Hypofractionation, $$$, and data

[DebtRising]

What is the erectile dysfunction rate for prostate hypofractionation?
What percentage of patients on 3 main hypofractionate trials have vascular disease, such as diabetes, which may pre-dispose to enhanced late vascular toxicity[admit based on pre-clincal data with proven arterial and venous disease caused by both radiation and diabetes processes].
What is the #1 question you field from sexually active men?
Would hypofractionation convince you to omit hormones for intermediate risk disease, which we can do with brachytherapy, and avoid hypotestosterone toxicities?
Protons, also so silly. What risk of second malignancy do you tell your patients with IMRT?
If proton proves in the same ballpark of toxicity would you refer your healthy Gleason 7 to proton center so he has less risk of second cancer, or demand for robust data follow up to prove it? [Not enough that <2 Gy is going to critical organ with spacer?]

To my new favorite poster, Dapper John Rattan.
Do not worry. Every day you inflict more suffering on your patients by treating rectal and esophageal cancer with 3D CRT instead of IMRT because insurance companies will not accept DVH changes as acceptable evidence, even though I am pretty sure lowering significant doses to normal tissues decreases toxicity. And guess what, there is even data to support that! Too bad it's not national randomized data. So stay bold - you do your administrator and ACO no harm!

Hypofract for prostate cancer should be adopted when a reasonable time frame of absolute erectile dysfunction rate is proven to be in the same range as conventional fractionation at 5-10 years. Not a composite QoL metric, with QoL metrics mysteriously almost always reverting to baseline with time in studies [funny how people learn to tolerate things]. That is my bar. If the man is already impotent, that consideration no longer applies.

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[John Rattan]

Huh? I like rectal and esophageal IMRT. Use it all the time. Mayo data fairly strong for IMRT in rectal cancer. Esophageal data lacking, but it makes sense, and if going to 50+, why not?

You're mistaking a technique that utilizes knowledge and skill and clinical judgement with slapping on a few extra fractions to make a few extra bucks.

I think there is a difference, but seems like many don't think so. It's "fraction creep". Could use 2 Gy to 78, and shave a week off, and that's not extreme. But, people want to take things to as far as they can. It's okay. They can think it has nothing to do with FFS medicine, but the evidence proves otherwise.

Seems as though my presence offends. Appreciate your insights, however, and will continue to be a reader.

Signing off....
JR

What is the erectile dysfunction rate for prostate hypofractionation?
What percentage of patients on 3 main hypofractionate trials have vascular disease, such as diabetes, which may pre-dispose to enhanced late vascular toxicity[admit based on pre-clincal data with proven arterial and venous disease caused by both radiation and diabetes processes].
What is the #1 question you field from sexually active men?
Would hypofractionation convince you to omit hormones for intermediate risk disease, which we can do with brachytherapy, and avoid hypotestosterone toxicities?
Protons, also so silly. What risk of second malignancy do you tell your patients with IMRT?
If proton proves in the same ballpark of toxicity would you refer your healthy Gleason 7 to proton center so he has less risk of second cancer, or demand for robust data follow up to prove it? [Not enough that <2 Gy is going to critical organ with spacer?]

To my new favorite poster, Dapper John Rattan.
Do not worry. Every day you inflict more suffering on your patients by treating rectal and esophageal cancer with 3D CRT instead of IMRT because insurance companies will not accept DVH changes as acceptable evidence, even though I am pretty sure lowering significant doses to normal tissues decreases toxicity. And guess what, there is even data to support that! Too bad it's not national randomized data. So stay bold - you do your administrator and ACO no harm!

Hypofract for prostate cancer should be adopted when a reasonable time frame of absolute erectile dysfunction rate is proven to be in the same range as conventional fractionation at 5-10 years. Not a composite QoL metric, with QoL metrics mysteriously almost always reverting to baseline with time in studies [funny how people learn to tolerate things]. That is my bar. If the man is already impotent, that consideration no longer applies.

 

[scarbrtj]

slapping on a few extra fractions to make a few extra bucks.

I could be wrong, but this sentiment... this tendency to impugn based on the number of fractions a radiation oncologist prescribes... is a relatively recent invention in our field. Some people seem to enjoy it a lot (present company excepted of course). For example, I still know docs who give 25.5/17 for Stage I seminoma versus 20/10. Or perhaps I should argue that if you give ANY radiation to a Stage I seminoma patient, you're only in it for the money? There's MUCH better data to make this argument in terms of its robustness (chemo, not beam, for seminoma) than there is for hypofractionation in prostate cancer. But I don't hear anyone making that argument in tumor boards, on the web, or anywhere. But let me make it: if you give beam to a Stage I seminoma patient, you're just in it for the money. Do I sound silly? "But adjuvant radiation is still an NCCN standard of care choice." "I don't care—there is high-quality randomized data showing the non-inferiority of chemo with a better side effect profile to boot, so if you give beam, you are only in it for the money." Again... silly? Or no? "Actually, if you do either, beam or chemo, you are in it for the money... you should just observe." Seminoma ironically makes a good analogy to prostate here. Prostate's standard fractionation is seminoma's external beam, prostate's hypofractionation is seminoma's carboplatin (not quite at the data quality level yet IMHO for hypofractionation), and observation is, well, observation; a lot of prostate (or seminoma) patients should be observed versus treated, right? But when they're not is it money to blame?

