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Based on the one of the last rad onc-related surveys (of which there are 494 per year) published by ASTRO, a primary concern of rad oncs was wanting to be seen as an oncologist rather than just a rad onc (aka being a technician/button pusher). Almost everyone wanted to be seen as an oncologist but very few felt that their practice reflected that desire.

Then we get this hot garbage published as a viewpoint in JAMA Onc from 3 attendings in the new rad onc specialty called PROMISE (not even making this up) at MSKCC that metastatic disease needs to be a distinct specialty in rad onc. The reasons they give essentially boils down to "stage IV patients are complicated and primary disease site rad oncs can't handle the complexity." I wanted to translate that for the rest of us:

"We are in academics and need to justify our existence. We somehow need to be able to ask for more funding for our 'new 'disease site. Most importantly, we would like to be considered for professorships and leadership positions and to do that, we need a 'disease site' and since one wasn't open when we took a job at MSKCC, we created our own and want to try to try and enforce this new model on other rad oncs across the country. In addition, MSKCC is on a non-RVU model so this is possible because we all know if this were Pitt or another RVU-based academic practice, this would never happen as the other rad oncs would never refer their patients and RVUs to us. #iamarealdoctor #radoncrocks"

Someone please tell me I am overreacting but this viewpoint is as bad as my idea of shaming medical students who match at terrible programs - hot garbage that we will all be dumber for having read. So a breast rad onc can't SBRT a right hip met? They have a hilarious figure in the paper that shows how the traditional referral paradigm is 2-3 weeks. Because we all know we can't sim and treat an urgent palliative patient unless they are treated by a rad onc who specializes in metastatic disease. So now the patient has two rad oncs? One who treated the primary breast cancer and then another rad onc who just does the SABR/SBRT? Just writing that was painful. The fact that this was accepted by JAMA Onc is a joke.

Are there really academic rad oncs that just do SABR/SBRT? I know it is a thing but how is it really a thing we are publishing about? We should be trying to hide that embarrassing fact from everyone. I'm just imagining what it must be like to be a button pushing basement catfish who doesn't treat their own patients and is just referred stage IV patients to essentially "spot-weld" random mets throughout the body. I'm embarrassed for any rad onc who does that. This is the type of "research" that is killing our field. But hey, as long as you get promoted based on a pile of retrospective chart reviews and JAMA Onc viewpoints, it's all good

To the PROMISE attendings of MSKCC, thank you for advocating for us to become less of oncologists and have less ownership of patients. You are shining paragons of our field and we all cannot wait to give up ownership of our patients and be seen even more as technicians by our referring med oncs and surgeons.

We should be advocating that primary disease site attendings are up to date on the latest treatment techniques so patients can be treated by their ONCOLOGIST who can SRS a brain met and SABR/SBRT a right hip met after they treated the breast primary. That's how you become an ONCOLOGIST to the patient and to the med onc or surgeon. You do not refer to another rad onc just to do SABR/SBRT - it makes both rad oncs look like button pushing basement catfish and removes the primary rad onc from a key role of helping drive the patient's care plan. Or are rad oncs who have a primary disease site too dumb to assimilate new data on oligometastatic disease?

Can anyone tell me whether there are breast surgeons who only operate on right sided breast cancers but then refer to another breast surgeon if there is a suspicious node in the contralateral side? Or a med onc that only gives chemo when the the breast cancer is localized to the breast but when there is a spine met, a different med onc who is specially trained in metastatic disease gives the chemo?

Edit: Spacing of paragraphs.
 
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elementaryschooleconomics

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When I read this article, I was initially optimistic. I thought to myself, "you know, it would be nice if, in these giant academic departments, people were allowed to 'specialize' in metastatic disease, and really champion the use of SBRT/SABR for oligomets, or whatever. and maybe develop trials and guidelines and protocols to encourage MedOncs/SurgOncs/etc to not hang on to these patients without considering the utility of XRT until it's too late. Maybe, this can be a way to encourage RadOncs to be more engaged in quarterbacking care in general, and we can move away from the technician moniker."

Then, I got to the Conclusion:

1613312266506.png

Are they serious with this?

Scenario: an academic RadOnc at a small-to-mid sized department in Pennsylvania who focuses on thoracic and GU malignancies is on call one week. She receives a consult request at 9PM on a Wednesday. "78 year old male with a history of prostate cancer, definitively treated with prostatectomy 7 years ago, now with new painful lytic lesion in L1, biopsy-proven metastatic prostate cancer, no concern for cord compression though MRI total spine pending."

"Oh my", she thinks. "While I'm used to treating GU as my primary disease site, and I perform prostate SBRT several times a month, this patient has metastatic disease. I clearly can't understand the unique challenges this patient faces, and I definitely can't adapt my knowledge of the literature and skill with SBRT treatment planning to...THE SPINE, an entirely different anatomic region!"

Her nerves are calmed, however, when she realizes Penn and their newly-formed PROMISE team, based on the pioneering Sloan model, can assume care of the patient. Thank God she can refer this out!

She calls back the primary team: "Don't worry, I can handle this. I'll email my secretary and arrange a referral to the team in Philly, patient will be seen next week as an outpatient. They can usually get treatment going in 7 days!"
 
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ramsesthenice

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Would these specialty hubs be paying for travel and lodging for patients to get their treatment at specialty centers? This is some first rate @sshartery right here. Honestly, they can keep the patients who think they are more special than the people around them and absolutely need to be treated by “the best” for their cancer. They tend to test my patience anyway.
 
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elementaryschooleconomics

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...then why did she write, explicitly, in her article, that she is first author on, that she is advocating for this Metastatic Specialists to be referral hubs? That single sentence changes the entire tone of her article.

Large academic departments should be where people are allowed to hyper-specialize to develop and disseminate new knowledge to practitioners everywhere for the benefit of all patients. These "Metastatic Referral Hubs" and "Palliative Care Networks" are being branded in a different way.

Unless, of course, she meant "referral hub" as in "feel free to call us asking for advice about unique scenarios". However, in medicine, "referral hub" to me means "send us your patients so we can treat them instead of you".
 
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scarbrtj

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A particularly head-spinningly crazy excerpt (does JAMA not have good reviewers?):

The treatment of metastatic cancer is complex and warrants specialized care.
Yes, usually by specialists known as medical and radiation oncologists.

