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Johns Hopkins Proton Therapy Certificate Course - Proton Therapy Certificate Course
medicine.learnmore.jhu.edu
To be clear, I'm not deriding the course itself.I don't understand the derision towards this course.
I think getting some training in protons is a good idea if you're going to start using them and don't have prior experience or training.
The cost and time investment for this particular course seems reasonable to me.
Medicare proton rate is about 3x more than IMRT per fraction.Can someone give me a per proton vs per photon cost on average? Probably better to compare protons to electrons on a per particle basis. I'm sure protons aren't 2000x more expensive. Let's give the protonists a break.
I'm talking about a particle-to-particle comparison. Protons are so much more massive. A mole of protons should cost way more than a mole of electrons. I wouldn't really be able to differentiate that personally if you handed me a bag of each, but that's because I work out.Medicare proton rate is about 3x more than IMRT per fraction.
Private insurance can reimburse protons something insane like 20 to 30x the Medicare IMRT rate per fraction.
Everyone’s mileage does and will vary.
professional fees are the same or very similar correct?Medicare proton rate is about 3x more than IMRT per fraction.
Private insurance can reimburse protons something insane like 20 to 30x the Medicare IMRT rate per fraction.
Everyone’s mileage does and will vary.
professional fees are the same or very similar correct?
To be clear, I'm not deriding the course itself.
I'm deriding the concept.
So has the CK and the uab truebeam course.Gamma knife certification has existed for a long time.
So has CK and the uab truebeam course.
As @elementaryschooleconomics alluded to, why were there 1 yr fellowships in protons in that case? Which is it
Maryland does very good hyperthermia work! maybe the only place (on east coast at least)Can throw this in while you’re there
Hyperthermia Therapy Practice School Thermal Therapy Course | University of Maryland School of Medicine
www.medschool.umaryland.edu
To do some physics jaywalking for a sec.... A mole of protons should cost way more than a mole of electrons. I wouldn't really be able to differentiate that personally if you handed me a bag of each, but that's because I work out.
Jesus, can I get a certificate for reading this post???To do some physics jaywalking for a sec...
If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).
But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):
View attachment 382477
So if handed a mole of protons you and your city would die.
But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.
But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.
My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.
And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.
You basically just presented a good argument for protons reimbursing more. Don't let this get out.To do some physics jaywalking for a sec...
If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).
But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):
View attachment 382477
So if handed a mole of protons you and your city would die.
But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.
But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.
My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.
And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.
Remember Billy Loos one year fellowship in lung sbrt at Stanford?I mean there are one year fellowships in SRS too.
No one thinks of these fellowships as necessary to do the job.
Very largely rad onc fellowships are for and are filled by international folks. The US MDs that do them are looking for an angle in to improve their academic job prospects. It’s never been about the learning
Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilitiesRemember Billy Loos one year fellowship in lung sbrt at Stanford?
Do they offer any proton seminars? The director at inova once told a patient of mine she needed protons for a t spine met because she was on IO.Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilities
I loved this one. Taking "see one, do one, teach one" very literally.Can't top the "proton fellowship" at Inova which include doc of the day photon responsibilities
How many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).to conflate added technology with added expertise
Do they offer any proton seminars? The director at inova once told a patient of mine she needed protons for a t spine met because she was on IO.
...i did (n=1)I don't think anyone does a one year fellowship in protons because they believe that's the only way they can treat with protons as an attending...
To be fair, the new version of Raystation has a robust evaluation tool that allows you to -fairly effortlessly- see the worst-case-scenario dosimetry for any metric. Its not terribly complex... so long as docs know they need to check such thingsHow many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).
The physicists are the "experts".
What we need to be experts on is the scale of uncertainty associated with our intervention, the sources of those uncertainties and when those uncertainties become dangerous (based on clinical data). This is the sort of expertise that allows us to actually look at plans in a meaningful way. Also imperative is a detailed discussion of the nature of toxicity, (less grade 1, more grade 4-5 needs to be honestly discussed) as well as the ethics of proton therapy in the setting of cost, resource utilization, uncertain differential efficacy, and potential for increased very high grade toxicity.
IMO, the most important goal of any practicum course on protons would be to facilitate attendees ability to make ethical decisions regarding the use of protons vs their more readily available alternative.
Is the JHH course going to do this...or is it going to be a primer of standard proton prescriptions, beam selection and immobilization...as well as a primer on the potential benefits of proton therapy.
To do some physics jaywalking for a sec...
If someone handed you a mole of protons, we might ordinarily think of a mole as a visible-to-the-eye amount of a particular atom or molecule, and in fact a mole of protons would equal about 1g of protons as a mole of hydrogen is about 1g of hydrogen. Metallic hydrogen (or "metallic protons") would thus probably be about 1cc in size if metallic hydrogen has the density of water (which it probably does).
But to get protons that concentrated you will be dealing with enormous repulsive Coulombic forces... and that 1g of protons would explode with about 21 kilotons of TNT force (E=mc2, or 1E-3*3E8*3E8 joules):
View attachment 382477
So if handed a mole of protons you and your city would die.
