What is the problem...can one define it? Let your voice be heard...

[kimplera]

Dan - Here are a few other thoughts about things that may be contributing as well. Highly biased by my personal experiences.

For nearly a decade radonc recruited one of the highest percentages of MD/PhD students of any field but unlike other fields, we pushed them to do descriptive reporting, retrospective reviews, or to compete for R01 level awards while having 20 patients under treatment with little startup funds to support research staff. Upcoming students learned that the field didn't value them and their experience and took their expertise elsewhere. This has left us with two problems - a decline in the number of applicants from top medical schools and a lack of scientific investment in how to improve the use of radiation.

We allowed ourselves to become enamored with shiny toys and more precise beams but no longer know where to point those beams - medonc doesn't have to aim at anything.

We let others take ownership of radiopharmaceuticals (both the development and use of) which could be a significant source of growth in the next decade. We didn't think this was interesting enough so just said - we'll let nucmed do that. This lack of innovation will be a major drag on the field for decades if we don't reverse course. I think we should push at every level (department, hospital, company, FDA, congress) for the use of dosimetry for these drugs. Dosimetry is our thing. No-one else does that in the 3D manner that we do.

(I say this at risk of potential blowback) Leadership of the field has also had multiple missteps which have been magnified by social media - at the ABR, ASTRO, SCAROP. These organizations run with a significant lack of transparency; an approach which, like the paternalistic approach to medicine, has run out of time. ASTRO selects the people they want to "run" for the board, the elections are for the most part a done deal at the time the candidates are announced (including multiple elections with one candidate). This doesn't engender any trust that our organizations are looking out for the best interests of all the members.

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[TheWallnerus]

We haven’t bought a single new practice since I joined but are building another new center in an underserved area to go live in a few years. Growth has been largely from increasing treatment of M1 disease, use of both intact and post op salvage RT for PCa (only 35% of patients nationally get SRT! Huge missed opportunity), about 700% increase in re-RT cases, more pancreas RT and liver RT, more spine RT. I have written before on this but MSKCC treats about 1000 spine sbrt cases I was told per year with ~3+ cFTEs supporting the program. At Michigan we treated about 250+ and used to be 5 per year when I joined. That is the volume of a busy radonc purely organically. Point is there are lots of indications for RT people don’t use it for. Many places now with PET imaging for prostate cancer has doubled their prostate cases as they have a whole new field of oligomets and oligoprogression.

So while I get your point, a lot of patients in northeast Ohio were simply not getting care. Our growth has not come at the expense of the other major player in town, CCF, to my knowledge.

We should be expanding courses of treatment, albeit shorter courses, given many patients can safely get numerous rounds of palliative or MDT. As patients with M1 live longer we now have more and more. Add on the expanded indications for treatment of the primary in nasopharyngx, prostate, soon to open RCC trial, etc. plus radio pharm is critical for radonc to be at the table.

And I sure hope I won’t hire 8 people per year…but if every program drastically increased prostate RT, spine and bone Mets SBRT, pancreas and liver RT, oligoprogression RT, treatment of the primary, and monitored these patients where almost 50% have new lesions in 1 year, I think many programs would need more radoncs. I see tons of places that do very little of the above mentioned treatments, a greater number appear in the community even at academic centers and these treatments need to be offered more broadly.

These are intriguing points which broadly I would summarize as: RT is being underutilized in oncology.

1) "35% of [CaP] patients get SRT." Can you give me some back-of-envelope estimates how many pts, in 2022 terms, that 35% would be, and how high you wish the % would actually be. I can give you my estimates. You found ~1000 pts potentially needing SRT over a 5y span in 33 practices.* That's ~200/yr/33 practices. If we assume there are 2000 RT practices in the US, this would scale out to roughly 12100 SRTable patients per year in the US. If we assume the utilization rate is 35%, that's about 4200 SRTs/yr right now, nationally. If it went to 100% utilization, you'd add maybe 8000 patients a year. And if you distribute that amongst 6000 ROs, you're adding a grand total of 1.3 extra new patients a year per RO if we had 100% SRT utilization! If I'm off by 500% (*narrator voice*... I'm never that off) in my estimates, you're adding 6.5 extra new patients per RO per year. Cutting the number of ROs is *the clearest* method to add more pts per RO.

