Rad Onc Twitter

[thecarbonionangle]

Urologists always seem to think they can “talk” about radiation. They “talk” to them about our modality in bladder and prostate and not surprisingly they chose surgery. No need to see a rad onc, you know. I loved that latest Lancet trimodality vs surgery paper. Some specialists are allergic to “data”.

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[BobbyHeenan]

Urologists always seem to think they can “talk” about radiation. They “talk” to them about our modality in bladder and prostate and not surprisingly they chose surgery. No need to see a rad onc, you know. I loved that latest Lancet trimodality vs surgery paper. Some specialists are allergic to “data”.

I really wish NCCN and/or CoC accreditation standards would include - patients were seen (or offered) rad onc appointment for all localized prostate and bladder cases.

I believe Australia has started this type of push/movement. Would love to see it here. It would massively increase clinic demands, but would absolutely shift the % of patients choosing xrt over surgery.

 

[medgator]

Urologists always seem to think they can “talk” about radiation. They “talk” to them about our modality in bladder and prostate and not surprisingly they chose surgery. No need to see a rad onc, you know. I loved that latest Lancet trimodality vs surgery paper. Some specialists are allergic to “data”.

At least that's still in the guidelines. What about the shysters freezing it or doing hifu upfront?

 

[TheWallnerus]

At least that's still in the guidelines. What about the shysters freezing it or doing hifu upfront?

Florida… so much sunshine… so many partially frozen prostates.

 

[DoctwoB]

You talkin' bout radiation? Or referring all your non low-risk patients reflexively to a Radiation Oncologist?

I do give the full unbiased (IMO) radiation spiel and offer rad-onc referral to all patients. About half my patients end up with some form of radiation, either brachy or xrt or combo. Of those that opt for surgery, about half accept the radonc referral to dive further into it, about half are deadset.

 

[DoctwoB]

Urologists always seem to think they can “talk” about radiation. They “talk” to them about our modality in bladder and prostate and not surprisingly they chose surgery. No need to see a rad onc, you know. I loved that latest Lancet trimodality vs surgery paper. Some specialists are allergic to “data”.

I'm sure there are a lot of urologists pushing poor information about radiation. I know I've seen many radoncs pushing incorrect information about surgery.

 

[sirspamalot]

I know I've seen many radoncs pushing incorrect information about surgery.

 

[thecarbonionangle]

I'm sure there are a lot of urologists pushing poor information about radiation. I know I've seen many radoncs pushing incorrect information about surgery.

In the words of BHO to Mitt, “please proceed!”

 

[Ray D. Ayshun]

I'm sure there are a lot of urologists pushing poor information about radiation. I know I've seen many radoncs pushing incorrect information about surgery.

I tell them that if they have surgery, they won't be able to have surgery in the future. Other things they won't be able to have include erections and dry underwear. In all seriousness, I just defer toxicity discussion to the surgeon in the rare instance the local urologist who doesn't operate hasn't already told them what to do.

 

[TheWallnerus]

I'm sure there are a lot of urologists pushing poor information about radiation. I know I've seen many radoncs pushing incorrect information about surgery.

 

[DoctwoB]

In the words of BHO to Mitt, “please proceed!”

Like i'm sure with urologists giving poor information about radiation, it has more to do with how the information is presented.

"I was told if i had surgery i would be incontinent forever / never have an erection again / dramatically shorten my penis." Is the usual one i've heard.

All possible side effects, but neglecting to mention the probabilities of recovery, the nuances of partial recovery, the fact that shortening goes away over time with no difference compared to xrt 2 years post op. Now granted, I am hearing this from the patient, maybe the radonc gave a reasonable discussion about risks of SUI and timecourse and degree of recovery and "I WILL LEAK FOREVER" is all they took away.

