Do you support encroachment into the field?

[CurbYourExpectations]

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Squad, best and brightest, SDN enjoyers, what are your thoughts on the current landscape of encroachment? Another fun survey. What are physician tasks? Do you want to be task shifted away from clinical activities and treatment planning? If so, why?

 

[RickyScott]

Conotouring and evaluating plans is a gazillion times more important than physical supervision. A doc must be physically present, but a community college dropout can be conturing tumors and deciding on plans. Is this the astro position?

 

[RadOncMegatron]

Isn’t this basically a way for a med onc or urologist to say give me a one year fellowship in rad onc? @DoctwoB can now own a linac and contour! 🤣

 

[CurbYourExpectations]

Isn’t this basically a way for a med onc or urologist to say give me a one year fellowship in rad onc? @DoctwoB can now own a linac and contour! 🤣

100%, I don't see a reason why you need a RadOnc physician if clearly not even physicians need to do the work, right ASTRO and big academic institutions?

And let's not get crazy with the 1 year fellowship, 2 week certificate. Hire a couple "APRTs", clearly they do as well as RadOncs.

 

[CurbYourExpectations]

0 supporters so far can't wait to see 🤣

 

[RadOncMegatron]

100%, I don't see a reason why you need a RadOnc physician if clearly not even physicians need to do the work, right ASTRO and big academic institutions?

And let's not get crazy with the 1 year fellowship, 2 week certificate. Hire a couple "APRTs", clearly they do as well as RadOncs.

Don’t they know in some countries like India where they train oncologists who do both chemo and radiation? Also, have they not heard of this new thing called “AI”? Might also impact us one day…

 

[HolySmokes]

Call me old fashioned but I think our job responsibilities have already been encroached more than what is best for patient care. Rad oncs should not only be doing their own contouring, but should be taking a much larger role in their own treatment planning as well.

Surgeons don't do residency just to tell a tech what they want cut and come in after to look over what was done.

 

[BobbyHeenan]

Once again academic rad onc departments thinking "how will this help my department?" and "our program is expanding, this will be great for our department" and through that first principal are destroying our field. It's the same phenomenon as residency expansion.

 

[CurbYourExpectations]

We should have not complained about their residency expansions, this is their response 😆

 

[grenz]

We should have not complained about their residency expansions, this is their response 😆

I honestly think this could be it. Faculty want resident coverage but there is pressure not to expand residencies. I think the market response is to look to advanced practitioners.

I don’t know about you guys, but I feel that in today’s complex oncology landscape, I frequently engage in deep thought about dose and fractionation, as well as whether to treat or not. I just don’t see that being replaced by anyone who didn’t complete a rad onc residency. We’re also expanding into radiopharmaceuticals, and if more of the field did that, it would throw up further barriers to any existential threats from encroachment.

 

[firewicket]

I am fine with utilizing them appropriately.
Lets get real. OTVs do not reeeaaaly need to be seen by a doctor. It is side effect and symptom management.
Consults and direction of RT clearly need to be done by a doctor.
Follow up and machine supervision (should that be allowed) seem fine for NP.
So in that regard, it seems fine.
Anything beyond that scope is inappropriate.

 

[CurbYourExpectations]

I honestly think this could be it. Faculty want resident coverage but there is pressure not to expand residencies. I think the market response is to look to advanced practitioners.

I don’t know about you guys, but I feel that in today’s complex oncology landscape, I frequently engage in deep thought about dose and fractionation, as well as whether to treat or not. I just don’t see that being replaced by anyone who didn’t complete a rad onc residency. We’re also expanding into radiopharmaceuticals, and if more of the field did that, it would throw up further barriers to any existential threats from encroachment.

Radiopharm is controlled in academic centers by nuc med probably 90%+ of the time, I do think/hope that private/hospital docs out in the real world are being aggressive about trying to get it to be them, but idk if they are. Are they out there? I don't do any radiopharm, nuc med does.

It is crazy to think about how easy it is for groups to encroach on us, but how difficult it would be for us to encroach on anyone.

 

[BobbyHeenan]

Radiopharm is controlled in academic centers by nuc med probably 90%+ of the time, I do think/hope that private/hospital docs out in the real world are being aggressive about trying to get it to be them, but idk if they are. Are they out there? I don't do any radiopharm, nuc med does.