2) MSKCC treats *1000* spine SBRT cases a year you say. That's a wild stat. This would necessitate 1000 SBRT consults per year. (At 5 fractions/1 week of RT duration, this works out to 20 spine SBRT patients "under beam" per day at MSKCC.) Now, we can assume on average, 4500 *new RT consults total* per year in Manhattan, and the national fraction average is about 17 fractions/pt right now. At 4500 consults total (spine SBRT included) and 17 fractions/pt average, you get ~300 pts under beam per day at MSKCC. So you're saying 20-25% of all RT consults at MSKCC are for spine SBRT, and ~7% of all daily patient fractions are spine SBRT? That sounds like some kind of OVER-utilization of RT. SBRT is all well and good, and according to price transparency MSKCC can get $60K for that spine SBRT, but do we want as a society to palliate bone pain for $60K/pt instead of using standard RT which is about as good, or pain meds? (*narrator voice*... $60K times 1000/yr is $60 million/yr; the APM wanted to save America $43 million/yr). Evidently we can't even agree as a society to give breast patients less RT side effects at an extra ~$5K/pt (assuming hypofractionation). This is the bubble I was alluding to in a previous post. MSKCC spine SBRT sounds like a gravy train; sorry.

This is the MSKCC annual report below. Note the Manhattan vs "Regional Network" growth over time for "Radiation Oncology" patients. It is >99% likely that the "Regional Network" has seen growth due to some sort of facility expansion, not patient growth inherent to MSKCC per se. Patient growth in Manhattan shows a downward, but statistically insignificant, trend over time. I'm sure revenues are up though and they have hired more staff in that time period!

(BTW, we may have taken another RT utilization hit for spinal RT/SBRT recently...)

3) In general I think oligomets and oligoprogression use in RT will diminish over time. Like in LungART, when we study something rigorously, and as the systemics improve, we will be fighting losing battles here. IMHO.

TL;DR
Math gives me comfort; rad onc math does not
*There were ~180K CaP cases in 2016, and will be ~270K in 2022. (There were ~220K in 2007.) That math is somewhat comforting But I think we both have some guesses why the incredible surge in CaP incidence is happening. I would recommend not overly hitching our wagon to prostate cancer's rising star, but what do I know.

ALSO: Only ~1-2% of the US population is more than 50 miles from a linac. Or 6 million people. At one RO per 100K (typical ratio), we need 60 more ROs plopped into these "RT deserts" in the US to "bridge the gap." Fortunately, we will graduate ~200 new ones this year. And 200 next year. And 200+ more the next. And on. And on.

 

[Palex80]

These are intriguing points which broadly I would summarize as: RT is being underutilized in oncology.

1) "35% of [CaP] patients get SRT." Can you give me some back-of-envelope estimates how many pts, in 2022 terms, that 35% would be, and how high you wish the % would actually be. I can give you my estimates. You found ~1000 pts potentially needing SRT over a 5y span in 33 practices. That's ~200/yr/33 practices. If we assume there are 2000 RT practices in the US, this would scale out to roughly 12100 SRTable patients per year in the US. If we assume the utilization rate is 35%, that's about 4200 SRTs/yr right now, nationally. If it went to 100% utilization, you'd add maybe 8000 patients a year. And if you distribute that amongst 6000 ROs, you're adding a grand total of 1.3 extra new patients a year per RO if we had 100% SRT utilization! If I'm off by 500% (*narrator voice*... I'm never that off) in my estimates, you're adding 6.5 extra new patients per RO per year. Cutting the number of ROs is *the clearest* method to add more pts per RO.

You forgot the M1 nasopharynx cases who need RT of the primary. There must be millions of those out there…

We should be expanding courses of treatment, albeit shorter courses, given many patients can safely get numerous rounds of palliative or MDT. As patients with M1 liAdd on the expanded indications for treatment of the primary in nasopharyngx, prostate, soon to open RCC trial, etc. plus radio pharm is critical for radonc to be at the table.

I did not want to get into the discussion of this issue, since I am not from the US, but scientifically speaking:

Basing your justification that „all is fine and indications are rising“ on single trials is dangerous. Sure, STAMPEDE Arm H showed that treating the primary provided an OS benefit in low-volume-M1 prostate patients, but 80% of those patients on the trial got ADT alone in the comparator. Nowadays, those mHSPC patients get Abi/Enza/Apa/Dara (choose what you wish) +/- Doxetacel. I am already hearing voices that we can not really suggest that RT to the primary will offer the same benefit in patients treated with this combo. And you know what? They are right.
Also seeing more indications due to a „soon to open RCC trial“ is … adventurous. It's merely a year since another negative trial came back negative in breast cancer, showing no benefit with local treatment for M1 disease.

 

[RickyScott]

Medstudents often rotate/are exposed to other specialties like urology, ent, gynonc, medonc and it is readily obvious that senior residents receive tens of offers, many unsolicited. (10+ yrs ago as a chief at my hellpit, I received around 5 unsolicited offers). There is a shortage of physicians.

Perhaps, chairs and PDs could meet with seniors from other specialties to verify that the world is not flat, so to speak.

 

[RadOncDoc21]

Haha. The problem is that people in charge are using a lot of words to discuss an exceedingly simple scenario in a free society.

Right… feels like my monthly discussions with admin.