Likewise Urologists could say post xrt "there is a real chance it will cause cancer / you will have a lot more trouble holding your pee and have accidents and wake up 10 times a night to pee / have chronic diarrhea and bowel symptoms"

Correct side effects presented incorrectly or misleadingly is essentially the same as just lying.

 

[TheWallnerus]

Like i'm sure with urologists giving poor information about radiation, it has more to do with how the information is presented.

"I was told if i had surgery i would be incontinent forever / never have an erection again / dramatically shorten my penis." Is the usual one i've heard.

All possible side effects, but neglecting to mention the probabilities of recovery, the nuances of partial recovery, the fact that shortening goes away over time with no difference compared to xrt 2 years post op. Now granted, I am hearing this from the patient, maybe the radonc gave a reasonable discussion about risks of SUI and timecourse and degree of recovery and "I WILL LEAK FOREVER" is all they took away.

Likewise Urologists could say post xrt "there is a real chance it will cause cancer / you will have a lot more trouble holding your pee and have accidents and wake up 10 times a night to pee / have chronic diarrhea and bowel symptoms"

Correct side effects presented incorrectly or misleadingly is essentially the same as just lying.

Doubt anybody lying tbh. I think asking a patient what the other doctor REALLY told them is a form of the telephone game.

 

[sirspamalot]

Most urologists do not represent radiation in a rational fair manner.. unless of course.. they own linacs. Then of course, radiation seems like a gift from the skies compared to surgery.

 

[TheWallnerus]

Most urologists do not represent radiation in a rational fair manner.. unless of course.. they own linacs. Then of course, radiation seems like a gift from the skies compared to surgery.

You should see how urologists with linacs love bladder preservation all of a sudden. I have seen it. It was quite humorous.

DoctwoB hope you take nothing personal, we are glad you come here. You are unique among urologists re rad onc though.

 

[communitydoc13]

Most community urologists in my area are judicious and none own linacs. I am all for younger men (60 down) with intermediate risk pCa getting surgery. There may be cases for high risk as well (particularly in the 50 y/o crowd). There is a lot of gray zone.

I have found some fairly prominent academic centers in my region to be markedly overaggressive with surgery in men around 70 with high risk or very high risk disease. These men always come back to me however. Recovery in these men can be hard. The community urologists have no interest in dealing with this.

 

[TheWallnerus]

Most community urologists in my area are judicious and none own linacs.

So... are they really that judicious? 🤑

 

[NotMattSpraker]

Urologists always seem to think they can “talk” about radiation. They “talk” to them about our modality in bladder and prostate and not surprisingly they chose surgery. No need to see a rad onc, you know. I loved that latest Lancet trimodality vs surgery paper. Some specialists are allergic to “data”.

Thoracic oncologists from every specialty including RO have been a little embarrassing on Twitter these days. I mean no offense, my opinion mannnnnn.

 

[sirspamalot]

Thoracic oncologists from every specialty

Uh, what?

 

[RadOncDoc21]

Most urologists do not represent radiation in a rational fair manner.. unless of course.. they own linacs. Then of course, radiation seems like a gift from the skies compared to surgery.

Same with neurosurgeons… all of a sudden SRS is a great option compared to surgery when they can bill out the same.

Maybe the saving grace is to have all docs receive technical billing (oh wait there’s stark law). It’s funny how only in medicine, we are unable to give incentives. Out in the real world, business deals are done and nobody blinks an eye.

 

[medgator]

Same with neurosurgeons… all of a sudden SRS is a great option compared to surgery when they can bill out the same.

Maybe the saving grace is to have all docs receive technical billing (oh wait there’s stark law). It’s funny how only in medicine, we are unable to give incentives. Out in the real world, business deals are done and nobody blinks an eye.

Just need everyone under the same tax ID and you're golden

 

[NotMattSpraker]

Uh, what?

Surgical, medical, and radiation oncologists that treat cancers in the thorax?

 

[thecarbonionangle]

Thoracic oncologists from every specialty including RO have been a little embarrassing on Twitter these days. I mean no offense, my opinion mannnnnn.

