surgery vs imrt for high risk prostate cancer debate - acro 2015
TRANSCRIPT
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ACRO 2015
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Drew Moghanaki, MD, MPHHunter Holmes McGuire Veterans Affairs Hospital
Virginia Commonwealth UniversityRichmond, Virginia
High Risk Prostate Cancer
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Disclosures
I am employed by the healthcare system that brought you this
2PIVOT, NEJM 2011
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What’s So Controversial?
• Nihilism about the value of radiotherapy for high risk– ADT alone?
• Justifying toxicity of tri-modality treatment– Surgery, Radiotherapy, and ADT
• Publications by data scientists– Misinforming urologists– Confusing patients– Irritating radiation oncologists
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4ADT Alone?
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Lancet, 2009
HR: 0·44 (0·30–0·66, p<0·0001)
1996-200278% = T3
23% = SV+40% = PSA>20
Max PSA <70
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Lancet, 2011
1995-200583% = T34% = T4
18% = GS 8-1063% = PSA >20
Max PSA <70
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Challenges for Urologists
• Difficult to “get it all”
• MRI may help– Outperforms Partin Tables– Unintended consequence
• False reassurance • More aggressiveness NVB sparing• Higher positive margin
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Gupta et al, Urol Oncol 2014Borofsky et al, Urol 2013Brown et al, Urol oncol 2009
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Non-Believers
• Failure after Prostatectomy– Urologists preferred to observe– Some considered ADT, at time of symptoms– Gradually, salvage RT was considered
• Data showed OS with salvage RT– Fast PSA doublers (Trock, 2008)– Slow PSA doublers (Cotter, 2011)
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RADIOTHERAPY
Helping Improve Urologists’ Outcomes in High Risk Patients for
Decades10
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Gambling with High Risk
11Karlin et al, J Urol 2014
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ASTRO/AUA Guideline
Clinical Principle: Physicians should “offer” adjuvant radiotherapy to patients with adverse pathologic findings [SV, EPE, +Margin]
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Still believes he will live longer
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15 year: Urinary Function
Resnick, NEJM 2013
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15 year: Sexual Function
Resnick, NEJM 2013
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15 year: Bowel Function
Resnick, NEJM 2013
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Data Scientists and Big Data
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Low Risk Interm Risk High Risk
Scandinavian RegistrySooriakumaan et al, BMJ 2014
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}
The survival of CURED patients should be equal, irrespective of treatment.
IF BASELINE HEALTH WAS SIMILAR AT BASELINE
OBVIOUSLY, THEY ARE NOT
Slide by Julian Rosenman, MD, PhD
}
Rad
ioth
erap
ySu
rger
yScandinavian Registry
n >30,000
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Years
Surv
ival
0 —
60 —70 —80 —90 —
100 —
|14
|10.5
|7
|3.5
|0
Cured radiation patientsCured surgery patients
Why such a difference? What is
missing?
Slide by Julian Rosenman, MD, PhD
Survival of Cured Patients
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The Absurd
21Nat Rev Urology 2013
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Hope and the ASCENDE Trial
276 = High Risk
12 months LHRH+
46 Gy EBRT
32 Gy EBRT vs 115 Gy I-125
7y DFS Nadir + 0.2 38% 82%Nadir + 2 71% 86%
22ASCO GU, 2015ABS, 2015ESTRO, 2015
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Take Home Points
• Sharp instruments often miss tumor– Leave behind toxicity
• Routine tri-modality therapy should be avoided– No need to bother with surgery
• Don’t get fooled by data scientists– QOL, Shared Decision, Multi-Disciplinary
Clinics23
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Dr. Ehdaie may want you to believe
• He knows how to interpret the data– Yes, he does.
• Surgery helps pts live longer.– Yes, for high risk in PIVOT– (Halsted once challenged radiotherapy)
• He’ll concede we need a RCT– SPCG 15 (open, est. completion 2027)– VA High Risk Study (concept) 24
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What Dr. Ehdaie may forget to mention
Gatekeeper effect…
He may be less familiar with this
(Since Zelefsky helps keeps things honest at MSKCC)
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