BackTable / Urology / Podcast / Transcript #113

Podcast Transcript: Radiotherapy for High Risk Prostate Cancer

with Dr. Daniel Spratt

This week on the BackTable Urology Podcast, Dr. Bagrodia talks with Dr. Daniel Spratt, professor and chairman of radiation oncology at Case Western University in Cleveland, about the workup and treatment of high risk prostate cancer. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Patient Intake & Diagnostic Imaging for High-Risk Prostate Cancer

(2) Imaging Strategies for Prostate Cancer Staging

(3) Integrating Genomic Profiling into Treatment Decision-Making for Prostate Cancer

(4) The Role of Timing in Hormone Therapy for Prostate Cancer

(5) Navigating Prostate Anatomy & Symptoms in Radiation Therapy Decision-Making

(6) Decoding the Types, Efficacy & Complications of Prostate Radiation Therapies

(7) The Role of Protons in Prostate Cancer Therapy

(8) The Initial Steps in High-Risk Prostate Cancer Management

(9) Strategic Approach to Lymph Node Radiation in Prostate Cancer

(10) Managing the Complexities of Prostate Cancer Treatment

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[Dr. Aditya Bagrodia]
Hello, everyone, and welcome back to the BackTable Podcast, your source for all things Urology. You can find all previous episodes of BackTable Urology on iTunes, Spotify, and @backtable.com.

[Dr. Daniel Spratt]
Doing Excellent. Thank you so much for having me.

[Dr. Aditya Bagrodia]
Well, the pleasure is all mine. As I was mentioning, I feel like we've had some really world-class radiation oncologists, Amar Kishan, Neil Desai talking about favorable intermediate-risk prostate cancer, as well as unfavorable intermediate-risk prostate cancer.

(1) Patient Intake & Diagnostic Imaging for High-Risk Prostate Cancer

[Dr. Aditya Bagrodia]
Today, we're going to round things out with high-risk prostate cancer. Absolutely a pleasure. I thought it might just be helpful to get some basic definitions in there. High-risk, very high-risk when patients are coming to you. Who are we talking about here?

[Dr. Daniel Spratt]
I would say defining high-risk is a little easier as a larger bucket. We're talking to high grades of Gleason 8 to 10, or Grade group 4 or 5, PSAs over 20. Now, it's probably more in the MRI realm, but clinical T3, rarely we see these T4 patients. I think the value of very high-risk, and the definition used in NCCN is highly debatable. That's from a retrospective study, I think out of Hopkins that I don't think has a lot of clinical implications, and most of the guidelines say you treat them the same. There's been some newer definitions. People call the STAMPEDE very high-risk, which is PSAs over 40, high-grade T3, having two or more of those features, which may have some actual clinical implications.

[Dr. Aditya Bagrodia]
Totally. We'll definitely jump on into it, the primary pattern 5, the T4, things along those lines. Essentially, high PSAs, Grade group 4 and above, radiographic, something's at least got your attention, that's who we're talking about.

[Dr. Aditya Bagrodia]
Starting with patient intake, what are the critical elements here as you're starting to formulate what might be a best option for this patient? Maybe we could start with urinary symptoms, sexual health, things along those lines?

[Dr. Daniel Spratt]
I think probably for almost any man that you're potentially going to give a radical therapy to, we're going to want to know whether it's the AUA or IPSS, some type of irritative obstructive-type symptom assessment or an epic 26. Any rectal bowel movement, history challenges, Crohn's, ulcerative colitis, things of that nature, erectile function, of course. Even beyond that, I think it's also what's the priority for the patient. Some guys may have function, but it's just not a big priority depending on the significant other. Comorbid conditions, obesity, metabolic syndrome diabetes, heart disease. There's social factors, of course, to factor in also when talking about feasibility of treatment, where to get it, things like that.

[Dr. Aditya Bagrodia]
I think that priority element is actually quite important. I do mean it, but I almost have found that I tell every patient when they describe their sexual frequency patterns, I'll say, "That's totally normal," because I don't want people to feel weird about being sexually inactive or being sexually active at whatever frequency, whether or not they're able to have erections and so on and so forth. GI history, that's probably something that I don't think that urologists focus on, maybe quite as much. Ulcerative colitis, Crohn's disease, colonoscopies. Is this all mandatory intake?

[Dr. Daniel Spratt]
I would say so. It's been ingrained in me back in my training in New York at Sloan Kettering. I remember Michael Zelefsky telling me that every, we'll call it five years of his career, he's like, "Oh, maybe we'll try to do some radiation on this guy with Crohn's." Then he's like, "I learned my lesson again." While there's definitely cases I've done, especially now with the rectal spacers, and the accuracy of radiation, that's something that I would say, if it's active, even if it's a history, there's got to be a reason why we're starting with radiation therapy because that could be potentially catastrophic. We're talking fistulas, we're talking a lot of things. It's a little more complicated in high-risk. If it's ultra high-risk, and you know you have surgery, you may need post-op radiation at some point. Those are even larger fields. It's a conversation with the patient for sure.

[Dr. Aditya Bagrodia]
Obviously, we're talking about relatively infrequent cases, lower probability events, but they do pop up. By all means, if there's a patient, I think, from our end on the urology side that we know is going to be inclined towards radiation, getting that history, and getting a colonoscopy set up, I think is something we can do. Then you mentioned cardiac history. Obviously, that's going to have an impact on androgen deprivation therapy, and maybe which types of medications they would be best suited for. Family history, is this something that you're really dialing in on?

[Dr. Daniel Spratt]
We do a focused cancer family history. I think that once you're in the high-risk category, people typically start discussing, "Should you be doing germline testing?" I think when there's a family history combined with being high-risk, it's really something more to make sure that conversation is had then. Not that it's emergent, of course, it's just to start that conversation. Yes, their family history of breast, prostate, pancreas, colon, et cetera, but that's part of their standard intake for us.

[Dr. Aditya Bagrodia]
I'm curious just logistics-wise when I was at UT Southwestern, anybody with a family history of high-risk or intraductal, they went to go see cancer genetics. On a move to San Diego, mostly due to practice patterns, availability of clinical geneticists, we were actually starting to order the germline testing. It's nice because we've had a couple of trials for say high-risk patients that have BRCA mutation that can get neoadjuvant PARP inhibitor. What do you all do? Is it you that's ordering germline testing, or making the referrals, or typically the urologist one step ahead? How does that work at your institution?

