Congrats to new ASTRO President..is this the first time that the President is on SDN?

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Chartreuse Wombat

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I have to say, I’m not surprised

Sameer put on an all out “charm offensive” which is essentially Sameer being Sameer.

I truly think the overlap between he and Neha is quite substantial, but I think people noticed how hard he worked on his listening tour.

I’d love to think about my friend as “our guy”, but it’s safe to say he’s still very linked to who many of us think are the very cause of the problem.

Let’s caution ourselves from expecting major changes, but we can hope that the tone is different and our voices are heard and considered. If we get transparency, some skin in the game and logical explanations and reasoning for decisions we disagree with, we are better off than we were.

I do know from both of them that some of the excesses of the agenda irritate them as much as does many of us. If at the least we stop trying to fix the world and start trying to fix rad onc. I.e. although climate change is a major issue, our impact and ability to fix it is limited, while we can drive hard against other issues like supply, the exams and predatory consolidation.

Hearty congrats to Sameer. I sincerely hope Neha gets her shot. She’s wonderful and a positive light from academia.
 
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RealSimulD said:
I have to say, I’m not surprised

Sameer put on an all out “charm offensive” which is essentially Sameer being Sameer.

I truly think the overlap between he and Neha is quite substantial, but I think people noticed how hard he worked on his listening tour.

I’d love to think about my friend as “our guy”, but it’s safe to say he’s still very linked to who many of us think are the very cause of the problem.

Let’s caution ourselves from expecting major changes, but we can hope that the tone is different and our voices are heard and considered. If we get transparency, some skin in the game and logical explanations and reasoning for decisions we disagree with, we are better off than we were.

I do know from both of them that some of the excesses of the agenda irritate them as much as does many of us. If at the least we stop trying to fix the world and start trying to fix rad onc. I.e. although climate change is a major issue, our impact and ability to fix it is limited, while we can drive hard against other issues like supply, the exams and predatory consolidation.

Hearty congrats to Sameer. I sincerely hope Neha gets her shot. She’s wonderful and a positive light from academia.
Click to expand...

I am so happy to see the engagement paid off. Congrats SK! Really looking forward to seeing how this goes, keeping my fingers crossed for a benign themed ASTRO in 2025. Would be sweet!
 
Chartreuse Wombat said:

Elections - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

ASTRO holds annual elections for its Board of Directors.
www.astro.org www.astro.org
Click to expand...

I am hoping to learn from this community. I recognize that it’s a demographic of the Radiation Oncology community in which many, if not, the majority, are not members. That’s OK. I still want to engage. I’m hoping we can change that overtime.

The only thing that I ask is that there is mutual respect. No name slinging or personal insults. This extends to ASTRO staff, who do good work and really care about the field.

I’m all for a healthy debate. I have a thick skin. People here who know me personally, I think, will vouch for that.

There are some issues facing our collective community. I’m not naïve. Overall, I’m an optimist. But I’m also pragmatic.

Although I’m currently at Mayo clinic, my thought process was heavily shaped by my 4 years in private practice and being a small business owner.

I still think private practice is the core of our community. I want to see opportunities for new graduates to be a small business owner.

I want to see more private practice Radiation Oncologists join ASTRO committees, especially in health policy and government relations. I’ve already reached out to a few people that I know. Two solo doctors, and one person in a four person practice. One of these doctors is going to do it, but has to renew their Astro membership

If you have an interest in doing this, reach out to me. These are voices that need to be at the table and need to be heard. I can’t make promises to any single individual. I can promise you that you are going to see more private practice doctors join health policy and government relations committees next summer then you have in the past 10+ years.

More than anything else, I want to hear from people.

Thanks

Sameer
 
Rad Onc SK said:
I am hoping to learn from this community. I recognize that it’s a demographic of the Radiation Oncology community in which many, if not, the majority, are not members. That’s OK. I still want to engage. I’m hoping we can change that overtime.

The only thing that I ask is that there is mutual respect. No name slinging or personal insults. This extends to ASTRO staff, who do good work and really care about the field.

I’m all for a healthy debate. I have a thick skin. People here who know me personally, I think, will vouch for that.

There are some issues facing our collective community. I’m not naïve. Overall, I’m an optimist. But I’m also pragmatic.

Although I’m currently at Mayo clinic, my thought process was heavily shaped by my 4 years in private practice and being a small business owner.

I still think private practice is the core of our community. I want to see opportunities for new graduates to be a small business owner.

I want to see more private practice Radiation Oncologists join ASTRO committees, especially in health policy and government relations. I’ve already reached out to a few people that I know. Two solo doctors, and one person in a four person practice. One of these doctors is going to do it, but has to renew their Astro membership

If you have an interest in doing this, reach out to me. These are voices that need to be at the table and need to be heard. I can’t make promises to any single individual. I can promise you that you are going to see more private practice doctors join health policy and government relations committees next summer then you have in the past 10+ years.

