Rad Onc Twitter

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Further to the infamous prostate NCDB article mentioned above, the 1st author seems to be a Harvard medstudent who wants to go in Urology at a "good place", so he might have tried to please all the stakeholders (U Mich and Harvard)...

I am an educator myself, so I'd like to be fair to the learners (medstudents in this case):

1- If one disagrees, then go to Twitter, or SDN, or write a letter to the editor.
BTW, Urologic Oncology, Seminars and Original Investigations seems OK, does not look like a throw-away journal.

2- A journal exists for publication purposes and the ensuing discussions, for ex, RedJ does not have to agree with the findings of an article, RedJ or NEJM can publish anything they want as long as the guidelines for authorship and scientific merits are followed. In this case, Urologic Oncology, Seminars and Original Investigations is just a platform for the article.
Don't blame the journal, blame the methodology.

3- So if anyone finds something wrong with the methodology, please post so others can learn.

4- For those who mentioned "academic dishonesty", please prove it to me, then I will believe it.
For now, I will give the medstudent the benefit of the doubt...
Again, I want to see the proof of academic dishonesty.

5- The 1st author might have done a good job (he thinks) with the analysis, only to come up with findings that the radonc community does not like. And some Urologists, presumably those anti-radonc, love this kind of stuff to lob at radonc community. So, it is not wrong for Spratt to hit it head-on, only to find out that he lobs the attack against a future Urology resident at U Mich, talking about shooting yourself in your own foot. RW was clearly inappropriate.

So, sit back, grab some popcorn/Coke/beer/wine, no need to watch Netflix folks...
Don't you love Twitter (sorry about my sarcasm)...

Chanan Reitblat, MD | Urology | Michigan Medicine

medicine.umich.edu medicine.umich.edu

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Radonc90 said:
Further to the infamous prostate NCDB article mentioned above, the 1st author seems to be a Harvard medtsudent who wants to go in Urology at a "good place", so he might have tried to please all the stakeholders (U Mich and Harvard)...

I am an educator myself, so I'd like to be fair to the learners (medstudents in this case):

1- If one disagrees, then go to Twitter, or SDN, or write a letter to the editor.
BTW, Urologic Oncology, Seminars and Original Investigations seems OK, does not look like a throw-away journal.

2- A journal exists for publication purposes and the ensuing discussions, for ex, RedJ does not have to agree with the findings of an article, RedJ or NEJM can publish anything they want as long as the guidelines for authorship and scientific merits are followed. In this case, Urologic Oncology, Seminars and Original Investigations is just a platform for the article.
Don't blame the journal, blame the methodology.

3- So if anyone finds something wrong with the methodology, please post so others can learn.

4- For those who mentioned "academic dishonesty", please prove it to me, then I will believe it.
For now, I will give the medstudent the benefit of the doubt...
Again, I want to see the proof of academic dishonesty.

5- The 1st author might have done a good job (he thinks) with the analysis, only to come up with findings that the radonc community does not like. And some Urologists, presumably those anti-radonc, love this kind of stuff to lob at radonc community. So, it is not wrong for Spratt to hit it head-on, only to find out that he lobs the attack against a future Urology resident at U Mich, talking about shooting yourself in your own foot. RW was clearly inappropriate.

So, sit back, grab some popcorn/Coke/beer/wine, no need to watch Netflix folks...
Don't you love Twitter (sorry about my sarcasm)...

Chanan Reitblat, MD | Urology | Michigan Medicine

medicine.umich.edu medicine.umich.edu

---
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Harvard is not immune from spouting trash. Vinay prassad mentioned they have published studies to the effect that consumption of nuts has a bigger absolute benefit than chemo in colon cancer.

Nut Consumption and Survival in Patients With Stage III Colon Cancer: Results From CALGB 89803 (Alliance) - PubMed

and to clarify, the benefit comes from “tree” nuts:
"Basic healthy eating can often be overlooked during cancer treatment. This study shows that something as simple as eating tree nuts may make a difference in a patient's long-term survival," said ASCO President Daniel F. Hayes, MD, FACP, FASCO
 
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As soon as someone cites "professionalism", I tune out.

It's what people in a place of privilege say when they've been challenged and have no means to attack the argument while also not wanting to be seen as directly attacking the person, so they invoke some long antiquated notion of how those below them "should" act as though it's virtue.

Spare me. BS being called BS is fine.

Rock on Dan.
 
DoctwoB said:
Resident urologist weighing in. First off, let me say I agree that another retrospective NCDB review showing improved OS with surgery over radiation is neither novel nor informative, as it does not address any of the glaring issues of selection bias from the other 5,000 NCDB reviews that have been done. It also lacks face validity (50% OS improvement makes no logical sense, or I need to start offering RP to patients as a life extending treatment for all indications).

That being said, the uproar caused in rad-onc caused by a bad article in a low rent urology journal is pretty appalling. Chairman of a program calling a paper that some resident wrote "tabloid trash" on social media is unprofessional IMO, and I usually like what Dr. Spratt writes. Even worse is the chairman below, calling for people to write letters to promotion committees to effectively end people's careers. Be better.