In most departments, patients with metastatic disease are treated by radiation oncologists who specialize in primary disease treatments.
This is the current standard of care; where is the evidence that it needs changing?

Although this system has the potential advantage of care delivery by specialists who understand histology-specific tumor biology, we must also recognize that treatment of metastatic tumors is independently rapidly evolving,
I "must" recognize? What happens if I don't? Will patient care be harmed?

with approaches that are not always histology specific. Moreover, an increasing number of patients are living with metastatic cancer, and they often face more complex clinical needs compared with patients undergoing treatments for primary disease.

They "often" do? Surgery is pretty complex. Is it time to increase surgery utilization in metastatic disease?

Since the initiation of our metastatic disease treatment program in 2016, we have gained significant institutional support, and the number of patients with stage IV cancer referred for consideration of RT has increased from 2986 in 2016 to 4687 in 2019, tangible evidence that the program has filled an unmet need at our institution.
"Tangible" evidence. All this means is that MSKCC rad onc essentially started intra-institutional advertising for more radiotherapy in Stage IV, and that their advertising program was successful. Scientifically, or even logically of course, this means zero.

Imagine if I opened up a melanoma radiotherapy program in a large academic center. I got derms to start letting me do definitive radiotherapy for melanoma and got surgeons to start letting me do postop RT on all node-positive melanomas. And then I published an opinion piece that I was seeing a lot of melanoma patients and that they were doing great etc etc. And wrote the piece with essentially no supporting scientific papers that said we need to start doing a lot more radiotherapy in melanoma and that melanoma has "an unmet need." If I did that, it wouldn't be all that different from what these authors did.

These types of desperate maneuvers ("let's dream up specious rad onc indications and sub-specializations") are akin to a patient Cheyne-Stokesing in the ICU. In this analogy, the patient Cheyne-Stokesing is the entire specialty of rad onc... if it wasn't clear. Of course that's just my opinion. I should try to get that opinion published.
 
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FrostyHammer

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Does this mean we'll see a MSKCC (or somewhere else) metastatic diseases fellowship open in the near future? Lol
 
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Radonc90

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It is a sales pitch for medonc in the NYC (or whatever city) to read it and to buy into it.
That is all.
This stuff will never fool the radonc community.

Think about it as a sales brochure to the unsuspecting medonc's.
Even MSKCC needs a sales pitch to increase their RVU.

This has nothing to do with science of medicine.
 
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RickyScott

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Self enamorment/narcissism. Had similar experience making breakfast this morning when thought popped into my mind that nobody was capable of making a better grilled cheese.
 
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metview

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MSK is a joke. I never heard of the place until 3rd of medical school when I was applying to rad onc, and I don't think anyone outside of oncology or NYC knows what it is. Per current residents, many attendings overtreat patients and rarely use hypofx. hmmmm....wonder why? $$$$$$$$$$$$$$$$$$$$
 
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Ray D. Ayshun

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Self enamorment/narcissism. Had similar experience making breakfast this morning when thought popped into my mind that nobody was capable of making a better grilled cheese.
You must've never seen diners, drive-ins and dives, which is a propos to the present discussion. The dumpier the spot, the better the grilled cheese.
 
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thecarbonionangle

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Echoing Churchill, the best argument to a radical reworking of the “leadership” in this field is a ten minute conversation with one of these “leaders”.
 
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I believe one of them has posted in the past? Maybe they can join us and explain their reasoning?
 

elementaryschooleconomics

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Also, let's not forget that while overall cases logged per resident has decreased from 2007 to 2018, the number of metastatic cases has increased ~8% and represents (on average) almost 30% of cases seen in residency:


Generalists/community docs see a ton of it as well, with at least ~40% of cases being palliative/metastatic:


Using radiation to treat patients with metastatic cancer is, on balance, the one facet of this specialty that folks have the most experience with. I'm all for Sloan et al creating a Metastatic RadOnc division to develop and disseminate things like the quad shot regimen or the Sundstrøm 17Gy in 2 fractions lung regimen, but advocating for the need to refer metastatic patients to tertiary (or quaternary) centers is a bridge too far.

In the past 6 months we've escalated from a Palliative Radiation Network to Metastatic Referral Hubs. Fascinating.
 
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ramsesthenice

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The old joke use to be what’s the difference between MSKCC and Shae Stadium?

Answer: The Mets usually win at MSKCC
 
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Gfunk6

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If you want to treat mets
Don't look to the community
You know in the end
Academics will always be there
And when you're in doubt
And when you've complex patients
Take a look all around
And MSKCC will be there

I'm sorry but I'm just thinking of the right words to say

I know they don't sound the way I planned them to be

But if you want to treat oligomets I'll make you a fellowship

I PROMISE, I PROIMSE you, I will
 
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fiji128

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Regarding the Jama Onc article, just wow. This is what a specialty that has nothing new of substance to offer publishes.

I can and do get palliative cases started from consult to beam within 24 hours if warranted, maybe I should publish my work flow too.
 
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thesauce

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DEPLORABLE

So much of academics in this field has become a joke. This is just as bad as those advocating for a fraction or 2 less and calling it “groundbreaking.”
 
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cujust

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Guys - I was asked by a friend to clarify the matters here.
The point of the article was to advocate the involvement of rad onc in management of metastatic patients, so that they can be managed by all oncology disciplines and get the most appropriate treatment.

Also the emphasis was on centers WITH the capacity to sub-specialize, and to accept referrals for complex cases (for example, those otherwise would not be treated w/ RT or those w/ multiple prior RT). We want to push the envelope further and expand much needed RT indication to a wider population. And to expand the use of RT we will need to have some trial evidence (eg. oligoprogression and anything beyond oligomet).

This was not intended to steal patients from the communities. I have referred many patients back to the communities for RT, and have spoken to many colleagues to make the transfer as smoothly as possible.

Happy to discuss further if you DM me.
 
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scarbrtj

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Guys - I was asked by a friend to clarify the matters here.
The point of the article was to advocate the involvement of rad onc in management of metastatic patients, so that they can be managed by all oncology disciplines and get the most appropriate treatment.

Also the emphasis was on centers WITH the capacity to sub-specialize, and to accept referrals for complex cases (for example, those otherwise would not be treated w/ RT or those w/ multiple prior RT). We want to push the envelope further and expand much needed RT indication to a wider population. And to expand the use of RT we will need to have some trial evidence (eg. oligoprogression and anything beyond oligomet).