We (rad onc) are doing the radiopharm heavy lifting at our center/network. With that said, reimbursement /RVU's/pro fees on the doctor side are absolutely abysmal while the hospital makes bank. We have to fight with hospital to explain this to them.

 

[OTN]

Once again ASTRO trying for something none of us want. Hey, ASTRO, instead of ROCR (great job there) and this APRT nonsense, how about advocating for our specialty? How about increasing knowledge and uptake of SBRT for liver mets and HCC, given that we are basically an afterthought there? How about advocating for dermatologists (and ENTs apparently) not being able to fleece our codes for all they're worth? How about pushing for APBI instead of hormones for early-stage breast cancer in older patients?

How about doing ANYTHING WORTHWHILE WHATSOEVER?

 

[alwaysbeIMRTing]

I'd like to say "this can' be real," but of course it is.

Residency expansion/fake workforce projections
Linac babysitting mandates
Anti-physician ownership
Woke DEI diversity hiring and promotion
Fraction and IMRT shaming and virtue signaling
Making rad oncs who work in urology practices pariahs
APM, ROCR, whatever the next version of hosing over employed RVU doctors will be
Academic satellite model

Of course making RTTs advanced providers (then what is a physician if not advanced?) is next on this self-immolating list.

I am fine with utilizing them appropriately.
Lets get real. OTVs do not reeeaaaly need to be seen by a doctor. It is side effect and symptom management.

Yes they do. I adjust treatment volumes, put patients on break, add fractions, prescribe controlled substances, etc. all the time based on what I learn from daily imaging and OTVs. I have no interest in finding out Jenny McJennison, MSN APRN, FNP-C, DNP, RN, BSN, CPR, LOL has resulted in my early stage head and neck patient ending up in the ICU because they weren't eating for 2 weeks and stopping treatment halfway through.

Once again ASTRO trying for something none of us want. Hey, ASTRO, instead of ROCR (great job there) and this APRT nonsense, how about advocating for our specialty? How about increasing knowledge and uptake of SBRT for liver mets and HCC, given that we are basically an afterthought there? How about advocating for dermatologists (and ENTs apparently) not being able to fleece our codes for all they're worth? How about pushing for APBI instead of hormones for early-stage breast cancer in older patients?

How about doing ANYTHING WORTHWHILE WHATSOEVER?

Are you even allowed to say that you are anti-ASTRO if you work at an academic center? I get the feeling it's like pledging fealty to the communist party of China. Sure, you're free not to be a member. But we'd like for you to spend a few months at a camp learning about why you really should.

 

[OTN]

I'd like to say "this can' be real," but of course it is.

Residency expansion/fake workforce projections
Linac babysitting mandates
Anti-physician ownership
Woke DEI diversity hiring and promotion
Fraction and IMRT shaming and virtue signaling
Making rad oncs who work in urology practices pariahs
APM, ROCR, whatever the next version of hosing over employed RVU doctors will be
Academic satellite model

Of course making RTTs advanced providers (then what is a physician if not advanced?) is next on this self-immolating list.


Yes they do. I adjust treatment volumes, put patients on break, add fractions, prescribe controlled substances, etc. all the time based on what I learn from daily imaging and OTVs. I have no interest in finding out Jenny McJennison, MSN APRN, FNP-C, DNP, RN, BSN, CPR, LOL has resulted in my early stage head and neck patient ending up in the ICU because they weren't eating for 2 weeks and stopping treatment halfway through.



Are you even allowed to say that you are anti-ASTRO if you work at an academic center? I get the feeling it's like pledging fealty to the communist party of China. Sure, you're free not to be a member. But we'd like for you to spend a few months at a camp learning about why you really should.

Not sure re: working at an academic center, I'd rather manage a Buc-ees

 

[Ray D. Ayshun]

Join's reading of the list of APRT responsibilities on the podcast was absurd. Maybe generated by AS (artificial stupidity). This is a Practitioner Advocating Research and Radiation Oncology Therapy. PARROT. Aren't we already overstocked with parrots?

 

[alwaysbeIMRTing]

Not sure re: working at an academic center, I'd rather manage a Buc-ees

It's probably easier to become a board certified radiation oncologist than to get a Buc-ees management position (or the real crème de la crème, a Chik Fil A franchise).