View attachment 336173
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The reason we care is because urologists (and most surgeons) are trash when it comes to using data to justify their bias towards surgery. That's not an insult to you since you actually come and discuss data. 99% of urologists would feel that it's beneath them to do the same. They know how bad the data is and use that as an excuse to cut on anyone without giving others a fair shake (and no they won't read LTE pieces). I'm not worried about the smart and prudent urologists, I'm worried about the fodder it gives the remaining 99%. We are just sick and tired of seeing surgeons use obviously biased data to push their own agenda especially because 99% don't know how to critically evaluate the literature. With the exception of protons for prostate cancer, I don't agree with @Dan Spratt about much at all, but in this case he's absolutely right to run his mouth because someone's got to show the urologists their place instead of the high horses they constantly ride.
 
why is D’amico putting his name on such a trash paper? He does not need the pub. This is embarassing.

urologists are some of the least evidence based surgeons. Besides the prostate cancer nonsense they do often, despite the data, they rarely mention bladder preservation to patients which should be criminal.
SBRT data for RCC is also looking pretty pretty good as well. Dont count on them mentioning that either.
 
thecarbonionangle said:
why is D’amico putting his name on such a trash paper? He does not need the pub. This is embarassing.

urologists are some of the least evidence based surgeons. Besides the prostate cancer nonsense they do often, despite the data, they rarely mention bladder preservation to patients which should be criminal.
SBRT data for RCC is also looking pretty pretty good as well. Dont count on them mentioning that either.
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That’s so bad! Dr. D’Amico!!! I cannot understand as I hold you in high regard. Et tu, brute?
 
Guys imma take a break for a bit. I find the discussion of the need to knock us off our high horses and Uro’s as knuckle dragging money grubbers (I think we make less then you for more hours on average?) to be less productive then some of the data driven chats we’ve had. I just wanted to leave a bit of perspective on the way out.

A typical night of call for me in residency was covering 5 hospitals, average 10-15 consults, and no post call day. Usually 2-5 of those consults were due to complications of radiation. Every resident I trained with had some version of a dot phrase “Mr. @Name@ is a @Age@ year old male with a history of prostate cancer treated with radiation therapy complicated by radiation cystitis now presenting with “blank”. And that’s been true for me in practice as well. At my not so busy hospital, I saw 3 today. One went home, one is a frequent flier that I’m trying to get out of the hospital long enough to get hyperbaric, and one is heading to hospice and nephrostomy tubes. I doubt his rad onc knows. FWIW, I almost never see complications of RALP in the hospital, and before you bring up bias, keep in mind a surgical complication weighs 1000x heavier in my memory then any other case I see.

Like radonc until recently, urology attracts med students with the top grades, scores and pubs. They know how to publish and how to read papers. And yet many are dubious of radiation. Why? Because of financial incentive? I’m sure that’s it for some, but if prostate cancer was cured tomorrow it wouldn’t effect my bottom line, nor that of most urologists significantly. Can you say the same? The real reason, IMO, is like Orwell said we are being asked to reject the evidence of our eyes and ears (yes the old men often scream as we irrigate their clot filled irradiated bladders at 2 am). You say that we are being greedy by steering a patient towards surgery over xrt, but most urologists are doing what they would recommend for their fathers. You say that we are on a high horse, but it feels fresh to be lectured by someone who has never been in the ER at 2am dealing with the complications of their own therapy. Your grade 2 toxicity that is an afterthought in your paper (and viewed as not worth extending fracionation for) is my patient who is on meds and often miserable, often for life. Which by the way, is the timeline in which xrt can cause issues, so limiting follow up duration on trials underestimates the effects we deal with, which are often decades later. These meds by the way, which are increasingly nasty (look up data for long term anticholinergics and dementia. It is VERY concerning.)

I view you all as my colleagues and believe that radiation and surgery are both excellent modalities for the treatment of prostate cancer and more. I respect the rad oncs I work with, they are knowledgeable and bring a great skill set. I’m saddened to see the direction your workforce is heading, and strongly considered radonc myself before choosing a surgical path. But keep in mind. Most Uro’s are interpreting the papers you show about xrt in light of their experience of years of dealing with the complications of radiation.
 
DoctwoB said:
Guys imma take a break for a bit. I find the discussion of the need to knock us off our high horses and Uro’s as knuckle dragging money grubbers (I think we make less then you for more hours on average?) to be less productive then some of the data driven chats we’ve had. I just wanted to leave a bit of perspective on the way out.

A typical night of call for me in residency was covering 5 hospitals, average 10-15 consults, and no post call day. Usually 2-5 of those consults were due to complications of radiation. Every resident I trained with had some version of a dot phrase “Mr. @Name@ is a @Age@ year old male with a history of prostate cancer treated with radiation therapy complicated by radiation cystitis now presenting with “blank”. And that’s been true for me in practice as well. At my not so busy hospital, I saw 3 today. One went home, one is a frequent flier that I’m trying to get out of the hospital long enough to get hyperbaric, and one is heading to hospice and nephrostomy tubes. I doubt his rad onc knows. FWIW, I almost never see complications of RALP in the hospital, and before you bring up bias, keep in mind a surgical complication weighs 1000x heavier in my memory then any other case I see.

Like radonc until recently, urology attracts med students with the top grades, scores and pubs. They know how to publish and how to read papers. And yet many are dubious of radiation. Why? Because of financial incentive? I’m sure that’s it for some, but if prostate cancer was cured tomorrow it wouldn’t effect my bottom line, nor that of most urologists significantly. Can you say the same? The real reason, IMO, is like Orwell said we are being asked to reject the evidence of our eyes and ears (yes the old men often scream as we irrigate their clot filled irradiated bladders at 2 am). You say that we are being greedy by steering a patient towards surgery over xrt, but most urologists are doing what they would recommend for their fathers. You say that we are on a high horse, but it feels fresh to be lectured by someone who has never been in the ER at 2am dealing with the complications of their own therapy. Your grade 2 toxicity that is an afterthought in your paper (and viewed as not worth extending fracionation for) is my patient who is on meds and often miserable, often for life. Which by the way, is the timeline in which xrt can cause issues, so limiting follow up duration on trials underestimates the effects we deal with, which are often decades later. These meds by the way, which are increasingly nasty (look up data for long term anticholinergics and dementia. It is VERY concerning.)

