India launches its 2nd proton therapy center

[taserlaser]

Elections!

Foiled by autocorrect yet again. Where‘s that second coffee… it’s like when GTV peeks out of CTV.

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[evilbooyaa]

So, I don’t think we’ve met but a patient of mine wanted a proton opinion and our patients tend to prefer driving to Flint rather than Detroit suburbs. Sent him to Flint. He claimed that he was told it had to be conventional fx, that the 5 fx I had recommended was not possible. So he came back to me.

5Fx for what?

 

[deleted1111261]

5Fx for what?

That was unclear - sorry!
Prostate.

 

[IonsAreOurFuture]

So, I don’t think we’ve met but a patient of mine wanted a proton opinion and our patients tend to prefer driving to Flint rather than Detroit suburbs. Sent him to Flint. He claimed that he was told it had to be conventional fx, that the 5 fx I had recommended was not possible. So he came back to me.

Thanks Simul, we do use protons for SBRT, but usually just for re-irradiation or with mets where we can't meet Xray constraints.

 

[deleted1111261]

Ah okay. This was a prostate case. I wasn’t clear in original message. I’m sure we will cross paths eventually !

 

[RickyScott]

That was unclear - sorry!
Prostate.

5 fraction prostate proton sbrt is probably quite dangerous. conventional fractionation is probably the best way to limit the increased side effects with protons.

 

[Chartreuse Wombat]

5 fraction prostate proton sbrt is probably quite dangerous. conventional fractionation is probably the best way to limit the increased side effects with protons.

This is the way..

 

[TheWallnerus]

There are certainly centers that are willing to accept IMRT rates for protons.

This is literally a definition of underbilling.

How many times on Twitter, in real life, and even here on SDN have rad onc people set their hair on fire going off on how wrong and illegal this is.

But hey, when proton centers underbill, suddenly these centers and attendings feel virtuous.

I cannot tell anyone if underbilling is illegal or not. It would sure be nice if people were consistent with their sanctimony though.

Btw, IMRT goes for about $350 a fraction and protons about $1100 a fraction. Any center who says they only bill $350 for a proton fraction is pre-lying for pre-auth.

 

[RickyScott]

This is literally a definition of underbilling.

How many times on Twitter, in real life, and even here on SDN have rad onc people set their hair on fire going off on how wrong and illegal this is.

But hey, when proton centers underbill, suddenly these centers and attendings feel virtuous.

I cannot tell anyone if underbilling is illegal or not. It would sure be nice if people were consistent with their sanctimony though.

Btw, IMRT goes for about $350 a fraction and protons about $1100 a fraction. Any center who says they only bill $350 for a proton fraction is pre-lying for pre-auth.

usually in this scenario the imrt rates are much higher and probably surpass CMS proton rates

 

[RickyScott]

I am going to keep posting this. And we know that at least one of the authors is credible.
Modern proton techniques with invasive rectal procedures (balloons/space oar)= 10% rectal bleeding requiring laser coagulation..

Analysis of Gastrointestinal Toxicity in Patients Receiving Proton Beam Therapy for Prostate Cancer: A Single-Institution Experience - PubMed

PBT was associated with acceptable rates of GR2+ transient GI toxicity, mostly in the form of RB, which correlated with anticoagulation use. High EPIC bowel domain quality of life was maintained in the 2 years after treatment.

pubmed.ncbi.nlm.nih.gov

 

[thecarbonionangle]

I am going to keep posting this. And we know that at least one of the authors is credible.
Modern proton techniques with invasive rectal procedures (balloons/space oar)= 10% rectal bleeding requiring laser coagulation..

