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

[evilbooyaa]

Robotics vs open in any site is not comparable to protons vs photons. Outside of lack of data indicating oncologic benefit for robotics, there are many acute toxicity reasons to do it in multiple sites. I don't believe there is a good acute toxicity rationale for most proton therapy. There certainly isn't a "time under treatment" rationale or diminished hospital recovery rationale.

Now...I believe that there is some data indicating poorer long term oncologic outcomes in some GYN cancers (early stage endometrial) and I have witnessed numerable peculiar regional failures after robot assisted thoracic surgeries (regional pleural based failures as opposed to more traditional suture line failure).

Whether a generation of surgeons is being trained in a technique that is at present oncologically inferior but progressively being used, I don't know. Curious what the thoracic surgeons and gyn/oncs think.

I presume you're discusing poorer long term oncologic outcomes with the robot - LACC trial was in early stage CERVICAL cancer and even that was a mix of old school laparascopic modified radical hysterectomy (which is likely more challenging than old school TLH/BSO). Trial is being re-run evaluating Robot vs open directly given most of the poor outcomes seemed to be driven mostly by the old school laparaoscpic techniques (although not powered on subset analysis to evaluate differences based on old school laparoscopic vs robot-assisted laparoscopic)

robot assisted TLH/BSO is a very reasonable SOC for the vast majority of endometrial cancer patients.

LARP seems to have lower hospitalization duration compared to RRP - I don't really have an issue with the urologists using the robot for things that deep in the pelvis.
That being said, there are general surgeons using the robot for a lap cholecystectomy, which I DO think is either 1) financially motivated or 2) making up for poor technical qualities of a surgeon.

---

Members don't see this ad.

 

[RickyScott]

I really didnt mean to spark a discussion on the merits of the robot. I just wanted to point out that there was no widespread robot "shaming" when it came out as opposed to IMRT.

 

[Ray D. Ayshun]

I really didnt mean to spark a discussion on the merits of the robot. I just wanted to point out that there was no widespread robot "shaming" when it came out as opposed to IMRT.

This is hardly the time in social evolution to start shaming robots. I, for one, welcome our new robot overlords.

 

[BobbyHeenan]

I really didnt mean to spark a discussion on the merits of the robot. I just wanted to point out that there was no widespread robot "shaming" when it came out as opposed to IMRT.

Someone step in and correct me if I'm wrong....

But I think some dynamic here may be at play.

If I'm not mistaken (again, could be VERY wrong here), I think robot and IMRT both seemed to begin to grow somewhat equally between private and academic centers. So both entities were "growing" that modality and there was not an asymmetry as to whom had this tech and who didn't. The same is not true of protons.

 

[TheWallnerus]

I really didnt mean to spark a discussion on the merits of the robot. I just wanted to point out that there was no widespread robot "shaming" when it came out as opposed to IMRT.

I agree. No robot shaming per se as best as I could tell. There was robot side eye from real old docs, that’s all I noticed. Middle aged and younger docs who were not robot users seemed to be robot neutral to robot curious.

 

[BobbyHeenan]

I agree. No robot shaming per se as best as I could tell. There was robot side eye from real old docs, that’s all I noticed. Middle aged and younger docs who were not robot users seemed to be robot neutral to robot curious.

The biggest thing I remember in that era of the robot was the residents/fellows bitching about the attendings taking all of the cases and doing it themselves so that the attendings could learn on the robot. So the the residents and fellows were "robotic trained" per where they trained, but in actuality they had done very few robot hours because the attendings were doing all the cases.

 

[communitydoc13]

I presume you're discusing poorer long term oncologic outcomes with the robot

Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer

Recent reports in both cervical and endometrial cancer suggest that minimally invasive surgery (MIS) had an unanticipated negative impact on long-term clinical outcomes, including recurrence and death. Given increasing use of robotic surgery since the LAP2 trial, we sought to compare the...

www.gynecologiconcology-online.net

This type of study. But these things (surgical outcomes by technique) evolve (much, much faster than protons).

Edit: should add that authors transparency should be lauded. I'm looking for a comparable radonc paper.

 

[evilbooyaa]

Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer

Recent reports in both cervical and endometrial cancer suggest that minimally invasive surgery (MIS) had an unanticipated negative impact on long-term clinical outcomes, including recurrence and death. Given increasing use of robotic surgery since the LAP2 trial, we sought to compare the...

www.gynecologiconcology-online.net

This type of study. But these things (surgical outcomes by technique) evolve (much, much faster than protons).