 

[Pointless]

Sentence 1: A dramatic increase in the resident complement over the last decade has significantly eroded the bargaining power of individual radiation oncologists in the marketplace, leading to a drop in quality of life and professional happiness.

Sentence 2: Academic radiation oncologists have abrogated their duty to advance the field, instead focusing on social science research and non-inferiority studies which have done nothing to either improve patient survival or side effect profiles.

This is it 100%.

 

[deleted1111261]

This is it 100%.

This is actually all that needs to be said

 

[Neuronix]

Again, the causes and effects will be complex, but how would you state what the problem is in 1 short sentence.

You wrote 1455 words about many possible problems facing the field, then you asked us to reply back in a short sentence.

I refuse to be distilled down to a tweet.

This is one of many problems with leadership in this field. You are talking at us and not taking our replies seriously. Listen to what people have to say and make your own summary, if that's what you want.

Props to Simul for making a whole podcast about the issues with our field and speaking in a transparent way. You want one good summary of what the problem is with this field? I put it at the top of this forum: Transcription of Dr. Parikh's speech

Enjoy the SCAROP meeting behind closed doors.

 

[ROforbetterorworse]

We haven’t bought a single new practice since I joined but are building another new center in an underserved area to go live in a few years. Growth has been largely from increasing treatment of M1 disease, use of both intact and post op salvage RT for PCa (only 35% of patients nationally get SRT! Huge missed opportunity), about 700% increase in re-RT cases, more pancreas RT and liver RT, more spine RT. I have written before on this but MSKCC treats about 1000 spine sbrt cases I was told per year with ~3+ cFTEs supporting the program. At Michigan we treated about 250+ and used to be 5 per year when I joined. That is the volume of a busy radonc purely organically. Point is there are lots of indications for RT people don’t use it for. Many places now with PET imaging for prostate cancer has doubled their prostate cases as they have a whole new field of oligomets and oligoprogression.

So while I get your point, a lot of patients in northeast Ohio were simply not getting care. Our growth has not come at the expense of the other major player in town, CCF, to my knowledge.

We should be expanding courses of treatment, albeit shorter courses, given many patients can safely get numerous rounds of palliative or MDT. As patients with M1 live longer we now have more and more. Add on the expanded indications for treatment of the primary in nasopharyngx, prostate, soon to open RCC trial, etc. plus radio pharm is critical for radonc to be at the table.

And I sure hope I won’t hire 8 people per year…but if every program drastically increased prostate RT, spine and bone Mets SBRT, pancreas and liver RT, oligoprogression RT, treatment of the primary, and monitored these patients where almost 50% have new lesions in 1 year, I think many programs would need more radoncs. I see tons of places that do very little of the above mentioned treatments, a greater number appear in the community even at academic centers and these treatments need to be offered more broadly.

I think it’s great that you are expanding indications within Case

If I had to guess, and this is no knock on you, but you have been very successful in a very short time and bc of it you view things very optimistically. Many of us have tried similar expansions but are not feasible outside of academic medical center conglomerates

Regarding prostate cancer, you have been at 3 large academic centers for the past 10 years now. Community urologists whole different ball game. You must know the data as well as anyone that overall RT use is declining in prostate cancer independent of stages where AS has increased

Community urologists aren’t in the let’s make a great prostate cancer MDC and give patient option. It’s more like cut cut cut

 

[Mandelin Rain]

There are bubbles all around.

Proton bubble.
MRgRT bubble.
Academic expansion/consolidation bubble.
PPS exempt bubble.
Breast bubble.
Rectal bubble.
Oligomet bubble.
Baby boomer bubble.
HPV vaccine bubble.
Tobacco bubble.


If you're basing the hope for the future on expanding pancreatic, liver, and oligomet programs, I think you've miscalculated. And... if you're being honest, you're overutilizing to put meat on the new shiny machines that bring bigly reimbursement so you can pay for new staff to support the shiny new machines bubble.

 

[RickyScott]

There are bubbles all around.

Proton bubble.
MRgRT bubble.
Academic expansion/consolidation bubble.
PPS exempt bubble.
Breast bubble.
Rectal bubble.
Oligomet bubble.
Baby boomer bubble.
HPV vaccine bubble.
Tobacco bubble.


If you're basing the hope for the future on expanding pancreatic, liver, and oligomet programs, I think you've miscalculated. And... if you're being honest, you're overutilizing to put meat on the new shiny machines that bring bigly reimbursement so you can pay for new staff to support the shiny new machines bubble.

Flash is going to save us, going to be our personal Jesus.

 

[BobbyHeenan]

I was a med student/resident during the rapid expansion over the last 10-15 year. Almost every department it seemed was expanding residency slots (or opening up new programs) because they were growing (growth often by opening or buying satellite facilities).