Your argument on hypofractionation versus standard fractionation—that it's a money thing—can be made even more substantially for brachy versus any external beam fractionation of any sort. That is to say if you were intellectually honest and follow this to its logical conclusion, you'd abandon the beam for seeds. So I'm a bit surprised (that if money is the sui generis reason an MD would choose more versus less external beam fractions in prostate cancer) you are not a brachy advocate first, hypofractionation advocate second, and writing a letter to your congressman about protons. Perhaps I could use brachy as a cudgel on you that you ever even do external beam for any low-risk prostate cancer. But that'd mean that I didn't appreciate the nuances of either approach, or that I would be justified in discounting any personal experiences you've had as a radiation oncologist with your own patients. I appreciate your insights, too; it just seems you have an idée fixe that if anyone chooses 39 or more fractions for prostate cancer they're a money-grubber. I know you know all this data; I'm an MSKCC fan I admit. But this was circa 2014, not too long ago. Pre-circa 2014, pre-hypofractionation data, we had data that more dose was better in prostate cancer. It seemed ALL the data showed more dose was better in those days. It made sense therefore to dose escalate. It made sense when going to "scary" doses in the 78, 80, or 80+ Gy range to decrease daily fraction sizes to 1.8 per day to limit late toxicities. This is before we were "sure" that prostate cancer cell alpha-betas were less than 2 or 3, or low, or whatever. Those of us who did this for a decade and a half (e.g. 81 Gy in 45 fractions using IG-IMRT) became enamored with its tolerability and high success rate. It's not easy to throw that baby out with the seductive hypofractionation bathwater. To use brachy's example again, we know that side effect/cure outcomes in different brachytherapists' hands can be different; are we 100% sure that beam techniques in different practitioners' hands can not vary too? In my hands, 81/45 does really, really well. If 81/45 paid equal that of 60/20, there is zero doubt the fractionation I would *currently* employ, and then I'd be free from any slings and arrows. Perhaps?

 

[Cancerdancer]

...But let me make it: if you give beam to a Stage I seminoma patient, you're just in it for the money...Seminoma ironically makes a good analogy to prostate here. Prostate's standard fractionation is seminoma's external beam, prostate's hypofractionation is seminoma's carboplatin"

You're right...but you don't leave yourself much of an argument, boxed in by your own logic, when faced by someone who correctly doesn't radiate stage I seminoma, and correctly doesn't make arguments that the data somehow favors 1.8 Gy/fraction for prostate cancer.

And no, you can't argue that different fractionation schedules do better/worse in the hands of different practitioners. Are you seriously trying to suggest that your technique is so crappy that you have to use 1.8 Gy/fraction because you're treating so much normal tissue, while the multitude of practitioners who enroll into multiple RCTs are all sufficiently better than you that the rectums of their patients can handle 3 Gy per fraction?

You might not wanna mention that logic to your patients. Nor your logic about seminoma RT = $$ = standard fractionation, but then standard fractionation doesn't = $$.

 

[medgator]

Stage I seminoma should be observed outside of the rare patient who is not going to be compliant with periodic radiographic/lab surveillance.

Trying to compare seminoma management to standard fx in prostate is nonsensical. Like many, including myself, have said before, the data for breast hypofx is far stronger, so if anything, the argument should be made you're only in it for the money if you put old ladies through 6-1/2 weeks of xrt. Really old men with low risk prostate cancer shouldn't be getting treated (or screened for that matter) at all but if you're going to treat, I don't see a problem using standard fx at this point unless you are so incentivized to finish patients quickly, you don't mind the acute (and possibly long term) side effect profile

 

[seper]

This conversation is hard to follow. But regarding seminoma, I'm yet to see a patient who is not a 20-something drifting aimlessly through life, without a steady job/solid benefits. Strict follow up schedule is not feasible. Real question is XRT vs. chemo, which I don't think is resolved conclusively.

 

[scarbrtj]

And no, you can't argue that different fractionation schedules do better/worse in the hands of different practitioners.

I was trying to argue that the SAME fractionation schedules can be wildly different in terms of side effects in DIFFERENT practitioners' hands. I see this all the time, personally. Not to mention in the literature. To the point that I can't just blithely accept the side effect profile in a published study or two and then try to predict what the toxicities will be in my hands, in my center. I can more "reliably rely" on the toxicity profiles I have seen in the treatments I have consistently applied on hundreds of patients over many, many years, given by me: that data is more applicable, to me, than the data from another study. This factors into an increasingly arcane notion known as "clinical judgment."

For example, what's the Gr3/4 esophagitis rate for 45/30 bid XRT for small cell lung cancer? Is it 27% or 19%? Of course it's never gonna be exactly the same trial to trial. But those are pretty different numbers. Gedankenexperiment: what if I had been doing 45/30 for years and carefully compiled my results and saw a 15% rate (full disclosure: I truly believe I have a <10% rate), and then a new trial came out using 30/10 with similar response rates and a Gr 3 rate of 20%? And then I tried to argue that I liked 45/30 because I see such low esophagitis rates? I'm just trying to say, sometimes personal experience counts and worshiping at the EBM altar can be good... but maybe bad if blindly pursued. Conservatism can be defined as "commitment to traditional values and ideas with opposition to change or innovation." I fully realize most of the world is becoming more liberal, less conservative.

