scarbrtj

Lord Monckton
Gold Donor
5+ Year Member
Dec 18, 2015
3,095
4,547
Status
  1. Attending Physician
Overheard in the CancerGeek podcast: "75% of CMS' rad onc claims are prostate, breast*, lung, and bone mets." Thus if there's "fiddling" with JUST ONE of these, it's going to cause really big ripples throughout the rad onc system. I'm trying (as I'm wont to do) to get people to understand what a strong wind rad onc is facing. This has been evolving the last 10y, but I definitely sense the gust(s) picking up...

1) I have already discussed the declining prostate cases being treated in rad onc. Falling patient numbers (less screening, less diagnoses, less incidence, less prevalence, more surgery), and falling fractions.

2) Lung cancer incidence ALSO dropping. "Lung cancer death rates declined by 51% from 1990 to 2017 among men and 26% from 2002 to 2017 among women. From 2013 to 2017, the rates of new lung cancer cases dropped by 5% per year in men and 4% per year in women. The differences reflect historical patterns in tobacco use, where women began smoking in large numbers many years later than men and were slower to quit." Did you know that if all cardiothoracic surgeons died from COVID tomorrow and all Stage I lung cancers started getting SBRT, there'd be only two to three Stage I lung cancer patients per year per rad onc in the USA? Even our wildest fantasies on lung cancer run into numerical problems. And now we have surgeons more willing to do Stage III surgeries.

3) BREAST
a) "I set out to find [HER2+] patients who had [local] recurrence... Approximately 2,000 patients later, I have not seen one."
b) "[A] population-based study revealed that rates of omitting radiation [between 1999 and 2010] increased from 15.5% in 1992 to 25% in 2007."
c) Extreme hypofx in breast will not just send "ripples" as mentioned above. More like tsunamis.

4) Bone mets. APM aims to force "behavioral changes" in America's rad oncs (direct quote per the podcast above) to cause more single-fractionating... see 3(c) above for potential ramifications.

Profit margin problems are on the horizon. If so, that means compensation changes, slowing hiring (even at the academic level!), etc. I do not feel APM will be salvational. It can be in terms of getting more reimbursement in cases of extreme hypofx, but really what we are talking about here is reimbursement AND patient numbers. If you aren't seeing as many patients, you don't need APM to decrease your reimbursement 'cause it's already happening.

To counter my take, many may say "I am seeing more patients." Mathematically, unless every data point I have is somehow fake news, this means other people are seeing less. It has to be. For the 9,484** (!) (probably too high because retirement, mis-classification, etc.) Medicare-accepting radiation oncologists in America, there are only so many patients to go around.

* May even be controversial that there's so many breast patients getting Medicare-funded treatment... does Medicare not notice this
** there are only about 150 radiation oncologists in the Philippines, a nation of ~100 million people
 
Last edited:
  • Like
  • Sad
Reactions: 6 users

Mandelin Rain

7+ Year Member
Apr 21, 2011
1,840
3,632
I wish your posts would be less:

1. Relevant
2. Accurate
3. Depressing

Similar to the job hunt, I'd even settle for 1/3.
 
  • Like
  • Haha
Reactions: 16 users

elementaryschooleconomics

Lord of Cobalt
Gold Donor
Nov 2, 2019
925
3,285
Status
  1. Resident [Any Field]
Breadlines are getting long, the locums emails I get are asking for board certification now (this hasn't been explicitly asked for in previous emails):

1601669434508.png
 
  • Like
  • Haha
Reactions: 4 users
About the Ads

Lamount

7+ Year Member
Mar 21, 2012
424
704
Status
  1. Attending Physician
Overheard in the CancerGeek podcast: "75% of CMS' rad onc claims are prostate, breast*, lung, and bone mets." Thus if there's "fiddling" with JUST ONE of these, it's going to cause really big ripples throughout the rad onc system. I'm trying (as I'm wont to do) to get people to understand what a strong wind rad onc is facing. This has been evolving the last 10y, but I definitely sense the gust(s) picking up...

1) I have already discussed the declining prostate cases being treated in rad onc. Falling patient numbers (less screening, less diagnoses, less incidence, less prevalence, more surgery), and falling fractions.