[Dr. Daniel Spratt]
It's different here. I've been at UH Seidman at Case for about two years. I think that a lot of us end up sending off through one of the industry tests rather than an in-house assay. Most of the time, probably the most common is I tell patients just to go to color.com. Not that I'm endorsing them, but one of these tests, because it just goes straight to the patient's house, they pay $250, or whatever the going rate is for it. A lot of patients seem to prefer that because it's like they get the results to them. It's not ordered through the hospital where they get a blood draw on things, but that's how most of it-- I think probably many of us ordered a different assay. We're working on a more standardized, you could call it, germline risk, or these high-risk clinics to standardize it. We've got a couple of different that, I would say are the most common people are ordering.

[Dr. Aditya Bagrodia]
I like that. I don't have any vested interest in ordering vitae because we have a workflow. We also have this study called THE PROMISE study, which is cool. The patient gets a pamphlet, they create their own portal, they get sent out a saliva swab and their own results and they can figure out who to share it with. I like getting away for some of that paternalistic, your physician has to be the quarterback for everything.

(2) Imaging Strategies for Prostate Cancer Staging

[Dr. Aditya Bagrodia]
Fantastic. We've gotten a good intake on things newly diagnosed. Talk a little bit about the next-- you mentioned germline testing. What's your ideal panel of staging, imaging, mandatory or highly preferred, other tests as you're formulating a treatment opinion?

[Dr. Daniel Spratt]
Yes. Typically next stage, assuming they're diagnosed, but if they've already had their biopsy and things of that nature is MRI and often here, we'd already have that before the biopsy, but an MRI of the prostate and then probably the vast majority of our patients, we get PSMA PET-CT, don't really have a preference. There's now even more on the market, but if for whatever reason they can't or if they came from the outside with, if it's a CT and bone scan, we would still repeat. We'd get a PSMA at that point. We don't get conventional imaging after the PSMA PET scan if that's done. That's the starting point because if there's metastasis, some of the other tests, like if we're going to order any biomarker tests, I wouldn't order that if the cancers' already spread to lymph nodes or distant mets.

[Dr. Aditya Bagrodia]
Sure. That's my imaging-wise preferred option. The MRI covers local staging, pelvic lymph nodes, and the PSMA PET and then I half-jokingly say that tumor board is, what do I do with this nonspecific PSMA PET finding in a rib? Have you found that that caused a lot of consternation? Is this something that's coming up or have your radiologists and nuclear medicine team inserted some phraseology to help diffuse anxiety?

[Dr. Daniel Spratt]
Yes. I was real lucky I was out last year in Australia and they've been doing PSMA PETs for much longer than us and actually we just had Luis Emmett, who's one of the big nuke meds out there who's led a lot of the studies with the groups. She just gave a didactic lecture to our team here, really calling out what she does and the importance, the various systems, there's PSMA-RADS, there's an MRADS or there's a variety of systems out there, but to really be very clear that these ribs are almost always-- if they don't have CT correlates and some other features, are false positives. They have actually great data where they leave these alone, where they actually have just done nothing and they show that patients after-- let's say they have a prostatectomy, PSA goes undetectable, so clearly these are not prostate cancer.
I think that's a big issue across the world actually but in the US when we got it up and running when I started here, there was these patients being called and you go from being a localized to a metastatic, and before you know it, someone's throwing them on ADT and abiraterone when it's really a run-of-the-mill intermediate-risk patient. We are trying to make a lot of progress and standardize things, but that was the intent of having her come out. I'd definitely recommend to anyone listening, it's worth inviting, even if you've got to pay her money to not over-call a lot of these soft calls.

[Dr. Aditya Bagrodia]
Yes, I definitely appreciate that. I literally have an unfavorable intermediate-risk prostate cancer that I'm seeing this morning. He's scheduled for our multidisciplinary clinic and he had a PSMA PET, SUVs a 2.4 in the third and fifth rib, they're nothing and he is freaking out, understandably. He is a professor here. Ideally PSMA PET, MRI pelvis, are you getting other testing? Say there is something suspicious, maybe going back to the chest on a PSMA PET, MRI chest, bone scan, is there any role for next testing and do you have a preferred one, Dan?

[Dr. Daniel Spratt]
I think it depends location and depends what's seen on the CT component of the PSMA. If you see something like, let's just take your example in a rib SUV two and a half, which is like nothing and if on the CT there's no sclerosis, there's literally nothing there, that's probably going to be a false positive. If there's maybe something but the resolution of the CT component, we often would get maybe either a more diagnostic CT. If it's a soft tissue area or if it's the spine, sometimes we'd be getting an MRI to follow up. I think some of these systems for PSMA PET, it's like we've incorporated PI-RADS, is I think these systems really should be quantified, obviously have your nuke med docs lead this effort, but pick something because that's the pretest probability, and if it's low, you probably want something else to confirm it. If it's high, you're good to go.

[Dr. Aditya Bagrodia]
Yes, it makes sense and I'm sure that on multiple levels this is going to be an evolution on how we synthesize that into our decision-making. Fantastic.

(3) Integrating Genomic Profiling into Treatment Decision-Making for Prostate Cancer

[Dr. Aditya Bagrodia]
As we talk a little about imaging, additional tests, maybe I'll just throw out what I do, get your input on that. Germline testing, that's mostly going to be a standard of care and seeing if patients are eligible for a neoadjuvant PARP clinical trial that we have here. Tumor sequencing, small proportion of patients with somatic BRCA mutations that could also be eligible for the trial. Then we generally get Decipher testing as well. Our radiation oncology team here, Tyler Seber, Brent Rose, and company, they're pretty active and we've got what I think are exciting trials based on genomic profiling. Can you talk a little bit about that?

