FLASH, futurism, fate

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communitydoc13 said:
Agree with entire post. I'd like to work another 15 years and I would take an 18 month certification (as long as I could keep working) to give oral chemo or weekly IV chemo, ADT, first and second line endocrine based therapies, bone strengtheners. It would open up so much to our specialty: Research opportunities for the prohibitive and underutilized talent pool that we've accumulated and market power for small hospital system jobs and multi specialty practices that would impact our entire jobs situation.

Making this happen of course...
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I would 100% also pursue this certification, no question.
 
Gfunk6 said:
Here is my opinion:

1. Many of us are seasoned and experienced Radiation Oncologists. We are well-trained, have talented colleagues and stay up-to-date on literature. We are hyper-specialized and we repeatedly do the same set of things over and over. This extensive education combined with a deep pool of experience yields folks who work at a very high level. As such, it is very easy to lose your frame of reference in terms of your self-worth and value. Things that are "obvious" to us at this level and should be "easy" for any MD to pickup are anything but.

2. Linacs and comparable machines (protons, MRI-linancs, GK, CK) cost a lot of money and can do a lot of things. As such they require a "captain of the ship" to supervise their use. A linac should not be treated like an OR where anyone can do what they need to and leave. Therefore having thoracic surgeons, gyn oncs, general surgeons, neurosurgeons, etc. to each have their own patients on treatment is an asinine concept to me.

3. We need to evolve as a specialty. There have been tons of posts and comments about this. Since it is not feasible to come up with dozens of new indications for XRT, we will necessarily encroach on other fields whether that is oral chemotherapy, IR or whatever.

4. Many surgeons would acknowledge that a PA can perform straightforward surgeries solo. However, when the proverbial **** hits the fan you want a physician to be in charge. Ditto with complex procedures. Ditto with Radiation Oncology.
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Yeah but nobody is really willing to be bold when it comes to innovation be it research, training in procedures, cross training in other fields. All I hear is why we cant, why we shouldn't, why we are doomed. But no its all about cost containment and trimming indications meanwhile people are forking over high 5 and 6 figs for immunotherapy. What I learned from all this is that youll never bean count your way to greatness all youll do is make yourself and your field more and more irrelevant and other fields eat your lunch.
 
communitydoc13 said:
Agree with entire post. I'd like to work another 15 years and I would take an 18 month certification (as long as I could keep working) to give oral chemo or weekly IV chemo, ADT, first and second line endocrine based therapies, bone strengtheners. It would open up so much to our specialty: Research opportunities for the prohibitive and underutilized talent pool that we've accumulated and market power for small hospital system jobs and multi specialty practices that would impact our entire jobs situation.

Making this happen of course...
Click to expand...

You don't give ADT?
 
knuckles said:
You don't give ADT?
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I’ll start casodex when indicated but defer to urology for LHRH agonists/antagonists out of courtesy. Don’t do zytiga or xtandi as referred to medonc for those. I had assumed this was pretty typical?
 
RollTideRadOnc said:
A lot of hot and bothered emotions on this thread!

just the because the basics of most single site xrt can be learned quickly does not impugn the potential benefits of deeper training. People need to get over themselves and their self importance it seems 😉

and as for “disparaging our speciality in public”... welcome to the world of anonymous, open discourse big boys and girls! All topics are on the table.

does anyone really think it would seriously take a thoracic surgeon more than a year to learn lung SABR, follow up and management of complications? How long would this realistically take to learn well?

I guess I had no idea that lung SABR is so terribly complex!!! I must have been doing something completely different all these years.

please, oh oracles of SDN, illuminate my darkness shrouded soul!
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I mean, you also don’t get immunity from posting self defeating garbage, right? Or are you not a big boy (or big girl)?

It is illogical to on the one hand attack reckless expansion of residency and the oversupply but then preach about lowering the entry to practice radiation oncology. I read tons of people talking crap about academics studying hypofractionation but some of these same people seem to have no problem publicly talking about how easy the job is, how we are expendable, etc etc. as if that type of public discourse doesn’t also hurt? You think all the people being scared out of rad onc because of the important job discussions on this board don’t also see this stuff and carry it with them?

gfunk summed things up perfectly. We forget Sometimes that radiation is an incredibly powerful and dangerous modality. You think a surgeon is going to want to take on the added liability?
 
Dude. Spin off on tangents much?

the technical and research stagnation of our field both contributes to a need for fewer rad oncs and it also simultaneously lowers the barrier to entry for other specialists to take a piece of our pie as planning, short treatment courses (1-5 fractions), etc etc become easier than using an iPhone.
 
