the patients in POP-RT. I'm confident that it provides a bPFS benefit. I'm also impressed by the SPPORT data. I think there is real toxicity to salvage therapy in the biochemical progression setting and the decision making in that scenario is very difficult. The toxicity of pelvic nodal radiation is not comparable to brachy boost. (I concede that a killer HDR program may make things different.)
My AS uptake rates are very high. Almost too high. Some of the low volume GG2 patients who I bring it up as an option that I try to steer them away from jump all over it.
Yup! Just saw a self referral who pissed off the high volume robotic guy by refusing rp... Can't blame him though, older with a psa of 45, high volume G8 whose buddy had a good experience with radiation...
The conversation for GG1-2 is slightly different for us than you. If someone knows they want surgery no matter what the treatment won’t change if they progress to a higher risk group. If they are dead set against surgery and know they will go the RT route we have to talk a bit more about options because I can’t offer Brachy as a monotherapy for higher risk groups. I always stress that it’s (probably) no more effective than EBRT or combo options so I am completely fine with AS. But if they are specifically looking for it, and a decent number of folks are, it may be worth thinking about treatment now (assuming they have a decent life expectancy of course). For GG2 patients there is also the issue of ADT. Can avoid it now, but go any further and you will need it. That is a deal breaker for some guys. No matter how many different ways you try to explain you won’t have any sex drive, the thought of not being able to get an erection is truly unacceptable.
Good point, and one that I should probably raise more. Would also be interested to see if there is data for higher rates of salvage xrt for delayed treatment rather then up front for GG2, which wouldn’t surprise me.