[Dr. Daniel Spratt]
Yes, the gene expression biomarker class, the one that really, I don't have data to say it's the most common, but it seems at least in the radiation oncology community, Decipher's what is being used because it's now been published in like 11 Phase 3 clinical trials that most of them have been completed and then profiled. Paul Nguyen, a large group of us in NRG that Paul led, just looked at three high-risk trials just showing just how pretty impressive Decipher's performance to where if you've got a low Decipher score, which is about 30%, 40% of high-risk patients, if you can believe it, really the benefit of long-term hormones is pretty minimal compared to just short-term hormones. That morbidity of long-term hormones is just pretty significant but that's why one of the NRG trials, it's NRG-GU009 is the number of the trial--

That trial is basically looking, can we de-intensify the low Decipher score patients, give them a shorter duration, the higher scores do we need to add an ARSI on top? It's not published and some may have missed this, but at ESMO STAMPEDE, you know how that big paper from Gerhardt Attard, the high-risk non-metastatic patients adding abiraterone improved metastasis-free survival? They profiled that cohort with Decipher and actually it was only the patients with Deciphers above basically 0.8, so the ultra-high, had any benefit. That's actually the main indication for me if they're not on one of these trials, I get it. Abiraterone for two years is expensive, even generic and toxic. They had 20%, 30% grade three side effects, so if they've got a lower Decipher, it's not ultra high, just stick with standard ADT till we have these other trials reporting out.

[Dr. Aditya Bagrodia]
Going back to the NCCN guidelines and very high-risk, abiraterone plus ADT is preferred as a management option and I think it, on one hand, is appealing as a "aggressive option," maybe in a young person with high-risk disease, but like you state, it's not a free ride and if we can do a better job of selecting patients who could benefit, that of course makes sense. I think generally there's a pretty nice suite of trials in favorable risk looking at trying to understand a little bit more about the biology and whether they could benefit from de-intensification or intensification of their treatment.

I'm reluctant to do it in the favorable intermediate-risk patients who are already ADT-averse because I don't want to necessarily complicate the discussion, but in the unfavorable intermediate-risk, as you and others have published, you're really going to get a significant proportion of people that could probably benefit from an intensification versus de-escalation. I have also found that maybe more so in the community, that people are already synthesizing Decipher tests on whether or not ADT should or shouldn't be added in the duration. Any comment on that?

[Dr. Daniel Spratt]
Yes, it's interesting, I often reflect on Oncotype for breast cancer, it's just 20-plus years old. Essentially it started from NSABP post-hoc trials that they profiled and it was used on about a million women for 20 years before an actual prospective TAILORx trial was done, which is equivalent to these NRG trials ongoing. It's one of these things, where is each-- It's like the early versus late adopters. At what point do we stick-- Clearly prostate cancer, I say we are the most archaic of cancers because we still use Gleason [laughs] grading as our most important feature from 60 years ago.

We clearly are not very willing to change but I think when you have this much data and cost matters, but for Medicare where it's covered or things like that, I think you can have honest conversations with patients where I'll say, "Look, ADT may improve your outcome, but it's going to be potentially 1%, 2%. That's a number needed to treat a 50 to 100. Is that good for you? I'm going to treat 100 guys like you and one of them benefits." I say, "Look, I can tell you if I had one in 100 odds, I'd play the lottery every day." It's not zero. It's not impossible but a lot of guys it's just not worth it for them.

[Dr. Aditya Bagrodia]
Yes, as I was preparing for today I was just reflecting on how we've counseled patients historically and ADT really is such a sticking point. I get it, and fairly consistently the trials have shown that the benefit of ADT in unfavorable intermediate-risk and beyond is associated with an improvement in metastasis for your survival, all of that but what if the patient is like, "You know what, doc. I don't care. I'll take option B second from the cheapest and save myself all this potential side effect profile," and when you look at the guidelines for high risk, your duration of ADT is between one and a half to three years. That's a pretty wide range. How do you pick?

[Dr. Daniel Spratt]
I think in the latest edition that's out, there's a section now called Risk Stratification, and under that, it actually says if you use more accurate tools and whether that's Decipher, now there's new tools like ArteraAI, some of these tests, is it may be appropriate to use a less or more intensive treatment because we're using such a crude system like Gleason scores. The 18 to 36 months, it's just from a amalgam of trials. Some use 36, some use 28, some use 24, some use 18. I tend to use 18 months. There's flaws in the trial that compared 18 to 36 months that we'll call it the nerds of us can talk about but at the end of the day, there's no difference in how long these guys lived. They had pretty similar outcomes. Obviously, far less toxicity.

I do 18 months and you'll see it's not out yet. We presented it but we're real fortunate-- Actually, you mentioned Amar Kishan. He and I lead this group called MARCAP I think of over 20 phase III randomized trial data and we actually got the we'll call it the compliance data of ADT. A lot of those trials, 50% of them actually got 3 years. They didn't get the intended duration. The actual duration received, it looks like maybe the optimal duration is maybe closer to 12, 13 months for the run-of-the-mill-- Not ultra-high-risk, just run-of-the-mill high-risk patient. Putting all that aside, I'd say 18 months is my go-to but I'm happy if I can get guys as close to that. Sometimes that's 12 months.

(4) The Role of Timing in Hormone Therapy for Prostate Cancer

[Dr. Aditya Bagrodia]
I think the same MARCAP data is also highlighting the importance of really the adjuvant phase of ADT and maybe I'll ask you to just comment on when prior to treatment is ideal for you and in your ideal world, what are the agents that you use and when do you start?

[Dr. Daniel Spratt]
The data you're referencing is we've looked primarily when giving short-term hormones that neoadjuvant or before radiation really is not oncologic. It doesn't actually add benefit. It doesn't mean it's harmful. It may shrink the prostate or you have other logistical reasons for using it but really it seems that the more oncologic phase is the concurrent and especially, adjuvant phase. If you're going to give four to six months of short-term, I typically start it when I stimulate a patient or at the first day of treatment, just logistics to minimize visits. I don't give them that two, three months in advance. In high risk, if you're giving them 18 months, we haven't shown that that extra two months in front makes a difference. If you don't need to cite or reduce them I typically don't use neoadjuvant but again, I have no opposition, especially if it's logistics.

It probably matters a lot less in high-risk with long duration. My go-to right now, again, costs always matter but a lot of guys I have really resonated with the Relugolix state oral GnRH antagonist, and one of the main things-- Of course, there's this rapid onset, rapid recovery, which is pretty incredible. Within a couple of months, they've recovered even with long-term hormones, which is-- Lupron, it takes two to three years if you give them two years of ADT. It's pretty impactful but actually, the biggest benefit to patients is when you tell a guy, "You're going to get a three-month or six-month shot," they feel like they have no control. It's like, it's in you and it's in you. I could be that guy I read online that's going to fall apart or I'm the guy that's fine but when you have the pills it's like within a week or two you know and I say, "Look, just see how you are."

