RTOG prostate hypofrac toxicity

[thesauce]

Of the two people in the room, you’re ether one with 9 years of medical training including 4 years of radiation oncology specific training. You’re the one being paid for this expertise.

To layout 15 “options” and let the patient order from your menu doesn’t make you a good, caring, enlightened doctor. It makes you a detached participant. Like a bad waiter.

If you don’t lay them all out, they will Google their condition and then get pissed that you didn’t talk about X, Y, and Z. Why didn’t you tell me proton therapy was the best???

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[deleted1111261]

Giving your recommendation is important - it's not 100% "you choose" and there has been devaluation of our expertise as a field and as doctors in general which is very frustrating.

The variable is how you get there. Do you just come in guns blazing "here's what we're doing" or do you lay out things and have reasonable pathway to decision. Some patients need the "here's what is happening" talk and others are capable of choosing.

From a financial standpoint, I could certainly get paid more if I told all prostates conventional fractionation and offered no hypofrac - they'd get cured just the same but it would be a change from what I normally do. It would be like the waiter only recommending the huge prime rib for their tip even though it still may be the best thing on the menu - both things can co-exist.

Sometimes you gotta hear, "Just don't order the squid," or whatever

 

[theradiator]

I'm sure everyone has read radiology reports that say "yup could be anything" and how useless those reports are.

Second point, NCCN has put their fingers on the scale by listing 3 of 15 regimens as "preferred".

 

[thesauce]

I'm sure everyone has read radiology reports that say "yup could be anything" and how useless those reports are.

Second point, NCCN has put their fingers on the scale by listing 3 of 15 regimens as "preferred".

The NCCN guidelines are exclusively academics that have realized that shorter courses make it far more likely that more patients will come to their center for treatment. It is hard to talk someone into 8-9 weeks of RT, but 5 weeks or 5 days is a lot easier. Then of course they can charge 7 times the rate of the community center that could’ve given the same treatment.

The toxicity of hypoF is higher. They even acknowledge that in their comments. If there wasn’t a financial motive, why would they possibly state a preference for a shorter/more toxic course?

 

[thecarbonionangle]

Interesting discussion. It takes me back to medical school ethics class and the idea of “paternalism”. Oh the patriarchy!

Honestly for me it depends for me on these issues of choice, i see the patients who have seen multiple rad oncs in reputable places and come to me for another consult. These people are usually highly educated, well read know their options quite well. These are the patients where a consult for a cancer, not prostate necessarily, might take a few hours. In the other hand, i can also get some very simple rural folks. These patients get very overhelmed with all the options so they usually have me pick.

If i treated prostate, id recommend probably a lot of SF. It is simply less side effects, less of a headache. Patients will alway remember how you made them feel and if they felt “sick” whole time, it reflects poorly on you. Referring may not understand the nuances of HF vs SF and how you did a shorter course. They will just see patient had rectal bleeding or bad dysuria and wonder wow why did this guy have a hard time?.
Thinking back, almost every time in residency it was a 70/28 or 60/20 patient with issues during and after. Its just my bias. Thankfully i can avoid these issues for now.

 

[deleted1111261]

Interesting discussion. It takes me back to medical school ethics class and the idea of “paternalism”. Oh the patriarchy!

Honestly for me it depends for me on these issues of choice, i see the patients who have seen multiple rad oncs in reputable places and come to me for another consult. These people are usually highly educated, well read know their options quite well. These are the patients where a consult for a cancer, not prostate necessarily, might take a few hours. In the other hand, i can also get some very simple rural folks. These patients get very overhelmed with all the options so they usually have me pick.

If i treated prostate, id recommend probably a lot of SF. It is simply less side effects, less of a headache. Patients will alway remember how you made them feel and if they felt “sick” whole time, it reflects poorly on you. Referring may not understand the nuances of HF vs SF and how you did a shorter course. They will just see patient had rectal bleeding or bad dysuria and wonder wow why did this guy have a hard time?.
Thinking back, almost every time in residency it was a 70/28 or 60/20 patient with issues during and after. Its just my bias. Thankfully i can avoid these issues for now.

Are you saying there is more rectal bleeding with 70/28 or 60/20. Have not seen that myself. “Sick” the whole time is very odd, too. Yeah, again I understand not choosing HF due to acute toxicity concerns (much of which most R O won’t/can’t quantity or make clear to patient - just a vague “you’ll get worse side effects” comment), but rectal bleeding - idk.

