Side effects following RT vs surgery vs surveillance for localized prostate cancer

[radoncolous]

Two new studies:

Chen, et al: Association Between Prostate Cancer Treatment and Quality of Life
Barocas, et al: Outcomes of Radiation, Surgery, or Observation for Localized Prostate Cancer

Seems like this is the best data to date on patient reported outcomes for modern RT, surgery, and surveillance, with IMO great support for RT. Far worse urinary and sexual side effects from surgery, with RT effects basically on par with active surveillance, with the exception of short-term bowel effects which are well known.

Will this data swing the pendulum more towards RT once patients become more informed? Any other thoughts?

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[medgator]

Will this data swing the pendulum more towards RT once patients become more informed? Any other thoughts?

Data can be published until we're all blue in the face. Nothing will change in the community unless you work in a urorads setup... as long as urologists continue to manage and workup these patients first.

I do see some self referrals but a lot of patients are just going to listen to their GU first after he/she diagnoses their prostate CA. And I say this first hand seeing multiple GUs who inappropriately cryo frontline and then salvaging some of those patients, assuming they haven't metted out. Then there's the guy who flies people to the Bahamas for HIFU (cash of course). Hifu did get fda approval last year though....

 

[Chartreuse Wombat]

The best comparison comes from the Protect study; an RCT comparing RP to XRT to AS.

http://www.nejm.org/doi/full/10.1056/NEJMoa1606221

I agree with gator; unless patients are required to meet with a radiation oncologist BEFORE treatment, nothing will change.

 

[seper]

These are, again, retrospective analyses of "population-based" databases. Any urology resident knows to disregard them.

Two new studies:

Chen, et al: Association Between Prostate Cancer Treatment and Quality of Life
Barocas, et al: Outcomes of Radiation, Surgery, or Observation for Localized Prostate Cancer

Seems like this is the best data to date on patient reported outcomes for modern RT, surgery, and surveillance, with IMO great support for RT. Far worse urinary and sexual side effects from surgery, with RT effects basically on par with active surveillance, with the exception of short-term bowel effects which are well known.

Will this data swing the pendulum more towards RT once patients become more informed? Any other thoughts?

 

[BobbyHeenan]

Until some sort of mandate comes down from NCCN or medicare that states in some form of language that "all patients should have the opportunity to discuss radiation options with a radiation oncologist before deciding upon a specific treatment modality" you can publish all you want but it's not going to move the needle much. Urology owns these patients and with the advent of more active surveillance minimizing surgeries they're clinging ever tighter to men that need treatment.

 

[MegaVoltagePhoton]

These are, again, retrospective analyses of "population-based" databases. Any urology resident knows to disregard them.

That's simply not correct. Non-randomized doesn't mean it's retrospective. Unless they're lying, Chen et al.'s study is prospective -- the patients prospectively were given QOL forms at baseline and then at regular intervals following treatment, after enrollment in a registry. Not so easy to "disregard" afterall.

 

[Krukenberg]

That's simply not correct. Non-randomized doesn't mean it's retrospective. Unless they're lying, Chen et al.'s study is prospective -- the patients prospectively were given QOL forms at baseline and then at regular intervals following treatment, after enrollment in a registry. Not so easy to "disregard" afterall.

The Chen study was indeed a population-based prospective cohort study. Not an RCT but definitely considered a high quality method, and probably the best comparison we'll get between RP, EBRT, and brachy.


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[MegaVoltagePhoton]

And the Barocas study was also prospective.

This highlights a problem in our field, where radoncs are way too trigger happy to criticize research that supports radiation -- often incorrectly, as was the case here.

 

[seper]

Hm... I guess if forms are mailed after treatment, you can count study as "prospective" nowadays. I'm not keeping up with science.

 

[MegaVoltagePhoton]

Hm... I guess if forms are mailed after treatment, you can count study as "prospective" nowadays. I'm not keeping up with science.

That's a little unfair, don't you think? What were they supposed to do -- have them fill out the 3, 6, 24 month QOL forms at the time of surgery or CT sim?

The first author of the Protect trial penned the editorial praising the two studies, let's not dismiss them.

 

[Chartreuse Wombat]

The appropriate criticism of the two recent JAMA papers is that treatment received was a choice made by the patient and his doctors. As such treatment allocation is not randomly assigned and there is real possibility of residual confounding. Otherwise the authors used reliable, valid instruments and the papers should not be dismissed easily (even by a urology resident). The bottom line is that the findings are consistent with what has been reported from the Protect trial-RP is worse for sexual function and urinary function; XRT is worse (although minimally) for bowel dysfunction. The majority of men are most concerned about urinary incontinence and sexual dysfunction. Radiation wins the comparison but unless the patterns of practice and referral change the utilization of RP will continue unabated.

 

[evilbooyaa]

Feel like it would be beneficial to get the New York Times to write an article about this or something. Every Rad Onc can know this data but like others have said, it won't change practice as Urology gets to patients first. Need to go directly to the source - patients, especially those who are googling their diagnosis.

 

[Phantom1]

Rad Onc has been subject to negative bias in retrospective studies across many different disease types for decades, i.e. we all know in retrospective studies that patients that were referred to radiation many times have more advanced disease, positive margins, worse performance status, inoperable etc..

Now for Prostate cancer we have high quality prospective randomized data in the ProtecT Study and ProtecT patient reported QOL data in NEJM. Radiation has improved sexual score and urinary scores when compared to surgery. The data is what it is, look at it yourself! The onus is not on us to defend this data, it was randomized. Hell, radiation was almost identical to observation for sexual score at the long term time point!

http://www.nejm.org/doi/full/10.1056/NEJMoa1606221#iid=f02

As radiation oncologists we should appreciate this, that our technology and modality is highly effective for prostate cancer with minimal side effects. Based off this data I tell my patients that radiation has a better sexual and urinary toxicity profile than surgery, with a slightly worse bowel toxicity than surgery. You can argue and debate back and forth about the nuances (nerve sparing vs non-nerve sparing, 3D vs IMRT), but the ball is now in the surgeons court to demonstrate otherwise...

 

[Chartreuse Wombat]

This presumes that you are fortunate enough to see the patient prior to surgery to make this case. Most men diagnosed with prostate cancer in the United States DO NOT see a radiation oncologist prior to treatment[/QUOTE]

 

[Krukenberg]

This presumes that you are fortunate enough to see the patient prior to surgery to make this case. Most men diagnosed with prostate cancer in the United States DO NOT see a radiation oncologist prior to treatment

[/QUOTE]

An approach of the Targeting Cancer campaign in Australia is to circumvent the surgeons by educating PCPs about appropriate clinical scenarios for rad onc referrals. Even if the PCP says "if you have prostate cancer, make sure you speak with a rad onc before deciding on treatment" could make a difference.


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