I view you all as my colleagues and believe that radiation and surgery are both excellent modalities for the treatment of prostate cancer and more. I respect the rad oncs I work with, they are knowledgeable and bring a great skill set. I’m saddened to see the direction your workforce is heading, and strongly considered radonc myself before choosing a surgical path. But keep in mind. Most Uro’s are interpreting the papers you show about xrt in light of their experience of years of dealing with the complications of radiation.
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I think this is a very good take. I absolutely can understand how a urologist views XRT problems...because when my patients get hematuria, it's the urologist I'm calling and they're very gracious and helpful and I'm thankful for that.

My only complaint with the modern urologist (of course painting with a broad brush), is that in my experience in BOTH academia and private practice, they are very very reluctant (or even unwilling) to consider a multi disciplinary clinic for newly diagnosed prostate cancer patients.

If we have some semblance of equipoise for modalities, it seems reasonable that patients should be seen by both providers before making a decision. Especially in a disease site where a "delay" in therapy is of minimal consequence - there is plenty of time to hear and learn about all standard of care options from the doctors that do these procedures.
 
thecarbonionangle said:
why is D’amico putting his name on such a trash paper? He does not need the pub. This is embarassing.

urologists are some of the least evidence based surgeons. Besides the prostate cancer nonsense they do often, despite the data, they rarely mention bladder preservation to patients which should be criminal.
SBRT data for RCC is also looking pretty pretty good as well. Dont count on them mentioning that either.
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For the same reason that Reshma Jagsi is on Dan Spratt's anti-SEER/NCDB paper when in reality she has published many papers using both and other large registries. Typical academic ivory tower hypocrites... They will do anything for another free publication just like a hungry dog does with a half-eaten chicken bone.
 
DoctwoB said:
Usually 2-5 of those consults were due to complications of radiation. Every resident I trained with had some version of a dot phrase “Mr. @Name@ is a @Age@ year old male with a history of prostate cancer treated with radiation therapy complicated by radiation cystitis now presenting with “blank”. And that’s been true for me in practice as well. At my not so busy hospital, I saw 3 today. One went home, one is a frequent flier that I’m trying to get out of the hospital long enough to get hyperbaric, and one is heading to hospice and nephrostomy tubes. I doubt his rad onc knows. FWIW, I almost never see complications of RALP in the hospital, and before you bring up bias, keep in mind a surgical complication weighs 1000x heavier in my memory then any other case I see.
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If you think about the incidence of radiation cystitis this single urologist is reporting, it doesn't look great for the incidence of radiation cystitis in prostate cancer for the whole of rad onc. I know that we as rad oncs "mis-underestimate" our toxicity rates ("we" being me included). I would think ENI is related to increased radiation cystitis probability, but I don't have data to back that up. I do try to remain honest with myself that when it comes to things like pelvic ENI or breast ENI, Newton's third law applies. There are no free, or guilt-free, lunches.
 
DoctwoB said:
Guys imma take a break for a bit. I find the discussion of the need to knock us off our high horses and Uro’s as knuckle dragging money grubbers (I think we make less then you for more hours on average?) to be less productive then some of the data driven chats we’ve had. I just wanted to leave a bit of perspective on the way out.

A typical night of call for me in residency was covering 5 hospitals, average 10-15 consults, and no post call day. Usually 2-5 of those consults were due to complications of radiation. Every resident I trained with had some version of a dot phrase “Mr. @Name@ is a @Age@ year old male with a history of prostate cancer treated with radiation therapy complicated by radiation cystitis now presenting with “blank”. And that’s been true for me in practice as well. At my not so busy hospital, I saw 3 today. One went home, one is a frequent flier that I’m trying to get out of the hospital long enough to get hyperbaric, and one is heading to hospice and nephrostomy tubes. I doubt his rad onc knows. FWIW, I almost never see complications of RALP in the hospital, and before you bring up bias, keep in mind a surgical complication weighs 1000x heavier in my memory then any other case I see.

Like radonc until recently, urology attracts med students with the top grades, scores and pubs. They know how to publish and how to read papers. And yet many are dubious of radiation. Why? Because of financial incentive? I’m sure that’s it for some, but if prostate cancer was cured tomorrow it wouldn’t effect my bottom line, nor that of most urologists significantly. Can you say the same? The real reason, IMO, is like Orwell said we are being asked to reject the evidence of our eyes and ears (yes the old men often scream as we irrigate their clot filled irradiated bladders at 2 am). You say that we are being greedy by steering a patient towards surgery over xrt, but most urologists are doing what they would recommend for their fathers. You say that we are on a high horse, but it feels fresh to be lectured by someone who has never been in the ER at 2am dealing with the complications of their own therapy. Your grade 2 toxicity that is an afterthought in your paper (and viewed as not worth extending fracionation for) is my patient who is on meds and often miserable, often for life. Which by the way, is the timeline in which xrt can cause issues, so limiting follow up duration on trials underestimates the effects we deal with, which are often decades later. These meds by the way, which are increasingly nasty (look up data for long term anticholinergics and dementia. It is VERY concerning.)