2) Lung cancer incidence ALSO dropping. "Lung cancer death rates declined by 51% from 1990 to 2017 among men and 26% from 2002 to 2017 among women. From 2013 to 2017, the rates of new lung cancer cases dropped by 5% per year in men and 4% per year in women. The differences reflect historical patterns in tobacco use, where women began smoking in large numbers many years later than men and were slower to quit." Did you know that if all cardiothoracic surgeons died from COVID tomorrow and all Stage I lung cancers started getting SBRT, there'd be only two to three Stage I lung cancer patients per year per rad onc in the USA? Even our wildest fantasies on lung cancer run into numerical problems. And now we have surgeons more willing to do Stage III surgeries.

3) BREAST
a) "I set out to find [HER2+] patients who had [local] recurrence... Approximately 2,000 patients later, I have not seen one."
b) "[A] population-based study revealed that rates of omitting radiation [between 1999 and 2010] increased from 15.5% in 1992 to 25% in 2007."
c) Extreme hypofx in breast will not just send "ripples" as mentioned above. More like tsunamis.

4) Bone mets. APM aims to force "behavioral changes" in America's rad oncs (direct quote per the podcast above) to cause more single-fractionating... see 3(c) above for potential ramifications.

Profit margin problems are on the horizon. If so, that means compensation changes, slowing hiring (even at the academic level!), etc. I do not feel APM will be salvational. It can be in terms of getting more reimbursement in cases of extreme hypofx, but really what we are talking about here is reimbursement AND patient numbers. If you aren't seeing as many patients, you don't need APM to decrease your reimbursement 'cause it's already happening.

To counter my take, many may say "I am seeing more patients." Mathematically, unless every data point I have is somehow fake news, this means other people are seeing less. It has to be. For the 9,484** (!) (probably too high because retirement, mis-classification, etc.) Medicare-accepting radiation oncologists in America, there are only so many patients to go around.

* May even be controversial that there's so many breast patients getting Medicare-funded treatment... does Medicare not notice this
** there are only about 150 radiation oncologists in the Philippines, a nation of ~100 million people


FWIW, the # of new lung cancer cases is flat (population increase balancing out decreased incidence)
 
  • Like
Reactions: 1 user

scarbrtj

Lord Monckton
Gold Donor
5+ Year Member
Dec 18, 2015
3,095
4,547
Status
  1. Attending Physician
FWIW, the # of new lung cancer cases is flat (population increase balancing out decreased incidence)
Last data I saw was something like 220,000 new lung cancers in 2010 and 228,000 new lung cancers in 2019. So, roughly, America has one radiation oncologist in practice for every one lung cancer patient America adds to the new lung cancer case amount per year. And probably two or three in practice for every new lung patient who’s an XRT candidate. Man. American patients are lucky. Number of new lung cases up ~0% last 10y but new rad oncs per year up by 60-70%.
 
  • Like
Reactions: 1 user

medgator

Persona Non Grata
Lifetime Donor
15+ Year Member
Sep 20, 2004
7,313
4,676
Status
  1. Attending Physician
Gardisil will basically kill h&n (and possibly gyn/gi) services in a few decades
 

scarbrtj

Lord Monckton
Gold Donor
5+ Year Member
Dec 18, 2015
3,095
4,547
Status
  1. Attending Physician
Gardisil will basically kill h&n (and possibly gyn/gi) services in a few decades
Well won’t kill it. But there’ll be so many rad oncs when you see one you’ll be unicorny. Or, and I am not being sensationalistic, the resident case loads will fall below minimums. Then what?
 
  • Hmm
  • Like
Reactions: 1 users

Palex80

RAD ON
10+ Year Member
Dec 17, 2007
1,952
1,123
40
Europe
Status
  1. Attending Physician
Most common subsite i see
Same for me. I am just saying... P16-positive oropharyngeal cancer is one type of oropharyngeal cancer and oropharyngeal cancer is one type of head and neck cancer. Claiming that eliminating HPV will diminish our patient load in head and neck cancer is not true. It will decrease it, but it will not diminish it.

And let's not even get into the argument if all p16-positive tumors are really HPV-related.
 

medgator

Persona Non Grata
Lifetime Donor
15+ Year Member
Sep 20, 2004
7,313
4,676
Status
  1. Attending Physician
Same for me. I am just saying... P16-positive oropharyngeal cancer is one type of oropharyngeal cancer and oropharyngeal cancer is one type of head and neck cancer. Claiming that eliminating HPV will diminish our patient load in head and neck cancer is not true. It will decrease it, but it will not diminish it.

