Boomer attending finally retiring

[RadOncDoc21]

This is a great thread because every radiation oncologist can think back on their training and relate.

Here's a photo from my programs first SBRT treatment circa 2012:
View attachment 364005

I bet that machine still works. We used that for our trigems! The radiation just always knows how to get where it’s suppose to be.

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[taserlaser]

This is a great thread because every radiation oncologist can think back on their training and relate.

Here's a photo from my programs first SBRT treatment circa 2012:
View attachment 364005

This literally looks like my orthovoltage setup yesterday for my 95 yo pt. 20 Gy x 1. Sometimes, I’m not sure how much has changed

 

[evilbooyaa]

This is a great thread because every radiation oncologist can think back on their training and relate.

Here's a photo from my programs first SBRT treatment circa 2012:
View attachment 364005

In regards to OP, sorry to hear a giant of the field has had their career ended in such a manner!



That being said, I am blown away that a man who was a household name in Rad Onc SO long ago was still working, and apparently had actual clinical volume (rather than just being a figurehead who sits around in meetings, farts, tells inappropriate jokes, and picks his nose most of the day). It's such a sad in academics when your facility actually expects such giants of the field to actually earn their money by seeing patients (and WITHOUT a resident to do all the work! The travesty!) and not simply rest on the laurels of research... that research that is now so old it could join the army, buy booze, or even rent a car without an extra fee.

/s

 

[sirspamalot]

Agree. A “bad” surgeon in the community is worse than a “bad” rad onc in the community.

You cannot even begin to imagine how bad a solo radonc working in Clucksville, Nowhereland can be... and, the dude had a ? stroke and was still practicing. But.. ok you say, maybe its a minor thing right? Uh.. beyond the funky schemes and margins.. lets skip over that for now..

The notes.. the the notes were so bad.. sure, cut n'paste nonsense prevailed, but when an attempt at writing WAS made it was.. nonsensical. There was no way for anyone to stop the train wreck short of saying "are you SURE, like SURE you want me to do this?" but they (tech staff) did it anyway. Nobody died.

(thank goodness?) No one has a benchmark on recurrence rates in our world.. unlike surgical M&M's. So.. unless you sever a cord or liquify an organ... you good. You can be a very bad radonc for a very long time.. possibly an entire career, and no one will know.

And I wince thinking about the minutiae I was tortured on 20 years ago. The fear of doing something wrong remains healthy (for me).

I will say this: if you are trained well, to be dutiful and careful, and if you are inclined to be that kind of person.. then it will never leave you.
Not age 30, not 50, and not 70. You are who you are... nobody just "changes" and your will to be 'good' is your own.

 

[sirspamalot]

In regards to OP, sorry to hear a giant of the field has had their career ended in such a manner!



That being said, I am blown away that a man who was a household name in Rad Onc SO long ago was still working, and apparently had actual clinical volume (rather than just being a figurehead who sits around in meetings, farts, tells inappropriate jokes, and picks his nose most of the day). It's such a sad in academics when your facility actually expects such giants of the field to actually earn their money by seeing patients (and WITHOUT a resident to do all the work! The travesty!) and not simply rest on the laurels of research... that research that is now so old it could join the army, buy booze, or even rent a car without an extra fee.

/s

 

[sirspamalot]

 

[evilbooyaa]

 

[flannery o'connor]

Boomer doctors were a million times realer and more knowledgable about medicine in general than our generation though.

 

[sirspamalot]

DM me puhweeze?

 

[Ray D. Ayshun]

Flannery O'Connor? I can't wait to see where this barrage is gonna go. I think we won the lottery.

 

[OTN]

Boomer doctors were a million times realer and more knowledgable about medicine in general than our generation though.

Nope, I cannot do it. I tried, I really did, but I simply cannot let this sit without replying, so I'll take the bait and start: How do you figure? Because my experience, especially within radiation oncology, has been the precise opposite, and that's just addressing the "knowledgeable" part of it.

When it comes to keeping it real, given the incredible generational position in which the Boomers were thrust post-WWII and their absolute refusal to either acknowledge this benefit or do anything to try to help future generations, I would say they are the least "real", greediest, least-self aware, laziest, most entitled, and most self-important generation in American history. They are running the gerontocracy which is bleeding this country dry.