 

[grenz]

We (rad onc) are doing the radiopharm heavy lifting at our center/network. With that said, reimbursement /RVU's/pro fees on the doctor side are absolutely abysmal while the hospital makes bank. We have to fight with hospital to explain this to them.

I imagine there are some ways you could negotiate for a medical director stipend or something to get some of the global. Bigger picture, I think this is a long game. There is a lot of effort towards incorporating Dosimetry which would unlock new codes for us to bill. There are also early phase studies of combining SBRT boosts with RP for underdosed Mets. Lots of ways this could become more “worth it” for rad onc and a natural extension of our current expertise.

 

[BobbyHeenan]

I imagine there are some ways you could negotiate for a medical director stipend or something to get some of the global. Bigger picture, I think this is a long game. There is a lot of effort towards incorporating Dosimetry which would unlock new codes for us to bill. There are also early phase studies of combining SBRT boosts with RP for underdosed Mets. Lots of ways this could become more “worth it” for rad onc and a natural extension of our current expertise.

Agree. Working on those things (stipend, etc) as we speak. Agree with bigger picture.

 

[grenz]

Agree. Working on those things (stipend, etc) as we speak. Agree with bigger picture.

And if anyone doesn’t believe us, take a look at just a few examples of what some really smart rad oncs are working on:

https://www.sciencedirect.com/science/article/pii/S0360301623053257

Tolerability of concurrent external beam radiotherapy and [177Lu]Lu-PSMA-617 for node-positive prostate cancer in treatment naïve patients, phase I study (PROQURE-I trial) - PMC

Prostate cancer patients with locoregional lymph node disease at diagnosis (N1M0) still have a limited prognosis despite the improvements provided by aggressive curative intent multimodal locoregional external beam radiation therapy (EBRT) with ...

pmc.ncbi.nlm.nih.gov

https://ascopubs.org/doi/10.1200/JCO.2025.43.5_suppl.129

 

[temujim]

ASTRO probably sees money with these APRTs (certification, continuing education, etc). This push I think also coming from Europe where the MD pay is relatively poor (so why do extra, particularly with adaptive). It will probably all come to nothing, since these tasks will likely be absorbed into AI.

Many of my patients only meet the med onc once; otherwise managed by APPs. Really don't want to be that guy.

 

[CurbYourExpectations]

Agreed.

To the point NMS made, what is the reasoning of having APRT go through a pathway for 1-2 years, or however long it takes to learn all of what RadOnc physicians have been training for over a decade for? Why not just pay them a little extra so that they enjoy their job more and assisting with the adaptive?

I think it's incredibly short sighted to have a 1-2 year program when pretty much all of these tasks will be AI controlled in the future, and maintaining physician involvement of all the major patient related tasks should be held paramount. I doubt they are just going to be psyched to fade into the background after doing extra training when all of the tasks start getting replaced by AI.

BTW over 95% don't want this so far. Feel like this could have been a lay up for them to just make a statement that encroachment shouldn't be happening.

 

[TheWallnerus]

ASTRO probably sees money with these APRTs (certification, continuing education, etc).

This is always the root answer to any ASTRO question. Whether making money for themselves... or making sure that a simple community rad onc doesn't make too much of it (or make it too easily).

 

[radiation]

Where is anybody seeing that ASTRO has anything to do with this, seems like it is coming from one institution and RTTs? ASTRO even publishing editorials against it

https://www.redjournal.org/article/S0360-3016(25)00595-4/abstract

 

[NotMattSpraker]

 

[alwaysbeIMRTing]

At this point it is a Pavlovian conditioned response. If ASTRO does anything, it is completely reasonable to automatically assume that it is anti-radiation oncology physician, especially anti-community practice rad onc. I would never fault anyone for that.

Does any other specialty have a professional society that is so reviled within the profession? Or anywhere close?

 

[medgator]

At this point it is a Pavlovian conditioned response. If ASTRO does anything, it is completely reasonable to automatically assume that it is anti-radiation oncology physician, especially anti-community practice rad onc. I would never fault anyone for that.

Does any other specialty have a professional society that is so reviled within the profession? Or anywhere close?