And let's not even get into the argument if all p16-positive tumors are really HPV-related.
In combination with decreased smoking, i think it will be significant
 
About the Ads

RickyScott

2+ Year Member
Oct 4, 2017
1,867
2,767
Status
  1. Attending Physician
Beyond the decline in hpv cancers, has anyone thought about what the demise of baby boomers in 2030s will mean for field?
 
  • Haha
Reactions: 1 user

ramsesthenice

7+ Year Member
Dec 2, 2011
755
881
Status
  1. Attending Physician
Gardisil will basically kill h&n (and possibly gyn/gi) services in a few decades

I think it will have a more significant effect in H/N cancers than GYN. Most ladies developing HPV mediated GYN tumors (advanced enough to need RT at least) don’t do a lot in terms of preventative care and tend to be of lower SES. I would wager vaccine compliance is no where near what it should be in this group.
 
  • Like
Reactions: 2 users

medgator

Persona Non Grata
Lifetime Donor
15+ Year Member
Sep 20, 2004
7,313
4,676
Status
  1. Attending Physician
Is there similar evidence to efficacy of HPV vaccination in preventing HPV+ Ophx as there is for cervical cancer?

Similar question for Anal cancer.
Not aware, but theoretically don't see why it wouldn't decrease incidence
 
About the Ads

Palex80

RAD ON
10+ Year Member
Dec 17, 2007
1,952
1,123
40
Europe
Status
  1. Attending Physician
Assuming 100% compliance... which is never the case with vaccines.
One should simply tell patients that the HPV vaccine also prevents penile cancer.
And bring up a picture of a nice T3 penile cancer to demonstrate what it looks like. >90% of male patients would ask "Where do I get my shot?".
 
  • Haha
  • Like
Reactions: 9 users

thecarbonionangle

5+ Year Member
Aug 23, 2014
1,813
2,581
Status
  1. Attending Physician
One should simply tell patients that the HPV vaccine also prevents penile cancer.
And bring up a picture of a nice T3 penile cancer to demonstrate what it looks like. >90% of male patients would ask "Where do I get my shot?".

i have a lot of respect for penile cancer. Every case i have seen it has been terrible.
 
  • Like
Reactions: 2 users

VA Hopeful Dr

Senior Member
15+ Year Member
Jul 28, 2004
23,822
37,923
Status
  1. Attending Physician
One should simply tell patients that the HPV vaccine also prevents penile cancer.
And bring up a picture of a nice T3 penile cancer to demonstrate what it looks like. >90% of male patients would ask "Where do I get my shot?".
Minus the picture, that's exactly how I (PCP) sell this to teenage boys. When I bring up penis cancer they will override their stupid mother and demand the vaccine.
 
  • Like
  • Haha
Reactions: 6 users

scarbrtj

Lord Monckton
Gold Donor
5+ Year Member
Dec 18, 2015
3,095
4,547
Status
  1. Attending Physician
Same for me. I am just saying... P16-positive oropharyngeal cancer is one type of oropharyngeal cancer and oropharyngeal cancer is one type of head and neck cancer. Claiming that eliminating HPV will diminish our patient load in head and neck cancer is not true. It will decrease it, but it will not diminish it.

And let's not even get into the argument if all p16-positive tumors are really HPV-related.
In combination with decreased smoking, i think it will be significant
*EPILOGUE*

World First: Saliva Test Detects Occult HPV Oral Cancer
"On surgery, the patient was found to have a **2 mm** squamous cell carcinoma in the left tonsil, but all all other oropharyngeal tissues were normal and HPV-16 DNA negative. Two weeks after undergoing the tonsillectomy, the patient's HPV-16 DNA viral load in the saliva samples became undetectable."

 
  • Like
Reactions: 1 user

Palex80

RAD ON
10+ Year Member
Dec 17, 2007
1,952
1,123
40
Europe
Status
  1. Attending Physician
*EPILOGUE*

World First: Saliva Test Detects Occult HPV Oral Cancer
"On surgery, the patient was found to have a **2 mm** squamous cell carcinoma in the left tonsil, but all all other oropharyngeal tissues were normal and HPV-16 DNA negative. Two weeks after undergoing the tonsillectomy, the patient's HPV-16 DNA viral load in the saliva samples became undetectable."

