Interesting News from AACR

[TheWallnerus]

Breast

Lymphoma:

Immunotherapy combination shows ‘remarkable’ activity for patients with advanced lymphoma​

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[Mandelin Rain]

Get money. Save aggressively. Don't apply.

 

[metallica81788]

I guess when that happens I'll give everybody partial breast 30Gy/5fx until someone tells me to stop

 

[Mandelin Rain]

I guess when that happens I'll give everybody partial breast 30Gy/5fx until someone tells me to stop

United Healthcare will be happy to oblige.

 

[fiji128]

30 fractions to 15 fractions to 5 fractions and to be 0 fractions in the not too far off future. Most community clinics are likely not to be an economically viable enterprise in a world where lets say 80% of our breast volume is gone.

 

[Mandelin Rain]

30 fractions to 15 fractions to 5 fractions and to be 0 fractions in the not too far off future. Most community clinics are likely not to be an economically viable enterprise in a world where lets say 80% of our breast volume is gone.

Yup. Breast keeps the lights on. And it works. Really well. Why we're contorting ourselves to eliminate our role in this disease is beyond me.

Lose a high proportion of breast, high proportion of rectal, and 1 fraction bone mets..... I'd hazard to say most community clinics won't be viable.

 

[TheWallnerus]

30 fractions to 15 fractions to 5 fractions and to be 0 fractions in the not too far off future. Most community clinics are likely not to be an economically viable enterprise in a world where lets say 80% of our breast volume is gone.

Yup. Breast keeps the lights on. And it works. Really well. Why we're contorting ourselves to eliminate our role in this disease is beyond me.

Lose a high proportion of breast, high proportion of rectal, and 1 fraction bone mets..... I'd hazard to say most community clinics won't be viable.

@fiji128 delete “likely” from your sentence and you’ve got it.

But I am calling it now and it is crazy no one else is seeing this. And by no one else I mean the big name people and places. If we go to five fraction it won’t just be community centers having problems. AKA Nick Zaorsky low volume centers (which are 3 out of 5 US XRT centers). It will be some large places too having problems.

When 6 week to 3 week happened I predicted a bit more gnashing of teeth than happened. Later I was surprised to find out every academic place was boosting their 3 week patients into 4 plus weeks of treatment thereby “lessening the blow” of hypofractionation by 33%.

Even academic places won’t be able to absorb a 3 week to 1 week switch like has happened en masse in the UK. If RT gets taken from us in a lot of breast cases outside our own sphere of influence, the existentiality of 3 week vs 1 week will be a moot point.

EDIT (and aside): The only reason you can have a rad onc who’s the department lymphoma expert is because of breast cancer

 

[metallica81788]

What I'm hearing from you is to treat the nodes while we still can for the future of our livelihoods!

 

[fiji128]

@fiji128 delete “likely” from your sentence and you’ve got it.

Re "likely." I'm just a bit more of an optimist!

 

[BobbyHeenan]

…I swear these people have never had a clinic of women miserable on their AI. If they did they'd be pushing harder for US trials that try to eliminate the AI, not the 5 radiation treatments in favorable biology patients.

 

[elementaryschooleconomics]

…I swear these people have never had a clinic of women miserable on their AI. If they did they'd be pushing harder for US trials that try to eliminate the AI, not the 5 radiation treatments in favorable biology patients.

COMPLETELY AGREE

New campaign:

"FIVE for FIVE"​

Trials aimed at omitting 5 years of endocrine therapy in favor of using one of the 5-fraction adjuvant radiation regimens (UK FAST, Florence APBI, UK FAST Forward).

Tumor board of the future: "This 73-year-old patient meets CALGB criteria, thus we will be omitting AI and she will receive APBI alone via the Florence regimen..."

 

[BobbyHeenan]

COMPLETELY AGREE

New campaign:

"FIVE for FIVE"​

Trials aimed at omitting 5 years of endocrine therapy in favor of using one of the 5-fraction adjuvant radiation regimens (UK FAST, Florence APBI, UK FAST Forward).