More than anything else, I want to hear from people.

Thanks

Sameer
Click to expand...
See ASTRO? See? Sameer didn't burst into flames by writing here.

Imagine how different the past 5 years could have gone if there was "Sameer-style" leadership!

*anxiously checks the news to make sure Sameer hasn't burst into flames yet*
 
Rad Onc SK said:
I am hoping to learn from this community. I recognize that it’s a demographic of the Radiation Oncology community in which many, if not, the majority, are not members. That’s OK. I still want to engage. I’m hoping we can change that overtime.

The only thing that I ask is that there is mutual respect. No name slinging or personal insults. This extends to ASTRO staff, who do good work and really care about the field.

I’m all for a healthy debate. I have a thick skin. People here who know me personally, I think, will vouch for that.

There are some issues facing our collective community. I’m not naïve. Overall, I’m an optimist. But I’m also pragmatic.

Although I’m currently at Mayo clinic, my thought process was heavily shaped by my 4 years in private practice and being a small business owner.

I still think private practice is the core of our community. I want to see opportunities for new graduates to be a small business owner.

I want to see more private practice Radiation Oncologists join ASTRO committees, especially in health policy and government relations. I’ve already reached out to a few people that I know. Two solo doctors, and one person in a four person practice. One of these doctors is going to do it, but has to renew their Astro membership

If you have an interest in doing this, reach out to me. These are voices that need to be at the table and need to be heard. I can’t make promises to any single individual. I can promise you that you are going to see more private practice doctors join health policy and government relations committees next summer then you have in the past 10+ years.

More than anything else, I want to hear from people.

Thanks

Sameer
Click to expand...
Sameer you keep saying this - about not berating people. Perhaps this has happened - I don’t know details.

I have screenshots of Astro staff collaborating to keep me out of committes.

Can ASTRO also end its pettiness ? Because it is a two way street
 
RealSimulD said:
Sameer you keep saying this - about not berating people. Perhaps this has happened - I don’t know details.

I have screenshots of Astro staff collaborating to keep me out of committes.

Can ASTRO also end its pettiness ? Because it is a two way street
Click to expand...
There's a couple troll accounts on twitter that cross some lines at times. They were pretty cringe for a while. I'm thinking they get lumped in with this forum, perhaps appropriately so. Still, I'm not sure I've seen too much of it here, on this moderated site.

In the same way, SDN was not responsible for the Reddit hosted Residency Spreadsheet. But it didn't stop ASTRO/red journal from conflating those two entities in the medical literature.
 
radoncftw said:
As a fellow brown Rad Onc who works in the community, I am really happy to see this.
Will be an interesting transition from the current president to SK. They seem very different
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For too long astro presidents viewed the title/position as some type of lifetime career award to celebrate or establish prominence in the field. sk seems to have actual policy ideas, notion of stewardship and an agenda.
 
I was against Sandler and I’m purely asking out of not really following it closely but did he do anything?
 
thecarbonionangle said:
I was against Sandler and I’m purely asking out of not really following it closely but did he do anything?
Click to expand...
Last Astro I attended was San Antonio with Paul Hariri accepting the position . For 30 minutes, the guy showed pictures of his life and family and talked up his tremendous journey and achievements that were culminating in that moment of recognition as he was now a working royal. Didn’t renew my Astro membership after that.
 
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RickyScott said:
Last Astro I attended was San Antonio with Paul Hariri accepting the position . For 30 minutes, the guy showed pictures of his life and family and talked up his tremendous journey and achievements that were culminating in that moment of recognition as he was now a working royal. Didn’t renew my Astro membership after that.
Click to expand...
I was in that room, totally underwhelming low energy. Dude matched his son too. Ended up on SOAP last year
 
thecarbonionangle said:
I was in that room, totally underwhelming low energy. Dude matched his son too. Ended up on SOAP last year
Click to expand...

I mean that doesn't really hold a candle to the sad story of Dr. Geraldine Jacobson.... known best for being chair of the perennial SOAPing RO Residency Program at WVU... who lost her chairperson job while she was president (I think).
 
Sameer should be credited for coming to SDN. I am hopeful that his tenure will be part of a process of ushering in significant change.

At the most general level, I believe that radonc has two possible paths forward, the one that it is following presently, and another that presents an opportunity for a much larger contribution to oncology.

The present path is clear. (I am not considering those peripheral academic pursuits, which include world class basic science and disparity work, that impact the clinician to no significant degree within foreseeable horizons, but have intrinsic value. I am not saying that academics don't do good work.)

The present path is to grow large academic networks and to pursue marginal gains in stereotaxy, dosimetry and dynamic re-planning in an attempt to establish a small differential value in terms of clinical outcomes while maximizing hypofractionation and consolidation of care. (Protons do not facilitate hypofractionation, nor safety, but have established differential value through culture and a specious narrative regarding their dosimetry). Hypofractionation overall is the opposite of a safety strategy.