They've been doing it for so long, decades at this point. Through the organization itself and through the PAC

It's really sad and I've never seen anything else like it in medicine.. the divide between academic and community practitioners

 

[NotMattSpraker]

I got all excited I was going to get an actual public and written opinion on a workforce issue from an ASTRO leader!

(I did not)

 

[CurbYourExpectations]

To play devil's advocate. There was a ton of complaints when ASTRO didn't ask the community opinion and now there are a ton of complaints when ASTRO is asking the community opinion. lol

 

[OTN]

I am once again asking where the data is which supports widespread adoption of adaptive RT.

 

[CurbYourExpectations]

I am once again asking where the data is which supports widespread adoption of adaptive RT.

How many APRTs do you think are needed for the 10-20 areas using regular adaptive therapy? I bet they'll be shooting for hundreds a year, there is just such a high need!

 

[alwaysbeIMRTing]

when ASTRO is asking the community opinion.

They don't care.
All they care about is control and trying to cram down regulatory mandates on supervision, billing, dose fractionation, and quality programs on every rad onc in the country. Community rad oncs are not to be trusted, not even for palliative RT. RTTs, on the other hand...

 

[NotMattSpraker]

To play devil's advocate. There was a ton of complaints when ASTRO didn't ask the community opinion and now there are a ton of complaints when ASTRO is asking the community opinion. lol

Totally. My issue with the societies on APRT has always been the lack of a public opinion.

Shawn Caldwell's PhD thesis explores this role and that was published in 2022. Albert Koong is on his committee. There was an IJROBP review paper in 2023. ASRT has had multiple articles and now a full issue all about this expanded scope of practice in the US. In that issue, they have a whole article about how APRT can manage skin cancer independently with a dermatologist.

Institutions are already hiring for APRTs today (albeit with unclear roles in practice).

At the same time, ASRT runs a conference concurrent with ASTRO and they fund a couple projects within ASTRO. I find it pretty interesting that on supervision, they are cool to send a letter on behalf of the field while getting no opinions. But for this potentially uncomfortable disagreement with ASRT, they are now, finally, gathering opinions.

A survey right now when a cousin organization is going full throttle and some SCAROP chairs are already hiring the position. Is Chirag's paper ASTROs official position? He is on committees, I think? We dont know.

Did ASRT approach ASTRO, ACRO, or the ACR about this expanded scope of practice at any time before, like... this week?

My "complaint" is I do not feel ASTRO (or ACRO, or the ACR honestly) really looks out for Radiation Oncologists. They look out for themselves: membership numbers, revenue, pet issues of select leadership folks. Pretty simple.

 

[CurbYourExpectations]

I think the real question is going to become not "what is the role of the APRT?", but "what is the need for the RadOnc participation?" This is the pregame to the party. RadOnc has been not very great at stopping encroachment.

 

[NotMattSpraker]

I think the real question is going to become not "what is the role of the APRT?", but "what is the need for the RadOnc participation?" This is the pregame to the party.

Maybe. There is no reason not to take control of this conversation now locally.

No requirement to let ASRT or ASTRO shape your practice (for now)

 

[Gfunk6]

I am once again asking where the data is which supports widespread adoption of adaptive RT.

Here is some data for you - adaptive RT is a billing exception to the case rate in ROCR. That is all the data ASTRO needs.

 

[CurbYourExpectations]

You have to admit though, it will be the most RadOnc thing ever if a majority of RadOncs end up voting to have someone replace them, RadOnc will be the biggest lifestyle specialty, so much involuntary vacation.

 

[NotMattSpraker]

ROCR 2.0 forces development of an adaptive code and a temporary modifier for use until the code is developed. Off table adaptive qualifies for this code. I suspect we will see a lot of off table adaptive if this were to pass.

 

[CurbYourExpectations]

With lots of randomized data showing there is clinical benefit for on table adaptive r-right?

 

[yesmaster]

There’s a clinic where it’s just a rheumatologist and RTT going at it. OA ldrt that is.

 

[A_DeMichele]

What type of machine?

There’s a clinic where it’s just a rheumatologist and RTT going at it. OA ldrt that is.

 

[alwaysbeIMRTing]

I do "adaptive" RT for at least half of my head and neck patients (I do SIBs), I replan halfway through due to anatomic changes. Sometimes three times. Never have any issues billing extra 77301s. I adapt and replan lungs often, too. Even prostates occasionally.

