Some outrageous statements on here
Derm vs. Rad Onc
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Some outrageous statements on here
D
deleted941485
Where the hell in this country are derms the primary purveyors of RT? How many of these patients are we not seeing?
D
deleted1002574
I think it’s possible ... they see more than us. Many have machines.
D
deleted941485
I guess I’m in the wrong neck of the woods. I’ve seen them in Derm offices but I still get referrals for them and not train wrecks either.
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They are likely the primary purveyors of RT for skin CA and it's probably not even close. SneakBoog in past said "Our local derm does more XRT than most departments."
There are 3.3 million people per year getting 5.4 million non-melanoma skin cancers per year.
Dermatologists will see the near majority of these.
Pick what fraction of derm offices have superficial RT machines, and "do the math" as I like to say.
Derms definitely treat more cancer patients than radiation oncologists. We only have a draw of about 1.8 million new pts a year, and only get to irradiate about 1/3 of those. (I have pointed this out before. There are twice as many derms as rad oncs. But they probably "first treat" about 5 times as many cancer patients as we, and who knows how many more times new patients in general.)
If derms irradiate just a fraction of the cancers they treat, then yeah. They dunk on rad onc in the skin cancer RT game.
D
deleted941485
Oh the benefits of being a bottom feeding specialty
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I’ve said it before and will say it again, we need to start being more on the front lines regarding radiation in the upfront management of things. Advertise to PCP and the general population how SBRT can cure lung and prostate cancer without leaving a scar. How radiation can cure skin cancers. I know it’s not easy and not what we are use to doing but I believe it’s necessary.
Agree. Also need to make it harder for other specialties to deliver radiation and push for stronger regulation on the machine side. Who is doing the QA on these? How often are they calibrating them, doing output checks, etc? Need to make certification not worth the hassle for a small derm shop who probably shouldn't be delivering radiation anyway. Would love to see data comparing outcomes of derm delivered radiation vs. rad onc
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I agree WHOLEHEARTEDLY but I’m getting hated-on big time by the specialities that I’m taking the upfront management from
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I'd like to know a bit more on the background of this "battle".
Did ASTRO talk to the AAD prior to publishing the guideline? Did they invite them to co-formulate it?
Most of the skin cancers radiation oncologists see are sent to them by dermatologists, when those very same dermatologists:
a) do not want to / cannot operate and do not have the means to deliver radiation therapy themselves
b) deem the risk for recurrence to be high and do not have the means to deliver radiation therapy themselves
Talking to each other never hurt... 🙂
Did ASTRO talk to the AAD prior to publishing the guideline? Did they invite them to co-formulate it?
Most of the skin cancers radiation oncologists see are sent to them by dermatologists, when those very same dermatologists:
a) do not want to / cannot operate and do not have the means to deliver radiation therapy themselves
b) deem the risk for recurrence to be high and do not have the means to deliver radiation therapy themselves
Talking to each other never hurt... 🙂
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Same here, the ones who came before us did not make this easy for us. Hell, it’s an uphill battle to explain to docs that I’m also an “oncologist” and not just a tech that the med onc orders to push buttons.
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American rad oncs wear a t-shirt under their dress shirt that reads “I know what is best for everyone.” 😉
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We are a bottom feeding specialty but our recruitment and growth rates are tops!
D
deleted774703
Seriously though wtf is ASTRO ACRO ASCO doing to stop this?
i imagine that AAD is much stronger than Astro at least but something needs to be done
wtf was the point of me doing any rad bio physics studying if ppl can prescribe RT without issue
i imagine that AAD is much stronger than Astro at least but something needs to be done
wtf was the point of me doing any rad bio physics studying if ppl can prescribe RT without issue
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Below is a link to a company that makes these superficial XRT machines for dermatologist. They have "triple-modulated radiotherapy and Brachytherapy utilizing our proprietary, state-of-the-art 3D Beam Sculpting." Can be used for keloids too. I remeber looking into one of these a while back and I think you need to be treating about 30 cases a month for this machine to be economically viable. Probably not a big number for dermatologist but no where near what a typical rad onc does.
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If you can't bring dermatology on board for your skin cancer guidelines its a pretty useless exercise at the end of the day. Just another case of ASTRO hanging out in left field telling everyone how smart they are without getting buy in from the one group that matters.