 

[deleted1111261]

Interesting discussion. It takes me back to medical school ethics class and the idea of “paternalism”. Oh the patriarchy!

Honestly for me it depends for me on these issues of choice, i see the patients who have seen multiple rad oncs in reputable places and come to me for another consult. These people are usually highly educated, well read know their options quite well. These are the patients where a consult for a cancer, not prostate necessarily, might take a few hours. In the other hand, i can also get some very simple rural folks. These patients get very overhelmed with all the options so they usually have me pick.

If i treated prostate, id recommend probably a lot of SF. It is simply less side effects, less of a headache. Patients will alway remember how you made them feel and if they felt “sick” whole time, it reflects poorly on you. Referring may not understand the nuances of HF vs SF and how you did a shorter course. They will just see patient had rectal bleeding or bad dysuria and wonder wow why did this guy have a hard time?.
Thinking back, almost every time in residency it was a 70/28 or 60/20 patient with issues during and after. Its just my bias. Thankfully i can avoid these issues for now.

Can you imagine talking to more than one academic GU RadOnc for 2-3 hours about this? This is what nightmares are made of!

 

[thecarbonionangle]

Are you saying there is more rectal bleeding with 70/28 or 60/20. Have not seen that myself. “Sick” the whole time is very odd, too. Yeah, again I understand not choosing HF due to acute toxicity concerns (much of which most R O won’t/can’t quantity or make clear to patient - just a vague “you’ll get worse side effects” comment), but rectal bleeding - idk.

Im not saying patients are trully objectively sick but prostates attracts some histrionic more dramatic inidividuals in my experience who yes do think even G1/G2 toxicities make them miserable and sick. I see my colleagues spend more time on OTVs with prostates sometimes than many other sites. You either love prostate or dread the long discussions, weekly discussion about poop and urinating. Rectal bleeding more common with anticoagulants, henorrhoids etc although numerically rare, when i talk to people they do say more common with HF.

 

[madchemist89]

I've done lots of hypofrac. I haven't noticed any anecdotal difference. Knock on wood.

 

[jondunn]

Im not saying patients are trully objectively sick but prostates attracts some histrionic more dramatic inidividuals in my experience who yes do think even G1/G2 toxicities make them miserable and sick. I see my colleagues spend more time on OTVs with prostates sometimes than many other sites. You either love prostate or dread the long discussions, weekly discussion about poop and urinating. Rectal bleeding more common with anticoagulants, henorrhoids etc although numerically rare, when i talk to people they do say more common with HF.

what kind of margins are you using?

 

[RO28]

It takes me about 1.5 hours now that I’ve got the spiel down, but yes I do - every single time

I actually ask my prostate consults to be scheduled for 90 min for just this reason. It takes a lot of time to to over all the options, not to mention ADT.

 

[CodeRedDew]

I actually ask my prostate consults to be scheduled for 90 min for just this reason. It takes a lot of time to to over all the options, not to mention ADT.

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

These situations are fortunately infrequent as a PGY5, but there are some attendings who insist we go back in the room to "watch the exam" or make up some other BS reason that falls in the realm of "because education".

Sorry for the rant (clearly I'm upset lol), but I have to ask - do people really take a few hours for a consult? I can't imagine taking "a few hours" for any consult. Would absolutely drive me insane. I imagine there are diminishing returns at some point....

Interesting discussion. It takes me back to medical school ethics class and the idea of “paternalism”. Oh the patriarchy!

Honestly for me it depends for me on these issues of choice, i see the patients who have seen multiple rad oncs in reputable places and come to me for another consult. These people are usually highly educated, well read know their options quite well. These are the patients where a consult for a cancer, not prostate necessarily, might take a few hours. In the other hand, i can also get some very simple rural folks. These patients get very overhelmed with all the options so they usually have me pick.

If i treated prostate, id recommend probably a lot of SF. It is simply less side effects, less of a headache. Patients will alway remember how you made them feel and if they felt “sick” whole time, it reflects poorly on you. Referring may not understand the nuances of HF vs SF and how you did a shorter course. They will just see patient had rectal bleeding or bad dysuria and wonder wow why did this guy have a hard time?.
Thinking back, almost every time in residency it was a 70/28 or 60/20 patient with issues during and after. Its just my bias. Thankfully i can avoid these issues for now.