“Chaos is a ladder”

 

[Gfunk6]

The best way to encourage Urologists to support a Rad Onc consultation is to cut them a share of IMRT profits. Boom! Instant change overnight

 

[Fpg1245]

The best way to encourage Urologists to support a Rad Onc consultation is to cut them a share of IMRT profits. Boom! Instant change overnight

But seriously that’s all it takes. I’ve seen it first hand

 

[TheWallnerus]

The best way to encourage Urologists to support a Rad Onc consultation is to cut them a share of IMRT profits. Boom! Instant change overnight

But seriously that’s all it takes. I’ve seen it first hand

Realistic thinking would save our specialty.

We need to take a leaf from the PGA/LIV book!

 

[sirspamalot]

Sell out for blood money?

 

[medgator]

The best way to encourage Urologists to support a Rad Onc consultation is to cut them a share of IMRT profits. Boom! Instant change overnight

ASTRO was very misguided on the anti-urorads campaign. Would have cut inappropriate patterns of care with surgery/cryo/hifu overnight.

They just couldn't see past their own noses in the air

 

[Fpg1245]

ASTRO was very misguided on the anti-urorads campaign. Would have cut inappropriate patterns of care with surgery/cryo/hifu overnight.

They just couldn't see past their own noses in the air

Are these urorads just running their machines into the ground? I mean they have to be about 10 years old on average at this point.

 

[RadOncDoc21]

Are these urorads just running their machines into the ground? I mean they have to be about 10 years old on average at this point.

Oh man, 10 years is nothing… I’ve seen some “IMRT” being delivered without any kind of useful imaging. I had a physicist tell me that these machines can actually last forever.

 

[TheWallnerus]

Are these urorads just running their machines into the ground? I mean they have to be about 10 years old on average at this point.

Oh man, 10 years is nothing… I’ve seen some “IMRT” being delivered without any kind of useful imaging. I had a physicist tell me that these machines can actually last forever.

The first fiducial-able IGRT I know of was the Exactrac system which I think first appeared around 2000 or 2001. A special code for it appeared in 2005 but was absorbed into a CPT code specific for kV X-ray Jan 1, 2006. Kupelian was doing prostate IGRT routinely before almost anyone on a pretty simple (the Novalis) linac with Exactrac. In 2006 Varian first started placing OBI on a linac. CBCT wasn’t really clinically usable though until 2007 once a lot of software bugs had been corrected.

 

[sirspamalot]

I remember when Dr. Martinez told me that OBI (in development, but I saw it on the monitor) would be the future when I did a visit at Beaumont circa 2002 or whatever (1st HDR prostate symposium). I was boggled, as of course.. we were still drawing wax on big films.

Imagine showing a resident one of those today. Laughter and pointing at us dinosaurs..

 

[OTN]

Oh man, 10 years is nothing… I’ve seen some “IMRT” being delivered without any kind of useful imaging. I had a physicist tell me that these machines can actually last forever.

While the machines may last forever, the service contracts do not

 

[medgator]

Are these urorads just running their machines into the ground? I mean they have to be about 10 years old on average at this point.

A lot of them are using iX with rapid arc or just upgrading to halcyon which is way cheaper than any standard linac off the shelf

 

[evilbooyaa]

I do give the full unbiased (IMO) radiation spiel and offer rad-onc referral to all patients. About half my patients end up with some form of radiation, either brachy or xrt or combo. Of those that opt for surgery, about half accept the radonc referral to dive further into it, about half are deadset.

Great to hear!

I'm sure there are a lot of urologists pushing poor information about radiation. I know I've seen many radoncs pushing incorrect information about surgery.

Like i'm sure with urologists giving poor information about radiation, it has more to do with how the information is presented.

"I was told if i had surgery i would be incontinent forever / never have an erection again / dramatically shorten my penis." Is the usual one i've heard.

