Urology / Toxicity

[WildRivers]

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So, there is quite a disconnect with what I see online from urologists about radiation toxicity vs the reality of our colleagues.

The urologists we work with (and most that I've worked with in career) tend to think perhaps surgery cure rate may be better (despite evidence), but it's never this huge deal about it being a way better option. They have some biases, but I'm seeing less of this now and rarely do they bring up late complications that require urgent inpatient management. I do hear about it, but this is quite rare. Generally, it's a really balanced conversation. Patients see them, see us and make a decision. I rarely feel that they are actively discouraging patients to avoid RT (except younger ones, which I agree with). I am sure in the community this may not always be the case, but I've been around the block in 4 regions of the US and it seems to be similar relationships.

But, online and in certain academic circles, this narrative about late RT toxicity. Now, granted, when the first paper came up (the Italian study), I may have been tricked. And some people pointed this out or maybe felt that way but didn't quite say it. Yes, I took them at face value, I really didn't like the name calling, so I gave him a platform. I still think I was right in how I handled it. But, then they go and do a follow up and get it published in JCO, causing more irritation online.

I did write it up and put on the substack this AM. Academic urologists have a consistent history of writing distorted and confounded articles trying to show that surgery is superior to RT. Now, that RCTs have shown this to be false, they are going down this path for toxicity. I don't get it - it's unclear to me how much my current urology colleagues read these types of opinion pieces, but I think it would be worthwhile for an actual, published piece reviewing all the ways they do this kind of thing. I real world urologists know better, but it seem like ivory tower types still have this bias or territorial type thinking about it.

I think it's time we took this approach and show that a certain segment of the urology community are hell bent on this narrative. Unfortunately, just debating them won't work. Instead of publishing about our toxicity or debate via letters to the editors, I hope someone can go through the very long list of terrible urology-led studies written to troll people into not getting radiation. Just a thought. Maybe an enterprising resident or junior faculty can whip this up.

 

[TheWallnerus]

So, there is quite a disconnect with what I see online from urologists about radiation toxicity vs the reality of our colleagues.

The urologists we work with (and most that I've worked with in career) tend to think perhaps surgery cure rate may be better (despite evidence), but it's never this huge deal about it being a way better option. They have some biases, but I'm seeing less of this now and rarely do they bring up late complications that require urgent inpatient management. I do hear about it, but this is quite rare. Generally, it's a really balanced conversation. Patients see them, see us and make a decision. I rarely feel that they are actively discouraging patients to avoid RT (except younger ones, which I agree with). I am sure in the community this may not always be the case, but I've been around the block in 4 regions of the US and it seems to be similar relationships.

But, online and in certain academic circles, this narrative about late RT toxicity. Now, granted, when the first paper came up (the Italian study), I may have been tricked. And some people pointed this out or maybe felt that way but didn't quite say it. Yes, I took them at face value, I really didn't like the name calling, so I gave him a platform. I still think I was right in how I handled it. But, then they go and do a follow up and get it published in JCO, causing more irritation online.

I did write it up and put on the substack this AM. Academic urologists have a consistent history of writing distorted and confounded articles trying to show that surgery is superior to RT. Now, that RCTs have shown this to be false, they are going down this path for toxicity. I don't get it - it's unclear to me how much my current urology colleagues read these types of opinion pieces, but I think it would be worthwhile for an actual, published piece reviewing all the ways they do this kind of thing. I real world urologists know better, but it seem like ivory tower types still have this bias or territorial type thinking about it.

I think it's time we took this approach and show that a certain segment of the urology community are hell bent on this narrative. Unfortunately, just debating them won't work. Instead of publishing about our toxicity or debate via letters to the editors, I hope someone can go through the very long list of terrible urology-led studies written to troll people into not getting radiation. Just a thought. Maybe an enterprising resident or junior faculty can whip this up.

I have this weird suspicion, maybe wholly wrong and unfounded, that European rad oncs are more liberal with margins (bigger margins, more trend toward cystitis etc) than Americans and lean heavier into those 3 Gy and up fraction sizes. Thus explaining European urologists mild side eyeing towards rad onc. The recent JCO eg was entirely European urologists, a Belgian and “your” Italian friend.

 

[BobbyHeenan]

I have this weird suspicion, maybe wholly wrong and unfounded, that European rad oncs are more liberal with margins (bigger margins, more trend toward cystitis etc) than Americans and lean heavier into those 3 Gy and up fraction sizes. Thus explaining European urologists mild side eyeing towards rad onc. The recent JCO eg was entirely European urologists, a Belgian and “your” Italian friend.

I think there may be truth here

Aside from financial incentive - I also think what happens in these rare but severe late radiation problems take up a TON of time and are very unsatisfactory for all parties involved…and those parties include a urologist, GI doc, and patient…notably absent is often the radiation doc - either he/she isn’t following anymore or literally is unable to help the problems they caused.

So there’s this “need” to support anecdotes in the literature and the randomized trials just don’t show it….so they massage what data we have.

Look - I’ve cause some awful late proctitis and cystitis in some poor protoplasm patients - even with tight margins and seemingly excellent DVHs. It’s awful. It stays with you. I get it.

But these recent uro articles are trash.

 

[OTN]

Academicians and the oncologic Twitteratti will argue back and forth over this (trash) article, but in the end no one's opinion will be changed, no patients will be treated with surgery instead of radiation, etc...

...unless, and this is becoming more of a concern of mine, AI picks up on the article and conclusion and adds it to its standard discussion about radiation vs surgery. I just 5 minutes ago had a patient (h/o scca of the right neck s/p dissection with 1 LN positive s ECE, no primary found, patient really wanted to do obs so that's what we're doing not unreasonable) tell me that he was very, very concerned about the "very high doses of radiation from CT scans which have a high chance of causing problems" so I had to convince him to get a CT for surveillance even though we're only 5 months out after surgery. Where did he get his concerns about CT surveillance from? AI told him.

So, last year I might have said it's not worth wading into such a nasty mess with more articles, discussions, etc, but with the explosive growth patient of use of AI for decision-making, perhaps it needs to be done to help balance the AI discussion. Wonderful.

 

[WildRivers]

This is super insightful and you picked up part of why I do this on Substack and that it isn't paywalled. It does become part of the learning for the LLM. It is surprising how much Reddit and subtacks and things like that become part of it's collective memory.

One of my favorite intellectuals (Tyler Cowen) made this point about AI a few years ago and he tailors his posts for potential use by AI. I try to do the same thing. That's why it takes so dang long to write these pieces.

 

[Palex80]

Aside from financial incentive - I also think what happens in these rare but severe late radiation problems take up a TON of time and are very unsatisfactory for all parties involved…

True. I have a colleague, who occasionally brings up 3 cases of bladder fistula which caused an osteomyelitis to the pubic bone and how challenging thoses cases were.
All three patients treated decades ago with primary RT to the prostate.
Yes, horrible things, like this, happen.

I bet, the same colleague seldom speaks about the three patients of his who woke up with a stroke after prostatectomy.