 

[medgator]

Boomer doctors were a million times realer and more knowledgable about medicine in general than our generation though.

 

[sirspamalot]

Nope, I cannot do it. I tried, I really did, but I simply cannot let this sit without replying, so I'll take the bait and start: How do you figure? Because my experience, especially within radiation oncology, has been the precise opposite, and that's just addressing the "knowledgeable" part of it.

When it comes to keeping it real, given the incredible generational position in which the Boomers were thrust post-WWII and their absolute refusal to either acknowledge this benefit or do anything to try to help future generations, I would say they are the least "real", greediest, least-self aware, laziest, most entitled, and most self-important generation in American history. They are running the gerontocracy which is bleeding this country dry.

 

[flannery o'connor]

I like to pile on Boomers as much as the next guy but lets be honest here. You can actually hold an honest, fortright dialogue with Boomer rad oncs, med oncs, and surgeons and give your opinion while they give yours and refer to one another by your last name and either come to an agreement or disagree respectfully. Do that with a millennial or gen x RO and they’ll try to cancel you or initiate steps to get rid of you. No intellectual flexibility at all and will do whatever their corporate masters tell them.



Boomers could actually manage a patient as a physician. Current crop of ROs are but mere technicians.



Also Boomers doctors had legitimate intellectual interests outside of medicine—you could talk literature, music, history, science, philosophy with them—can you say the same about our generation?



And at the end of the day, has IMRT and voluming increased curative rates? Let’s be honest here and wake up to ourselves. It’s not the Boomers who have ruined us, it’s our generation and the malignant people we have allowed to metastasize throughout the profession.

 

[sirspamalot]

Yeah man, maybe another 38 yo RO with his nuts in his stomach can find more indications to eliminate RT indications! Must be the Boomers!

Ooooooh. Me likey. But the thread moderators will be shuttin' this down faster than a chiller blowout does on a linac in 3....2..

 

[medgator]

I like to pile on Boomers as much as the next guy but lets be honest here. You can actually hold an honest, fortright dialogue with Boomer rad oncs, med oncs, and surgeons and give your opinion while they give yours and refer to one another by your last name and either come to an agreement or disagree respectfully. Do that with a millennial or gen x RO and they’ll try to cancel you or initiate steps to get rid of you. No intellectual flexibility at all and will do whatever their corporate masters tell them.



Boomers could actually manage a patient as a physician. Current crop of ROs are but mere technicians.



Also Boomers doctors had legitimate intellectual interests outside of medicine—you could talk literature, music, history, science, philosophy with them—can you say the same about our generation?

I'm a Gen X'er, but my experience has been (in addition to ours being the greatest of the current crop alive 😁😁) that the millennials graduating the last few years actually had to work their ass off to match into rad onc vs some of the boomers who literally walked into the field in the 80s and 90s when it was as easy to match into as it is today. Those boomers couldn't contour a parotid to save their life.

So yes, there is definitely some academic rot with millennials and their stupid elimination/de-escalation studies, no doubt, but it pales in comparison to the legion of boomer chairs and faculty who have expanded and trashed the specialty to no end (Marcus Randall, D Hallahan, L potters, M Steinberg etc).

 

[flannery o'connor]

I'm a Gen X'er, but my experience has been (in addition to ours being the greatest of the current crop alive 😁😁) that the millennials graduating the last few years actually had to work their ass off to match into rad onc vs some of the boomers who literally walked into the field in the 80s and 90s when it was as easy to match into as it is today. Those boomers couldn't contour a parotid to save their life.

So yes, there is definitely some academic rot with millennials and their stupid elimination/de-escalation studies, no doubt, but it pales in comparison to the legion of boomer chairs and faculty who have expanded and trashed the specialty to no end (Marcus Randall, D Hallahan, L potters, M Steinberg etc).

I don't know if it does. Think of all the indications that have vanished over time. It is absolutely criminal that we lost lymphoma.

 

[medgator]

I don't know if it does. Think of all the indications that have vanished over time. It is absolutely criminal that we lost lymphoma.

Shouldn't be surprising.... And honestly was that a really big part of our practice to begin with?

 

[flannery o'connor]

Shouldn't be surprising.... And honestly was that a really big part of our practice to begin with?

