Rad Onc Twitter

[TheWallnerus]

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It’s basically a negative trial

Any time a trial rejects its null we have to say it’s “positive.” The trial is positive in showing strong evidence that protons don’t give ~50% worse probability of progression/death versus IMRT.

(Here’s the leap: therefore based on this positive result protons become standard.)

 

[CurbYourExpectations]

I love that a similar trial that shows this trial is probably not real was named "TORPeDO". Is the irony lost on anyone?
I don't think the US can perform trials like this well.

 

[Mandelin Rain]

Protons = Fetch

 

[temujim]

Protons show a 10% OS benefit in Opx cancer and radiation oncologists s*it on the trial. Fair enough, lots of problems with it.

Neoadjuvant pembro in "resectable HN" shows a DFS benefit, no OS benefit (maybe a hint in CPS10+) - with 10% withdrawal in the SoC arm --> it's in NCCN and THE new standard of care. Med oncs and ENTs everywhere doing this. Adjuvant cemiplimab in skin shows a DFS benefit and literally overlapping OS curves. In NCCN as THE new standard of care, and med oncs are using cemi neoadjuvantly with no data whether the patient could be cured with surgery or RT.

Congrats all on the moral/scientific superiority. Enjoy the bread lines.

 

[drowsy12]

That’s a terrible post that ignores logic. If protons improved OS for a reason, then you would have a point. It’s quite clear this is a spurious finding and doesn’t pass muster. It’s not for less tox or better efficacy. It’s informative censoring

 

[OTN]

Protons show a 10% OS benefit in Opx cancer and radiation oncologists s*it on the trial. Fair enough, lots of problems with it.

Neoadjuvant pembro in "resectable HN" shows a DFS benefit, no OS benefit (maybe a hint in CPS10+) - with 10% withdrawal in the SoC arm --> it's in NCCN and THE new standard of care. Med oncs and ENTs everywhere doing this. Adjuvant cemiplimab in skin shows a DFS benefit and literally overlapping OS curves. In NCCN as THE new standard of care, and med oncs are using cemi neoadjuvantly with no data whether the patient could be cured with surgery or RT.

Congrats all on the moral/scientific superiority. Enjoy the bread lines.

I am not required to push a technology for which the data does not support its use just because medonc wants to put immunotherapy in the water. Radiation oncologists are known for a good grasp of the data for solid tumors. If we move away from that I'm not sure what we'll have left.

 

[temujim]

I am not required to push a technology for which the data does not support its use just because medonc wants to put immunotherapy in the water. Radiation oncologists are known for a good grasp of the data for solid tumors. If we move away from that I'm not sure what we'll have left.

Don't tell me. Tell the ENTs doing TORS despite 2 negative phase II trials, and then that ENT tells the patient they're going to get 50 gy based on a feasibility trial.

 

[CaesarRO]

Protons show a 10% OS benefit in Opx cancer and radiation oncologists s*it on the trial. Fair enough, lots of problems with it.

Neoadjuvant pembro in "resectable HN" shows a DFS benefit, no OS benefit (maybe a hint in CPS10+) - with 10% withdrawal in the SoC arm --> it's in NCCN and THE new standard of care. Med oncs and ENTs everywhere doing this. Adjuvant cemiplimab in skin shows a DFS benefit and literally overlapping OS curves. In NCCN as THE new standard of care, and med oncs are using cemi neoadjuvantly with no data whether the patient could be cured with surgery or RT.

Congrats all on the moral/scientific superiority. Enjoy the bread lines.

Don't tell me. Tell the ENTs doing TORS despite 2 negative phase II trials, and then that ENT tells the patient they're going to get 50 gy based on a feasibility trial.

Not sure what you're arguing here.

Brainlessly touting suspicious data in this case does nothing to move the needle on RT utilization.

If anything it shifts utilization to a select few institutions and causes a massive backlog of patients needing treatment with protons instead of photons.

So what exactly is your argument here?

