FUTURE RESIDENT, DO NOT BECOME A RADIATION ONCOLOGIST!!!

[MegaVoltagePhoton]

PP folks aren't the ones who have shamelessly ramped up residency spots by >50% over the last decade, nor have they opposed common sense payment reform like case/bundled payment and site-neutral payment models.

It's hard not to want to pile on when you see your local nci center getting paid way more for the exact same thing you're doing and pushing protons unnecessarily, while pumping out grads that the job market doesn't need.

I personally have not experienced this but others on this forum also indicate that the academic practices in their areas will denigrate the PP nearby in terms of quality of care.

I don’t disagree with the residency oversaturation piece. There are legitimate criticisms and then there are baseless ones. “Academics failing us” on abscopal effect stuff is a baseless one. Claiming all rad onc research is bogus is another baseless one.

And as long as we’re sharing anecdotes like marked up prices at academic centers, I have my own list of anecdotes as well, stemming from a list of re irradiation cases referred to me from patients whose care was utterly botched on the outside. Does that mean I should generalize to all private practice?

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[RickyScott]

I don’t disagree with the residency oversaturation piece. There are legitimate criticisms and then there are baseless ones. “Academics failing us” on abscopal effect stuff is a baseless one. Claiming all rad onc research is bogus is another baseless one.

And as long as we’re sharing anecdotes like marked up prices at academic centers, I have my own list of anecdotes as well, stemming from a list of re irradiation cases referred to me from patients whose care was utterly botched on the outside. Does that mean I should generalize to all private practice?

It is not helpful to complain about academic colleagues. Honestly, with the exception of chair/leadership, they are ultimately damaged by the oversupply of residents/high prices just as much as private practice. ( In fact, I would argue they are more affected: in terms of getting a raise/promotion during your career, a nonprofit hospital in my experience is more likely to be reasonable-look at MGMA data/productivity etc. they really dont want the hassle of replacing you, if it can be avoided. An academic department, not so much- they always know they can easily replace you with one of the graduating residents/fellows for less- and they probably like the guy more, because he has been kissing ass for 4 years.....) My mentors favorite saying during residency was something like - the school eventually screws everyone.

 

[seper]

Medical schools are funny employers for physician specialists, agree. The fact that they dominate the coastal RadOnc job markets says a lot about how miserable our situation is.

 

[OTN]

I don’t disagree with the residency oversaturation piece. There are legitimate criticisms and then there are baseless ones. “Academics failing us” on abscopal effect stuff is a baseless one. Claiming all rad onc research is bogus is another baseless one.

And as long as we’re sharing anecdotes like marked up prices at academic centers, I have my own list of anecdotes as well, stemming from a list of re irradiation cases referred to me from patients whose care was utterly botched on the outside. Does that mean I should generalize to all private practice?

That was me who said academic have failed us on radiation and immunotherapy, and I will say it again. We have known about the abscopal effect for decades, and we have known about immunotherapy coming for at least the last 9 years. We have known about pre-clinical data showing synergy between radiation and immunotherapy for more than 15 years: Synergy of radiation therapy and immunotherapy in murine renal cell carcinoma. - PubMed - NCBI

Despite all this, we have very, very little actual useful clinical data regarding how we should be taking advantage of this synergy. It's unfair and derogatory to say we PP docs only want the data to see more patients and make more money. I want the data to be able to offer this to my patients and use the technique and skills I trained so long for in a way to help more patients. I'm glad to hear, according to what you're saying, the data is finally being collected. I look forward to being able to use it to help my patients.

 

[Mandelin Rain]

I'm glad Canadian and English academicians found out we can hypofractionate breast cancer.

Thank you foreign academics!

 

[Mandelin Rain]

To expand on my tongue in cheek response, the examples cited as major advances by "academics" are largely industry/technology/physics driven (IGRT, SBRT lung), wholly incomplete/undirected like dose de-escalation for HPV+ HN, or outright prehistoric (ADT for prostate cancer? I'm pretty sure castration existed as a treatment for prostate cancer for some time now).

If these are the major accomplishments of all the American academic centers over the past 2 decades, blow me over with a feather.

 

[RickyScott]

It was

That was me who said academic have failed us on radiation and immunotherapy, and I will say it again. We have known about the abscopal effect for decades, and we have known about immunotherapy coming for at least the last 9 years. We have known about pre-clinical data showing synergy between radiation and immunotherapy for more than 15 years: Synergy of radiation therapy and immunotherapy in murine renal cell carcinoma. - PubMed - NCBI

Despite all this, we have very, very little actual useful clinical data regarding how we should be taking advantage of this synergy. It's unfair and derogatory to say we PP docs only want the data to see more patients and make more money. I want the data to be able to offer this to my patients and use the technique and skills I trained so long for in a way to help more patients. I'm glad to hear, according to what you're saying, the data is finally being collected. I look forward to being able to use it to help my patients.

I'm glad Canadian and English academicians found out we can hypofractionate breast cancer.

Thank you foreign academics!

Most developments come from overseas- brain srt, body srs/srt, us guided prostate brachy

That was me who said academic have failed us on radiation and immunotherapy, and I will say it again. We have known about the abscopal effect for decades, and we have known about immunotherapy coming for at least the last 9 years. We have known about pre-clinical data showing synergy between radiation and immunotherapy for more than 15 years: Synergy of radiation therapy and immunotherapy in murine renal cell carcinoma. - PubMed - NCBI

Despite all this, we have very, very little actual useful clinical data regarding how we should be taking advantage of this synergy. It's unfair and derogatory to say we PP docs only want the data to see more patients and make more money. I want the data to be able to offer this to my patients and use the technique and skills I trained so long for in a way to help more patients. I'm glad to hear, according to what you're saying, the data is finally being collected. I look forward to being able to use it to help my patients.