 

[Mandelin Rain]

This conversation is hard to follow. But regarding seminoma, I'm yet to see a patient who is not a 20-something drifting aimlessly through life, without a steady job/solid benefits. Strict follow up schedule is not feasible. Real question is XRT vs. chemo, which I don't think is resolved conclusively.

I'd say that this is pretty accurate. A typical testicular case I see no-shows without calling at least once, then reschedules two more times, and then repeats this process when I refer him to the med onc for discussion of Carbo.

 

[Reaganite]

I find it disheartening that every other post on this forum is so focused on over-treatment and our profession's greed. Not saying some of that isn't there, but I just don't get the constant harping on it, and I wonder how much good it really does us as a field. Medicare has cited radiation oncology websites in previous decisions to cut payment. I speak as someone who is in true private practice, running a freestanding XRT center, and I'll tell you--I see so many things we should be talking about that never seem to make their way into these forums. For example, there is very heavy HMO penetration in my community, and by pitting rad onc against rad onc, these guys have been able to cut the GLOBAL payment (tech+prof) for full course 3D and IMRT treatments to <$3,000 and $6,000-ish respectively. It's impossible to run a center on that. Then you have your PPOs which do pay well...if you can actually get them to pay. Insurance companies are becoming increasingly sneaky about denying payment. "Pre-cert doesn't guarantee payment." "Oh, we never received those comparison DVH's." "Please re-submit and we have 60 days to respond." 60 days later and it's a denial for some other document they claim they didn't receive...then they have another 60 days to respond. It's f'n ridiculous. Throw in the fact the local urorads takes all the good Medicare prostate patients, the local hospital has bought out the Med Onc group, etc. and those few true Medicare breast patients that we all want to observe or hypofractionate can make or break a private center. We can call each other out for over-treating breast, but let's not forget the real jerks who are screwing us over.

 

[scarbrtj]

and I wonder how much good it really does us as a field

At the end of the day, this is my point: it does us immense harm. Like Quixote, I joust back. (I guess that's the definition of quixotic.) But I don't want that bad, awful, incorrect impression existing uncontested out here on the Internet for a non-rad onc, MD or especially otherwise, to see. Today I had a peer-to-peer call to justify 30/12 for bone mets in a lady with breast CA. I was treating the entire L-spine and most of the right pelvis. I think 2.5/day goes down a bit easier than 3/day in these circumstances for very large tx volumes (where's my data???), but insurance guidelines say 10 fractions or less is the "usual and customary" treatment. After a phone call, I got 12 fractions approved. Others might say "Slapping on a few extra fractions to make a few extra bucks." We, our whole specialty, should pull back on the damaging rhetoric and remember the Asian philosophy that says one can not strike a blow on one's enemy without also doing harm to one's self.

 

[medgator]

by pitting rad onc against rad onc, these guys have been able to cut the GLOBAL payment (tech+prof) for full course 3D and IMRT treatments to <$3,000 and $6,000-ish respectively.

Not even a months worth of non curative keytruda or opdivo. Crazy.

$ for $ photons is as cost effective of a cancer killer as you can get but as a pp doc as well in a freestanding center, Reaganite is absolutely correct. That's highway robbery and I'm sure the CEOs of those hmo/insurance companies are laughing all the way to bank

 

[Palex80]

This conversation is hard to follow. But regarding seminoma, I'm yet to see a patient who is not a 20-something drifting aimlessly through life, without a steady job/solid benefits. Strict follow up schedule is not feasible. Real question is XRT vs. chemo, which I don't think is resolved conclusively.

I am sorry, but that does not reflect my impression.
There are a bunch of patients, who can be very well followed up closely. Most recurrences tend to occur in the first couple of years post orchiectomy anyway.

On the other hand, data are popping up now showing that 1x carboplatin AUC7 may not be as effective as we thought and perhaps even inferior to RT.
The SWENOTECA (Swedish-Norwegian testis cancer group) reported a recurrence rate of 9.3% after 1x carboplatin AUC7 in the presence of risk factors, which was not "that much better" than active surveillance (15.5%). This basically means that carboplatin will roughly lower the risk of recurrence by 40% (15.5%->9.3%). That's not a lot.
This probably also shows while the Oliver trial, which led to the rise of carboplatin was flawed. It included all kind of patients with low or high risk of recurrence and the difference between RT and carboplatin may have actually been so small, because patients without risk factors have more or less the same recurrence risk if they go for AS or carboplatin (4% vs. 2.2%). Remember that the Oliver trial was powered to detect a 3% absolute difference in recurrence between carboplatin and radiotherapy as a non-inferiority design.
If "enough" low-risk patients were entered in the trial (which we do not know, since the data was never published) AS may actually have also been non-inferior to carboplatin or RT, since the absolute difference in "real-world" Norway/Sweden between AS and carboplatin for low-risk stage I disease in terms of recurrence risk seems to be less than 2%.