More effective and less toxic than ABVD...again, another arena where the patients lose.

 

[RickyScott]

Shouldn't be surprising.... And honestly was that a really big part of our practice to begin with?

In residency we had so many lymphomas and myleomas on beam. Now I see one every 3-4 months.

 

[medgator]

More effective and less toxic than ABVD...again, another arena where the patients lose.

I agree that the role in consolidation shouldn't have been eliminated but really that's a losing fight with med onc. Honestly felt like I wasn't seen that much in training or in practice.

Much easier to control referrals in solid tumors vs malignant heme imo

 

[TheWallnerus]

Shouldn't be surprising.... And honestly was that a really big part of our practice to begin with?

It was not. But otoh it’s about the 7th or 8th most common cancer.

 

[sirspamalot]

It was not. But otoh it’s about the 7th or 8th most common cancer.

This thread died with a whimper like our specialty did. Dayum.

 

[RickyScott]

GI next to die.

 

[medgator]

GI next to die.

Maybe pancreas and gastric. Gastric pretty much dead. Everything else looking ok

 

[RickyScott]

Maybe pancreas and gastric. Gastric pretty much dead. Everything else looking ok

Benefit of xrt in rectal is minimal

 

[medgator]

Benefit of xrt in rectal is minimal

Not if you never go to surgery..

 

[OTN]

I treat a lot of esophagus in addition to rectal. I can't see them going anywhere. I think we're about where we should be in pancreas (I treat a decent amount for palliation) and gastric (data shows we don't bring much to the table).

We also play an important role in liver metastases, HCC, and cholangiocarcinoma. Don't see those going anywhere, either.

 

[Mandelin Rain]

Not if you never go to surgery..

I keep seeing this, and think it's a long shot of an endgame.

There's fairly excellent local control (even without XRT) with TME, and outside of APR, surgery is relatively well tolerated. Why screw things up? I could see definitive chemorads being attempted in select APR patients, but I feel that surgeons would want preop XRT in APR cases anyway.

I feel that 5 or 0 is far more likely that a definitive 30 fractions for proximal/mid-rectals 10 years from now.

 

[NotMattSpraker]

I keep seeing this, and think it's a long shot of an endgame.

There's fairly excellent local control (even without XRT) with TME, and outside of APR, surgery is relatively well tolerated. Why screw things up? I could see definitive chemorads being attempted in select APR patients, but I feel that surgeons would want preop XRT in APR cases anyway.

I feel that 5 or 0 is far more likely that a definitive 30 fractions for proximal/mid-rectals 10 years from now.

Where I trained this used to come up a lot. There is a small semi-vocal minority that believes TME alone is good for many patients, and it probably is true. But it seems the vast majority of oncologists do not agree. I think we will see a lot of 5, very little 30, and some 0 in the highly selected patients that can get away with that (not many).

That said, I do not think surgeons or medical oncologists do that good of a job measuring and reporting toxicity. Radiation toxicity is often over estimated (probably our fault) and medical oncologists and surgeons often gloss over their toxicity as "well tolerated" in the literature. I do think that the new push to incorporate QoL sub-studies in trials and advancing technology for studying QoL will change the landscape a bit.

All that technological advancement we've had may pay off more than we think today. Just floating a prediction based on nothing really.

 

[medgator]

I keep seeing this, and think it's a long shot of an endgame.

There's fairly excellent local control (even without XRT) with TME, and outside of APR, surgery is relatively well tolerated. Why screw things up? I could see definitive chemorads being attempted in select APR patients, but I feel that surgeons would want preop XRT in APR cases anyway.

I feel that 5 or 0 is far more likely that a definitive 30 fractions for proximal/mid-rectals 10 years from now.

Not sure in the era of opra vs rapido

 

[medgator]

I treat a lot of esophagus in addition to rectal. I can't see them going anywhere. I think we're about where we should be in pancreas (I treat a decent amount for palliation) and gastric (data shows we don't bring much to the table).

We also play an important role in liver metastases, HCC, and cholangiocarcinoma. Don't see those going anywhere, either.

