Whatever happened to the MSK prostate dose escalation studies?

[dieABRdie]

Do you restrict dose to the urethra while doing the FLAME regimen? To my knowledge there are no urethra dose constraints in the study protocol used?

I have not been... maybe I should but I am also not aware of particular urethra dose constraints here.

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[jondunn]

I have not been... maybe I should but I am also not aware of particular urethra dose constraints here.

I probably would just allow 105% of the prescription dose. no need to boost the urethra. i would personally for sure limit it.

 

[wandering star]

When you run your own in house pharmacy it reminded me of day trading. You were constantly looking for the "hot stock" or in this instance the top few drugs that had the highest profit margins. There was never much rhyme or reason to it. But I remember for topical androgel e.g. we would pay like $300 for a bottle and the insurance companies would reimburse us like $700. But for something like phenergan? We would pay $10 and get reimbursed something like $11. I think memantine had a great profit margin. Pharmacy is a miasma but on the whole this is true: if you do a lot of prescribing, and there are ~5 or more docs in the practice, you should have your own in house pharmacy. An in house pharmacy will NEVER make sense for a pure rad onc group (almost no matter how big they are).

Relevant recent controversy: aducanumab, approved for Alzheimer's disease on scant clinical evidence, thereby leading to the resignation of several FDA advisors who recommended against approval, is now priced at $56,000 per patient:

Why Is Aducanumab Priced at $56,000 per Patient? Lessons for Drug-Pricing Reform | NEJM

The author describes several layers of perverse incentives that led to this pricing decision. The reimbursement to the hospital is a percentage of the price paid, so if the drug costs more, the hospital or doctor makes more -- hence, it is better for the hospital if the drug is more expensive. The price paid by Medicare (most patients will be covered by Medicare) is related to the average sales price of the drug, so the drug company wants to set the price high, deny discounts, find a willing insurance company to pay it, thereby ensuring that the average cost paid by private insurance is indeed $56,000 so that Medicare must follow (i.e., Medicare can't drive the negotiation even though it will pay for the bulk of the orders).

In the attached podcast interview the author describes physicians as glorified pharmacists, underpaid for diagnostic services but overpaid as a drug dispensary. This kind of incentive structure forces more prescriptions of overpriced medicines just to stay in business. He describes several solutions, one of which is to increase reimbursement for services that use that big MD brain and decrease reimbursement for being a drug dispensing machine.

 

[Radonc90]

For those of us who still use 180 cGy/fr, what is the LOWEST and HIGHEST fractions that you do?

I have been using the RTOG schema 7740 cGy/43 fr for > 15 years w/o issues.
I am just curious re LOWEST or HIGHEST # fractions and the rationale for doing whatever you choose.

PS: Assuming intermediate-risk Gleason 7 and PSA < 9, treating prostate only (no nodes)...

 

[Radonc90]

RTOG 0126 data is in Red Journal issue Jan 2022...

 

[TheWallnerus]

For those of us who still use 180 cGy/fr, what is the LOWEST and HIGHEST fractions that you do?

I have been using the RTOG schema 7740 cGy/43 fr for > 15 years w/o issues.
I am just curious re LOWEST or HIGHEST # fractions and the rationale for doing whatever you choose.

PS: Assuming intermediate-risk Gleason 7 and PSA < 9, treating prostate only (no nodes)...

The MSKCC way was 81/45 for everything... Gleason 5/PSA 4 all the way to Gleason 10/PSA 200.

 

[medgator]

The MSKCC way was 81/45 for everything... Gleason 5/PSA 4 all the way to Gleason 10/PSA 200

No 86.4??

 

[evilbooyaa]

For those of us who still use 180 cGy/fr, what is the LOWEST and HIGHEST fractions that you do?

I have been using the RTOG schema 7740 cGy/43 fr for > 15 years w/o issues.
I am just curious re LOWEST or HIGHEST # fractions and the rationale for doing whatever you choose.

PS: Assuming intermediate-risk Gleason 7 and PSA < 9, treating prostate only (no nodes)...

79.2 in 1.8s is my Rx dose for conv fx. All prostates (if getting conv fx) get this dose.

 

[jondunn]

79.2 in 1.8s is my Rx dose for conv fx. All prostates (if getting conv fx) get this dose.

2 gy a fraction too spicy for you?

/s

 

[RickyScott]

2 gy a fraction too spicy for you?

/s

As someone who trained in the 1.8 era, there is more use of flomax when switching to 2 gy. Rarely, I still deliver 1.8 in someone with severe luts.