 

[OTN]

Don't tell me. Tell the ENTs doing TORS despite 2 negative phase II trials, and then that ENT tells the patient they're going to get 50 gy based on a feasibility trial.

I have referring MDs tell patients wrong dosing schedules all the time. I’ve never had a problem explaining why we’re going to do what I want to do.

I feel very fortunate to work with excellent ENTs who know how to interpret data.

 

[udrag14]

That’s a terrible post that ignores logic. If protons improved OS for a reason, then you would have a point. It’s quite clear this is a spurious finding and doesn’t pass muster. It’s not for less tox or better efficacy. It’s informative censoring

You are selecting for better socioeconomic status. What type of insurance pays for protons? Someone with private insurance or medicaid product.

My conclusion of this paper.... Protons are the standard of care if your insurance will pay for it.

 

[TheWallnerus]

Protons show a 10% OS benefit in Opx cancer and radiation oncologists s*it on the trial

When protons “show” a 10% OS benefit in opx cancer I’ll be the first to leave the coprophilia behind (pardon the pun). Ever heard of the Cleveland Steamer. Maybe in rad onc we need the phrase Houston Steamer.

 

[thesauce]

When protons “show” a 10% OS benefit in opx cancer I’ll be the first to leave the coprophilia behind (pardon the pun). Ever heard of the Cleveland Steamer. Maybe in rad onc we need the phrase Houston Steamer.

It’s 90% with IMRT so that means it’s 100% with protons right?

 

[TheWallnerus]

It’s 90% with IMRT so that means it’s 100% with protons right?

Ha sure.

That last ten percent may not sound like a lot… but it’s tremendous, a tremendous gulf

 

[Palex80]

My conclusion of this paper.... Protons are the standard of care if your insurance will pay for it.

It depends... Because if you have a good insurance you are likely going to live longer, irrelevant of photons or protons, with or without an oropharyngeal cancer.

 

[RadOncDoc21]

It depends... Because if you have a good insurance you are likely going to live longer, irrelevant of photons or protons, with or without an oropharyngeal cancer.

Not true, according to the patients I see who never see a doctor. They all tell me they they have no significant medical history and have never been sick- despite their blood pressure being 200/111 while coughing up blood.

 

[yesmaster]

Steve Frank is the type to cry bloody murder if a private practice rad onc prescribes conventional prostate RT for $25-30k, but doesn’t bat an eye giving $300k protons for prostate and sticking in an implant then says it’ll save money for the system.

 

[udrag14]

It depends... Because if you have a good insurance you are likely going to live longer, irrelevant of photons or protons, with or without an oropharyngeal cancer.

Literally the second point of my post. Proton is associated with better insurance which is associated with better survival.

If you just look at straight protons versus photon, it is the same outcomes but no discussion on the huge cost of proton therapy.

 

[medgator]

Literally the second point of my post. Proton is associated with better insurance which is associated with better survival.

If you just look at straight protons versus photon, it is the same outcomes but no discussion on the huge cost of proton therapy.

Not sure there is any indication that exists or has been reported so far prospectively to justify the incremental costs of protons of as late 2025.

But because the costs have to be paid for all of these installed cyclotrons, protons will be used, evidence be damned!

 

[TheWallnerus]

Not sure there is any indication that exists or has been reported so far prospectively to justify the incremental costs of protons of as late 2025.

But because the costs have to be paid for all of these installed cyclotrons, protons will be used, evidence be damned!

Really wonder why more than just a small handful of academic proton centers shuttered/insolvent otoh

 

[Doctorer]

Really wonder why more than just a small handful of academic proton centers shuttered/insolvent otoh

It's because the fixed costs are extremely high, especially for the giant centers that were built in the past. Filling 3-4 rooms isn't easy, and requires both a large enough referral network to bring in patients, as well as some amount of incentive (or at least, no disincentive) for physicians to actually treat patients on protons. The proton world is filled with plenty of academic JVs that have had financial difficulties in the past (California, Emory, Maryland, etc).