To expand on my tongue in cheek response, the examples cited as major advances by "academics" are largely industry/technology/physics driven (IGRT, SBRT lung), wholly incomplete/undirected like dose de-escalation for HPV+ HN, or outright prehistoric (ADT for prostate cancer? I'm pretty sure castration existed as a treatment for prostate cancer for some time now).

If these are the major accomplishments of all the American academic centers over the past 2 decades, blow me over with a feather.

Just to set record straight- SBRT lung is not american. Japanese/swedish started quite a bit before us. IGRT- xray tubes on ceiling/ct linacs were used in japan historically. A dual computed tomography linear accelerator unit for stereotactic radiation therapy: a new approach without cranially fixated stereotactic frames. - PubMed - NCBI

Cone beam developed at william beaumont, but yes american academic centers really dont contribute much, if at all, in the grand scheme.

 

[radiaterMike]

Random comments on others' comments

I might be wrong, but I think SBRT started in America (with a pretty invasive means of doing it)

Preliminary clinical experience with linear accelerator-based spinal stereotactic radiosurgery. - PubMed - NCBI

Radiation related immunotherapy has gone in and out of fashion over the decades. Lukas Milas was studying it in the 1980s. There are probably several reasons it was never developed: immunotherapy (as a field) has grown over the years; initial studies were not all that impressive; safe and effective immunotherapy agents have only recently been developed (IFN and IL-2 have been around for a while but poorly tolerated).

Agree with MegaVoltagePhoton that many PP (particularly in competitive markets) mention their doctors' publications for all of the reasons stated by MegaVoltagePhoton

I would not totally dismiss SEER (or other registry studies such as NCDB, SEER/Medicare, etc.) as some show up in 'big' journals like JCO, JNCI, etc. The SEER/Medicare study by Sheets (proton vs. IMRT for prostate cancer) is mentioned frequently, as is the SEER study for post-op RT for Stage III NSCLC patients. Others come up in NCCN guidelines, tumor boards, SDN posts, etc. Obviously (as in all published studies) there are varying levels of quality. While less 'impactful' than JCO or JNCI, a Red J paper is impressive (as is a Green J paper) to academic and PP groups.

 

[OTN]

It was




Most developments come from overseas- brain srt, body srs/srt, us guided prostate brachy


Just to set record straight- SBRT lung is not american. Japanese/swedish started quite a bit before us. IGRT- xray tubes on ceiling/ct linacs were used in japan historically. A dual computed tomography linear accelerator unit for stereotactic radiation therapy: a new approach without cranially fixated stereotactic frames. - PubMed - NCBI

Cone beam developed at william beaumont, but yes american academic centers really dont contribute much, if at all, in the grand scheme.

Bob Timmerman (Indiana originally, now at UTSW) did a lot of the early, groundbreaking work in SBRT. His contributions can't be discounted.

 

[maruchan]

Look a bit further: instead of just looking at lists that say somebody got a job as an “assistant professor” at university of whatever look at their contact/office address and put it in google maps or go to any large academic center’s website and search for their satellites or affiliated offices. It’s crazy ... many of these “assistant professors” in “academics” are working in satellite centers l 1.5 to 2 or literally over 2.5-3 hours away, (sometimes not even in the same state!) from the actual main campus in offices that very clearly were private practices within the past few years. Does anybody consider this an “academic” position?

Man when I was applying some who went into academics complained about having to treat two disease sites or occasionally covering the vacation of another office, then it was impossible to fill positions at the satellite 20 minutes away then 45 minutes away and now residents are fighting for “academic” jobs at little private practices hours and hours away that were bought out, then I assume the doctor was kicked out, the academic centers sign put on the door, the rates jacked up, and some sad little “senior instructor” or “associate Professor” with PhD brought in.

I did google them. The majority (90%) of those are real academic positions. There are a couple satellite jobs mixed in that list, but it's not like all the top grads are getting stuck at middle of nowhere satellites.

If you're outside those top programs though....who knows. Probably a lot of them do get stuck at satellites. Someone else can do that research.

 

[thecarbonionangle]

The idea that theres all these jobs waiting for people which arent posted and just takes cold calling is ludicrous to me. Its is clear this is a minority of jobs. Its one of the most frustrating parts about the field to me, this culture of lack of transparency. I talk to friends in other fields and there are clearly defined places with job postings. Why is the astro job site such a ghost-town? Why are the jobs not posted?

 

[KHE88]

It's not ludicrous, it's true. And it underscores the importance of selecting a residency program with a chairman and program director with a track record of taking a personal interest in their residents' career development and taking pride in where they end up. Note that these programs may not necessarily be the "big names." Many if not most jobs will not be posted online. Word of mouth is often good enough to get a good candidate in on referral. I just finished interviewing, and half of the jobs I interviewed for were not posted online. Also, wtf are you talking about, the ASTRO job site has had a noticeably big uptick in postings over the past month, especially academic jobs in desirable locations! And I would expect this to continue as we approach ASTRO and the interview season for new grads.