The present path is low value for many reasons. It is low value because it facilitates institutional growth, consolidation and negotiation of higher rates. It is low value because the clinical significance of increased stereotaxy is dwarfed by the clinical significance of improved human behavior, environmental safety (not our lane) and now systemic management of malignancy. It is low value because it is associated with a markedly increased intrinsic cost in terms of capital investment, physics support and physician time per patient. (This intrinsic cost is what we are asking support for by efforts like ROCR).

The present path is also low value to the prospective radiation oncologist, as fewer and larger employers typically mean less pay, less autonomy and less value within the institutions that they reside. (Your satellite hire from 2020 is not valued like your main site hire from 2004).

The alternative path is to acknowledge that XRT overall is an overwhelmingly high value intervention, but that it's value is constantly re-contextualized by systemic therapy (at this point, more so than by technology) . It is to acknowledge that a field that typically does not do the initial work-up or diagnostic procedure, and that treats diseases that overwhelmingly lead to demise by systemic progression, will inherently lose value over time. It is to look for ways to take one of the most talented workforces in medicine and move them rationally and safely into the realm of systemic therapy while preserving said workforces role as stewards of therapeutic radiation.

We should also expand indications for benign disease.

Hoping for the best.
 
@Rad Onc SK

Hi Sameer,

Thanks for coming.

When will Simul be allowed to post again on the ASTRO Community Forums ?

I think this is necessary to prove that you are sincere in creating dialogue and change as the president-elect of ASTRO.

I don't ban anyone from SDN who are from ASTRO or anywhere else just for disagreeing with people and bringing up difficult issues respectfully.

Simul should have the same respect from ASTRO.

All the best,
An anonymous ASTRO member who doesn't wish to be blacklisted for their work with SDN. It's too funny to hear in person when people are talking negatively about my online identity and/or SDN.
 
1689354036551.png
 
Neuronix said:
@Rad Onc SK

Hi Sameer,

Thanks for coming.

When will Simul be allowed to post again on the ASTRO Community Forums ?

I think this is necessary to prove that you are sincere in creating dialogue and change as the president-elect of ASTRO.

I don't ban anyone from SDN who are from ASTRO or anywhere else just for disagreeing with people and bringing up difficult issues respectfully.

Simul should have the same respect from ASTRO.

All the best,
An anonymous ASTRO member who doesn't wish to be blacklisted for their work with SDN. It's too funny to hear in person when people are talking negatively about my online identity and/or SDN.
Click to expand...

Today SDN is the healthiest place for Rad Onc discourse in my opinion and it's not close. Thanks for your efforts moderating this community.

Hopefully ASTRO can improve, maybe we can even get to a place where people wont need anonymous accounts to safely share unique opinions. It's a big mountain to climb in this field, Ill be watching very closely.
 
Neuronix said:
@Rad Onc SK

Hi Sameer,

Thanks for coming.

When will Simul be allowed to post again on the ASTRO Community Forums ?

I think this is necessary to prove that you are sincere in creating dialogue and change as the president-elect of ASTRO.

I don't ban anyone from SDN who are from ASTRO or anywhere else just for disagreeing with people and bringing up difficult issues respectfully.

Simul should have the same respect from ASTRO.

All the best,
An anonymous ASTRO member who doesn't wish to be blacklisted for their work with SDN. It's too funny to hear in person when people are talking negatively about my online identity and/or SDN.
Click to expand...
Crap, you heard that?
 
Rad Onc SK said:
I am hoping to learn from this community. I recognize that it’s a demographic of the Radiation Oncology community in which many, if not, the majority, are not members. That’s OK. I still want to engage. I’m hoping we can change that overtime.

Thanks

Sameer
Click to expand...

I think you would be surprised who reads/browses these forums (even on occasion). I imagine a very high proportion are ASTRO members.
 
Sameer - congrats on the election and welcome to SDN. I am encouraged that you elected to post here and I hope it continues.

For all of the derision SDN has seemed to generate, I'll say that I learn more about the current state of our field, both medical and political, from SDN than I ever could from other "sanctioned" sources like the Red Journal. This board is an excellent resource for practicing docs and should not be relegated to the equivalent of 4chan in the eyes of academia.

Those who have been in charge of our field have failed us quite miserably and I truly hope that your election is the start of a larger move to turn the ship around. Much needs to be done to salvage what is still the best specialty in medicine (at least in my opinion). I think you will find many on this board with great ideas and open minds, should you continue to engage here.

Congrats again and good luck!
 
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RealSimulD said:
I have to say, I’m not surprised

Sameer put on an all out “charm offensive” which is essentially Sameer being Sameer.

I truly think the overlap between he and Neha is quite substantial, but I think people noticed how hard he worked on his listening tour.

