can we talk about urorad?

[medgator]

I'm not sold on adjuvant RT. With ultra-sensitive PSA testing and good follow-up, as long as they get sent to me before PSA reaches 1.0, I don't mind just watching patients with +margins or pT3a. T3b are going to fail distantly, but heck, lump them in there, too. As the data shows, 30-70% won't fail and won't need RT. I think a balance of watching PSA and early salvage is a cost-effective, low morbidity approach, and I think the consensus guidelines reflected that approach, as an alternative. The control arms treated with salvage RT way too late when the PSA would be 6 or something crazy and there is no way to salvage those folks.

Been giving most of them 6 months of ADT, too.

I use the data from the german study looking at a wait-and-see approach vs adjuvant RT in terms of a bPFS benefit. I don't believe the updates have shown a metastasis-free survival benefit as of yet, but if I can prevent people from going on to Lupron (which the SWOG study also demonstrated) and give them a bPFS benefit, I like to offer it to my T3 patients especially when I can counsel them on the 0.3% risk of G3-4 toxicity.

I think the risk factor of a +margin alone is a more nuanced conversation.

I know the RTOG is currently studying it, but I am also one of those people that likes to give 4-6 mos of ADT during XRT for bad disease (T3, G8, etc.... I'll go 1-2 years for +nodes).

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[deleted4401]

Problem with all those studies is that the salvage policy wasn't well defined and it was not an era of ultra sensitive psa. Definitely controversial and there is level 1 evidence to treat, but those studies don't reflect modern practice, specifically that when psa is 0.2, can salvage pretty easily.

 

[Ursus Martimus]

Problem with all those studies is that the salvage policy wasn't well defined and it was not an era of ultra sensitive psa. Definitely controversial and there is level 1 evidence to treat.

Generally, the presence of level 1 evidence is not considered controversial. That is to say, unless there is competing level 1 evidence to the contrary.

 

[Neuronix]

Generally, the presence of level 1 evidence is not considered controversial. That is to say, unless there is competing level 1 evidence to the contrary.

Level 1 evidence has to apply to your patient group. This is where the controversy lies. In the SWOG 8794 adjuvant vs. salvage study, the median PSA at time of salvage was 1.0. We know from other data (http://forums.studentdoctor.net/showpost.php?p=14372354&postcount=7) that the salvage rate depends on the PSA at the time of salvage. With frequent PSA and "ultra-sensitive" tests, patients should be getting treated now at about the 0.2-0.5 level based on ASTRO/AUA consensus guidelines.

So the question becomes: does SWOG 8794 apply to modern practice? i.e. the patients who were "salvaged" with a PSA >0.5 were likely setup to fail, where they don't necessarily need to be. We have to ignore some other factors that would push you to treat immediately, such as patient compliance or urologists not doing the right thing in your community. Knowing that PSA <0.5 is much more salvageable, will randomization of patients to salvage ONLY if the PSA is <0.5 vs. adjuvant for high risk factors (SVI, T3b, positive margin) make a difference in survival?

There is evidence for equivalence of adjuvant and salvage radiation only when salvage is performed in a timely fashion: http://www.sciencedirect.com/science/article/pii/S009042959900299X (edit: also http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2010.09447.x/full). This also may be a reason why the SWOG found a survival and distant metastasis free benefit, while the German and EORTC studies did not. Also, the EORTC only found a benefit for positive margins on subset analysis (http://jco.ascopubs.org/content/25/27/4178.long) which could be the most important factor. Though I don't know what the median PSA at time of salvage were for those studies.

So in the end, it's still reasonable to only give adjuvant radiation for positive margins, or to be dogmatic about the SWOG study and recommend adjuvant radiation for all high risk features until more trial data becomes available.