Daily adaptive RT sounds a little like the derms who are "adapting" the superficial energy daily. Or a lot like.

44 fraction prostate and breast IMRT (things that actually are evidenced to work and benefit patients) are unethical overtreatments for extra money in the community that need case rates to guard against monsters like me, but on table adaptive RT (and now apparently off table?) and protons at academic centers... better than fine. Do you need an MR linac to use these codes? Probably best to restrict them to academic centers where they can't be abused.

 

[TheWallnerus]

I do "adaptive" RT for at least half of my head and neck patients (I do SIBs), I replan halfway through due to anatomic changes. Sometimes three times. Never have any issues billing extra 77301s. I adapt and replan lungs often, too. Even prostates occasionally.

Daily adaptive RT sounds a little like the derms who are "adapting" the superficial energy daily. Or a lot like.

44 fraction prostate and breast IMRT (things that actually are evidenced to work and benefit patients) are unethical overtreatments for extra money in the community that need case rates to guard against monsters like me, but on table adaptive RT (and now apparently off table?) and protons at academic centers... better than fine. Do you need an MR linac to use these codes? Probably best to restrict them to academic centers where they can't be abused.

Daily 77301s get you a better daily reimbursement than protons. Imagine the ROI on daily 77301s versus building a proton center.

 

[DoctwoB]

Isn’t this basically a way for a med onc or urologist to say give me a one year fellowship in rad onc? @DoctwoB can now own a linac and contour! 🤣

No can do, I'm terrible at drawing circles. Lmk when the AI will do it for me and i'm in.

In all seriousness though we need to be more protective about the cerebral aspects of our field, less so about the technical, which is really our biggest value ad. Most APP protections have been about the opposite, restricting procedures or technical things. The old joke is you can teach a monkey to operate, and it's true to a degree. Most procedures are a matter of repetition and pattern recognition. Mayo has a "foley team" (#jealous) with I think RNs (or maybe PAs) that take care of every difficult foley, scope foleys in, etc. And I have no doubt theyre great at it since it's all they do. I'm sure contouring and the technical aspects of RT treatment are the same.

Where the training matters is in making the treatment plan, weighing different options, pros/cons, when not to treat, etc.

 

[NotMattSpraker]

Daily adaptive RT sounds a little like the derms who are "adapting" the superficial energy daily. Or a lot like.

I disagree based on where we stand today. Even the radiation oncologists in that coding hearing had trouble explaining the clinical benefit of daily US guidance for superficial RT. The data support is a garbage partially-retracted dataset.

It is easy to see the theoretical upside of on table adaptive RT, and it is being tested in prospective trials.

In all seriousness though we need to be more protective about the cerebral aspects of our field, less so about the technical, which is really our biggest value ad.

Biggest value and biggest portion of per patient RVUs for radiation oncologists (treatment planning and OTVs). But that's just how it is today. Maybe we should spend more time propping up our value to the public instead of trying to use legislation to shut down "shady community" urologists, dermatologists, radiation oncologists, etc.

In the past, Sameer told me this was one of the strongest reasons to support ROCR. If these codes are de-valued, I will feel the pain.

I guess he is not worried about this with the APRT role expansion? Maybe it is the next president's problem 🙂

 

[medgator]

I disagree based on where we stand today. Even the radiation oncologists in that coding hearing had trouble explaining the clinical benefit of daily US guidance for superficial RT. The data support is a garbage partially-retracted dataset.

It is easy to see the theoretical upside of on table adaptive RT, and it is being tested in prospective trials.



Biggest value and biggest portion of per patient RVUs for radiation oncologists (treatment planning and OTVs). But that's just how it is today. Maybe we should spend more time propping up our value to the public instead of trying to use legislation to shut down "shady community" urologists, dermatologists, radiation oncologists, etc.

In the past, Sameer told me this was one of the strongest reasons to support ROCR. If these codes are de-valued, I will feel the pain.

I guess he is not worried about this with the APRT role expansion? Maybe it is the next president's problem 🙂

Sameer pushed to kill urorads and the IOAE when he was in charge of the ASTRO PAC years ago.

When people speak with their words and/or actions, listen?