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Of course it will be...but will anyone followup with the RCT that shows no difference between robot and open? I look forward to the TV urologists disparaging their British colleagues as incompetentThe immediate response will be: in the UK they don't use the robot therefore the surgical side effect outcomes aren't as good as they are in the US.
Of course it will be...but will anyone followup with the RCT that shows no difference between robot and open? I look forward to the TV urologists disparaging their British colleagues as incompetent
As palex alluded to, the patient reported data is where surgery loses. I agree though that Urologists are in the driver's seat when it comes to prostate cancer management. The only thing that helps that are educated patients and PCPsIt suggests both treatments are similar and superior to observation. Not sure how surgery really "loses" is all this.
The urologists will still see the patient first and tell them (behind closed doors) that surgery is better. We can say anything we want in tumor board and the urologist will just say "the patient wants surgery"
The only thing that helps that are educated patients and PCPs
Yup. It's the only cancer I know of that way. Most PCPs send their breast masses to radiology for mammogram and stereotactic biopsy before they see a surgeon. Lung masses can be sent to IR or pulmonary for biopsy by a PCP before they see a surgeon.As long as urology does the endorectal ultrasounds and performs the biopsies, they will control the patients.
Yup. It's the only cancer I know of that way. Most PCPs send their breast masses to radiology for mammogram and stereotactic biopsy before they see a surgeon. Lung masses can be sent to IR or pulmonary for biopsy by a PCP before they see a surgeon.
Any chance at all that IR could take over biopsy if MRI guidance takes off?
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Any chance at all that IR could take over biopsy if MRI guidance takes off?
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Good thought, not sure I want start managing prostatitis thoughThat's the wrong question IMO. I think we should be doing them.
damico said this in his editorial; can someone explain further? thanks:
"Finally, a trend favoring radiation and short-course androgen-deprivation therapy over surgery was observed. Specifically, the point estimate for the hazard ratio for death from prostate cancer when comparing these two treatments was 0.80 (95% CI, 0.22 to 2.99). If this trend becomes significant, then one may consider radiation and androgen-deprivation therapy as a preferred option for otherwise healthy men 65 years of age or older with early prostate cancer for whom treatment as compared with monitoring may be more effective (P=0.09 for interaction) in reducing death from prostate cancer."
I think Anthony is overreaching. There were 17 deaths attributable to prostate cancer in this study-woefully underpowered to draw meaningful inference at this point. The interaction with age (Table 2 in the original paper) was referenced in the preceding paragraph of his editorial and should be considered hypothesis generating. Interaction means that the treatment effect differs according to a baseline variable (in this case age above or below 65). To repeat this is hypothesis generating and this effect was not observed in the SPCG-4 study of surgery versus watchful waiting (with many more events- 66 deaths attributable to prostate cancer in the surgery arm and 99 in the watchful waiting arm) . The mention of the HR for the comparison between surgery and radiation is a big surprise. To repeat, in total there were 17 deaths attributed to prostate cancer for the whole study-5 in the surgery arm and 4 in the radiation arm. To call this a trend is really a stretch (yes 4 is less than 5 but..). A simple glance at the 95% CI for the HR of 0.22-2.99 makes this very clear.damico said this in his editorial; can someone explain further? thanks:
"Finally, a trend favoring radiation and short-course androgen-deprivation therapy over surgery was observed. Specifically, the point estimate for the hazard ratio for death from prostate cancer when comparing these two treatments was 0.80 (95% CI, 0.22 to 2.99). If this trend becomes significant, then one may consider radiation and androgen-deprivation therapy as a preferred option for otherwise healthy men 65 years of age or older with early prostate cancer for whom treatment as compared with monitoring may be more effective (P=0.09 for interaction) in reducing death from prostate cancer."
The urologists that we had been working closely with for years got a robot about 6 months ago. Prior to that, they sent us 4 patients per month. We haven't seen a single referral from them for 6 months now.
Doesn't make sense to me unless they are hospital-employed?
Robots don't make more money for the urologists than a regular RP afaik, I think it helps the hospital that owns the robot more
I know 8 weeks of radiation isn't right for everyone, but neither is losing your ability to have intercourse. If you already have ED, then pick between a higher risk of incontinence versus a lower risk of bloody stools.
Compared to incontinence from surgery, I think he's insinuating a lower risk of proctitits with imrt/igrtYou mean a higher risk of bloody stools?
Compared to incontinence from surgery, I think he's insinuating a lower risk of proctitits with imrt/igrt
though most of them just said 'don't treat'... which may not be the complete take home conclusion.
4-6 months of ADT added to 65-70 Gy XRT has been demonstrated to improve survival-no such benefit has been evident for an additional 4-9 Gy added to 68-7o Gy.This is what got pushed to my phone.
http://www.nytimes.com/aponline/2016/09/14/health/ap-eu-med-prostate-cancer.html?_r=0
This totally glosses over the facts that over 50% of active surveillance patients, most of whom were low risk, ended up being treated over 10 years. The incidence of metastatic disease more than doubled for active surveillance (albeit the numbers are small overall: 6.3% vs. 2.4% or 3.0%, p=0.004). A total of 9 men would need to be treated with either prostatectomy or radiotherapy to avoid 1 patient having clinical progression. That seems pretty significant to me. Further, since this is prostate, we'll probably need another 10 years to see a survival difference--though I think it's unlikely we ever will with the # of metastatic progressions and this being low risk disease.