I view you all as my colleagues and believe that radiation and surgery are both excellent modalities for the treatment of prostate cancer and more. I respect the rad oncs I work with, they are knowledgeable and bring a great skill set. I’m saddened to see the direction your workforce is heading, and strongly considered radonc myself before choosing a surgical path. But keep in mind. Most Uro’s are interpreting the papers you show about xrt in light of their experience of years of dealing with the complications of radiation.
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Its good youre here and youre take is important and helpful. Having seen your other posts it's great that you do work to learn oncology itself.
I think every rad onc's lens is different though. The urologists I work with for example are pretty bad. Simple oncologic discussions and explanations fly over their heads. The responsibility is not ours to hand hold urologists or show concern for their late nights in the ED. The number of patients that bad urologists harm due to ignorance or profit motive is astounding and thats what what the reactions youre seeing to the study is. If you want to offer poor or medical mistreatment to your own father then you are allowed to do that but I think most urologists will think twice about operating on their very high risk node positive family member
 
TheWallnerus said:
If you think about the incidence of radiation cystitis this single urologist is reporting, it doesn't look great for the incidence of radiation cystitis in prostate cancer for the whole of rad onc. I know that we as rad oncs "mis-underestimate" our toxicity rates ("we" being me included). I would think ENI is related to increased radiation cystitis probability, but I don't have data to back that up. I do try to remain honest with myself that when it comes to things like pelvic ENI or breast ENI, Newton's third law applies. There are no free, or guilt-free, lunches.
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Our urologists also complain about xrt cystitis and proctitis. I keep telling them I have been at same hospital for 10 years and see close to 0.
 
RickyScott said:
Our urologists also complain about xrt cystitis and proctitis. I keep telling them I have been at same hospital for 10 years and see close to 0.
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Maybe i should bring up all the RP pts i end up seeing who end up metting out shortly after surgery?
 
medgator said:
Maybe i should bring up all the RP pts i end up seeing who end up metting out shortly after surgery?
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Also, plenty of us are experts in giving adjuvant RT for pN+ patients. Always fun reading an op note that says "multiple enlarged lymph nodes were removed and sent for frozen section, which returned positive for carcinoma. We then proceeded with prostatectomy..."

Luckily we have more SEER data to conclude that RP "should not be aborted in pN1 patients": Contemporary Trends and Survival Outcomes After Aborted Radical Prostatectomy in Lymph Node Metastatic Prostate Cancer Patients - PubMed (nih.gov)
 
DoctwoB said:
Guys imma take a break for a bit. I find the discussion of the need to knock us off our high horses and Uro’s as knuckle dragging money grubbers (I think we make less then you for more hours on average?) to be less productive then some of the data driven chats we’ve had. I just wanted to leave a bit of perspective on the way out.

A typical night of call for me in residency was covering 5 hospitals, average 10-15 consults, and no post call day. Usually 2-5 of those consults were due to complications of radiation. Every resident I trained with had some version of a dot phrase “Mr. @Name@ is a @Age@ year old male with a history of prostate cancer treated with radiation therapy complicated by radiation cystitis now presenting with “blank”. And that’s been true for me in practice as well. At my not so busy hospital, I saw 3 today. One went home, one is a frequent flier that I’m trying to get out of the hospital long enough to get hyperbaric, and one is heading to hospice and nephrostomy tubes. I doubt his rad onc knows. FWIW, I almost never see complications of RALP in the hospital, and before you bring up bias, keep in mind a surgical complication weighs 1000x heavier in my memory then any other case I see.

Like radonc until recently, urology attracts med students with the top grades, scores and pubs. They know how to publish and how to read papers. And yet many are dubious of radiation. Why? Because of financial incentive? I’m sure that’s it for some, but if prostate cancer was cured tomorrow it wouldn’t effect my bottom line, nor that of most urologists significantly. Can you say the same? The real reason, IMO, is like Orwell said we are being asked to reject the evidence of our eyes and ears (yes the old men often scream as we irrigate their clot filled irradiated bladders at 2 am). You say that we are being greedy by steering a patient towards surgery over xrt, but most urologists are doing what they would recommend for their fathers. You say that we are on a high horse, but it feels fresh to be lectured by someone who has never been in the ER at 2am dealing with the complications of their own therapy. Your grade 2 toxicity that is an afterthought in your paper (and viewed as not worth extending fracionation for) is my patient who is on meds and often miserable, often for life. Which by the way, is the timeline in which xrt can cause issues, so limiting follow up duration on trials underestimates the effects we deal with, which are often decades later. These meds by the way, which are increasingly nasty (look up data for long term anticholinergics and dementia. It is VERY concerning.)

I view you all as my colleagues and believe that radiation and surgery are both excellent modalities for the treatment of prostate cancer and more. I respect the rad oncs I work with, they are knowledgeable and bring a great skill set. I’m saddened to see the direction your workforce is heading, and strongly considered radonc myself before choosing a surgical path. But keep in mind. Most Uro’s are interpreting the papers you show about xrt in light of their experience of years of dealing with the complications of radiation.
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I sympathize your residency is as difficult as described. I can also understand how frustrating it must be to “clean up after another’s toxicity”

i caution however against broad brushing RT as toxic

yes, some patients get late toxicity and it can sometimes be bad. We never claim to have 0 toxicity. Every treatment has risk of side effects.

But remember you are likely to NEVER see the many more successful stories that exist as there is not a need for your services in those cases

You may not see RALP toxicities but I certainly have. I can’t count how many salvage RT cases I’ve treated where at baseline a man has become impotent after being told he was going to have his nerves spared or has bad incontinence. Each scenario they’ve been extremely unhappy

Yet I don’t let that color me blindly against urology as each modality has its role.

I never tell patients that RT is automatically better than RP or vice versa bc guess what that data does NOT exist. This “emulation trial”, which is just a made up name for a propensity matched NCDB analysis doesn't change that.