This was not intended to steal patients from the communities. I have referred many patients back to the communities for RT, and have spoken to many colleagues to make the transfer as smoothly as possible.

Happy to discuss further if you DM me.
The problem with the article is one that has been mentioned many times around here in the past. For my part I don't think the article itself is "offensive" or requires "censuring." But its entire thesis is just becoming a laughable old saw and tired mayonnaise. It's the part of the article where it says MSKCC compels board-certified rad oncs to undergo credentialing in SABR and SRS before they used these modalities on metastatic patients. Credentialing to do these types of procedures is also known as "residency" followed by "board certification"... but I realize this is an increasingly radical take. Why not credential for external beam therapy of all sorts? Why not credential rad oncs to give electrons? Or credential for brachy? Credential to be AUs for radioactive substances? A lay person (ie a med onc) reading this article might go "Gee, I wonder if the community guy had credentialing for all the SABR he's doing." Because per the article that seems necessary or at least advisable in order to do SABR or SRS for metastatic disease. "Disease site expertise" in rad onc is always a soi disant expertise (especially in your first year out of residency!). We all get birthed as board-certified rad oncs and there is no recognized subspecialization (eg neuroradiology fellowship after DR residency) in radiation oncology. Whoever says we need all this extra credentialing or approval or recognized specialization in radiation oncology should get the ACGME to agree. It's fine in an institutional academic setting and makes perfect sense there (for division of labor as much as anything). But it's not needed for good care.
 
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Lamount

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The problem with the article is one that has been mentioned many times around here in the past. For my part I don't think the article itself is "offensive" or requires "censuring." But its entire thesis is just becoming a laughable old saw and tired mayonnaise. It's the part of the article where it says MSKCC compels board-certified rad oncs to undergo credentialing in SABR and SRS before they used these modalities on metastatic patients. Credentialing to do these types of procedures is also known as "residency" followed by "board certification"... but I realize this is an increasingly radical take. Why not credential for external beam therapy of all sorts? Why not credential rad oncs to give electrons? Or credential for brachy? Credential to be AUs for radioactive substances? A lay person (ie a med onc) reading this article might go "Gee, I wonder if the community guy had credentialing for all the SABR he's doing." Because per the article that seems necessary or at least advisable in order to do SABR or SRS for metastatic disease. "Disease site expertise" in rad onc is always a soi disant expertise (especially in your first year out of residency!). We all get birthed as board-certified rad oncs and there is no recognized subspecialization (eg neuroradiology fellowship after DR residency) in radiation oncology. Whoever says we need all this extra credentialing or approval or recognized specialization in radiation oncology should get the ACGME to agree. It's fine in an institutional academic setting and makes perfect sense there (for division of labor as much as anything). But it's not needed for good care.


I don't think institutional "credentialing" for SBRT (and brachy, for that matter) is a terrible idea. Incidentally, I am working through some institutional guidelines to try to make sure no patient starts treatment before the case was presented in chart rounds.

The reason for this is... well... people who don't do it so often sometimes forget some of the basics. Not just standard constraints... but also how size should affect fractionation. I would venture to say that many in private practice are more comfortable with SBRT than an academic disease-site specific rad oncs where SBRT is seldom used... thus it may not be as relevant for PP folks.
 

theradiator

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Guys - I was asked by a friend to clarify the matters here.
The point of the article was to advocate the involvement of rad onc in management of metastatic patients, so that they can be managed by all oncology disciplines and get the most appropriate treatment.

Also the emphasis was on centers WITH the capacity to sub-specialize, and to accept referrals for complex cases (for example, those otherwise would not be treated w/ RT or those w/ multiple prior RT). We want to push the envelope further and expand much needed RT indication to a wider population. And to expand the use of RT we will need to have some trial evidence (eg. oligoprogression and anything beyond oligomet).

This was not intended to steal patients from the communities. I have referred many patients back to the communities for RT, and have spoken to many colleagues to make the transfer as smoothly as possible.

Happy to discuss further if you DM me.
A couple of general comments. As stated by Vinay Prasad in his recent podcast, don't write a commentary if you don't want people to get mad at you. Original research is safer!


You should be commended for trying to steer the palliative radiation conversation away from 8 Gy X 1, which would inevitably lead our field to irrelevance for metastatic cancer.

The notion that a MSK breast oncologist is unwilling or unable to perform SBRT for bone metastasis or that a MSK lung oncologist does not take care of brain metastases must seem strange to a medical oncologist or someone otherwise unfamiliar with the workflow of academic radiation oncology, particular inpatient consults. Is this the kind of thing is best discussed on the pages of JAMA Oncology or could this be better worked out in a different forum such as faculty meeting?
 
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Radonc90

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@cujust, I understand some of the points you mentioned above. However, as others have said, it is a somewhat laughable idea...

Here are my thoughts:

Patients are referred to tertiary care center for highly complex stuff like:
- Burned patients go to Burn Centers, specialized in that stuff.
- Kidney or Heart transplant goes to Transplant Centers.
- Recurrent tongue ca goes to places that can do oral interstitial brachytherapy.

In the radonc world...Metastatic. Is. Not. Highly. Complex. Stuff.

OK,

Let's make another analogy:

1- Honda (or any car mfg) dealer is best for complex stuff like Transmission failure or Engine computer issues,
stuffs that are so specialized that only they can handle that. This part I understand.
But Honda dealers often say "come here, we have guys that are so good at oil change, it is only $100
for the oil change". This is bc where the money is, the bread and butter of car repair.
2- Independent mom-and-pop mechanic shop down the street: "Nah, we can do the same oil change for $50".
3- Me: "what the hell, I do the oil change in my driveway for $25, bc the labor is mine".

In the radonc world, metastatic Tx is the "oil change" analogy, anyone with basic radonc skill can do it.

If one cannot understand the "oil change" analogy, then one should not practise radonc. Period.
 
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Thank you @cujust for your response. I have many issues with the article but the main one if you and your friends could address is how pushing for 'metastatic disease' to be a disease site in rad onc is very detrimental to the very idea of a rad onc being an oncologist. It reinforces the stereotype that rad oncs are basement dwelling button pushing technicians. Somehow, stage IV patients are so complicated that a breast rad onc needs to refer to a PROMISE attending. And that PROMISE attending, who is not a breast expert, is somehow so knowledgeable that they can take this stage IV patient and all others (lung, prostate, head/neck, sarcoma, gyn, etc) from every other disease site, and help drive the clinical plan with the primary rad onc, med onc, and/or surgeon?