This comes back to the old question--is it worth treating to prevent disease progression or improve QOL? I think so. I think this push towards "if it doesn't improve survival it isn't worth it" is bleeding over from some other specialties where cost is an ever increasing issue, but I'm not in favor of it in a lot of radiation situations. If we have to show survival benefit to every scenario in which we radiate, a lot of patients will suffer because we won't be radiating a lot of things we do now.
The only thing I wish had been done differently from a radiation perspective is that all patients got 5-8 months of ADT (3-6 neoadjuvant + concurrent). My training always tried to avoid ADT due to QOL issues. ADT seems overkill for low risk, though maybe that helps for 74 Gy 3D-Conformal? Are outcomes equivalent with 78 Gy IMRT so that ADT is not necessary or was the ADT never necessary? I would think so.
I think adding adt made the trial more relevant at those xrt doses. Agree with you that overall survival isn't the only issue here, having metastatic disease and lifelong lupron isn't a great way to liveThis is what got pushed to my phone.
http://www.nytimes.com/aponline/2016/09/14/health/ap-eu-med-prostate-cancer.html?_r=0
This totally glosses over the facts that over 50% of active surveillance patients, most of whom were low risk, ended up being treated over 10 years. The incidence of metastatic disease more than doubled for active surveillance (albeit the numbers are small overall: 6.3% vs. 2.4% or 3.0%, p=0.004). A total of 9 men would need to be treated with either prostatectomy or radiotherapy to avoid 1 patient having clinical progression. That seems pretty significant to me. Further, since this is prostate, we'll probably need another 10 years to see a survival difference--though I think it's unlikely we ever will with the # of metastatic progressions and this being low risk disease.
This comes back to the old question--is it worth treating to prevent disease progression or improve QOL? I think so. I think this push towards "if it doesn't improve survival it isn't worth it" is bleeding over from some other specialties where cost is an ever increasing issue, but I'm not in favor of it in a lot of radiation situations. If we have to show survival benefit to every scenario in which we radiate, a lot of patients will suffer because we won't be radiating a lot of things we do now.
The only thing I wish had been done differently from a radiation perspective is that all patients got 5-8 months of ADT (3-6 neoadjuvant + concurrent). My training always tried to avoid ADT due to QOL issues. ADT seems overkill for low risk, though maybe that helps for 74 Gy 3D-Conformal? Are outcomes equivalent with 78 Gy IMRT so that ADT is not necessary or was the ADT never necessary? I would think so.
I think we should begin to emphasize prevention of metastatic disease. It is a state with significant negative QOL effects and once documented begins an incredibly expensive treatment course. A couple of months of the newer agents cost many times what XRT does in any scenarioThis is what got pushed to my phone.
http://www.nytimes.com/aponline/2016/09/14/health/ap-eu-med-prostate-cancer.html?_r=0
This totally glosses over the facts that over 50% of active surveillance patients, most of whom were low risk, ended up being treated over 10 years. The incidence of metastatic disease more than doubled for active surveillance (albeit the numbers are small overall: 6.3% vs. 2.4% or 3.0%, p=0.004). A total of 9 men would need to be treated with either prostatectomy or radiotherapy to avoid 1 patient having clinical progression. That seems pretty significant to me. Further, since this is prostate, we'll probably need another 10 years to see a survival difference--though I think it's unlikely we ever will with the # of metastatic progressions and this being low risk disease.
This comes back to the old question--is it worth treating to prevent disease progression or improve QOL? I think so. I think this push towards "if it doesn't improve survival it isn't worth it" is bleeding over from some other specialties where cost is an ever increasing issue, but I'm not in favor of it in a lot of radiation situations. If we have to show survival benefit to every scenario in which we radiate, a lot of patients will suffer because we won't be radiating a lot of things we do now.
The only thing I wish had been done differently from a radiation perspective is that all patients got 5-8 months of ADT (3-6 neoadjuvant + concurrent). My training always tried to avoid ADT due to QOL issues. ADT seems overkill for low risk, though maybe that helps for 74 Gy 3D-Conformal? Are outcomes equivalent with 78 Gy IMRT so that ADT is not necessary or was the ADT never necessary? I would think so.
I think we should begin to emphasize prevention of metastatic disease. It is a state with significant negative QOL effects and once documented begins an incredibly expensive treatment course. A couple of months of the newer agents cost many times what XRT does in any scenario
Pain, cord compression, pathologic fx in some cases...Its been my main go to whenever I speak to a healthy patient. I tell them that a lot of the studies focus on overall survival but that is really not the appropriate endpoint to think about. The quality of life after developing mets however is significantly worse (adt, chemo, frequent hospital visits, scans etc)
I was looking at the supplementary tables (http://www.nejm.org/doi/suppl/10.1056/NEJMoa1606220/suppl_file/nejmoa1606220_appendix.pdf). I noticed that among the prostate cancer deaths (table s4) that of the 5 prostate cancer deaths in the RP arm only 2 actually had an RP! Same for the 4 prostate cancer deaths in the RT arm.
So by treatment received the prostate cancer deaths is: 13 (AS), 2 (RP), 2 (RT). I don't know if this would be statistically significant but it certainly makes the hazard ratios more impressive.
I understand that intent to treat is the standard way to evaluate a trial but when the difference between intent to treat and treatment received is this large I think it should be more clearly discussed in the paper.
In real life patients end up not getting the intended course of treatment. also if you exclude people who didn't get the intervention then you've broken the randomization.
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