I suggest open 2 way discussion for EACH prostate cancer patient and let them decide what side effect risk profile and logistics of treatment they want to pursue
 
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We can both be nicer to each other, but unfortunately this is where the venting will happen, in an anonymous forum, where one does not HAVE to respect the other specialty.

I think painting specialties with a 'broad-brush' is not ideal, but not against ToS. As long as folks are not directly calling out other SDN members, it's OK.

That being said, knowing what urology resident call was like as a medical student.... I can't imagine willingly signing up for that. Due to the shortage, the number of hospitals that are covered by sub-specialty surgeons, both as an attending and in residency, is outrageously high.

But, I do think any urologist arguing AGAINST a multi-disciplinary prostate clinic... knows why he/she is doing it.
 
MegaVoltagePhoton said:
Just a question...do the risk of radiation proctitis or radiation cystitis go away in the postop setting? My urologists love to use these as reasons to operate, but also tell patients it’s ok because you can do radiation after surgery.
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Nothing like giving a big chunk of the inferior bladder the prescription dose
 
MegaVoltagePhoton said:
Just a question...do the risk of radiation proctitis or radiation cystitis go away in the postop setting? My urologists love to use these as reasons to operate, but also tell patients it’s ok because you can do radiation after surgery.
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I imagine risk may be higher given inability to keep a full bladder and the fact that most RTOG trials subtract out any bladder that is in the CTV. Have seen some bladder DVHs that look worse in a post-op setting at least based on % based constraints.
 
evilbooyaa said:
I imagine risk may be higher given inability to keep a full bladder and the fact that most RTOG trials subtract out any bladder that is in the CTV. Have seen some bladder DVHs that look worse in a post-op setting at least based on % based constraints.
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I pay attention to bladder and will shave ptv depending on circumstances. (64 Gy equivalent to 70 per recent trial) Also daily CBCTs. Nevertheless, multiple large randomized postop trials with long term followup, many of which used 3d/no igrt that had negiligible/if any G3 cystitis.
 
RickyScott said:
I pay attention to bladder and will shave ptv depending on circumstances. (64 Gy equivalent to 70 per recent trial) Also daily CBCTs. Nevertheless, multiple large randomized postop trials with long term followup, many of which used 3d/no igrt that had negiligible/if any G3 cystitis.
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Patients can be miserable without G3 cystitis. Just because we don't care (it's just G2 cystitis, it's not G3!) doesn't mean it's not life affecting.

Supplementary Table S6/S7 from 9601 - G3 late GU toxicity - ~6.5%, G2 late GU toxicity - ~25%, G2
G3 late GI toxicity - ~2%, G2 late GI - ~16%

RTOG 0534 - Late G2+ GU ~34%.
 
for sure there will be much more bladder in field. Sure the dose is lower but I just think it is funny that urologists bring up cystitis and proctitis as the bogeyman for these high risk patients yet also sell them on the fact that radiation is available as a fallback.

completely not consistent.

also all the urologists on Twitter asked Dan about the “similar rad onc studies” as did the urologist here. But...what are those similar studies? The Kishan study has limitations as a retrospective analysis but it’s also a big study with individual patient data (not registry) and was published in jama presumably after hefty review. That’s not comparable to a ncdb study at all.

Are there other studies I am missing?
 
MegaVoltagePhoton said:
Just a question...do the risk of radiation proctitis or radiation cystitis go away in the postop setting? My urologists love to use these as reasons to operate, but also tell patients it’s ok because you can do radiation after surgery.
Click to expand...
evilbooyaa said:
Patients can be miserable without G3 cystitis. Just because we don't care (it's just G2 cystitis, it's not G3!) doesn't mean it's not life affecting.

Supplementary Table S6/S7 from 9601 - G3 late GU toxicity - ~6.5%, G2 late GU toxicity - ~25%, G2
G3 late GI toxicity - ~2%, G2 late GI - ~16%

RTOG 0534 - Late G2+ GU ~34%.
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A decent number of prostatectomy pts have baseline G2 urinary issues prior to radiation
 
MegaVoltagePhoton said:
I just think it is funny that urologists bring up cystitis and proctitis as the bogeyman for these high risk patients yet also sell them on the fact that radiation is available as a fallback.
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I quite literally just read this in a note 1 hour ago...

"Due to the potential for long term toxicity from radiation therapy, radical prostatectomy is the preferred option. Additionally, radiation represents an excellent salvage option should he experience failure."


Thankfully, not only does radical prostatectomy have zero potential for long-term toxicity, but it also is preventative of long-term toxicity for other modalities that may be utilized in the future.
 
Mandelin Rain said:
I quite literally just read this in a note 1 hour ago...

"Due to the potential for long term toxicity from radiation therapy, radical prostatectomy is the preferred option. Additionally, radiation represents an excellent salvage option should he experience failure."


Thankfully, not only does radical prostatectomy have zero potential for long-term toxicity, but it also is preventative of long-term toxicity for other modalities that may be utilized in the future.
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It’s a Christmas miracle and it’s not even Christmas!
 
Urologist: radiation terrible no good bad, someone i know saw this one complication. I dont know the data but this is what i heard!!! Takes prostate out

urologist after cut through, +N and positive margins or rising PSA: well radiation is now needed. forget what i said about you bleeding out from cystitis. Surgery had no side effects!!! And now your penis is shorter, you can’t get it up despite me “sparring” the nerves and you may even need hormones, and yeah you may leak urine for a while, getchu some diapers. ain’t this great!? I really helped you didn’t I?
 
