*MODERATOR EDIT* - Ignore this. Thread starts on the post below
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MehDon't mind me, imma just leave this here.
Whoa whoa whoaDon't mind me, imma just leave this here.
Its amazing what happens when you become chair and you have to feed the proton beast. All of a sudden protons are a great treatment!Ironic that Ron was the senior author for an early study showing excess toxicity with PBT
Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer - PubMed
Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal...pubmed.ncbi.nlm.nih.gov
No, he's not just "pro-surgery". He's anti-radiation.Haha, here I thought I was just dropping a contraversial paper link. Didn't know about the distaste for DrCoops here. May I ask why, other then perhaps having a pro-surgery view (when the reverse would be applauded here?)
Oh my God this garbage paper couldn't have illustrated my point better:
View attachment 378014
I assume people can understand my concerns with what I highlighted, and I won't waste my time explaining it.
Except Cooperberg. I know he can't understand it but someone with more patience than me needs to teach him.
Fwiw, I'm in my 40s and would get surgery from now until about 2040 if I needed treatment and there was hope of maintaining erectile function. I'd say the same to my patients. Otoh, we do have a rct addressing this comparison. Both surgery and radiation, and staging, have improved since it's inception. Even so, I'm not sure the point of continuing to reask this question beyond accruing pubs, publicity and academic advancement. Everyone knows the referral stream in this disease is initiated by the urologists and however much some of us would like to convince ourselves we can account for all the confounders retrospectively, it simply can't be done. The best way is an rct, and unlike rcc, it's been done.Haha, here I thought I was just dropping a contraversial paper link. Didn't know about the distaste for DrCoops here. May I ask why, other then perhaps having a pro-surgery view (when the reverse would be applauded here?)
Back to the paper: I get and understand unmeasured confounding variables and bias. Prostatectomy protects against MIs and all that. On the other hand, to say I will only ever accept randomized data is a bit Nihlistic. In 10 years, if SBRT for RCC has taken off with retrospective trials showing much better outcomes then surgery, you would poopoo a surgeon who would never change their practice until a big RCT that will never accrue comes out. Take this paper; prospectively collected, highly granular database, far exceeding crappy SEER, NCDB, etc. Well thought out and applied statistical analysis with testing of rubustness of conclusions. Is it subject to unmeasured counfounders? Of course! Does that mean the data is worthless? I certainly would say not.
Side note, but I highly suspect if we had a widely measured objective physical performance metric, it would eliminate a lot of the issue of unmeasured confounding. Since really what we are "eyeballing" is apparent physical fitness. Something like VO2 max, mile walking speed, etc. "Get up and go" time does this in a way (and is a great measure of frailty,) but is a pain to measure and applies only at the frail end of the spectrum.
@Dr_coops is one of the worst in the med sphere IMO
Just a disclaimer with my response:TBF the things you highlighted are all things that can be accounted for in statistical analysis. It's the things you can't account for like "3 comorbidities" and "3 comorbidities" being very different things that is the problem.
"Case Closed!"I do ignore papers from Cooperberg though.
YupMoreso - he has a known history of unprofessional behavior both on and off social media.
It's the pub that matters, not the sentiment. Why do this paper in the first place? Why not make a chair or a knife or something?Can’t believe I’m defending him but
Cooperberg was pretty pragmatic at least on Twitter about this
Outright said this paper does not show RP is better
So hey. We still have a seat at the table.
Literal LOLIt's the pub that matters, not the sentiment. Why do this paper in the first place? Why not make a chair or a knife or something?
In this one instance, THUS FAR, I would agree with you. In this vacuum, in this moment.Can’t believe I’m defending him but
Cooperberg was pretty pragmatic at least on Twitter about this
Outright said this paper does not show RP is better
So hey. We still have a seat at the table.
Same here, Who is Cooperberg?Arriving late to the party. Who is Cooperberg and why is he such a tool?
Yup.Wasnt this dude accused on twitter of bullying a minority in our field?
Is he running for speaker of the house? He should.Wasnt this dude accused on twitter of bullying a minority in our field?
now this is a cliff hanger!I love to trash my former employer given that leadership is actually evil... like in the biblical sense...
In the 15 year results I didn't see a signal for much of anything. A paper was published re the population, noting a third had int or high risk disease. The only signal I noted was less clinical progression at 10 years in those who got rt when the PSA was >10.A few points I found worth discussion (hoping for honest discussion, not trying to just fan flames)
If we assume that improved PC mortality is due to unmeasured confounders, how do we explain that the mortality difference was only present in higher risk disease and increased proportionally with risk. Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.
To address the point of "we do have randomized data." Well we do. In the PROTECT trial. Where everyone and their father had low risk disease, and everything you or I do had no survival benefit compared to active monitoring (said tongue in cheek, with all the usual caveats). To act as if PROTECT gives us meaningful data in the treatment of higher risk disease is to really extrapolate from tiny samples, and if anything there was some signal towards surgery (for cancer mets, xrt for hrqol). Maybe we will someday get results from the SWOG trial in oligometastatic disease as well, though that is clearly a different paradigm.
