They will approve if you do a comparison and show the small bowel getting toasted in the boost, sometimes even without, depends on the p2p reviewer and insurance plan, evicore is just the third party entity
I do that in non-chemo candidates... You do that with chemo?
We generally switch the sequence, since many patients are not able to keep their bladder full during the later course of treatment.
Which means you are doing it the right way! Keep irradiating the prostate. It's the fact that you are treating it, that's keep recurrence rates low. And besides what's the downside to irradiating it? Urethritis?
I wouldn't think any intravesicular therapies are "therapizing" the prostatatic urethra. And what about partial cystectomy for early non-CIS bladder CA and even sometimes MIBC; this would also invalidate a pay-attention-prostate mindset. I'm open to hearing some data about prostate's risk of involvement with bladder cancer. AFAIK there is none especially in regards to XRT patients. If anything there seems to be a lot of data (sin of omission reporting?) that it is rare, near 0%.
Because we have always been doing it like this!!!I mentioned that there is data that a pretty low-side-effect drug has activity in brain mets and may want to be at least considered after brain met RT; but for this no "meaningful" endpoints could be impacted... and don't engage in it just because it's "reasonable."
Now again AFAIK there is literally no (again please prove me wrong) data that doing/not doing prostate RT for bladder cancer has any pluses/minuses; but elective prostate RT is the "right way" to do it? Because it's reasonable maybe
There is a vas deferens in logic between these two stances!
This is good! Would still like to see RT-focused data (but it'st here where I think there's zero data about prostate). There is much higher risk of occult disease in mastectomy (or internal mammary!) specimens (away from the primary) than suggested by lumpectomy-only-sans-RT recurrence rates e.g. We see this a lot in cancer actually. So 24% is high but it's likely not indicative of the real untreated-prostate recurrence risk. If I were to publish my single-institution data
I would have 90+% long-term bladder LC rates sans prostate RT.
You're talking about an exceedingly rare clinical presentation. But yes with very rare, unusual presentations, sometimes the thinking process has to change. But the reason there's ENI in bladder CA is due to some old guy at Mass General's afflatus... not some rigorous, data-driven process. It's one of the most invidious reasons to argue for a treatment in medicine. While I don't particularly assume every bladder CA is multifocal, total bladder RT covers for that potentiality. Suppose one could make the same argument for unknown microscopic disease in the nodes in the case of ENI (which assumes every patient has microscopic nodal dz, and treating it helps), but the toxicity differences for elective total bladder RT versus that plus elective nodal coverage are pretty large. (And there's citeable data going pretty far back in time that no-ENI chemoRT for bladder CA has ~zero percent isolated nodal relapse rates.)
Probably? Off the top of my head, maybe... Lymphoma (ie ISRT vs greater). HNSCC?
Should have said "measurable" instead of "pretty large." But see previous examples (lymphoma, HNSCC, e.g.) how volume(s) affect toxicity. Data that V∝T (V=volume, T=toxicity) in rad onc? I'd call that a Law.