Almost across the board every chairman viewed residency expansion as something their department needed or deserved or "had the numbers for." Not ONE SINGLE CHAIRPERSON sounded the alarm that just because your department is expanding it does not mean the society needs more rad oncs - your department might, but patients or the field did not.

No one stood up to this and everyone had an excuse as to whose role it was to look out for the interest of the field - there was buck passing (it's ASTRO, not it's SCAROP, no it's ACGME), editorials (Canary in Coal Mine), and weak kneed claims of legal action with ZERO settled case law or merit all cited as excuses as to why no one wanted to do anything about what was happening.

 

[seper]

Dan, we are not going to fill residency spots because RadOnc is not a good path for gainful employment.
325K starting jobs in Ann Arbor? Locum replacement in rural Ohio? Not good enough, my friend

 

[jondunn]

There are bubbles all around.

Proton bubble.
MRgRT bubble.
Academic expansion/consolidation bubble.
PPS exempt bubble.
Breast bubble.
Rectal bubble.
Oligomet bubble.
Baby boomer bubble.
HPV vaccine bubble.
Tobacco bubble.


If you're basing the hope for the future on expanding pancreatic, liver, and oligomet programs, I think you've miscalculated. And... if you're being honest, you're overutilizing to put meat on the new shiny machines that bring bigly reimbursement so you can pay for new staff to support the shiny new machines bubble.

Ding ding ding. This much spine SBRT is straight over-utilization, though I’m sure @Dan Spratt won’t engage on this

He has a budget to fill and spine SBRT helps that. The data for spine SBRT is really weak

 

[ROforbetterorworse]

I was a med student/resident during the rapid expansion over the last 10-15 year. Almost every department it seemed was expanding residency slots (or opening up new programs) because they were growing (growth often by opening or buying satellite facilities).

Almost across the board every chairman viewed residency expansion as something their department needed or deserved or "had the numbers for." Not ONE SINGLE CHAIRPERSON sounded the alarm that just because your department is expanding it does not mean the society needs more rad oncs - your department might, but patients or the field did not.

No one stood up to this and everyone had an excuse as to whose role it was to look out for the interest of the field - there was buck passing (it's ASTRO, not it's SCAROP, no it's ACGME), editorials (Canary in Coal Mine), and weak kneed claims of legal action with ZERO settled case law or merit all cited as excuses as to why no one wanted to do anything about what was happening.

This is well said @BobbyHeenan

The "good guys" often state we aren't expanding even though we have the numbers. So what if you have the numbers? It is the entitled viewpoint masquerade

 

[RickyScott]

I was a med student/resident during the rapid expansion over the last 10-15 year. Almost every department it seemed was expanding residency slots (or opening up new programs) because they were growing (growth often by opening or buying satellite facilities).

Almost across the board every chairman viewed residency expansion as something their department needed or deserved or "had the numbers for." Not ONE SINGLE CHAIRPERSON sounded the alarm that just because your department is expanding it does not mean the society needs more rad oncs - your department might, but patients or the field did not.

No one stood up to this and everyone had an excuse as to whose role it was to look out for the interest of the field - there was buck passing (it's ASTRO, not it's SCAROP, no it's ACGME), editorials (Canary in Coal Mine), and weak kneed claims of legal action with ZERO settled case law or merit all cited as excuses as to why no one wanted to do anything about what was happening.

But astro was holding “masterclasses” in “leadership” ?

 

[BobbyHeenan]

But astro was holding “masterclasses” in “leadership” ?

Exactly.

No one stood up as a leader for the field as a whole because incentives were mis aligned - what was good for your department (expansion) was not good for the field. It would have taken a strong, brave leader to speak up. Outside of Chirag Shah there were few (?any).

 

[TheWallnerus]

Ding ding ding. This much spine SBRT is straight over-utilization, though I’m sure @Dan Spratt won’t engage on this

He has a budget to fill and spine SBRT helps that. The data for spine SBRT is really weak

1) tripling to 100% RT utilization in SRT CaP would add 1-2 extra patients per RO per year nationally
2) If 1000 SBRT pts per year at Manhattan MSKCC, that’s ~20% of their patient load or more and grosses them maybe $60m a year
3) America only needs 60 more rad oncs in rural locales to create near perfect RT distribution access; 98% of US population has good access as is

The above based on and/or generated by Dan and/or talking w/ him

Whewie

I know most of what he said was pep talking but on rumination, I am more unpepped

 

[Mandelin Rain]

Title: The SBRT Bubble
Subtitle: When everything is treated in 5 fractions or less, will we still get paid more to treat things in 5 fractions or less?

 

[Mandelin Rain]

Title: The Proton Bubble
Subtitle: Of course there's no data forthcoming.