 

[KHE88]

Also be aware that the ASTRO job site is catching 30-40% of jobs posted online in my experience. Also check practicelink, NEJM career center, ziprecruiter, doccafe, indeed, etc.

 

[RadOncgal]

It's not ludicrous, it's true. And it underscores the importance of selecting a residency program with a chairman and program director with a track record of taking a personal interest in their residents' career development and taking pride in where they end up. Note that these programs may not necessarily be the "big names." Many if not most jobs will not be posted online. Word of mouth is often good enough to get a good candidate in on referral. I just finished interviewing, and half of the jobs I interviewed for were not posted online. Also, wtf are you talking about, the ASTRO job site has had a noticeably big uptick in postings over the past month, especially academic jobs in desirable locations! And I would expect this to continue as we approach ASTRO and the interview season for new grads.

I completely agree with you!! I didn’t really understand the importance of this until a few months ago. I am a PGY-5 and have already been referred to 3 positions (2 academic and 1 PP) in locations I would be happy living in by my PD. Having invested faculty is soo important in this field since many jobs are filled through word of mouth and personal connections. It’s really not fair that there isn’t more transparency.

 

[Reaganite]

The idea that theres all these jobs waiting for people which arent posted and just takes cold calling is ludicrous to me. Its is clear this is a minority of jobs. Its one of the most frustrating parts about the field to me, this culture of lack of transparency. I talk to friends in other fields and there are clearly defined places with job postings. Why is the astro job site such a ghost-town? Why are the jobs not posted?

There have been multipe hires in southern california for academics, satellites, pp. Etc. over the last few years. How many have you seen posted? Its all word of mouth and almost all those hired had some connection to the area (and few came from top 10s i should add).

 

[medgator]

Also be aware that the ASTRO job site is catching 30-40% of jobs posted online in my experience. Also check practicelink, NEJM career center, ziprecruiter, doccafe, indeed, etc.

Many big hospital systems with associated employed medical groups may have their own sites dedicated to employed physician opportunities as well, and they don't always make the astro site either

 

[RickyScott]

ASTRO, doesnt catch every job, but certainly the majority in my experience.

 

[deleted18755]

There have been multipe hires in southern california for academics, satellites, pp. Etc. over the last few years. How many have you seen posted? Its all word of mouth and almost all those hired had some connection to the area (and few came from top 10s i should add).

This is so unfortunate and only furthers the hierarchy and power dynamics with potential abuse . . . residents have to take even more abuse and kiss ass no matter what because a phone call from that attending to his buddy may be the only way the resident can get his foot in the door for an interview since the attending is the only one who knows where the best jobs are?

I am absolutely certain that at least some job postings are put up for show and that the group already has an internal candidate or somebody in mind for the job. I'm pretty sure this isn't unique to radiation oncology or medicine in a general, and as unfortunate as it may be neither is the lack of transparency of potential jobs and needing to know somebody who knows somebody to get an interview I imagine. Still very sad and frustrating I'm sure.

 

[thecarbonionangle]

This is so unfortunate and only furthers the hierarchy and power dynamics with potential abuse . . . residents have to take even more abuse and kiss ass no matter what because a phone call from that attending to his buddy may be the only way the resident can get his foot in the door for an interview since the attending is the only one who knows where the best jobs are?
.

Thats my point! This system only puts residents at a disadvantage. Its absurd to have to literally ask people what they have heard, maybe some know, some will not tell you if you arent an ass kisser. Its perpetuates the obscene toxic power dynamic. For the pp guys on here, post the jobs and be open please!

I cant’t believe the deniers here always defending the system. The ASTRO job site is a sorry excuse for a “job site”. Most of the jobs are even for non rad oncs, ive seen nursing jobs on there. WTF are these people talking about? We must have been looking at different sites for years. I guess these days in the fake news era you encounter people who live in completely different realities. Losing battle here, mates!

 

[OTN]

I don't think word-of-mouth jobs are unique to radonc. We may hire a surgical oncologist friend of mine for our group, and he said it's been like that in his field as well.

 

[DebtRising]

Also be aware that the ASTRO job site is catching 30-40% of jobs posted online in my experience. Also check practicelink, NEJM career center, ziprecruiter, doccafe, indeed, etc.

30 to 40%? This is false, like out of the universe false. Employers have been around - they post the jobs on the highest traffic site - it’s Astro, and it doesn’t even cost that much. Why don’t you go to any of those other sites right now and objectively investigate yourself by tabulating the total number of positions, how many are unique compared to Astro, how many are not locums, and how many are recent postings.

No reason to be so ridiculous.

There’s no magic well of word of mouth jobs either. Most jobs are posted unless there is either a strong internal candidate who has been in the program (and thus you won’t get those jobs) or there are so many connected people, as I said before, that the position has 20+ applicants already. And beware of the non posted positions and don’t shun what is posted - there are varying levels of disclosure and terms, and when a “super exclusive non posted awesomesauce” job is filled, the employer knows there were 19 other people clamoring for the position. Do your homework and be careful

 

[thecarbonionangle]

The job options for surgery, internal med, anesthesia just to name a few are much more broad compared to other fields. Most hospitals have ORs, floors with patients. Our specialty is very limited. Further limiting the options for graduates by having a word of mouth system is not good for our field. I just think we would all benefit from transparency. If you really want to show there is a job crisis, then you have to have most jobs advertised to reach a conclusion with data. The ASTRO job site doesnt have anywhere close to the number of jobs needed to employ a quarter of our graduates. I haven’t seen a job in some Southern less “desirable” states on there in forever. The longer we continue this system, the people in “leadership” who talk euphemisms of “free market”, “market self-correction” which means i will be unemployed or underemployed, will continue to say all the jobs are out there just have to hear about it and there is no job problem.