Can't you and your friends see how that sort of doesn't make sense? Let alone to write an article about it and put in a super misleading figure on the "standard" palliative care workflow. We all know, any rad onc can sim and treat an urgent patient the same day if needed and does not need to an expert in 'metastatic disease'.

To quote myself, is there a med onc that only gives chemo when the the breast cancer is localized to the breast but when there is a spine met, a different med onc who is specially trained in metastatic disease gives the chemo? It sounds ridiculous because the very concept is absurd but that's what the 3 authors are pushing.

We need to be oncologists and your article is in direct contradiction to that. We crap on IR docs who want to ablate bone mets because they aren't oncologists. Well, a PROMISE rad onc attending isn't too far away from an IR doc who is just referred a bone met to ablate. Please tell me how I'm wrong.

The point of the article was to advocate the involvement of rad onc in management of metastatic patients, so that they can be managed by all oncology disciplines and get the most appropriate treatment.
Isn't this the definition of a tumor board? Or simply communicating like a normal rad onc would with the med onc and surgeon about a metastatic patient's plan? Neither concept is new or warrants an article. The point of the article was to advertise and push a "new" rad onc disease site called metastatic disease. Stop gaslighting. This all could have easily been accomplished by a meeting and presentation to the MSKCC med oncs and surgeons.

Before I wrote the post, I showed it to a few med oncs and surgeons. The med oncs laughed at the idea of metastatic disease as a 'new' disease site. A urologist I asked jokingly said so I guess if there is a high positive node on pre-op imaging, I'll take out of the prostate and a metastatic disease trained urologist will go after the node. It's a joke and we should all be embarrassed.

Also the emphasis was on centers WITH the capacity to sub-specialize, and to accept referrals for complex cases (for example, those otherwise would not be treated w/ RT or those w/ multiple prior RT).
I am at an academic center and guess what, those types of cases naturally come to us, especially the re-irradiation cases. Again, this is not a new concept which is that academic centers have the ability to sub-specialize in a variety of sub-sites and specialties so private practice docs will often send complicated cases to a person who just sees one disease site aka academics. Again, does not warrant an article. Stop gaslighting.

We want to push the envelope further and expand much needed RT indication to a wider population. And to expand the use of RT we will need to have some trial evidence (eg. oligoprogression and anything beyond oligomet).
So then push the field forward. We are all behind you and agree. Go run detailed retrospective studies on re-irradiation which would be useful since there isn't that much good data or oligmet clinical trials. Don't waste our time and your time by publishing this kind of crap. It's like DoorDash spending $5.5 million to advertise their $1 million charity donation. Translation: DoorDash spent $6.5 million on advertising. Stop gaslighting and just admit you guys wanted to toot your own horn, get an article in a high impact journal, and convince Simon Powell that 'metastatic disease' is a new disease site unique to rad onc for promotion and research funding.

I am a believer in academics and I am a believer in private practice/community practice. But this article is worst type of academic circle-jerking that drives many of the brightest residents to private practice and I can't blame them. Instead of tooting your own horn, why can't you guys just do metastatic disease research like other people and publish that? Does David Palma call himself a metastatic disease expert? No. He is an oncologist who specializes in the treatment of head/neck and lung cancers with radiotherapy and author of the SABR-COMET trial. And he isn't perfect because he has a couple not well designed trials but at least he isn't parading around writing bullsh*t articles about how metastatic disease is the new rad onc disease site which show our referring docs that rad oncs are bunch of basement dwelling button pushing technicians for whom metastatic disease is too complicated to understand.

This was not intended to steal patients from the communities. I have referred many patients back to the communities for RT, and have spoken to many colleagues to make the transfer as smoothly as possible.
This is not how I read the article's conclusion but ok, if you say so.

Happy to discuss further if you DM me.
I'm not sliding into your DMs. These discussions should happen for others to see so it can be critiqued. Two weeks ago, I posted terrible idea of shaming medical students who match at terrible programs. I got absolutely slammed and rightfully so. But I didn't ask people to DM me their thoughts. If we can't acknowledge our mistakes and own them, we are so far beyond f*cked that you guys might as well just hire me as head of the PROMISE service at MSKCC.
 
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Palex80

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I don't think institutional "credentialing" for SBRT (and brachy, for that matter) is a terrible idea. Incidentally, I am working through some institutional guidelines to try to make sure no patient starts treatment before the case was presented in chart rounds.

The reason for this is... well... people who don't do it so often sometimes forget some of the basics. Not just standard constraints... but also how size should affect fractionation. I would venture to say that many in private practice are more comfortable with SBRT than an academic disease-site specific rad oncs where SBRT is seldom used... thus it may not be as relevant for PP folks.
I understand your point but these are two totally different things.

Let's assume we have a case of T1 N0 NSCLC, medically inoperable ptient. Would he fare better if:

a) his case was managed by a radiation oncologist who had done a fellowship on SBRT
or if
b) his case was managed by an "ordinary" radiation oncologist who treats with SBRT (for any site) two times per month but will take the time to discuss the case and review the plan with his 3 other partners who also manage an SBRT patient each once per month.

I don't know.
I think both options are reasonable. And if it's not a difficult SBRT case, like a very centrally located tumor, I assume the outcome would be the same.
Still there are many people who think that only option a) should be considered for all patients receiving SBRT in the lung.
 
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cujust

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All- I appreciated your comments and I liked the discussions of controversial topics. It is natural that people disagree. I don't have the bandwidth to address all of the points here but to select a few:

1) Credentialing is helpful in large academic centers where everyone is very subspecialized, as someone pointed out above. It certainly benefited our institution. The article did not say everyone should undergo this process everywhere.
2) There are med oncs specializing in phase 1 programs and conducting trials inclusive of different histologies. Having a dedicated metastatic disease service in rad onc allows us to have a similar purpose in taking care of patients and conducting trials to answer questions.
3) The service actually makes rad oncs more of an oncologist than what was stated above- this is our firsthand experience. The attendings are well versed in several lines of systemic therapies and experimental trial drugs the patients may be getting, and are aware of possible interactions with RT in different settings.
4) To say metastatic disease in the rad onc world is not complex is absolutely wrong - that's what makes people think we are technicians. Do you want the med oncs to come to you to discuss when and how the patient's next line of therapy should be given and get your suggestions on if/where the patient would benefit from RT, and involve you in the treatment decision making jointly? Or do you want them to just send whatever patient they think need palliation and have you be the technician for 8Gyx5 or SBRT? Your call.