 

[Ursus Martimus]

So giving preference to German Study over SWOG study is quite interesting given the German and EORTC followup is 10 years vs Swog 15 years, given the natural history of prostate cancer. Note as well German trial was not powered to show OS difference. Swanson et al., JCO, 25(16):2225-9 also shows differences for differences to median time to failure, local failure, and distant mets for <= 0.2 ng/ml, >2 and <=1 ng/ml, and > 1ng/mL. As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)

 

[thesauce]

Level 1 evidence has to apply to your patient group. This is where the controversy lies. In the SWOG 8794 adjuvant vs. salvage study, the median PSA at time of salvage was 1.0. We know from other data (http://forums.studentdoctor.net/showpost.php?p=14372354&postcount=7) that the salvage rate depends on the PSA at the time of salvage. With frequent PSA and "ultra-sensitive" tests, patients should be getting treated now at about the 0.2-0.5 level based on ASTRO/AUA consensus guidelines.

So the question becomes: does SWOG 8794 apply to modern practice? i.e. the patients who were "salvaged" with a PSA >0.5 were likely setup to fail, where they don't necessarily need to be. We have to ignore some other factors that would push you to treat immediately, such as patient compliance or urologists not doing the right thing in your community. Knowing that PSA <0.5 is much more salvageable, will randomization of patients to salvage ONLY if the PSA is <0.5 vs. adjuvant for high risk factors (SVI, T3b, positive margin) make a difference in survival?

There is evidence for equivalence of adjuvant and salvage radiation only when salvage is performed in a timely fashion: http://www.sciencedirect.com/science/article/pii/S009042959900299X. This also may be a reason why the SWOG found a survival and distant metastasis free benefit, while the German and EORTC studies did not. Also, the EORTC only found a benefit for positive margins on subset analysis (http://jco.ascopubs.org/content/25/27/4178.long) which could be the most important factor. Though I don't know what the median PSA at time of salvage were for those studies.

So in the end, it's still reasonable to only give adjuvant radiation for positive margins, or to be dogmatic about the SWOG study and recommend adjuvant radiation for all high risk features until more trial data becomes available.

I have a very hard time leaving off radiation in the adjuvant setting for patients that met the criteria for SWOG. That trial has got to be one of the biggest homeruns for radiation that I've seen across all disease sites. NNT of <10 to save a life! For prostate cancer!! There is even an improvement in QOL!

While early salvage may be just as good, you are relying on the system to get them regular PSAs and timely followups to the appropriate physicians. I can't tell you how many times I've had a patient come in with a PSA >3.0 post-prostatectomy because they moved or otherwise stopped following up with a Urologist and the only provider they were seeing is their PCP who didn't know post-op PSAs should be treated differently. Now with some PCPs not even drawing PSAs...

However, I do agree with Neuronix that you have to know your patient base.

 

[medgator]

So giving preference to German Study over SWOG study is quite interesting given the German and EORTC followup is 10 years vs Swog 15 years, given the natural history of prostate cancer. Note as well German trial was not powered to show OS difference. Swanson et al., JCO, 25(16):2225-9 also shows differences for differences to median time to failure, local failure, and distant mets for <= 0.2 ng/ml, >2 and <=1 ng/ml, and > 1ng/mL. As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)

To be fair to simul, this is a level 2a recommendation despite the level I evidence likely owing to the controversy that still exists and, as such, observation is still offered as an alternative.

 

[Ursus Martimus]

To be fair to simul, this is a level 2a recommendation despite the level I evidence likely owing to the controversy that still exists and, as such, observation is still offered as an alternative.

So level 2a recs from NCCN are controversial? NCCN offers few cat 1 recs across all disease sites, which by your rationale, would make almost all cancer care controversial. I think you are confusing level 1 data with level 1 recommendation.

 

[Neuronix]

As far as being dogmatic about swog, that is exactly what NCCN recommends as Level 2A (...uniform consensus (ie no controversy) that the intervention is appropriate)

I'm just giving the other side of the argument here. For a lengthier and more eloquent version, see:

http://www.sciencedirect.com/science/article/pii/S0022534713043656

Adjuvant Versus Salvage Post-Prostatectomy Radiation Therapy: A Critical Review of the Evidence
Anthony V. D'Amico, MD, PhD August 2013

"Therefore, while awaiting the results of the RADICALS and RAVES trials, discussing PSA surveillance and delaying RT until PSA failure (confirmed PSA level of more than 0.2 ng/ml) for men with Gleason score 7 or less and pT3aR0 or pT2R1 disease warrants consideration.