 

[thecarbonionangle]

Also be aware that the ASTRO job site is catching 30-40% of jobs posted online in my experience. Also check practicelink, NEJM career center, ziprecruiter, doccafe, indeed, etc.

WOW!!! Talk about FAKE NEWS. 30-40%?

 

[medgator]

There have been multipe hires in southern california for academics, satellites, pp. Etc. over the last few years. How many have you seen posted? Its all word of mouth and almost all those hired had some connection to the area .

Ditto for FL, despite the dearth of ASTRO listings.

As to the other posts above me, no one is implying that the job market is "fine" because many of the good jobs are obtained via connections and not through the ASTRO job site, but rather there are less and less of the jobs getting posted there because:

1) More of the go-getters are probably making connections early to fill those jobs , that they never need to be posted

and

2) There really are less jobs overall to post to ASTRO.

I guarantee I saw more FL, TX, NC, and CA jobs 5-10 years ago on the ASTRO site than I do now, and that's directly related to what I've posted above IMO. I can only speak to what I've seen in the SE, but #1 definitely has been happening in my neck of the woods.

 

[nkmiami]

In terms of south florida, there really has been very little job activity for the past couple of years. For the hundredth time, the decrease in jobs is directly related to increased supply of residents as hypofractionation expands: supply/demand. It is not that job postings have gone underground, connections etc. Just because some jobs fill this way, does not mean it is the majority. There has been basically no lateral movement over the past several years.

In South Floirda, there is very little hypofractionation of prostate anywhere and widespread hypofractionation of breast only at the major institutions, so the market has plenty of room to contract under pressure from insurances, adoption of ASTRO guidelines.

 

[medgator]

In terms of south florida, there really has been very little job activity for the past couple of years. For the hundredth time, the decrease in jobs is directly related to increased supply of residents as hypofractionation expands: supply/demand. It is not that job postings have gone underground, connections etc. Just because some jobs fill this way, does not mean it is the majority. There has been almost no lateral movement over the past several years.

In South Floirda, there is very little hypofractionation of prostate anywhere and hypofractionation of breast only at the major institutions, so the market has plenty of room to contract under pressure from insurances, adoption of ASTRO guidelines.

Crazy.... as much as I like to beat up on the Cigna's and Evicore's of the world, there's a reason why they do what they do

 

[bob1988]

I know of 2 jobs in desirable areas right now that aren't posted fwiw. If you search nejm, indeed etc there are a few jobs posted that aren't on Astro, not a huge amount, but they are there.

 

[nkmiami]

I know of 2 jobs in desirable areas right now that aren't posted fwiw. If you search nejm, indeed etc there are a few jobs posted that aren't on Astro, not a huge alount, but they are there.

With increasing academic satellites, hospital consolidations etc, the amount of radiation oncologists who are employed seems to have increased significantly. Per ASTRO data I believe it had crossed 50% many years ago. Someone who attends the ARRO session could post the data. Employed/instituitonal positions are more likely to be posted than pp, so I would think todays jobs are more likely to be posted than they were 10 years ago.

 

[Neuronix]

In terms of south florida, there really has been very little job activity for the past couple of years. For the hundredth time, the decrease in jobs is directly related to increased supply of residents as hypofractionation expands: supply/demand. It is not that job postings have gone underground, connections etc. Just because some jobs fill this way, does not mean it is the majority. There has been basically no lateral movement over the past several years.

In South Floirda, there is very little hypofractionation of prostate anywhere and widespread hypofractionation of breast only at the major institutions, so the market has plenty of room to contract under pressure from insurances, adoption of ASTRO guidelines.

Also in "desirable" locations, since the practices are not expanding, any positions that open up are often because the position is bad. People leave because they're fed up and miserable. So then an opening comes up that looks so great to the new grads! And they walk into the same trap and also leave in a few years. Of course nowadays they have to leave the area thanks to a giant non-compete.

 

[scarbrtj]

Per ASTRO data I believe it had crossed 50% many years ago

Another way to state this is: if you go into rad onc, there's a >50% chance that a former radiation therapist (your department "boss" at the hospital) will always possess greater administrative hierarchy than you will as MD. NO offense to the therapists! We love you.

 

[RickyScott]

I think the only way to fix this is for "collective voices" from the specialty to advocate for sustainable prices. ie. prostate radiation should be below 30,000$ If insurance cos takes notice, it will dissuade large academic centers from expanding satellites and residency spots to fill these giant departments. Because of the fixed cost nature of radiation, and the high prices that these systems can charge, there is a strong incentive to build satellites and fill them with recent grads
Here is a recent example of 10X fee differentials in trauma:

A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill.

"Comprehensive data from the Health Care Cost Institute shows that the average price that health insurers paid hospitals for trauma response (which is often lower than what the hospital charges) was $3,968 in 2016. But hospitals in the lowest 10 percent of prices received an average of $725 — while hospitals in the most expensive 10 percent were paid $13,525. Data from Amino Health, a health cost transparency company, shows the same trend. On average, Medicare pays just $957.50 for the fee."

