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radoncle said:
Are the inflated prices a reflection of the technical fees mainly or both the technical and professional fees? Obviously most of the bill is technical, but if they’ve negotiated for example 500% of Medicare rates, are the professional fees also 500%?
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If doctor is not employed and is providing professional services under a PSA then the prof would run through the doc's contract with insurance while the tech would go through the hospital's separate contract. These rates could definitely be different since they are being negotiated by different entities. My guess is the locations charging these inflated rates mostly have employed physicians so probably irrelevant, but I suppose if you were truly in a setting where the hospital had that kind of leverage and they actually allowed you to bill the prof under your own tax ID you'd have some leverage to get some high multiple of Medicare.
 
Reaganite said:
If doctor is not employed and is providing professional services under a PSA then the prof would run through the doc's contract with insurance while the tech would go through the hospital's separate contract. These rates could definitely be different since they are being negotiated by different entities. My guess is the locations charging these inflated rates mostly have employed physicians so probably irrelevant, but I suppose if you were truly in a setting where the hospital had that kind of leverage and they actually allowed you to bill the prof under your own tax ID you'd have some leverage to get some high multiple of Medicare.
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I have heard rumors of hospitals telling insurance companies to bump up technical component, and take that increase out of lowering professional.
 
RickyScott said:
I have heard rumors of hospitals telling insurance companies to bump up technical component, and take that increase out of lowering professional.
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Wow. That’s pretty crazy considering the technical component is typically multiples of the professional component.
 
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United States Radiation Oncology Fellowship Growth from 2010-2020​


The uh, 11% of fellowship programs popping up in hospitals without residency programs really makes me sad...
 
thecarbonionangle said:
It is basically a backdoor to a residency because you can take a “fellow” and let them be there for four years and take boards through alternative pathway and end up BC. This is being done already.
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There's some hint in the growth of radiation oncologist numbers that there have been more ROs created than could be explained based on the number of ROs being graduated from residencies each year. The fellowship backdoor is maybe a reason for that seemingly impossible trend.

To the people that say "board certification really protects us." Oh, you think the fellows doing a fellowship at a place that doesn't even have a RO residency are NOT practicing radiation oncology and that lack of RO board certification prevents them from supervising, signing off on Rx's, etc?

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TheWallnerus said:
There's some hint in the growth of radiation oncologist numbers that there have been more ROs created than could be explained based on the number of ROs being graduated from residencies each year. The fellowship backdoor is maybe a reason for that seemingly impossible trend.

To the people that say "board certification really protects us." Oh, you think the fellows doing a fellowship at a place that doesn't even have a RO residency are NOT practicing radiation oncology and that lack of RO board certification prevents them from supervising, signing off on Rx's, etc?
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Oh it is absolutely happening. This is why these places are doing this. You get a “fellow”, often FMG, you can take advantage of and fire anytime while dangling the carrot of BC after 4 years. No Acgme protections. No problem!! We in business.
 
TheWallnerus said:
uh what the what

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I don't have a problem with this at all. Inserting a spaceOAR is not rocket science. It is a matter of having a small amount of specific knowledge regarding anatomy, imaging, and physical skills (which certainly don't require an MD to understand), and after that a matter of technical proficiency. You could theoretically train somebody who did not graduate high school to do it proficiently in a short amount of time.

Whom would you rather have inject 2 part epoxy in your butt/taint_area_CTV? A new residency grad who just spent 3 months memorizing radbio trivia like whether it's WEE1 or WEE2 that controls such and such CDK and stayed a Holiday Inn Express to learn spaceOAR and got drunk with the spaceOAR rep at Twin Peaks the night before or the NP at the urorads prostate factory who has done 700 spaceOAR insertions and does 4 a week?

Don't get me wrong, I have no love lost for NPs, but I know who I'm choosing. Absolutely a fine way to utilize midlevels if done properly.

Edit: I can't tell you have many urologists I've referred patients to for spacer placements when I couldn't do them myself and they came back so totally botched that it made the planning no better than or even worse than if I hadn't sent them for the injection.

Second edit: It's around 5 in 2 years. Not a lot but way too many IMO.
 