I’d love to think about my friend as “our guy”, but it’s safe to say he’s still very linked to who many of us think are the very cause of the problem.

Let’s caution ourselves from expecting major changes, but we can hope that the tone is different and our voices are heard and considered. If we get transparency, some skin in the game and logical explanations and reasoning for decisions we disagree with, we are better off than we were.

I do know from both of them that some of the excesses of the agenda irritate them as much as does many of us. If at the least we stop trying to fix the world and start trying to fix rad onc. I.e. although climate change is a major issue, our impact and ability to fix it is limited, while we can drive hard against other issues like supply, the exams and predatory consolidation.

Hearty congrats to Sameer. I sincerely hope Neha gets her shot. She’s wonderful and a positive light from academia.
Click to expand...

Thank you Simul. I appreciate the fact that we are in the honeymoon phase. There are going to be some things in the future that may aggravate a large part of the forum. I’m gonna do my best. I really am. I’m going to listen. And I’m going to try to explain things as best I can, when decisions are made that are initially unpopular.

Unfortunately, the reality is some of the recent decisions made by CMS and the rock, especially related to the valuation of large capital equipment has really put us behind the eight ball. Radiology and Radiation Oncology are especially affected. That’s why you’re going to see negative cuts continue, especially on the technical side of our code set.

As you’ve seen me say, over and over again, 77301 is going to be very hard to defend if we have to go back to the RUC.

A legitimate beef I’ve heard is the composition of the board, in my opinion. There is not a single member who is in a small practice. In my opinion, we need to change this. I have some ideas. Some of the initial steps taken by ASTRO. A really good. I think I have some practical steps that may help. We’ll see.

I will start my board term in October.

The definition of private practice is really broad and really diverse.

I really want to find private practice doctors, especially small business owners, who want to get engaged. Owning technical would be nice, but is hard to find. In a nutshell, I want to find people who understand how the dollars flow and the stress of running a small business. But it’s the same people that often don’t have the time, understandably, to commit to ASTRO or other specialty organizations. I do understand this.

Staying engaged in ASTRO, when I was in private practice was really hard. Fortunately, my practice in Oklahoma supported me. I cannot tell you how much I appreciated everyone of my partners. As I’ve told a few of you, leaving that practice to move to Mayo what is the single, hardest decision I’ve ever made in my life. In the end, it was the right decision and I’ve been really happy at Mayo, but I would’ve been really happy had I stayed in Oklahoma. I don’t think I would’ve been elected to Astro president, although that was never in my life goal.

The next 24 hours, for both, Simul and I, is going to be survival. We are both hosting birthday parties in our house. If I survive, I’ll see you on the flipside on Sunday or Monday 🙂 we’ve got 22 teenage girls coming over tomorrow.
 
NotMattSpraker said:
I am so happy to see the engagement paid off. Congrats SK! Really looking forward to seeing how this goes, keeping my fingers crossed for a benign themed ASTRO in 2025. Would be sweet!
Click to expand...

I’ve been told that the meeting theme is a decision for me to make. I’ve received nothing but positive feedback from the people who have heard it.

Benign diseases is going to be a hefty part of it. RPT too. If there’s time, we should emphasize “polymetastatic” disease. Basically, I want the presidential symposium and the theme of the meeting to focus on how we can use RT to help more patients. If anyone here has ideas, please let me know.

That’s what I’m thinking.
 
RickyScott said:
For too long astro presidents viewed the title/position as some type of lifetime career award to celebrate or establish prominence in the field. sk seems to have actual policy ideas, notion of stewardship and an agenda.
Click to expand...

I have some pretty specific ideas.

I’ll be happy to share more of them.

I’m putting together something more fluid and readable. Right now it’s a checklist in my iPhone 🙂

I didn’t think I’d win this election, so I didn’t see the point in investing a whole lot of effort into making it something readable.

You’ve already heard some of them. And I think they are mom and apple pie things that we should all be able to rally around.

We need to engage community doctors and create a mentorship program that will get more of them on the board. ASTRO has already started this. I’m certainly going to emphasize this. There’s a few people I know that would be awesome additions to ASTRO committees. But it can’t just be “Sameer’s buddies”. We need a diversity of folks. But I really really really want to find small business owners. They are getting harder to find, but they are out there.
 
communitydoc13 said:
Sameer should be credited for coming to SDN. I am hopeful that his tenure will be part of a process of ushering in significant change.

At the most general level, I believe that radonc has two possible paths forward, the one that it is following presently, and another that presents an opportunity for a much larger contribution to oncology.

The present path is clear. (I am not considering those peripheral academic pursuits, which include world class basic science and disparity work, that impact the clinician to no significant degree within foreseeable horizons, but have intrinsic value. I am not saying that academics don't do good work.)