The large hospital systems associated with ASTRO leadership, you can bet they are in the top 10% in our field, and with a fixed cost business, radiation provides a powerful incentive for satellites and residency expansion...(while falsely focusing on utilization-choose wisely- than prices)

."Translating Discovery to Cure"

 

[dukeresident]

PP folks aren't the ones who have shamelessly ramped up residency spots by >50% over the last decade, nor have they opposed common sense payment reform like case/bundled payment and site-neutral payment models.

It's hard not to want to pile on when you see your local nci center getting paid way more for the exact same thing you're doing and pushing protons unnecessarily, while pumping out grads that the job market doesn't need.

I personally have not experienced this but others on this forum also indicate that the academic practices in their areas will denigrate the PP nearby in terms of quality of care.

The academic practices definitely denigrate the nearly PP based on my experiences. The question is , is it justified?

 

[dukeresident]

It was




Most developments come from overseas- brain srt, body srs/srt, us guided prostate brachy


Just to set record straight- SBRT lung is not american. Japanese/swedish started quite a bit before us. IGRT- xray tubes on ceiling/ct linacs were used in japan historically. A dual computed tomography linear accelerator unit for stereotactic radiation therapy: a new approach without cranially fixated stereotactic frames. - PubMed - NCBI

Cone beam developed at william beaumont, but yes american academic centers really dont contribute much, if at all, in the grand scheme.

The American academic centers certainly suck up a lot of money

 

[medgator]

The academic practices definitely denigrate the nearly PP based on my experiences. The question is , is it justified?

Depends on the practice, of course.

Then again, academic centers in glass houses shouldn't throw stones at the old timer PP centers giving 7 weeks to breast ca and 4 weeks to bone mets, while they treat low risk prostate on proton registries and charge mid-five figures for SBRT oligomet treatments

 

[scarbrtj]

The academic practices definitely denigrate the nearly PP based on my experiences. The question is , is it justified?

Sorry if this is obtuse. But to me, this encapsulates many key existential issues--academic/PP friction, radiation oncology's identity crises and its silly sanctimony coupled with inexplicable ostrichian mimicry--in our specialty.

Read this:
Improved dose homogeneity with simple IMRT translates into superior overall cosmesis and reduces the risk of skin telangiectasia. These results are practice changing and should encourage centers still using two-dimensional RT to implement simple breast IMRT.

And then this:
Don’t routinely use intensity modulated radiotherapy (IMRT) to deliver whole breast radiotherapy as part of breast conservation therapy.
Clinical trials have suggested lower rates of skin toxicity after using modern 3-D conformal techniques relative to older methods of 2-D planning. In these trials, the term “IMRT” has generally been applied to describe methods that are more accurately defined as field-in-field 3-D conformal radiotherapy.

(I love "the quotes" ASTRO put around IMRT. Like, do you do "IMRT" or IMRT in your practice? As when surgeons ask each other: did the patient receive an "appendectomy" or an appendectomy? Ha.) The only thing this and other "ASTRO outrages" (see I can use quotes too) have done is totally confuse and muddy the water for every single person on the planet (payors, dosimetrists, therapists, physicists, coders, patients, etc.) who is not a board certified radiation oncologist.

 

[evilbooyaa]

Well the issue with breast is that there is IMRT, where the standard definition is multiangle, either fixed field or using VMAT or Tomo or whatever, but something where the beam comes from multiple angles, and "IMRT" which is just two tangential fields with inverse planning to maximize homogeneity.

The latter definition is OK, the former is not. I agree with ASTRO. Some call the latter 'Tangential IMRT' or 'Sliding window'. The issue is that people don't think or actually read the paper - they just read the abstract, go "aww yeah IMRT, time to get paid!" and do RapidArc, don't evaluate the plan for OARs (cause you know, no physician contours), and end up with a mean heart dose of 10+ Gy.

What I disagree with ASTRO is their number 4 - a simple proton registry for prostate cancer should not be the minimum standard for that treatment in this day and age.

 

[medgator]

I thought the IMRT thing came down to algorithm, i.e. forward planned by dosimetrist = 3D, inverse planned by computer = IMRT.

Then again, we have those original papers discussing "IMRT" and IIRC, before my time in practice, Medicare supposedly allowed F in F and electronic compensation (forward planned IMRT) to be billed as IMRT.

 

[KHE88]

I don't get the issue with the quotes. They put it in quotes to point out that IMRT referenced in those studies is not real IMRT, and not what everybody calls IMRT these days. Forward-planned IMRT, simple IMRT, whatever. Nobody calls it that. It's called field-in-field and literally everybody knows it's 3D. Breast IMRT means one thing only.

We need to stop beating this anti-hypofractionation anti-IMRT drum. It's not a good look. Just because academic centers are using SBRT or proton therapy inappropriately does not justify overtreatment in PP.

 

[scarbrtj]

They put it in quotes to point out that IMRT referenced in those studies is not real IMRT, and not what everybody calls IMRT these days. Forward-planned IMRT, simple IMRT, whatever. Nobody calls it that. It's called field-in-field and literally everybody knows it's 3D. Breast IMRT means one thing only.

"Not real IMRT".... like false IMRT? Like a false vocal cord? Or the falx cerebri? Even false teeth are teeth IMHO. Maybe a false prophet? Jesus said "watch out for the false prophets"... ASTRO says watch out for the false IMRT! Just think: one day we will be arguing over what is "true" IMPT (at UF Jacksonville when I first toured there they used milled blocks like a dot-decimal system... false!).