Turaco said:
I don't have a problem with this at all. Inserting a spaceOAR is not rocket science. It is a matter of having a small amount of specific knowledge regarding anatomy, imaging, and physical skills (which certainly don't require an MD to understand), and after that a matter of technical proficiency. You could theoretically train somebody who did not graduate high school to do it proficiently in a short amount of time.

Whom would you rather have inject 2 part epoxy in your butt/taint_area_CTV? A new residency grad who just spent 3 months memorizing radbio trivia like whether it's WEE1 or WEE2 that controls such and such CDK and stayed a Holiday Inn Express to learn spaceOAR and got drunk with the spaceOAR rep at Twin Peaks the night before or the NP at the urorads prostate factory who has done 700 spaceOAR insertions and does 4 a week?

Don't get me wrong, I have no love lost for NPs, but I know who I'm choosing. Absolutely a fine way to utilize midlevels if done properly.

Edit: I can't tell you have many urologists I've referred patients to for spacer placements when I couldn't do them myself and they came back so totally botched that it made the planning no better than or even worse than if I hadn't sent them for the injection.

Second edit: It's around 5 in 2 years. Not a lot but way too many IMO.
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I know SpaceOAR is a divisive topic for a lot of people, but that's a disingenuous argument.

Whom would you rather have inject a 2 part epoxy in your butt/taint area, an RN just hired by a UroRads prostate factory who never even heard the word "CTV" until they accidentally wandered into Dosimetry and stayed a Holiday Inn Express to learn spaceOAR and got drunk with the spaceOAR rep at Twin Peaks the night before, or the GU RadOnc who has done 700 spaceOAR insertions and does 4 a week?

Anything is easy, once you learn it, from SpaceOAR insertion to swapping out a car engine. Any sane person, for any procedure/task with some level of risk (be it SpaceOAR or installing brakes on the minivan which you drive your children in to school), will (and should) ALWAYS pick the person with more experience.

That's not the issue. The issue is we keep eroding our value to society and making ourselves unnecessary. It's one thing to have an RN triage patient calls after hours, it's one thing to have an NP diagnose an uncomplicated UTI and prescribe (relatively) appropriate antibiotics.

It's something entirely else if PROCEDURES like SpaceOAR are handed to nurses, too.
 
elementaryschooleconomics said:
I know SpaceOAR is a divisive topic for a lot of people, but that's a disingenuous argument.

Whom would you rather have inject a 2 part epoxy in your butt/taint area, an RN just hired by a UroRads prostate factory who never even heard the word "CTV" until they accidentally wandered into Dosimetry and stayed a Holiday Inn Express to learn spaceOAR and got drunk with the spaceOAR rep at Twin Peaks the night before, or the GU RadOnc who has done 700 spaceOAR insertions and does 4 a week?

Anything is easy, once you learn it, from SpaceOAR insertion to swapping out a car engine. Any sane person, for any procedure/task with some level of risk (be it SpaceOAR or installing brakes on the minivan which you drive your children in to school), will (and should) ALWAYS pick the person with more experience.

That's not the issue. The issue is we keep eroding our value to society and making ourselves unnecessary. It's one thing to have an RN triage patient calls after hours, it's one thing to have an NP diagnose an uncomplicated UTI and prescribe (relatively) appropriate antibiotics.

It's something entirely else if PROCEDURES like SpaceOAR are handed to nurses, too.
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Agree.... Would be nice for us to prove we need said 4-5 figure medical device to begin with
 
Turaco said:
I don't have a problem with this at all. Inserting a spaceOAR is not rocket science.
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elementaryschooleconomics said:
Anything is easy, once you learn it, from SpaceOAR insertion to swapping out a car engine.
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If society is going to be OK with a nurse sticking needles up a patient's butt to 1) pull tissue out to diagnose cancer, or 2) put foreign objects in to treat cancer, society should be just fine with nurses drawing circles on a CT scan, or a 3-second eyeball of a computer screen for an IGRT match.