I think our liver sbrt volumes will go up going forward at the expense of IR

 

[RickyScott]

Where I trained this used to come up a lot. There is a small semi-vocal minority that believes TME alone is good for many patients, and it probably is true. But it seems the vast majority of oncologists do not agree. I think we will see a lot of 5, very little 30, and some 0 in the highly selected patients that can get away with that (not many).

That said, I do not think surgeons or medical oncologists do that good of a job measuring and reporting toxicity. Radiation toxicity is often over estimated (probably our fault) and medical oncologists and surgeons often gloss over their toxicity as "well tolerated" in the literature. I do think that the new push to incorporate QoL sub-studies in trials and advancing technology for studying QoL will change the landscape a bit.

All that technological advancement we've had may pay off more than we think today. Just floating a prediction based on nothing really.

Chances are that a new drug or 2 introduced for rectal cancer over the next 20 years will erase whatever tiny benefit is conferred with xrt in setting of tme.

 

[temujim]

That said, I do not think surgeons or medical oncologists do that good of a job measuring and reporting toxicity. Radiation toxicity is often over estimated (probably our fault) and medical oncologists and surgeons often gloss over their toxicity as "well tolerated" in the literature. I do think that the new push to incorporate QoL sub-studies in trials and advancing technology for studying QoL will change the landscape a bit.

100%. Surgeons in particular are shocked when someone accurately grades their toxicity.

 

[NotMattSpraker]

Chances are that a new drug or 2 introduced for rectal cancer over the next 20 years will erase whatever tiny benefit is conferred with xrt in setting of tme.

Could it be similar to the chances that pharma becomes financially unsustainable in the next 20 years and there is a pendulum swing away from drugging everything?

Right now the focus on financial toxicity seems mainly for promotion of academics, but eventually it people will have to act on it.

 

[OTN]

100%. Surgeons in particular are shocked when someone accurately grades their toxicity.

I'm pretty sure, based on conversations with patients, I'm the only one who ever brings up postoperative ED in men with rectal cancer.

 

[Fpg1245]

100%. Surgeons in particular are shocked when someone accurately grades their toxicity.

Surgeons are shocked when anyone critiques anything they do. Especially if they’re non surgeons

 

[sirspamalot]

Until UM says NO, those in PP will continue to offer as many clicks as possible. How do I know? Sigh..

--- Open Scene

In a clinic yesterday:

"I think doing moderate hypofractionation is reasonable for your prostate cancer sir. This means doing 25-28 fractions instead of the usual 44."

"Won't the larger dose per day hurt me?"

"Its all good, its biologically the same effective dose. Studies have shown similar outcomes and equal or better toxicity profile. Plus, it costs less. If you go to most places, they'll simply say you have to have 44 and thats that. Since we are in fact paid by the day, I'll let you draw your own conclusions. Without a compelling reason like a ginormous prostate or big AUA score, of which you have neither, hypofrac is just fine."

"Well, it just so happens I got an opinion before I came here. And.. they said it'd be 44."

-Close Scene

Choose Greedily

 

[TheWallnerus]

100%. Surgeons in particular are shocked when someone accurately grades their toxicity.

Surgeons are shocked when anyone critiques anything they do. Especially if they’re non surgeons

It's so important to measure one's own outcomes.

At my training institution for years they had used their own in-house developed radiosurgery system ("PR" in the graph below) to treat AVMs. They were fine with it and thought, in their own minds (nsg included), that most or all patients had nidus obliteration. (The things is, time to nidus obliteration is kind of just as important as nidus obliteration rate in SRS for AVM.) At one site, they ditched this system and switched to the commercial BrainLAB system. So for several years patients were treated on either BrainLAB ("BL" in the graph below) or the in-house system. As a resident I thought it would be a neat project to gather all the data and perform actuarial analysis on the outcomes of one system versus the other:

They never treated a patient on the in-house system again.

 

[TheWallnerus]

Benefit of xrt in rectal is minimal

Not if you never go to surgery..

I treat a lot of esophagus in addition to rectal. I can't see them going anywhere.

I keep seeing this, and think it's a long shot of an endgame.

Where I trained this used to come up a lot. There is a small semi-vocal minority that believes TME alone is good for many patients, and it probably is true. But it seems the vast majority of oncologists do not agree.

"Benefit of XRT is minimal..."
"Not if you never go to surgery."

I can say "You won't ever go to Hell if you just go to church."