Edit: should add that authors transparency should be lauded. I'm looking for a comparable radonc paper.

Huh - interesting. Didn't think RA-TLH/BSO was a question in endometrial cancer...

 

[Fpg1245]

Huh - interesting. Didn't think RA-TLH/BSO was a question in endometrial cancer...

GYN for some reason the robot seems to make things a bit worse.

 

[DoctwoB]

I presume you're discusing poorer long term oncologic outcomes with the robot - LACC trial was in early stage CERVICAL cancer and even that was a mix of old school laparascopic modified radical hysterectomy (which is likely more challenging than old school TLH/BSO). Trial is being re-run evaluating Robot vs open directly given most of the poor outcomes seemed to be driven mostly by the old school laparaoscpic techniques (although not powered on subset analysis to evaluate differences based on old school laparoscopic vs robot-assisted laparoscopic)

robot assisted TLH/BSO is a very reasonable SOC for the vast majority of endometrial cancer patients.

LARP seems to have lower hospitalization duration compared to RRP - I don't really have an issue with the urologists using the robot for things that deep in the pelvis.
That being said, there are general surgeons using the robot for a lap cholecystectomy, which I DO think is either 1) financially motivated or 2) making up for poor technical qualities of a surgeon.

Agreed I can't see much point to a robotic choley (perhaps niche cases, higher risk of CBD injury, etc) unless the surgeon lacks lap skills, with the exception of teaching.

One of the problems with adopting robotics has been generally the cases that we use the robot for are the more complex ones, like prostatectomies, partial nephrectomies, Whipple's, etc because that is where we see more benefit. The problem is that these are not junior resident level cases, so it gets hard for juniors to get console time beyond very specific portions of said cases (like dropping the bladder from the anterior abdominal wall in a prostatectomy). So having the robotic choley or hernia is great for the residents, though probably meh for the patients and more costly.

 

[IonsAreOurFuture]

Interesting proton news out of Spain, IBA and Raystation have been selected to equip 10 new proton centers across the country, including one in Madrid. I think Madrid already has 2 proton facilities at Quironsalud Hospital and at Universidad de Navarra.

IBA and RaySearch partner on ten new proton therapy facilities in Spain

Construction deal worth $229 million, maintenance expenses to be negotiated at a later date

www.dotmed.com

This will be the IBA Proteus one-room system like those in Louisiana, Detroit, Kansas City and Albuquerque.

 

[medgator]

Osteoradionecrosis of the Jaw Following Proton Radiation Therapy for Head and Neck Cancer

This case series reports the prevalence and clinical characteristics of osteoradionecrosis of the jaw in patients with oral and oropharyngeal cancer treated with proton radiation therapy.

jamanetwork.com

 

[communitydoc13]

Osteoradionecrosis of the Jaw Following Proton Radiation Therapy for Head and Neck Cancer

This case series reports the prevalence and clinical characteristics of osteoradionecrosis of the jaw in patients with oral and oropharyngeal cancer treated with proton radiation therapy.

jamanetwork.com

Anyone here think that they have had a 10+ percent ORN risk with their photon treatment?

As said many times. They don't know the dose they are giving.

 

[RickyScott]

Anyone here think that they have had a 10+ percent ORN risk with their photon treatment?

As said many times. They don't know the dose they are giving.

Never seen it. In imrt era, it is incredibly rare.

 

[madchemist89]

Almost nonexistent in my experience

 

[Mandelin Rain]

"We'll treat with them anyways."

 

[temujim]

Never seen it. In imrt era, it is incredibly rare.

2.1% on the RT/cis arm in RTOG 1016.

But I tell my patients <1/250 or so.

 

[communitydoc13]

2.1% on the RT/cis arm in RTOG 1016.

Yes, and that was therapeutic escalation. Accelerated XRT with q3 week cis. Too much treatment.

 

[TheWallnerus]

Never had an ORN case

Never had to refer a prostate RT patient to GI for late rectal bleeding

Never had a significant symptomatic pneumonitis patient after stage III lung

Never had a rib fracture or pneumonitis after breast RT

WHAT AM I DOING WRONG, please help me increase my patients to the proper levels of toxicity!