But to actually have 1 cubic centimeter of pure protons you would have to forge that inside a neutron star under incredible gravitational pressure. So that 1cc of protons would have a huge density, maybe 100 billion kilograms packed into just 1cc of space. (This is much, much more than a mole, obviously.) If it didn't explode, the 1cc of protons would just fall through your hand, all the way through the middle of the earth, and just oscillate back and forth (over a long period of time) before coming to rest at the earth's core.
But it would explode, because gravity would be not strong enough to hold it together, and by handing you a bag of protons we would destroy the planet. The energy output of 1cc of stellar compressed protons would be ~100,000x greater than the energy released by the asteroid that killed the dinosaurs.
My back of envelope calcs say ~2 Gy of protons irradiating 1kg of matter takes about 1.3E10 protons, and a mole of protons would contain ~50 trillion more protons than that.
And that means that over the history of humanity, (much) less than one mole of protons will treat every single human being ever irradiated with proton beam therapy.
Jesus, can I get a certificate for reading this post???
It seems fantastic. The 1 week practicum courses are way more valuable than the DEI/mentorship/retrospective/KOL opinion garbage at most conferences. GK, CK, ABS to some extent.
Overtraining of residents devalues us, not the practicum courses, assuming they don’t start accepting med/surg onc’s.
The idea that you have to have been a resident or faculty at a Penn/Harvard/MDA or else you’ll cause brainstem necrosis is just a myth perpetuated by those places to conflate added technology with added expertise.
Even this I doubt. The physicists took it in their own hands to lower the delivered gray for what would, say, normally be a 2 Gy fraction, downwards by 10% to a 1.8 Gy dose. And instead of calling that a misadministration they call it a cobalt gray equivalent… how neat!… and call the 1.8 Gy a dose of 2.0 Gy instead. (Back in the day I know a lot of old boomer MDs who would have loved physics’ cover for lowering their IMRT doses by 10% across the board, but still writing the same numerical Rx dose in the chart.)The physicists are the "experts
How many docs are actually "experts" regarding proton therapy. On this board, long term proton practitioners have acknowledged reviewing plans as though they are photon plans. The details of modern photon dosimetry are a mystery to all but a tiny fraction of MDs (I'm pretty sure JHH doesn't have any docs with a detailed knowledge of dose engines, although they may show up on papers regarding this topic).
The physicists are the "experts".
What we need to be experts on is the scale of uncertainty associated with our intervention, the sources of those uncertainties and when those uncertainties become dangerous (based on clinical data). This is the sort of expertise that allows us to actually look at plans in a meaningful way. Also imperative is a detailed discussion of the nature of toxicity, (less grade 1, more grade 4-5 needs to be honestly discussed) as well as the ethics of proton therapy in the setting of cost, resource utilization, uncertain differential efficacy, and potential for increased very high grade toxicity.
IMO, the most important goal of any practicum course on protons would be to facilitate attendees ability to make ethical decisions regarding the use of protons vs their more readily available alternative.
Is the JHH course going to do this...or is it going to be a primer of standard proton prescriptions, beam selection and immobilization...as well as a primer on the potential benefits of proton therapy.
Photon dosimetry - what the TPS shows is what the patient gets within 5%, maybe within 7% if your physicist is lazy. If > 10% discordant, alarm bells start going off.
Proton dosimetry - we don't understand enough of it, we treat with fixed RBE of 1.1 but RBEs can be up to 1.7, leading up to 50% variability in deposited dose. No alarm bells go off, keep treating, world keeps spinning.
Keep putting holes in brainstems, temporal lobes, ribs, mandibles, all in situations where the computer screen said it was gonna be just fine
That can't be true I was told IMRT causes brain impairment and protons don't cause any side effects
Most of what I see in the literature recently is driven by physicists bc the setups to examine biological effects across the proton track/energy are in their purview. All of this should have been done 40+ years ago, but squeezing money out of the NCI for radbio is tough. Particularly after the field hand waved and said 1.1 CGE and we've treated people and its fine.Even this I doubt. The physicists took it in their own hands to lower the delivered gray for what would, say, normally be a 2 Gy fraction, downwards by 10% to a 1.8 Gy dose. And instead of calling that a misadministration they call it a cobalt gray equivalent… how neat!… and call the 1.8 Gy a dose of 2.0 Gy instead. (Back in the day I know a lot of old boomer MDs who would have loved physics’ cover for lowering their IMRT doses by 10% across the board, but still writing the same numerical Rx dose in the chart.)
Physicists meddled mightily in what should have been our purview: biology.
There was no need to prove safety 40 years ago b/c proton machines were minting money and KOLs in Rad Onc said it was unethical to treat with anything besides protons, if protons were available.Most of what I see in the literature recently is driven by physicists bc the setups to examine biological effects across the proton track/energy are in their purview. All of this should have been done 40+ years ago, but squeezing money out of the NCI for radbio is tough. Particularly after the field hand waved and said 1.1 CGE and we've treated people and its fine.
There was no need to prove safety 40 years ago b/c proton machines were minting money and KOLs in Rad Onc said it was unethical to treat with anything besides protons, if protons were available.
Only when those folks retired or DIED was there an interest in actually evaluating need.