Anyway, I realize that people will always disagree. Feel free to write a rebuttal to the journal and state the concerns/disagreement - this will reach a wider audience than SDN.

Have a nice evening!
 

Radonc90

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Let me clarify what I said above.

IMHO, Metastatic is "not complex enough to refer". Any good decent radonc (academic vs PP) can handle it.
In other words, met can be complex, but in my book, not complex enough to refer.
Kidney transplant: yes to referral.
Cardiac transplant: yes to referral.

PS: When I saw the tile of that article, I read for a few lines then stop.
I sit on the Rank and Tenure committee for promotion, so I know the drill...
 
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Thank you @cujust for taking the time to respond. I disagree with your response just as you disagree with my points. Thank you for engaging.

I think I realized what is partly really grinding my gears. Basically, the PROMISE service exists because you guys (MSKCC rad onc dept) are on a non-RVU model. If I remember, you guys have a set number of consults per week and number of sims per year you need to hit. There are other departments like that and almost always, some sort of inpatient rad onc service or call system exists to deal with the palliative care consults. In academic practices where there are RVU incentives, there is no such service like PROMISE because metastatic patients go back to the primary rad onc because of clinical care but also because of RVUs. If you guys moved to an RVU based compensation model, all of the sudden, the primary disease site attendings would be wanting their patients back because of "continuity of care" or whatever clinical justification.

Basically PROMISE means "palliative consult service that exists because primary disease site rad oncs can't be flooded daily with the high number of (mostly inpatient and some outpatient) consults and this works at MSKCC because attendings are not incentivized on an RVU bonus model. Oh and I'm not in Manhattan 5 days a week so need some kind of inpatient consult service to take those patients."

Also, many of you guys split time between the main site and satellites so it is impractical for you guys to take back all your own patients when they met out. So there is a practical scheduling consideration here as well.

So PROMISE exists as a function of the financial compensation system (and how you guys split time between the main site and satellites) of your dept. But then, 3 of the attendings decide to do some massive mental gymnastics about why PROMISE and their service is so special and that they are founding a new disease site for rad onc. Give me a f*cking break. PROMISE would not exist if MSKCC moved to an RVU model, I guarantee it. So as a fellow academic, it is just insulting to see 3 attendings pat themselves on the back for something that should never have been written about. It's a total academic circle jerk in the worst way possible.

3) The service actually makes rad oncs more of an oncologist than what was stated above- this is our firsthand experience. The attendings are well versed in several lines of systemic therapies and experimental trial drugs the patients may be getting, and are aware of possible interactions with RT in different settings.
I'm sure that's true of the PROMISE attendings. But I'm sure it's also true of breast rad oncs, lung rad oncs, head/neck rad oncs, etc. If anything, it is hard to believe a PROMISE attending can be more up to date on the complicated management of metastatic patients for every single disease site than a primary disease site attending who has one or two disease sites.

4) To say metastatic disease in the rad onc world is not complex is absolutely wrong - that's what makes people think we are technicians. Do you want the med oncs to come to you to discuss when and how the patient's next line of therapy should be given and get your suggestions on if/where the patient would benefit from RT, and involve you in the treatment decision making jointly? Or do you want them to just send whatever patient they think need palliation and have you be the technician for 8Gyx5 or SBRT? Your call.
No one said anything about metastatic disease being not complicated. It can be very complicated. Again, to my point above, there is no way a PROMISE attending knows more about the complicated management of each disease site for metastatic patients than an attending with one or two primary disease sites. You are basically saying that without PROMISE, med oncs wouldn't talk to the rad oncs about the care of stage IV patients. I disagree strongly.

There is no such service like PROMISE at my institution and guess what, med oncs come to me to discuss when and how the patient's next line of therapy should be given and get my suggestions on if/where the patient would benefit from RT, and involve me in the treatment decision making jointly. This is normal across many academic institutions. Maybe not all but it's not like a med onc talking to me about a when/how to RT a met vs going on systemic therapy is some kind of unicorn situation. Happens almost every. single. day. I PROMISE it's true.

In summary, I don't care that a service like PROMISE exists. In fact, given your dept's financial compensation structure and mix of main site/satellite coverage of the attendings, it makes perfect sense. Many depts have a similar service. The issue is you guys writing an article about it making a huge deal of literally nothing and insulting rad oncs everywhere by saying that metastatic disease is so complicated that it warrants its own 'disease site' hence the PROMISE service. Instead the article should have said, "we need the a team of dedicated attendings to help deal with a massive volume of mostly inpatient consults and we aren't incentivized to keep our own patients that met out so yeah, we are submitting this to JAMA Onc so we can use it for promotion lol, please accept this crap!"

Edit: Added the last paragraph.
 
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Anyone else notice that in the “Metastatic Disease Program” that they dropped radiation planning as a step?
 
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cujust

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Thank you @cujust for taking the time to respond. I disagree with your response just as you disagree with my points. Thank you for engaging.

I think I realized what is partly really grinding my gears. Basically, the PROMISE service exists because you guys (MSKCC rad onc dept) are on a non-RVU model. If I remember, you guys have a set number of consults per week and number of sims per year you need to hit. There are other departments like that and almost always, some sort of inpatient rad onc service or call system exists to deal with the palliative care consults. In academic practices where there are RVU incentives, there is no such service like PROMISE because metastatic patients go back to the primary rad onc because of clinical care but also because of RVUs. If you guys moved to an RVU based compensation model, all of the sudden, the primary disease site attendings would be wanting their patients back because of "continuity of care" or whatever clinical justification.

Basically PROMISE means "palliative consult service that exists because primary disease site rad oncs can't be flooded daily with the high number of (mostly inpatient and some outpatient) consults and this works at MSKCC because attendings are not incentivized on an RVU bonus model. Oh and I'm not in Manhattan 5 days a week so need some kind of inpatient consult service to take those patients."