 

[thesauce]

I did not want to get into the discussion of this issue, since I am not from the US, but scientifically speaking:

Basing your justification that „all is fine and indications are rising“ on single trials is dangerous. Sure, STAMPEDE Arm H showed that treating the primary provided an OS benefit in low-volume-M1 prostate patients, but 80% of those patients on the trial got ADT alone in the comparator. Nowadays, those mHSPC patients get Abi/Enza/Apa/Dara (choose what you wish) +/- Doxetacel. I am already hearing voices that we can not really suggest that RT to the primary will offer the same benefit in patients treated with this combo. And you know what? They are right.

They are not right. As systemic therapy and imaging improves, the need for local therapy increases, not decreases. That is the reason we started treating oligometastatic disease to begin with. What you’re describing is simply an excuse for insurance companies and medoncs to exclude RT, but it doesn’t have sound oncologic rationale.

 

[deleted1116990]

By cutting programs in half you may make the already underserved rural communities have no access to radoncs. This is a bad thing.

This is important.

I have heard this strawman multiple time from academics and it drives me absolutely nuts.

Two things here.

First, as already pointed out, blindly increasing numbers does not funnel more people into rural positions. It would take a nuanced effort to select residents in such a way that they would be more likely to go to rural areas. If anything, over the past 15 years, rad onc has selected for candidates the LEAST likely relocate and happily remain in rural areas. It is theoretically possible, that at some point you saturate the market so heavily that new graduates who want to work in NYC are forced to work in rural Iowa simply to not default on their debt obligations. This would be a lose-lose for everybody: the new grads, the established rad oncs, the training programs, and the patients.

Second, and more importantly, the problem with recruiting rad oncs to "underserved" rural communities is that the ability to practice independently has been destroyed. Doubling the number of graduating residents has allowed rural hospital systems to convert retiring independent rad onc's contracts into employed positions and staff them with locums until a new grad accepts an employed position. This can take many years. These communities are only "underserved" in the sense that they are staffed by locums. Somebody is providing care. I am aware of zero Linacs out there that have to be turned off because the owner can't find a rad onc to manage it. There used to be an attractive draw for rad oncs to relocate to places like this because they could practice independently and have autonomy over their practice and billing. However, because of what the academic programs have done with resident training, hospitals have a much easier time refusing to work with independent rad oncs in order to capture a percentage of the rad onc's professional collections, which can be significant.

Worse still, in many states the academic center has actually bought up the rural hospitals and expects to staff them with rad oncs with identical contracts as those at satellites in the metro area, which is patently ridiculous. This is obviously a conflict of interest in that the academic center is motivated to overtrain, especially in an environment where their residents have poor job prospects and they have a number of unattractive rural staffing obligations to fill with fat margins for the health system if they are able to do so.

Bottom line, if the supply and demand balance is brought back to something more in our favor, rad oncs will have more negotiating power with rural hospitals and these positions will become more attractive. This is how you get more rad onc talent to rural areas. Not just brute force increasing resident numbers.

 

[RickyScott]

Rural communities are in fact rural, which means sparsely populated. I know this may sound like a tautology, but I guess it is not for some. Not a lot of patients on treatment etc to justify physicists/staff and machine expenses. Luckily, by relieving us of direct supervision, cms enabled one day a week coverage of centers with very few pts on beam, provided someone puts up the capital for equipment and staff.

I think the “rural” staffing argument is a ploy to increase the appeal of the field to women and minorities.

 

[Ray D. Ayshun]

Does a rural place really need someone well-trained to treat bone mets while the academic center within 4-5 hrs tells the definitive patients what a garbage job the rural place will do, and that they might as well stay at a hotel for the 5 days of treatment?

 

[deleted1116990]

Rural communities are in fact rural, which means sparsely populated. I know this may sound like a tautology, but I guess it is not for some. Not a lot of patients on treatment etc to justify physicists/staff and machine expenses. Luckily, by relieving us of direct supervision, cms enabled one day a week coverage of centers with very few pts on beam, provided someone puts up the capital for equipment and staff.

America is an interesting country. The word "rural" is thrown around a lot but in reality means very different things. Rural Tennessee can mean a small town with a hospital where people are driving an hour from nearby communities and has 35 on treatment.

Rural Wyoming can mean the only town within a 4 hour driving distance that has 8 on treatment and can barely keep the lights on.

Does a rural place really need someone well-trained to treat bone mets while the academic center within 4-5 hrs tells the definitive patients what a garbage job the rural place will do, and that they might as well stay at a hotel for the 5 days of treatment?

I know you're joking, but I think most people underestimate the amount of patients who refuse to leave their town for treatment. I have treated stupidly complicated NPX cases in the middle of nowhere. I can't imagine what octolocums would have come up for that. But that's the system the current overtraining environment is engendering: permanent octolocums for rural patients.