 

[temujim]

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

These situations are fortunately infrequent as a PGY5, but there are some attendings who insist we go back in the room to "watch the exam" or make up some other BS reason that falls in the realm of "because education".

Sorry for the rant (clearly I'm upset lol), but I have to ask - do people really take a few hours for a consult? I can't imagine taking "a few hours" for any consult. Would absolutely drive me insane. I imagine there are diminishing returns at some point....

Exit the room like Tyler

Longest consult ever had was about an hour fifteen. Had to walk a fake doctor through every clinical trial in that primary site from the 1970s to arrive at how what we were recommending was the standard of care.

 

[TheWallnerus]

I actually ask my prostate consults to be scheduled for 90 min for just this reason. It takes a lot of time to to over all the options, not to mention ADT.

Do you REALLY go over “all” the options Humor me…

Reminds me of an old paper of Steve Webb’s. I’m paraphrasing but he said no modern IMRT is truly inversely optimized, only optimized with constraints. If truly inversely optimized, the computer would consider all modalities (carbon, neutron, proton, all photon energies, brachy), all dose rates, all fractionations and times of day, all beam angles, all margin choices, etc.

There is, at least in my mind after talking to the patient, one option I consider best. I have no problem sharing that with the patient “top line,” and if they like that option, we proceed on to logistics. I also tell them they will likely get a slightly different opinion from another doctor; I don’t recall a single patient ever wanting me to make that happen.

Many disease sites are really complex, prostate included. In my heart of hearts I know the best “consult”: enroll the patient in medical school and 4 years later after graduation come to me for a 6 month, 5 day a week intensive training course in their particular disease site. Then I’m getting closer to thinking the patient is “fully informed.”

 

[elementaryschooleconomics]

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

Ah, I'm so sorry. I feel this in my soul.

I'm worried one of my senior partners will eventually have a stroke trying to convince me to do a DRE. I absolutely refuse. Whenever the argument starts, I immediately ask how the DRE will change management. I've heard some fascinating answers.

My favorite reason he gave was some absolute gibberish about a "boggy" prostate as it pertained to field size. I cannot for the life of me recall exactly how he said it, but it was something about estimating potential prostate motion, and the implication was that he would make his target area larger.

This was some 4-field box shenanigans. We do VMAT with CBCT for our prostates, since it's 2022 and all. I guess after we palpate some boggy prostates we'll do some whole-abdomen XRT for endometrial cancer, and then set up the reverse hockey stick field in a breast patient for good measure.

Might as well go to the airport and head right to our gate with an open water bottle and our shoes on, and talk about the AOL CD which arrived in the mail to access the World Wide Web.

 

[TheWallnerus]

I immediately ask how the DRE will change management. I've heard some fascinating answers.

Rather than some technical reason, I find the younger docs nowadays just throw their hands in the air and go “It’s a measure of quality”

 

[Reaganite]

Maybe we ought to call out these RO reviewers on social media? Interesting strategy . . .

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

These situations are fortunately infrequent as a PGY5, but there are some attendings who insist we go back in the room to "watch the exam" or make up some other BS reason that falls in the realm of "because education".

Sorry for the rant (clearly I'm upset lol), but I have to ask - do people really take a few hours for a consult? I can't imagine taking "a few hours" for any consult. Would absolutely drive me insane. I imagine there are diminishing returns at some point....

One of the biggest epiphanies in my career about just how much utter nonsense there is in this field came after an attending laid into me for giving an incorrect date on a biopsy. Just like you I gave the "finalized" date of the biopsy on a pt who ended up receiving subsequent surgery and chemo so I could have pulled the biopsy date out of my ass, and it wouldnt have mattered. Said attending would also get pissed if you didnt quote some nsabp study in your run-of-the-mill breast conservation case...as if there was some referring oncologist out there who didnt know we radiated the breast after lumpectomy. Meanwhile your average note from the surgeon is: "assessment: breast cancer, plan: refer to radiation."

 

[Ray D. Ayshun]

Rather than some technical reason, I find the younger docs nowadays just throw their hands in the air and go “It’s a measure of quality”

What exactly does that make us if we do that to a patient just to make them feel good?