Also, many of you guys split time between the main site and satellites so it is impractical for you guys to take back all your own patients when they met out. So there is a practical scheduling consideration here as well.

So PROMISE exists as a function of the financial compensation system (and how you guys split time between the main site and satellites) of your dept. But then, 3 of the attendings decide to do some massive mental gymnastics about why PROMISE and their service is so special and that they are founding a new disease site for rad onc. Give me a f*cking break. PROMISE would not exist if MSKCC moved to an RVU model, I guarantee it. So as a fellow academic, it is just insulting to see 3 attendings pat themselves on the back for something that should never have been written about. It's a total academic circle jerk in the worst way possible.


I'm sure that's true of the PROMISE attendings. But I'm sure it's also true of breast rad oncs, lung rad oncs, head/neck rad oncs, etc. If anything, it is hard to believe a PROMISE attending can be more up to date on the complicated management of metastatic patients for every single disease site than a primary disease site attending who has one or two disease sites.


No one said anything about metastatic disease being not complicated. It can be very complicated. Again, to my point above, there is no way a PROMISE attending knows more about the complicated management of each disease site for metastatic patients than an attending with one or two primary disease sites. You are basically saying that without PROMISE, med oncs wouldn't talk to the rad oncs about the care of stage IV patients. I disagree strongly.

There is no such service like PROMISE at my institution and guess what, med oncs come to me to discuss when and how the patient's next line of therapy should be given and get my suggestions on if/where the patient would benefit from RT, and involve me in the treatment decision making jointly. This is normal across many academic institutions. Maybe not all but it's not like a med onc talking to me about a when/how to RT a met vs going on systemic therapy is some kind of unicorn situation. Happens almost every. single. day. I PROMISE it's true.

In summary, I don't care that a service like PROMISE exists. In fact, given your dept's financial compensation structure and mix of main site/satellite coverage of the attendings, it makes perfect sense. Many depts have a similar service. The issue is you guys writing an article about it making a huge deal of literally nothing and insulting rad oncs everywhere by saying that metastatic disease is so complicated that it warrants its own 'disease site' hence the PROMISE service. Instead the article should have said, "we need the a team of dedicated attendings to help deal with a massive volume of mostly inpatient consults and we aren't incentivized to keep our own patients that met out so yeah, we are submitting this to JAMA Onc so we can use it for promotion lol, please accept this crap!"

Edit: Added the last paragraph.

Do you think this kind of conversation is helpful? If so, then continuation of the conversation is fine.

A few points:
- From what you wrote it is obvious that you do not understand the compensation structure at MSK, so stop disseminating wrong information of other institutions (and I find no point of clarifying it to you).
- There is actually a dedicated inpatient consult service/program; so your presumption of the premises of PROMISE team is wrong. Should we also write another opinion piece about our dedicated inpatient team? :))
- I am not sure if you actually read the article. The program is not just "palliative consult". Integrated multi-D clinic (bone met clinic, spine met clinic etc) and research are big part of this. There are so many histolog-agnostic trials we are running now and having this program makes it much easier.
- As a fellow academic, you should know that an opinion piece does not count toward academic peer-reviewed publication for promotion.
- This is an opinion piece. You can certainly have different opinions. But please write a rebuttal if you want your voice heard widely. Why the anger?

Anyway, I am really not sure if this kind of online exchange is productive? Happy to share more thoughts if this can be helpful. Otherwise, as the only non-anonymous person here you all know where to find me! :)
 
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RadOncMegatron

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Do you think this kind of conversation is helpful? If so, then continuation of the conversation is fine.

A few points:
- From what you wrote it is obvious that you do not understand the compensation structure at MSK, so stop disseminating wrong information of other institutions (and I find no point of clarifying it to you).
- There is actually a dedicated inpatient consult service/program; so your presumption of the premises of PROMISE team is wrong. Should we also write another opinion piece about our dedicated inpatient team? :))
- I am not sure if you actually read the article. The program is not just "palliative consult". Integrated multi-D clinic (bone met clinic, spine met clinic etc) and research are big part of this. There are so many histolog-agnostic trials we are running now and having this program makes it much easier.
- As a fellow academic, you should know that an opinion piece does not count toward academic peer-reviewed publication for promotion.
- This is an opinion piece. You can certainly have different opinions. But please write a rebuttal if you want your voice heard widely. Why the anger?

Anyway, I am really not sure if this kind of online exchange is productive? Happy to share more thoughts if this can be helpful. Otherwise, as the only non-anonymous person here you all know where to find me! :)
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Yo, I'm not with @cujust on this one (ie I am not in favor of a oligomets speciality), but good to see the she can throw down and won't let anonymous posters get away with too much.

It's always good for us to be careful we might get a clap back from some of our finest :claps:

I forget sometimes the folks we complain about are quite formidable.
 
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She brought it!

Some of the replies were quite impolite and unprofessional (especially if truly from an academic). Even with the disrespect, she handled it with grace. I really didn’t like the tone directed at her. She’s right - it’s an opinion piece and a description of their process. One can surely disagree without being disagreeable. Then again, isn’t this the same person that wants to shame students?

Side note: at a place like Sloan, do you really want the breast person doing spine sbrt ?? Could be dicey!
 
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As someone who spends half their time just treating oligomets, refining techniques for treating oligomets, and publishing (retrospective stuff) on the topic, I do emphasize with cujust.

There is a lot of thought and specialized equipment that goes into the SBRT/SRS cases that I do, and I know a lot of rad oncs both inside and outside of academics who I don't think do it the right way and compromise control or give undue toxicity. It's not as easy as draw a few circles, prescribe a dose, and let physics/dosimetry figure out the rest.

But, from experience I also know that this is a fight I cannot win. Most rad oncs in my experience only refer for brachy, maybe. They hire for personality or connections, not skills with techniques. As long as everyone can draw circles and give dose on whatever linac they have, that is what they will do.

But we also have to respect that there is no clear data that my way is the best way. Sure I go to higher doses than most of my colleagues, and I have very specific protocols for simulation and IGRT. My colleagues mostly think it's too cumbersome and just do it their own way. And what can I say? More dose does not necessarily equal better outcome. Even the oligomet trials I do not think get it right--but I think they have to be written at a basic enough level that everyone can accrue.