 

[Mandelin Rain]

The only way to push people toward rural sites with supply-side dynamics is to supersaturate the more desirable areas with rad oncs to the point that a few unlucky souls crystallize out of solution and drop to the bottom of the beaker. Or, I guess, to take insoluble people to begin with (cough: FMGs with visa issues).

Both are obviously poor ideas.

 

[Palex80]

They are not right. As systemic therapy and imaging improves, the need for local therapy increases, not decreases. That is the reason we started treating oligometastatic disease to begin with. What you’re describing is simply an excuse for insurance companies and medoncs to exclude RT, but it doesn’t have sound oncologic rationale.

I do not agree with your assessment.

Stampede Arm H showed an 8% survival benefit in low-volume M1 HSPC with RT to the primary added to ADT at 4 years. Noone knows what that figure is nowadays, when these patients get a systemic combination treatment.

The narrative that „local control becomes more important if systemic control becomes better“ works both ways. Sometimes systemic control becomes so good, that an effect of RT on local control diminishes. It is the resson why RT is being challenged by antihormonal treatment only in favorable breast cancer of the elderly or trials are looking to abolish RT in patients responding excellent to neoadjuvant chemo/Her2/IO combos in aggressive localized breast cancer.

And there’s even evidence to prove that.

Fifteen years ago nephrectomy was s.o.c. in metastatic kidney cancer. A disease where very little was available in terms of systemic treatment. Nowadays, this has been abandoned and proven not beneficial for the patients in a randomized trial (CARMENA), because systemic treatment simply got better, eliminating the role of nephrectomy for most patients with metastatic disease.

Last but not least:
1. We are not sure if „local control“ was what led to the OS benefit in Stampede Arm H. Palliative interventions for local progression were as likely in both groups (with/without RT).
2. Stampede did not evaluate oligometastatic patients. A patient can have 20 lymph node metastases and still be low-volume metastatic.

 

[RickyScott]

America is an interesting country. The word "rural" is thrown around a lot but in reality means very different things. Rural Tennessee can mean a small town with a hospital where people are driving an hour from nearby communities and has 35 on treatment.

Rural Wyoming can mean the only town within a 4 hour driving distance that has 8 on treatment and can barely keep the lights on.


I know you're joking, but I think most people underestimate the amount of patients who refuse to leave their town for treatment. I have treated stupidly complicated NPX cases in the middle of nowhere. I can't imagine what octolocums would have come up for that. But that's the system the current overtraining environment is engendering: permanent octolocums for rural patients.

My understanding is that there aren’t really any catchment areas with 100k that aren’t served by a linac. If you get much less than that, the construction staffing and expense will be at a loss. Physician can come out half a day a week if someone funds the center.

 

[deleted1116990]

The only way to push people toward rural sites with supply-side dynamics is to supersaturate the more desirable areas with rad oncs to the point that a few unlucky souls crystallize out of solution and drop to the bottom of the beaker. Or, I guess, to take insoluble people to begin with (cough: FMGs with visa issues).

Both are obviously poor ideas.

This was my first point. We have doubled resident numbers and it hasn't touched that problem. Avera is advertising a steaming pile of employed dogs--- jobs in SD/IA/MN for the past 6 months now. They just got reposted to ASTRO job board again. All of them. Not one filled. You would probably have to quadruple or more residency spots from their current position to the point people would actually saturate out/capitulate and take these exploitative rural contracts. Many would just abandon rad onc altogether before moving to a place like that or taking a job like that. It's theoretically do-able, but chairs would have to pump those numbers up to something unthinkable. If they advertised independent practice option at those hospitals, they would be filled quickly.

 

[RickyScott]

This was my first point. We have doubled resident numbers and it hasn't touched that problem. Avera is advertising a steaming pile of employed dogs--- jobs in SD/IA/MN for the past 6 months now. They just got reposted to ASTRO job board again. All of them. Not one filled. You would probably have to quadruple or more residency spots from their current position to the point people would actually saturate out/capitulate and take these exploitative rural contracts. Many would just abandon rad onc altogether before moving to a place like that or taking a job like that. It's theoretically do-able, but chairs would have to pump those numbers up to something unthinkable. If they advertised independent practice option at those hospitals, they would be filled quickly.

Rural also implies a small component of the job market

 

[TheWallnerus]

They are not right. As systemic therapy and imaging improves, the need for local therapy increases, not decreases. That is the reason we started treating oligometastatic disease to begin with.

I do not agree with your assessment... [it] works both ways

Eli Glatstein had a saying: "We are one drug away from being out of the radiation game in 'X cancer'" (he never said 'X cancer,' but you get the drift).