 

[deleted941485]

One of the biggest epiphanies in my career about just how much utter nonsense there is in this field came after an attending laid into me for giving an incorrect date on a biopsy. Just like you I gave the "finalized" date of the biopsy on a pt who ended up receiving subsequent surgery and chemo so I could have pulled the biopsy date out of my ass, and it wouldnt have mattered. Said attending would also get pissed if you didnt quote some nsabp study in your run-of-the-mill breast conservation case...as if there was some referring oncologist out there who didnt know we radiated the breast after lumpectomy. Meanwhile your average note from the surgeon is: "assessment: breast cancer, plan: refer to radiation."

It’s just a shame I didn’t come to this realization as an MS4 and gtfo while I still had a soul. Some fields just have better things to do.

 

[Neuronix]

Rather than some technical reason, I find the younger docs nowadays just throw their hands in the air and go “It’s a measure of quality”

Why DRE? In upfront setting so the doc can document T2 disease and urology can justify surgery or urorads can justify radiation. In recurrent setting so the doc can do more workup including in-office imaging.

You know what state I live in...

Other than that I can't think of a good reason to do a DRE if patient is getting a quality prostate MRI and the tumor secretes PSA.

 

[elementaryschooleconomics]

Why DRE? In upfront setting so the doc can document T2 disease and urology can justify surgery or urorads can justify radiation. In recurrent setting so the doc can do more workup including in-office imaging.

You know what state I live in...

Other than that I can't think of a good reason to do a DRE if patient is getting a quality prostate MRI and the tumor secretes PSA.

I know exactly who @TheWallnerus is talking about (in terms of personality).

There are many, many people who, after the crucible of residency, cannot conceive of doing things different than how they were trained. Some eventually break free, some do not.

I've been thinking: maybe I'll do a DRE and get a PSA immediately after, because I assume palpating the gland will elevate the value artificially. Then, I can tell insurance companies the guy is a higher risk than he really is and get more things approved. This will be done with a wink and a nod to the patient, as we laugh about making his insurance pay for his healthcare like they're supposed to. America!

 

[RickyScott]

Why DRE? In upfront setting so the doc can document T2 disease and urology can justify surgery or urorads can justify radiation. In recurrent setting so the doc can do more workup including in-office imaging.

You know what state I live in...

Other than that I can't think of a good reason to do a DRE if patient is getting a quality prostate MRI and the tumor secretes PSA.

I would argue DRE is worthless even without an mri and there are multiple papers to this effect. Even in the setting of knownprostate cancer, Nodules are as often benign as they are malignant and who knows what you are actually palpating following the biopsy. Plus, the urologist already did one and he did an ultrasound. As far as dates of biopsy vs reported- this kind of bizarre behavior just reflects a personality disorder.

 

[Mandelin Rain]

What exactly does that make us if we do that to a patient just to make them feel good?

And they pay us for it.

 

[temujim]

I know exactly who @TheWallnerus is talking about (in terms of personality).

There are many, many people who, after the crucible of residency, cannot conceive of doing things different than how they were trained. Some eventually break free, some do not.

I've been thinking: maybe I'll do a DRE and get a PSA immediately after, because I assume palpating the gland will elevate the value artificially. Then, I can tell insurance companies the guy is a higher risk than he really is and get more things approved. This will be done with a wink and a nod to the patient, as we laugh about making his insurance pay for his healthcare like they're supposed to. America!

Except for one or two bright spots, I viewed my residency as training me what not to do. Went to a pretty good program, but still it was massive self education for the most part.

 

[Ray D. Ayshun]

And they pay us for it.

Right. When I hear it's a charity case I dre'd I'm less apt to cry in the shower in the fetal position. Though my salary is rvu based, so I'm paid either way. Good news is that a dre isn't specifically coded...

Edit:. I don't do dres

 

[OTN]

Haven't done a DRE since I graduated residency. I see no (zero) reason to subject a patient to an uncomfortable exam which will not change their clinical course. I have yet to hear a justification for doing one which wasn't complete and total hogwash.

 

[Mandelin Rain]

Right. When I hear it's a charity case I dre'd I'm less apt to cry in the shower in the fetal position. Though my salary is rvu based, so I'm paid either way. Good news is that a dre isn't specifically coded...

Edit:. I don't do dres

COVID killed most physical exam for me absent some specific/acute complaint. Like I'm not routinely having patients expel deep breaths into my tiny clinic room when we just reviewed the perfect chest scan they had done the day before.

