Rad Onc Twitter

[StealthTech]

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Haha. I don’t think Evan understands malpractice as a legal concept. Let’s hope some other people don’t understand slander.

The question of whether using the Vanquish® water vapor ablation system for prostate cancer constitutes malpractice is a subject of significant debate within the oncological community.
As the image shows, there is a sharp divide between those adopting new "focal therapy" technologies and those adhering to established standards of care like radiation or surgery.
The Arguments
The "Malpractice" Perspective (e.g., Evan Thomas MD/PhD):
Standard of Care: In many medical circles, treating prostate cancer with water vapor ablation is not yet considered the standard of care. Critics argue that performing these procedures outside of a strictly controlled clinical trial ignores long-term oncological outcomes.
"Messy Salvages": The concern is that if the ablation fails or the cancer recurs, the resulting scar tissue makes follow-up "salvage" treatments (like radiation or surgery) significantly more difficult and prone to complications.
Lack of Long-Term Data: Unlike traditional treatments with decades of data, newer focal therapies lack the robust, long-term evidence required to prove they are as effective at preventing cancer death.
The "Innovation" Perspective (e.g., Dr. Rahul Mehan):
Precision and Quality of Life: Proponents argue that by using AI and real-time imaging, they can target only the tumor while sparing surrounding healthy tissue, significantly reducing the risk of impotence and incontinence—common side effects of traditional treatments.
Focal Therapy Evolution: While traditionally used for Benign Prostatic Hyperplasia (BPH), adapting water vapor (convection) therapy for localized cancer is seen by some as the next logical step in "organ-sparing" oncology.
Is it Malpractice?
Legally and professionally, "malpractice" typically requires proving that a physician deviated from the accepted standard of care and that this deviation caused actual harm to the patient.
Grey Area: If a patient is fully informed that the procedure is "off-label" or "investigational" and chooses it to avoid the side effects of surgery, it is much harder to argue malpractice.
Institutional Review: Most academic institutions would require such procedures to be done under an Institutional Review Board (IRB) approved protocol. Performing them as routine "private practice" is what triggers the strongest accusations from the medical community.

 

[Mandelin Rain]

Haha. I don’t think Evan understands malpractice as a legal concept. Let’s hope some other people don’t understand slander.

Wine and computers not just for contouring anymore.

 

[fiji128]

The question of whether using the Vanquish® water vapor ablation system for prostate cancer constitutes malpractice is a subject of significant debate within the oncological community.
As the image shows, there is a sharp divide between those adopting new "focal therapy" technologies and those adhering to established standards of care like radiation or surgery.
The Arguments
The "Malpractice" Perspective (e.g., Evan Thomas MD/PhD):
Standard of Care: In many medical circles, treating prostate cancer with water vapor ablation is not yet considered the standard of care. Critics argue that performing these procedures outside of a strictly controlled clinical trial ignores long-term oncological outcomes.
"Messy Salvages": The concern is that if the ablation fails or the cancer recurs, the resulting scar tissue makes follow-up "salvage" treatments (like radiation or surgery) significantly more difficult and prone to complications.
Lack of Long-Term Data: Unlike traditional treatments with decades of data, newer focal therapies lack the robust, long-term evidence required to prove they are as effective at preventing cancer death.
The "Innovation" Perspective (e.g., Dr. Rahul Mehan):
Precision and Quality of Life: Proponents argue that by using AI and real-time imaging, they can target only the tumor while sparing surrounding healthy tissue, significantly reducing the risk of impotence and incontinence—common side effects of traditional treatments.
Focal Therapy Evolution: While traditionally used for Benign Prostatic Hyperplasia (BPH), adapting water vapor (convection) therapy for localized cancer is seen by some as the next logical step in "organ-sparing" oncology.
Is it Malpractice?
Legally and professionally, "malpractice" typically requires proving that a physician deviated from the accepted standard of care and that this deviation caused actual harm to the patient.
Grey Area: If a patient is fully informed that the procedure is "off-label" or "investigational" and chooses it to avoid the side effects of surgery, it is much harder to argue malpractice.
Institutional Review: Most academic institutions would require such procedures to be done under an Institutional Review Board (IRB) approved protocol. Performing them as routine "private practice" is what triggers the strongest accusations from the medical community.