Based on this the SWENOTECA is currently randomizing patients to 1x BEP vs. 1x carbo for high risk stage I disease.
Adjuvant Bleomycin, Etoposide and Cisplatin (BEP) Versus Carboplatin in Stage I Seminomatous Testicular Cancer - Full Text View - ClinicalTrials.gov

1x BEP is probably going to be excellent and I expect 0-1% relapses, but the question is then going to be what one considers optimal care for a stage I patients with a risk of recurrence on AS of 20%, assuming that you can effectively salvage almost everybody with a recurrence?

What's "worse"? Giving 100 patients one cycle of BEP each as adjuvant treatment or giving 20 patients with a recurrence on active surveillance three cycles of BEP each?
Is it worse to expose more patients to less chemo per patient but in the end need "more chemo" for all or to give a limited number of patients more chemo each but at the end of the day need "less chemo" for all?
And this is of course assuming that 3x BEP is the optimal salvage strategy for a stage I seminoma recurrence, which may not be the case.

Lots of patients will reccur with stage IIA/B disease and can be treated with radiation therapy alone or a de-escalated concept.
The 3x carboplatin AUC10 schedule from the UK (which should be less toxic than 3x BEP) shows promising early efficacy data.
Carboplatin AUC 10 for IGCCCG good prognosis metastatic seminoma. - PubMed - NCBI
The German-speaking study group is also doing a trial aimed at de-escalation combing carboplatin and involved node radiotherapy.
Therapy De-escalation in Seminoma Stage IIA/B - Full Text View - ClinicalTrials.gov


Some are advocating that 2x Carbo may be more effective in stage I.
The Spaniards have been doing that for quite some time now, Aparicio has published several papers on that including a very handy nomogram predicting recurrence risk for patients on AS.
I highly recommend to use the nomogram when talking to a patient.
Prognostic factors for relapse in stage I seminoma: a new nomogram derived from three consecutive, risk-adapted studies from the Spanish Germ Cell ... - PubMed - NCBI


You will hardly find a patient in Europe getting radiation nowadays for stage I seminoma. If treatment is desired by the patient, most get 1x Carbo.
If I was a patient, I would go for AS. I would then try to get myself treated in case of recurrence with stage IIA/B disease using some deescelated approach.
3x BEP is just not good in my opinion.

 

[seper]

Yeah I've heard big shot MedOncs saying that carbo X 1 is not ideal.

 

[medgator]

FDA Panel Backs Novartis' Pioneering New Cancer Gene Therapy

the military industrial complex is going to be so jealous.... as this expands into other malignancies and combined with immunotherapy...

"The treatments are given just once and are expected to cost up to $500,000."

 

[medgator]

In the news....

Many Breast Cancer Patients Receive More Radiation Therapy Than Needed

So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients’ Ills

An exclusive analysis for Kaiser Health News found that only 48 percent of eligible breast cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.

The analysis was completed by eviCore healthcare, a South Carolina-based medical benefit management company, which analyzed records of 4,225 breast cancer patients treated in the first half of 2017. The women were covered by several commercial insurers. All were over age 50 with early-stage disease.

 

[evilbooyaa]

Read the first story in the first link - Patient received chemotherapy. The percentage of patients treated with HF-WBRT that were also treated with chemo concurrently is low, and the guidelines on hypofrac state that hypofrac cannot be consensus recommended in patients who receive chemotherapy.

Not to at all say that HF-WBRT in patients who receive chemo is wrong, but it isn't the only answer in early stage breast

Of course, nobody outside of Rad Oncs will have that knowledge, and journalists don't care about actually researching anything in relation to their stories nowadays, so this is the garbage we get.

They talk to the treating Rad Onc, who defends his position (reasonably IMO), but they just ignore it and move on like he's the idiot.

They reference Ben Smith later, who says he doesn't think there's a difference and that chemo patients should get HF-WBRT. Cool, that the randomized trials don't really include chemo and you're gonna push practice based on retrospective data, but at least how about an update to the HF-WBRT consensus guidelines then?

Later on they reference a patient who got 3 weeks of RT and how, even though she had bad side effects, clearly the 7 weeks would've been worse. Layman logic. Ignoring the fact that treatment per fraction is different. Maybe her Rad Onc should've done more field in field. Respiratory infections from whole breast treatment?

 

[Palex80]

Read the first story in the first link - Patient received chemotherapy. The percentage of patients treated with HF-WBRT that were also treated with chemo concurrently is low, and the guidelines on hypofrac state that hypofrac cannot be consensus recommended in patients who receive chemotherapy.

I'm going to play the devil's advocate here.

In the two randomized trials of boost vs. no-boost after breast conserving surgery 10% (EORTC-you need to add-up the numbers in the appendix file) and 20% (French-Lyon) of the patients had chemo.
Am I allowed to give a boost in patients who have had chemo? Because we don't have adequate data on them.
After all 80%-90% of the patients in the randomized trials did not have chemo.

How am I supposed to know that a boost is safe if the patients have had chemo? Maybe they will develop excessive toxicity? Maybe they'll all die of pneumonitis because they had evil taxanes and the boost is going to increast the mean lung dose!
Or perhaps I don't even need to give a boost, because chemo is going to lower the absolute risk of recurrence, making the additional effect of the boost negligible?

Oh my God! I have been malpracticing for years!

 

[evilbooyaa]

I'm going to play the devil's advocate here.