If I really think a guy should have XRT, I will drop "diaper" a few times in the consult visit. I usually try to play it fairly straight though.

I don't play that Gillette song in the background, though. And I'm not talking about the razors.
 
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DoctwoB said:
Resident urologist weighing in. First off, let me say I agree that another retrospective NCDB review showing improved OS with surgery over radiation is neither novel nor informative, as it does not address any of the glaring issues of selection bias from the other 5,000 NCDB reviews that have been done. It also lacks face validity (50% OS improvement makes no logical sense, or I need to start offering RP to patients as a life extending treatment for all indications).

That being said, the uproar caused in rad-onc caused by a bad article in a low rent urology journal is pretty appalling. Chairman of a program calling a paper that some resident wrote "tabloid trash" on social media is unprofessional IMO, and I usually like what Dr. Spratt writes. Even worse is the chairman below, calling for people to write letters to promotion committees to effectively end people's careers. Be better.





View attachment 336173
Click to expand...
DoctwoB-
I appreciate you weighing in. Great to hear the perspective of a urology resident. I was very disappointed in how my posts were interpreted and have personally apologized to the medical student who was first author of the paper and offered to personally mentor or help him.

I know all too well that social media posts can be misinterpreted given the tiny character limit and often minimal context of dozens of tweets. However, I want SDN to understand one thing- My post in no way was intended to be personal against anyone, especially not a medical student. My posts never are meant to be personal, but are to focus on data and to speak directly. My post was in regards to a publication that blatantly is propagating misinformation in the public domain, in a scientific journal, and in the journal that represents the SUO. This paper harms patients, period. People must accept that if you put your work in the public domain it is open to criticism and calling it tabloid trash is gentle to what it should be called and what patients would call it who feel they have been lied to by physicians and have been harmed by them.

It just so happens that papers have authors, and there is a first author of that paper, and that first author happened to be a medical student. That is why I blame in part the mentors (and their lack of training on understanding the problem with the paper) and was very clear that in no way is the medical student responsible. He was trusting their mentors, who work at Harvard and naturally should be trusted to guide them well. I also hold the editors, reviewers, and journal responsible, just as the NY Times and other non-biomedical journals would be...even tabloids have standards. Those journals get sued even for misinformation.

Thus, my criticism is directed at a flawed paper and not a personal attack on a student. I have stated this clearly on social media and personally to the student, and here as well. I have mentored >40 students, dozens of urology residents and fellows and faculty, and my comments in no way were meant to be anti urology (as I stated clearly). Radonc has put out similar trash and I have written high profile papers in JCO about brachy, papers about protons, carbon, etc and work hard as an editor and reviewer for >30 journals to not allow this type of garbage through, even when it shows RP is worse. I publicly have stated when I was a resident I was the first author of a paper showing brachy was better than EBRT, and I now publicly use my own paper as an example of the problems and harms of that type of research.

So to those fueling the fire that this had anything to do with a student, this is misguided and spinning something that is not true. A paper with a misleading title and conclusions that is impossible (which most urologists know) is unethical to publish and deserves to be called out. The mentors should have not done this and the journal should have not published it.

We should not take criticism of our work as personal. Trying to insult my professionalism (which I was not a Chair when I made the posts) is personal. Patients deserve us to not accept misinformation that can harm them. I am disheartened that so many would rather see patients harmed by these lies and stick up for their buddies/specialty instead. Reminds me of politics. I have received hundreds of messages thanking me for calling out this garbage from both urologists, radoncs, medoncs, and most importantly, patient advocacy groups.

Remember, while we type and have these dialogues patients are dying of cancer or developing serious side effects from our treatment. These are the real problems we should be focused on.

Keep up the great work everyone and remember that you will always end up on top when you are fighting for patients.

Best,
Dan
 
Dan Spratt said:
DoctwoB-
I appreciate you weighing in. Great to hear the perspective of a urology resident. I was very disappointed in how my posts were interpreted and have personally apologized to the medical student who was first author of the paper and offered to personally mentor or help him.

I know all too well that social media posts can be misinterpreted given the tiny character limit and often minimal context of dozens of tweets. However, I want SDN to understand one thing- My post in no way was intended to be personal against anyone, especially not a medical student. My posts never are meant to be personal, but are to focus on data and to speak directly. My post was in regards to a publication that blatantly is propagating misinformation in the public domain, in a scientific journal, and in the journal that represents the SUO. This paper harms patients, period. People must accept that if you put your work in the public domain it is open to criticism and calling it tabloid trash is gentle to what it should be called and what patients would call it who feel they have been lied to by physicians and have been harmed by them.

It just so happens that papers have authors, and there is a first author of that paper, and that first author happened to be a medical student. That is why I blame in part the mentors (and their lack of training on understanding the problem with the paper) and was very clear that in no way is the medical student responsible. He was trusting their mentors, who work at Harvard and naturally should be trusted to guide them well. I also hold the editors, reviewers, and journal responsible, just as the NY Times and other non-biomedical journals would be...even tabloids have standards. Those journals get sued even for misinformation.

Thus, my criticism is directed at a flawed paper and not a personal attack on a student. I have stated this clearly on social media and personally to the student, and here as well. I have mentored >40 students, dozens of urology residents and fellows and faculty, and my comments in no way were meant to be anti urology (as I stated clearly). Radonc has put out similar trash and I have written high profile papers in JCO about brachy, papers about protons, carbon, etc and work hard as an editor and reviewer for >30 journals to not allow this type of garbage through, even when it shows RP is worse. I publicly have stated when I was a resident I was the first author of a paper showing brachy was better than EBRT, and I now publicly use my own paper as an example of the problems and harms of that type of research.

