What’s your least favorite shady practice?

[medgator]

How often?

Enough for me to remember it and hear about it from referrings?

Harder to keep people happy without the NCI CC brand name on my office

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[evilbooyaa]

Enough for me to remember it and hear about it from referrings?

Is risk for recall reaction higher with a hypofractionated regimen compared to conventional frac? I see it in my 3-fields (which are conventionally frac'd) occasionally.

 

[medgator]

Is risk for recall reaction higher with a hypofractionated regimen compared to conventional frac? I see it in my 3-fields (which are conventionally frac'd) occasionally.

I wasn't swayed enough from what i saw the guidelines to take the chance.... Seen a few nasty reactions with adria in anaplastic thyroid patients. If one really looks at the guidelines, the chemo question is basically answered by saying some of the patients got chemo in some of the trials and nothing bad happened.

It's a pretty rare scenario these days anyways as most med oncs give TC/TCH when possible.

 

[ramsesthenice]

OK fair enough. Thanks for the healthy discussion.

I suppose if there is involvement all the way to the fundus I'd be a little bit more concerned, but in all honesty, we sim full and empty bladder to create a generous ITV of both cervix and uterus, and plan and treat on full bladder. Most cervicals seem to have some motion at the uterus but within a 1cm PTV margin.

I just don't find myself using 3D for cervix anymore. How do you determine whether a uterus is big and mobile vs say big and fixed? If it's on full and empty bladder scans, I'd still create an ITV and place an additional 1cm for a PTV margin. I think it'd be interesting to see what percentage of the time a 1cm PTV margin is actually necessary, or can we shrink it to 0.5cm like most disease sites (assuming an ITV is created).

I just do full and empty bladder scans and then look at what I get. Nothing more than that. No fancy physical exams or anything like that.

 

[deleted1002574]

I wasn't swayed enough from what i saw the guidelines to take the chance.... Seen a few nasty reactions with adria in anaplastic thyroid patients. If one really looks at the guidelines, the chemo question is basically answered by saying some of the patients got chemo in some of the trials and nothing bad happened.

It's a pretty rare scenario these days anyways as most med oncs give TC/TCH when possible.

How does it reflect fractionation? Were those reactions with adria in thyroid patients with hypofractionation?

 

[medgator]

How does it reflect fractionation? Were those reactions with adria in thyroid patients with hypofractionation?

Nope. It's the big unknown though, isn't it? What changed between the initial ASTRO breast guidelines and the update? Did we get a lot more info on chemo? From reading the guidelines, nope.

We do have this prospectively reported though:

https://ascopubs.org/doi/full/10.1200/JCO.18.00317

All patients treated with chemotherapy in this study received an anthracycline- or taxane-based regimen, and among these patients, the proportion with an adverse cosmetic outcome was 4.1% higher with HF-WBI than with CF-WBI

Additional study of current-era chemotherapy combined with HF-WBI could be beneficial to decrease the uncertainty surrounding cosmetic outcome.

Yup, not gonna risk it. Cosmesis matters. Same reason i hate catheter-based apbi even though (some of) the surgeons love it.

Shame away!

 

[RadOncDoc21]

Nope. It's the big unknown though, isn't it? What changed between the initial ASTRO breast guidelines and the update? Did we get a lot more info on chemo? From reading the guidelines, nope.

We do have this prospectively reported though:

https://ascopubs.org/doi/full/10.1200/JCO.18.00317

Yup, not gonna risk it. Cosmesis matters. Same reason i hate catheter-based apbi even though the surgeons love it.

Shame away!

Normally, I would mention guidelines and fraction shame but I’ve also experienced the power of an unforeseen reaction or symptom and the impact it can have on the recommendations for your future patients and the impact it can have on the referring provider. Those are the patients you always remember and try to figure out what could have been done differently.

Sometimes, the risk of doing something is not worth the gain, especially when you know that something you already have been doing is tried and true.

 

[OTN]

Nope. It's the big unknown though, isn't it? What changed between the initial ASTRO breast guidelines and the update? Did we get a lot more info on chemo? From reading the guidelines, nope.

