On 2014 Nov 07, Stephen Strum commented:

I have looked at the full article in JCO and will re-read it, but it seems to me that the issue of salvage RT in the context of men with persistent PC after a local or local-regional therapy could be focused on additional key issues along with stronger advice. Issues that come to mind are the many papers that demonstrate that the first PSA post-RP taken at about 5-6 weeks post-op should use an ultrasensitive PSA. Papers by Doherty et al, Witherspoon and others showed that those with ultrasensitive values ≤ 0.01 had outstanding prognoses e.g., Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%),compared to 47 relapses out of 61 patients (75%) who did not reach this level. More importantly, in 31 years of focused work caring for men with PC at all stages of illness, I rarely (< 1%) of the time see any diligence regarding use of nomograms and/or ANNs(artificial neural nets)done prior to initial therapy or at the time of so-called PSAR. Nomograms using PSAV + pathologic findings at RP are very helpful in risk assessment for men likely to be helped by salvage IMRT vs not.

Another key issue not discussed in this paper is the RT treatment field and again, the use of nomograms, and ANNs to get a risk assessment for which patients are at risk for nodal spread. Too many men are being treated with RT fields that are not inclusive of where the disease is.

To this end, I will say that ODAC blew it badly when they rejected a simple iron contrast nanoparticle (Combidex) to identify nodal mets at a level of sensitivity and specificity that is dramatically superior to the lousy sensitivity of CT abdomen and pelvis exams. The latter studies involve a half billion dollars globally on an annual basis but even more importantly MISdirect the use of RT and give the RadOnc and patient a false sense of where the active PC is.

We have some wonderful tools that remain in the proverbial Al Gore "lockbox", often discussed in academic meetings but rarely used in the day in and day out care of men faced with prostate cancer.

Stephen B. Strum, MD, FACP Member ASCO since 1973, AUA since 1998, ASTRO since 2002 PCRI (Prostate Cancer Research Institute) First Medical Director and Co-Founder 1997

On 2014 Nov 07, Stephen Strum commented:

I have looked at the full article in JCO and will re-read it, but it seems to me that the issue of salvage RT in the context of men with persistent PC after a local or local-regional therapy could be focused on additional key issues along with stronger advice. Issues that come to mind are the many papers that demonstrate that the first PSA post-RP taken at about 5-6 weeks post-op should use an ultrasensitive PSA. Papers by Doherty et al, Witherspoon and others showed that those with ultrasensitive values ≤ 0.01 had outstanding prognoses e.g., Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%),compared to 47 relapses out of 61 patients (75%) who did not reach this level. More importantly, in 31 years of focused work caring for men with PC at all stages of illness, I rarely (< 1%) of the time see any diligence regarding use of nomograms and/or ANNs(artificial neural nets)done prior to initial therapy or at the time of so-called PSAR. Nomograms using PSAV + pathologic findings at RP are very helpful in risk assessment for men likely to be helped by salvage IMRT vs not.

Another key issue not discussed in this paper is the RT treatment field and again, the use of nomograms, and ANNs to get a risk assessment for which patients are at risk for nodal spread. Too many men are being treated with RT fields that are not inclusive of where the disease is.

To this end, I will say that ODAC blew it badly when they rejected a simple iron contrast nanoparticle (Combidex) to identify nodal mets at a level of sensitivity and specificity that is dramatically superior to the lousy sensitivity of CT abdomen and pelvis exams. The latter studies involve a half billion dollars globally on an annual basis but even more importantly MISdirect the use of RT and give the RadOnc and patient a false sense of where the active PC is.

We have some wonderful tools that remain in the proverbial Al Gore "lockbox", often discussed in academic meetings but rarely used in the day in and day out care of men faced with prostate cancer.

Stephen B. Strum, MD, FACP Member ASCO since 1973, AUA since 1998, ASTRO since 2002 PCRI (Prostate Cancer Research Institute) First Medical Director and Co-Founder 1997