Protons are blowing Rad Onc's boat out the CMS water

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Good Lord.

I thought I treated a lot of skin and collected good resources.

I bow to you.
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Fantastic - if only all of my attendings in residency combined over four years had given me anything as helpful. It shows you can do whatever the heck you want.

Now make one for breast - go. Spoiler: You can do whatever the heck you want, cue the critics.
 
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metallica81788 said:
Fantastic - if only all of my attendings in residency combined over four years had given me anything as helpful. It shows you can do whatever the heck you want.

Now make one for breast - go. Spoiler: You can do whatever the heck you want, cue the critics.
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Every single breast cancer case could be treated with 5 fractions of partial breast, or 5 fraction whole breast or chest wall (plus/minus a supraclav field). Sounds easy!
 
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taserlaser said:
I’m going to also go on a rant on #5

I treat a lot of skin. A LOT. Orthovoltage, electrons, VMAT, you name it. Converting some of my breast consult space for even more skin space between my RO skin partner and I.

The wild west is probably a good way of putting it. I spent a lot of my time early on in my (still junior) practice on reviewing strategies here. I could go on a rant here for about an hour on how no one can agree on how to treat this.

I‘ll attach a few dose and fractionations that come from different sources. Note whiel there are some commonalities, in other cases they are WILDLY different.

ASTRO guidelines:
View attachment 359637

NCCN:
View attachment 359638

Some US dermatology guidelines:

View attachment 359639
This one I think is hilarious because it references ‘Total Dose Fractions’ and puts the units in Gy instead of its proper/original nomenclature.

Taken from the old Orton and Ellis tables courtesy this book:

View attachment 359647

View attachment 359640
View attachment 359641
From a UK patterns of practice survey, McPartlin BJR 2014
View attachment 359642

View attachment 359643
One opinion paper post covid suggests rather hypofrac/descalation of treatment for a lot of these frail patients:

View attachment 359645


Let alone some of the more recent skin SBRT publications looking at dose escalated treatment for more bulky skin cancers.

Heck, someone I used to train with used what is usually published as a HDR brachy dose with good effect, also not in any of these above. ‘The secret sauce’

One thing I’ve tried to come to terms with is what is an effective tumorcidal dose? It’s nice to try and say to give a 85 yr old 30 fractions but it’s really not practical and there are other good hypofractionation options that may be more suitable.

Also what’s hard with this - a lot of these institutional outcomes don’t report technique well. Few places have access to superficial radiotherapy, electrons are a lot more common in places that have linacs. Are these corrected for RBE, do they even need to be corrected to RBE? Are they being prescribed to 90%, is this being prescribed to Dmax? A lot of these details are not reported, and I think it matters.

What I will say which (somewhat) perplexes me and have given some thought to, is a lot of these doses if you look at more of the moderate/extreme hypofraction (eg 5-10 fr), the linear quadratic model starts to break down for what is tumorcidal for non-bulky tumors, as compared to conventional 2Gy/fr. There does seem to be a time element that is not well captured there. There may be something to using the tdf tables, for which most/all of these doses do fall along in the ‘sweet spot’ for. Probably because they are derived from this, and not vice versa. Is there difference in LC between a tumorcidal 5 fr/7 fr/10fr/20 fr/30fr regimen? Maybe? We can’t well tease it out from our current data I think.

The Zaorsky meta-analysis is good, but without good randomized data, I don’t know if one can’t really say I think since treatments can differ in technique by quite a bit.

What to do for definitive melanoma? What is effective palliation for melanoma/SCC on IO - is daily treatment truly the best?

This stuff drives me nuts. I wish we had better trials and data past - “we did this and it worked”

Also - if anyone has thoughts on above, would LOVE their insight & experience. I’m all ears.
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What is your dose and technique when using electrons?
 
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@taserlaser

I recently had a bad skin case referred to me (we don't do a lot of skin) and I was blown away at the wide range of schemes. I was trained with basically one of 3 fractionation schemes based on 10, 20 or 30+ fractions, but completely agree that some think 45/15 is OK while others will push for 40/8. Radically different BEDs...
 