Alleged personal issues aside, I do agree with the conclusions that this doesn't prove surgery is a superior option in high risk disease or anything like that, but does suggest it is a good option in the correct patient. There is a vocal minority that believe surgery should not be used in high risk disease, and this argues against that. Of course, proper counselling is needed that surgery is likely to be part of a multimodal treatment approach involving a reasonable to high liklihood of xrt. Conversely, my experience is that patients with high risk disease undergoing xrt do better with combined modality therapy with brachy/xrt/adt.
Dude, if I could clone you 100x I would.A few points I found worth discussion (hoping for honest discussion, not trying to just fan flames)
If we assume that improved PC mortality is due to unmeasured confounders, how do we explain that the mortality difference was only present in higher risk disease and increased proportionally with risk. Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.
To address the point of "we do have randomized data." Well we do. In the PROTECT trial. Where everyone and their father had low risk disease, and everything you or I do had no survival benefit compared to active monitoring (said tongue in cheek, with all the usual caveats). To act as if PROTECT gives us meaningful data in the treatment of higher risk disease is to really extrapolate from tiny samples, and if anything there was some signal towards surgery (for cancer mets, xrt for hrqol). Maybe we will someday get results from the SWOG trial in oligometastatic disease as well, though that is clearly a different paradigm.
Alleged personal issues aside, I do agree with the conclusions that this doesn't prove surgery is a superior option in high risk disease or anything like that, but does suggest it is a good option in the correct patient. There is a vocal minority that believe surgery should not be used in high risk disease, and this argues against that. Of course, proper counselling is needed that surgery is likely to be part of a multimodal treatment approach involving a reasonable to high liklihood of xrt. Conversely, my experience is that patients with high risk disease undergoing xrt do better with combined modality therapy with brachy/xrt/adt.
Have heard ASTRO pres is super kind @sirspamalotnow this is a cliff hanger!
Yes it was super kind of him to show up, tell us he's listening (but is too busy to be here often) and then after the hard questions flowed..Have heard ASTRO pres is super kind @sirspamalot
Yes it was super kind of him to show up, tell us he's listening (but is too busy to be here often) and then after the hard questions flowed..
POOF
He be gone.
I genuinely thought he would do good things.
Quickly learning very few people in this field will do the right thing if it’s hard, uncomfortable, or unpopular.
Then if you do that, people become hostile. It’s very unfortunate.
I love the day to day of rad onc more than ever, but finding it ever harder to recommend medical students go to in to this field because of the people and leadership.
Yes, I have that exact scenario now: "Can you assist this med student interested in radoc with some guidance"
My guidance:
A big problem is the level of contextual nuance in the phrase "negative engagement".Yes yes yes. And that also goes for the anon prolific Twitter accounts (also prolific SDN posters) who have been known to reply to and engage with medical students in negative fashion on Twitter.
‘It is amazing how disrespectful people act in advising trainees either by making it about them and their personal baggage, being overly positive/gaslighting, or overly negative’
Yes yes yes. And that also goes for the anon prolific Twitter accounts (also prolific SDN posters) who have been known to reply to and engage with medical students in negative fashion on Twitter.
We are making this too complicated.Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.
PREACHWe are making this too complicated.
Gleason score stratification according to age at diagnosis in 1028 men
Gleason score stratification according to age at diagnosis has been retrospectively evaluated in 1028 men with biopsy-proven prostate cancer (PCa).From January 2006 to December 2014, 2435 Caucasian men aged between 37 and 92 years underwent transperineal ...www.ncbi.nlm.nih.gov
An interesting phenomenon with prostate cancer is that older patients are more likely to be diagnosed with higher grade disease (this is opposite to breast cancer).
Age has a pretty big impact on overall survival.
Playing with men's life expectancy calculators at age 62 vs 70 make you realize how different these ages are regarding competitive risk mortality within 15 years.
You can never trust cause specific survival numbers too much.
None of us are doing much good for low risk or favorable intermediate risk patients.
I spend too much energy in my clinic thinking about how to manage men close to 80 who now have high risk prostate cancer after a period of AS.collective intellectual energy
Or attacking newly matched people or current residents. These people are already in our field.Yes. Reply to ASTRO org, Sameer, Michalski, honestly the list is SUPER long.. pick anyone haha.
Do that instead of harassing medical students please.
Has been true for the good PP jobs too. A combination of timing when you graduate, connections and whether some negative news came out regarding hypofx, apm, rocr etc that might derail hiring plans for your cycle.
I always make sure they understand how timing and luck play a big role in "job outcomes and career success" in a very small field like Rad Onc, especially in academics.