Tumor board of the future: "This 73-year-old patient meets CALGB criteria, thus we will be omitting AI and she will receive APBI alone via the Florence regimen..."

I am so hoping the EUROPA trial comes out no difference in survival or recurrence and we can go on to run QoL analysis and cost analysis (Prolia, dexa scans, chasing hot flashes with other meds, etc).

 

[fiji128]

I am so hoping the EUROPA trial comes out no difference in survival or recurrence and we can go on to run QoL analysis and cost analysis (Prolia, dexa scans, chasing hot flashes with other meds, etc).

Brief Summary: In low risk early stage patients ≥70 years, exclusive Partial Breast Irradiation (PBI) as radiation therapy (RT) approach might be superior in terms of Health-Related Quality of Life (HRQoL), when compared to exclusive endocrine therapy (ET) following breast-conserving surgery (BCS). Assuming an equal rate of disease control, unnecessary long-term toxicity of ET may be avoided. Enrollment 926 participants. Study completion date January 15, 2030 (Ugh).

 

[BobbyHeenan]

Brief Summary: In low risk early stage patients ≥70 years, exclusive Partial Breast Irradiation (PBI) as radiation therapy (RT) approach might be superior in terms of Health-Related Quality of Life (HRQoL), when compared to exclusive endocrine therapy (ET) following breast-conserving surgery (BCS). Assuming an equal rate of disease control, unnecessary long-term toxicity of ET may be avoided. Enrollment 926 participants. Study completion date January 15, 2030 (Ugh).

If the trial does show PBI is as good or better, would then wonder if you can extrapolate to the 60's .

At least maybe you'd be able to just start the AI then have a REALLY quick trigger to stop it if any intolerance noted. THere are a good portion of ladies who don't even notice any side effects, so no harm no foul there. BUt I hate to see the 70 year old really slugging it out "just three more years" when I question if they even need it.

 

[jondunn]

for the record - the breast picture was not from AACR. I saw it on twitter - it's a breast surgeon speaking at ASBS (American society of breast surgeons)

 

[thesauce]

for the record - the breast picture was not from AACR. I saw it on twitter - it's a breast surgeon speaking at ASBS (American society of breast surgeons)

The breast surgeon was giving a talk about radiation approaches?

 

[RadOncDoc21]

Unfortunately, I’m not surprised. Breast always starts with the breast surgeon and in order to survive, I gladly kissed the ring.

 

[TheWallnerus]

Unfortunately, I’m not surprised. Breast always starts with the breast surgeon and in order to survive, I gladly kissed the ring.

Surgeons are important for referrals, and important for rad onc. Rad onc would be s**t today were it not for (neurological) surgeons.

We really wouldn’t have the SBRT craze today without Adler, and we wouldn’t have had that craze or even IMRT without Carol. Two of rad onc’s biggest transformative forces of the past 50 years (both for its practitioners and patients), and the two didn’t happen because of rad oncs. (Rad oncs were highly anti SBRT in the beginning, but surgeons were not.)

 

[Mandelin Rain]

This thread brought this to mind.

 

[thesauce]

Unfortunately, I’m not surprised. Breast always starts with the breast surgeon and in order to survive, I gladly kissed the ring.

I send more patients to the breast surgeons than they send to me

 

[medgator]

I send more patients to the breast surgeons than they send to me

Newly diagnosed breast pts with a core bx? I end up sending our local breast surgeon ports/pegs and the occasional skin cancer as well

 

[RadOncDoc21]

Consider yourselves fortunate my friends, I’m too far down the totem poll. Palliative care sees more definitive cases upfront then I do! The community docs have been trained to send all cancers including skin, prostate, lung nodules to “oncology” and there isn’t a damn thing I can do about it… I’ve tried! The system here is setup for private monopolies.

Good thing, I’m employed or I’ll be homeless selling my body for tuna and cigarettes again.

 

[Ray D. Ayshun]

Consider yourselves fortunate my friends, I’m too far down the totem poll. Palliative care sees more definitive cases upfront then I do! The community docs have been trained to send all cancers including skin, prostate, lung nodules to “oncology” and there isn’t a damn thing I can do about it… I’ve tried! The system here is setup for private monopolies.