The present path is to grow large academic networks and to pursue marginal gains in stereotaxy, dosimetry and dynamic re-planning in an attempt to establish a small differential value in terms of clinical outcomes while maximizing hypofractionation and consolidation of care. (Protons do not facilitate hypofractionation, nor safety, but have established differential value through culture and a specious narrative regarding their dosimetry). Hypofractionation overall is the opposite of a safety strategy.

The present path is low value for many reasons. It is low value because it facilitates institutional growth, consolidation and negotiation of higher rates. It is low value because the clinical significance of increased stereotaxy is dwarfed by the clinical significance of improved human behavior, environmental safety (not our lane) and now systemic management of malignancy. It is low value because it is associated with a markedly increased intrinsic cost in terms of capital investment, physics support and physician time per patient. (This intrinsic cost is what we are asking support for by efforts like ROCR).

The present path is also low value to the prospective radiation oncologist, as fewer and larger employers typically mean less pay, less autonomy and less value within the institutions that they reside. (Your satellite hire from 2020 is not valued like your main site hire from 2004).

The alternative path is to acknowledge that XRT overall is an overwhelmingly high value intervention, but that it's value is constantly re-contextualized by systemic therapy (at this point, more so than by technology) . It is to acknowledge that a field that typically does not do the initial work-up or diagnostic procedure, and that treats diseases that overwhelmingly lead to demise by systemic progression, will inherently lose value over time. It is to look for ways to take one of the most talented workforces in medicine and move them rationally and safely into the realm of systemic therapy while preserving said workforces role as stewards of therapeutic radiation.

We should also expand indications for benign disease.

Hoping for the best.
Click to expand...

Well said. I think ASTRO should be a Platform in which ideas can come together. It should be a place where we can help Radiation Oncologists develop skills to take back to their communities, and help more patients. Radiation Oncologists can also do more than just practice medicine. We can be leaders. I just spent the morning with a very good friend in private practice who has developed when the largest screening programs for first responders in the country. She’s a National leader. She is in solo practice in doing this. She’s just one example of the amazing talent we have in this field.
 
Neuronix said:
@Rad Onc SK

Hi Sameer,

Thanks for coming.

When will Simul be allowed to post again on the ASTRO Community Forums ?

I think this is necessary to prove that you are sincere in creating dialogue and change as the president-elect of ASTRO.

I don't ban anyone from SDN who are from ASTRO or anywhere else just for disagreeing with people and bringing up difficult issues respectfully.

Simul should have the same respect from ASTRO.

All the best,
An anonymous ASTRO member who doesn't wish to be blacklisted for their work with SDN. It's too funny to hear in person when people are talking negatively about my online identity and/or SDN.
Click to expand...

In all honesty, I don’t know what all of that is about. Simul and I talk pretty frequently. We can catch up on this next week. That’s all I can promise right now.

He and I both have busy weekends! I think we are both just trying to survive the chaos that is coming into our respective households tomorrow!
 
Doctorer said:
I think you would be surprised who reads/browses these forums (even on occasion). I imagine a very high proportion are ASTRO members.
Click to expand...

I believe that. I personally had never heard of SDN until my name was being thrown around in a thread a few years ago.

Someone sent me the link and I read the comments. Simul stuck up for me, even though we hadn’t spoken in over a decade. I appreciated that.

I think it was after that when we reconnected, although my memory is fuzzy. We may have reconnected before then. But we definitely started talking more after that. We are both from Michigan. We first connected back in the fall of 2003, believe it or not. A long time ago.
 
Rad Onc SK said:
I have some pretty specific ideas.

I’ll be happy to share more of them.

I’m putting together something more fluid and readable. Right now it’s a checklist in my iPhone 🙂

I didn’t think I’d win this election, so I didn’t see the point in investing a whole lot of effort into making it something readable.

You’ve already heard some of them. And I think they are mom and apple pie things that we should all be able to rally around.

We need to engage community doctors and create a mentorship program that will get more of them on the board. ASTRO has already started this. I’m certainly going to emphasize this. There’s a few people I know that would be awesome additions to ASTRO committees. But it can’t just be “Sameer’s buddies”. We need a diversity of folks. But I really really really want to find small business owners. They are getting harder to find, but they are out there.
Click to expand...
Congrats on being elected president of ASTRO. Thanks for posting here.



From your posts on SDN it seems like you will be a great advocate for our field. I think one place that ASTRO could be of help is labeling 5-fraction breast radiation as SBRT. ASTRO is currently working on new partial breast radiation guidelines. The current draft does not include SBRT as an appropriate technique. A 5-fractions IMRT plan is a substantial cut in reimbursement and will likely preclude widespread adoption. My full reasoning for why five fractions breast should be called SBRT is explained in the thread linked below. If you /ASTRO could have them add SBRT as an accepted technique, it would be greatly appreciated.


Is 5 Fraction Partial Breast Irradiation SBRT?
 
radiation123 said:
Congrats on being elected president of ASTRO. Thanks for posting here.