Most of the guys-- I call it the 20/20 rule. 20% of guys, I don't know how but they have no side effects. They're just like, "Oh, I still have sex. I still feel fine." 20% are like, "I am freaking miserable, Doc. My life, I'm moody and I'm grumpy. I'm horrible, gaining weight," and 60% it's an annoyance but it's nothing, I'll call it, major. You tell me if you can figure that-- I can't figure out a priority, who's who. The pill is nice because they take it and almost all of them who would have resisted hormones to start with, they all are willing to actually at least go on it. Then if you want to transition for convenience, maybe they'll get a shot later.

[Dr. Aditya Bagrodia]
That's exactly what I do and for exactly those reasons and maybe even more so in the intermediate-risk patients where it's a little bit more dubious but I like that strategy. I think the recovery-- You mentioned the delayed recovery after Lupron, not to mention the fact that about 30% of people will never recur reasonable function. I'm on board and I think it makes sense, not to mention a possible improvement in a cardiac profile. I like this.

(5) Navigating Prostate Anatomy & Symptoms in Radiation Therapy Decision-Making

[Dr. Aditya Bagrodia]
You mentioned [unintelligible 00:25:47] reduce a couple of times and maybe I'll just ask how you synthesize prostate anatomy symptoms, median lobes, size. How does that factor into your approach here?

[Dr. Daniel Spratt]
I don't want to say I was-- maybe I just didn't pay attention in my training but I had this idea in my mind that guys with LUTS obstructive symptoms that, oh, I can just give them ADT, shrink their prostate down, it's going to go away, and I can tell you probably 95% of the time, unless it's just these crazy, locally advanced massive cancers, it just doesn't happen. It's just their prostate shrunk but they still have their LUTS. What I do for guys, this is just an example, is I'll put them on ADT, hoping for that, we'll call it 5% if they've got these obstructive symptoms. Then I'm a bigger user of HoLEPs, for example. I think guys just do fantastic and this is, of course, assuming they don't want to have surgery, don't do any of that. I really have no concerns even if their glands get up to 100, 150 CCs with modern planning techniques and dose constraints.

When it starts to become 200, 300 CCs you can just imagine, it just means more rectum, more bladder, more everything and so, you've got to really be thinking "Why am I radiating this if there's other options out there?" I think that there's an evolution, for example-- It's probably a minority of people but there's data out there. People do SBRT in high-risk disease.

Some people will say it's got to be less than 60 grams. Some people, less than 80. Some 100. Some 120. Some don't even have a limit. For me, if the prostate is over 80 grams I would just tell them it's less ideal to do SBRT. In general, there's got to be a reason why we're doing radiation and not the surgical approach if they've got lots of LUTS. There really has to be a convincing reason from that patient, "Why are you not having your prostate out?"

[Dr. Aditya Bagrodia]
I appreciate that. Some of my thoughts, larger prostates can be asymptomatic and if they're not symptomatic, I think this historical idea that a larger prostate is a contraindication to radiation is a myth. For higher-risk disease where as you mentioned, there's typically a little bit of a longer ADT run-in, six, eight weeks, if they've got substantial LUTS and there's not something meaningful going on in a couple of weeks, I think doing an outlet procedure based on the size of the prostate.

You mentioned HoLEP, which I think is fantastic. TURP, of course, is a gold standard that's widely accessible. Robotic simple prostatectomy. Even some older patients that may not tolerate general anesthesia, I don't think prostate artery embolization for glands bigger than 80 CCs is necessarily a bad option. Generally, after the TURP, I think giving them six to eight weeks to heal up and settle out makes sense. Does this sound about reasonable to you, Dan?

[Dr. Daniel Spratt]
Yes. My synthesis of the data is for a traditional TURP, I typically give longer for healing. There's all of these cases that people have gotten into trouble where they radiate too soon after. There's many reasons I'll say I like going to urology meetings but I always pay attention to when they talk about HoLEPs and then how soon after these radiation series and I've seen some really compelling data where even it's 30 days after. I typically give them maybe 30 to 60 days after a HoLEP and go forward at some interval but if they're on long-term hormones there's not this urgency.

[Dr. Aditya Bagrodia]
We're finally getting to radiating the prostate and sometimes in higher risk diseases the modifiables, in my opinion, are a little bit more restricted. We've got duration of ADT. You've talked a bit about that. We've got type of ADT, which you've addressed. The addition of abiraterone and to paraphrase maybe Decipher very, very, very high risks, greater than about 0.8 is what you mentioned. Then a conversation based on Primary Pattern 5, T4 disease, maybe in younger, healthier patients it's a bit more compelling as well. Those are our systemic concerns. We've talked a little bit about prostate anatomy, size, meat, and lobe symptoms.

(6) Decoding the Types, Efficacy & Complications of Prostate Radiation Therapies

[Dr. Aditya Bagrodia]
Then of course there's the actual type of radiation. Even at the beginning of my career, it was pretty easy to give a little synopsis of what's out there. Now, it's conventionally fractionated IMRT, hypofractionated, ultra-hypofractionated, combination, protons. Maybe this would be a good time for me to request that you share your spiel, if you will, for a high-risk prostate cancer patient, including efficacy and complications.

[Dr. Daniel Spratt]
Yes. I'll give you my take, and I know that there are definitely radiation oncologists that would feel differently, but what I tell guys for high-risk disease is, first of all, I do not feel there's much of a role of conventional fractionation. I just looked at some practice patterns, and still, probably, I think it's 50% of the US uses conventional fractionation for high-risk. They say because you're treating lymph nodes, maybe we need to do that. For me, I think we've got great data. There's no role for that. To me, giving eight to 10 weeks of radiation therapy should be a rare scenario.
I think the addition of brachytherapy, I tend to-- I've written a lot about this, and had some nice debates with American Brachy Society members, I think that the data to add brachytherapy boost shows a small PSA benefit, and when I mean small, call it 10%, maybe as time goes on, it obviously expands, for a 20-plus percent increase in severe toxicity, including those couple of deaths on the Ascende-RT trial. Quality of life, even for high-risk men, in modern high-risk trials, I often say if you look at-- there's a trial called FLAME, which was just external beam with a external beam boost, or this trial called POP-RT from India, which is just external beam, modern high risk. It's like 1% of guys are dying of prostate cancer in 5 to 8 years.
Only 5 to 10% even have BCR in five years. This is very different than 30 years ago, given the staging and stage migration, grade migration. Anything that severely increases toxicity, or has the potential to, to me tips the favorability in the opposite direction, because I think we've learned this from the surgery plus or minus adjuvant radiation. The whole concept was, "You can give salvage. There's no difference here. You can give external beam, and for that maybe 10% of guys, you may have cured by giving brachy, you can do it as salvage if you need." It doesn't preclude you from that. I think that given there's no metastasis-free survival benefit of doing these ultra-high doses, I do not personally recommend it. I probably do more than the average regarding ultrahypofrac in high-risk and we've run a number of trials.