Again, I'm not saying that if you do HF-WBRT for patients who received chemo you're doing anything wrong.

But, when the smartest minds in our field (or at least the ones that have been given the power to create 'consensus' guidelines) write a consensus guideline on HF-WBRT, and outline a bunch of factors that are slam dunk for HF-WBRT, but then can't come to a consensus on whether HF-WBRT should be used in patients who have received chemo, I don't think it's wrong to not offer hypofrac in that situation.

And I think it's wrong for journals or Rad Oncs or anybody to fraction-shame a Rad Onc who believes in that.

Once we get randomized phase III data on hypofrac w/ RNI it'll likely be more of a concern.

 

[Palex80]

True. But the same masterminds never questioned in a guideline if you should boost in the presence of chemo.
And we don't have Phase III data on that either, do we?

I think it's all about the $$$. And even the greatest masterminds need $$$.

I hypofractionated all breast cancer patients who don't get extensive RNI, with the exception of the very young ones. But I'll probably start doing it in those too.

 

[medgator]

True. But the same masterminds never questioned in a guideline if you should boost in the presence of chemo.

A boost is conventionally fractioned to a much smaller volume. Really shouldn't be an issue.

And if astro thought it was ok, the original guideline would have reflected that.

Europe isn't as litigious as the US is, one thing to keep in mind

 

[evilbooyaa]

True. But the same masterminds never questioned in a guideline if you should boost in the presence of chemo.
And we don't have Phase III data on that either, do we?

I think it's all about the $$$. And even the greatest masterminds need $$$.

I hypofractionated all breast cancer patients who don't get extensive RNI, with the exception of the very young ones. But I'll probably start doing it in those too.

Well you don't have data that says you have to boost in the presence of chemo (I haven't done an exhaustive lit search to see if somebody has actually looked into this question), so in the interest of cost-cutting (which seems to be all we ever talk about anymore) why do you boost ANY of your patients who get chemo? You don't have any data to support your position.

/sarcasm

Palex, at the end of the day, you do things your way that I vehemently disagree with that I will never be able to convince you through a study (because nobody will believe a study randomizing SCLC patients to surveillance MRIs or just regular observation is ethical), and you can keep thinking that everything I propose or defend as variation in practice in our specialty (see above) or in oncology in general (surveillance imaging is all for that sweet imaging money that Rad Oncs see no part of) is just because I support doing everything and anything for money.

 

[Palex80]

Evilboyaa

To me the argument, that "toxicity may be higher with hypofractionation in the presence of chemo" is ridiculous. That is the point I was trying to make by making the whole boost argument. Relax.

I do not know what ASTRO will need to change its mind.

The German S3 guideline recommends hypofractionation for all patients with out RNI.
http://www.leitlinienprogramm-onkol...ersion_Konsultationsfassung_Version_0.4.1.pdf

 

[radiation]

Again, I'm not saying that if you do HF-WBRT for patients who received chemo you're doing anything wrong.

But, when the smartest minds in our field (or at least the ones that have been given the power to create 'consensus' guidelines) write a consensus guideline on HF-WBRT, and outline a bunch of factors that are slam dunk for HF-WBRT, but then can't come to a consensus on whether HF-WBRT should be used in patients who have received chemo, I don't think it's wrong to not offer hypofrac in that situation.

And I think it's wrong for journals or Rad Oncs or anybody to fraction-shame a Rad Onc who believes in that.

Once we get randomized phase III data on hypofrac w/ RNI it'll likely be more of a concern.

New guidelines are much more inclusive, including chemo

https://t.co/J7VoALgHyr

 

[nkmiami]

I believe the START A and B trials included 500+ woman with chemo as well as about 100 woman treating the chest wall/ nodes. ALso, in these trials, higher grade tumors did well w/hypofracionation.
)

 

[evilbooyaa]

New guidelines are much more inclusive, including chemo

https://t.co/J7VoALgHyr

Good to see. Look forward to the publication and subsequent discussion at my institution.

 

[Palex80]

Good to see. Look forward to the publication and subsequent discussion at my institution.

Excellent work!

 

[Gfunk6]

I’m attending RSS annual meeting. Dr. Zelefsky of MSKCC - whom I think we all agree is a luminary in prostate cancer - states that based on recent randomized data, the entire institution is using moderate and ultra-hypofractionation as standard for organ confined prostate cancer.

Food for thought.

 

[Chartreuse Wombat]

I’m attending RSS annual meeting. Dr. Zelefsky of MSKCC - whom I think we all agree is a luminary in prostate cancer - states that based on recent randomized data, the entire institution is using moderate and ultra-hypofractionation as standard for organ confined prostate cancer.

Food for thought.

He is on solid ground with moderate hypo but the evidence for 4-5 fractions is quantitatively and qualitatively much weaker. I guess CyberKnife advertisements in the NYT provokes a response. No more 45-50 fractions at MSK?

 

[BobbyHeenan]

Read the first story in the first link - Patient received chemotherapy. The percentage of patients treated with HF-WBRT that were also treated with chemo concurrently is low, and the guidelines on hypofrac state that hypofrac cannot be consensus recommended in patients who receive chemotherapy.


They reference Ben Smith later, who says he doesn't think there's a difference and that chemo patients should get HF-WBRT....