OTN said:
Seriously. The most cost-effective SpaceOAR placement is to leave it in the box.
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Except maybe in protons where the SpaceOAR could be necessary-ish. And they say two wrongs don't make a right: not when it comes to protons and SpaceOAR!
 
I understand above objections from Wallrus and Elementary.

To answer, yes I don't care if it an MD or midlevel with the same exact experience and training on that specific procedure doing the insertion/injection/implant (not sure what the politically correct word here is, that was surprising to me that it mattered). Obviously I would prefer the experienced MD over the inexperienced midlevel. As a patient, my first question would be how many of these have you done before and how many have you screwed up? It's a simple and straightforward procedure, and like everything midlevel does, it always goes with the caveat that they known when the situation is not normal and when not to proceed or call for help.

But you don't need a $200/hour Ferrari technician to put air in the tires or top off the washer fluid in your testarossa (back in the old days when rad oncs could afford Ferrari, analogy probably lost on many now with Honda payments). Hoisting engine out of the car and change the timing belts? Yeah, probably don't let Goober do that. Is that what we're talking about here?

So, unless you're making the argument that midlevels should not exist because they are sucking away RVUs physicians could be earning themselves and you want to sign up to literally do everything, it does seem like an appropriate use. In a busy clinic, relegating duties and making efficient use of staff is important. I have seen the single-disease-site academics who have 10 patients on treatment but micromanage everything to the point that they end up staying there 60 hours a week (and make resident lives miserable too). As a procedural analogy, how it's always a PA who harvests the vein during CABG. Yeah, harvesting the saphenous vein and closing up the chest seems like something an MD should be doing, but that midlevel is likely damn good at doing those specific things he/she/etc does all day every day.

I think it's a huge leap to from if we allow midlevels to insert spaceOAR then next they will be drawing target volumes and signing off on plans. One of those things is not like the other! We all know it's not just "drawing circles" and that competently creating volumes and sparing OARs while factoring individual patient circumstances requires the full breadth of our decade long medical training. Inserting spaceOAR does not IMO.

Regarding the hate for spaceOAR, did I miss something? Is it that people don't believe the randomized data, don't believe it's worth it because that's the way we always did it before (presumably without things like ultrahypofractionation, dose escalation, and focal boosts), or that it's a waste of money (in which case it seems odd to simultaneously argue that we are losing procedural revenue to midlevels (presumably in a setting where your compensation is RVU-based)? Or just a couple of anecdotes of bad placements? Compared to the rest of what we do, it's bizarre that we are treating it like a highly risky procedure.
 
medgator said:
Agree.... Would be nice for us to prove we need said 4-5 figure medical device to begin with
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I don't know man, it seems like dramatically lowering the rectal dose is at least a priori a good thing. Or maybe we believe in the magic that allows us to shave a few mm off our posterior PTV margins but not in any other direction. Or maybe I've been partying too hard with the spaceOAR rep.
 
Turaco said:
I don't know man, it seems like dramatically lowering the rectal dose is at least a priori a good thing. Or maybe we believe in the magic that allows us to shave a few mm off our posterior PTV margins but not in any other direction. Or maybe I've been partying too hard with the spaceOAR rep.
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Pretty sure my 4-6 mm margins on the rectum the last decade+ have been doing OK.... Were people seriously noticing high rates of proctitis before the advent of spaceOAR?
 
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Turaco said:
I don't know man, it seems like dramatically lowering the rectal dose is at least a priori a good thing. Or maybe we believe in the magic that allows us to shave a few mm off our posterior PTV margins but not in any other direction. Or maybe I've been partying too hard with the spaceOAR rep.
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I think the SpaceOAR reps have done a great job promoting their product. I’ve stopped using them about 2 years ago and haven’t seen any significant difference in outcomes or in regards to toxicities. Yes, this is all anecdotal and I might just be killing all of my patient’s rectums but thus far no issues.
 