So to those fueling the fire that this had anything to do with a student, this is misguided and spinning something that is not true. A paper with a misleading title and conclusions that is impossible (which most urologists know) is unethical to publish and deserves to be called out. The mentors should have not done this and the journal should have not published it.

We should not take criticism of our work as personal. Trying to insult my professionalism (which I was not a Chair when I made the posts) is personal. Patients deserve us to not accept misinformation that can harm them. I am disheartened that so many would rather see patients harmed by these lies and stick up for their buddies/specialty instead. Reminds me of politics. I have received hundreds of messages thanking me for calling out this garbage from both urologists, radoncs, medoncs, and most importantly, patient advocacy groups.

Remember, while we type and have these dialogues patients are dying of cancer or developing serious side effects from our treatment. These are the real problems we should be focused on.

Keep up the great work everyone and remember that you will always end up on top when you are fighting for patients.

Best,
Dan
Click to expand...

Not as much trash talked about radiation around these parts by urology, after they bought their own machine and own radonc. Funny how that works out.

If I were on Twitter rather than SDN, I wouldn't be able to call out hiding behind a medical student while you publish a study with "controversial" (at best) conclusions for exactly what it is: cowardice.

Glad you're there, though, Dan. Keep up the good fight.
 
OTN said:
Not as much trash talked about radiation around these parts by urology, after they bought their own machine and own radonc. Funny how that works out.

If I were on Twitter rather than SDN, I wouldn't be able to call out hiding behind a medical student while you publish a study with "controversial" (at best) conclusions for exactly what it is: cowardice.

Glad you're there, though, Dan. Keep up the good fight.
Click to expand...
Yip, also true for cryo or the latest purple laser.
 
Dan Spratt said:
DoctwoB-
I appreciate you weighing in. Great to hear the perspective of a urology resident. I was very disappointed in how my posts were interpreted and have personally apologized to the medical student who was first author of the paper and offered to personally mentor or help him.

I know all too well that social media posts can be misinterpreted given the tiny character limit and often minimal context of dozens of tweets. However, I want SDN to understand one thing- My post in no way was intended to be personal against anyone, especially not a medical student. My posts never are meant to be personal, but are to focus on data and to speak directly. My post was in regards to a publication that blatantly is propagating misinformation in the public domain, in a scientific journal, and in the journal that represents the SUO. This paper harms patients, period. People must accept that if you put your work in the public domain it is open to criticism and calling it tabloid trash is gentle to what it should be called and what patients would call it who feel they have been lied to by physicians and have been harmed by them.

It just so happens that papers have authors, and there is a first author of that paper, and that first author happened to be a medical student. That is why I blame in part the mentors (and their lack of training on understanding the problem with the paper) and was very clear that in no way is the medical student responsible. He was trusting their mentors, who work at Harvard and naturally should be trusted to guide them well. I also hold the editors, reviewers, and journal responsible, just as the NY Times and other non-biomedical journals would be...even tabloids have standards. Those journals get sued even for misinformation.

Thus, my criticism is directed at a flawed paper and not a personal attack on a student. I have stated this clearly on social media and personally to the student, and here as well. I have mentored >40 students, dozens of urology residents and fellows and faculty, and my comments in no way were meant to be anti urology (as I stated clearly). Radonc has put out similar trash and I have written high profile papers in JCO about brachy, papers about protons, carbon, etc and work hard as an editor and reviewer for >30 journals to not allow this type of garbage through, even when it shows RP is worse. I publicly have stated when I was a resident I was the first author of a paper showing brachy was better than EBRT, and I now publicly use my own paper as an example of the problems and harms of that type of research.

So to those fueling the fire that this had anything to do with a student, this is misguided and spinning something that is not true. A paper with a misleading title and conclusions that is impossible (which most urologists know) is unethical to publish and deserves to be called out. The mentors should have not done this and the journal should have not published it.

We should not take criticism of our work as personal. Trying to insult my professionalism (which I was not a Chair when I made the posts) is personal. Patients deserve us to not accept misinformation that can harm them. I am disheartened that so many would rather see patients harmed by these lies and stick up for their buddies/specialty instead. Reminds me of politics. I have received hundreds of messages thanking me for calling out this garbage from both urologists, radoncs, medoncs, and most importantly, patient advocacy groups.

Remember, while we type and have these dialogues patients are dying of cancer or developing serious side effects from our treatment. These are the real problems we should be focused on.

Keep up the great work everyone and remember that you will always end up on top when you are fighting for patients.

Best,
Dan
Click to expand...

I don’t know, Dan. You have nothing to be sorry for IMO. A fake randomized trial? Give me a break. It had to be addressed head-on. Serious issues with that journal’s editorial board...

You are a strong leader and a solid advocate for our profession. Carry on...but help us to contract residencies for the love of God 🙂
 
So I went through the actual paper that Dr. Spratt and others are outraged about. Below is the link as it hasn't posted on here yet.

pubmed.ncbi.nlm.nih.gov

Radical prostatectomy versus external beam radiation therapy for high-grade, clinically localized prostate cancer: Emulation of a target clinical trial - PubMed

In observational analyses designed to emulate a target clinical trial of men with high-grade, clinically localized prostate cancer, RP was associated with improved OS compared with EBRT+ADT.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Yup, a total garbage study brought to you by a group of Harvard urologist. I wonder if it would've even been published if it came from lets say a mid tier state medical school. Surprised to see Anthony D'Amico name attached to this.