From your posts on SDN it seems like you will be a great advocate for our field. I think one place that ASTRO could be of help is labeling 5-fraction breast radiation as SBRT. ASTRO is currently working on new partial breast radiation guidelines. The current draft does not include SBRT as an appropriate technique. A 5-fractions IMRT plan is a substantial cut in reimbursement and will likely preclude widespread adoption. My full reasoning for why five fractions breast should be called SBRT is explained in the thread linked below. If you /ASTRO could have them add SBRT as an accepted technique, it would be greatly appreciated.


Is 5 Fraction Partial Breast Irradiation SBRT?
Click to expand...

Sorry, just saw this. Yes, this is a problem. Several people have been working on it. I don’t know a whole lot more than that. I don’t think we’re any closer to a solution, from what I can tell.

Believe it or not, Raj Singla from Evicore was trying to help us get better reimbursement for five fraction breast. But then he left. He was a good guy in a tough spot at times. (Many times, i think)

I’ll ask some folks closer to the source and see what I can dig up.
 
Rad Onc SK said:
Sorry, just saw this. Yes, this is a problem. Several people have been working on it. I don’t know a whole lot more than that. I don’t think we’re any closer to a solution, from what I can tell.

Believe it or not, Raj Singla from Evicore was trying to help us get better reimbursement for five fraction breast. But then he left. He was a good guy in a tough spot at times. (Many times, i think)

I’ll ask some folks closer to the source and see what I can dig up.
Click to expand...
Thanks for responding and thanks for looking into it.

Is there any reason that ASTRO cannot just add SBRT as an accepted technique on the new partial breast guidelines they are about to publish?

My argument is that it would qualify as SBRT under the AAPM task group 101 definition of SBRT: “the delivery of large doses in a few fractions, which results in a high biological effective dose BED.” With appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT as set forth in table 1 of that paper (Benedect et al, Med Phys 2010). The link for the paper is provided below. 25-30 Gy in 5 fractions are also already considered stereotactic radiation in other disease sites such as CNS.

If ASTRO added it as an accepted technique in the new partial breast guidelines, then we would at least have a better chance of having it covered when doing a peer to peer with a private insurance.

The ultimate dream would be if that ASTRO called it SBRT in their guidelines then we could lobby for NCCN to call it SBRT in NCCN guidelines. After that we could pressure Medicare to add it as a coverable diagnosis for SBRT.


https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1118/1.3438081
 
Just wanted to raise a point that someone brought up on twitter: If ROCR is advantageous for billing and stemming payment decreases, shouldnt protons want to join?
 
communitydoc13 said:
Sameer should be credited for coming to SDN. I am hopeful that his tenure will be part of a process of ushering in significant change.

At the most general level, I believe that radonc has two possible paths forward, the one that it is following presently, and another that presents an opportunity for a much larger contribution to oncology.

The present path is clear. (I am not considering those peripheral academic pursuits, which include world class basic science and disparity work, that impact the clinician to no significant degree within foreseeable horizons, but have intrinsic value. I am not saying that academics don't do good work.)

The present path is to grow large academic networks and to pursue marginal gains in stereotaxy, dosimetry and dynamic re-planning in an attempt to establish a small differential value in terms of clinical outcomes while maximizing hypofractionation and consolidation of care. (Protons do not facilitate hypofractionation, nor safety, but have established differential value through culture and a specious narrative regarding their dosimetry). Hypofractionation overall is the opposite of a safety strategy.

The present path is low value for many reasons. It is low value because it facilitates institutional growth, consolidation and negotiation of higher rates. It is low value because the clinical significance of increased stereotaxy is dwarfed by the clinical significance of improved human behavior, environmental safety (not our lane) and now systemic management of malignancy. It is low value because it is associated with a markedly increased intrinsic cost in terms of capital investment, physics support and physician time per patient. (This intrinsic cost is what we are asking support for by efforts like ROCR).

The present path is also low value to the prospective radiation oncologist, as fewer and larger employers typically mean less pay, less autonomy and less value within the institutions that they reside. (Your satellite hire from 2020 is not valued like your main site hire from 2004).

The alternative path is to acknowledge that XRT overall is an overwhelmingly high value intervention, but that it's value is constantly re-contextualized by systemic therapy (at this point, more so than by technology) . It is to acknowledge that a field that typically does not do the initial work-up or diagnostic procedure, and that treats diseases that overwhelmingly lead to demise by systemic progression, will inherently lose value over time. It is to look for ways to take one of the most talented workforces in medicine and move them rationally and safely into the realm of systemic therapy while preserving said workforces role as stewards of therapeutic radiation.

We should also expand indications for benign disease.

Hoping for the best.
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Great points. I concur that demise by systemic progression is a great opportunity for our field to increase our role in stage IV disease, to the benefit of hundreds of thousands of patients a year.

