Contingency plans... (COVID-19 thread)

[radoncgrad2019]

Hormones alone? Is 40 Gy of radiation adding anything to GS 9, PSA 30 cancer?

Who said PSA30?

Also - do you treat nodes on every single high risk prostate cancer patient? If you’re not treating nodes, who Cares if you give 40 in 5 or 80 gy in 40 fx?



Moderator note: Please post without swearing or personal callouts. This post has been edited.

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[thecarbonionangle]

You can take pelvis to 5x5 and prostate/sv to 7.25-8 x5

 

[Chartreuse Wombat]

Hormones alone? Is 40 Gy of radiation adding anything to GS 9, PSA 30 cancer?

The only evidence that radiation therapy improves OVERALL SURVIVAL IN PROSTATE CANCER comes from the two trials that compared ADT + /- XRT in men with very high risk disease (65-70 Gy in 1.8 Gy fractions) and the STAMPEDE trial in low-volume metastatic disease (36 Gy in 6 fractions once a week OR 55 Gy in 20 fractions). I would expect that 40 Gy in 5 fractions would add something.

 

[Phantom1]

Just have to say, opened up the COVID-19 thread and read posts about prostate fractionation... Long Live Rad Onc!

In all seriousness, our technology has gotten so good, and side effects minimized so much that we are competing out surgery in the randomized studies. If I had high risk prostate cancer there is no way I would let someone operate on me. Choice is go through a major surgery with immediate incontinence and loss of sexual function, or sit on a table for 5 treatments ( or 20) and be done with it. Radiation is the clear winner.

 

[Haybrant]

Hormones alone? Is 40 Gy of radiation adding anything to GS 9, PSA 30 cancer?

It’s adding something for metastatic disease so it probably is in your hypothetical. The primary needs to be controlled in prostate cancer to avoid issues down the road and in a number of bad players even sooner. Once it explodes you’re screwed the urethra is a dainty little structure easily damaged and occluded

 

[seper]

That would not be an acceptable SBRT plan with respect to conformity.

You can take pelvis to 5x5 and prostate/sv to 7.25-8 x5

 

[radoncgrad2019]

That would not be an acceptable SBRT plan with respect to conformity.

Que?

 

[thecarbonionangle]

That would not be an acceptable SBRT plan with respect to conformity.

you need to do some reading son!!

 

[medgator]

That would not be an acceptable SBRT plan with respect to conformity.

Dose painted sbrt.... Now I've seen it all....

 

[thecarbonionangle]

Dose painted sbrt.... Now I've seen it all....

I’m hearing some are even billing SBRT for breast 6x5, WOW?

some bill IMRT for breast FIF.

 

[medgator]

I’m hearing some are even billing SBRT for breast 6x5, WOW?

some bill IMRT for breast FIF.

One day it won't matter. One day

 

[RadOncDoc21]

Dose painted sbrt.... Now I've seen it all....

Lol, I’ve seen SBRT plans for elective necks. Not saying I ever done it before but have seen it. Of course what really is the definition of SBRT? In the billing world it’s all about the number of fractions and really has nothing to do with the plan. Of course, I don’t agree but it’s the world we live in. Right now, I’m just trying to find some toilet paper... I might have to use my residency completion certificate.

 

[medgator]

Lol, I’ve seen SBRT plans for elective necks. Not saying I ever done it before but have seen it. Of course what really is the definition of SBRT? In the billing world it’s all about the number of fractions and really has nothing to do with the plan. Of course, I don’t agree but it’s the world we live in.

And dose/fx (500 cGy min), along with technique, conformality, some would also say immobilization?

Right now, I’m just trying to find some toilet paper... I might have to use my residency completion certificate.

If that isn't enough, you've (hopefully) still got your chief resident and internship ones?

 

[MegaVoltagePhoton]

Hormones alone? Is 40 Gy of radiation adding anything to GS 9, PSA 30 cancer?

serious?

 

[thecarbonionangle]

Lol, I’ve seen SBRT plans for elective necks. Not saying I ever done it before but have seen it. Of course what really is the definition of SBRT? In the billing world it’s all about the number of fractions and really has nothing to do with the plan. Of course, I don’t agree but it’s the world we live in. Right now, I’m just trying to find some toilet paper... I might have to use my residency completion certificate.

my plan is to use the ASTRO/ACR mailings they bombard me with once i run out of TP.

 

[evilbooyaa]

That would not be an acceptable SBRT plan with respect to conformity.