"This is the first study, to our knowledge, to specifically emulate a hypothetical target trial comparing definitive local therapies for prostate cancer. Given the difficulty of conducting randomized clinical trials in clinically-localized prostate cancer, carefully conducted observational analyses designed to emulate a hypothetical target trial may therefore provide the best source of evidence."

"Despite utilizing a rigorous framework to emulate a hypothetical target trial, this study has a number of limitations. Most importantly, it is non-randomized and subject to unmeasured confounding given a limited set of pre-treatment covariates available in the NCDB. Furthermore, the NCDB only captures OS, and thus we are unable to examine other meaningful oncologic outcomes such as development of metastatic disease or cancer-specific mortality." -lol
 
Last edited:
Dan Spratt said:
DoctwoB-
I appreciate you weighing in. Great to hear the perspective of a urology resident. I was very disappointed in how my posts were interpreted and have personally apologized to the medical student who was first author of the paper and offered to personally mentor or help him.

I know all too well that social media posts can be misinterpreted given the tiny character limit and often minimal context of dozens of tweets. However, I want SDN to understand one thing- My post in no way was intended to be personal against anyone, especially not a medical student. My posts never are meant to be personal, but are to focus on data and to speak directly. My post was in regards to a publication that blatantly is propagating misinformation in the public domain, in a scientific journal, and in the journal that represents the SUO. This paper harms patients, period. People must accept that if you put your work in the public domain it is open to criticism and calling it tabloid trash is gentle to what it should be called and what patients would call it who feel they have been lied to by physicians and have been harmed by them.

It just so happens that papers have authors, and there is a first author of that paper, and that first author happened to be a medical student. That is why I blame in part the mentors (and their lack of training on understanding the problem with the paper) and was very clear that in no way is the medical student responsible. He was trusting their mentors, who work at Harvard and naturally should be trusted to guide them well. I also hold the editors, reviewers, and journal responsible, just as the NY Times and other non-biomedical journals would be...even tabloids have standards. Those journals get sued even for misinformation.

Thus, my criticism is directed at a flawed paper and not a personal attack on a student. I have stated this clearly on social media and personally to the student, and here as well. I have mentored >40 students, dozens of urology residents and fellows and faculty, and my comments in no way were meant to be anti urology (as I stated clearly). Radonc has put out similar trash and I have written high profile papers in JCO about brachy, papers about protons, carbon, etc and work hard as an editor and reviewer for >30 journals to not allow this type of garbage through, even when it shows RP is worse. I publicly have stated when I was a resident I was the first author of a paper showing brachy was better than EBRT, and I now publicly use my own paper as an example of the problems and harms of that type of research.

So to those fueling the fire that this had anything to do with a student, this is misguided and spinning something that is not true. A paper with a misleading title and conclusions that is impossible (which most urologists know) is unethical to publish and deserves to be called out. The mentors should have not done this and the journal should have not published it.

We should not take criticism of our work as personal. Trying to insult my professionalism (which I was not a Chair when I made the posts) is personal. Patients deserve us to not accept misinformation that can harm them. I am disheartened that so many would rather see patients harmed by these lies and stick up for their buddies/specialty instead. Reminds me of politics. I have received hundreds of messages thanking me for calling out this garbage from both urologists, radoncs, medoncs, and most importantly, patient advocacy groups.

Remember, while we type and have these dialogues patients are dying of cancer or developing serious side effects from our treatment. These are the real problems we should be focused on.

Keep up the great work everyone and remember that you will always end up on top when you are fighting for patients.

Best,
Dan
Click to expand...
If I write a crap database paper can you mentor me too?

On a serious note, you have nothing to apologize for and have overwhelming support. Please don’t take your foot off the gas on this topic!
 
I stand by my assertion that it's academic dishonestly almost on the level of falsifying data. Abstracts are available to the general public (and the lay press who screams at the scientifically illiterate public to "trust the experts"), and I guarantee you somewhere out there today a urologist is telling a patient that new data just came out that shows that RP has a much better chance of curing your high risk prostate cancer than RT. Authors/journal should retract and apologize or else be prepared for this to affect their academic careers.
 
Turaco said:
I stand by my assertion that it's academic dishonestly almost on the level of falsifying data. Abstracts are available to the general public (and the lay press who screams at the scientifically illiterate public to "trust the experts"), and I guarantee you somewhere out there today a urologist is telling a patient that new data just came out that shows that RP has a much better chance of curing your high risk prostate cancer than RT. Authors/journal should retract and apologize or else be prepared for this to affect their academic careers.
Click to expand...
I agree with this.

It is academically dishonest. It will be misinterpreted. It will justify poor care for patients.

Retraction or repercussions are appropriate.
 
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Turaco said:
and I guarantee you somewhere out there today a urologist is telling a patient that new data just came out that shows that RP has a much better chance of curing your high risk prostate cancer than RT.
Click to expand...

Mandelin Rain said:
It is academically dishonest. It will be misinterpreted. I will justify poor care for patients.
Click to expand...
"You can guarantee it" because you are correct. Just look at all the times the article has been re-tweeted by urologists at this point with "RP improves survival versus radiation" bylines attached. I won't post the re-tweets here lest I be called... *gasp* unprofessional *gasp*
 
Dan Spratt said:
That is why I blame in part the mentors (and their lack of training on understanding the problem with the paper) and was very clear that in no way is the medical student responsible. He was trusting their mentors, who work at Harvard and naturally should be trusted to guide them well.
Click to expand...
fiji128 said:
Yup, a total garbage study brought to you by a group of Harvard urologist.
Click to expand...
Harvard

iyprfQ5.png
 
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