[Dr. Aditya Bagrodia]
Dan, let me ask you real quick. Just for brachy, are we talking about low-dose seed implants or high-dose catheters?

[Dr. Daniel Spratt]
Yes. There's no level-one data for HDR. I think HDR is probably-- I think objectively, although there lacks good evidence, has less toxicity than LDR. I think many people have pivoted over to HDR.
The problem is that there's no level one data for HDR compared to just dose-escalated external beam. I think what the field has done is they hear the word brachy and they just think it's all the same. There's been some big teaching points in that they said, "Oh, well, let's just do HDR single fraction." LDR is just one insertion. It was in low-risk disease, 40% of these guys recurred. The danger, and I call this out a lot in radiation oncology is, just because you call it brachy, or just because you call it radiation there's no dose escalation trials. We don't know what the optimal dose is. It's retrospective. Do I think it is safer? Yes. Do I think it necessarily improves outcomes? I have no clue.

[Dr. Aditya Bagrodia]
No, I appreciate that. Maybe if we go with most intensive, which would be combined brachy plus external, sounds like unless you have a hyper-motivated patient that wants to do everything in God's green earth to be as aggressive as possible, recognizing that comes along with some additional toxicity, that's not going to be your standard recommendation.

[Dr. Daniel Spratt]
No, I'd be doing, as I referenced that FLAME trial where you do an external beam boost. It showed a near identical PSA, or biochemical control benefit, as adding an LDR boost with functionally, 0% increase in toxicity, and doesn't add the cost of adding an LDR implant. I know this is not loved by the brachy community, but I think doesn't devalue its role. It's just it may be better as a salvage option, or when you can be as monotherapy in earlier-stage disease.

[Dr. Aditya Bagrodia]
Combination, maybe not top choice. I'm a little surprised with the conventionally fractionated. In my mind, that's like you can get this at a quaternary cancer center or you can get it with Joe Schmo and the sticks and good old fashioned eight weeks, five days per week, conventionally fractionated radiation therapy. Pros are friendly fire at a high dose to adjacent organs and associated toxicities are low. You can get the lymph nodes. We'll maybe talk about that explicitly. That's a big pro, I guess, accessibility where you don't have to work on a really refined, robust team to get the planning and the imaging. Absolutely perfect for things like ultra-hypofractionated, maybe just a little bit more on--

[Dr. Daniel Spratt]
Yes. I completely agree with your assessment when you compare to ultra-hypofractionated. When you talk about four or six weeks of what's called moderate hypofract, so there's trials, one called PROFIT and another called CHIP, but in PROFIT, there's actually less late toxicity using 20 fractions of radiation. You do not need ultra-specialized equipment to give 20 to 28 fractions of radiation therapy for prostate cancer instead of 40 to 45 treatments. Is it wrong to do 40 to 45? No. Is it as convenient for the patient or we'll call it cost effective? No. About once a year I have a guy who literally says, "That's what I want," and to me, I view them as they're non-inferior when each done correctly but I do think in similar to other cancer types, why do something that adds patient burden if there's no benefit?

[Dr. Aditya Bagrodia]
As you'd mentioned with the FLAME trial, ostensibly with the boost, there's something about that higher dose per fraction in terms of cell kill that's a value versus just getting the ultimate dose in over a longer time.

[Dr. Aditya Bagrodia]
I guess, are there symptom or size-specific factors that precludes people from receiving less fractions?

[Dr. Daniel Spratt]
Generally, we're talking if these glands are, we'll call it around 100cc or less, is that I think some of the data that some of it came from Dr. Pollock and this moderate hypofrac trial that I think stuck in people's minds. It's really old data that doesn't seem to be reproduced in other trials that they say, "Oh, if you've got obstructive symptoms or large glands, don't do hypofractionation." It really doesn't seem to bear out. That's really not a reason. If a guy has obstructive symptoms, I do SBRT or moderate hypofrac. They're going to equally have side effects. It's not like if you do conventional, they're going to have no worse side effects from it. Many of my guys I feel that prefer a shorter acute phase, then there's eight, nine weeks of just chronically having this irritation, and they're like, "Let me put them on some ibuprofen if you need, or Flomax, give them a couple of weeks of SBRT and get through it," and you're done.

[Dr. Aditya Bagrodia]
Yes. I really liked the analogy that Neil Desai gave, which is, do you want me to rip off the bandaid or do you want me to pull it off slowly? Maybe that's a memorial thing from Zelefsky and company, but I think that's what it boils down to. It's like, "Do you want this in a shorter, condensed format where there may be a little bit more urinary and rectal toxicity or do you want it a little bit slower where there's a lot more involvement interfacing with the health care system and maybe the toxicities are a little bit more acceptable?"

[Dr. Daniel Spratt]
I'll say that I don't think there's actually lower toxicity. I think that the late long-term toxicity is really the same in the studies. They're superimposable. The early phase, the acute first 90 days, you're spot on. That goes back to that analogy of ripping it off versus slowly peeling it off. I think if we're talking about one year, two years, five years, et cetera, it's the same.

[Dr. Aditya Bagrodia]
Just to make sure that I'm clear, so ultra-hypofrac, that's five fractions administered basically every other day for a couple of weeks?

[Dr. Daniel Spratt]
Yes, usually. Like always, there's exceptions. People do four, some people do six or seven but generally, it's five. Generally every other day. Some people do it once a week, some do it five days in a row, but generally every other day.

(7) The Role of Protons in Prostate Cancer Therapy

[Dr. Aditya Bagrodia]
I'm here in Southern California where protons have also-- Loma Linda has a big center. Any opinion on protons? Are they useful, equivalent, any different than good old-fashioned hypofrac?