Need to think more outside the box my dude. SBRT does not inherently have, billing wise, any strict definitions as to what conformity or heterogeneity is allowed. Just 500cGy/Fx, maximum of 5 fraction. Call it 5-fraction IMRT if you want. Dose painting SBRT can and is easier to do than with a complex IMRT plan.

 

[medgator]

Need to think more outside the box my dude. SBRT does not inherently have, billing wise, any strict definitions as to what conformity or heterogeneity is allowed. Just 500cGy/Fx, maximum of 5 fraction. Call it 5-fraction IMRT if you want. Dose painting SBRT can and is easier to do than with a complex IMRT plan.

Yet still meet CI and GI constraints? Just doesn't make sense to me...

 

[evilbooyaa]

Yet still meet CI and GI constraints? Just doesn't make sense to me...

You can't think about CI (conformity index) when you have a large complex PTV. Not sure what you mean by GI constraints - gastrointestinal?

Call it 5Fx IMRT with dose painting if that makes it easier to process. Conformity Index is overrated IMO. Focus should be on meeting dose constraints.

 

[medgator]

You can't think about CI (conformity index) when you have a large complex PTV. Not sure what you mean by GI constraints - gastrointestinal?

Call it 5Fx IMRT with dose painting if that makes it easier to process.

Gradient index. It isn't going to be sbrt if you are trying to give different doses to different targets at the same time

 

[scarbrtj]

Saw this on the Twitter and made for a good if scary perusal. Good 'ol lazy daisy radiotherapy we will miss you? COVID-19 avoidance/mitigation 'bout as complex as the radiotherapy.

 

[evilbooyaa]

Gradient index. It isn't going to be sbrt if you are trying to give different doses to different targets at the same time

I know I sound like a hippie right now but you need to think outside the box a little bit. Don't get caught up in rigid definitions of things. Billers don't care about conformity or gradient index. Again, this is most common in the re-irradiation scenario.

Regardless, to me dose constraints and coverage are more important to me than any of the old school indices we used to determine appropriateness of SBRT.

 

[RadOncDoc21]

I know I sound like a hippie right now but you need to think outside the box a little bit. Don't get caught up in rigid definitions of things. Billers don't care about conformity or gradient index. Again, this is most common in the re-irradiation scenario.

Regardless, to me dose constraints and coverage are more important to me than any of the old school indices we used to determine appropriateness of SBRT.

Agree!

On a side note, I’ve also always wondered why billing definitions never ever really equal the amount of work being done. Another pet peeve of mine is why do ICD codes care so much more about the location of cancer then they do the histology? Why do I have to quantify time spent with a patient vs the quality. Would a consult I spent 45 min talking about the coronavirus matter more than a 20 min consult of me going over with a patient my treatment plan, their diagnosis and imaging studies?

Of course this is all a rant!

 

[deleted941485]

Just have to say, opened up the COVID-19 thread and read posts about prostate fractionation... Long Live Rad Onc!

In all seriousness, our technology has gotten so good, and side effects minimized so much that we are competing out surgery in the randomized studies. If I had high risk prostate cancer there is no way I would let someone operate on me. Choice is go through a major surgery with immediate incontinence and loss of sexual function, or sit on a table for 5 treatments ( or 20) and be done with it. Radiation is the clear winner.

And yet despite that, I’m more confident urology will still exist as an intact viable specialty in 25 years compared to us.

 

[MegaVoltagePhoton]

And yet despite that, I’m more confident urology will still exist as an intact viable specialty in 25 years compared to us.

not sure what you mean by that...even if all high risk cancers are operated on, a ton will need postop rt no?

I mean yeah we need to not expand but I don’t think radiation for prostate is going anywhere.

 

[medgator]

not sure what you mean by that...even if all high risk cancers are operated on, a ton will need postop rt no?

I mean yeah we need to not expand but I don’t think radiation for prostate is going anywhere.

I think what he means is like it is today, urology will be in far more demand all over the country than we are in 25 years. Radiation isn't going away, but there simply aren't going to be enough jobs for everyone getting out today and going forward

 

[GapCalc]

What are people doing for telehealth physical exams? I put a lot of time into my consults and want to be reimbursed appropriately, but I find that not being able to perform a “comprehensive” physical exam is a limiting factor.

Any tips for the telehealth pros?

 

[MegaVoltagePhoton]

I think what he means is like it is today, urology will be in far more demand all over the country than we are in 25 years. Radiation isn't going away, but there simply aren't going to be enough jobs for everyone getting out today and going forward

Fair. I hope not true in 25 years.