The onus is on us to prove the value of the techniques we provide. Until we do that, there is no point in trying to convince others to send us patients or claim that we do things better for patients. In the end, I never turn anyone away who asks me for help, even when I don't get RVUs for it. I would also never write an editorial on the topic--again I just think it's a fight I cannot, and based on what little evidence I have, should not win.
 
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RadOncDoc21

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As someone who spends half their time just treating oligomets, refining techniques for treating oligomets, and publishing (retrospective stuff) on the topic, I do emphasize with cujust.

There is a lot of thought and specialized equipment that goes into the SBRT/SRS cases that I do, and I know a lot of rad oncs both inside and outside of academics who I don't think do it the right way and compromise control or give undue toxicity. It's not as easy as draw a few circles, prescribe a dose, and let physics/dosimetry figure out the rest.

But, from experience I also know that this is a fight I cannot win. Most rad oncs in my experience only refer for brachy, maybe. They hire for personality or connections, not skills with techniques. As long as everyone can draw circles and give dose on whatever linac they have, that is what they will do.

But we also have to respect that there is no clear data that my way is the best way. Sure I go to higher doses than most of my colleagues, and I have very specific protocols for simulation and IGRT. My colleagues mostly think it's too cumbersome and just do it their own way. And what can I say? More dose does not necessarily equal better outcome. Even the oligomet trials I do not think get it right--but I think they have to be written at a basic enough level that everyone can accrue.

The onus is on us to prove the value of the techniques we provide. Until we do that, there is no point in trying to convince others to send us patients or claim that we do things better for patients. In the end, I never turn anyone away who asks me for help, even when I don't get RVUs for it. I would also never write an editorial on the topic--again I just think it's a fight I cannot, and based on what little evidence I have, should not win.
I admire your honesty and approach and respect you for your contributions not only on here but what you are doing with your patients. I wish there were more in academics like you. I have to compete with an academic center that is claiming that only gamma knife can be used for brain mets.
 
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Very kind of you buddy. Thank you :thumbup:

I have to compete with an academic center that is claiming that only gamma knife can be used for brain mets.

You sure it isn't our center? LOL. We have both GK and linac SRS options and oh boy some of the surgeons are stuck on the GK.

I try to be neutral about it, which does not win me any favors. There's so much pressure in life to tow the party/institutional line. The worst is when the surgeon insists on having me sit there all day to treat 15 brain mets on GK when I could have just done a monoisocentric linac setup. Even worse than that is when the plan quality on the GK sucks because they wanted to treat all 15 brain mets with a single shot too. What happened to the only way to cure brain mets is at 50% IDL? Now all of a sudden everything is at 70%+ IDL because we couldn't let the treatment time be 10 hours?

While there is some stuff I like for GK with a head frame, 90%+ of your brain met cases are served just fine by a good linac setup IMO. A lot of patients want that Gamma Knife or CyberKnife though. Marketing works. Don't get me started on protons.
 
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Example #467 that we all have too much time on our hands and need more patients to treat.

I read this article as: We are trying to sell a couple unneeded FTE for new grads to our administration, so we invented a new role and contorted ourselves to demonstrate the value of it. It comes along with a promise that we'll start a fellowship in palliative XRT in the next two years.
 
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At this point, we can agree to disagree. I don't want people to get lost in the weeds of this thread. And it has generated more than enough discussion on and off SDN that people can make up their own minds.

The main point is that rad oncs are oncologists and metastatic disease is a very important extension of what rad oncs do, in academia and the community. It is should never be, and hopefully never will be, a separate disease site as I sincerely believe the best person to manage metastatic disease is the primary rad onc who treated their primary cancer and at this point, trained in SABR/SBRT and SRS (except for the oldest of boomers, SABR/SBRT and SRS aren't exotic techniques done only in the ivory tower). If others disagree, ok that's fine because everyone is entitled to their own opinion, but I sincerely believe you are in the minority and want you all to realize the potential damage you are doing to the image of rad oncs as oncologists by pushing this idea that metastatic disease is a separate disease site for rad oncs.


- From what you wrote it is obvious that you do not understand the compensation structure at MSK, so stop disseminating wrong information of other institutions (and I find no point of clarifying it to you).
The big picture I was trying to get across was that MSKCC was not a heavily RVU driven dept. Can you enlighten us? I'm genuinely curious but understand if you don't want to share. I thought at least for junior docs, it's 4 weeks of vacation, 250 sims/year, ~8 consults/week for ~$420k (maybe head/neck has a lower consult and sim threshold because of pt complexity). And if there is an RVU bonus structure, it is small (<10% of your total pay). By the way, for the medical students and residents, if you think $425k is a lot, you're wrong. For 250 sims/year, on the professional fees alone, you should be making much more than that. Of course there are small things like good citizenship but usually that's a small part of anyone's pay. I assume there is some pay tied to teaching and research? We do have some teaching and research metrics as well and most of them are pretty easy to meet.

- There is actually a dedicated inpatient consult service/program; so your presumption of the premises of PROMISE team is wrong. Should we also write another opinion piece about our dedicated inpatient team? :))
Lol that made me chuckle. And I stand corrected about the workings of your inpatient team and PROMISE. Thank you for correcting me and now I have learned something. I apologize for making an assumption that was wrong in my earlier posts. I don't think it changes my main points of my argument but appreciate being corrected, thank you.

- As a fellow academic, you should know that an opinion piece does not count toward academic peer-reviewed publication for promotion.
Yes, of course. I meant promotion as in self-promotion and advertisement. Hence the DoorDash example and "tooting your own horn." I should have clarified.

- This is an opinion piece. You can certainly have different opinions. But please write a rebuttal if you want your voice heard widely. Why the anger?
I'm angry at the idea of rad oncs calling for a new disease site of metastatic disease. It makes us look bad to the med oncs and it is insulting to our colleagues in private practice/the community. Our field has enough problems and bad publications (see the horrendous Penn article by Butala et al about certifying a network of palliative care networks that @medgator posted above) without making rad oncs looking like basement button pushers and calling for a referral hub that evokes the tired trope of "academic good, community bad" which I know you said wasn't your intention but it sort of reads that way.

