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Surgical, medical, and radiation oncologists that treat cancers in the thorax?
Surgical, medical, and radiation oncologists that treat cancers in the thorax?
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“Chaos is a ladder”
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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
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Realistic thinking would save our specialty.
We need to take a leaf from the PGA/LIV book!
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Sell out for blood money?
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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.
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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.
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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.
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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..
Imagine showing a resident one of those today. Laughter and pointing at us dinosaurs..
While the machines may last forever, the service contracts do not
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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
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Great to hear!
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.
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?
Halcyon seems to be an excellent machine for a Urorads shop that is starting up or looking for a replacement.. Fast and pretty reliable.
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The whole Spicer, Forde, Mogahanaki, Stiles thing (and their minions) feels very cringey to me.
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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.
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.
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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.
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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!”
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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
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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.
They buy a Halcyon and burn through 50-60 patients a day on one machine....
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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.
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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
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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.
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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.
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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
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@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.
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You forgot to add "No Cap"
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I 100% believe this goes on. I think the argument here is that we all have our own biases, just let the doctors that do the procedures have a chance to talk to the patients.
I am fortunate to work with some excellent urologists, some others are not. I'm sure the reverse is true.
I do think radiaiton oncologists tend to under-estimate late effects of XRT. Many patients are lost to follow up and late hematuria/proctitis can happen without us knowing it.
I still think any new prostate diagnosis should be seen by both rad onc and urology.
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I get the sentiment. I’m sure I would be annoyed if there was a situation where a radonc somehow treated with no GU involvement unless I really knew and trusted the radonc to give a balanced/fair perspective. I get VERY annoyed when I see a CT report saying “ 2cm renal mass consistent with RCC, recommend percutaneous ablation, cal XXX to schedule”
On the other hand if the patient is set on a treatment course and declines the referral, there’s not much point. So while I support the idea in theory, I do think mandating it is wrong and denying of patient agency. I never want to smooth talk someone who really wanted xrt to get surgery and you should feel the same for the reverse situation, since then every complication/side effect becomes your fault personally rather then a part of your shared treatment plan.
For my part I do try to give an honest/balanced spiel and have a great relationship with radonc at my shop, as I feel they do the same. There are other radoncs in the area that are “evangelists” for a certain modality, like SBRT for prostate or brachy. I have nothing against either, they both have a role, but when pushed to the exclusion of all else or in borderline cases it circles back to holding only a hammer.
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Just a quick note, I don't believeit is true that "PROTECT trial showed no difference in erectile function at 2 years". From the PROTECT trial:
"RT and surgery both reduced the proportion of men reporting potency at 6 mo (18.5% and 5%, respectively). Although there was some recovery by 2 yr, only 28–30% of men in the RT group and 15% in the surgery group reported being potent at 6 yr (p < 0.001; Fig. 4 and Supplementary Table 5)."
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You rad oncs and your “data.” So good at understanding and breaking it down. How cute!
Meanwhile, I’m having a discussion with a patient on why his urologist told him that leaving the prostate inside the body will cause him to have more of a chance of disease recurrence after radiation. He also told the patient that after surgery, radiation can be given which is curative but after radiation, surgery can not be given, which means he’ll likely die. No bias discussion there at all!
Meanwhile, I’m having a discussion with a patient on why his urologist told him that leaving the prostate inside the body will cause him to have more of a chance of disease recurrence after radiation. He also told the patient that after surgery, radiation can be given which is curative but after radiation, surgery can not be given, which means he’ll likely die. No bias discussion there at all!
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Bolded line - ????? Figure 2 from https://www.nejm.org/doi/full/10.1056/NEJMoa1606221
Worse PRO sexual outcomes for RP compared to AS OR 'radical radiotherapy' all the way out to 6 years. What data are you twisting to get to no difference in erectile funciton at 2 years?
There is no OR complication when the alternative is lifelong no erectile function and needing a pad every day (happens 50% of the time!)
When were those patients who had long-term sequellae treated with radiation? Is it possible that treatments have become less toxic compared to the folks you see who were treated 10-25 years ago?
As I've told you multiple times in the past, you only see the numerator of these toxicities, and you have no sense as to the denominator. 1 in 3 men gets prostate cancer, and prior to like a decade ago, they all probably got treated in some way.
But the bulk of your post about 'if other **** goes wrong in the pelvis', I do get that. And again, not saying it's wrong to favor it, but to push for surgery and ignore what's MUCH more important to men in their 50s (erectile function) than in their 70s and worrying about **** that might happen 15-25 years down the road is a bit of putting the cart before the horse I think.
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MSKCC pre-surgical nomogram biochemical control numbers are not equal to XRT biochemical control numbers, at least for high-risk disease. It is an apples to oranges comparison but XRT will always look better because of the differences in how biochemical failure is defined. If you're treating FIR with 60-70% biochemical control you're not doing so hot.
Local salvage after RT really needs to stop being a boogeyman. The utility is low becaus emany of those patients will have distant failure as well but I would guess outcomes are really not that horrid if done early on.
Sigh, what a tired old trope.
Thank god for the MASTER meta-anslysis. Should be mandatory reading for anyone who treats prostate cancer.
A Systematic Review and Meta-analysis of Local Salvage Therapies After Radiotherapy for Prostate Cancer (MASTER) - PubMed
In a large study-level meta-analysis, we looked at treatment outcomes and toxicity for men treated with a number of salvage treatments for radiorecurrent prostate cancer. We conclude that relapse-free survival at 5 years is equivalent among salvage modalities, but reirradiation may lead to lower...
pubmed.ncbi.nlm.nih.gov
"Yes, surgery is not generally recomended after radiation due to high risk of side effects. Good thing we have radiation options (and cryo) that are just as effective as surgery and cause less side effects!"
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That’s where the bad stuff was
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This is why i told urologist to “proceed”. He would make my point himself.
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Wow, 1 CK treatment with no issues and he’s cured! I’m so glad they are humbly not using him for advertising!
As much as I want there to be good publicity around our field, I can see how easily one post can turn everything around which is why I’m not a big fan of social media. I miss the days when we let “data” do all the talking!
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Is adt and sbrt a thing? I don't really do sbrt outside low risk or favorable intermediate.
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I have done it for all risk groups. Sbrt is really indicated to capture distant pts or those with severe transportation hardships.
I do it for unfavorable intermediate.
I'm also glad that a senator is extolling the virtues of SBRT for prostate cancer. Lord knows we need all the publicity we can get.
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I'm glad he posted too. A tweet like that takes balls. And after several months of ADT, the clock's ticking.
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Are you guys ok when the senator blames SBRT for not being able to get a hard on one night he’s out with his secretary?
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An effective and long term solution to erectile dysfunction after ADT will be hard.
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Why neoadjuvant ADT? I thought we stopped that after the Spratt meta analysis.
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Exactly my point! He could easily tweet how SBRT killed his mojo and all the “brutal” toxicities of radiation.
We’ve opened Pandora’s box for tweets and postings to determine our value.
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Maybe large prostate. I still like to start ADT and get radiation after a couple of weeks.