 

[communitydoc13]

Never had an ORN case

Never had to refer a prostate RT patient to GI for late rectal bleeding

Never had a significant symptomatic pneumonitis patient after stage III lung

Never had a rib fracture or pneumonitis after breast RT

WHAT AM I DOING WRONG, please help me increase my patients to the proper levels of toxicity!

Well, this is remarkable.

I have had rare cases pneumonitis for intact stage III but several in the post-op setting (back when I used to do that).

Rare late rectal bleeding but not never and typically a pt on AC.

1 case of symptomatic ORN in a classic pt (refused extractions, OC, heavy smoker). If you are following OC pts with MRI there will be occasional radiographic ORN however.

Rare extraordinary toxicity likely mediated by pt biology in a number of sites (breast, rectal).

Never a rib fracture from breast RT however. Not one. That takes protons.

 

[udrag14]

Never had an ORN case

Never had to refer a prostate RT patient to GI for late rectal bleeding

Never had a significant symptomatic pneumonitis patient after stage III lung

Never had a rib fracture or pneumonitis after breast RT

WHAT AM I DOING WRONG, please help me increase my patients to the proper levels of toxicity!

You have too many healthy cancer patients.

I have seen a couple ORN cases but the tumor was already eating at the mandible.

Two patients recently with GI bleeding but actually had other stuff going on.

Rest haven't had either.

 

[TheWallnerus]

You have too many healthy cancer patients.

I have seen a couple ORN cases but the tumor was already eating at the mandible.

Two patients recently with GI bleeding but actually had other stuff going on.

Rest haven't had either.

I don’t find that people’s “I had one or two cases” is statistically significantly different from saying someone had zero cases. Hashtag math. Hashtag blessed.

I know how to give somebody ORN or rectal bleeding or pneumonitis. I saw attendings and colleagues achieve that in the past and through the years. Eg, ENI for breast cancer. The most statistically significant finding from MA-20 was more pneumonitis with ENI iirc. Hashtag treatment volumes.

 

[sirspamalot]

Never had an ORN case

Never had to refer a prostate RT patient to GI for late rectal bleeding

Never had a significant symptomatic pneumonitis patient after stage III lung

Never had a rib fracture or pneumonitis after breast RT

WHAT AM I DOING WRONG, please help me increase my patients to the proper levels of toxicity!

#MakeMoneyUsingProtonsorGTFO
#I_love_academia
#MDAHAHAHAHAHAHlosers

 

[udrag14]

I don’t find that people’s “I had one or two cases” is statistically significantly different from saying someone had zero cases. Hashtag math. Hashtag blessed.

I know how to give somebody ORN or rectal bleeding or pneumonitis. I saw attendings and colleagues achieve that in the past and through the years. Eg, ENI for breast cancer. The most statistically significant finding from MA-20 was more pneumonitis with ENI iirc. Hashtag treatment volumes.

Yeap I agree with you. Honestly, feel like a lot of severe toxicities are random chance. I review all the plans again for inconsistencies for these patients, and many of them are well within constraints.

 

[RadOncDoc21]

Yeap I agree with you. Honestly, feel like a lot of severe toxicities are random chance. I review all the plans again for inconsistencies for these patients, and many of them are well within constraints.

I had a doc claim I fried a lady’s skin off even though she never received radiation (atopic dermatitis). I’ve apparently also gave a patient radiation pneumonitis even though I didn’t treat anywhere near the lungs (prostate).

I get we cause side effects, but no need to be responsible for all of them. Most of these claims came from either residents or uninformed ER docs but not enough time to educate everyone especially when we continue to find ways to blame each other.

 

[temujim]

I had a doc claim I fried a lady’s skin off even though she never received radiation (atopic dermatitis). I’ve apparently also gave a patient radiation pneumonitis even though I didn’t treat anywhere near the lungs (prostate).

I get we cause side effects, but no need to be responsible for all of them. Most of these claims came from either residents or uninformed ER docs but not enough time to educate everyone especially when we continue to find ways to blame each other.

In my younger days, full of energy, would call these physicians to educate them. And sure enough next note from them, "XYZ secondary to radiation".

 

[medgator]

I had a doc claim I fried a lady’s skin off even though she never received radiation (atopic dermatitis). I’ve apparently also gave a patient radiation pneumonitis even though I didn’t treat anywhere near the lungs (prostate).