We do have this prospectively reported though:

https://ascopubs.org/doi/full/10.1200/JCO.18.00317

Yup, not gonna risk it. Cosmesis matters. Same reason i hate catheter-based apbi even though (some of) the surgeons love it.

Shame away!

You mean SAVI? My cosmetic results from SAVI have been nothing short of fantastic.

 

[medgator]

You mean SAVI? My cosmetic results from SAVI have been nothing short of fantastic.

Even at the device insertion site? That seems to bother some of the patients and even surgeons I've talked to. Plus with 3 week hypofx, it's not much more of a burden on the pt and way less taxing to nurses, physics and the therapists. I imagine it'll be even less used when 30/5 goes mainstream.

 

[OTN]

Even at the device insertion site? That seems to bother some of the patients and even surgeons I've talked to. Plus with 3 week hypofx, it's not much more of a burden on the pt and way less taxing to nurses, physics and the therapists. I imagine it'll be even less used when 30/5 goes mainstream.

I've only seen small incision scars there, really pretty minimal. Agree with hypofractionation (though I do 4 weeks), the benefit isn't nearly as high as it once was.

 

[medgator]

I've only seen small incision scars there, really pretty minimal. Agree with hypofractionation (though I do 4 weeks), the benefit isn't nearly as high as it once was.

Just got a call from the breast surgeon who doesn't want to re excise a cauterized margin on a recent lumpectomy pt, 79 y/o pt2 er+ h2n- because of covid in the hospital.

Unreasonable to do hypofx with a higher boost dose? Normally i do 10 gy/5 fx, was thinking 14-16 Gy/7-8 fx?

 

[RO28]

Urologists that operate on clearly node positive prostate

 

[xrthopeful]

Oh urologists are the shadiest cancer surgeons in the game. It’s crazy

 

[medgator]

Urologists that operate on clearly node positive prostate

At least surgery is in the nccn for high risk disease.... Better than the guys that cryo or do HIFU in anybody upfront. Happens in the community. Much worse than urorads

 

[DoctwoB]

Urologists that operate on clearly node positive prostate

The data (admittedly retrospective) disagrees with you friend.

Which Patients with Clinically Node-positive Prostate Cancer Should Be Considered for Radical Prostatectomy as Part of Multimodal Treatment? The Impact of Nodal Burden on Long-term Outcomes - PubMed

Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or...

pubmed.ncbi.nlm.nih.gov

 

[DoctwoB]

Oh urologists are the shadiest cancer surgeons in the game. It’s crazy

Speaking for the urologists, whilst we are obviously human and have our bad apples, our AS uptake rate for low risk prostate is higher and faster then rad onc . . .

Perceptions of Active Surveillance and Treatment Recommendations for Low-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists - PubMed

Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

pubmed.ncbi.nlm.nih.gov

 

[DoctwoB]

At least surgery is in the nccn for high risk disease.... Better than the guys that cryo or do HIFU in anybody upfront. Happens in the community. Much worse than urorads

Yeah Hifu or cryo for anything other then salvage post xrt or on trial for focal therapy is a big area of abuse. Likewise staging procedures that didn’t need to be staged, which is like prolonged fractionation but adds the additional anesthetic risk. Other main areas (per our board member chairman) are excess in office testing (I.e renal US, uroflow, cysto, urodynamics) on everyone who walks though the door.

 

[medgator]

Yeah Hifu or cryo for anything other then salvage post xrt or on trial for focal therapy is a big area of abuse. Likewise staging procedures that didn’t need to be staged, which is like prolonged fractionation but adds the additional anesthetic risk. Other main areas (per our board member chairman) are excess in office testing (I.e renal US, uroflow, cysto, urodynamics) on everyone who walks though the door.

Or ordering lots of cysto fish assays when you get paid on lab revenue. Like these guys:

Florida urologist to pay $3.8 million for allegedly ordering unnecessary medical tests

Meir Daller ordered more than 13,000 FISH tests for his Medicare patients, allegedly collecting bonuses based on tests.

www.healthcarefinancenews.com

 

[ramsesthenice]

Speaking for the urologists, whilst we are obviously human and have our bad apples, our AS uptake rate for low risk prostate is higher and faster then rad onc . . .