As for the NCCN discussion, I would agree with their category 2A recommendation.

Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

As I stated previously, I think it would be appropriate to treat or only treat for positive margins. But they do state RT OR Observation in their guidelines, both as category 2A evidence. There is no (RT Preferred) as they sometimes do. This is a complicated issue.

 

[medgator]

So level 2a recs from NCCN are controversial? NCCN offers few cat 1 recs across all disease sites, which by your rationale, would make almost all cancer care controversial. I think you are confusing level 1 data with level 1 recommendation.

Controversial enough that they allow for observation as the alternative.

Their level I recommendations are based on "high-level evidence" which AFAIK would be a cooperative group RCT like SWOG, EORTC etc which is level I evidence. Despite having that level I evidence, NCCN saw fit to make the recommendation "2A"

Contrast this the situation in H&N Ca, where we have level I evidence for a benefit in post-op Tx of ECE and +margin. There, the NCCN clearly states a "Category 1" recommendation for adjuvant chemo/RT in that situation, based on Level I evidence. They don't say observation. They don't say post-op RT alone.

 

[deleted4401]

Right. What everyone else said

It is controversial. I don't take much things as "the word", but if Tony D'Amico says something, I do take it as "the word". He's a brilliant collater and synthesizer of data, and he recognizes that logical people can disagree. Do I think that it's wrong to use SWOG criteria? Absolutely not. But, in my practice, I don't argue with the urologists because that study doesn't represent modern medicine, and tweaking practice towards reality isn't a bad thing.

Back to the beach...

 

[Ursus Martimus]

Fair enough, although I still think discussants are confusing level data with category recommendation. Again, there are only a handful of cat 1 recs in NCCN.

 

[Gfunk6]

Another interesting Urorads article,

http://www.azcentral.com/story/mone...phoenix-radiation-referral-medicare/14192375/

 

[vokey588]

Another interesting Urorads article,

http://www.azcentral.com/story/mone...phoenix-radiation-referral-medicare/14192375/

How is ASTRO ensuring that any anti-loophole law that is passed doesn't prevent radiation oncologists themselves from owning treatment centers? It seems like that is a risk of their efforts.

 

[medgator]

How is ASTRO ensuring that any anti-loophole law that is passed doesn't prevent radiation oncologists themselves from owning treatment centers? It seems like that is a risk of their efforts.

By definition we can't self refer. Radiologists don't send orders for scans to their own machines.

Rad oncs don't diagnose prostate ca and make referrals. Urologists do

 

[thesauce]

"In 2013, the U.S. Government Accountability Office found that more than half of the nearly $1.3 billion paid by Medicare for IMRT therapy went to radiation centers that treat prostate cancer."

More than half? I had no idea it was that bad...

 

[medgator]

"In 2013, the U.S. Government Accountability Office found that more than half of the nearly $1.3 billion paid by Medicare for IMRT therapy went to radiation centers that treat prostate cancer."

More than half? I had no idea it was that bad...

I could see it.... the big 3 we treat are lung, breast and prostate. Urorads by far has been the biggest abuse out of those 3 sites IMO. Still not quite as big as the 80% of medicare proton spending going to prostate, but still it's a disheartening number.

 

[Gfunk6]

sI agree with ASTRO in principle regarding self-referring Urorads centers. However, I believe that their approach is wrong. If you simply ban physicians (e.g. ALL non-Rad Oncs) who own linear accelerator from self-referring then you have gone down a slippery slope. As I mentioned in other threads, it is essentially impossible for the vast majority of Rad Oncs to purchase their own accelerator. The expense and risk are too high. You need buy-in from other physicians. If you simply ban self-referral, then you are hastening the death of physician-owned practices and accelerating MDs into employment models.

A more intelligent way to go about this would be on the physician payment reform end. The ONLY reason self referral exists is $$$. If you create capitated reimbursement models or case rates then I guarantee you that utilization will drop. Of course, this means that all the members of ASTRO Executive Team in large academic centers who invested in protons will eat it financially.