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evilbooyaa said:
Radically different BEDs.
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Yes but less different if we factor in time. Be that as it may…

We have to recall from rad bio teaching a common tumor D-zero is 3 Gy which means 15 Gy/5 fx provides 1-(0.37^5)= 99.3% cell kill for most tumors. If skin cancer tumors contain very few cancer cells vs other tumors we treat, it shouldn’t surprise us that a wide range of BEDs can work. IMHO.
 
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TheWallnerus said:
If skin cancer tumors contain very few cancer cells vs other tumors we treat, it shouldn’t surprise us that a wide range of BEDs can work.
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I agree, but I don't know if it's just cell number. I suspect our guidelines include much higher doses than necessary for most basal cell CA (when is the last time any of you saw a failure with a small BCC) and even small localized SCC, where I think we talking about very small differences in local control on the order of 90% to 95% when we play with these different dose schemes.

But, I wouldn't get too cute with adjuvant RT for squamous regimens when high risk features are present. By the time high risk features are present (PNI, deep tissue invasion, nodal disease) SCC acting completely differently than the disease that surgeons are putting liquid nitrogen on.

Also, SCC in immunocompromised patients is often horrible. Don't know if immunogenicity playing a role here, but I'm thinking probably so.
 
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communitydoc13 said:
I agree, but I don't know if it's just cell number. I suspect our guidelines include much higher doses than necessary for most basal cell CA (when is the last time any of you saw a failure with a small BCC) and even small localized SCC, where I think we talking about very small differences in local control on the order of 90% to 95% when we play with these different dose schemes.

But, I wouldn't get too cute with adjuvant RT for squamous regimens when high risk features are present. By the time high risk features are present (PNI, deep tissue invasion, nodal disease) SCC acting completely differently than the disease that surgeons are putting liquid nitrogen on.

Also, SCC in immunocompromised patients is often horrible. Don't know if immunogenicity playing a role here, but I'm thinking probably so.
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Last point a good one. Dendritic cells, antigen presenting cells, the special immunologic environment of the skin, and what not.
 
communitydoc13 said:
Also, SCC in immunocompromised patients is often horrible. Don't know if immunogenicity playing a role here, but I'm thinking probably so.
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Yep. Had a run of those recently.. no good options if they fail RT, esp if they are immunocompromised because of being on transplant anti rejection drugs (no IO) which basically increased their risk of BCC/SCC to begin with
 
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communitydoc13 said:
I agree, but I don't know if it's just cell number. I suspect our guidelines include much higher doses than necessary for most basal cell CA (when is the last time any of you saw a failure with a small BCC) and even small localized SCC, where I think we talking about very small differences in local control on the order of 90% to 95% when we play with these different dose schemes.

But, I wouldn't get too cute with adjuvant RT for squamous regimens when high risk features are present. By the time high risk features are present (PNI, deep tissue invasion, nodal disease) SCC acting completely differently than the disease that surgeons are putting liquid nitrogen on.

Also, SCC in immunocompromised patients is often horrible. Don't know if immunogenicity playing a role here, but I'm thinking probably so.
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Transplant patients with skin or lung cancer do awful. It’s like treating an entirely different disease.
 
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Lamount said:
Transplant patients with skin or lung cancer do awful. It’s like treating an entirely different disease.
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Having AIDS, which I haven’t seen a patient with AIDS in maybe 20 years, makes cancers less responsive to radiation too. Cell mediated immunity must interact with XRT somehow. I wish I knew how.
 
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If you ever considered getting protons in your city, this ASTRO is the one for you.

It sounds like Varian will be getting out of selling new systems, and I wonder if it's because they can't compete with this new machine that fits in a traditional vault:

www.businesswire.com

Mevion Introduces New MEVION S250-FIT Proton Therapy System

The new MEVION S250-FIT Proton Therapy System is the first and only full proton therapy system that can fit in an existing LINAC vault.
www.businesswire.com

This will bring the cost of room construction way down, like an order of magnitude compared to the old 3 story gantries that cost 30 million. It sounds like retrofits might even be an option, if you have a large enough existing vault - maybe an older one previously used for total body irradiation. Might need some neutron shielding added, but otherwise, Wow!
 
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IonsAreOurFuture said:
If you ever considered getting protons in your city, this ASTRO is the one for you.