 

[medgator]

Fair. I hope not true in 25 years.

Urology has been a lot better about expansion afaik, and the demographics of their field is such that there have been and will be more retirements coming while demand is increasing.

I know several in various stages of practice and they get bombarded with recruitment emails for all kinds of locations with competitive salaries, places where there are no/low quality RO jobs

 

[Neuronix]

What are people doing for telehealth physical exams? I put a lot of time into my consults and want to be reimbursed appropriately, but I find that not being able to perform a “comprehensive” physical exam is a limiting factor.

Any tips for the telehealth pros?

I'm billing them all based on time.

 

[RadOncMegatron]

I'm billing them all based on time.

What about for phonecalls less than 5 minutes? The lowest option I see is for physician 5-10 min 99441.

 

[scarbrtj]

I’m hearing some are even billing SBRT for breast 6x5, WOW?

some bill IMRT for breast FIF.

Speaking of FiF breast (look closely), if it's good enough for the Wuhanians...

I know I sound like a hippie right now but you need to think outside the box a little bit. Don't get caught up in rigid definitions of things. Billers don't care about conformity or gradient index. Again, this is most common in the re-irradiation scenario.

Regardless, to me dose constraints and coverage are more important to me than any of the old school indices we used to determine appropriateness of SBRT.

Need to think more outside the box my dude. SBRT does not inherently have, billing wise, any strict definitions as to what conformity or heterogeneity is allowed. Just 500cGy/Fx, maximum of 5 fraction. Call it 5-fraction IMRT if you want. Dose painting SBRT can and is easier to do than with a complex IMRT plan.

Are you plagiarizing me?!?

 

[w00tz]

What about for phonecalls less than 5 minutes? The lowest option I see is for physician 5-10 min 99441.

Maybe try talking slower with longer pauses between sentences. Can also start talking about weather. Only ask about what they're wearing as a last ditch effort to stretch it to 5 mins.

 

[thecarbonionangle]

What about for phonecalls less than 5 minutes? The lowest option I see is for physician 5-10 min 99441.

round up like lawyers, cmon

 

[medgator]

Maybe try talking slower with longer pauses between sentences. Can also start talking about weather. Only ask about what they're wearing as a last ditch effort to stretch it to 5 mins.

I go through basic pandemic protocol, easy to do a quick PSA about how they are high risk and should be covering their face when planning to leave house etc.

 

[scarbrtj]

I'm working with Google to have an AI make all my telehealth consult/followup calls for me while I'm off doing other stuff. And turns out GPUs do more than just make IMRT optimization fast. Next step: deepfaking my face for video.

 

[taserlaser]

The question is, is are you the real scarbrtj, or have we just been communicating with the AI one? Will the real scarbrtj please stand up?

 

[RickyScott]

Just wanted to post this because I think this is best epdimiological research to data. Random antibody testing by Stanford in Santa Clara. Case fatality rate appears .1-.2%

COVID-19 Antibody Seroprevalence in Santa Clara County, California

Background Addressing COVID-19 is a pressing health and social concern. To date, many epidemic projections and policies addressing COVID-19 have been designed without seroprevalence data to inform epidemic parameters. We measured the seroprevalence of antibodies to SARS-CoV-2 in Santa Clara...

www.medrxiv.org

 

[xrthopeful]

Scarb is keyser soze

 

[thecarbonionangle]

I'm working with Google to have an AI make all my telehealth consult/followup calls for me while I'm off doing other stuff. And turns out GPUs do more than just make IMRT optimization fast. Next step: deepfaking my face for video.

"they see you rollin', they hatin'"

 

[seper]

"Premier Biotech serology test used in this study has not been approved by the FDA by the time of the study, and validation studies for this assay are ongoing"

Is that the supplier which is expected to be the busiest?

Just wanted to post this because I think this is best epdimiological research to data. Random antibody testing by Stanford in Santa Clara. Case fatality rate appears .1-.2%

COVID-19 Antibody Seroprevalence in Santa Clara County, California

Background Addressing COVID-19 is a pressing health and social concern. To date, many epidemic projections and policies addressing COVID-19 have been designed without seroprevalence data to inform epidemic parameters. We measured the seroprevalence of antibodies to SARS-CoV-2 in Santa Clara...

www.medrxiv.org

 

[xrthopeful]

"they see you rollin', they hatin'"

Please Proceed, Governor!