 

[RickyScott]

Haven't done a DRE since I graduated residency. I see no (zero) reason to subject a patient to an uncomfortable exam which will not change their clinical course. I have yet to hear a justification for doing one which wasn't complete and total hogwash.

My favorite justification for a biopsy is “once I palpated an anal or rectal cancer” , which implies we should dre breast pts as well.

 

[TheWallnerus]

COVID killed most physical exam for me absent some specific/acute complaint. Like I'm not routinely having patients expel deep breaths into my tiny clinic room when we just reviewed the perfect chest scan they had done the day before.

The physical exam is to modern medicine like learning how to do multiplication/division/addition/subtraction on paper is to a person in elementary school. It’s foundationally necessary. But not necessary to persist using every single day of your life. It’s why we have these fancy “calculators.”

 

[elementaryschooleconomics]

Except for one or two bright spots, I viewed my residency as training me what not to do. Went to a pretty good program, but still it was massive self education for the most part.

Totally agree.

The nature of academic environments breeds dogma and not rocking the boat. My observation is that:

1) There's a very clear hierarchy in most departments
2) The people who stay (and survive) in academia know they need to respect the hierarchy
3) The top-level people are often older (50s+) and often have very set practice patterns
4) Deviating from the "institutional practice" ruffles a lot of feathers which inhibits chance for promotion
5) Therefore, there is little incentive to be "innovative"
6) This gets passed on to the residents

I'm grossly over-generalizing here, and this is not a universal truth. But the most dogmatic departments appear, to me at least, to be the most "inbred". For departments which hire their own residents and people stay for 10-30 years....there's gonna be some weirdness.

 

[RO28]

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

These situations are fortunately infrequent as a PGY5, but there are some attendings who insist we go back in the room to "watch the exam" or make up some other BS reason that falls in the realm of "because education".

Sorry for the rant (clearly I'm upset lol), but I have to ask - do people really take a few hours for a consult? I can't imagine taking "a few hours" for any consult. Would absolutely drive me insane. I imagine there are diminishing returns at some point....

ooof I've been there, you have my sympathies. Not all my prostate consults take that long, but ya know some of them also want to go through their lists of supplements their naturopath prescribed or I spend time telling them why marijuana is not an acceptable treatment option for prostate cancer. This happens often enough where I practice that I really do like having the 90 minutes when I need it. I may doxx myself with this comment, but in residency a friend and I came up with a nomogram to predict how long a prostate consult was going to take. We joke about publishing it when we retire.

I also no longer do a DRE unless I'm convinced its going to change my management.

 

[RO28]

Do you REALLY go over “all” the options Humor me…

Reminds me of an old paper of Steve Webb’s. I’m paraphrasing but he said no modern IMRT is truly inversely optimized, only optimized with constraints. If truly inversely optimized, the computer would consider all modalities (carbon, neutron, proton, all photon energies, brachy), all dose rates, all fractionations and times of day, all beam angles, all margin choices, etc.

There is, at least in my mind after talking to the patient, one option I consider best. I have no problem sharing that with the patient “top line,” and if they like that option, we proceed on to logistics. I also tell them they will likely get a slightly different opinion from another doctor; I don’t recall a single patient ever wanting me to make that happen.

Many disease sites are really complex, prostate included. In my heart of hearts I know the best “consult”: enroll the patient in medical school and 4 years later after graduation come to me for a 6 month, 5 day a week intensive training course in their particular disease site. Then I’m getting closer to thinking the patient is “fully informed.”

Within Reason, depending on how the day is going.

 

[deleted1111261]

ooof I've been there, you have my sympathies. Not all my prostate consults take that long, but ya know some of them also want to go through their lists of supplements their naturopath prescribed or I spend time telling them why marijuana is not an acceptable treatment option for prostate cancer. This happens often enough where I practice that I really do like having the 90 minutes when I need it. I may doxx myself with this comment, but in residency a friend and I came up with a nomogram to predict how long a prostate consult was going to take. We joke about publishing it when we retire.

I also no longer do a DRE unless I'm convinced its going to change my management.

I want the Nomo!!

 

[evilbooyaa]

The issue is, how many things can you "offer" a guy for prostate cancer? It's dizzying. Like a typical low intermediate risk guy...... Are you really discussing pro- and cons- of active surveillance, surgery (robotic vs open), brachy (LDR vs HDR), beam (SBRT vs moderate hypo vs conventional), short course ADT (+ vs -), SpaceOAR vs Enema vs Balloon vs whatever, Fiducials vs CBCT alone? Say nothing of the nonstandard treatment they have have read about.