I've often thought it a great paradox that stage IV disease is viewed by some as the sole purview of medical oncology. Indeed, chemo does great for small volume disease and we need better drugs and more of them, but very few patients die of small volume disease.

The proximate cause of death in stage IV patients is usually due to a local control issue, a problem of uncontrolled gross disease, because microscopic disease won't obstruct a bile duct or airway or cause a fatal hemorrhage.

What if we could reduce radiation toxicity to the point where we could eliminate all gross disease, and not just 1-3 mets?

Personally I'm very excited about the ARREST trial prelim results that will be presented in Montreal at CARO this September. CARO is the Canadian Association of Radiation Oncology, and ARREST is looking at treating all visible lesions more than 10 in number. It is a dose escalation trial with a goal of 6 Gy x 5 fractions to all sites, which is pretty well tolerated by most sites in the body and a lot more potent than 30 Gy in 10.

I believe our own systemic toxicity (eg lymphopenia) when combined with immunotherapy is going to be the main rate limiting factor for our entry into stage IV; that and politics.
 
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IonsAreOurFuture said:
I've often thought it a great paradox that stage IV disease is viewed by some as the sole purview of medical oncology. Indeed, chemo does great for small volume disease and we need better drugs and more of them, but very few patients die of small volume disease.
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Agree with all of your points here exempting the last one. MSKCC seems to have a focused initiative regarding Stage IV disease. Hoping that our role increases. Of course our role will continue to be re-contextualized by improvements in systemic therapy. The lymphoma story is telling. No doubt that bulky and bony sites of disease remain preferential sites of failure and that RT can help there at doses with very low toxicity. It is also true that we as a field are no longer seeing these patients.

The lymphopenia narrative has been pushed hard by the proton folks for a while. Nothing consistent in the data as far as I can tell. Something that would be better studied in a few academic places. (I believe in dissemination of SOC and consolidation of experimental care...you know, the opposite of ROCR consequences).

Looking forward to the randomized protons vs photons oligometastatic disease trial. Wonder how far off that is. (Better be hundreds and hundreds of patients BTW). Hard enough to demonstrate a survival benefit for XRT vs no XRT.

Is it possible that at some point national radiation oncology services will be better served by a small group of highly specialized ion practitioners? I guess it's possible, but this is as far away from the present state of knowledge and what represents value based care today as I can think.

If this is the tacit goal of academic leadership, they should absolutely be shrinking the residency numbers, and also selecting strongly for residents with the best analytical ability. Probably should cull 3/4 of the existing attendings. Definitely no SOAPING unless you're going to convert one of your physicists to a doc. I think they have to go to med school though. Leadership should be honest with the rank and file.

If you are going to try to disseminate protons as community SOC, it's gotta be cheap. As in 1-2 orders of magnitude cheaper than it is today.

If you are going to take @Lamount 's approach (protons as a adjunctive tool, maybe not the heavy lifter but better in certain circumstances), then fine. Just factor the cost into the global radonc expenditure assessment when setting the case based rates that we are all subject to. This will be the best incentive structure. Academics using protons because they believe in them. Community docs referring because they believe in them....and, if more heavy utilization becomes justified, a strong incentive to make protons affordable to the community!

Now we are talking about "stabilizing payment"....and expenditures. Why wouldn't everyone want that?
 
RickyScott said:
Just wanted to raise a point that someone brought up on twitter: If ROCR is advantageous for billing and stemming payment decreases, shouldnt protons want to join?
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Protons currently have much higher overhead costs than Xray or brachy for the same disease site, so getting paid the same flat fee for a more complex plan and delivery would not be sustainable at this time. It would be like asking for whole brain and SRS to get paid the same rates in the 1990s to early 2000s, when SRS was very labor intensive and required a dedicated machine and specialized staff.

As it is, protons are already a very good value for patients and payers in terms of dollars spent on care vs reimbursement for that care. Margins are higher percentage wise for IMRT or SBRT than protons in most cases, and the start up costs are lower.
 
IonsAreOurFuture said:
protons are already a very good value for patients and payers in terms of dollars spent on care vs reimbursement for that care
Click to expand...
Not value. That is relative margin. If you buy an expensive car and were charged only a little bit more that total parts and labor for that car, that is not good value. Good value has to do with performance relative to other options, resale value....other things

IonsAreOurFuture said:
very labor intensive and required a dedicated machine and specialized staff
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Asking to perpetuate the mistakes of the past. I'm not saying that IMRT pricing or other pricing from the 90s and 00s were right (or didn't expedite the downfall of the field in some way after helping attract in some way folks like me). No need to perpetuate this stuff, particularly when the number of winners is so much smaller.
 
I don’t think all proton facility physicians are devious. What are they supposed to do? I also think Ions, sameer, mark storey - yes they are proponents but I don’t think of them as “shills”. It’s more the industry, our society and some centers/physicians that are creating misinformation, fighting for carve outs, etc.