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Urorads redux, as far as ASTRO is concerned
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In fact, I would say: worse. At least the urologists wanted to partner with rad onc, and would have a rad onc and all the physics etc on board. They were trying to do it 1) to benefit themselves, and 2) in a medically proper and even collegial way. Meanwhile, derm did their own thing, which was ENTIRELY IN THEIR PURVIEW to do. And ASTRO hasn't and prob can't do a thing about it. They got mad at urologists maybe treating 50-100,000 men a year with EBRT for CaP (and made their displeasure all about the money not about the care per se, which was transparent), while derms could be treating 3 million people a year with RT if they wanted to.
It surprises me (namely, that you don't have to be a "radiation oncologist" to prescribe radiation) when this info surprises other people. Firstly, I imagine there might still exist some simply ABR, non RO, certified "radiation therapists" in America practicing. Second, I know some endocrinologists who prescribe radioactive iodine. Third, there can be therapeutic levels of RT given in some cardiology procedures (sometimes, rarely). Fourth, when you have a medical license you have a license to practice medicine. A radiation oncologist can legally do a craniotomy (better know how to do it and have good outcomes or you'll get sued or be guilty of murder, but if you're good at craniotomies and have a hospital that will OK it you can do them all day long) and a neurosurgeon could buy their own linac and do RT (if they get an insurance company to let them bill it, which prob isn't hard). There are some state-to-state variations. I.e., correct me if I'm wrong someone, but I think you have to be a rad onc to use a linac or prescribe EBRT in California. But idk about SRT.
So why study rad bio and physics to the level that we do in rad onc? This is a good question. I think you could offer a three day course in the physics and rad bio of superficial RT and be 100% clinically competent IMHO though. Especially if you were a good derm, and intelligent, and then had 100 cases under your belt (which they could probably do in a month). I would totally trust a derm to prescribe SRT.
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These are all very superficial machines. Afaik, derm is limited to 50 kv or something like that without a rad onc involved.Below is a link to a company that makes these superficial XRT machines for dermatologist. They have "triple-modulated radiotherapy and Brachytherapy utilizing our proprietary, state-of-the-art 3D Beam Sculpting." Can be used for keloids too. I remeber looking into one of these a while back and I think you need to be treating about 30 cases a month for this machine to be economically viable. Probably not a big number for dermatologist but no where near what a typical rad onc does.
I've actually seen large derm groups buy hdr machines, even a linac and they end up hiring or partnering with an RO
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The top machine energies are in the 300kV range, and you don't *have* to have a rad onc involved at least not based on energies really. I have said before cardiologists could buy linacs to do cardiac rhythm SBRT stuff.
It’s funny how we can debate endlessly over a 200 person residency excess ( which we should be concerned about) but won’t fight over 3 million pool of potential pts. It’s probably true you don’t need a rad onc run to do 99% of these cases just like a NP could do 99% of typical family medicine but it's the 1% that matters.I’m sure all of us have seen disaster mohs cases where the derm has left a huge hole in the pts head and still couldn’t get negative margins. I'm skeptical a derm will know the indications to treat perineural invasion to the base of skull. I do think most derms are not doing the appropriate technical QA on these.
More than anything it’s more of the principle of us owning our modality and advocating for the specialty. But the vibe here sometimes just seems to take on a woe is me mentality and be complacent accepting whatever hand we get dealt
More than anything it’s more of the principle of us owning our modality and advocating for the specialty. But the vibe here sometimes just seems to take on a woe is me mentality and be complacent accepting whatever hand we get dealt
D
deleted573262
This morning Dr Zaorsky added a longer series of tweets worth checking out:
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i think this was like a 2015 article he is citing for the $16000 reimbursements.