[Dr. Daniel Spratt]
You know this, and hopefully the audience knows this, that there is zero high-level evidence that protons is going to significantly increase cure rates or reduce side effects. I think insurance reimbursement reflects and Astro statement reflects that lack of data. I think that the efficacy is the same. If you're giving an amount of radiation to the same target, it's going to kill it the same way. I don't think there's a oncologic benefit. Side effect-wise, and I'm ignoring, let's say you're treating pelvic nodes, I'll put it this way, I'll say it's theoretical and it's theoretical for some patients. We have protons here and just had two patients who traveled far. That's the only thing they wanted. Did a plan comparison. One patient, the theoretical dose looked a little better, the other one, it actually looked worse.
I just say this is theoretical. It's not something that-- some do five fractions of protons, I personally don't, and so I just say you're giving up some convenience potentially for it. I don't think it's something that should be pushed. It's an option that has equal efficacy and if done right you could say a theoretical and that's the most I would ever state. I don't feel strongly at all anyone needs it.

[Dr. Aditya Bagrodia]
I appreciate that. My understanding as a urologist is, exactly said, not necessarily worse, not necessarily better, but perhaps a little bit more difficult to administer in a ultra hypofractionated manner. Is that true?

[Dr. Daniel Spratt]
There are centers-- Mayo Clinic I've been told they've done some great work with proton SBRT, just for those out there-- actually, you don't even bill for protons. Actually, SBRT billing trumps the proton so you don't make any more money. We haven't done that here, but it's why sometimes should someone get one phone versus

[Dr. Aditya Bagrodia]
Maybe now I would just request you to walk us a little bit through the logistics, some of the considerations, fiducials, SpaceOARs, when are you using those or using them routinely. The patient's decided on radiation for the high-risk prostate cancer, walk us through a little bit about, "Hey, Mr. Smith, this is what the next four to six weeks looks like."
[Dr. Daniel Spratt]
What we would do is we would get-- Whether it's an oral or if it's an injection for ADT, get that started. Usually, if it's going to be an injection, we try to link that up with one of his early visits just so it's not multiple visits. First step for us is for most guys it,'s got to be pretty bad disease with true posterior extracapsular extension. Not posterior lateral like in the neurovascular bundle, but true posterior to not do a rectal spacer. I partner with our urology group, it's the way we've streamlined it here. Yoni Shoag and this guy, Randy Vince, but Yoni will do 5 to 10 spacers on Tuesdays and just boom, boom, boom back to back, just knock them all out, and he'll put fiducials in at the same time. Spacer goes in--

[Dr. Aditya Bagrodia]
Let me ask you a quick question, Dan.

[Dr. Daniel Spratt]
Go for it.

[Dr. Aditya Bagrodia]
This is something that actually came up in our tumor board yesterday. There was a patient who had 160cc prostate, clearly extracapsular extension. It was posterolateral, extending a bit towards the midline and we were having a whole discussion, and SpaceOARs came up and this idea of ECE posteriorly being a contraindication was mentioned. I was thinking surgically when you go wide, you can either get right onto your longitudinal rectal wall fibers or you can get onto the perirectal fat or you can get into a interfascial nerve spring plane. When you inject your SpaceOAR, I'd also imagine, of course, you don't want to get into the rectal wall and have to sort through all of that, but if you stay wide, could that potentially allow you to deliver a more effective dose or have a bit more of a margin to spare the interior wall and still address that disease?

[Dr. Daniel Spratt]
Oh, 100%. For me, like I said, it's probably almost all of my guys with high risk. There are people who say if it's high-risk you can't do a spacer. If there's ECE anywhere, you can't do a spacer. The plane as you're saying behind [unintelligible 00:45:17] if you're in the right plane, you shouldn't be dissecting through tumor and separating it at all. That's where I say it's got to be those cases that you're like, "Is there a rectal invasion? I'm not sure on the MRI." Those are the cases I don't do it, but the vast majority I think it's safe to do. Again it's partnering-- there's Rad Oncs who do a great job placing them. I have found both at my last center and here having a go-to one or two urologists that I can show the SIM images and they're just logistically able to knock them out, they get super proficient. The Rad Oncs, some, who are fantastic but they'll squeeze it in between consults. It's not necessarily like they're ultra in the zone, but for high-risk, I don't have concern about it.

[Dr. Aditya Bagrodia]
I personally don't think, fast forward 10 years, we're going to see a bunch of recurrences posterior to where the spacer, which is now gone, used to be. SpaceOAR or rectal SpaceOAR, I guess it's proprietary that fiducials, that that happens. SIM, CTs, MRIs, molds?

[Dr. Daniel Spratt]
Yes. I would say if it's a guy coming locally, about a week later we do a SIM. If a lot of my patients come from another city or state, I do it the next day just so they spend one night in a hotel. It's a CT. If they've already had an MRI, I actually don't get another MRI. We just register the initial MRI, even though the spacer's there now just to save them the cost of another MRI. If they've got hip prosthesis or something, then I'll get another MRI just for target delineation. Then planning, obviously, we use a variety of auto contour tools and we're always trying to speed up that, but I would say about a week later they're ready to rock and roll, start treatment. They got it mobilized at the time of SIM and they're ready to start.

[Dr. Aditya Bagrodia]
Then we're getting onto treatment, usually what? An hour, hour, and a half for the A to Z experience? Is that about accurate?

[Dr. Daniel Spratt]
Here, my spiel and it's pretty spot on if the guys-- usually we have them drink water before they come in. It's usually 45 minutes door to door. The beam is on for six minutes but they've got to get on the table, they do some imaging, adjust them, treat them. These guys will have a full bladder, they got to go pee afterwards. It's about 45 minutes and that was pretty consistent in my last center. There I used to say 45 minutes car door to car door because in Ann Arbor, we'll say parking was easier. Once you already start to be in a city, even though Cleveland's not a massive city, parking adds some time. I imagine San Diego if you throw in some of that.

[Dr. Aditya Bagrodia]
That's the single biggest complaint from our patients, are parking in valet and things along those lines. Generally, let's maybe say an hour A to Z.he other phone or a car versus the other car. I think as long as it's clearly pitched, and for me, it's usually Medicare patients where Medicare pays the same amount, if they really mentally feel they want that-- but usually after the conversation, most are not as interested as they were coming in.

[Dr. Aditya Bagrodia]
Makes sense. I will just say as a urologist, the number of people that are specifically asking for seeds or proton is uncommonly high.

(8) The Initial Steps in High-Risk Prostate Cancer Management

[Dr. Aditya Bagrodia]
Maybe now I would just request you to walk us a little bit through the logistics, some of the considerations, fiducials, SpaceOARs, when are you using those or using them routinely. The patient's decided on radiation for the high-risk prostate cancer, walk us through a little bit about, "Hey, Mr. Smith, this is what the next four to six weeks looks like."