Lot of true believing in both sentiments above.

Lest ye all forget:

 

[RickyScott]

"Benefit of XRT is minimal..."
"Not if you never go to surgery."

I can say "You won't ever go to Hell if you just go to church."

Lot of true believing in both sentiments above.

Lest ye all forget:

Upfront Folfox alone has never been compared to neoadjuvant folfox + chemo/xrt for rectal cancer. (Make for great non inferiority trial) We have no idea if radiation adds anything. We do know that chemo/xrt has around 5% absolute local control benefit over doing nothing in the setting of tme?

 

[elementaryschooleconomics]

Boomers could actually manage a patient as a physician. Current crop of ROs are but mere technicians.

Ah, I don't normally respond to trolls, let alone banned ones, but this is hilarious.

1) I would like to point out the use of the word "could" here, as in, past tense, as in, once upon a time.

2) In that sense, I agree! The Boomers who are currently in their mid-60s generally graduated residency between 1985-1990.

3) So let's evaluate this statement in the spirit of a Constitutional Scholar and Originalist Theory:

- The Soviet Union still existed
- There was no internet
- There were no NCCN guidelines
- There was no QUANTEC...
- Actually, there wasn't even Emami yet either

Here's a great slide from an AAPM presentation:

Oh, here's a Gilbert Fletcher article about breast cancer from 1985:

He's citing his own work from earlier in his career, giving breasts 100Gy over 12 weeks. Instead of saying "breast is the worst", he keeps it classy and cites "The Enigma of Breast Cancer".

So, sure - for their time, Boomers could manage a patient as a physician. But like...are we supposed to consider that impressive? I think the required pre-med courses I took covered topics learned only in some obscure Fellowship back in the day.

Problem is: having an impressive amount of knowledge in 1985, heck, top 1% knowledge among medical doctors at the time, wouldn't be enough to pass Step 1 today.

And I know many of them who "locked in" with their 1985 genius-level knowledge to continue practicing to this day...without cracking a textbook since before the Challenger exploded.

 

[taserlaser]

Ah, I don't normally respond to trolls, let alone banned ones, but this is hilarious.

1) I would like to point out the use of the word "could" here, as in, past tense, as in, once upon a time.

2) In that sense, I agree! The Boomers who are currently in their mid-60s generally graduated residency between 1985-1990.

3) So let's evaluate this statement in the spirit of a Constitutional Scholar and Originalist Theory:

- The Soviet Union still existed
- There was no internet
- There were no NCCN guidelines
- There was no QUANTEC...
- Actually, there wasn't even Emami yet either

Here's a great slide from an AAPM presentation:

View attachment 364410

Oh, here's a Gilbert Fletcher article about breast cancer from 1985:

View attachment 364411

He's citing his own work from earlier in his career, giving breasts 100Gy over 12 weeks. Instead of saying "breast is the worst", he keeps it classy and cites "The Enigma of Breast Cancer".

So, sure - for their time, Boomers could manage a patient as a physician. But like...are we supposed to consider that impressive? I think the required pre-med courses I took covered topics learned only in some obscure Fellowship back in the day.

Problem is: having an impressive amount of knowledge in 1985, heck, top 1% knowledge among medical doctors at the time, wouldn't be enough to pass Step 1 today.

And I know many of them who "locked in" with their 1985 genius-level knowledge to continue practicing to this day...without cracking a textbook since before the Challenger exploded.

Yeah that definitive RT for breast data that circulated in the 70s/80s is wild to me. Reminds me of prostate LDR (100Gy+ over a few months). Posting this as well - I think Todd originated it on Twitter a while back.

 

[RadOncDoc21]

Ah, I don't normally respond to trolls, let alone banned ones, but this is hilarious.

1) I would like to point out the use of the word "could" here, as in, past tense, as in, once upon a time.

2) In that sense, I agree! The Boomers who are currently in their mid-60s generally graduated residency between 1985-1990.

3) So let's evaluate this statement in the spirit of a Constitutional Scholar and Originalist Theory:

- The Soviet Union still existed
- There was no internet
- There were no NCCN guidelines
- There was no QUANTEC...
- Actually, there wasn't even Emami yet either

Here's a great slide from an AAPM presentation:

View attachment 364410

Oh, here's a Gilbert Fletcher article about breast cancer from 1985:

View attachment 364411

He's citing his own work from earlier in his career, giving breasts 100Gy over 12 weeks. Instead of saying "breast is the worst", he keeps it classy and cites "The Enigma of Breast Cancer".