Has the need for local therapy increased in lymphoma, Stage III N2+ lung postop... We are dialing down the local therapy in HPV HNSCC, in NPC. There is a trend for no RT in N+ rectal. You can have a favorable breast cancer patient that's SLN+ and provide zero local therapy to the axilla or RNI and have <1% ax recurrence rate. Melanoma is poised to be the number one malignancy in 20y... how much local RT will we be doing in that disease where systemic therapies seem to be following a Moore's Law.

The rad oncs of now look/will look back at the rad oncs of the 20th century and say/will say "You guys kind of overdid it with the reliance on local therapy changing natural histories of disease."

Rural also implies a small component of the job market

On this, IDK. We need to keep in mind that 58% of centers nationwide treat just 25% of its RT patients (these have the lowest quartile of pt volume), while the top 7% treat 25% of its RT patients too (these are the high volume centers). Unknown is how much low volume correlates to "rural," but at the very least, most (or at least a lot of) rad oncs work in low volume centers.

OTOH, 1/3 of all rad oncs work for just ~90 systems/centers nationwide; I presume these are high volume (but actually comprise <5% of all systems/centers... they are prob not "rural" obv).

 

[Ray D. Ayshun]

America is an interesting country. The word "rural" is thrown around a lot but in reality means very different things. Rural Tennessee can mean a small town with a hospital where people are driving an hour from nearby communities and has 35 on treatment.

Rural Wyoming can mean the only town within a 4 hour driving distance that has 8 on treatment and can barely keep the lights on.


I know you're joking, but I think most people underestimate the amount of patients who refuse to leave their town for treatment. I have treated stupidly complicated NPX cases in the middle of nowhere. I can't imagine what octolocums would have come up for that. But that's the system the current overtraining environment is engendering: permanent octolocums for rural patients.

Kinda joking. Partly making a comment about the messaging from academics, which is 1 we need more rural radoncs and 2 they get substantially better care at nonrural centers.

 

[TheWallnerus]

Kinda joking. Partly making a comment about the messaging from academics, which is 1 we need more rural radoncs and 2 they get substantially better care at nonrural centers.

Rad onc is kind of neurotic

They want students to go train at the best places but then go practice in the sticks

Once you go practice in the sticks, your accumen gets worse however so rad onc doesn't want people getting treated in the sticks

Once people go to the academic places to get treated, they seem to get exposed to maximize-the-$$$/minimize-the-tech-EBM tx's with MRgRT, protons, SBRT for everything approaches and at the same time the academic places rail on the people in the sticks for doing breast IMRT or >10fxs for a bone met

 

[RO28]

These organizations run with a significant lack of transparency; an approach which, like the paternalistic approach to medicine, has run out of time. ASTRO selects the people they want to "run" for the board, the elections are for the most part a done deal at the time the candidates are announced (including multiple elections with one candidate). This doesn't engender any trust that our organizations are looking out for the best interests of all the members.

To this point with ASTRO, as young attendings we are frequently told to "get involved!!!!" to advance the field, etc, blah, blah, blah. However, I continue to apply to work (for free) on an ASTRO sub-committee and I am consistently turned down. Is it because I am in community practice? Is it because I am too junior? Is it because I'm a rad onc no name and these committees are already pre-selected to advance a certain agenda? Who knows, it doesn't matter. It is SO HARD to get involved via "acceptable" pathways for those of us who want to, who have ideas and want to make meaningful change.

 

[deleted1111261]

I went through each and every post and did not see one comment that has not been discussed many, many, many times.

Summary for the Chairman

+ = Limited to RO
- = all specialties

- Perception or reality that there are too many trainees +
- Head in sand behavior about supply concerns and overall dismissal of the issue +
- Limited opportunities for true scientists +
- High profile research that reduces our own footprint +
- Decreased opportunity for ownership/private practice -
- Arduous licensure/certification process +
- Consolidation leading to poor quality jobs -
- "One Trick Pony" / reliance on linac +
- Geographic limitations + (but also includes other small fields)
- Perception that science of radiation oncology is transitioning to social science -
- Disdain from the tower towards community practice +
- Reimbursement decline -
- Institutions (ASTRO, Red Journal, Academics on Twitter) do not like to be questioned or debated with and take it personally instead of a chance to improve. +

This is not to pick another fight. I said above - we have spoken about all this before. You said, be quiet, let other's talk. They have spoken - not one issue that was brought up has not been brought up before. You claim you have read the forums and have done your own research. Have you truly? I would love to hear what you learned from this post that was not discussed in the past. I would also like to believe this is something more than The Dan Show of talking about how great of a chair you are and how great Case is doing (both of which, believe it or not, I think are true statements). I just sincerely believe this is laziness on your part. We have done our part. What more do you want from us?