Good thing, I’m employed or I’ll be homeless selling my body for tuna and cigarettes again.

I recently put this up outside and business has picked up

 

[TheWallnerus]

I recently put this up outside and business has picked upView attachment 353328

why are Jesus memes the funniest memes

 

[Ray D. Ayshun]

why are Jesus memes the funniest memes

Bc we're from the south? Maybe

 

[temujim]

I recently put this up outside and business has picked upView attachment 353328

Your divine mercy could have a sharper penumbra...

 

[metallica81788]

We don't call 'em the healing rays for nothing!

 

[thesauce]

Newly diagnosed breast pts with a core bx? I end up sending our local breast surgeon ports/pegs and the occasional skin cancer as well

PCPs often send me suspicious breast masses and BIRADS 4+ mammograms and I order the biopsy. If the diagnosis is already made, PCPs will often dual-refer to me and the surgeon.

 

[Mandelin Rain]

PCPs often send me suspicious breast masses and BIRADS 4+ mammograms and I order the biopsy. If the diagnosis is already made, PCPs will often dual-refer to me and the surgeon.

n=1

 

[grenz]

PCPs often send me suspicious breast masses and BIRADS 4+ mammograms and I order the biopsy. If the diagnosis is already made, PCPs will often dual-refer to me and the surgeon.

So how did you train your PCPs to change their referral practices? If I were in their shoes, I’d just rather have one reflexive referral for each problem, which would usually be either an oncologist or the specialist surgeon (ENT, urology, etc).

 

[medgator]

PCPs often send me suspicious breast masses and BIRADS 4+ mammograms and I order the biopsy. If the diagnosis is already made, PCPs will often dual-refer to me and the surgeon.

 

[deleted1116990]

PCPs often send me suspicious breast masses and BIRADS 4+ mammograms and I order the biopsy. If the diagnosis is already made, PCPs will often dual-refer to me and the surgeon.

Dear lord, how will you ever manage endocrine therapy and treatment sequencing without involving a medical oncologist up front?

And people think I'm weird for ordering Lupron in clinic.

 

[deleted1111261]

Consider yourselves fortunate my friends, I’m too far down the totem poll. Palliative care sees more definitive cases upfront then I do! The community docs have been trained to send all cancers including skin, prostate, lung nodules to “oncology” and there isn’t a damn thing I can do about it… I’ve tried! The system here is setup for private monopolies.

Good thing, I’m employed or I’ll be homeless selling my body for tuna and cigarettes again.

Me too. I have upgraded to tinned spanish mackeral and Juul pods, but if times get tough, will be back to Chicken-Of-The-Sea and Marlboro Reds.

These guys that are crushing it in PP, getting all these upfront cases - you don't think the rest of us aren't hustling? I literally have pathology behind my office and she is a friend of the practice - she gives me any positive path and I harangue the ordering physician to send me the patient. I have met with everyone (everywhere I work) and rarely can I change a pattern that has been set in place for 2 decades.

Other than just saying you are a complete oncologist, what actionable steps can you take to change the pattern of referrals? I got a competitor next door cleaning my clock.

 

[RadOncDoc21]

I’ve hustled in the past and sometimes it works but it’s damn near impossible to break up some of the referral patterns despite me being a rock star and all.

It’s really tough when there’s only one group of surgeons, med oncs in town. It’s really really tough when the few referrals I do get end up leaving!

 

[Palex80]

 

[RadOncDoc21]

I guess he should be approved to receive CME reimbursement for the meeting.

 

[Ray D. Ayshun]

You'd never guess, but I'm actually busy

 

[deleted1111261]

HUSK IS SO DAMN GOOD

 

[thesauce]

n=1

I’m happy to be the one

 

[thesauce]

So how did you train your PCPs to change their referral practices? If I were in their shoes, I’d just rather have one reflexive referral for each problem, which would usually be either an oncologist or the specialist surgeon (ENT, urology, etc).