As has the uptake of AS for unfavorable IR patients with medical comirbidities (at least in my area)

In all seriousness, the urologists in my area are great. let’s keep this thread focused on shady stuff within the field so we can have healthy and educational debates about what constitutes shade or not instead of getting in pissing matches with other specialties.

 

[medgator]

Speaking for the urologists, whilst we are obviously human and have our bad apples, our AS uptake rate for low risk prostate is higher and faster then rad onc . . .

Perceptions of Active Surveillance and Treatment Recommendations for Low-risk Prostate Cancer: Results from a National Survey of Radiation Oncologists and Urologists - PubMed

Most prostate cancer specialists in the United States believe AS effective and underused for low-risk prostate cancer, yet continue to recommend the primary treatments their specialties deliver.

pubmed.ncbi.nlm.nih.gov

As was your propensity to prescribe eligard/ADT based on reimbursement....

https://www.nejm.org/doi/full/10.1056/NEJMsa0910784

Some urologists who were big prescribers back in the day have zero interest in it now

 

[DoctwoB]

As has the uptake of AS for unfavorable IR patients with medical comirbidities (at least in my area)

In all seriousness, the urologists in my area are great. let’s keep this thread focused on shady stuff within the field so we can have healthy and educational debates about what constitutes shade or not instead of getting in pissing matches with other specialties.

Apologies for the derailment, my point of course was not to argue that urologists are superior just to point out that we’re all human and equally likely to respond to incentives across fields, a percentage of which will resort to unethical means to do so.

 

[evilbooyaa]

The data (admittedly retrospective) disagrees with you friend.

Which Patients with Clinically Node-positive Prostate Cancer Should Be Considered for Radical Prostatectomy as Part of Multimodal Treatment? The Impact of Nodal Burden on Long-term Outcomes - PubMed

Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or...

pubmed.ncbi.nlm.nih.gov

But why put a patient through that rather than just doing RT? Like yeah the Abdullah data suggests you can maybe omit RT in lowest risk patients that are N+, and in those with a ton of LNs the cat's out of the bag already so there isn't a huge benefit, but that's in clinically node negative people found to have incidental disease at time of surgery. Different when compared to clinically LN+.

And it's a single arm retrospective case series. Although I am surprised that only 33% of those N+ patients got radiation. Was expecting a higher number. I suppose if you can justify a less than 50% need of doing RT then could be a consideration.

 

[RO28]

The data (admittedly retrospective) disagrees with you friend.

Which Patients with Clinically Node-positive Prostate Cancer Should Be Considered for Radical Prostatectomy as Part of Multimodal Treatment? The Impact of Nodal Burden on Long-term Outcomes - PubMed

Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or...

pubmed.ncbi.nlm.nih.gov

It seems that about half of these patients got neoadjuvant ADT prior to surgery though, correct? In the discussion they mentioned that patients who had surgery + ADT had long term control rates of about 60% at 8 years, but I don't see anywhere in the results that they compared these patients against the ones that did not get ADT. How does this group fare in terms of outcomes? My experience with patients who have N+ cancer and upfront surgery is no neoadjuvant ADT and I'm not sure that is the best approach.

 

[DoctwoB]

It seems that about half of these patients got neoadjuvant ADT prior to surgery though, correct? In the discussion they mentioned that patients who had surgery + ADT had long term control rates of about 60% at 8 years, but I don't see anywhere in the results that they compared these patients against the ones that did not get ADT. How does this group fare in terms of outcomes? My experience with patients who have N+ cancer and upfront surgery is no neoadjuvant ADT and I'm not sure that is the best approach.

Likewise our practice where I trained was not to use neoadjuvant ADT, but I certainly could believe there is a benefit. And while there is level 1 SWOG evidence for starting ADT with pN+disease this trial is poo pood for various reasons and in practice it is rarely done.

 

[Palex80]

The data (admittedly retrospective) disagrees with you friend.