[Dr. Daniel Spratt]
What we would do is we would get-- Whether it's an oral or if it's an injection for ADT, get that started. Usually, if it's going to be an injection, we try to link that up with one of his early visits just so it's not multiple visits. First step for us is for most guys it,'s got to be pretty bad disease with true posterior extracapsular extension. Not posterior lateral like in the neurovascular bundle, but true posterior to not do a rectal spacer. I partner with our urology group, it's the way we've streamlined it here. Yoni Shoag and this guy, Randy Vince, but Yoni will do 5 to 10 spacers on Tuesdays and just boom, boom, boom back to back, just knock them all out, and he'll put fiducials in at the same time. Spacer goes in--

[Dr. Aditya Bagrodia]
Let me ask you a quick question, Dan.

[Dr. Daniel Spratt]
Go for it.

[Dr. Aditya Bagrodia]
This is something that actually came up in our tumor board yesterday. There was a patient who had 160cc prostate, clearly extracapsular extension. It was posterolateral, extending a bit towards the midline and we were having a whole discussion, and SpaceOARs came up and this idea of ECE posteriorly being a contraindication was mentioned. I was thinking surgically when you go wide, you can either get right onto your longitudinal rectal wall fibers or you can get onto the perirectal fat or you can get into a interfascial nerve spring plane. When you inject your SpaceOAR, I'd also imagine, of course, you don't want to get into the rectal wall and have to sort through all of that, but if you stay wide, could that potentially allow you to deliver a more effective dose or have a bit more of a margin to spare the interior wall and still address that disease?

[Dr. Daniel Spratt]
Oh, 100%. For me, like I said, it's probably almost all of my guys with high risk. There are people who say if it's high-risk you can't do a spacer. If there's ECE anywhere, you can't do a spacer. The plane as you're saying behind [unintelligible 00:45:17] if you're in the right plane, you shouldn't be dissecting through tumor and separating it at all. That's where I say it's got to be those cases that you're like, "Is there a rectal invasion? I'm not sure on the MRI." Those are the cases I don't do it, but the vast majority I think it's safe to do. Again it's partnering-- there's Rad Oncs who do a great job placing them. I have found both at my last center and here having a go-to one or two urologists that I can show the SIM images and they're just logistically able to knock them out, they get super proficient. The Rad Oncs, some, who are fantastic but they'll squeeze it in between consults. It's not necessarily like they're ultra in the zone, but for high-risk, I don't have concern about it.

[Dr. Aditya Bagrodia]
I personally don't think, fast forward 10 years, we're going to see a bunch of recurrences posterior to where the spacer, which is now gone, used to be. SpaceOAR or rectal SpaceOAR, I guess it's proprietary that fiducials, that that happens. SIM, CTs, MRIs, molds?

[Dr. Daniel Spratt]
Yes. I would say if it's a guy coming locally, about a week later we do a SIM. If a lot of my patients come from another city or state, I do it the next day just so they spend one night in a hotel. It's a CT. If they've already had an MRI, I actually don't get another MRI. We just register the initial MRI, even though the spacer's there now just to save them the cost of another MRI. If they've got hip prosthesis or something, then I'll get another MRI just for target delineation. Then planning, obviously, we use a variety of auto contour tools and we're always trying to speed up that, but I would say about a week later they're ready to rock and roll, start treatment. They got it mobilized at the time of SIM and they're ready to start.

[Dr. Aditya Bagrodia]
Then we're getting onto treatment, usually what? An hour, hour, and a half for the A to Z experience? Is that about accurate?

[Dr. Daniel Spratt]
Here, my spiel and it's pretty spot on if the guys-- usually we have them drink water before they come in. It's usually 45 minutes door to door. The beam is on for six minutes but they've got to get on the table, they do some imaging, adjust them, treat them. These guys will have a full bladder, they got to go pee afterwards. It's about 45 minutes and that was pretty consistent in my last center. There I used to say 45 minutes car door to car door because in Ann Arbor, we'll say parking was easier. Once you already start to be in a city, even though Cleveland's not a massive city, parking adds some time. I imagine San Diego if you throw in some of that.

[Dr. Aditya Bagrodia]
That's the single biggest complaint from our patients, are parking in valet and things along those lines. Generally, let's maybe say an hour A to Z.

(9) Strategic Approach to Lymph Node Radiation in Prostate Cancer

[Dr. Aditya Bagrodia]
Lymph nodes, are you routinely rating them along with the prostate and the SVs or SVs, is that also part of your field?

[Dr. Daniel Spratt]
I always radiate full dose to the SVs. Especially in this PSMA PET era, the amount of isolated SV recurrences is just through the roof, but I actually typically do not radiate lymph nodes. I think that similar to the surgical trial data, and I know it's controversial of the benefit or lack of extended node dissection, it may be diagnostic, not therapeutic. We're not diagnostic by treating them. We're not gaining information. Again, if there's a recurrence in that node, you can give a nodal field later. I tend to, in most things, lead towards the side of quality of life. If it's T3B disease high grade or really high PSA or especially if it's node-positive, I definitely treat the lymph nodes, but run-of-the-mill Gleason PSA of 8 or 9, I wouldn't treat the nodes and just tell them that we really don't have fantastic data. We have one trial that's 250 patients that there's a benefit and multiple negative trials.

(10) Managing the Complexities of Prostate Cancer Treatment

[Dr. Aditya Bagrodia]
I appreciate that logic and I think it's totally an evolution in the way we think about things. Do we do something upfront or let things declare themselves? It's almost like a litmus test before we expose patients to that potential toxicity.

[Dr. Aditya Bagrodia]
Two questions, efficacy. Doc, what are the chances of this being curative? I always tell patients when I'm counseling them for any surgery, "I'm going to tell you about the common things, I'm going to tell you about the bad things." Can you just maybe comment on both of those things, please?