I actually agree with this and use hypofrac for whole breast for probably 90% of my whole breast patients....

With that said, they're doing partial breast protons at MDA (and I know this is going on at other proton centers), so it's hard to hear fraction shaming in that context.

 

[nkmiami]

at ASTRO allan pollack did not give that kind of endorsement of hypofractionation, based on his own randomized trials, and made the point gu side effects can occurr 5+ years. In the middle of manhattan, hypofractionation makes a lot of sense for someone who has a waiting list of pts to be treated. MSKCC treats a lot of pts with brachy/combination. I believe it will eventually become standard, and offer it presently, but not as the default.
In breast cancer, the hypofractionation arms werent just equivalent, but likely better side effects, tumor control in british trial. I wouldnt expect doc with 10-15 pts/single linac to adopt this approach. When I see major academic centers whose linacs arent exploding with pts, adopting hypofractionation.....

 

[MegaVoltagePhoton]

at ASTRO allan pollack did not give that kind of endorsement of hypofractionation, based on his own randomized trials, and made the point gu side effects can occurr 5+ years. In the middle of manhattan, hypofractionation makes a lot of sense for someone who has a waiting list of pts to be treated. MSKCC treats a lot of pts with brachy/combination. I believe it will eventually become standard, and offer it presently, but not as the default.
In breast cancer, the hypofractionation arms werent just equivalent, but likely better side effects, tumor control in british trial. I wouldnt expect doc with 10-15 pts/single linac to adopt this approach. When I see major academic centers whose linacs arent exploding with pts, adopting hypofractionation.....

Yes, but the Fox Chase trial was a small trial, and we now have 3 larger noninferiority studies, 2 of which showed BETTER late toxicity with hypofrac, and one of which did not, but had a low dose conventional frac arm. Seems like cherry picking to focus on a smaller, single institution trial which actually only showed worse toxicity in the subset of patients with poorer IPSS at baseline. MDACC has also not reported worse toxicity with their hypofrac trial.

 

[medgator]

United States Department of Health and Human Services

REPORT TO CONGRESS: Episodic Alternative Payment Model for Radiation Therapy Services

https://innovation.cms.gov/Files/re...SVnJxb0FhRnliYW1wK1lDcG9qQlBQWGdiK1dzNkUifQ==

 

[seper]

Interesting read for state of the field, thx

 

[Gfunk6]

Medgator, thanks for sharing - very informative

 

[BobbyHeenan]

United States Department of Health and Human Services

REPORT TO CONGRESS: Episodic Alternative Payment Model for Radiation Therapy Services

https://innovation.cms.gov/Files/reports/radiationtherapy-apm-rtc.pdf?mkt_tok=eyJpIjoiWmpWaU5tUTVPRGxsWXpjNCIsInQiOiJNZzY4M1RJRGlhKzhcLzFGSk9XcFJuMWU3bDRJWUdWWGpSRGIraDA1aFZzTG14MlhiVmpiVlFkM1JPbHV3eGRQeGxoRCthSlRqbDQwNDArMTFTeXhIeVNFYkFUUlV3VzFkOFpSVnJxb0FhRnliYW1wK1lDcG9qQlBQWGdiK1dzNkUifQ==

Interesting read - thanks for posting.

I skimmed it.....

- ASTRO did the field zero favors by going after the uro rad stuff. All it did is get the eye of medicare upon us and let these types of policy papers imply that the boom of IMRT is due to perverse incentives (and not due to us getting better data/indications for things like anal cancer (RTOG 0529), gyn (0418), and lung (post hoc 0617 analysis)).

- Bundling was probably coming regardless, but the above didn't help.

 

[medgator]

Interesting read - thanks for posting.

I skimmed it.....

- ASTRO did the field zero favors by going after the uro rad stuff. All it did is get the eye of medicare upon us and let these types of policy papers imply that the boom of IMRT is due to perverse incentives (and not due to us getting better data/indications for things like anal cancer (RTOG 0529), gyn (0418), and lung (post hoc 0617 analysis)).

- Bundling was probably coming regardless, but the above didn't help.

Wholeheartedly agree. Between that and the lukewarm support for bundles and site-neutral payments, it's pretty clear which faction of rad onc ASTRO and its PAC support

Sent from my LG-H910 using SDN mobile

 

[OTN]

Wholeheartedly agree. Between that and the lukewarm support for bundles and site-neutral payments, it's pretty clear which faction of rad onc ASTRO and its PAC support

Sent from my LG-H910 using SDN mobile

Yep - and that's precisely why I let my ASTRO membership lapse and will not be renewing.

 

[nkmiami]

I wish ASTRO cared about the oversupply of residents more than billing, and ASTRO can actually have control over that issue.
Regarding urorads, ASTRO only decided to take that on years after it had become well established. The organization really should represent its members interests.

 

[Chartreuse Wombat]

I wish ASTRO cared about the oversupply of residents more than billing, and ASTRO can actually have control over that issue.
Regarding urorads, ASTRO only decided to take that on years after it had become well established. The organization really should represent its members interests.