Which Patients with Clinically Node-positive Prostate Cancer Should Be Considered for Radical Prostatectomy as Part of Multimodal Treatment? The Impact of Nodal Burden on Long-term Outcomes - PubMed

Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or...

pubmed.ncbi.nlm.nih.gov

Data from the world experts in urologic surgery, full of selection and publication bias... Not to be trusted.
You won't get the same results in your "ordinary" patients who are treated by the urologist "next door".

 

[DoctwoB]

But why put a patient through that rather than just doing RT? Like yeah the Abdullah data suggests you can maybe omit RT in lowest risk patients that are N+, and in those with a ton of LNs the cat's out of the bag already so there isn't a huge benefit, but that's in clinically node negative people found to have incidental disease at time of surgery. Different when compared to clinically LN+.

And it's a single arm retrospective case series. Although I am surprised that only 33% of those N+ patients got radiation. Was expecting a higher number. I suppose if you can justify a less than 50% need of doing RT then could be a consideration.

Of course the quality of evidence here is quite limited. It also depends on your views of toxicitirs of salvage vs primary xrt and the cons of local radiation failure. Like all high risk disease these patients are at high risk for progression regardless of what we do. Of those that progress, with primary XRT 40% will require urologic intervention.

In my biased opinion

Data from the world experts in urologic surgery, full of selection and publication bias... Not to be trusted.
You won't get the same results in your "ordinary" patients who are treated by the urologist "next door".

Youre not wrong about the bias, and honestly those results do seem a little too good to be true, but that argument that you can’t replicate academic centers results in private practice (it’s the same darn surgery??)! Is specious and smacks of elitism. There’s nothing saying the best surgeons stay in academia any more then the best radoncs do.

 

[medgator]

. There’s nothing saying the best surgeons stay in academia any more then the best radoncs do.

When it comes to treating prostate, outside of brachy, volume matters way less than it does for surgery in terms of competence by the practicing physician. Planning wise, far easier than lung, gi or h&n imo

 

[deleted1002574]

Of course the quality of evidence here is quite limited. It also depends on your views of toxicitirs of salvage vs primary xrt and the cons of local radiation failure. Like all high risk disease these patients are at high risk for progression regardless of what we do. Of those that progress, with primary XRT 40% will require urologic intervention.

In my biased opinion


Youre not wrong about the bias, and honestly those results do seem a little too good to be true, but that argument that you can’t replicate academic centers results in private practice (it’s the same darn surgery??)! Is specious and smacks of elitism. There’s nothing saying the best surgeons stay in academia any more then the best radoncs do.

You won't find argument on this board about that

 

[scarbrtj]

but that argument that you can’t replicate academic centers results in private practice (it’s the same darn surgery??)! Is specious and smacks of elitism. There’s nothing saying the best surgeons stay in academia any more then the best radoncs do.

You won't find argument on this board about that

Striking a particular rad onc nerve @DoctwoB, and I have never quite understood it. I dare say the mindset is a bit sui generis to rad onc. Why? IDK. Rad oncs have (outside of protons, MR linacs etc) more or less the same equipment academics vs PP ("it's the same darn IMRT"). More or less access to the same textbooks, journals, NCCN guidelines, etc ("it's the same darn dose and volume"). Train at very good academic places (more or less!, "it's the same darn way I did it in residency"). And yet...

 

[RadOncDoc21]

Striking a particular rad onc nerve @DoctwoB, and I have never quite understood it. I dare say the mindset is a bit sui generis to rad onc. Why? IDK. Rad oncs have (outside of protons, MR linacs etc) more or less the same equipment academics vs PP ("it's the same darn IMRT"). More or less access to the same textbooks, journals, NCCN guidelines, etc ("it's the same darn dose and volume"). Train at very good academic places (more or less!, "it's the same darn way I did it in residency"). And yet...

You def brought up some old wounds... I forgot all about that ridiculous comment. What was he smoking?

 

[Palex80]

Youre not wrong about the bias, and honestly those results do seem a little too good to be true, but that argument that you can’t replicate academic centers results in private practice (it’s the same darn surgery??)! Is specious and smacks of elitism. There’s nothing saying the best surgeons stay in academia any more then the best radoncs do.

It's Briganti!
He is the GOD of lymph nodes in prostate cancer. He even has his own nomogram named after him (several versions of it).