It sounds like Varian will be getting out of selling new systems, and I wonder if it's because they can't compete with this new machine that fits in a traditional vault:

www.businesswire.com

Mevion Introduces New MEVION S250-FIT Proton Therapy System

The new MEVION S250-FIT Proton Therapy System is the first and only full proton therapy system that can fit in an existing LINAC vault.
www.businesswire.com

This will bring the cost of room construction way down, like an order of magnitude compared to the old 3 story gantries that cost 30 million. It sounds like retrofits might even be an option, if you have a large enough existing vault - maybe an older one previously used for total body irradiation. Might need some neutron shielding added, but otherwise, Wow!
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Just need some prospective RCTs to show where the benefit of protons is exactly over photons/VMAT and then we should be set.
 
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medgator said:
Just need some prospective RCTs to show where the benefit of protons is exactly over photons/VMAT and then we should be set.
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Too late, patients are already requesting protons for things like bone mets… it’s ridiculous and shameful.
 
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I see protons hanging around forever. They’ll never go away and will always be considered superior regardless the data. We have data showing some worse side effects with prostate and breast eg, but… it hasn’t mattered. It’s amazing.
 
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medgator said:
Just need some prospective RCTs to show where the benefit of protons is exactly over photons/VMAT and then we should be set.
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Eh. We didn’t need that for IMRT. We got the studies afterwards.

I’m okay with low cost units and par reimbursement- levels the playing field.

This is good for community. If MRL and protons get to a reasonable price point, I’d be happy.
 
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I have a salvage prostate I might be about to treat who's also considering protons 1000 miles away. I've talked with him enough at this point, or been talked at enough, to figure that I will want any future patient who wants protons, to get protons.
 
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RealSimulD said:
Eh. We didn’t need that for IMRT. We got the studies afterwards.

I’m okay with low cost units and par reimbursement- levels the playing field.

This is good for community. If MRL and protons get to a reasonable price point, I’d be happy.
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IMRT was much closer to 3d in cost and reimbursement than it was to protons, and essentially the same Linac could do both.

This news might be a game changer, but other than dosimetric studies, where is the clinic data for those of us treating bread and butter adult cases?
 
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Ray D. Ayshun said:
I have a salvage prostate I might be about to treat who's also considering protons 1000 miles away. I've talked with him enough at this point, or been talked at enough, to figure that I will want any future patient who wants protons, to get protons.
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Excellent thought process
 
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medgator said:
IMRT was much closer to 3d in cost and reimbursement than it was to protons, and essentially the same Linac could do both.

This news might be a game changer, but other than dosimetric studies, where is the clinic data for those of us treating bread and butter adult cases?
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Totally. But they are going to be commonplace. I’d rather they be cheap so it’s not just rich centers taking patients away.

And reimburse same until proven better
 
QUOTE="Ray D. Ayshun, post: 23581344, member: 638902"]
I have a salvage prostate I might be about to treat who's also considering protons 1000 miles away. I've talked with him enough at this point, or been talked at enough, to figure that I will want any future patient who wants protons, to get protons.
[/QUOTE]

/thread.

I practice near a a proton center and have been forced to pre-screen any prostate patient with insurance that covers protons. The retention rate is like 0% for engineers (the guys who will spend 3 hours asking u about how a linac works) and anyone who has read that ****ing prostate canswers book.
 
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Reaganite said:
...
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I practice near a a proton center and have been forced to pre-screen any prostate patient with insurance that covers protons. The retention rate is like 0% for engineers (the guys who will spend 3 hours asking u about how a linac works) and anyone who has read that ****ing prostate canswers book.
[/QUOTE]
Some insurers wisened up years ago

kesq.com

Major California health insurer won't pay for expensive cancer treatment - KESQ

A major California health insurer says it won’t pay for an expensive cancer treatment because there’s no science to justify the price. The Los Angeles Times says beginning in October, Blue Shield of California won’t cover proton beam treatment for early-stage prostate cancer. Blue Shield will...
kesq.com kesq.com
 
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Reaganite said:
QUOTE="Ray D. Ayshun, post: 23581344, member: 638902"]
I have a salvage prostate I might be about to treat who's also considering protons 1000 miles away. I've talked with him enough at this point, or been talked at enough, to figure that I will want any future patient who wants protons, to get protons.
Click to expand...