They have really cut down on that and now it's about (very ballpark) $3000-$4000 per patient
/soapbox
I'm not woe is me. It's more how stupid is we. And ASTRO's skin cancer guideline is exhibit 1. Just because it's "cancer" and we are oncologists we can make a guideline that mentions surgery's pros and cons? What do we know from surgery? What do we know from skin cancer referrals? Diagnosis? ASTRO concentrates on STUPID stuff. If they concentrated on supporting all rad oncs that'd be great. Just a few days ago someone said they do IMRT for lung/esoph "100% of the time." Does everyone realize that the higher-ups in rad onc 10 years ago were saying that 100% IMRT in any disease site was tantamount to fraud? Do they realize that ASTRO said rad oncs who work with urologists were just doing it for the money? I'm better than any non-radiation oncology doctor in the world at radiation. But so what? It's like if you were a cameraman on a TV show. What would you know about set design, production, scripting, etc.? The director may not know the minutiae of the camera tech, but he prob knows a bit, and you'd rather have him than the cameraman in charge of the show. Derms direct skin cancer care in the USA. They may not know the intricacies of perineural invasion pathways, but how many lives has that really lost or saved?
/soapbox
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What you are saying is not only practical but the truth. We can all “talk” about what “should” be done versus understanding what is “actually” being done.
I can deliver the “best” radiation, but it doesn’t mean the neighborhood dermatologist or urologist really care.
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Idk I mean I think this is worse than UroRads. Derms doing RT themselves without even having to hire a RO. Some derm offices actually hire a RO which I think is fine (in the same way I think UroRads is whatever).
The concept of doing photon based therapy but being able to bill it as brachytherapy is laughable. Similar to Xoft/electrons for IORT in breast billed as say a brachytherapy treatment.
This used to be much more of an issue back when EBT reimbursed stupidly well, as others have noted the reimbursement has dropped significantly due to billing abuse by Dermatologists such as one of the authors.
I think it's brave of Zaorsky to directly call out one of the authors for being a hypocrite. Of course it won't matter since leadership in any medical association are almost never held to task for their shenanigans, but I respect the move.
The concept of doing photon based therapy but being able to bill it as brachytherapy is laughable. Similar to Xoft/electrons for IORT in breast billed as say a brachytherapy treatment.
This used to be much more of an issue back when EBT reimbursed stupidly well, as others have noted the reimbursement has dropped significantly due to billing abuse by Dermatologists such as one of the authors.
I think it's brave of Zaorsky to directly call out one of the authors for being a hypocrite. Of course it won't matter since leadership in any medical association are almost never held to task for their shenanigans, but I respect the move.
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florida
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As the response to the LTE makes clear "The guideline task force represented all stakeholders including leading dermatologists, dermatopathologists, cutaneous surgeons, medical oncologists, medical physicists and radiation oncologists." Dermatology has more problems than we do right now. See below
Why Private Equity Is Furious Over a Paper in a Dermatology Journal (Published 2018)
The sudden, unexplained removal of a research paper on private equity firms buying dermatology practices has raised questions about corporate influence.
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As long as CMS turns their attention to derm for radiation based reimbursement cuts in light of this, I'm all for it.
Push the envelope you greedy derm bastards! Take the scrutiny from us.
Push the envelope you greedy derm bastards! Take the scrutiny from us.
I posted about this years ago. I was appalled when a buddy of mine from med school let me tag along to his big derm conference in town. They were pushing these superficial units and they gave a half day lecture on rad bio and physics. It was taught by a dermatologist who didn’t know the difference between his a** and a whole in the ground. Whole thing was a joke. My buddy did a moh’s fellowship that turned into a half moh’s half “rt” fellowship because moh’s reimbursement tanked. We suck!
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This is all hearsay of course, but even at 300 kv, are they really going to be able to treat everything? Not that I'm aware of. Fwiw, I've seen some pretty nasty recurrences and persistence of disease from some derm practices that use them.
Most egregious example i saw was a pt referred by a derm who used a unit to treat a lip scc, and within 3-6 months, pt had bilateral nodal mets, primary site looked ok.
So I guess a Gyn Onc can conceivably do vaginal cylinders (or even T&R) without a radiation oncologist using a 50kV unit? I'm surprised it's not happening yet.
www.xoftinc.com
Elekta Xoft | Brachytherapy | Elekta
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It's all about what you do and don't wanna get into I suppose.So I guess a Gyn Onc can conceivably do vaginal cylinders (or even T&R) without a radiation oncologist using a 50kV unit? I'm surprised it's not happening yet.
Elekta Xoft | Brachytherapy | Elekta
Please, please know this everyone...
Even the American Academy of Family Physicians says that much of radiology is in their scope of practice.