Well yeah, it will work with tonsillectomy, but what are you going to do about base of tongue and the other sites?
You can't really resect base of tongue because the saliva test came back positive, can you? Think of all the morbidity.
 

scarbrtj

Lord Monckton
Gold Donor
5+ Year Member
Dec 18, 2015
3,095
4,547
Status
  1. Attending Physician
You can't really resect base of tongue because the saliva test came back positive, can you?
Maybe the rad oncs can come in with ~50 Gy wide field to the entire oropharynx (to treat the subclinical lesion that's "somewhere") in the event of a positive saliva test? With weekly HPV viral level draws?
 
  • Like
Reactions: 1 user

medgator

Persona Non Grata
Lifetime Donor
15+ Year Member
Sep 20, 2004
7,313
4,676
Status
  1. Attending Physician
Maybe the rad oncs can come in with ~50 Gy wide field to the entire oropharynx (to treat the subclinical lesion that's "somewhere") in the event of a positive saliva test? With weekly HPV viral level draws?
Why not just annual vs every other year panendos +/- mucosal biopsies? Tx when they actually show up
 
  • Like
Reactions: 1 users

Palex80

RAD ON
10+ Year Member
Dec 17, 2007
1,952
1,123
40
Europe
Status
  1. Attending Physician
Maybe the rad oncs can come in with ~50 Gy wide field to the entire oropharynx (to treat the subclinical lesion that's "somewhere") in the event of a positive saliva test? With weekly HPV viral level draws?
That will be tough...
a) There may be test false-positives. So you will be overtreating people who don't even have cancer in the first place?
b) There may be test true-positives that will never evolve to significant cancer. Think of all the H&N lymph node CUP patients we treat. We treat them because we find enlarged neck nodes. In some of them we actually find the primary cancer if we look hard enough (FGD-PET-CT, deep & comprehensive biopsies, diagnostic tonsillectomies), in some of them the primary cancer pops up months/years later down the road and in some of them the primary lesion never shows up - even when these patients never receive elective RT to the pharynx (which is also the source of the major debate "To treat or not to treat the pharynx when you are treating the neck in CUP").
Therefore there are certainly a lot of patients with primary lesions in the pharynx that die off on their own without any intervention and without ever metastasizing (--> insignificant cancers). I may even have one of these as I am typing these lines and may never find out - we will never know the incidence, unless we start doing autopsies on traffic accident vicitims and slicing up their pharynxes. The same happens from time to time with testicular cancer: we find big nodes in the abdomen and just necrosis in the testis.
You would pick up some of these lesions with that test and overtreat these patients as well (--> perhaps a modern version of the PSA-based overdiagnosis and overtreatment of PCA?).
c) Will weekly HPV viral level draws really tell you enough? We know that EBV viral level draws after RCT of nasopharyngeal cancer helps, but we don't do weekly evaluations there too.
d) You would have to prove first than treating 100 people with a positive saliva test with 50 Gy is superior in terms of overall survival, toxicity, functional outcomes and costs compared to observing 100 people with regular endoscopy (and perhaps FGD-PET-CTs?) and then treating X people with a biopsy-proven cancer down the road. This will be quite challenging.
 
Last edited:
  • Like
Reactions: 2 users

evilbooyaa

Staff member
Moderator
7+ Year Member
Oct 10, 2011
6,854
6,762
Status
  1. Attending Physician
Well yeah, it will work with tonsillectomy, but what are you going to do about base of tongue and the other sites?
You can't really resect base of tongue because the saliva test came back positive, can you? Think of all the morbidity.


B/l Tonsillectomies and BoT Biopsies, if BoT microscopically positive but macroscopically negative then treat with 50Gy RT alone?

If BoT biopsy negative, repeat saliva test in 6 months?
 
  • Like
Reactions: 1 user

Your message may be considered spam for the following reasons:

  1. Your new thread title is very short, and likely is unhelpful.
  2. Your reply is very short and likely does not add anything to the thread.
  3. Your reply is very long and likely does not add anything to the thread.
  4. It is very likely that it does not need any further discussion and thus bumping it serves no purpose.
  5. Your message is mostly quotes or spoilers.
  6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
  7. This thread is locked.
About the Ads