All possible side effects, but neglecting to mention the probabilities of recovery, the nuances of partial recovery, the fact that shortening goes away over time with no difference compared to xrt 2 years post op. Now granted, I am hearing this from the patient, maybe the radonc gave a reasonable discussion about risks of SUI and timecourse and degree of recovery and "I WILL LEAK FOREVER" is all they took away.

Likewise Urologists could say post xrt "there is a real chance it will cause cancer / you will have a lot more trouble holding your pee and have accidents and wake up 10 times a night to pee / have chronic diarrhea and bowel symptoms"

Correct side effects presented incorrectly or misleadingly is essentially the same as just lying.

What was probably told to the patient is that surgery has a higher risk of permanent erectile dysfunction and urinary incontinence than radiation. I do the same. Patient probably worries about that risk and fixates on it... I don't really mention the penis shortening thing when I'm talking abou tsurgery. I also tell patients that radiation has a higher chance of urinary irritative symptoms and rectal symptoms.

I usually then conveniently point out that the American Urological Association (AUA) form for symptoms asks about all the things that radiation causes at higher rates in management of prostate cancer, but NOT the one urinary symptoms that Urologists would cause in management of prostate cancer.

Most community urologists in my area are judicious and none own linacs. I am all for younger men (60 down) with intermediate risk pCa getting surgery. There may be cases for high risk as well (particularly in the 50 y/o crowd). There is a lot of gray zone.

I have found some fairly prominent academic centers in my region to be markedly overaggressive with surgery in men around 70 with high risk or very high risk disease. These men always come back to me however. Recovery in these men can be hard. The community urologists have no interest in dealing with this.

In regards to the bolded, but WHY? This is DOGMA that is unfounded in data. And if we do nothing else on SDN, we challenge DOGMA for the sake of DOGMA.

I would LOVE to be educated why someone in their 50s (usually those who are MOST enthusiastic to minimize long-term erectile dysfunction) should 'preferentially' get surgery as opposed to radiation. Not saying surgery is wrong, but why is radiation considered wrong in a man under 50, or 60, or whatever cut-off one wants to use?

A lot of them are using iX with rapid arc or just upgrading to halcyon which is way cheaper than any standard linac off the shelf

Halcyon seems to be an excellent machine for a Urorads shop that is starting up or looking for a replacement.. Fast and pretty reliable.

 

[evilbooyaa]

Thoracic oncologists from every specialty including RO have been a little embarrassing on Twitter these days. I mean no offense, my opinion mannnnnn.

The whole Spicer, Forde, Mogahanaki, Stiles thing (and their minions) feels very cringey to me.

 

[sirspamalot]

If you're in your 50's and you want to have a shot at some erectile function, rads be the way.

Walsh's Oncologic Sparing Prostatectomy aside.. there ain't no way. And yet.. a couple patients after prostatectomy swore they had full erections. Wife was not in the room to confirm.

 

[DoctwoB]

If you're in your 50's and you want to have a shot at some erectile function, rads be the way.

Walsh's Oncologic Sparing Prostatectomy aside.. there ain't no way. And yet.. a couple patients after prostatectomy swore they had full erections. Wife was not in the room to confirm.

And yet, PROTECT trial showed no difference in erectile function at 2 years. Are you counselling your patients as such?

As for age and XRT for prostate cancer, I do agree that it is not an absolute contraindication. However:

1. The younger you are, the better you recover from surgery. continence outcomes, ED outcomes, etc. are all better at 50 then 60 then 70.
2. The younger you are, the more years you have ahead of you for XRT to mess things up. Secondary cancers. Radiation cystitis. urethral strictures. ureteral strictures. Non-radiation induced cancers (after all, plenty of rectal and bladder cancers in men with no prior XRT) with treatment complicated by prior radiation. and so on. Many on this forum poo-poo these problems, but I deal with them LITERALLY every day. Plenty of guys out there with radiation many years ago with late onset issues like this. Maybe your radiation didn't cause a urethral stricture. But maybe they had a traumatic catheter put in 15 years later that did because they had prior radiation. Or maybe they passed a kidney stone and developed a ureteral stricture afterwards. And now they're proper F*ck**, since endoscopic surgical treatments of post-radiation strictures have a failure rate approaching 100%. XRT is the gift that keeps on giving, and patients (and urologists who take call) are often the recipients. Since I started my practice 3 years ago, I've had dozens if not hundreds of surgical cases related to long term complications of radiation. 0 related to sequalae of prostatectomy.

So comparing a 50 year old to a 70 year old, surgery is relatively lower risk and radiation higher risk for the younger patient, and the reverse is true.

 

[RadOncDoc21]

And yet, PROTECT trial showed no difference in erectile function at 2 years. Are you counselling your patients as such?

As for age and XRT for prostate cancer, I do agree that it is not an absolute contraindication. However:

1. The younger you are, the better you recover from surgery. continence outcomes, ED outcomes, etc. are all better at 50 then 60 then 70.
2. The younger you are, the more years you have ahead of you for XRT to mess things up. Secondary cancers. Radiation cystitis. urethral strictures. ureteral strictures. Non-radiation induced cancers (after all, plenty of rectal and bladder cancers in men with no prior XRT) with treatment complicated by prior radiation. and so on. Many on this forum poo-poo these problems, but I deal with them LITERALLY every day. Plenty of guys out there with radiation many years ago with late onset issues like this. Maybe your radiation didn't cause a urethral stricture. But maybe they had a traumatic catheter put in 15 years later that did because they had prior radiation. Or maybe they passed a kidney stone and developed a ureteral stricture afterwards. And now they're proper F*ck**, since endoscopic surgical treatments of post-radiation strictures have a failure rate approaching 100%. XRT is the gift that keeps on giving, and patients (and urologists who take call) are often the recipients. Since I started my practice 3 years ago, I've had dozens if not hundreds of surgical cases related to long term complications of radiation. 0 related to sequalae of prostatectomy.

So comparing a 50 year old to a 70 year old, surgery is relatively lower risk and radiation higher risk for the younger patient, and the reverse is true.

Nah bruh… don’t want to brag but my patients be like “that was way better then I expected, thank you Dr RadOncDoc21, you’re the best!”

 

[taserlaser]

While the machines may last forever, the service contracts do not

At risk of doxing myself, we once had such an old machine here we blew a hole right through the target. Pretty sure I saw it on a trophy in the department at one point.

 

[thecarbonionangle]

Putting on ASTRO shill hat: If any patient below 50 “should” have surgery for PCA because of the horrible side effects of radiation which have caused “hundreds” of surgeries for our colleagues while enriching them and we are so worried about secondary malignancy, shouldn’t all patients below 50 have protons? NAPT and ASTRO secret proton cabal might say so!! An echo of an evil chair laugh is heard in background

 

[CaesarRO]

And yet, PROTECT trial showed no difference in erectile function at 2 years. Are you counselling your patients as such?

As for age and XRT for prostate cancer, I do agree that it is not an absolute contraindication. However:

1. The younger you are, the better you recover from surgery. continence outcomes, ED outcomes, etc. are all better at 50 then 60 then 70.
2. The younger you are, the more years you have ahead of you for XRT to mess things up. Secondary cancers. Radiation cystitis. urethral strictures. ureteral strictures. Non-radiation induced cancers (after all, plenty of rectal and bladder cancers in men with no prior XRT) with treatment complicated by prior radiation. and so on. Many on this forum poo-poo these problems, but I deal with them LITERALLY every day. Plenty of guys out there with radiation many years ago with late onset issues like this. Maybe your radiation didn't cause a urethral stricture. But maybe they had a traumatic catheter put in 15 years later that did because they had prior radiation. Or maybe they passed a kidney stone and developed a ureteral stricture afterwards. And now they're proper F*ck**, since endoscopic surgical treatments of post-radiation strictures have a failure rate approaching 100%. XRT is the gift that keeps on giving, and patients (and urologists who take call) are often the recipients. Since I started my practice 3 years ago, I've had dozens if not hundreds of surgical cases related to long term complications of radiation. 0 related to sequalae of prostatectomy.