You have to explain to engineers that protons rely on slight of word. 80gy at the edge of the beam in rectum is much more toxic to normal tissue than 80 gy in the middle of the prostate due to bed effects. I have had some luck with this explanation.

If you somehow were to normalize the dose distribution/isodose lines for bed, it is not very flattering.
 
medgator said:
I practice near a a proton center and have been forced to pre-screen any prostate patient with insurance that covers protons. The retention rate is like 0% for engineers (the guys who will spend 3 hours asking u about how a linac works) and anyone who has read that ****ing prostate canswers book.
Click to expand...
Some insurers wisened up years ago

kesq.com

Major California health insurer won't pay for expensive cancer treatment - KESQ

A major California health insurer says it won’t pay for an expensive cancer treatment because there’s no science to justify the price. The Los Angeles Times says beginning in October, Blue Shield of California won’t cover proton beam treatment for early-stage prostate cancer. Blue Shield will...
kesq.com kesq.com
[/QUOTE]


Medicare and Part C will never “wise up” and I am not sure why this is
 
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It's weird that the place I'm mentioning said they'd put the patient up in an apartment, while I'm told I can't give gas money to the head and neck patient who's considering not getting treatment because he can't afford to drive.
 
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The sad reality is that hospital, academic centers, and mega healthcare corporations can and do induce patients to be treated at their centers. From free room and board to the grotesque limos of CTCA they have a free hand. On the other hand, the small guy can get busted for providing an Uber ride to a patient whose care broke down.

Just one more step in the inevitable march to three medical systems in the US:

1. "UHC" like - takes all your premiums and denies all claims; unending profit for shareholders and executives. COVID-19 was an absolute gold mine for them, patients happily paid their premiums and sat at home with their CVAs, MIs, and progressive cancers for fear of going to the ER.

2. "Kaiser" like - take all your premiums and absolutely minimize/withhold care. There's a reason that your Kaiser premium is so low compared to your other options, you get way you pay for.

3. "Medicaid" like - no prior auth but reimbursement is bottom of the barrel.
 
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Ray D. Ayshun said:
It's weird that the place I'm mentioning said they'd put the patient up in an apartment, while I'm told I can't give gas money to the head and neck patient who's considering not getting treatment because he can't afford to drive.
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Hmm not sure the rules but we have a grant that funds our gas card assistance to patients…have a lot of rural patients
 
Ray D. Ayshun said:
It's weird that the place I'm mentioning said they'd put the patient up in an apartment, while I'm told I can't give gas money to the head and neck patient who's considering not getting treatment because he can't afford to drive.
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If you are affiliated with a hospital, there is usually a charitable foundation that is set up to help patients get care. You can probably make a tax deductible donation to setup a gas card fund or gas reimbursements for patients.

You are correct though, Medicare usually doesn't allow providers to discount, incentivize or sway patients with free travel - some Advantage plans may be more flexible though.
 
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Last edited:
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IonsAreOurFuture said:
If you are affiliated with a hospital, there is usually a charitable foundation that is set up to help patients get care. You can probably make a tax deductible donation to setup a gas card fund or gas reimbursements for patients.

You are correct though, Medicare usually doesn't allow providers to discount, incentivize or sway patients with free travel - some Advantage plans may be more flexible though.
Click to expand...

Guess I should take a wrecking ball to the Ronald McDonald house
 
IonsAreOurFuture said:
Mevion has identified Stanford as being the first site to install its new machine in a traditional vault:

Mevion Identifies Site for New Compact Proton Therapy System in Development | Mevion Medical Systems

www.mevion.com www.mevion.com

I think a floodgate of announcements is going to open over the next year, but I could be wrong. Once the large academic centers announce their systems, the more forward-thinking private practice players will start making competing announcements.
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I get the sense the future narrative is if you do not have proton, you have no business treating patients. It is cheap, can be put in a vault and patients will not like excuses!
 