As long as they are using "AI" its probably fine.

 

[OTN]

The question of whether using the Vanquish® water vapor ablation system for prostate cancer constitutes malpractice is a subject of significant debate within the oncological community.
As the image shows, there is a sharp divide between those adopting new "focal therapy" technologies and those adhering to established standards of care like radiation or surgery.
The Arguments
The "Malpractice" Perspective (e.g., Evan Thomas MD/PhD):
Standard of Care: In many medical circles, treating prostate cancer with water vapor ablation is not yet considered the standard of care. Critics argue that performing these procedures outside of a strictly controlled clinical trial ignores long-term oncological outcomes.
"Messy Salvages": The concern is that if the ablation fails or the cancer recurs, the resulting scar tissue makes follow-up "salvage" treatments (like radiation or surgery) significantly more difficult and prone to complications.
Lack of Long-Term Data: Unlike traditional treatments with decades of data, newer focal therapies lack the robust, long-term evidence required to prove they are as effective at preventing cancer death.
The "Innovation" Perspective (e.g., Dr. Rahul Mehan):
Precision and Quality of Life: Proponents argue that by using AI and real-time imaging, they can target only the tumor while sparing surrounding healthy tissue, significantly reducing the risk of impotence and incontinence—common side effects of traditional treatments.
Focal Therapy Evolution: While traditionally used for Benign Prostatic Hyperplasia (BPH), adapting water vapor (convection) therapy for localized cancer is seen by some as the next logical step in "organ-sparing" oncology.
Is it Malpractice?
Legally and professionally, "malpractice" typically requires proving that a physician deviated from the accepted standard of care and that this deviation caused actual harm to the patient.
Grey Area: If a patient is fully informed that the procedure is "off-label" or "investigational" and chooses it to avoid the side effects of surgery, it is much harder to argue malpractice.
Institutional Review: Most academic institutions would require such procedures to be done under an Institutional Review Board (IRB) approved protocol. Performing them as routine "private practice" is what triggers the strongest accusations from the medical community.

Did you just post AI?

 

[TheWallnerus]

Did you just post AI?

Rad onc had intelligence that was artificial before artificial intelligence was cool.

 

[Gfunk6]

Haha. I don’t think Evan understands malpractice as a legal concept. Let’s hope some other people don’t understand slander.

I think he has a fundamental misunderstanding between what is legal (this device received 510k clearance last year) and what is proper.

 

[drowsy12]

there have been med Mal cases for a LOT less than this

my understanding from the twitter feed was this was approved for non-cancer ablation, not cancer treatment. not sure if correct, but IF correct, a lawyer has looked at a case for a lot less (in the event there is a recurrence and subsequent complication as a result of re-treatment).

 

[TheWallnerus]

there have been med Mal cases for a LOT less than this

my understanding from the twitter feed was this was approved for non-cancer ablation, not cancer treatment. not sure if correct, but IF correct, a lawyer has looked at a case for a lot less (in the event there is a recurrence and subsequent complication as a result of re-treatment).

I don’t think you can diagnose people, or a doctor’s treatment, over the internet

 

[RickyScott]

Haha. I don’t think Evan understands malpractice as a legal concept. Let’s hope some other people don’t understand slander.

Plenty of urologists would maintain that focal therapy is a standard of care. I think even the aua maintain it Iis an option. Our local pps exempt nci center offers hifu. “Malpractice” comes across as unhinged.

 

[drowsy12]

it's not focal therapy it's this particular focal therapy in this particular context, that's his contention

regardless of whether it's med Mal or not, it deserves to be called out. not sure why people are being strangely defensive. agree with spratt, Evan, etc on this issue.