 

[Lamount]

Just wanted to post this because I think this is best epdimiological research to data. Random antibody testing by Stanford in Santa Clara. Case fatality rate appears .1-.2%

COVID-19 Antibody Seroprevalence in Santa Clara County, California

Background Addressing COVID-19 is a pressing health and social concern. To date, many epidemic projections and policies addressing COVID-19 have been designed without seroprevalence data to inform epidemic parameters. We measured the seroprevalence of antibodies to SARS-CoV-2 in Santa Clara...

www.medrxiv.org

No doubt the denominator is higher than we thought... but then again, it's almost certain the numerator is as well. For instance, they don't test for Covid when someone dies at home, or in a nursing home... and these may comprise a majority of the cases.
In fact, sometimes, they don't even tell anyone that they died

 

[RickyScott]

No doubt the denominator is higher than we thought... but then again, it's almost certain the numerator is as well. For instance, they don't test for Covid when someone dies at home, or in a nursing home... and these may comprise a majority of the cases.
In fact, sometimes, they don't even tell anyone that they died

True, but also there is economic incentive for hospital to provide a covid diagnosis. For uninsured, fed gov reimbursing minimum for any covid pt on vent of 39,000$ and 13000 for admission. SWIM works at hospital where anyone with a cough now diagnosed with COVID.
Mskcc was soliciting this free money on twitter- fishing for covid patients?

 

[RickyScott]

"Premier Biotech serology test used in this study has not been approved by the FDA by the time of the study, and validation studies for this assay are ongoing"

Is that the supplier which is expected to be the busiest?

Would expect study to be most rigorous possible under the circumstances. This is john ioannidis’ group.

“Ioannidis's 2005 paper "Why Most Published Research Findings Are False"[1] is the most downloaded paper in the Public Library of Science[14][15] and is considered foundational to the field of metascience.[16] In the paper, Ioannidis demonstrates that most...”

 

[xrthopeful]

No doubt the denominator is higher than we thought... but then again, it's almost certain the numerator is as well. For instance, they don't test for Covid when someone dies at home, or in a nursing home... and these may comprise a majority of the cases.
In fact, sometimes, they don't even tell anyone that they died

Scarb?

 

[Chartreuse Wombat]

Would expect study to be most rigorous possible under the circumstances. This is john ioannidis’ group.

“Ioannidis's 2005 paper "Why Most Published Research Findings Are False"[1] is the most downloaded paper in the Public Library of Science[14][15] and is considered foundational to the field of metascience.[16] In the paper, Ioannidis demonstrates that most...”

I encoourage all to read the paper. It is completely theoretical and basically calls into question many of the analytical processes in the scientific literature. Be careful, however, not to use this paper to trash all of science as some have (especially if an experiment ends up with an answer one doesn't like). Of course randomized controlled trials are not perfect but most of the criticisms in the paper relate to basic science (small sample sizes in animal studies) and epidemiologic studies (p-hacking etc).

 

[Lamount]

I encoourage all to read the paper. It is completely theoretical and basically calls into question many of the analytical processes in the scientific literature. Be careful, however, not to use this paper to trash all of science as some have (especially if an experiment ends up with an answer one doesn't like). Of course randomized controlled trials are not perfect but most of the criticisms in the paper relate to basic science (small sample sizes in animal studies) and epidemiologic studies (p-hacking etc).

I enjoy this paper and I agree with the it’s broad conclusions... but with clinical research, we usually don’t know the pre-test probability. This can vary by orders of magnitude whereas power cannot. It’s very hard to apply these equations except in fields with a known distribution (i.e genomics, epidemiology)... but most animal research and clinical trials would be more tricky. How can one ever gauge if a study’s low power dramatically impacts PPV if there is no consensus on the pre-test probability?

 

[Chartreuse Wombat]

I enjoy this paper and I agree with the it’s broad conclusions... but with clinical research, we usually don’t know the pre-test probability. This can vary by orders of magnitude whereas power cannot. It’s very hard to apply these equations except in fields with a known distribution (i.e genomics, epidemiology)... but most animal research and clinical trials would be more tricky. How can one ever gauge if a study’s low power dramatically impacts PPV if there is no consensus on the pre-test probability?

The frequentist approach is the most conservative and no assumptions about priors are made. Most clinical trials use this approach and as a result are conservative. Bayesian approaches invoke pre-test probabilities and are more efficient. CTEP tends to be conservative. My point is not to use this paper to bash all of science. A well-designed, randomized controlled trial is the best method to determine the true effect.

 

[medgator]

Hypofx and hydroxychloroquine, approach with caution?

 

[xrthopeful]

I think it may be the lupus and the medication, not the hypofrac part