Thread by @indranilsays

A Sunday reflection and rant about the way prostate cancer treatment is evolving and its implications on my practice.
I am a clinical oncologist in India, and I've been treating PRCA patients with radiation and systemic therapy for 11 years.
1/n 🧵

Considering that I also treat HN and GI, prostate treatment has been very different, in terms of philosophy and intensity.
I love treating prostate cancer precisely because of this difference in approach.
2/n

More than 80% of the patients I see are high-risk, node-positive, or metastatic.
And they are middle-class retired Indian men, who value their independence and free time.
They are also predominantly asymptomatic or mildly symptomatic.
3/n

I love telling them that prostate cancer is going to be their companion. They should not think about it. They don't need daily medicines.
Yes, they can: eat anything, do anything, go away to the US/UK to visit children/grandchildren for as long as they want, consume alcohol.
4/n

(and blasphemy) it doesn't matter if their GnRH injection got delayed for any reason. Take it again as soon as you can manage, don't buy your flight tickets based on these. Live.
5/n

Your radiation (when applicable) starts when you want, within a reasonable timeframe. 10 min sessions. 20 or 5 treatments. Schedule work or party while you're on treatment. Your RT schedule will be adjusted based on your other commitments. Live.
6/n

Treatment was simple, affordable for a retired man, paying out of pocket. Forget about your cancer for 3-6 months.
This cancer is your companion (like your diabetes, heart disease), we will need to change gears if necessary, I will let you know. Live.
7/n

All that has now changed.
Some amazing trials now show that the all-guns-blazing approach makes people 'live' longer.
Their tiniest disease spread will get picked up on PSMA PET.
Multi-agent hormonal/systemic therapies have 'benefits' even in non-metastatic disease.
8/n

So what does this mean for my retired, middle-class, asymptomatic patient and me?
1. He needs to be explained multiple medications, timings, tests, options.
2. His upfront treatment cost has more than doubled.
3. He may have to ask for help from his children for costs
++
9/n

4. The frequency of hospital visits and tests have increased.
5. Upfront toxicity has increased. (This matters a lot, because remember they are usually asymptomatic from cancer. And while extra fatigue doesn't kill, it matters)
10/n

My patients are no longer 'happy' or 'at peace'. Their life revolves around LFTs, potassium, blood pressure records, pedal edema, fatigue.
And I am miserable.
11/n

I am miserable because while I am following #ebm, I am not absolutely certain it is the best or the smartest way to treat my patient cohort.
I believe this misses the point that 'living' and 'OS, MFS, rPFS, BFFS' are not the same in the usually asymptomatic men with prca.
12/n

I am sorry, but I wish sometimes that the next blockbuster development for non-metatstatic or early metastatic HSPC is delayed a few years. My sincere apologies to the brilliant researchers I admire. This is just a rant.

I have followed this simple philosophy for my own Dad, diagnosed in 2010 with biochemical failure and local progression in 2014. No fancy salvage Sx/RT. Just intermittent ADT. Perfectly well, walking, playing tennis, travelling, investing.
12/n

When he forgets his PSA test because he is busy, I feel happy. 'Beating' cancer is when it doesn't occupy your thoughts or your life.
13/n

I've also worked to simplify prostate cancer RT in my work. Early adoption of hypofractionation and SBRT in high risk disease. No fiducials, 3D image guided VMAT. Max 10 mins on couch. Cut costs, visits, complexity.
14/n

I doubt protons or MR guided IGRT will justify the cost or complexity. My apologies for the rant @SbrtSean
15/n

For prostate cancer at least I've always felt that there was more than what the Kaplan Meier curve shows. And that there is a smartness in simplicity in my practice.
16/n

Tagging some of the researchers who I really admire and who are really taking the treatment to new heights. Just so that you get another point of view.
@Prof_Nick_James @PCaParker @PBlanchardMD @nickva1 @DrSpratticus @VedangMurthy @neerajaiims

I believe there is a middle ground of personalized minimalist care based on patient choice in the first line therapy of prostate cancer.