I'm angry for a lot of reasons at the current state of our field which I should probably detail elsewhere but also I'm projecting onto these 3 MSKCC attendings. Why? This year, I read LORs for a couple of students applying into rad onc who did a year at MSKCC for research. Nothing wrong with what they published but to gaslight young students into spending an entire year publishing what amounts to minor retrospective chart reviews (when they would have matched just fine, especially this year) leaves a really bad taste in my mouth when we look at the current state of the field and the job market those kids are going to graduate into. And also I don't hate MSKCC and know many attendings there - you guys are great institution and the -omics work such as with cbioportal has been incredible for our field so thank you. Again, it is just the idea of the article that I'm attacking because to me, it attacks the very idea of a rad onc being an oncologist.
 
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All of this makes an even stronger point to dramatically tightening residecy requirements, closing down bad no good “residencies”, getting rid of unlimited certificates for old timers . If the concern is that certain people dont know how to do sbrt/srs “comfortably”, should they be working at all? Maybe they should be trained? this is a mandatory competency in 2021. To hire these people is criminal.

we need better training programs and highly competent people to lift our field out of the toxic sludge deep sewers, where even the rats and cockroaches no longer go, where boils no longer heal, where animals no longer have eyes. Is there even life down here?
 
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All of this makes an even stronger point to dramatically tightening residecy requirements, closing down bad no good “residencies”, getting rid of unlimited certificates for old timers . If the concern is that certain people dont know how to do sbrt/srs “comfortably”, should they be working at all? Maybe they should be trained? this is a mandatory competency in 2021. To hire these people is criminal.

we need better training programs and highly competent people to lift our field out of the toxic sludge deep sewers, where even the rats and cockroaches no longer go, where boils no longer heal, where animals no longer have eyes. Is there even life down here?
How can Columbia, Stanford, Maryland, inova and the like fill their unaccredited fellowship spots without the bottom half of residents graduating from programs that probably shouldn't even be open in the first place??

Think of the fellowship programs!
 
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As someone who spends half their time just treating oligomets, refining techniques for treating oligomets, and publishing (retrospective stuff) on the topic, I do emphasize with cujust.

There is a lot of thought and specialized equipment that goes into the SBRT/SRS cases that I do, and I know a lot of rad oncs both inside and outside of academics who I don't think do it the right way and compromise control or give undue toxicity. It's not as easy as draw a few circles, prescribe a dose, and let physics/dosimetry figure out the rest.

But, from experience I also know that this is a fight I cannot win. Most rad oncs in my experience only refer for brachy, maybe. They hire for personality or connections, not skills with techniques. As long as everyone can draw circles and give dose on whatever linac they have, that is what they will do.

But we also have to respect that there is no clear data that my way is the best way. Sure I go to higher doses than most of my colleagues, and I have very specific protocols for simulation and IGRT. My colleagues mostly think it's too cumbersome and just do it their own way. And what can I say? More dose does not necessarily equal better outcome. Even the oligomet trials I do not think get it right--but I think they have to be written at a basic enough level that everyone can accrue.

The onus is on us to prove the value of the techniques we provide. Until we do that, there is no point in trying to convince others to send us patients or claim that we do things better for patients. In the end, I never turn anyone away who asks me for help, even when I don't get RVUs for it. I would also never write an editorial on the topic--again I just think it's a fight I cannot, and based on what little evidence I have, should not win.
A discussion regarding the nuances of treating oligomets would be a worthwhile thread. Almost as good as this one probably.
 

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How can Columbia, Stanford, Maryland, inova and the like fill their unaccredited fellowship spots without the bottom half of residents graduating from programs that probably shouldn't even be open in the first place??

Think of the fellowship programs!
Don’t forget Miami cancer center. They seem to love cheap labour in that city!!
 
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Side note: at a place like Sloan, do you really want the breast person doing spine sbrt ?? Could be dicey!
Yes, I do. The MSKCC rad oncs I know are great physicians and spine SBRT isn't so complicated that they couldn't learn it (if they weren't trained in it during residency). I think they should be doing spine SBRT and SRS for brain mets. If anything, you are depriving patients of developing a continued relationship and continuity of care with their wonderful MSKCC breast rad onc.
 
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Yes, I do. The MSKCC rad oncs I know are great physicians and spine SBRT isn't so complicated that they couldn't learn it (if they weren't trained in it during residency). I think they should be doing spine SBRT and SRS for brain mets. If anything, you are depriving patients of developing a continued relationship and continuity of care with their wonderful MSKCC breast rad onc.
Precisely. No one comes out of residency as an expert in anything. What residency should be able to do is lay a foundation of knowledge, and, more importantly, teach someone how to learn Radiation Oncology for the rest of their life, to adapt and change as the specialty evolves. Then, when Sloan develops new techniques and regimens to improve the care of the longer-living metastatic population, these board-certified Radiation Oncologists across the nation can learn from these hyper-specialized centers and apply novel treatments to patients. The "Metastatic Academic Radiation Oncologist" thus creates new knowledge for a Generalist/[insert whatever here] Radiation Oncologist to continue to play a vital and pivotal role in the care of patients as part of a multidisciplinary team.

At least, that's how I've always envisioned this process.
 
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RadOncMegatron

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I shake my head at the idea that there can be a "metastatic disease site expert." Well why not lung oligometastatic disease site expert? Or Lung SRS for ALK+ patients?

Heck, why not left sided breast cancer specialist rad oncs?

We all see the rationale for "met site expert," but please @cujust the down side to such a proposition is very great! The shame it brings to our specialty, the shame it brings to those who are not disease site experts, and the shame from our referring colleagues (med onc, surg onc, etc.) who must be beside themselves thinking we require another subsite specialty? I beg MSKCC and MDACC to stop splintering our field more than it is...

The editorial should have read "In the normal course of radiation oncology training , our physicians are the only ones to learn all of oncology from peds, gyn, even TBI for hematologic malignancies. Our graduates are at the top of the class [well not now... but I digress] and our field is leading the way for oligometastases in the clincal trial space. As an educator, I am confident the average radiation oncologist is able to take a lead role in the treatment of oligometastatic disease and is adept in the use of SRS and SBRT. This is part of our 'bread and butter' and I have full confidence in my colleagues."

Edit: I would not write "bread and butter" in an academic article but you get the point.
 
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RadOncDoc21

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Oct 24, 2010
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I fancy myself a proximal seminal vesicle prostate cancer expert.
I only specialize in initial thoracic bone mets, preferably either lung or prostate primary. My partner prefers lumbar spine and pelvis, breast primary mainly but only ER+ and ki-67 less than 10%.
 
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