 

[TheWallnerus]

it's not focal therapy it's this particular focal therapy in this particular context, that's his contention

regardless of whether it's med Mal or not, it deserves to be called out. not sure why people are being strangely defensive. agree with spratt, Evan, etc on this issue.

What’s defensive about opining that calling something malpractice is incorrect, irresponsible, hyperbolic, etc, if you have never heard from or know nothing about the patients’ outcomes or opinions. Now, I’m ASSUMING Evan has none of this info. Which might be wrong on my part. But if Evan had that info it would be good for him to say so.

 

[drowsy12]

What’s defensive about opining that calling something malpractice is incorrect, irresponsible, hyperbolic, etc, if you have never heard from or know nothing about the patients’ outcomes or opinions. Now, I’m ASSUMING Evan has none of this info. Which might be wrong on my part. But if Evan had that info it would be good for him to say so.

it's well known on this forum for old timers that you and Evan have beef. I will chalk this up to BEEF.

 

[WildRivers]

Definition of med mal is pretty specific. Many of us have to take those courses to lower premiums.

Deviation from standard of care that leading to harm, injury or death.

One can agree that this is deviation from standard of care. But have to prove adverse outcome or toxicity/death.

Can't really say that without knowing outcome. You can do a weird treatment, but if there is no worse outcome, doesn't meet medico-legal definition.

This is not an endorsement of the treatment. I think its horrendous. I think Evan is flippant and inflammatory on social media and that is too bad because I find him to be intelligent and a nice person in real life. I think maybe people could have said that about me in the past. (EDIT: at least the nice person part for me)

 

[TheWallnerus]

Billit's well known on this forum for old timers that you and Evan have beef. I will chalk this up to BEEF.

I have a beef with Evan? Really? How do I get off his beef list…

 

[radiaterMike]

she'll find it

 

[evilbooyaa]

It's not malpractice (technically) now because they haven't had a bad outcome.

If/when the patient recurs, would it be considered malpractice then?

 

[thecarbonionangle]

Urology has such a dense concentration of straight up badness. Its hard to shake off that view once you start seeing them like that.

 

[TheWallnerus]

It's not malpractice (technically) now because they haven't had a bad outcome.

If/when the patient recurs, would it be considered malpractice then?

Is it malpractice if they recur after I use 1.5 Gy fraction sizes 😉

 

[emt409]

Haha. I don’t think Evan understands malpractice as a legal concept. Let’s hope some other people don’t understand slander.

I’m OK getting raked over the coals a little bit to have brought some attention to the issue.

Unfortunately, unless you add a little bit of spice to a post, it does not get weighted as well by the algorithms.

Malpractice has a broader definition than just what constitutes the minimum legal criteria.

As someone else pointed out, this would not meet the legal standards of malpractice until the patient had a recurrence and had a negative about associated with it. And then any decent plaintiff attorney could probably get this thru a jury.

Moreover the nitpicking on the definition of malpractice is particularly ironic here because if it was anything, a twitter post would be libel and not slander.

 

[TheWallnerus]

Moreover the nitpicking on the definition of malpractice is particularly ironic here because if it was anything, a twitter post would be libel and not slander.

Dammit. Right. I corrected it!

 

[emt409]

Haha, no worries.

 

[Palex80]

 

[TheWallnerus]

View attachment 416790

This reminds me of the old Robin Williams joke

What do you call an Amish man with his hand up a horse’s butt?

A mechanic.

 

[DoctwoB]

FWIW there is an ongoing trial to evaluate water vaper thermal therapy for GG2 prostate cancer called the vapor 2 trial looking at this system. Sadly its a single arm trial, but anyone awaiting new randomized results in local therapy for prostate cancer is going to be waiting for a long time.

Can't say if the above tweets were on trial or not. Haven't seen data beyond company reported interim results at 6 months, "At 6 months, 91% of eligible patients (n = 110) showed no targeted MRI visible intermediate-risk disease following a single Vanquish procedure, which means absolutely nothing, because it could well be the effects of treatment mask the cancer on MRI. We will see what the 12 month per protocol biopsy shows.

the benefit of VTT is its a super quick, super easy procedure, that at least in the context of bph that preserves antegrade ejaculation has a low complication rate and i don't expect it would complicate any salvage therapies. Does require a catheter, typically for 3-5 days.