At the risk of being attacked as an ASTRO sycophant I must protest the notion that ASTRO can control the supply of residents. There is no mechanism for this. The ACGME decides whether new positions are approved and they cannot consider supply in that determination-if the resources (patients, faculty, machines) are available then new requests are approved. ABR has no jurisdiction. The only group that can effect this issue is SCAROP (chairs of academic departments). Many have appealed to SCAROP membership (myself included) but little movement on the issue as new programs and complement increases continue.

FWIW I am dues paying member of ASTRO and have been actively involved with ACGME and ABR (and perhaps thus part of the problem) but I feel strongly that there is an oversupply and that Chairs should stop opening programs and increasing resident complements. I have made this known to the "leadership". The medical students are mostly aware but the number of applicants seems to be holding at ~250/year which is greater than the number of ACGME approved positions so the demand part of the equation doesn't seem to be working. To repeat, i think we are training too many people and this is a bad thing on a number of levels; primarily because it will hospitals with greater leverage as they seek to employ more physicians.

 

[OTN]

If there is an oversupply of residents and ASTRO purports to be the leading organization supporting radiation oncologists, then the responsibility falls squarely on its shoulders to do something about it. I don't care at all if there is no "mechanism" in place for ASTRO for restrict residency positions. There is an issue, ASTRO wants to lead our field, so do it. We all know ASTRO is composed mostly of academic radoncs, the exact same ones who make up SCAROP, and they simply must not want to restrict expansion/decrease residency spots, full stop. As a result, I refuse to support the organization until they start to actually listen to their members. I'm not holding my breath.

I also strongly disagree with the academicians' statement that they cannot use supply-and-demand to determine residency positions. Other specialties do it with no problem, and one could easily make the argument, if one cared about supply and demand in the field, that it is the responsibility of the "leaders" of our field to make sure public health dollars used to support physician training programs are used as efficiently as possible.

 

[Chartreuse Wombat]

If there is an oversupply of residents and ASTRO purports to be the leading organization supporting radiation oncologists, then the responsibility falls squarely on its shoulders to do something about it. I don't care at all if there is no "mechanism" in place for ASTRO for restrict residency positions. There is an issue, ASTRO wants to lead our field, so do it. We all know ASTRO is composed mostly of academic radoncs, the exact same ones who make up SCAROP, and they simply must not want to restrict expansion/decrease residency spots, full stop. As a result, I refuse to support the organization until they start to actually listen to their members. I'm not holding my breath.

I also strongly disagree with the academicians' statement that they cannot use supply-and-demand to determine residency positions. Other specialties do it with no problem, and one could easily make the argument, if one cared about supply and demand in the field, that it is the responsibility of the "leaders" of our field to make sure public health dollars used to support physician training programs are used as efficiently as possible.

Perhaps your approach of leaving the organization will yield results if enough people follow you. I prefer to try to influence the leadership from within the organization and I think your assertion that ASTRO should simply fix the problem is oversimplifying a complicated problem.

I attended a meeting at HQ recently and the results of the recent member survey were presented. The survey found that "oversupply" was a larger concern of the membership than on the previous survey but still a minority of respondents were concerned. The ASTRO presenter was framing the issue as one of "maldistribution" (too many training program spots in the NorthEast and not enough in the SOuthEast MidWest. Again I don't buy the maldistribution canard and voiced my opinion that the specialty was training too many people.

 

[evilbooyaa]

Here we go with too many residency spots again.

The issue here is that the people in power of SCAROP (and ASTRO?) are the ones who are benefited the most by having expansion of residencies, likely including chairmen/women of big Rad onc residency departments. Despite the accomplishments of the people at the top, they are just as aligned with their own (and their departments) self interests, and as long as they get theirs, everybody else can go kick rocks.

Here's the path to success for a chairman: Expand by buying more private practices or funneling volume from satellites to main facility. Justify that you have more attendings and more cases to get more residents. Expand residents to have 1:1 coverage for every attending as possible, even if that means having residents go to 3+ sites to cover these attendings. Create more graduates. Because there are more jobs than graduates now, offer 'fellowships' in things that are essentially CORE to residency training in this day and age (Palliative Radiation Oncology, SRS/SBRT to think of a few) and do not really add any clinical value. That just means you got a junior attending on the cheap as a 'fellow', and since he's board eligible, he can do all the weekend stuff by himself, even though he's 'just' a fellow. Even if residents don't accept BS fellowships, there is now more supply so pay drops as departments realize they can pay people less and still have a glutton of applicants. Sit back and pat yourself on the back as your department is now making more money than ever, because as the volume increases, every attending has 24/7 coverage (meaning no need to hire PAs/NPs and their pesky 100k+ salaries and inability to do treatment planning), junior faculty are paid less than what they were 10 years ago, and you may even have a fellowship candidate or two.

Residents? Who cares about those. They should be thankful that they even have a place to train, given how competitive Rad Onc is! Maybe they can work at one of the satellite practices that the department is buying now, and since they already have ties to the community, they'll be willing to accept even LESS money than bringing in people from the outside!

Any chairman that continues to expand residency spots, at this time, does so only to further his and his department's interests, NOT in the interest of the residents themselves. And that'd be fine, if it wasn't for the fact that the group that sanctions these continued expansions are run by the exact same group of people. It's a massive conflict of interest that those who have the most to gain have the power to make it happen. Maybe the push to make IORT not count as 'interstitial brachytherapy' (a welcome one on the grand scheme of things, from my perspective) will make it so that meeting the numbers for 5 of those cases (over a 4-year residency) isn't as easily attainable to justify expansion. Maybe.