Analysis of Gastrointestinal Toxicity in Patients Receiving Proton Beam Therapy for Prostate Cancer: A Single-Institution Experience - PubMed

PBT was associated with acceptable rates of GR2+ transient GI toxicity, mostly in the form of RB, which correlated with anticoagulation use. High EPIC bowel domain quality of life was maintained in the 2 years after treatment.

pubmed.ncbi.nlm.nih.gov

Five-Year Biochemical Results, Toxicity, and Patient-Reported Quality of Life After Delivery of Dose-Escalated Image Guided Proton Therapy for Prostate Cancer - PubMed

Image guided PT provided excellent biochemical control rates for patients with localized prostate cancer. The actuarial rates of high-grade toxicity were low after PT. From pretreatment to 5 years of follow-up, a significant decline was found only in mean EPIC sexual summary scores. Prospective...

pubmed.ncbi.nlm.nih.gov

UW does not have CBCT in the PTC as far as I know but someone correct me if im wrong. The UF data has image guidance and more follow up, more patients. Devils advocates would argue: have you ever seen such a cure rate for IR?

 

[TheWallnerus]

usually in this scenario the imrt rates are much higher and probably surpass CMS proton rates

Certainly can be, but I have seen it both ways at the Medicare Advantage level

 

[IonsAreOurFuture]

I am going to keep posting this. And we know that at least one of the authors is credible.
Modern proton techniques with invasive rectal procedures (balloons/space oar)= 10% rectal bleeding requiring laser coagulation..

Analysis of Gastrointestinal Toxicity in Patients Receiving Proton Beam Therapy for Prostate Cancer: A Single-Institution Experience - PubMed

PBT was associated with acceptable rates of GR2+ transient GI toxicity, mostly in the form of RB, which correlated with anticoagulation use. High EPIC bowel domain quality of life was maintained in the 2 years after treatment.

pubmed.ncbi.nlm.nih.gov

Those are terrible results! Even 3D conformal wasn't that bad.

We know that rectal balloons are worse than SpaceOAR for rectal bleeding, something like 15% vs 3%, but I think something else is at play.

I agree with carbonionangle that IGRT may be part of it, as very few centers built prior to 2016 or so have CBCT at isocenter. I think Seattle is one of the old Procure multiroom centers from 2010 to 2015ish that went belly up and got bought out.

I think margin size may have something to do with it as well. If you don't image, you tend to use bigger margins like over 5 mm posteriorly. I have previously turned down a job offer because the Linac didn't have CBCT, and I think IGRT is even more crucial with protons.

 

[communitydoc13]

Five-Year Biochemical Results, Toxicity, and Patient-Reported Quality of Life After Delivery of Dose-Escalated Image Guided Proton Therapy for Prostate Cancer - PubMed

Image guided PT provided excellent biochemical control rates for patients with localized prostate cancer. The actuarial rates of high-grade toxicity were low after PT. From pretreatment to 5 years of follow-up, a significant decline was found only in mean EPIC sexual summary scores. Prospective...

pubmed.ncbi.nlm.nih.gov

UW does not have CBCT in the PTC as far as I know but someone correct me if im wrong. The UF data has image guidance and more follow up, more patients. Devils advocates would argue: have you ever seen such a cure rate for IR?

Seems like a weird thing to reference. Cure rate? I don't event know how this data adds much to anything other than the remarkably good IPSS scores of men in FL.

Do Florida men piss better? Apparently so!!!

These guys didn't even have BPH much less life threatening prostate cancer!

 

[thecarbonionangle]

Seems like a weird thing to reference. Cure rate? I don't event know how this data adds much to anything other than the remarkably good IPSS scores of men in FL.

Do Florida men piss better? Apparently so!!!

These guys didn't even have BPH much less life threatening prostate cancer!

Florida is known for “straight shooters”

 

[RickyScott]

Five-Year Biochemical Results, Toxicity, and Patient-Reported Quality of Life After Delivery of Dose-Escalated Image Guided Proton Therapy for Prostate Cancer - PubMed

Image guided PT provided excellent biochemical control rates for patients with localized prostate cancer. The actuarial rates of high-grade toxicity were low after PT. From pretreatment to 5 years of follow-up, a significant decline was found only in mean EPIC sexual summary scores. Prospective...

pubmed.ncbi.nlm.nih.gov

UW does not have CBCT in the PTC as far as I know but someone correct me if im wrong. The UF data has image guidance and more follow up, more patients. Devils advocates would argue: have you ever seen such a cure rate for IR?

which is why I dont trust it. Even if you have 100% local control, which you cant, 10-20 (at least)% will fail in nodes, bone etc . Not going to get into the weeds, but very sketchy.