 

[TheWallnerus]

Are any of the top 100 influential people in oncology radiation oncologists? MERRY CHRISTMAS

The 100 Most Influential People in Oncology in 2025 (Full List) - OncoDaily

The 100 Most Influential People in Oncology in 2025 (Full List) / 100 influential people in oncology, 100 Influential People in Oncology 2025, cancer,

oncodaily.com

 

[radiaterMike]

at least 1 neurosurgeon .... Patrick Dempsey Recognized among The 100 Most Influential People in Oncology in 2025 - OncoDaily

 

[TheWallnerus]

The face of a child can say so much.

Especially the mouth part of the face.

The Maryland Proton Center is letting the children do the talking. (And the advertising.)

 

[TheWallnerus]

The face of a child can say so much.

Especially the mouth part of the face.

The Maryland Proton Center is letting the children do the talking. (And the advertising.)

Proton treatment for prostate has "far fewer side effects."

 

[BobbyHeenan]

Proton treatment for prostate has "far fewer side effects."

Not surprising given they have been the worst on advertising. That one *infamous* graphic they took down talking about major survival bumps for protons was disgusting.

If our leaders had any stones at all they'd publicly name and shame.

 

[radoncftw]

Wow
Curious what Bill Regine thinks about PartiQOL

 

[BobbyHeenan]

Wow
Curious what Bill Regine thinks about PartiQOL

In a public/scientific forum amongst peers: probably the same milquetoast line we saw from the ASTRO President that it is "another standard of care option."

In a room with a patient or to patient facing cameras for an ad? Protons have less side effects.

 

[Palex80]

Both commercials would have likely been banned in Europe.

 

[pikachu]

Both commercials would have likely been banned in Europe.

On what basis? (not asked confrontationally - i genuinely don’t know how the rules on consumer directed ads for medical care differ between USA/EU)

 

[Palex80]

On what basis? (not asked confrontationally - i genuinely don’t know how the rules on consumer directed ads for medical care differ between USA/EU)

1. Putting a child-patient-survivor for an advertisement would draw severe criticism.
If the child was an actor (and not a survivor) it may have been easier.

Here are two EU policies on this matter:

The community code relating to medicinal products for human use

Directive - 2001/83 - EN - EUR-Lex

eur-lex.europa.eu

Testimonials are generally not allowed to promote medicinal products.

and: The audiovisual media services directive

Directive - 2018/1808 - EN - EUR-Lex

eur-lex.europa.eu

The testimonial of the child will fall within the "Credulity Rule". This means that viewers are more likely to believe in the ad because the child-survivor is saying it. It is viewed as emotional manipulation.

2. Saying that proton RT leads to "far fewer side effects" is misleading. There is no reference provided to back up that claim in the ad (and there is literally no data for that). Ads that make such statements need to back them up with data.
Here is the respective EU directive.

Unfair commercial practices directive

EU rules to protect consumers from unfair practices before, during and after a commercial transaction

commission.europa.eu

Your EUniqueness will be added to our own. Resistance is futile.

or...

 

[TheWallnerus]

1. Putting a child-patient-survivor for an advertisement would draw severe criticism.
If the child was an actor (and not a survivor) it may have been easier.

Here are two EU policies on this matter:

The community code relating to medicinal products for human use

Directive - 2001/83 - EN - EUR-Lex

eur-lex.europa.eu

Testimonials are generally not allowed to promote medicinal products.

and: The audiovisual media services directive

Directive - 2018/1808 - EN - EUR-Lex

eur-lex.europa.eu

The testimonial of the child will fall within the "Credulity Rule". This means that viewers are more likely to believe in the ad because the child-survivor is saying it. It is viewed as emotional manipulation.

2. Saying that proton RT leads to "far fewer side effects" is misleading. There is no reference provided to back up that claim in the ad (and there is literally no data for that. Ads that make statements like this need to back this up by data.
Here is the EU directive on that.

Unfair commercial practices directive

EU rules to protect consumers from unfair practices before, during and after a commercial transaction

commission.europa.eu

View attachment 413322

Your EUniqueness will be added to our own. Resistance is futile.

or...

