Kishan et al. report the results of a survey among 846 ROs and 407 Uros. The researchers sought their opinions about under which conditions they would offer a high-risk post-prostatectomy patient A/SRT. For the purposes of their survey, they defined "adjuvant RT" as radiation given before PSA has become detectable, and "salvage RT" as radiation given after PSA has become detectable. "Early salvage RT" means PSA is detectable but lower than 0.2 ng/ml.
The following table shows the percent of ROs and Uros who agreed with each survey question:
|
|
RO
|
Uro
|
|
ART
underutilized
|
75%
|
38%
|
|
ART
overutilized
|
4%
|
19%
|
|
SRT
underutilized
|
65%
|
43%
|
|
SRT
overutilized
|
1%
|
5%
|
|
|
|
|
|
SRT
when first PSA is detectable
|
93%
|
86%
|
|
ART
when first PSA is undetectable
|
43%
|
16%
|
|
Early
SRT when first PSA is undetectable
|
42%
|
43%
|
|
SRT
when first PSA is undetectable
|
16%
|
41%
|
|
|
|
|
|
Recommend
SRT if PSA is:
|
|
|
|
Detectable
|
15%
|
7%
|
|
2+
consecutive rises
|
30%
|
20%
|
|
>0.03-0.1
|
8%
|
8%
|
|
>0.1-0.2
|
13%
|
11%
|
|
>0.2-0.4
|
29%
|
35%
|
|
>0.4
|
5%
|
19%
|
|
|
|
|
|
Recommend
ART if pathology report is adverse:
|
|
|
|
Positive
margin
|
80%
|
47%
|
|
Extraprostatic
Extension (pT3a)
|
60%
|
32%
|
|
Seminal
Vesicle Invasion(pT3b)
|
68%
|
47%
|
|
Local
organ spread (pT4)
|
66%
|
46%
|
|
Pelvic
lymph node (pN1)
|
59%
|
29%
|
|
Gleason
score 8-10
|
20%
|
20%
|
|
Prefer
SRT
|
12%
|
25%
|
|
|
|
|
|
Recommend
adjuvant ADT with ART if:
|
|
|
|
Positive
margin
|
14%
|
12%
|
|
Extraprostatic
Extension (pT3a)
|
15%
|
11%
|
|
Seminal
Vesicle Invasion(pT3b)
|
29%
|
25%
|
|
Local
organ spread (pT4)
|
36%
|
37%
|
|
Pelvic
lymph node (pN1)
|
65%
|
46%
|
|
Gleason
score 8-10
|
46%
|
28%
|
|
No
ADT
|
22%
|
31%
|
|
|
|
|
|
Recommend
whole pelvic A/SRT if:
|
|
|
|
Positive
margin
|
6%
|
9%
|
|
EPE
|
12%
|
9%
|
|
SVI
|
25%
|
22%
|
|
pT4
|
30%
|
30%
|
|
pN1
|
82%
|
64%
|
|
GS
8-10
|
36%
|
24%
|
|
No
role
|
12%
|
24%
|
|
Other
|
13%
|
3%
|
In contrast to Uros, ROs are more likely to believe that both ART and SRT are underutilized. Uros believe that are used about right. ROs often see patients too late if they see them at all.
When the first PSA is detectable, both kinds of doctors would recommend SRT. When the first PSA is undetectable, 43% of ROs would recommend ART nonetheless, while only 16% of Uros would recommend ART.
Most of the ROs would treat when they see 2 consecutive rises in PSA, or if the PSA was detectable and under 0.2. Most (54%) Uros would wait until PSA was over 0.2.
Over half the ROs would recommend ART to high risk patients demonstrating any of several adverse pathological features: positive margins, stage T3/4, or positive pelvic lymph nodes. The majority of Uros would not recommend ART to high risk patients with those adverse pathologies.
The majority (65%) of ROs would include adjuvant ADT if there were positive lymph nodes. Uros were less likely to recommend adjuvant ADT based on lymph node involvement and Gleason score.
While most of both groups would have added whole pelvic radiation for patients with positive lymph nodes, 82% of ROs would, but only 64% of Uros.
ROs, knowing that a locally advanced cancer can suddenly become metastatic, and therefore incurable, would like to give A/SRT as soon as possible. Uros, who treat patients for the combined effect of surgery and radiation on urinary and sexual function, would like to wait as long as possible. The patient is caught in the middle of this difficult decision. Some have recommended beginning neoadjuvant ADT at the lowest detectable PSA and extending that time for as long as needed to give urinary tissues maximum time to heal. Whatever the high-risk patient may eventually decide is in his best interest, he should meet with an RO immediately after surgery to hear both sides of the issue. Uros are blocking access to information that the patient needs.