 

[medgator]

ASTRO leadrship /ABR/Chairman are essentially the same clique who continue to preach "hypofractionation/choosing wisely" while increasing residents slots.

Kinda have to wonder what happened to the leadership in the 90s that (rightfully) closed down programs/decreased spots and lengthened training by a year (further reducing market supply at that time).

 

[medgator]

. As a result, I refuse to support the organization until they start to actually listen to their members. I'm not holding my breath.

Many in PP have switched to ACRO as an organization to support.

Personally we will continue ACR accreditation at our practice, no reason to switch to astro imo especially now with how they have handled these issues

 

[OTN]

Many in PP have switched to ACRO as an organization to support.

Personally we will continue ACR accreditation at our practice, no reason to switch to astro imo especially now with how they have handled these issues

Yep, my large private practice group chose ACRO accreditation rather than ASTRO for these exact reasons.

 

[winstonfoot5]

I attended a meeting at HQ recently and the results of the recent member survey were presented. The survey found that "oversupply" was a larger concern of the membership than on the previous survey but still a minority of respondents were concerned.

I dont think this is correct - At ASTRO 2017 it was presented that >50% of membership are concerned about a looming oversupply of rad oncs

 

[Chartreuse Wombat]

I dont think this is correct - At ASTRO 2017 it was presented that >50% of membership are concerned about a looming oversupply of rad oncs

Winstonfoot5 is correct. I reviewed the slides from the meeting and pasted the relevant one below (concern about oversupply increased from 34% to 53%: 31% response rate). I regret the error.

 

[Irradi8or]

United States Department of Health and Human Services

REPORT TO CONGRESS: Episodic Alternative Payment Model for Radiation Therapy Services

https://innovation.cms.gov/Files/reports/radiationtherapy-apm-rtc.pdf?mkt_tok=eyJpIjoiWmpWaU5tUTVPRGxsWXpjNCIsInQiOiJNZzY4M1RJRGlhKzhcLzFGSk9XcFJuMWU3bDRJWUdWWGpSRGIraDA1aFZzTG14MlhiVmpiVlFkM1JPbHV3eGRQeGxoRCthSlRqbDQwNDArMTFTeXhIeVNFYkFUUlV3VzFkOFpSVnJxb0FhRnliYW1wK1lDcG9qQlBQWGdiK1dzNkUifQ==

The Ben Smith article from 2010 continues to plague us. Page 3 of the PDF, with reference to the Smith, Haffty...Buchholz et al paper, "In another study, researchers predicted that, “from 2010 to 2020, the demand for radiation therapy during the initial treatment course is expected to increase by 22% (from 470,000 patients receiving radiation therapy in 2010 to 575,000 patients receiving radiation therapy in 2020) as a result of the aging and diversification of the US population.”

 

[medgator]

The Ben Smith article from 2010 continues to plague us. Page 3 of the PDF, with reference to the Smith, Haffty...Buchholz et al paper, "In another study, researchers predicted that, “from 2010 to 2020, the demand for radiation therapy during the initial treatment course is expected to increase by 22% (from 470,000 patients receiving radiation therapy in 2010 to 575,000 patients receiving radiation therapy in 2020) as a result of the aging and diversification of the US population.”

Yup.... wish they'd issue a retraction

 

[DebtRising]

The medical students are mostly aware but the number of applicants seems to be holding at ~250/year which is greater than the number of ACGME approved positions so the demand part of the equation doesn't seem to be working.

No one believes people on the internet. Fact of life. Applicants won't decline because we bring up the evidence - ASTRO, ACGME, has to highlight. That is where I disagree with your assessment of ASTRO's responsibility. They had the old model predicting under supply posted on their website. When the model was proven wrong, they simply removed the old link and text [almost all indexed pages are archived].

Source of information matters. I have done best to put together the pieces of evidence of oversupply in many posts - so what. I am an anonymous internet nothing. Where is leadership of field highlighting 'We have done our due diligence, our employment model was wrong, it is now PUBLISHED, we are training too many men and women for job that does not exist, at same time we are pushing for less intense management treatment which will diminish physician need even more'? That is the role of a specialty advocacy group. Are medical students truly aware of oversupply, or do they just acknowledge internet posts which they can then dismiss?

Instead ASTRO bury head in sand. You want to open fellowship? No statement. You want to end re-certification for older generation who benefits from this? Great idea. Easy to see where bitterness comes from if you not in the inner circle.

The Shah paper also had chilling effect. Been in meetings with high level people, topic brought up, they look at floor. This response may have set tone for debate, unless someone from Wash U always waiting outside to assault anyone who bring up reasonable concern about employment. Even dialogue difficult to get started. Yet 53% of graduates feeling oversupply. 53%!!

No one takes responsibility for disseminating the honest information then sits back and say 'look at all these people applying'. I have moved on. Nothing will change until something bad happens, and lot of talent and ambition continue to be wasted. But at least we have more fellowships now. Worst part is, many people know something bad will happen, calculation is that it will happen after they retire and/or core of ASTRO has demonstrated no compassion for rank and file of this field.