ASTRO 🔫🦶

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Good discussion on Twitter…

What is it exactly about this proposal that would limit further cuts exactly? If they switch to per patient (not per fraction) billing, why does that limit future cuts? Or does it not limit cuts but more so just protects protons/PPS exemption?

I don't buy the excuses about the PPS exempt centers/proton exemptions either.

One of the books that has shaped my thinking on these "big picture" issues is Skin in the Game. Taleb has his own issues, but the notion that a group of people that have major COI/exemptions from rules they wish to impose being intimately involved with drafting policy is asinine.
 
Intimately involved? Thats like saying a young woman (Stormy) was intimately involved with a presidential candidate.

They are the only players in the scene, for monetary benefit purely for themselves, and doing it nasty ... behind closed doors.
 
ASTRO gutting technical and coming for YOUR hard earned technical money?
 
thecarbonionangle said:
ASTRO gutting technical and coming for YOUR hard earned technical money?
Click to expand...

I'm pro fee only and hypofrac a TON. I bet if I ran the numbers I make more money with this proposal.
Maybe I should support this but at face value I didn't like lack of comment period and lack of transparency and the carve outs. I feel like if they got that part wrong, then there may be other things going on that they got wrong.
 
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BobbyHeenan said:
Good discussion on Twitter…

What is it exactly about this proposal that would limit further cuts exactly? If they switch to per patient (not per fraction) billing, why does that limit future cuts? Or does it not limit cuts but more so just protects protons/PPS exemption?

I don't buy the excuses about the PPS exempt centers/proton exemptions either.

One of the books that has shaped my thinking on these "big picture" issues is Skin in the Game. Taleb has his own issues, but the notion that a group of people that have major COI/exemptions from rules they wish to impose being intimately involved with drafting policy is asinine.
Click to expand...
They are trying to create an even greater competitive advantage for themsleves.
 
There is definitely corruption here. it will never be rooted out. Elites are making too much money to care. Everyone says cut the guy over there not me (technical, protons). It was done poorly because they could have opened it to public comment like all the guidelines (recent APBI comment period) but instead there is the appearance things are being “rammed through”. Elitists on twitter accuse people of being misinformed and not doing their homework. Fingerpointing circular firing squad is the state of our field. Sameer says don’t let perfect be the enemy of good. Perhaps. It frustrates me that we are constantly trying to cut ourselves. It doesn’t benefit the field as a whole to cut things, even if you don’t like them. Can we possibly come
Together to have a consensus? Yes but ASTRO needs to be transparent. There needs to be other people at the table besides the usual players. People are tired of being told to sit down and let the adults handle it.
 
BobbyHeenan said:
I bet if I ran the numbers I make more money with this proposal.
Click to expand...

Don't bet, calculate. See what it really shows. Lets say you do get a 3% increase. But what about the real problem which is how it sets up our specialty for inevitable erosion.

Instead of fighting us on 25 codes, now it'll be one code per disease site. They will begin eroding it 3% a year every year. Easy to do when its one code. Say goodnight to brachytherapy as a modality also.. .buh bye. Everyone gets EBRT hypofrac and thats that.

Anyone dumb enough to support total capitulation to ASTRO's whims.. you might as well stand up and applaud their workforce effort. It'll end the same way...... total disaster.

Thank goodness I am in the last 10 years of my career.

Think of ASTRO like the carbon fiber sub captain "hey, this is new and it surely will work out just fine" .. .no thanks, I chose #lyfe
 
BobbyHeenan said:
I'm pro fee only and hypofrac a TON. I bet if I ran the numbers I make more money with this proposal.
Maybe I should support this but at face value I didn't like lack of comment period and lack of transparency and the carve outs. I feel like if they got that part wrong, then there may be other things going on that they got wrong.
Click to expand...

This, and also the implication that if you personally benefit from this program compared to right now, then it's good. Or the idea that we shouldn't get too caught up in the details, thats how RO-APM died. Yes, "run your personal numbers, dont worry about all the other stuff". So thoughtful these folks.

Believe it or not, I have a really good handle on the stakes for my personal job, but I also care about this field and the future. Is that so hard to believe? I guess probably it is for some ASTRO board members.

One "ASTRO insider" (although not on this policy) seems to be standing out to me as exceptionally reasonable the last couple days. If you are still an ASTRO member, vote Sameer!
 
NotMattSpraker said:
This, and also the implication that if you personally benefit from this program compared to right now, then it's good. Or the idea that we shouldn't get too caught up in the details, thats how RO-APM died. Yes, "run your personal numbers, dont worry about all the other stuff". So thoughtful these folks.

Believe it or not, I have a really good handle on the stakes for my personal job, but I also care about this field and the future. Is that so hard to believe? I guess probably it is for some ASTRO board members.

One "ASTRO insider" (although not on this policy) seems to be standing out to me as exceptionally reasonable the last couple days. If you are still an ASTRO member, vote Sameer!
Click to expand...
The silence from Neha is deafening. Vote Sameer!
 
thecarbonionangle said:
The silence from Neha is deafening. Vote Sameer!
Click to expand...
Can't vote if you can't vote ....cause you ain't a member

Think About It GIF by Identity
 
Diversify your billing and coding portfolio.