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medgator said:
@Turaco this is my biggest problem. I've personally seen a colostomy happen thanks to a spaceOAR complication (abscess). Never happened in the several years before when i treated with IMRT
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It's not 2 outta 3 I misspoke on that but it's a lot higher than is admitted, up to and including death as a SpaceOAR toxicity.
 
medgator said:
@Turaco this is my biggest problem. I've personally seen a colostomy happen thanks to a spaceOAR complication (abscess). Never happened in the several years before when i treated with IMRT
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I understand how that could change things, especially if you are new to placing spaceOAR and did that one yourself. It would be hard to convince oneself to continue doing them especially if you did it yourself and only had a few under your belt.

But that's a very rare complication. Why do you think it happened and when did it occur?
 
TheWallnerus said:
It's not 2 outta 3 I misspoke on that but it's a lot higher than is admitted, up to and including death as a SpaceOAR toxicity.
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Major Complications and Adverse Events Related to the Injection of the SpaceOAR Hydrogel System Before Radiotherapy for Prostate Cancer: Review of the Manufacturer and User Facility Device Experience Database - PubMed (nih.gov)

It would be interesting to better quantify the rare major toxicities and correlate them with improper placement, operator technique, and procedural experience. Your linked article suggests that some believe there is inherent danger of spaceOAR even when placed perfectly (changing the inherent radio sensitivity of the rectal parenchyma... huh? I would have to ask them explain please) Which is why I would care more about the track record of the person putting that stuff up in me. As I said, I've had bad luck letting patients go to their urologist to have this done (but the bad luck has been in the form of not enough material injected to be useful or not along enough of the prostate to be useful, or asymmetrically displacing the rectum). One guy wanted to do it transrectally and tried to convince me why that was ok. My hunch is the bad outcomes are related to pilot error.
 
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TheWallnerus said:
Ha. I know.
Why happened: implanted foreign body near stool-holding bowel.
When: almost certainly within 90 days of SpaceOAR insertion.
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No, I mean was it a proper insertion, were antibiotics given appropriately, was proper prep performed, were there other patient factors that were ignored, did you send to an incompetent urologist like my guy who wanted to do it transrectally, etc? Or was it a late complication that would bolster the argument that spaceOAR alters the rectum's tolerance to radiation (somehow? and so much so that it outweighs the dose reduction benefit)
 
Not to be too tangential but maybe SpaceoOAR would be clinically meaningful if there is a DIL that's close to the rectum and boosting a la (hypo)FLAME becomes more standard.

Caveat being more likely to benefit in high.risk prostate where SpaceOAR is relatively contraindicated.

I'm personally trying to do more SpaceOAR because maybe it'll be marketable for my eventual job search.
 
brushbeamscanning said:
Not to be too tangential but maybe SpaceoOAR would be clinically meaningful if there is a DIL that's close to the rectum and boosting a la (hypo)FLAME becomes more standard.

Caveat being more likely to benefit in high.risk prostate where SpaceOAR is relatively contraindicated.

I'm personally trying to do more SpaceOAR because maybe it'll be marketable for my eventual job search.
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Last time I looked into this, I could not find any good data to suggest spaceOAR should not be done in high risk patients. Just a theoretical concern that you could push a small amount of ECE out of the high dose fields. These patients will all be getting ADT and are at risk for distant failures. Additionally, if you are doing DIL boost, which is presumably in perhipheral zone abutting rectum, you can put spaceOAR in to boost it and still cover the hydrogel with enough dose to control microscopic disease. You're not really sparing rectum as much by doing this but allowing you to more safely dose escalate the DIL. The fear is that your imaging is not good enough to tell if the rectum isn't wrapping around the edges of the gel and invaginating back into the high dose region, or worse, if some of the gel got inserted into mucosa and is tricking you into thinking the rectum is spared and you blast away.

Would be interested to see if there is any data showing peri-rectal local failures in high risk patients with spaceOAR. I certainly would not boost a lesion abutting rectum to 95 Gy without it.
 