It's like a 3 hour event if you do that, and the patient tabs you as an indecisive waffler and sees someone else. I think at some point it's reasonable to pick what your standard is and offer that.

Favorable intermediate-risk prostate cancer is literally the longest consult in the world when it is done correctly and thoroughly. This is why I'm happy to not be an academic GU guy. To do this properly SHOULD take like 1.5 hours IMO.

I don't get into discussion of open vs robotic surgery... I don't do daily enemas or daily rectal balloons, don't do fiducials unless doing spaceOAR simultaneously. Daily enemas or daily rectal balloons is like doing a DRE on one of the prostate patients described in this thread. Unnecessary. You can do it if you want but it's making you feel better not the patient.

But the rest, yes, is a discussion of what is important to the patient. Some patients, for example, have excellent potency and are worried about minimizing that risk, and thus discussion leads away from surgery and ADT (or discussion of what they are losing oncologically by dropping ADT).

The decision for a patient to make in terms of prostate cancer is a matter of 1) how quickly do they want to be done, 2) what are they OK with their risk of recurrence being (~50% of RADICALS/RAVES patients), and 3) what toxicities out of the pool of 5 or so are they ok with being at highest risk for.

*Cries in residency* where I have 30 minute window to listen to the nurses' (typically unhelpful) intake/history, talk to the pt about all of their options/answer their questions, and then staff the pt with my attending, who not only proceeds to make a big deal about inconsequential things (eg. me incorrectly telling them pt's biopsy was February 15th (ie. when path was finalized) but was actually February 12th), but also makes me watch them re-hash everything I JUST said to the patient. All while I awkwardly stand in the corner without a computer to do notes or option to escape and ultimately have to (painfully) watch them do the all mighty, non-management-changing DRE they insist performing even though the pt already has an mpMRI prostate and targeted biopsy demonstrating GS 6 disease.

I'm convinced these faculty just like to bring misery to their trainees and unironically always have the audacity to wonder why they're behind in clinic. I'd be lying if I said a part of me didn't sometimes wish for the pt to have an unexpected diarrheal episode when these attendings are doing the DRE (which almost happened with a pt who had significant flatulence/IBS issues).

These situations are fortunately infrequent as a PGY5, but there are some attendings who insist we go back in the room to "watch the exam" or make up some other BS reason that falls in the realm of "because education".

Sorry for the rant (clearly I'm upset lol), but I have to ask - do people really take a few hours for a consult? I can't imagine taking "a few hours" for any consult. Would absolutely drive me insane. I imagine there are diminishing returns at some point....

Oof. That sounds like a rough program, especially the bolded. Unfortunately, I'm well aware of residents, even senior level residents, that really need everything double checked to avoid suboptimal care.

 

[elementaryschooleconomics]

Unfortunately, I'm well aware of residents, even senior level residents, that really need everything double checked to avoid suboptimal care.

In my experience, anyone with "senior" as part of their description requires double-checking:

Senior residents
Senior faculty
Senior partners

 

[deleted941485]

Favorable intermediate-risk prostate cancer is literally the longest consult in the world when it is done correctly and thoroughly. This is why I'm happy to not be an academic GU guy. To do this properly SHOULD take like 1.5 hours IMO.

I don't get into discussion of open vs robotic surgery... I don't do daily enemas or daily rectal balloons, don't do fiducials unless doing spaceOAR simultaneously. Daily enemas or daily rectal balloons is like doing a DRE on one of the prostate patients described in this thread. Unnecessary. You can do it if you want but it's making you feel better not the patient.

But the rest, yes, is a discussion of what is important to the patient. Some patients, for example, have excellent potency and are worried about minimizing that risk, and thus discussion leads away from surgery and ADT (or discussion of what they are losing oncologically by dropping ADT).

The decision for a patient to make in terms of prostate cancer is a matter of 1) how quickly do they want to be done, 2) what are they OK with their risk of recurrence being (~50% of RADICALS/RAVES patients), and 3) what toxicities out of the pool of 5 or so are they ok with being at highest risk for.


Oof. That sounds like a rough program, especially the bolded. Unfortunately, I'm well aware of residents, even senior level residents, that really need everything double checked to avoid suboptimal care.