Oh wait... it's already diversified!

Now ASTRO and whoever else wants to have us bill one code, and one code only, for a multi-week or just one day course of treatment.

If you cut your portfolio from a bunch of different stocks (77263, 77290, 77301, 77427, etc) down to just one stock (77xxx... M-code... the theoretical "God Code" per disease site), you run a real risk. As many have mentioned, you may get a good rate on 77xxx today, but not so good tomorrow. With a bunch of different codes billed across time and space, you confuse your enemy; you run the OODA loop. NB: Your enemy is the insurance company and CMS.

Don't let ASTRO sell you beachfront property in Arizona.
 
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At this point ASTRO is selling me NFT virtual property in Decentraland and telling me it'll increase in value, unlike the crash and burn of the APM ASTRO $hitcoin...

Bored Chill GIF
 
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Do you hypofractionate a lot, like me? (I actually hypofractionate more than nearby pps exempt center) Recognize that you still benefit greatly from all the widespread extended conventional fractionation going on out there. Ending conventional fractionation will put a lot of docs out of work/diminish new hiring and thereby create downward pressures on the job market/salaries, and most importantly, mobility.
Several months after Astro stated the job market is totally fine, they are pushing to eliminate conventional fractionation.
 
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It's super fun when those involved in ASTRO leadership disparage its members

edit: this is probably better for the twitter discussion, but it's directly related to the above post so I put it here
 
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OTN said:





It's super fun when those involved in ASTRO leadership disparage its members
Click to expand...

Brendon Stiles does not know how easy it is to create a modeled dose distribution on a computer with a commercial dose engine.

Ipsilateral stage III.
Probably didn’t need GEUD
Which we even have in the country.
 
OTN said:





It's super fun when those involved in ASTRO leadership disparage its members

edit: this is probably better for the twitter discussion, but it's directly related to the above post so I put it here
Click to expand...

stephen colbert lol GIF by The Late Show With Stephen Colbert
 
medgator said:
stephen colbert lol GIF by The Late Show With Stephen Colbert
Click to expand...
Must be sad to have to find ways to make themselves feel more valuable and then have to use Twitter to verify their importance to each other.
 
As somebody who is disconnected from academic circles, I don’t understand. Drew Moghanaki is a VA doc. I would never ask him for his opinion on lung cancer. Why is he getting all elitist
 
yesmaster said:
As somebody who is disconnected from academic circles, I don’t understand. Drew Moghanaki is a VA doc. I would never ask him for his opinion on lung cancer. Why is he getting all elitist
Click to expand...
He's drew. Why do you think he's at the VA rather than main campus through multiple jobs now
 
The rad onc isn't important in the planning process unless they are doing the planning. The dosimetrist will be the deciding factor here. Better hire a thoracic only dosimetrist who gives a crap. Good luck.
 
I am usually trying to keep my stage III pts at the mothership to put on my IIT... but if they want to be treated locally and I know the group uses 4D CT sim and daily CBCT for stage III, I am comfortable referring.

I do usually try to keep the patients in house who are re-treatments, or definitive ultra-central hypofx ... For these idiosyncratic cases, I do think it is helpful to do this sort of thing often (at the risk of p!ssing most of you off)
 
sirspamalot said:
routine 4D CT for a large bulky stage III?

I don't think its routinely necessary. If they are able to breath gently, the whole thing is usually tethered to the hilum. I guess, as my old flight instructor used to say.. "it depends."
Click to expand...

Level 7 can move > 1 cm... will have to dig up the image, but I have posted an example here before. You don't know if you needed a 4D... unless you get a 4D
 
Lamount said:
Level 7 can move > 1 cm... will have to dig up the image, but I have posted an example here before. You don't know if you needed a 4D... unless you get a 4D
Click to expand...


Found it... this example was just 7 mm, but still worth keeping in mind.

1688161101444.png
 
In the good ol' days we used 4 cm below the carina as the cutoff, 'member when?

If you're doing 3D with a 1-2 cm margin (med vs parenchyma) and minimal excursion...

IMRT? Sure, if you're going to be doing minimal PTV expansion (5mm or less) then but of course.. but if its huge, it just isn't going anywhere.

Stage III is wide range of presentations..
 
Ok I’m not a thoracic “expert” but you guys are kidding yourself. Only advancement in 20 year has been immunotherapy and not better or tighter RT margins. Granted it makes sense to the employee the best RT technique possible but to pretend this is meaningfully moving the needle in IIIA/B is ridiculous.

Edit: that tweet saying you need to be at an academic center to properly treat stage III lung is Astro in a nut shell. Like have you ever meet the vast majority of these patients?
 