Finally, I grew up in metro Detroit and I have moved back. Ann Arbor is not "small town" America. There are >100,000 people in the city itself, a major university, multiple ethnic restaurants (more than 1 biryani option!), 30 minutes from an international airport that goes to Europe and Asia direct/nonstop. It is also 40 minutes from Detroit and less to some of the suburbs. Nick going from Penn State to Cleveland is a huge upgrade in terms of where he is living in terms of city amenities. I think the rust belt cities are amazing places to live and raise families in - Detroit, Cleveland, Columbus, Grand Rapids, Cincinnati, Indianapolis, Kansas City, Minneapolis amongst others. Yes, the weather sucks, but we are nice, welcoming, kind, have low cost of living, affordable housing. Let's not be all Sloan-y about it and think the rest of the country is a cultural hellpit wasteland.

This tangentially reminds me of the chairman at LIJ-Northwell who told me that he had so much trouble finding a job after graduating residency. He could not find a job in Manhattan so he had to go all the way to ... Long Island.

 

[TheWallnerus]

In 2020, MSKCC Manhattan started 4173 patients spread among 34 attendings by my count.

In 2020, American rad oncs started 1.06m patients spread among ~5500 rad oncs.

MSKCC sees significantly less patients per rad onc than the national average.

The avg MSKCC rad onc is seeing 2.5 new patients a week, yet they (MSKCC rad onc itself, not the attendings per se) seem to be doing VERY well. I wonder why that is... maybe their reimbursement is different than what I see. Or maybe they use procedures that reimburse very well a lot more than I do. IDK. I am not an economist.

 

[TheWallnerus]

However, I continue to apply to work (for free) on an ASTRO sub-committee and I am consistently turned down.

I applied every year each for 12 years to get on an ASTRO sub-committee. After the 12th consecutive year of rejection, I rejected ASTRO

 

[Mandelin Rain]

The avg MSKCC rad onc is seeing 2.5 new patients a week, yet they (MSKCC rad onc itself, not the attendings per se) seem to be doing VERY well. I wonder why that is... maybe their reimbursement is different than what I see. Or maybe they use procedures that reimburse very well a lot more than I do. IDK. I am not an economist.

PPS-Exempt Cancer Hospitals (PCHs) | CMS

Medicare PPS Excluded Cancer Hospitals.

www.cms.gov

 

[RO28]

I applied every year each for 12 years to get on an ASTRO sub-committee. After the 12th consecutive year of rejection, I rejected ASTRO

Yes, I have also been informed some pineapples are on their way to my home!

 

[Mandelin Rain]

Yes, I have also been informed some pineapples are on their way to my home!

Is this like a swinger thing or something?

 

[TheWallnerus]

Yes, I have also been informed some pineapples are on their way to my home!

Right after the pineapples you get invited to pitch in in some shape, form, or fashion, it's very nice

 

[RadOncDoc21]

I applied every year each for 12 years to get on an ASTRO sub-committee. After the 12th consecutive year of rejection, I rejected ASTRO

This is the way…

 

[deleted1111261]

ACRO Pineapples were actually super high quality. Very tasty!

 

[TheWallnerus]

ACRO Pineapples were actually super high quality. Very tasty!

I made a house out of one of mine

 

[deleted1111261]

I applied every year each for 12 years to get on an ASTRO sub-committee. After the 12th consecutive year of rejection, I rejected ASTRO

This, too. ASTRO keeps asking for people to apply and rejects us all the time. They want diverse voices, but all need to sing same song. If you dissent/criticize, you are of zero value to the organization.

 

[thecarbonionangle]

Is this like a swinger thing or something?

It could be. Show up to the party. You might see Lally in a speedo. Maybe not. But yes pinapples are a known swinger angle.

 

[thecarbonionangle]

This, too. ASTRO keeps asking for people to apply and rejects us all the time. They want diverse voices, but all need to sing same song. If you dissent/criticize, you are of zero value to the organization.

Problem with the calls for “diversity” is that they clearly just want URMs to sing their songs, stay in their brown lane. Women are known to get “exhausted” when they are questioned.
no doubt that any URM would be “cancelled” if they disagreed with the group think MO. What they really want is a URM puppet, a useful idiot to shill for them. I don’t see a commitment to diversity of ideas at all.

 

[RickyScott]

Problem with the calls for “diversity” is that they clearly just want URMs to sing their songs, stay in their brown lane. Women are known to get “exhausted” when they are questioned.
no doubt that any URM would be “cancelled” if they disagreed with the group think MO. What they really want is a URM puppet, a useful idiot to shill for them, maybe even get more protons for them! I don’t see a commitment to diversity of ideas at all.

Hmm, guy at Hopkins?

 

[thecarbonionangle]

Proton guy at Hopkins?

Many are saying it!

 

[deleted1116990]

ASTRO paid a toxic race-baiting grifter to give a speech at its annual conference a few years ago. Joke organization focused on being politically correct instead of actually correct for its members.