Turaco said:
Last time I looked into this, I could not find any good data to suggest spaceOAR should not be done in high risk patients. Just a theoretical concern that you could push a small amount of ECE out of the high dose fields. These patients will all be getting ADT and are at risk for distant failures. Additionally, if you are doing DIL boost, which is presumably in perhipheral zone abutting rectum, you can put spaceOAR in to boost it and still cover the hydrogel with enough dose to control microscopic disease. You're not really sparing rectum as much by doing this but allowing you to more safely dose escalate the DIL. The fear is that your imaging is not good enough to tell if the rectum isn't wrapping around the edges of the gel and invaginating back into the high dose region, or worse, if some of the gel got inserted into mucosa and is tricking you into thinking the rectum is spared and you blast away.

Would be interested to see if there is any data showing peri-rectal local failures in high risk patients with spaceOAR. I certainly would not boost a lesion abutting rectum to 95 Gy without it.
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FLAME was a non-SpaceOAR-using study. The late gr2+ GI toxicity in FLAME was 13% with a boost, and 12% without the scary boost, for an absolute differential of 1%. Which means any intervention looking to close this gap has a number-need-to-treat (NNT) of 100, which as you know is a very high number in NNT land. And you think you can implant SpaceOAR, with toxicity risks that are clearly greater than XRT itself, and hope to have the NNT for rectal toxicity reduction with SpaceOAR in a FLAME approach to get in the, optimistically, 100-to-200 range?

GOOD LUCK. One can dream!

VsZY29B.png
 
TheWallnerus said:
FLAME was a non-SpaceOAR-using study. The late gr2+ GI toxicity in FLAME was 13% with a boost, and 12% without the scary boost, for an absolute differential of 1%. Which means any intervention looking to close this gap has a number-need-to-treat (NNT) of 100, which as you know is a very high number in NNT land. And you think you can implant SpaceOAR, with toxicity risks that are clearly greater than XRT itself, and hope to have the NNT for rectal toxicity reduction with SpaceOAR in a FLAME approach to get in the, optimistically, 100-to-200 range?

GOOD LUCK. One can dream!

VsZY29B.png
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I hear you. But FLAME went to pretty dramatic lengths to prioritize rectal sparing and sacrifice target coverage in questionable areas. This likely explains the GI tox rates you pointed out. Would be interesting to see the effects of such a boost with better target coverage in the presence of a spacer (and of course the trial/experiment of giving 100% boost GTV coverage regardless of rectal dose without a spacer will probably never be done). It is curious to state that spaceOAR has toxicity risks greater than RT itself in the setting of data that shows that spaceOAR lowers GI toxicity.

Of course, if you are doing the same GTV shaving and plan adjusting that FLAME did in the presence of spaceOAR, you are probably not going get that NNT you are talking about. But that's not what I'm talking about!

I am certainly open to revisiting spaceOAR but I'm just not seeing the evidence to abandon right now.
 
Turaco said:
I am certainly open to revisiting spaceOAR but I'm just not seeing the evidence to abandon right now.
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I'm not seeing the evidence to consider it either. I've done about 5-10 cases and didn't see any difference. I follow my patients long term and gi toxicity hasn't been a real issue for me with either conventional or hypofx.

Once i saw the MAUDE data plus a high risk pt ending up with colostomy (wasn't my placement), along with the costs involved of placing, i stopped doing it
 
Turaco said:
I hear you. But FLAME went to pretty dramatic lengths to prioritize rectal sparing and sacrifice target coverage in questionable areas. This likely explains the GI tox rates you pointed out. Would be interesting to see the effects of such a boost with better target coverage in the presence of a spacer (and of course the trial/experiment of giving 100% boost GTV coverage regardless of rectal dose without a spacer will probably never be done). It is curious to state that spaceOAR has toxicity risks greater than RT itself in the setting of data that shows that spaceOAR lowers GI toxicity.

Of course, if you are doing the same GTV shaving and plan adjusting that FLAME did in the presence of spaceOAR, you are probably not going get that NNT you are talking about. But that's not what I'm talking about!

I am certainly open to revisiting spaceOAR but I'm just not seeing the evidence to abandon right now.
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eh it's piddling business to read and look at the results of a randomized trial and then think: they did that trial a bit wrong and I shall now bring to bear my unique flavor and insights to improve on their reported results.
 