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fiji128 said:
Ok I’m not a thoracic “expert” but you guys are kidding yourself. Only advancement in 20 year has been immunotherapy and not better or tighter RT margins. Granted it makes sense to the employee the best RT technique possible but to pretend this is meaningfully moving the needle in IIIA/B is ridiculous.
Click to expand...
100%

People who think contouring is the most important factor in outcomes are kidding themselves (obviously to a certain extent). The compounding uncertainty added in subsequent steps of planning and delivery processes far outweigh that of finely detailed contouring IMO. I roll my eyes at certain faculty who nitpick fine contouring details then ignore how steep dose gradients fall apart when hitting play on the 4DCT
 
I think IMRT (circa 2005) and SBRT (circa 2010) were really the last steps forward. Protons ain't nothing but a financial grind. FLASH if it pans out, maybe. Other than that, we are just spewing minutiae. I have my cynicism level set to 99.8% that we will make any further meaningful advances.

Well, except for "Radiation + (latest) IO removes need for (insert surgical procedure/s)!" if we aren't totally eradicated by "25 fractions, 5 fractions, NO FRACTIONS.. .GGGGG G GGGG GONE!"
 
sirspamalot said:
I think IMRT (circa 2005) and SBRT (circa 2010) were really the last steps forward. Protons ain't nothing but a financial grind. FLASH if it pans out, maybe. Other than that, we are just spewing minutiae. I have my cynicism level set to 99.8% that we will make any further meaningful advances.

Well, except for "Radiation + (latest) IO removes need for (insert surgical procedure/s)!" if we aren't totally eradicated by "25 fractions, 5 fractions, NO FRACTIONS.. .GGGGG G GGGG GONE!"
Click to expand...
Fair, past 15 years.
 
FindMeOnTheLinks said:
100%

People who think contouring is the most important factor in outcomes are kidding themselves (obviously to a certain extent). The compounding uncertainty added in subsequent steps of planning and delivery processes far outweigh that of finely detailed contouring IMO. I roll my eyes at certain faculty who nitpick fine contouring details then ignore how steep dose gradients fall apart when hitting play on the 4DCT
Click to expand...
Preach.

Really...just...this.

The further I get away from residency, as a very busy generalist in various far-flung settings...the more and more my memories of residency seem absolutely absurd. They feel dissociative, like the concerns the faculty had and tried to impart into me were some sort of fiction.

It's incredibly unfortunate that basically all Radiation Oncology residency programs take place at urban academic medical centers, which are all different degrees of "large". Sure, a residency in the New York City metro area is bigger than a residency in the Durham/Chapel Hill "triangle" area of North Carolina....but the triangle is still significantly better than a thousand other practices.

Because that's really the gap. The 2022 "Geographic Access" paper has 2,313 radiation facilities in the USA.

1688221547319.png


If you think about it, that crazy cluster of green dots from Boston to DC is where the vast majority of us get our training, along with California and the zig-zag line that runs from Houston to Chicago.

Obsessing over stupid, millimeter changes to a crappy circle drawing on a static slice of a DICOM file is NOT what affects outcomes for millions of cancer patients in this country.

In my clinic yesterday, much of my time was spent figuring out alternative nutrition strategies for a patient who couldn't afford a weekly 6-pack of Ensure, or an 80-year-old woman on TID Xanax from her PCP who tells me she doesn't want to be alive anymore, or the 5-week delay in getting basic diagnostic scans performed...none of those folks care about millimeter expansions.

Let alone proton carve outs in proposals submitted to Congress.

Strong work, ASTRO.
 
elementaryschooleconomics said:
Preach.

Really...just...this.

The further I get away from residency, as a very busy generalist in various far-flung settings...the more and more my memories of residency seem absolutely absurd. They feel dissociative, like the concerns the faculty had and tried to impart into me were some sort of fiction.

It's incredibly unfortunate that basically all Radiation Oncology residency programs take place at urban academic medical centers, which are all different degrees of "large". Sure, a residency in the New York City metro area is bigger than a residency in the Durham/Chapel Hill "triangle" area of North Carolina....but the triangle is still significantly better than a thousand other practices.

Because that's really the gap. The 2022 "Geographic Access" paper has 2,313 radiation facilities in the USA.

View attachment 373722

If you think about it, that crazy cluster of green dots from Boston to DC is where the vast majority of us get our training, along with California and the zig-zag line that runs from Houston to Chicago.

Obsessing over stupid, millimeter changes to a crappy circle drawing on a static slice of a DICOM file is NOT what affects outcomes for millions of cancer patients in this country.

In my clinic yesterday, much of my time was spent figuring out alternative nutrition strategies for a patient who couldn't afford a weekly 6-pack of Ensure, or an 80-year-old woman on TID Xanax from her PCP who tells me she doesn't want to be alive anymore, or the 5-week delay in getting basic diagnostic scans performed...none of those folks care about millimeter expansions.

Let alone proton carve outs in proposals submitted to Congress.

Strong work, ASTRO.
Click to expand...
Narcissism of small differenxes
 
sirspamalot said:
routine 4D CT for a large bulky stage III?

I don't think its routinely necessary. If they are able to breath gently, the whole thing is usually tethered to the hilum. I guess, as my old flight instructor used to say.. "it depends."
Click to expand...

Oh cool we're doing this again...
 
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