This post taught me a lot

However, re: the ad with the kid, I sort of viewed it as: if I'm eight years old and I have a brain tumor, I am going to drive or fly to the nearest proton center ASAP... I don't care what my doctor, mom, or dad say

next up in the US: commercials featuring kids having positive experiences from gender affirming care

 

[communitydoc13]

I don't care what my doctor, mom, or dad say

next up in the US: commercials featuring kids having positive experiences from gender affirming care

Strange comment in an era where executive mandates, devoid of expert input, leverage institutions to shutter whole departments.

Parents of course want the best for their children. They shouldn't be manipulated.

But...the interventions couldn't be more different. Gender affirming care in young people (and adults) is overwhelmingly counseling with subsequent consideration of very cheap medications (spironolactone, estrogen, progesterone, testosterone). There is no big ticket 180K intervention. Consideration of any intervention is very much contingent on what doctors, mom or dad say. It takes years and years, and typically reluctant parents are ultimately looking for help for their kids. These are parents who believe that expertise in such matters exists in the medical world. Of course, many parents will never even acknowledge that something like gender dysphoria exists.

Outside of surgery, I doubt that gender affirming care was ever a big money maker for any system. Gender affirming surgical care may be quite profitable for sought after practitioners. (Similar to in-demand plastics for all patients).

Centers that provided gender affirming care, became in demand due to word of mouth. This is of course the best (as in least corruptible) form of advertising. Some advertising is reasonable for centers like this (as in...we are here).

Cancer center advertising can be particularly odious, due to the time pressure and desperation of the consumer.

Are you concerned about "transgender for everyone"?

 

[TheWallnerus]

Strange comment in an era where executive mandates, devoid of expert input, leverage institutions to shutter whole departments.

Parents of course want the best for their children. They shouldn't be manipulated.

But...the interventions couldn't be more different. Gender affirming care in young people (and adults) is overwhelmingly counseling with subsequent consideration of very cheap medications (spironolactone, estrogen, progesterone, testosterone). There is no big ticket 180K intervention. Consideration of any intervention is very much contingent on what doctors, mom or dad say. It takes years and years, and typically reluctant parents are ultimately looking for help for their kids. These are parents who believe that expertise in such matters exists in the medical world. Of course, many parents will never even acknowledge that something like gender dysphoria exists.

Outside of surgery, I doubt that gender affirming care was ever a big money maker for any system. Gender affirming surgical care may be quite profitable for sought after practitioners. (Similar to in-demand plastics for all patients).

Centers that provided gender affirming care, became in demand due to word of mouth. This is of course the best (as in least corruptible) form of advertising. Some advertising is reasonable for centers like this (as in...we are here).

Cancer center advertising can be particularly odious, due to the time pressure and desperation of the consumer.

Are you concerned about "transgender for everyone"?

Just trying to follow some things to logical conclusions as this is the first medical advertisement I've seen where a child is testimonializing. Makes you think.

I'm going to give the benefit of the doubt to MPTC that this ad's market is children—having a kid hawk protons to adults feels a little too craven. The ad is like a cereal commercial on Saturday morning sort of thing. I'm not trying to be flippant here just dispassionate. (I remember seeing ads like that and then trying to influence my parents' cereal buying choices, so ads to kids can be very effective.) The kid (with cancer) sees the ad and says to her parents "I want protons." The parents say "No, Dr. Smith is a good doctor and we are happy with everything planned." Where is another medical treatment where there could be parental/child tension over the treatment course and a medical ad could tip that tension one way or the other? One thing pops in the mind. Ads framing gender affirming care for kids could get them the gender affirming care they want, maybe even especially older teenage kids. Some people might welcome those ads. And if I felt icky about such an ad maybe I'm the problem... just as I'm feeling icky about the proton ad.

As you said, obviously the interventions couldn't be more different. Obviously. Yet given that this MPTC ad even exists it opens one to consider some... perhaps strange... possibilities. I'm not judging if the possibilities are good or bad.