I get we cause side effects, but no need to be responsible for all of them. Most of these claims came from either residents or uninformed ER docs but not enough time to educate everyone especially when we continue to find ways to blame each other.

I call out that BS hardcore and document if needed to. Usually good at nipping it in the bud. And sometimes they don't even know how to manage our complications when they try.

Boomer pulm didn't hit one of my stage 3 lung pts etc high dose pred hard enough or long enough.... Had to literally overrule his Rx to get her in a good place

 

[TheWallnerus]

In my younger days, full of energy, would call these physicians to educate them. And sure enough next note from them, "XYZ secondary to radiation".

 

[Lamount]

I call out that BS hardcore and document if needed to. Usually good at nipping it in the bud. And sometimes they don't even know how to manage our complications when they try.

Boomer pulm didn't hit one of my stage 3 lung pts etc high dose pred hard enough or long enough.... Had to literally overrule his Rx to get her in a good place

Just this week, when the inpatient team was trying to discharge my patient with clear post-obstructive PNA by claiming it was pneumonitis. Steroids just wasn’t helping

“Pneumonitis during second week of radiotherapy is extremely atypical and is inconsistent with the clinical picture. I recommend that the inpatient team adequately manage patient’s likely PNA with empiric antibiotics as to prevent short-interval readmission”. That did the trick patient. Pt got abx, and like MAGIC, O2 demand returned to baseline

 

[Reaganite]

Have heard (but never verified) there may be some charge associated with radiation related complications? Noticed a few follow up notes from surgeons with a code that seemed to be related to "severe" XRT-related pelvic fibrosis in some vaginal cuff brachy patients I treated.

 

[elementaryschooleconomics]

Have heard (but never verified) there may be some charge associated with radiation related complications? Noticed a few follow up notes from surgeons with a code that seemed to be related to "severe" XRT-related pelvic fibrosis in some vaginal cuff brachy patients I treated.

My guess would be 77499, but man, those are some wRVU-hungry surgeons...

 

[TheWallnerus]

My guess would be 77499, but man, those are some wRVU-hungry surgeons...

"There is no clinical indication for even one picogray of dose in normal tissue." - Herman Suit

"There is no reason not to bill something if you can." - TheWallnerus

 

[thesauce]

Even CMS says they have no problem with practices maximizing their billing charges so long as those things were actually done

 

[sirspamalot]

Well hallelujah. Anyone want to do a deep fake of our leadership talking about protons?

 

[evilbooyaa]

Have heard (but never verified) there may be some charge associated with radiation related complications? Noticed a few follow up notes from surgeons with a code that seemed to be related to "severe" XRT-related pelvic fibrosis in some vaginal cuff brachy patients I treated.

Are you doing pelvics on em yourself? 7Gy x 3 to depth can cause G2-3 vaginal stenosis by itself especially in a patient not compliant with dilation.

 

[Reaganite]

Are you doing pelvics on em yourself? 7Gy x 3 to depth can cause G2-3 vaginal stenosis by itself especially in a patient not compliant with dilation.

I was actually being facetious . They are adding some code pertaining to extensive pelvic adhesions in my patients who most definitely did not receive pelvic radiation.

 

[IonsAreOurFuture]

A 3rd center for Tampa

I read yesterday that Moffitt announced a one room proton center using the IBA half gantry system that is also going into Arkansas and Albuquerque and 10 centers in Spain.

Tampa General hospital has also announced their center and another one is reportedly in the works, but further behind I think.

 

[medgator]

A 3rd center for Tampa

I read yesterday that Moffitt announced a one room proton center using the IBA half gantry system that is also going into Arkansas and Albuquerque and 10 centers in Spain.

Tampa General hospital has also announced their center and another one is reportedly in the works, but further behind I think.

Tgh one has multiple partners. Have not heard of a third one. Surprised Moffitt took this long, although not surprised considering the tgh/moffitt divorce a few years ago and perhaps that is why they have been dragging their feet

Tampa General Hospital, Florida Cancer Specialists, Proton Therapy Partners and Florida Urology Partners Come Together with Plans to Open the Region’s First Proton Therapy Center

Tampa General Hospital (TGH), the Florida Cancer Specialists & Research Institute (FCS), Proton Therapy Partners and Florida Urology Partners today announced a new collaborative partnership with plans to build a proton therapy center in Tampa Bay that would offer patients across the West Coast...

flcancer.com

Would be nice if the prospective randomized data proliferated as fast as the centers do

 

[grenz]

A 3rd center for Tampa

I read yesterday that Moffitt announced a one room proton center using the IBA half gantry system that is also going into Arkansas and Albuquerque and 10 centers in Spain.