So comparing a 50 year old to a 70 year old, surgery is relatively lower risk and radiation higher risk for the younger patient, and the reverse is true.

As has been said. Very much appreciate your willingness to come here and share your perspective. Very valuable.

Two questions:
1) wrt "I see it every day" -- do you notice any patterns with the technique used or you don't dive that deep? I have heard of places still doing 4 field box with a subsequent cone down even today. I'd expect a lot more toxicity with something like that vs IMRT all the way through.
2) as a youngish Rad Onc I do worry that we under capture the late late toxicities. Like 30-40 years later.

I think we see the counter examples of over aggressive surgeons. My biggest frustration is the highest risk cases where it's clear the patient would still need RT and ADT post op and the surgeon convinces the patient surgery is still a benefit. Haven't seen any data that trimodality adds any benefits to RT+ADT in high/very high risk.

 

[dieABRdie]

Are these urorads just running their machines into the ground? I mean they have to be about 10 years old on average at this point.

They buy a Halcyon and burn through 50-60 patients a day on one machine....

 

[elementaryschooleconomics]

1) wrt "I see it every day" -- do you notice any patterns with the technique used or you don't dive that deep? I have heard of places still doing 4 field box with a subsequent cone down even today. I'd expect a lot more toxicity with something like that vs IMRT all the way through.

I feel like this is my current mission on SDN:

Dear current and future new grads/early career docs taking over small practices staffed by the same doc(s) since 1995 -

@CaesarRO is not exaggerating. I'll take this claim a step further: I haven't just heard of this, I've seen it with my own eyes. I've argued against it, and lost.

So if you find yourself taking over such a practice, you're not crazy, yes this is happening. Sadly you're not alone, and it's probably more common than you think.

Yes, your contouring and planning is significantly better than the Boomer(s) who retired. Yes, even though you're better at this than they are, you have now inherited a community of physicians who have seen Dr Boomer's 4-Field-Box Bloody Proctitis happen 3-4 times a year since Britney Spears was #1 on the TRL countdown.

Just...slow and steady. Don't rage at the machine and trash Dr Boomer. The best revenge is doing well for your patients and community.

 

[RadOncDoc21]

I feel like this is my current mission on SDN:

Dear current and future new grads/early career docs taking over small practices staffed by the same doc(s) since 1995 -

@CaesarRO is not exaggerating. I'll take this claim a step further: I haven't just heard of this, I've seen it with my own eyes. I've argued against it, and lost.

So if you find yourself taking over such a practice, you're not crazy, yes this is happening. Sadly you're not alone, and it's probably more common than you think.

Yes, your contouring and planning is significantly better than the Boomer(s) who retired. Yes, even though you're better at this than they are, you have now inherited a community of physicians who have seen Dr Boomer's 4-Field-Box Bloody Proctitis happen 3-4 times a year since Britney Spears was #1 on the TRL countdown.

Just...slow and steady. Don't rage at the machine and trash Dr Boomer. The best revenge is doing well for your patients and community.

Boomer doc got 3 houses, an ex wife and a mistress. He’s likely on his yacht snorting coke while that smart young physician is preaching about omitting breast radiation making 250k a year in Podunk, SD hoping he makes partner in 8 years!

 

[Fpg1245]

Boomer doc got 3 houses, an ex wife and a mistress. He’s likely on his yacht snorting coke while that smart young physician is preaching about omitting breast radiation making 250k a year in Podunk, SD hoping he makes partner in 8 years!