I used to option and data dump on these prostate patients my first year out. They are the most exhausting consults. So you know what I did…I stopped doing that. You see me…you get EBRT. That’s it. If you don’t ask about brachy, I don’t tell you about it and I don’t do it anymore. Protons? Sure we’ve got ‘em gonna have to go to the mothership.

I turned a 70min consult into 20 mins face to face time with exam and everything. Was never meant to be that complicated. I get out earlier and I’m not as burnt out.

 

[RO28]

I used to option and data dump on these prostate patients my first year out. They are the most exhausting consults. So you know what I did…I stopped doing that. You see me…you get EBRT. That’s it. If you don’t ask about brachy, I don’t tell you about it and I don’t do it anymore. Protons? Sure we’ve got ‘em gonna have to go to the mothership.

I turned a 70min consult into 20 mins face to face time with exam and everything. Was never meant to be that complicated. I get out earlier and I’m not as burnt out.

I moderate my data dump. I don't talk about fiducials or spaceoar because I don't use them. I do talk about brachy because I share a lot of patients with a brachytherapist at the nearby academic center.

I do enjoy when the urologist has already started the ADT so I don't have to get into that.

 

[TheWallnerus]

I used to option and data dump on these prostate patients my first year out. They are the most exhausting consults. So you know what I did…I stopped doing that. You see me…you get EBRT. That’s it. If you don’t ask about brachy, I don’t tell you about it and I don’t do it anymore. Protons? Sure we’ve got ‘em gonna have to go to the mothership.

 

[temujim]

I used to option and data dump on these prostate patients my first year out. They are the most exhausting consults. So you know what I did…I stopped doing that. You see me…you get EBRT. That’s it. If you don’t ask about brachy, I don’t tell you about it and I don’t do it anymore. Protons? Sure we’ve got ‘em gonna have to go to the mothership.

I turned a 70min consult into 20 mins face to face time with exam and everything. Was never meant to be that complicated. I get out earlier and I’m not as burnt out.

Used to think one made up the long consult time on the back end; ie ~60 second OTVs and once a year follow-ups (if that). But maybe not so much anymore with hypofx and higher acute tox.

 

[jondunn]

So why do it?

youre talking about why hypofrac, bobby is talking about nodes.


some of you have convinced yourselves that prostate hypofrac is much more toxic when that's not really what the data says. look at the curves on CHIIP

 

[medgator]

youre talking about why hypofrac, bobby is talking about nodes.


some of you have convinced yourselves that prostate hypofrac is much more toxic when that's not really what the data says. look at the curves on CHIIP

And some of you are ostriches in the sand when it comes to actually treating those patients or looking at the ASTRO guidelines on it.

I offer hypofx. It isn't a better treatment, just cheaper and quicker

 

[deleted941485]

And some of you are ostriches in the sand when it comes to actually treating those patients or looking at the ASTRO guidelines on it.

I offer hypofx. It isn't a better treatment, just cheaper and quicker

We used to ask how can we do this better? Now its how to we do it cheaper? The former has made our field attractive. The latter is starving it of talent and out of existence.

 

[seper]

I do DRE's on prostate cases. Among other things, often enough one picks up poor sphincter tone = pre-existing fecal urgency and incontinence

 

[elementaryschooleconomics]

look at the curves on CHIIP

Good idea, Figure 4 from CHHiP: (behold, Saturday morning figures made in freeware image software)

So, I treat a lot of prostate in my generalist practice. I engage in shared decision making with my patients as much as possible, and let them pick (unless there's something about their individual presentation which causes me to push them in a certain direction). On any given day, I have a bunch of guys on several different regimens, but usually 79.2Gy in 44fx, 70Gy in 28fx, or 60Gy in 20fx (+/- ADT).

1) To make an overgeneralized, unfair statement: many of the men we treat for prostate cancer are otherwise very healthy and have never had significant health issues. Therefore, their perceptions of symptoms can be very skewed compared to other people who have experienced health challenges earlier in life. Small changes in bowel or bladder function become huge sources of stress and anxiety, negatively affecting quality of life. I wouldn't make the claim about there being significant differences in "severe" toxicity, but there's an obvious difference in acute toxicity, defined as "mild" by the RTOG scale. As anyone who routinely treats prostate patients can attest to: symptoms classed as objectively "mild" by the RTOG scale can absolutely dominate these patient's lives and cause significant anxiety and anguish. My longest OTVs are men who think their world is ending because they get up to pee 4 times a night instead of 2. On our end it seems frivolous and we roll our eyes, but to a lot of these guys this is the most stressful thing they have ever experienced.