 

[thesauce]

http://www.nature.com/pcan/journal/vaop/ncurrent/full/pcan20179a.html

Here's a new one. Bring on the urologist's convoluted explanation for this finding and how it has nothing to do with financial gain...

 

[PruritisAni]

http://www.nature.com/pcan/journal/vaop/ncurrent/full/pcan20179a.html

Here's a new one. Bring on the urologist's convoluted explanation for this finding and how it has nothing to do with financial gain...

Looks like if you have actual prostate cancer, you are better off going to a urorads....

 

[thesauce]

LOL. Well - high risk anyway.

 

[MD20001]

Sorry to bump an old thread but curious to see what the status is with the UroRads centers. Any progress made by ASTRO to fight these centers? Seems like the discussion of these places has disappeared

 

[medgator]

Sorry to bump an old thread but curious to see what the status is with the UroRads centers.

They still exist.

Any progress made by ASTRO to fight these centers? Seems like the discussion of these places has disappeared

ASTRO let that ship sail well before they tried to fight it. Unfortunately their efforts essentially hurt many in the freestanding/pp community as collateral damage. They likely realized:

1) how many physicians they were alienating in the process and

2) how futile such a fight was likely to be going forward

And have likely moved on

 

[MD20001]

Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume

 

[w00tz]

I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?

 

[medgator]

I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?

Agree it's dumb to open one now, but for existing ones that have already paid off a machine and/or vault, many are likely aware of where things are going. Many urorads centers offer brachy/sbrt etc already

 

[scarbrtj]

Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume

Well, that is the urologists' speciality... draining things.

 

[Chartreuse Wombat]

I'm surprised people are opening new ones with APM around the corner. Does anyone know what a prostate treatment will reimburse yet with the new payment model?

From ASTRO Website July 11, 2019. Of course this is the proposed rule, not the final rule.

 

[medgator]

Blah wish there was a better way to combat it. For those in high volume urorads areas, how are you fighting them? Our big urology group recently opened their own site and it has completely drained our volume

Partner with your own group of urologists. Multi-specialty groups are the future of RO outside of academics. Or offer things like HDR, sbrt, hypofx etc if they aren't

 

[WVXRT]

Anybody know about the reno NV job? Whats the deal? PM me if u want

 

[scarbrtj]

From ASTRO Website July 11, 2019. Of course this is the proposed rule, not the final rule.

View attachment 278869

do you (anybody) have a link for that

 

[scarbrtj]

Partner with your own group of urologists. Multi-specialty groups are the future of RO outside of academics. Or offer things like HDR, sbrt, hypofx etc if they aren't

they have been, and always will be, the best model for a rad onc in PP IMHO (and this of course is really the model in academics: a multi-specialty group). If you're going to be an end-of-the-referral-chain catfish (not my phraseology), partner with--do not shun, do not refuse collaboration, do not antagonize--others.

 

[Chartreuse Wombat]

do you (anybody) have a link for that

CMMI Radiation Oncology Alternative Payment Model “RO Model” Proposed Rule Summary - American Society for Radiation Oncology - American Society for Radiation Oncology (ASTRO)

Read ASTRO's summary of the CMMI Radiation Oncology Alternative Payment Model Proposed Rule

www.astro.org

 

[OTN]

Our local urorads group does basically all the prostate cancer in town- 99% at least. We're finding that the most viable option for competing (outside of doing your own biopsies, which some radoncs have taken to doing) is going directly to the large primary care groups in town and talking about how we're a far cheaper option, given our ability to provide SBRT/hypofractionation, etc, which the urorads group most decidedly does not do (45 fractions for everyone). Once they become responsible for downstream costs in an ACO-type model, which is starting to happen, we may be able to get patient steerage our way by offering cheaper solutions. We shall see.

 

[taserlaser]

Our local urorads group does basically all the prostate cancer in town- 99% at least. We're finding that the most viable option for competing (outside of doing your own biopsies, which some radoncs have taken to doing) is going directly to the large primary care groups in town and talking about how we're a far cheaper option, given our ability to provide SBRT/hypofractionation, etc, which the urorads group most decidedly does not do (45 fractions for everyone). Once they become responsible for downstream costs in an ACO-type model, which is starting to happen, we may be able to get patient steerage our way by offering cheaper solutions. We shall see.

