Somebody in academics should run NGS on the samples for this trial and I’m sure you could come up with a paper on it.
im not surprised urology continues to have such low ability to critically analize data.
I can’t remember who first said you know a good compromise when no one is happy. I think the academic compromise is probably closer to the truth here.
let’s start with 4%. That is 1/25 patients. And also an unmistakable number that could not be physically overlooked without actively trying. It is also an extreme outlier from a single arm of a small study in which another arm with RT didn’t see anything like this. DoctwoB, I think you are generally a very reasonable voice who I appreciate best my a part of our community which is why I am confused you seem to feel like you need to discuss a controversial outlier with your patients. They have a hard enough time understanding the basics. I don’t think you are under any obligation to discuss nuanced data from post hoc analyses that don’t match up with higher quality data or your own clinical experience.
Now to my friends, I doubt 1% is quite high enough. We know that as time ticks by data from follow up degrades in quality and we are almost certainly under reporting. It also depends on what you consider a secondary cancer. Are you including Tis bladder tumors? Or just invasive tumors. I also did a little math exercise for myself. I treat pretty much all of the secondary cancers managed with RT for our state post prostate RT (any pelvic really, but only talking prostate here). I treated 4 last year. I noodled our urologists and colorectal surgeons and roughly counting 80% were managed surgically. Entering the number of patients diagnosed in our state database from 10 years ago and a reasonable estimate of the number of radiated patients at that time, I get something close to 2%. Of course, the RT patients are more likely to smoke and eat high meat diets which also increase their risk of bladders and rectal tumors so it’s a little hard to guess how much of that 2% is excess from radiation.
Indeed. But secondary malignancies are often defined as a severe adverse event in the protocol and would be reported by the sites.Good thought. I hadn't thought about it before. I checked the Bolla and the SWOG; couldn't find a mention of second primary cancers.
Here are some random wide-net, probably biased, retrospective abstracts with giant N-values. Again, "Almost 5%" is kind of imprecise but not exactly horribly, shootably-offensive wrong.
This is wrong in this case. We are looking at a relatively rare event. A small randomized trial is meaningless. In this trial they compare 8 vs 1 events? Both arms are getting XRT?That being said, it is a prospective study that looked at secondary cancer as a prespecified outcome, not a retrospective database like SEER which will be more prone to error.
OMG
Second malignancy probabilities in prostate cancer patients treated with SBRT and other contemporary radiation techniques
Patients with localized prostate cancer have multiple options for treatment including radical prostatectomy (RP), conventionally fractionated intensity-modulated radiotherapy (CF-IMRT), moderately hypofractionated intensity-modulated radiotherapy (HF-IMRT), brachytherapy (BT), or stereotactic...www.thegreenjournal.com
Excellent, updating my prostate note template to say:OMG
Second malignancy probabilities in prostate cancer patients treated with SBRT and other contemporary radiation techniques
Patients with localized prostate cancer have multiple options for treatment including radical prostatectomy (RP), conventionally fractionated intensity-modulated radiotherapy (CF-IMRT), moderately hypofractionated intensity-modulated radiotherapy (HF-IMRT), brachytherapy (BT), or stereotactic...www.thegreenjournal.com
Just a community doc here, but I really think stating anywhere between 0.5 and 1 % over a time frame of 10-15 years is reasonable and concordant with the bulk of large population studies that we have. Competing risk of dying from other things seems to eat into absolute risk of being diagnosed with second malignancy after this time frame even in the 50 something year old cohorts of pts. Given the patients that we typically treat with XRT for prostate cancer (I rarely treat pts in their 50s), I am very comfortable with any of my partners quoting these numbers.1% increased risk over baseline?
SBRT came within a statistical hair of decreasing second malignancy risk versus surgery.OMG
Second malignancy probabilities in prostate cancer patients treated with SBRT and other contemporary radiation techniques
Patients with localized prostate cancer have multiple options for treatment including radical prostatectomy (RP), conventionally fractionated intensity-modulated radiotherapy (CF-IMRT), moderately hypofractionated intensity-modulated radiotherapy (HF-IMRT), brachytherapy (BT), or stereotactic...www.thegreenjournal.com
Final score: Rad Onc: 28 Urologist: 0SBRT came within a statistical hair of decreasing second malignancy risk versus surgery.