Tampa General hospital has also announced their center and another one is reportedly in the works, but further behind I think.

What do the business plans of these newer centers look like? Is PE still heavily involved?In the old days the centers relied on very unrealistic financial projections and subsequently several went into bankruptcy

 

[sirspamalot]

What do the business plans of these newer centers look like? Is PE still heavily involved?In the old days the centers relied on very unrealistic financial projections and subsequently several went into bankruptcy

The Centers cost went way down and the reimbursement while less is still high.

There is a company called Apollo Healthcare helping some centers fight the UM battle. They are printing serious money doing it.

 

[BobbyHeenan]

I heard through the grape vine that the pro forma on the Moffitt facility mostly excluded prostate and they felt like they had the volume for other indications (esp head/neck) for it to still make sense.

With the current interest rate environment, I would guess the PE is not as interested in these places as they were when money was cheap.

Presuming the lung and head/neck data is published soon...we're about to find out if protons help much. As you all know thouhg, common cancers and medicare no prior auth lead to a lot of patients that can be put on those machines for breast and prostate...and those trials may take longer to mature.

 

[NotMattSpraker]

The Centers cost went way down and the reimbursement while less is still high.

There is a company called Apollo Healthcare helping some centers fight the UM battle. They are printing serious money doing it.

That is a fascinating company, I hadn't seen that before. It's like an Evicore for practices?

It's too bad no one is incentivized to "make therapies more accessible" by funding trials that support their use...

 

[BobbyHeenan]

The Centers cost went way down and the reimbursement while less is still high.

There is a company called Apollo Healthcare helping some centers fight the UM battle. They are printing serious money doing it.

Any relation to Dr Steven Frank?

Ben Frank – Apollo Healthcare

apollohealthcare.com

 

[NotMattSpraker]

Any relation to Dr Steven Frank?

Ben Frank – Apollo Healthcare

apollohealthcare.com

No idea but I laughed out loud when I learned that MDACC offers fellowships in administration.

I feel so stupid for limiting my imagination to clinical fellowships.

 

[sirspamalot]

That is a fascinating company, I hadn't seen that before. It's like an Evicore for practices?

It is the anti-Evicore.. they are happy to help, but for a cut of the action. They win, center wins. '

For those that are interested in investing in a company with technology (50k-250k) to raise the bar on dealing with prior auth, please PM me. Think of this concept on steroids (ie for more than radonc)...

 

[Gfunk6]

No idea but I laughed out loud when I learned that MDACC offers fellowships in administration.

Really? I'm signing up for it!

 

[Gfunk6]

The Centers cost went way down and the reimbursement while less is still high.

There is a company called Apollo Healthcare helping some centers fight the UM battle. They are printing serious money doing it.

Well, the problem is when the rug gets pulled out on protons by CMS (and it will) the bankruptcy attorneys will make a fortune. Just think to when CMS did the same for electronic brachytherapy a few years ago. Personally, I would rather have a Xoft unit gathering cobwebs than a multi-vault cyclotron . . .

 

[evilbooyaa]

Really? I'm signing up for it!

WTAF

Is this for like doctors? Or for like MBAs to learn how to do the admin

*EDIT* - It is not for actual doctors. Thank goodness.

 

[NotMattSpraker]

WTAF

Is this for like doctors? Or for like MBAs to learn how to do the admin

*EDIT* - It is not for actual doctors. Thank goodness.

Right, but why limit cheap labor to physicians? Managers cost money too, why pay full price? I mean look at how happy they are, I bet they just rained their first Press Gainey reports down on some unfortunate doctors. Dude in the bottom right liked it a little too much.

Jokes aside, I have actually heard great things about MDACC leadership programs/support/mentorship that are available to physicians and physicists in the rad onc department. More centers should have those resources available, we'd probably have better leadership of our field.

 

[medgator]

Well, the problem is when the rug gets pulled out on protons by CMS (and it will) the bankruptcy attorneys will make a fortune. Just think to when CMS did the same for electronic brachytherapy a few years ago. Personally, I would rather have a Xoft unit gathering cobwebs than a multi-vault cyclotron . . .