Who defines what is real and what is false IMRT? It's great you know that it means "one thing only." Static or dynamic leaves... 2 fields or more than two... one arc or more than one arc... tomo or non-tomo? Which "one thing" does it mean, pray tell? Should all the breast IMRT authors be demanded to make a retraction, or put the letters IMRT "in quotes" throughout their papers? Why were those authors so chicanerous? How about this editorial from Haffty? Should he have been pilloried for suggesting physical wedges are the simplest form of IMRT? Is he too a false prophet or doesn't know the data as well as all who seem to know that all the breast IMRT papers are not really IMRT papers at all... we should be calling them the breast 3D papers I suppose. As someone mentioned above, field-in-field, forward planned IMRT was up until a few years ago absolutely defined in Medicare LCDs as IMRT. (I hope payors never get to ultimately define our scientific terms for us.) No one does pure inverse planned IMRT, and no one does pure forward planned IMRT. "Field-in-field" (FiF) doesn't have to be pejorative; one can argue there's "rough FiF" and "fine FiF" if one considers dMLCs to be highly & finely quantized FiFs (you can make any static MLC FiF dose distribution equal a dMLC dose distribution with enough FiFs). It's all a hybrid and there are no firm definitions as to what isn't IMRT in the pantheon of dose-shaping technologies which have existed since the first seminal IMRT paper. If we had just stuck with Webb's definition of IMRT, field-in-field ("odd" MLC patterns in multiple fields e.g.) is absolutely IMRT. The NOMOS Peacock was very field-in-field-ish, e.g., and no one quibbled if it was IMRT way back when. Billing definitions are one thing, scientific definitions another. We've conflated the two too much--to everyone's detriment.

At the end of the day, there are more statistically convincing "breast IMRT" (again with the quotes!) papers showing a benefit to "breast IMRT" than there are papers showing proton benefits... yet proton centers are going in like crazy, and ASTRO (aka Our Academic Overlords) is strangely Choosing-Wisely-mute re: protons, but vocal re: IMRT.

As an aside, one reason this is on my mind as it were is at my hospital I missed our last cancer cmte. meeting and it was decided in my absence by all the non-rad oncs to choose a measure to show us having improving quality and the IMRT ASTRO measure was chosen. In 2013, we had ~50% IMRT for breast and last year it was <5%. So the med oncs were all like "yeah you should NEVER use IMRT for breast, makes sense, IMRT does nothing for breast cancer" and ... well, there you go. (I remember in the ~2004-6 timeframe one of my general surgeons coming up to me in the hallway talking about how breast cosmesis and RT complications had improved after we started using IMRT for breast... how quaint.)

 

[KHE88]

IMRT = multiple differently angled photon fields with simultaneously optimized cross-field fluence patterns determined with inverse planning using cost function algorithms on a computer to create an ultraconformal dose distribution
Field in field = simply adding an extra blocked tangent field to reduce a hotspot

How can you not see that those are not the same thing?
Are you upset because you can't bill field and field as IMRT? I want to give you the benefit of the doubt, so am I missing something here?
How much extra work is really involved in planning and delivering that extra blocked field?

And yes, there already exists debate as to what IMPT is, because spot scanned proton therapy is "intensity modulated" in it's very nature. So again, we have unfortunate terminology because it's really about simultaneously optimizing fluence of multiple proton pencil beams. So you've got algorithms to do this using 2D scanning "2.5-D" scanning, and 3-D scanning, which some would argue is the only real IMPT.

Arguing semantics like this is really losing sight of the forest for the trees. Yes, we seem to have a nomenclature problem. But it is absolutely right of ASTRO to call it "IMRT" with quotes. If you want to call it false IMRT, fine. IMRT is a misnomer to begin with as it's fluence that's modulated, not intensity.

 

[medgator]

IMRT = multiple differently angled photon fields with simultaneously optimized cross-field fluence patterns determined with inverse planning using cost function algorithms on a computer to create an ultraconformal dose distribution
Field in field = simply adding an extra blocked tangent field to reduce a hotspot

How can you not see that those are not the same thing?
Are you upset because you can't bill field and field as IMRT? I want to give you the benefit of the doubt, so am I missing something here?
How much extra work is really involved in planning and delivering that extra blocked field?

And yes, there already exists debate as to what IMPT is, because spot scanned proton therapy is "intensity modulated" in it's very nature. So again, we have unfortunate terminology because it's really about simultaneously optimizing fluence of multiple proton pencil beams. So you've got algorithms to do this using 2D scanning "2.5-D" scanning, and 3-D scanning, which some would argue is the only real IMPT.

Arguing semantics like this is really losing sight of the forest for the trees. Yes, we seem to have a nomenclature problem. But it is absolutely right of ASTRO to call it "IMRT" with quotes. If you want to call it false IMRT, fine. IMRT is a misnomer to begin with as it's fluence that's modulated, not intensity.

One day bundled site-neutral payments will render this argument an exercise in academic minutiae.

Until then there are real dollars attached to it. Imo, more work is required for FinF vs just slapping on tangential fields with wedges. Whether that's more than imrt can be debated. Personally, the LCDs of Medicare say it is NOT imrt, so we aren't billing it like that. Several years ago I believe it could have been billed like that, electronic compensation used to be able to.

Astro had proposed to Medicare to consider splitting imrt into simple (to hurt the urorad/prostate centers) and complex (h&n, abdomen, pelvis with nodes) a few years ago. Didn't go anywhere.