[Dr. Daniel Spratt]
High-risk disease, someone could have a predicted 2% risk of mets at 10 years. They could have a 40% risk. I think that's where all these details start needing to be combined. We have a calculator online and it's starcap.org. It predicts death from prostate cancer, but there's lots of tools out there because even in high risk, as you know, they're definitely not all the same. MSK Nomogram is a great one, but run-of-the-mill, we'll take that Gleasonate PSA of eight, guy with organ-confined disease. Most of the modern data is going to say that they have maybe a 3%, 4% risk of death from prostate cancer at 10 years. It's low. Mets is probably closer to, we'll call it 10% plus or minus. Regarding side effects--

[Dr. Aditya Bagrodia]
Let me ask you one quick-- because obviously our prostate cancer patients live and die by PSAs. While I can try to explain to them that, "Using, say, a memorial or nomogram, you get surgery, good news is, 10-15 years out, your chance of dying is 1%. More sobering, your likelihood of having a biochemical occurrence at five and ten years is closer to 50%, 60%. You're not going to die, but we may have some more work to do." I feel like it's challenging on the radiation side with the definitions, trying to synthesize what the PSA is doing early on. Is this a bounce? Is this a marker of some potentially nasty disease? Recently at ASCO, there was a presentation which I appreciate the intention of looking at an early PSA response of less than 0.1 as being a marker. How do you take NPSA and alleviate anxiety?

[Dr. Daniel Spratt]
First of all, I know there's an ongoing trial, but generally I believe that the long-term, we'll call it metastasis death, et cetera, is similar whether you start with surgery or whether you start with radiation. What I tell them is that, like in almost any cancer, and as a Rad Onc, this is just part of training, Glioblastoma of the brain, esophageal cancer, breast cancer, you name it, almost no cancer is treated with surgery alone. It's not because surgeons aren't awesome at what they do. It's just cancer often has microscopic spread adjacently or there's microscopic margins you can't see on imaging. If let's take that memorial nomogram in a high-risk patient, and let's say it says you have an 80% chance of PSA recurrence, I say, fine.

We know that, let's just say adjuvant, and we think early salvage is similarly effective, it usually would cut down that PSA recurrence chance by half. We'll say you have a 40% chance after surgery, and if you need radiation, you'll have 40% thereafter. If you do radiation and long-term hormones, I tell them that it's probably floating around 40%. Maybe you could call it 45% because it's uncommon that you have an isolated local recurrence. It's not impossible. We see them.

The reason that the long-term outcomes are similar is that if you do surgery and radiation or radiation upfront, the chances that if it still comes back, it's metastatic, it's the most common area, and you're the same prognosis. I think PSA is informative, but I also try to just let them know that you don't feel PSA. It's really up to the patient and the provider, what to do with it.

[Dr. Aditya Bagrodia]
Yes, I appreciate that. I like some of that way of explaining it, because I do think it's challenging and I don't know that we're going to have the time to get into the nuances of when you get really concerned about a atypical PSA response and you are factoring in those ultra-low PSAs in the high-risk patients, they always get us on high alert, intraductal cribriform factors. Are you going to pursue a biopsy or image this patient sooner rather than later? It's complicated.

I appreciate that and I think what you've just described is a logical way to diffuse some of the anxiety and say, "Hey, these are the cards we're dealt. Here's the things that we can do, and there are certain things that are unknown and out of our control." Then, sorry I interrupted you, toxicity-wise, just the general, "Here's how you might feel in the next 30 to 60 days and a couple of years out."

[Dr. Daniel Spratt]
I'm going to pause on the hormone therapy, even though that's highly relevant here, just to separate it out. With, we'll call it moderate hypofrac or conventional or if you were doing SBRT, in the acute and long term phase, most of the modern studies, it floats around the 1%, 2%, grade three, meaning an intervention is needed, whereas needing Flomax, which I feel like it's handed out like water, that probably floats in the 10, 15% in the modern trials where you need a medicine, but low-grade, like grade one, that's probably like 40, 50 plus percent, where they know something's different, life goes on, maybe they wake up another time at night, but something's changed. In terms of when you look at quality of life, most guys in the studies and patients by three to six months after they're in this irritative phase.

More frequency, more urgency, maybe some nocturia-- less so now than when I trained on the GI side. Again, that's probably partially from the spacers, partially just from planning techniques and imaging, but that frequency and urgency is just super-- I call it, it's an annoyance for patients and that's why that baseline function matters so much. Long term I think a big misnomer that I think for this audience is people always say radiation is the gift that keeps on giving, or there's this late phase. We've looked at this and when you look at the dozens of trials that have followed guys for 20 years, there's not some peak 5, 8, 10, 15 years that you see all this craziness happen. Crazy stuff can happen, but it's something that-- we sometimes forget that people are still humans and other things happen in their life as well. Those are very infrequent events.

When you look at grade three side effects beyond three years, it's exceptionally rare. Of course, the urologist will say, "I saw this and I saw this," but the denominator might be 1000 patients.

[Dr. Aditya Bagrodia]
I agree, it's just like surgery. We talk about anesthetic complications and the low probability, terrible things, but it does seem to resonate with the, "Let me tell you about the common things and the bad things," and the bad things being refractory, recalcitrant radiation, cystitis, extremely bad strictures et cetera. Dan, I've certainly learned a ton over the course of our conversation. Very much appreciate the thoughtful approach to things. I think sometimes it's easy to think that when it comes to a surgery, there's a lot of skill involved. I personally feel that when it comes to radiation oncology, there's a lot of skill involved to really optimize and tailor that treatment, both based on evidence as well as understanding what's important to patients and experience as well. As we wrap up and come upon an hour, any parting thoughts for the listenership?

[Dr. Daniel Spratt]
First, thanks so much again for the invitation. I still think there's a remarkable-- I'm honored to be in this profession and I think that what I've noticed and not that far into my career is the collaboration between radiation oncology and urology and of course, medical oncology. It has advanced so far from when I trained. Maybe that's a reflection of maybe where I trained, but I think it's just so awesome to see that it is palpable. People just want these guys to have good quality of life and do well. I think working together is just-- People, especially if you're early in your career, I think we all want what's best for the patient and so it's exciting. I'm excited to see where the field keeps going.

[Dr. Aditya Bagrodia]
I love it. Hey, I echo those sentiments and totally it's a team sport with the patient at the center. Thanks again, Dan, really appreciate it.

[Dr. Daniel Spratt] Yes, thank you so much.

Podcast Contributors

Dr. Daniel Spratt

Dr. Daniel Spratt is the chair of radiation oncology at University Hospitals Cleveland Medical Center Seidman Cancer Center and a professor with Case Western Reserve University in Cleveland, Ohio.

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2023, August 23). Ep. 113 – Radiotherapy for High Risk Prostate Cancer [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.