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scarbrtj said:
The researchers are to be congratulated on their excellent lack of capitalizing the word/SI unit "gray."

www.swissinfo.ch

New radiotherapy technique could revolutionise cancer therapy

A Swiss institute has tested a new ultrafast, high-dose radiation technique using protons that scientists say could revolutionise cancer therapy.
www.swissinfo.ch www.swissinfo.ch
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1601322912923.png


Great, thanks lay press. Patients with side effects: "the newspaper said no damage!"
 
RickyScott said:
Not looking so good. Also didnt realize potential benefits of FlASH offset by fractionation. That bloody scalp is one month s/p xrt Merkel !
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1) significant fractionation is expected/theorized to lose effect

2) that study is not FLASH (>60-100Gy/sec or so), they write about 10 Gy/sec dose rate delivered

3) their intro says flash is >10 Gy/ 100msec which is just a downright misleading way to write that and confuse readers while discussing “10 Gy/sec”. That makes me seriously question why the authors wrote it that way because it's simply misleading to a casual reader who would assume they are using FLASH doses
 
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StIGMA said:
1) significant fractionation is expected/theorized to lose effect

2) that study is not FLASH (>60-100Gy/sec or so), they write about 10 Gy/sec dose rate delivered

3) their intro says flash is >10 Gy/ 100msec which is just a downright misleading way to write that and confuse readers while discussing “10 Gy/sec”. That makes me seriously question the ethics of the authors to write it that way
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Had thought 40 gy/sec was typical of flash. Hard to believe if effect present at 40gy/sec, it is also not at least partially present at 10 gy/sec. if benefits of flash hinge on comparison to single fraction xrt, does not sound very promising given that we are not talking about a benefit that is a an order of magnitude difference.
 
RickyScott said:
Had thought 40 gy/sec was typical of flash. Hard to believe if effect present at 40gy/sec, it is also not at least partially present at 10 gy/sec. if benefits of flash hinge on comparison to single fraction xrt, does not sound very promising given that we are not talking about a benefit that is a an order of magnitude difference.
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I'm not sure there's a universally agreed upon lower limit. The idea is that any effect will disappear at lower rates (including <40 Gy/ sec). I would expect most FLASH, if it were to be effective, to be delivered in quite hypofractionated regimens. With proton FLASH (treating through the target with the transmission portion of the beam, not the Bragg peak which is set beyond the patient), this could mean [for example with a 3 field plan], treating 1 field per day for perhaps 3 total fractions or 6 total fractions. This would allow some conformality while theoretically still allowing FLASH biological effects.
 
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scarbrtj said:
The guy's hypotheses are not readily falsifiable.

- after MedOnc : What does a clinical oncologist do?
- after Rads or IR: Henry Kaplan, MD, founding Chair of the Department of Radiology, developed the first high-energy linear accelerator for therapeutic use in the 1950’s.
- you’re a thoracic surgeon and want to do SABR lung? Have at it!: If they can do immuno, they can do SABR?
- you’re a gyn Onc. You do it all anyway, including all the hard work for brachy. Might as well do a 1 year gyn RO fellowship!
- you’re a urologist and want to do SpaceOAR and SABR? Have at it!
- breast surgeon and you want to do external beam APBI? Maybe that’s a 3 month fellowship? 😉: Hello, I'm Jayant Vaidya.
- Neurosurg already does GK: Hello, I'm Jonathan Adler.
- GenSurg and wanna learn liver SABR do you can bury it under your recommendations for RFA? Be my guest.
- Derm and wanna do skin applicator brachy? Be certified with a weekend course!: Dermatologists are already, by their own profession, the primary purveyors of skin cancer radiotherapy in the United States.

Sixty years ago Buschke asked "What is a radiotherapist?" How close are we to that ideal today. How close can we get with a consult and a few 15-minute office visits for treatment...

While the patient is under our care, we take full and exclusive responsibility, exactly as does the surgeon who takes care of a patient with cancer. This means that we examine the patient personally, review the microscopic material, perform gynecological examinations, take a specimen for biopsy if necessary, examine the larynx, bladder, or whatever is necessary. On the basis of this thorough, clinical investigation, we consider the plan of treatment that we suggest to the referring physician and to the patient. We reserve for ourselves the right to an independent opinion regarding diagnosis and advisable therapy, and, if necessary, the right of disagreement with the referring physician. In some instances, we may even differ with the pathologist if the integration of equivocal microscopic findings into the entire clinical picture suggests the necessity for re-interpretation and change of diagnosis. During the course of treatment, we ourselves direct any additional medication that may be necessary, such as antibiotics or sedatives, blood transfusions, etc. We are ready to be called in an emergency, such as laryngeal edema or uterine hemorrhage, at any time.
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I need to remind myself to look back on this every time I consider rad onc over med onc. I wish the would just combine them in Canada like they have in the UK tbh bc I'd be glad to learn how to do both even if it took like 8 years
 
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