An argument could actually be made for that imo, ditto for 3D... finf vs tangents or an appa spine where you contour cord and kidneys

 

[scarbrtj]

How much extra work is really involved in planning and delivering that extra blocked field?

Much more human work is involved in FiF vs inverse optimization--especially if you're anal retentive re: inhomogeneity. It takes me <5 minutes to use the GUI optimization or "irregular surface compensator" (which is also inverse optimization btw) in Eclipse to make a plan. To make equivalent FiF breast plans, dosimetrically, can take an hour or two.

Yes, we seem to have a nomenclature problem. But it is absolutely right of ASTRO to call it "IMRT" with quotes. If you want to call it false IMRT, fine. IMRT is a misnomer to begin with as it's fluence that's modulated, not intensity.

Fluence equals intensity times time; i.e., intensity is watts per square meter, and fluence is joules (watt seconds) per square meter. Thus you can't modulate the fluence without modulating the intensity of the beam (given that there is always a dose rate, e.g. MU/min, in any external beam application).

 

[KHE88]

Ok, so you're arguing that a field-in-field plan is more complex than an IMRT plan (real IMRT)?
Do you want to talk about the technical charges differential (3x I believe) between 3D and IMRT, which is the real issue here? Are you saying those technical charges are justified for field-in-field "false-IMRT" also?

It's clear you were practicing during the time when IMRT became mainstream. Perhaps there was some confusion as to what that term meant 15 years ago. I am finishing training now, and I would be shocked if someone said IMRT and a new grad got confused and wasn't sure that was referring to field-and-field or the proper definition (that again, literally everyone knows without getting into semantics) that I referenced above.

It's proper to say that fluence is what is modulated. Intensity can be taken to mean any number of things.

 

[medgator]

Ok, so you're arguing that a field-in-field plan is more complex than an IMRT plan (real IMRT)?
Do you want to talk about the technical charges differential (3x I believe) between 3D and IMRT, which is the real issue here? Are you saying those technical charges are justified for field-in-field "false-IMRT" also?

It's clear you were practicing during the time when IMRT became mainstream. Perhaps there was some confusion as to what that term meant 15 years ago. I am finishing training now, and I would be shocked if someone said IMRT and a new grad got confused and wasn't sure that was referring to field-and-field or the proper definition (that again, literally everyone knows without getting into semantics) that I referenced above.
.

But scarbrtj's point still stands imo. The definition of imrt has in fact changed with time.

In terms of technical charges vs work, A FinF plan can be more time intensive than a simple 2-field 3D plan with a dvh and critical structures, yet they will bill the exact same.

A low risk prostate imrt plan will bill more than a FinF breast plan with scv fields but the breast plan will take far longer to plan for the dosimetrist

 

[RadRadRad]

Ok, so you're arguing that a field-in-field plan is more complex than an IMRT plan (real IMRT)?
Do you want to talk about the technical charges differential (3x I believe) between 3D and IMRT, which is the real issue here? Are you saying those technical charges are justified for field-in-field "false-IMRT" also?

It's clear you were practicing during the time when IMRT became mainstream. Perhaps there was some confusion as to what that term meant 15 years ago. I am finishing training now, and I would be shocked if someone said IMRT and a new grad got confused and wasn't sure that was referring to field-and-field or the proper definition (that again, literally everyone knows without getting into semantics) that I referenced above.

It's proper to say that fluence is what is modulated. Intensity can be taken to mean any number of things.

Not sure what you mean by complex but definitely from a dosimetrist standpoint fif 3D can be more time consuming to plan than imrt. I sometimes do my own imrt optimizations. Would not have the patience to do my own fif.

 

[scarbrtj]

Intensity can be taken to mean any number of things.

Despite an orgy of literature saying otherwise, you know what IMRT is exactly, and you know that “intensity can be taken to mean any number of things...” which is true, I guess, outside physics. When I’m working out, intensity is, like, sweat. On stage, intensity is how much you give to your performance. But in physics, which is where we are sort of ensconced, intensity only means one thing: power per unit area. Multiply the intensity times time, it’s fluence, or energy per unit area. You’re in training now, you say; I’d want my trainees to understand that. Thus when it was named “intensity modulated," it was named not incorrectly.

Ok, so you're arguing that a field-in-field plan is more complex than an IMRT plan (real IMRT)?

I want you to do your own gedankenexperiment. Imagine a complex dose distribution created inside a patient using "real IMRT" as you say. Can you think of a way in which numerous FiF beams (with virtual beamlet sizes as small as you would want) from many multiple angles could create the same dose distribution inside the patient? I can. And in fact, it could be done... with considerable time and effort perhaps, with fraction treatment times perhaps lasting a day, but it could (and not just in theory) be done. The "more homogenous" that dose distribution is from "real IMRT," the less arduously complex that FiF plan becomes, as well. So I ask: if "real IMRT" and FiF plans could create the same complex dose distribution, why isn't a FiF plan just as real as "real IMRT"?

 

[scarbrtj]

Do you want to talk about the technical charges differential (3x I believe) between 3D and IMRT, which is the real issue here?

It should absolutely not be the real issue here. It's the false issue. It's the shooting ourselves in the foot issue. It's the making ourselves looking ridiculous and backbiting issue. It's the existential issue for us, and it never should have been. Your sanctimony over the issue is sort of the issue, and that was my initial point of order as it were.