Turaco said:
It is curious to state that spaceOAR has toxicity risks greater than RT itself in the setting of data that shows that spaceOAR lowers GI toxicity.
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SpaceOAR *at best* lowers GI toxicities by 5%, and that's an NNT of 20. You have to implant SpaceOAR in 20 patients to help 1 avoid XRT GI toxicity severity (roughly). So the "number needed to harm" with SpaceOAR-less XRT for severe GI toxicity is 20. But what is the number needed to harm for SpaceOAR vs XRT for things like pulmonary emboli, or abscesses, or death. This is where the space exists (pun) to argue that SpaceOAR is not worth it and using it brings more toxicity overall than not.
 
I don't think they did the trial wrong. There was an impressive benefit with a boost to the DIL which they went to great lengths to prioritize OAR constraints (primarily bladder/rectal interface) where ~50% of patients ere not able to achieve the planned boost dosage.

In the scenario where boosting a DIL is more commonly adopted/standardized, spaceOAR maybe one method to further improve outcomes for a carefully selected subset (I will admit this is a very small subset). The GI toxicities are in the scenario of standard dose fractionation, not in the situations of further dose-escalation where they will likely be a more apparent benefit.
 
The concept of FLAME (and some other trials, for instance PET-PLAN) is isotoxic dose escalation.
Which basically means that you keep the dose constraints more or less the same in both trial arms and push for higher doses in the experimental, knowing that you will not be able to deliver the envisioned dose everywhere in the PTV because of the dose constraints you've set.
It's an excellent and very logical concept in my opinion.
 
TheWallnerus said:
FLAME was a non-SpaceOAR-using study. The late gr2+ GI toxicity in FLAME was 13% with a boost, and 12% without the scary boost, for an absolute differential of 1%. Which means any intervention looking to close this gap has a number-need-to-treat (NNT) of 100, which as you know is a very high number in NNT land. And you think you can implant SpaceOAR, with toxicity risks that are clearly greater than XRT itself, and hope to have the NNT for rectal toxicity reduction with SpaceOAR in a FLAME approach to get in the, optimistically, 100-to-200 range?

GOOD LUCK. One can dream!

VsZY29B.png
Click to expand...
I'm not particularly a fan of SpaceOAR either, but I think the point of SpaceOAR in context of FLAME would be to reduce that 13% without SpaceOAR to X% with SpaceOAR. It's not going to help everyone but proportionally it could help those SIBs that abut the rectum, and presumably their NNTs would be considerably lower. But for GTVs not near the rectum, I agree with you, the NNT would be even higher.
 
FrostyHammer said:
I'm not particularly a fan of SpaceOAR either, but I think the point of SpaceOAR in context of FLAME would be to reduce that 13% without SpaceOAR to X% with SpaceOAR. It's not going to help everyone but proportionally it could help those SIBs that abut the rectum, and presumably their NNTs would be considerably lower. But for GTVs not near the rectum, I agree with you, the NNT would be even higher.
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This is exactly what I was saying except probably in an easier to understand way.

Edit: I did not realize before discussion here there was such vitriol for spaceOAR in the rad onc community. I have not really observed it in IRL. It's either support or indifference.
 
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TheWallnerus said:
SpaceOAR *at best* lowers GI toxicities by 5%, and that's an NNT of 20. You have to implant SpaceOAR in 20 patients to help 1 avoid XRT GI toxicity severity (roughly). So the "number needed to harm" with SpaceOAR-less XRT for severe GI toxicity is 20. But what is the number needed to harm for SpaceOAR vs XRT for things like pulmonary emboli, or abscesses, or death. This is where the space exists (pun) to argue that SpaceOAR is not worth it and using it brings more toxicity overall than not.
Click to expand...

You are also assuming the benefit behaves in a stepwise fashion. I.e. you either get the toxicity or you don't. Perhaps there is more nuance to it that makes analyzing it from a simple NNT calculation not explain the full story (non-stochastic situation that shows increased benefit with decreasing rectal dose):

"At 3 years, more men in the control group than in the spacer group had experienced a MID decline in bowel QOL (41% vs 14%; P=.002) and urinary QOL (30% vs 17%; P=.04). Furthermore, the control group were also more likely to have experienced large declines (twice the MID) in bowel QOL (21% vs 5%; P=.02) and urinary QOL (23% vs 8%; P=.02)."