But that’s the problem - everyone gets roped in. And even if they are balanced in their approach, they won’t fight against their own interests. That would be stupid.
 
IonsAreOurFuture said:
Protons currently have much higher overhead costs than Xray or brachy for the same disease site, so getting paid the same flat fee for a more complex plan and delivery would not be sustainable at this time. It would be like asking for whole brain and SRS to get paid the same rates in the 1990s to early 2000s, when SRS was very labor intensive and required a dedicated machine and specialized staff.

As it is, protons are already a very good value for patients and payers in terms of dollars spent on care vs reimbursement for that care. Margins are higher percentage wise for IMRT or SBRT than protons in most cases, and the start up costs are lower.
Click to expand...

What disease sites do you think are a good value for protons over photons the way SRS is a good value for patients over WBRT?
 
IonsAreOurFuture said:
Protons currently have much higher overhead costs than Xray or brachy for the same disease site, so getting paid the same flat fee for a more complex plan and delivery would not be sustainable at this time. It would be like asking for whole brain and SRS to get paid the same rates in the 1990s to early 2000s, when SRS was very labor intensive and required a dedicated machine and specialized staff.

As it is, protons are already a very good value for patients and payers in terms of dollars spent on care vs reimbursement for that care. Margins are higher percentage wise for IMRT or SBRT than protons in most cases, and the start up costs are lower.
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Those patients could (almost always) get photons at similar fractionation schemes (or less fractions given some proton centers only offer conventional fx), so the bolded statement is really difficult for me to follow.
 
evilbooyaa said:
Those patients could (almost always) get photons at similar fractionation schemes (or less fractions given some proton centers only offer conventional fx), so the bolded statement is really difficult for me to follow.
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Do you think there is value in lower mean heart dose in NSCLC? I do.
 
medgator said:
Isn't LAD dose even a better metric?
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I am sure there is a difference between dose to superior “heart” which isn’t really heart just below level 7 and dose to the lad/left ventricle. Also, have issue with the word “dose.” 5 gy of microwave has very different biological effect than 5 gy of photons. With protons, 20 gy in one part of the field can have a very different biological effect than 20 gy in another (something we don’t see with photons) . This compounded by how all these effects are impacted/very sensitive to range and set up uncertainty. Proton beam seeing a lit bit more or less rib may be an issue.

pubmed.ncbi.nlm.nih.gov

Bayesian Adaptive Randomization Trial of Passive Scattering Proton Therapy and Intensity-Modulated Photon Radiotherapy for Locally Advanced Non-Small-Cell Lung Cancer - PubMed

Purpose This randomized trial compared outcomes of passive scattering proton therapy (PSPT) versus intensity-modulated (photon) radiotherapy (IMRT), both with concurrent chemotherapy, for inoperable non-small-cell lung cancer (NSCLC). We hypothesized that PSPT exposes less lung tissue to...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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medgator said:
Isn't LAD dose even a better metric?
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There are multiple types of heart failure. LAD and other coronaries probably increase ischemic risk at certain thresh-holds (v15 >10%). There is growing data about constraints for other cardiac substructures like the atrium. I predict in the future you will have more validated constraints (left atrium V60 <25.6%,pericardium D30% <18.9 Gy, and right atrium V55 <19.5%). Cardio-oncology is also a growing field. more advanced cardiac imaging (i. Myostrain etc) along with medical optimization will have a growing role.
 
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thecarbonionangle said:
There are multiple types of heart failure. LAD and other coronaries probably increase ischemic risk at certain thresh-holds. There is growing data about constraints for other cardiac substructures like the atrium. I predict in the future you will have more validated constraints. Cardio-oncology is also a growing field. more advanced cardiac imaging (i. Myostrain etc) along with medical optimization will have a growing role.
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In lung ca with higher doses to the heart, aren’t really seeing that much more- if any heart failure, or heart attacks- , just more deaths. IMO it is really poorly understood. Lamount?
 
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RickyScott said:
In lung ca with higher doses to the heart, aren’t really seeing that much more- if any heart failure, or heart attacks- , just more deaths. IMO it is really poorly understood. Lamount?
Click to expand...

Have to cure their lung cancer to get to the point where cardiac toxicity matters down the road; that is the main issue with my population
 
RickyScott said:
In lung ca with higher doses to the heart, aren’t really seeing that much more- if any heart failure, or heart attacks- , just more deaths. IMO it is really poorly understood. Lamount?
Click to expand...
There has now been multiple papers, some using AI, which have correlated dosimetric
Data from 0617 to different toxicities including cardiac. I agree that is not slam dunk must meet constraints but you can often meet them. avoiding the heart structures often comes at a cost of some increased lung dose so it depends on the case, clinical trade offs. I mostly try to keep my LAD dose low if possible to
Mean <4, v15<10%. I have been reading with great interest on the other newer constraints but have not yet incorporated into our planning.
 
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