45.... yikes. Can’t imagine those patients learning afterwards that SBRT is an option

 

[DukeNukem]

Of course ASTRO has it out for urorads. Academic rad oncs don't want the competition.

But who's the real enemy to radiation oncologists?

Academic satellite jobs are the only things available here. They open up right next to the private practices and the private practices struggle to survive.

The urorads jobs pay 600k ish. Academic satellite jobs pay 300k ish. The hours worked are very similar. There's a huge glut of desperate residents ready to do anything to be employed, so the satellites have no problem filling. That extra 300k in salary that should go to the rad onc goes right into an admin's pocket instead of the rad onc's.

 

[Haybrant]

Of course ASTRO has it out for urorads. Academic rad oncs don't want the competition.

But who's the real enemy to radiation oncologists?

Academic satellite jobs are the only things available here. They open up right next to the private practices and the private practices struggle to survive.

The urorads jobs pay 600k ish. Academic satellite jobs pay 300k ish. The hours worked are very similar. There's a huge glut of desperate residents ready to do anything to be employed, so the satellites have no problem filling. That extra 300k in salary that should go to the rad onc goes right into an admin's pocket instead of the rad onc's.

I see where you’re going with it but Inherent conflict in self referral is a pretty self explanatory problem, just bc it pays better doesn’t make it ok. That said who knows maybe they have a way of being 100% honest and self-policing and if so good on them

 

[medgator]

I see where you’re going with it but Inherent conflict in self referral is a pretty self explanatory problem, just bc it pays better doesn’t make it ok. That said who knows maybe they have a way of being 100% honest and self-policing and if so good on them

Self referral? Ever heard of Stark law exemptions? Sometimes these ROs joint venture with the urologists. Food for thought.

What's worse BTW.... Imrt or hifu/cryo/inappropriate RP?

 

[OTN]

Self referral? Ever heard of Stark law exemptions? Sometimes these ROs joint venture with the urologists. Food for thought.

What's worse BTW.... Imrt or hifu/cryo/inappropriate RP?

I always took this slant on it as well. At least these patients are getting radiation options now.

 

[Haybrant]

I always took this slant on it as well. At least these patients are getting radiation options now.

Right so if the other urologists are practicing crappy medicine which they do then I agree, and I suspect academic centers set this up in some way through back handed methods. In that way ok, but it doesn’t make either situation right. That’s why we need to stop w the way our system is setup but that’s a discussion for a different thread

 

[medgator]

Right so if the other urologists are practicing crappy medicine which they do then I agree, and I suspect academic centers set this up in some way through back handed methods.

??

Fwiw, most academic urologists I know stick to guidelines and don't practice cryo for upfront treatment of PCa. Out in the community though, it is not uncommon, esp among the older urologists

 

[Reaganite]

Of course ASTRO has it out for urorads. Academic rad oncs don't want the competition.

But who's the real enemy to radiation oncologists?

Academic satellite jobs are the only things available here. They open up right next to the private practices and the private practices struggle to survive.

The urorads jobs pay 600k ish. Academic satellite jobs pay 300k ish. The hours worked are very similar. There's a huge glut of desperate residents ready to do anything to be employed, so the satellites have no problem filling. That extra 300k in salary that should go to the rad onc goes right into an admin's pocket instead of the rad onc's.

Exactly. The Urorads centers I've seen/heard about have taken much better care of their radoncs than typical academic satellites. I usually see 500k+ salary figures (even in good geographies) and most urologists I know are much cooler to work for than the dbag hospital admins and radonc chairmen actively trying to destroy our field. Astro hates urorads and stark radiation exemptions in general because they help preserve private practice and prevent academic monopolies.