That said,

 

[Mandelin Rain]

Can you imagine if external beam radiation therapy required a urinary catheter for 5 days in most/every patient? I don't think urologists would describe it as a "super easy" "low complication" procedure.

 

[pikachu]

Can you imagine if external beam radiation therapy required a urinary catheter for 5 days in most/every patient? I don't think urologists would describe it as a "super easy" "low complication" procedure.

Or a bone drill to get through the sternum (!)

 

[metallica81788]

I have far more issue with that above than the urology procedure thing

 

[OTN]

 

[RadOncMegatron]

Or a bone drill to get through the sternum (!)
View attachment 417040

Hey at least they missed the aorta!

 

[Gfunk6]

Or a bone drill to get through the sternum (!)
View attachment 417040

Looks like UCLA is re-writing rule #6 of the House of God

There is no body cavity that cannot be reached with a bone drill and a good strong arm.

 

[Doctorer]

“Your scientists were so preoccupied with whether they could, they didn't stop to think if they should.”

Pretty incredible, if you think about it. Drilling??? Through the sternum??? To deliver cryotherapy???

Idiocracy was a documentary.

 

[medgator]

“Your scientists were so preoccupied with whether they could, they didn't stop to think if they should.”

Pretty incredible, if you think about it. Drilling??? Through the sternum??? To deliver cryotherapy???

Idiocracy was a documentary.

Was a dud when it came out too

The last decade has been its revival

 

[Palex80]

36% response rate in 2nd line NSCLC - "bricks are falling".

Doxetaxel produces around 20% ORR.

https://ascopubs.org/doi/10.1200/JCO.2023.41.16_suppl.e21197

 

[drowsy12]

 

[Palex80]

It's breast.

So, you skip a planning CT and calculating a plan based on that, and instead of that ... you block an adaptive slot on the Ethos with a team of 7 (!) people?

Is that a good trade-off?

 

[TheWallnerus]

As intelligent as I’m sure they all are, billing a sim and a treatment on the same day is often times a way to bill very unintelligently.

 

[medgator]

As intelligent as I’m sure they all are, billing a sim and a treatment on the same day is often times a way to bill very unintelligently.

If they are hopps with a good contract or PPS-exempt, pretty sure they don't care

It's just us mpfs folks trying to get every penny we can to keep the lights on

 

[BobbyHeenan]

Or a bone drill to get through the sternum (!)
View attachment 417040

I saw that too and about came up out of my chair. That is an SBRT chip shot in an area of lung that doesn't move much, would have near zero chance of clinically meaningful lung toxicity.

It's a wild world out there...but IR is so quick to think "it's FDA approved" means we should do it. Maybe i'm being presumptuous but I refuse to believe this patient saw rad onc and elected to have THAT put in his chest.

 

[medgator]

I saw that too and about came up out of my chair. That is an SBRT chip shot in an area of lung that doesn't move much, would have near zero chance of clinically meaningful lung toxicity.

It's a wild world out there...but IR is so quick to think "it's FDA approved" means we should do it. Maybe i'm being presumptuous but I refuse to believe this patient saw rad onc and elected to have THAT put in his chest.

I only see crappy IR stuff like this happening at hospitals with weak rad onc programs

 

[Doctorer]

I only see crappy IR stuff like this happening at hospitals with weak rad onc programs

I don't think UCLA Radonc would struggle SBRTing that, rather they never saw that patient in the first place.

 

[Aptamer]

I don't think UCLA Radonc would struggle SBRTing that, rather they never saw that patient in the first place.

Their pulm/CT surgery/whoever probably don't want to refer to Drew M.

 

[Palex80]

Their pulm/CT surgery/whoever probably don't want to refer to Drew M.

Some Twitter-battle, maybe?

 

[drowsy12]