How are we supposed to believe that SBRT is more conformal/has a lower conferred risk than brachytherapy?OMG
Second malignancy probabilities in prostate cancer patients treated with SBRT and other contemporary radiation techniques
Patients with localized prostate cancer have multiple options for treatment including radical prostatectomy (RP), conventionally fractionated intensity-modulated radiotherapy (CF-IMRT), moderately hypofractionated intensity-modulated radiotherapy (HF-IMRT), brachytherapy (BT), or stereotactic...www.thegreenjournal.com
Since a RP had higher incidences, maybe the physical disruption of the prostate caused by the implant and surgery stimulated the normal cells to become malignant. Let’s call it an invasive induced malignancy.How are we supposed to believe that SBRT is more conformal/has a lower conferred risk than brachytherapy?
Love it. Quoting it in my future discussions with patients. Sbrt has less secondary cancers than surgery. Done dealSince a RP had higher incidences, maybe the physical disruption of the prostate caused by the implant and surgery stimulated the normal cells to become malignant. Let’s call it an invasive induced malignancy.
Of course I don’t believe this but apparently we can make **** up now.
I've heard air makes cancer spread. Would be interesting to know if RALP has higher/lower secondary malignancies than open RP.Since a RP had higher incidences, maybe the physical disruption of the prostate caused by the implant and surgery stimulated the normal cells to become malignant. Let’s call it an invasive induced malignancy.
Of course I don’t believe this but apparently we can make **** up now.
Patients ask me that at least a few times a year. Maybe there is something to it after allI've heard air makes cancer spread. Would be interesting to know if RALP has higher/lower secondary malignancies than open RP.
How many times do you hear the hypothesis that living near a transformer causes cancer? I had forgotten that one, until a week or so ago.Patients ask me that at least a few times a year. Maybe there is something to it after all
Breast bud radiation also utilized. Absolute risk of second malignancies insanely high in this cohort. (~30% at 10 years in the non-radiated arm).Surprised this hasn't been posted yet. 2nd malignancy rate after long-term follow up of SPCG-7 (RT + ADT vs. ADT alone for LA-prostate cancer): Second Cancers in Patients With Locally Advanced Prostate Cancer Randomized to Lifelong Endocrine Treatment With or Without Radical Radiation Therapy: Long-Term Follow-up of the Scandinavian Prostate Cancer Group-7 Trial - PubMed
What it lacks in N compared to SEER studies, I think it more than makes up for in the purity of a RT vs. no RT RCT with excellent follow up (the Scandinavian countries have national health databases that basically capture every citizen's entire health history).
Median follow up was 12.2 years, absolute 2nd malignancy risk increase of 1.8% at 10 years (19% relative risk increase, p=NS). Strongest increase was in urinary bladder cancers (SS), but most were superficial. Second strongest was lung cancer
Nice reference. Sadly, no one actually reads the Red JournalSurprised this hasn't been posted yet. 2nd malignancy rate after long-term follow up of SPCG-7 (RT + ADT vs. ADT alone for LA-prostate cancer): Second Cancers in Patients With Locally Advanced Prostate Cancer Randomized to Lifelong Endocrine Treatment With or Without Radical Radiation Therapy: Long-Term Follow-up of the Scandinavian Prostate Cancer Group-7 Trial - PubMed
What it lacks in N compared to SEER studies, I think it more than makes up for in the purity of a RT vs. no RT RCT with excellent follow up (the Scandinavian countries have national health databases that basically capture every citizen's entire health history).
Median follow up was 12.2 years, absolute 2nd malignancy risk increase of 1.8% at 10 years (19% relative risk increase, p=NS). Strongest increase was in urinary bladder cancers (SS), but most were superficial. Second strongest was lung cancer
Dude, get it right. It’s windmills. Patients don’t even know what a transformer is anymore.How many times do you hear the hypothesis that living near a transformer causes cancer? I had forgotten that one, until a week or so ago.
That was my exact though when I read the abstract. There are dose differences so potentially that’s important but the fact they mentioned the conformality of SBRT explaining why rates were so low was laughable.How are we supposed to believe that SBRT is more conformal/has a lower conferred risk than brachytherapy?
I think he feels compelled to keep feeding the beast by giving medical students and residents papers to write. Some call it mentoring others consider it leading lambs to slaughter.The fact that ANYONE is quoting this trial, where RT was used in both arms, to say rate of RT-induced cancers is X, is just bonkers.
Honestly, between this and the 'emulation of a clinical trial' paper that D' Amico was on, he is on a pretty ****ty run of garbage research that he is associated with. Maybe he has dementia setting in.