So maybe think about how we are determining toxicity grading and QOL and why is there such a dramatic improvement in the QOL stat but a more modest but still solidly significant improvement in graded toxicity ((9.2% vs 2.0%; P=.028) and grade ≥2 (5.7% vs 0%; P=.012))

In other words, I don't fully buy the "if you put a spaceOAR in 20 people then exactly 1 person will benefit and the other 19 will derive exactly zero benefit at all." I also don't think we have enough data at this point to confidently say that the benefit is "at best" 5%. In fact, in the 2017 update showed an absolute benefit of 7.2%. And in the 2015 paper you linked, of 222 men, they reported zero " device-related adverse events, rectal perforations, serious bleeding, or infections." So you can do the math on that. If you believe your NNT analysis of 20:1, then given 0 of 222 harmed, it would seem that NNR is much higher than 20:1, no?
 
Turaco said:
You are also assuming the benefit behaves in a stepwise fashion. I.e. you either get the toxicity or you don't. Perhaps there is more nuance to it that makes analyzing it from a simple NNT calculation not explain the full story (non-stochastic situation that shows increased benefit with decreasing rectal dose):

"At 3 years, more men in the control group than in the spacer group had experienced a MID decline in bowel QOL (41% vs 14%; P=.002) and urinary QOL (30% vs 17%; P=.04). Furthermore, the control group were also more likely to have experienced large declines (twice the MID) in bowel QOL (21% vs 5%; P=.02) and urinary QOL (23% vs 8%; P=.02)."

So maybe think about how we are determining toxicity grading and QOL and why is there such a dramatic improvement in the QOL stat but a more modest but still solidly significant improvement in graded toxicity ((9.2% vs 2.0%; P=.028) and grade ≥2 (5.7% vs 0%; P=.012))

In other words, I don't fully buy the "if you put a spaceOAR in 20 people then exactly 1 person will benefit and the other 19 will derive exactly zero benefit at all." I also don't think we have enough data at this point to confidently say that the benefit is "at best" 5%. In fact, in the 2017 update showed an absolute benefit of 7.2%. And in the 2015 paper you linked, of 222 men, they reported zero " device-related adverse events, rectal perforations, serious bleeding, or infections." So you can do the math on that. If you believe your NNT analysis of 20:1, then given 0 of 222 harmed, it would seem that NNR is much higher than 20:1, no?
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How about this math.
Reported deaths in literature from SpaceOAR insertion: N≥1
Reported deaths in literature from prostate IMRT: N=0

You can't fool a Norwegian!

Or attorneys.
 
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TheWallnerus said:
How about this math.
Reported deaths in literature from SpaceOAR insertion: N≥1
Reported deaths in literature from prostate IMRT: N=0

You can't fool a Norwegian!

Or attorneys.
Click to expand...

wait so I should publish my series of fatalities (n=2, thus a series) related to bladder perforation in the setting of refractory radiation cystitis after imrt for prostate cancer? 😘
 
DoctwoB said:
wait so I should publish my series of fatalities (n=2, thus a series) related to bladder perforation in the setting of refractory radiation cystitis after imrt for prostate cancer? 😘
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I would. Maybe we should start squirting the hydrogel at the prostate base too. In reality, it may take full prostatic hydrogel entombment for adequate normal tissue protection.
 
DoctwoB said:
wait so I should publish my series of fatalities (n=2, thus a series) related to bladder perforation in the setting of refractory radiation cystitis after imrt for prostate cancer? 😘
Click to expand...
Radiation cystitis after salvage radiation doesn’t happen
 
DoctwoB said:
wait so I should publish my series of fatalities (n=2, thus a series) related to bladder perforation in the setting of refractory radiation cystitis after imrt for prostate cancer? 😘
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I'm sure it'll get accepted by the top urological journal which will use that as high quality evidence to withhold RT referrals even more than they already do. Everyone loves to hear what they want to hear, journals are no exception, and surgical journals are certainly no exception.
 
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