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thecarbonionangle said:
I get the sense the future narrative is if you do not have proton, you have no business treating patients. It is cheap, can be put in a vault and patients will not like excuses!
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Yep. Or MRL
One or the other, or you’re a hack.
This is happening
 
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thecarbonionangle said:
I get the sense the future narrative is if you do not have proton, you have no business treating patients. It is cheap, can be put in a vault and patients will not like excuses!
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Dammit. This is d-baggery at its finest...and I'm on the losing end!
 
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thecarbonionangle said:
I get the sense the future narrative is if you do not have proton, you have no business treating patients. It is cheap, can be put in a vault and patients will not like excuses!
Click to expand...

...some of that sentiment I agree with.

But there are a large number of ongoing randomized trials (about damn time) in disease sites with common indications for radiation (oropharynx, esophagus, prostate, stage III lung)....if these end up + for protons the flood gates are about to open. may as well have a plan if you have the capital.
 
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BobbyHeenan said:
...some of that sentiment I agree with.

But there are a large number of ongoing randomized trials (about damn time) in disease sites with common indications for radiation (oropharynx, esophagus, prostate, stage III lung)....if these end up + for protons the flood gates are about to open. may as well have a plan if you have the capital.
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Talking to people at ASTRO it does seem like many are looking into it or at least starting to have capital plans. It is only a matter of time for flood gates unless all those trials are negative, which i doubt. I think the esophagus trial will be positive and likely oropharynx. Prostate and stage III lung are a toss up for me. Stage III lung will likely have a smaller analysis where protons are beneficial. I doubt they will show it is “always” better.
 
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thecarbonionangle said:
Talking to people at ASTRO it does seem like many are looking into it or at least starting to have capital plans. It is only a matter of time for flood gates unless all those trials are negative, which i doubt. I think the esophagus trial will be positive and likely oropharynx. Prostate and stage III lung are a toss up for me. Stage III lung will likely have a smaller analysis where protons are beneficial. I doubt they will show it is “always” better.
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I think oropharynx will be a + trial. Esophagus hard to tell too (will they be using hte total treatment burden end point or something more granular like OS?). Some of hte lung trial I think will depend on how post radiation CT's and pneumonitis is read...my anecdotal experience is I see more interstitial lung changes after proton than photon. very anecdotal obviously.

I will be shocked if prostate shows any difference.

SOme may come down to patient reported outcomes. It is amazing to me the psychological impact good marketing and beautiful isodose curve pictures can have on patients. I saw a post prostate proton patient with tremendous proctitis a couple of years ago for a different cancer and we talked about his ongoing rectal bleeding. his take on it : "just imagine how bad it would have been with photons."
 
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BobbyHeenan said:
I think oropharynx will be a + trial. Esophagus hard to tell too (will they be using hte total treatment burden end point or something more granular like OS?). Some of hte lung trial I think will depend on how post radiation CT's and pneumonitis is read...my anecdotal experience is I see more interstitial lung changes after proton than photon. very anecdotal obviously.

I will be shocked if prostate shows any difference.

SOme may come down to patient reported outcomes. It is amazing to me the psychological impact good marketing and beautiful isodose curve pictures can have on patients. I saw a post prostate proton patient with tremendous proctitis a couple of years ago for a different cancer and we talked about his ongoing rectal bleeding. his take on it : "just imagine how bad it would have been with photons."
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Why do you think oropharynx would be positive? Less toxicity, better outcomes or both? Just wondering since I’m not sure what the advantage would be vs IMRT.
 
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RadOncDoc21 said:
Why do you think oropharynx would be positive? Less toxicity, better outcomes or both? Just wondering since I’m not sure what the advantage would be vs IMRT.
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I think it is likely to show better taste preservation, less dose to OC, better DVH but possibly at the cost of more skin toxicity. there will be meat to spin it both ways.
 
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RadOncDoc21 said:
Why do you think oropharynx would be positive? Less toxicity, better outcomes or both? Just wondering since I’m not sure what the advantage would be vs IMRT.
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not better survival. slightly better side effect profile. enough to get the private insurer/nccn green light.
skin toxicity maybe worse with protons, swallowing better is going to be my guess. especially if treating ipsilateral only.

this is just a wild as* guess though based upon my review of institutional series and anecdotal cases.
 
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