FWIW the differential in technical charges is about 1.5x, not 3x. For the private practice hospital based rad onc, the differential for him or her is essentially 1x between IMRT and 3D. Because IMRT can almost always make a "better" plan than 3D, it's a tough row to hoe when you get out there in the real world one day and have to start making financially-based, our-history-screwed-us-up-a-bit, (modestly) deleterious treatment choices for patients... because we had aspersions cast over the motivations behind IMRT in our culture, or what was "true IMRT," etc.

 

[KHE88]

Scarbrtj, I disagree with you on a number of points. Since you are harping on semantics, MiMiC operation is directly modulating fluence (particles per unit area), not intensity (particles per unit area per unit time). It is the fluence that is modulated, and intensity is thus affected. It is not the intensity that is directly modulated. Thus it's a misnomer, and IMRT would in a perfect world be called FMRT.

Technically, you can consider wedges and blocks in the field to "modulate" the beam, but that is not IMRT. We do this all day in 3DCRT plans, but nobody tries to call a 3 field rectal plan IMRT because we threw wedges and blocks in. FiF, we are just adding another blocked field with a small number of MUs. But it's not about just modulation, it's about the TPS and LINAC's capability to to deliver these complex fluence patterns. It's what the MLCs are doing to in their blocking and virtual "wedging" function and how they are doing it and how they became instructed to do it. This requires a more complicated QA/verification process, one of many things factoring into the technical charge differential (although I will admit I am not an expert on coding and charges).

Should you get paid more for a field-in-field breast plan than simply slapping tangents between skin wires? Yes, but probably not a lot. If you are contouring the breast and OARs (heart, lung, contralateral breast) and instructing your dosimetrist to meet certain PTV and OAR criteria as you already should be doing for any 3D breast plan (although we all know that's not the case and maybe that's the issue), having them add in a FiF to lower a hotspot doesn't add much time or complexity. Certainly not to the level of true IMRT. Maybe I just have awesome dosimetrists, but throwing in a FiF to drop a hot spot is really no biggie for them.

So yes, I take issue when somebody says "breast IMRT" and you want to pretend that they could be talking about field-in-field. Maybe there was some confusion a while ago re: the aforementioned papers, but until this thread I've never heard about somebody getting tripped up on what breast IMRT meant. I agree with ASTRO 100% on calling out improper use of the term IMRT, and I suppose we'll have to leave it at that.

I'm still confused as to whether you think true IMRT and FiF ("simple" IMRT) should be paid the same (professionally, technically, or both). I think this is the third time I've asked you to clarify that, but you keep going off on tangents.

 

[nkmiami]

Scarbrtj, I disagree with you on a number of points. Since you are harping on semantics, MiMiC operation is directly modulating fluence (particles per unit area), not intensity (particles per unit area per unit time). It is the fluence that is modulated, and intensity is thus affected. It is not the intensity that is directly modulated. Thus it's a misnomer, and IMRT would in a perfect world be called FMRT.

Technically, you can consider wedges and blocks in the field to "modulate" the beam, but that is not IMRT. We do this all day in 3DCRT plans, but nobody tries to call a 3 field rectal plan IMRT because we threw wedges and blocks in. FiF, we are just adding another blocked field with a small number of MUs. But it's not about just modulation, it's about the TPS and LINAC's capability to to deliver these complex fluence patterns. It's what the MLCs are doing to in their blocking and virtual "wedging" function and how they are doing it and how they became instructed to do it. This requires a more complicated QA/verification process, one of many things factoring into the technical charge differential (although I will admit I am not an expert on coding and charges).

Should you get paid more for a field-in-field breast plan than simply slapping tangents between skin wires? Yes, but probably not a lot. If you are contouring the breast and OARs (heart, lung, contralateral breast) and instructing your dosimetrist to meet certain PTV and OAR criteria as you already should be doing for any 3D breast plan (although we all know that's not the case and maybe that's the issue), having them add in a FiF to lower a hotspot doesn't add much time or complexity. Certainly not to the level of true IMRT. Maybe I just have awesome dosimetrists, but throwing in a FiF to drop a hot spot is really no biggie for them.

So yes, I take issue when somebody says "breast IMRT" and you want to pretend that they could be talking about field-in-field. Maybe there was some confusion a while ago re: the aforementioned papers, but until this thread I've never heard about somebody getting tripped up on what breast IMRT meant. I agree with ASTRO 100% on calling out improper use of the term IMRT, and I suppose we'll have to leave it at that.

I'm still confused as to whether you think true IMRT and FiF ("simple" IMRT) should be paid the same (professionally, technically, or both). I think this is the third time I've asked you to clarify that, but you keep going off on tangents.

What would you call eclipse electronic tissue compensation? (basically 3d sliding wedge that was inversely planned/ hundreds of FIF)

 

[KHE88]

What would you call eclipse electronic tissue compensation? (basically 3d sliding wedge that was inversely planned/ hundreds of FIF)

You can look it up, but basically another forward-planned (not inversely planned) technique using dMLCs to improve dose homogeneity without the added complexity and time required of true inverse planned IMRT. True IMRT uses multiple (5 or more) fields (not parallel opposed) for critical structure avoidance. ECOMP still uses parallel opposed beams and does not allow OAR avoidance like true IMRT.

Why are you guys refusing to admit that there is a difference between true IMRT and FiF, ECOMP, whatever else forward-planned techniques?
Kind of feel like I'm in bizzaro world here.