Then they get fired because the numbers are way down and then their CV shows up in my inbox and heads directly to the trash.

Enjoy the virtue signaling, maybe the big academic center that spawned you will give you a job

 

[elementaryschooleconomics]

Boomer doc got 3 houses, an ex wife and a mistress. He’s likely on his yacht snorting coke while that smart young physician is preaching about omitting breast radiation making 250k a year in Podunk, SD hoping he makes partner in 8 years!

TRUTH

One time, I had one of the - let's go with "Vintage Edition RadOncs" - tell me about this elaborate trust setup he created so his kids would avoid capital gains taxes...

...then turn around and approve a palliative plan where he only treated half the tumor. Fun times!

 

[Doctorer]

TRUTH

One time, I had one of the - let's go with "Vintage Edition RadOncs" - tell me about this elaborate trust setup he created so his kids would avoid capital gains taxes...

...then turn around and approve a palliative plan where he only treated half the tumor. Fun times!

He was treating the important half.

 

[DoctwoB]

As has been said. Very much appreciate your willingness to come here and share your perspective. Very valuable.

Two questions:
1) wrt "I see it every day" -- do you notice any patterns with the technique used or you don't dive that deep? I have heard of places still doing 4 field box with a subsequent cone down even today. I'd expect a lot more toxicity with something like that vs IMRT all the way through.
2) as a youngish Rad Onc I do worry that we under capture the late late toxicities. Like 30-40 years later.

I think we see the counter examples of over aggressive surgeons. My biggest frustration is the highest risk cases where it's clear the patient would still need RT and ADT post op and the surgeon convinces the patient surgery is still a benefit. Haven't seen any data that trimodality adds any benefits to RT+ADT in high/very high risk.

I’ll admit I generally don’t deep dive so can’t comment on the xrt techniques used. I do live in a “well served” area that is usually all about new tech, so many patients get “cutting edge” care, sometimes to their detriment.

With regards to the high risk question, I get the “most men biochemically recur and get xrt so why bother” argument, but considerable equipoise exists. The data all sucks and we can throw retrospective databases at each other in favor of surgery or xrt. There is some data for higher local failure and/or intervention/surgery rates for up front xrt vs up front surgery (though not with brachy boost I believe). There is also data that while radiation +ADT has a lower BCR rate, BCrs are more fatal presumably due to lack of effective salvage and selection effect of years of ADT.

The problem is not surgery in high risk cancer, which can be and is appropriate. The problem is if patients are not adequately counseled about the probability of multimodal therapy.

The good news is we may get an answer with SPCG 15 though by that time the paradigm may have shifted with NHT as part of ADT for XRT and use of PSMA guided salvage therapy.

 

[udrag14]

TRUTH

One time, I had one of the - let's go with "Vintage Edition RadOncs" - tell me about this elaborate trust setup he created so his kids would avoid capital gains taxes...

...then turn around and approve a palliative plan where he only treated half the tumor. Fun times!

The trust setup isn't that hard. It is for estate taxes. I have them setup for my kids because it is easier to make the trust the beneficiary. It also protects the money from divorce, bankruptcy, etc etc

 

[communitydoc13]

In regards to the bolded, but WHY? This is DOGMA that is unfounded in data. And if we do nothing else on SDN, we challenge DOGMA for the sake of DOGMA.

@DoctwoB with good answer above.

The other factor is just the long term risk of biochemical failure (which does not correlate terribly well with pCa survival).

Biochemical failure is common. Run through MSKCC pre-surgical nomogram and look at 10 year biochemical control numbers (these numbers only get worse over time). Even in really ideal cases these are like 89% and in most cases run in the 60%-70% range. These trend fairly well with XRT biochemical control numbers.

Local salvage after XRT is usually complicated and often stupid. Indefinite ADT (even intermittent) is a bit of a bummer.

I'm happy to salvage a man in his late 60s who got surgery in his 50s.