2) The first red arrows in my high-quality graph is at the two week timepoint. Bowel tox is about 35% in hypo, 15% in conventional. Bladder tox is 50% in hypo, 35% in conventional.

3) The onset of early symptoms can set the tone for the entire treatment course. If an already anxious guy starts experiencing symptoms as "early" as 2 weeks (out of a 6 or 9 week course), it's going to be a long haul. This is where guys want to quit treatment because they just started and know they're facing many more weeks.

4) The two circles are the bulk of treatment (really all of treatment if you're doing 70Gy in 28fx). Mod hypo consistently has higher acute toxicity. Definitely "mild" per the RTOG scale, however, not always perceived as "mild" by the patient.

5) My glorious purple line is 9 weeks, where even conventional is finished. Between 6 and 9 weeks is where the conventional curve finally overtakes mod hypo (well, technically mod hypo is complete at this point, so there's nothing to overtake). This deep into the game, guys can see the finish line. They've been coming for weeks. Nothing has exploded. If/when "mild" symptoms show up at week 7 for my conventional patients, the anxiety is significantly less, I can throw some Flomax at them, we talk about the light at the end of the tunnel, etc. It's much less likely a guy 7 weeks in with mild symptoms will threaten to quit.

I know this is total anecdote. If anyone has published anything on this, please point me to it. All I can say based on my experience:

- Prostate guys are usually very healthy
- In people who have never faced major health issues, small symptoms are incredibly distressing
- Mod hypo has a higher incidence of mild toxicity which starts earlier
- The early onset of side effects in already anxious patients can be very detrimental to the overall treatment course

I understand the academic narrative about pushing mod hypo for prostate. However, prostate mod hypo IS NOT the same as breast hypofrac, though you would never know it, based on the way it's currently discussed. If a favorable intermediate risk guy comes in for a consult, and his voice shakes when he's talking to me, and his wife cries while asking if he's going to die - I am almost certainly going to push that guy towards conventional. If the next favorable intermediate risk guy comes in solo, saying "everybody gets this, right doc", and tells me his biggest concern is finishing before the golf courses open back up - that guy is getting pushed towards mod hypo.

(side note: this post isn't directed at anyone participating in this thread, I just want to add to the digital record for eternity that prostate and breast hypofrac are often lumped together, when they absolutely should not be)

 

[jondunn]

yes the curves tell the story:

GU: across grade 1-3 acute GU toxicity, there is no difference in rates, just hypofrac peaks earlier.

GI: the peak again is earlier, but grade 1-2 rate is higher (about 70 vs 57%). grade 3 peak earlier and higher too.

 

[jondunn]

and if mr linac or proton or whatever new expensive new fancy QUINTENARY academic center machine in the future shows some similar 12-13% acute grade 1-2 difference in GI but not GU, I won't think its a major difference either.

im consistent with my line

 

[elementaryschooleconomics]

yes the curves tell the story:

GU: across grade 1-3 acute GU toxicity, there is no difference in rates, just hypofrac peaks earlier.

GI: the peak again is earlier, but grade 1-2 rate is higher (about 70 vs 57%). grade 3 peak earlier and higher too.

To me, this circles back to two issues:

1) Do classic RTOG/CTCAE scales, as reported by physicians/trialists who are not the patient receiving treatment, tell the full story?
2) Specifically, is it a "good" assumption to make that Grade 1 bowel tox is "experienced" the same by Patient A as Patient B?

Clearly, my answer is "no" for both questions.

This is the same issue that was pointed out with the recent proton/SpaceOAR paper:

Mostly: I think we (medicine in general) can do better with how we think about side effects. This isn't exactly a "hot take", I know, and the literature is moving in that direction. In RadOnc, I think prostate (re: SpaceOAR and mod hypo) is the area where a higher level of scrutiny regarding reported toxicity rates needs to be employed.

 

[jondunn]

Agree it is a challenge to know who is right and who is wrong about what level of toxicity change is clinically significant

For all the criticisms, the Lin proton esophagus vs IMRT trial actually tried to do something very cool with the total toxicity burden endpoint