 

[thecarbonionangle]

Why is it that one hears that working for urorads is a career killer? Would you guys hire a urorads guy to your practice if they were looking to make a move? I dislike the stupid stigma around these jobs

 

[medgator]

Why is it that one hears that working for urorads is a career killer? Would you guys hire a urorads guy to your practice if they were looking to make a move? I dislike the stupid stigma around these jobs

Depends on the situation.... some of these urorads gigs are really JV gigs where the RO treats other stuff on the Linac besides GU, or they are multi-specialty setups with med onc involved as well.

If the guy/gal was still up to snuff on full-spectrum PP, I wouldn't have a problem hiring them. The problem is when you get the stereotypical "urorads" setup where the RO essentially becomes a "tech" and just signs off on 7-9 field/VMAT 1.8-2 Gy/d prostate plans every day and can't treat anything else since they've been out of the game so long.

 

[Haybrant]

??

Fwiw, most academic urologists I know stick to guidelines and don't practice cryo for upfront treatment of PCa. Out in the community though, it is not uncommon, esp among the older urologists

I’m referencing surgery for very high risk PCa, node positive, PSA greater than 50. See it a reasonable amount at my and other academic centers in my area. It’s really not ok if one just says well there is a high risk you’ll need radiation after and pretend that covers them in consent. The patient has no clue what the implications of that actually are

 

[medgator]

I’m referencing surgery for very high risk PCa, node positive, PSA greater than 50. See it a reasonable amount at my and other academic centers in my area. It’s really not ok if one just says well there is a high risk you’ll need radiation after and pretend that covers them in consent. The patient has no clue what the implications of that actually are

At least it's an nccn listed option, and they hopefully send those patients for adjuvant xrt.

There are urologists out in the real world who would fly patients out to the Caribbean or Mexico for HIFU for prostate ca before it was FDA approved. Cash only, obviously since it would not be covered by insurance. Assuming they didn't feel like doing upfront cryo instead.

If it comes to that or urorads in the eyes of aggressive and shrewd urologists, you tell me which is worse for patient care.

 

[Haybrant]

At least it's an nccn listed option, and they hopefully send those patients for adjuvant xrt.

There are urologists out in the real world who would fly patients out to the Caribbean or Mexico for HIFU for prostate ca before it was FDA approved. Cash only, obviously since it would not be covered by insurance. Assuming they didn't feel like doing upfront cryo instead.

If it comes to that or urorads in the eyes of aggressive and shrewd urologists, you tell me which is worse for patient care.

Both are bad. That it’s in NCCN is part of the same racket that academic centers allowed.

 

[evilbooyaa]

Both are bad. That it’s in NCCN is part of the same racket that academic centers allowed.

I hate that RP for high-risk diease in prostate cancer is an acceptable option in NCCN guidelines as much as you do. I had posts on this years ago trying to understand what the basis of evidence was to at all allow it into the guidelines (which is STILL very, very poor)

That being said, it is not nearly in the same ball park of shady as cryo or HiFU for upfront management of localized prostate cancer.

 

[Burt Radnolds]

I hate that RP for high-risk diease in prostate cancer is an acceptable option in NCCN guidelines as much as you do. I had posts on this years ago trying to understand what the basis of evidence was to at all allow it into the guidelines (which is STILL very, very poor)

That being said, it is not nearly in the same ball park of shady as cryo or HiFU for upfront management of localized prostate cancer.

I have heard urologists say and openly write in their notes that there is evidence that RP is the superior option in high risk disease. While I do not concur, if you peruse the available literature, there is data to suggest that outcomes are similar (much like the rest of the RP vs XRT data). My belief is that ADT/IMRT/brachy boost is the likely winner.

 

[evilbooyaa]

I have heard urologists say and openly write in their notes that there is evidence that RP is the superior option in high risk disease. While I do not concur, if you peruse the available literature, there is data to suggest that outcomes are similar (much like the rest of the RP vs XRT data). My belief is that ADT/IMRT/brachy boost is the likely winner.

Yes, there is retrospective data that does not attempt to (or does not adequately) control for co-morbidities that shows patients undergoing RP live longer.

That may be the 'critical review' standard for urologists citing literature, but every Rad Onc knows who is more likely to get a RP and who is more likely to get ADT+RT out of a high-risk prostate cancer population, and how that influences survival much more than the choice of treatment modality does.