Now why can't radiation oncology, ostensibly a branch of radiology, be in the scope of practice of other specialties too?
If it's not happening by now, it will within the next 5 years:
Dermatologists will be delivering more daily radiation treatments in America than radiation oncologists.
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I've been banging, "you can treat the clinically relevant portion of our job for specialized indications very easily to other doctors" drum for a while. I'm always accused as self hating, but here we are....
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Actually they used to do that in Europe. When I started my residency I met a very nice gynecologist who was only a few years close to retiring. He explained to me how he nad his colleagues used to deliver brachytherapy for cervical cancer back in the old days (LDR) without any radiation oncologists. Gynecologists have a long history of training for delivering RT and actually delivering it too.
We shave a orthovoltage machine with our in-house dermatology department. They treat using up to 50kV, when the lesions get bigger / deeper they ask us to treat the patients. The machine can treat up to 100kV. We actually wanted a 200kV-capable machine but they wanted one additional low energy, so we had to but this one.
Neurosurgeons are also known to deliver radiation therapy on their own. If the field of functional neurosurgery ever truly picks up, I imagine them or even the neurologists to grow even more interest in pushing us out.
And while we are at it: Rheumatologists may actually grow interest in treating stuff with RT (we have a special "benign disease" thread on the forum). An orthovoltage machine is well capable of treating finger-arthritis.
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My experience as well. During my internship I worked with a gyn oncologist who trained with Gilbert Fletcher. I am dating myself but I learned more about gyn brachytherapy from him than I did during residency.
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and they deliver chemo, and neurosurgeons invented gamma knife and cyberknife. Really would like to see fellowships in chemo for radoncs.
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Why do we need a fellowship for that if other specialties can give radiation without doing one? Now I wouldn’t give chemo personally.
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It comes down to risk and "might makes right." Regarding risk, let's say you're a non-NSG, non-med onc, non-rad onc MD. Which of the following would you like to explore doing on a daily basis? Craniotomies, toxic IV chemotherapy, or 2 Gy daily doses of EBRT? No brainer right. And regarding "might makes right," if you are a diagnoser, or a main branch referrer, you can "call the shots." Derms are not only radiation oncologists, they're also pathologists too to some extent.
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They treat 7 days a week...
D
deleted941485
Cosmetics will come and go. RT May or may not pan out for most derms but Hey at least they’ll always be medical Derm. It ain’t glamorous but it pays bills and keeps derms employed. And they aren’t interested in Deescalation either. Which is a lot more than I can say for us
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I am a mohs surgeon and not a radiation oncologist. As a member of the American College of Mohs Surgeons, I can tell you that no one at those meetings is advocating the use of in office XRT machines. The giants in the field like Zitelli, Miller, and the Cooks do not promote their use. My understanding is that a few derms In California and Florida started billing for these with inappropriate codes which netted them huge profits for a few years but CMS has fixed that. In my experience, serious dermatologists are not the ones using this. They are marketed to and sought out by the more unscrupulous or gullible derms. With that said, I have not found radiation to be that effective for tough SCCs. I believe mohs to be the gold standard and think immunotherapy, like cepilimumab, shows a lot of promise and will likely be standard adjuvant for cases that can’t be cleared with mohs.
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So what make you... and what maketh us too I suppose... of your academy stating they are the “primary users” of RT for skin cancer.
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Have to disagree with you on the last part there. Not all SCCs are the same but radiation is very effective unless it’s already outside the box and it’s after 5 mohs procedures and months to years and when it’s already locally advanced then we get to see the patient.
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Hard to believe that cemplimab will produce anywhere close to the local control of radiation. Hasn't been reliably shown to date for any immunotherapy compound in any cancer...
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I certainly agree in principle but this might be too confident and we need to watch the left flank
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Melanoma?
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I have no problem with Mohs as first line. Radiation works great for high risk features on path or recurrent. Immunotherapy should be saved. It is not a local therapy. Makes no sense to give it after Mohs unless radiation not possible or has failed.
Im sorry that the rad oncs that you work with have not educated you as such. You are the company you keep!
In my experience I have a great relationship with my referring Derms.
Im sorry that the rad oncs that you work with have not educated you as such. You are the company you keep!
In my experience I have a great relationship with my referring Derms.