It’s even easier for them now since they have one person for everything.

It took (a lot of) work. I met with the big PCP groups and other specialties and explained what we (radoncs) did. I gave presentations at the local schools and medical societies as well. It took time but it worked. You have to be willing to work your ass off and provide excellent customer service, communication and patient care. It is not an easy path but sooooo worth it.

 

[thesauce]

Dear lord, how will you ever manage endocrine therapy and treatment sequencing without involving a medical oncologist up front?

And people think I'm weird for ordering Lupron in clinic.

LOL. I hope you’re joking.

Sequencing of endocrine therapy…I’ll help you out: it comes at the end.

The medoncs have their PAs/NPs do most of the workups. They do the workups because that’s the way it’s always been done. There is nothing magical about the way they order scans or biopsies. I haven’t messed one up yet

 

[thesauce]

Consider yourselves fortunate my friends, I’m too far down the totem poll. Palliative care sees more definitive cases upfront then I do! The community docs have been trained to send all cancers including skin, prostate, lung nodules to “oncology” and there isn’t a damn thing I can do about it… I’ve tried! The system here is setup for private monopolies.

Good thing, I’m employed or I’ll be homeless selling my body for tuna and cigarettes again.

You don’t have to choose

 

[RickyScott]

It’s even easier for them now since they have one person for everything.

It took (a lot of) work. I met with the big PCP groups and other specialties and explained what we (radoncs) did. I gave presentations at the local schools and medical societies as well. It took time but it worked. You have to be willing to work your ass off and provide excellent customer service, communication and patient care. It is not an easy path but sooooo worth it.

This doesn’t work in major metros where most primary care work for large systems. And the ones that dont, won’t send their pts anywhere near large systems. Do anesthesiologists and radiologists in multi center hospitals hustle?

 

[thesauce]

This doesn’t work in major metros where most primary care work for large systems. And the ones that dont, won’t send their pts anywhere near large systems. Do anesthesiologists and radiologists in multi center hospitals hustle?

It can work even in those scenarios and I’ve seen it. And yes, even when the large system has their own medonc, radonc, and every other specialty.

 

[TheWallnerus]

This doesn’t work in major metros where most primary care work for large systems. And the ones that dont, won’t send their pts anywhere near large systems. Do anesthesiologists and radiologists in multi center hospitals hustle?

They do. Hustling doing all the work they have piled up before them. More like Charlie Hustle than rad onc hustle! Every time one rad onc hustles it sends another rad onc to the breadline!

 

[medgator]

This doesn’t work in major metros where most primary care work for large systems. And the ones that dont, won’t send their pts anywhere near large systems. Do anesthesiologists and radiologists in multi center hospitals hustle?

It's a delicate needle to thread but I've seen it happen.... Best situation is a pro only PP group that keeps its identity distinct from the hospital.

Essentially trying to capture the captive employed specialists referrals as well as the business from the independent docs out in the community

 

[jondunn]

It's a delicate needle to thread but I've seen it happen.... Best situation is a pro only PP group that keeps its identity distinct from the hospital

I agree. I think in the modern setting, this is the best bet.

 

[BobbyHeenan]

HUSK IS SO DAMN GOOD

Sean Brock left but it's still really good. His cook books are OK but the magic he does is not replicable in a home kitchen like other "farm to table" ish cook books I've liked.

If you ever find yourself with too much to drink later at night in Charleston, SC (and I presume their other locations), getting that late night Husk burger is a religious experience.

 

[metallica81788]

Husk has dropped off tremendously since Covid and Sean Brock left. There are much better meals to be had in that city. However, the bar is still great with a great burger.

 

[Ray D. Ayshun]

Husk has dropped off tremendously since Covid and Sean Brock left. There are much better meals to be had in that city. However, the bar is still great with a great burger.

I agree. Was kinda disappointed recently as I had a great meal in Savannah a few years ago, and pretty good one in Greenville a couple years ago. Have yet to eat at the Nashville Husk, but may not now, as I know of about 50 places I'd rather eat in Nashville as compared to Charleston Husk.