So, sure - for their time, Boomers could manage a patient as a physician. But like...are we supposed to consider that impressive? I think the required pre-med courses I took covered topics learned only in some obscure Fellowship back in the day.

Problem is: having an impressive amount of knowledge in 1985, heck, top 1% knowledge among medical doctors at the time, wouldn't be enough to pass Step 1 today.

And I know many of them who "locked in" with their 1985 genius-level knowledge to continue practicing to this day...without cracking a textbook since before the Challenger exploded.

“The Enigma of breast cancer”… classy. Definitely sounds better then Breast is the worst… which it is!

 

[Fpg1245]

“The Enigma of breast cancer”… classy. Definitely sounds better then Breast is the worst… which it is!

The generation prior to the boomers brought a little class to the enterprise for sure

 

[sirspamalot]

Ah, I don't normally respond to trolls, let alone banned ones, but this is hilarious.

1) I would like to point out the use of the word "could" here, as in, past tense, as in, once upon a time.

2) In that sense, I agree! The Boomers who are currently in their mid-60s generally graduated residency between 1985-1990.

3) So let's evaluate this statement in the spirit of a Constitutional Scholar and Originalist Theory:

- The Soviet Union still existed
- There was no internet
- There were no NCCN guidelines
- There was no QUANTEC...
- Actually, there wasn't even Emami yet either

Here's a great slide from an AAPM presentation:

View attachment 364410

Oh, here's a Gilbert Fletcher article about breast cancer from 1985:

View attachment 364411

He's citing his own work from earlier in his career, giving breasts 100Gy over 12 weeks. Instead of saying "breast is the worst", he keeps it classy and cites "The Enigma of Breast Cancer".

So, sure - for their time, Boomers could manage a patient as a physician. But like...are we supposed to consider that impressive? I think the required pre-med courses I took covered topics learned only in some obscure Fellowship back in the day.

Problem is: having an impressive amount of knowledge in 1985, heck, top 1% knowledge among medical doctors at the time, wouldn't be enough to pass Step 1 today.

And I know many of them who "locked in" with their 1985 genius-level knowledge to continue practicing to this day...without cracking a textbook since before the Challenger exploded.

Oh yeeeaaaah...

 

[evilbooyaa]

Until UM says NO, those in PP will continue to offer as many clicks as possible. How do I know? Sigh..

--- Open Scene

In a clinic yesterday:

"I think doing moderate hypofractionation is reasonable for your prostate cancer sir. This means doing 25-28 fractions instead of the usual 44."

"Won't the larger dose per day hurt me?"

"Its all good, its biologically the same effective dose. Studies have shown similar outcomes and equal or better toxicity profile. Plus, it costs less. If you go to most places, they'll simply say you have to have 44 and thats that. Since we are in fact paid by the day, I'll let you draw your own conclusions. Without a compelling reason like a ginormous prostate or big AUA score, of which you have neither, hypofrac is just fine."

"Well, it just so happens I got an opinion before I came here. And.. they said it'd be 44."

-Close Scene

Choose Greedily

Equal? Mostly true.
Conventional hypofx for prostate cancer has a lower risk of acute GI toxicity compared to moderate hypofx across all trials. Compared to the most common used mod hypofx regimens, it seems to have equivalent rates of late GI toxicity, as well as acute and late GU toxicity.

Better toxicity from mod hypofx for prostate? No evidence for that.

 

[sirspamalot]

Long term its about the same for whatever you choose (appropriately), we just don't have 20 year PSA data. Thus, Choose Greedily/Wisely.

 

[Lamount]

Long term its about the same for whatever you choose (appropriately), we just don't have 20 year PSA data. Thus, Choose Greedily/Wisely.

I'm not a prostate guy... but I see nothing wrong with giving the patient the choice: shorter treatment vs. less acute tox.

 

[medgator]

I'm not a prostate guy... but I see nothing wrong with giving the patient the choice: shorter treatment vs. less acute tox.

Exactly how i couch it