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How does reducing trainees affect the ability of CMS to dictate their reimbursement? This is not exactly a free market situation.

Everything is supply and demand. CMS can get away with paying so low because someone will do it for that price. If you have paid attention to price erosion the last few decades or LISTENED to anyone detail the story, you would see how CMS and other payers have slowly cooked us.

If there were too few of us, they would have been paying us extra to do the work.

Everything in life is SUPPLY AND DEMAND. Even when someone tells you it isn’t!!!
 
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LADoc00

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It would be hilarious if in response to the cuts programs simply halved or more the number of trainees. There is a huge shortage of residency spots in general now due to the massive swelling of medical schools.

The whole economics of medicine is a trainwreck followed by a slow bleeding death now. Its beyond comically tragic, its surreal.

Get your loot and get out, fast. Pay off your school debt, pay off your house, save save save.
 
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y2k_free_radical

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Everything is supply and demand. CMS can get away with paying so low because someone will do it for that price. If you have paid attention to price erosion the last few decades or LISTENED to anyone detail the story, you would see how CMS and other payers have slowly cooked us.

If there were too few of us, they would have been paying us extra to do the work.

Everything in life is SUPPLY AND DEMAND. Even when someone tells you it isn’t!!!
Following the lead of BCBS ANTHEM and UNITED HEALTH
 
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Alteran

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It would be hilarious if in response to the cuts programs simply halved or more the number of trainees. There is a huge shortage of residency spots in general now due to the massive swelling of medical schools.

The whole economics of medicine is a trainwreck followed by a slow bleeding death now. Its beyond comically tragic, its surreal.

Get your loot and get out, fast. Pay off your school debt, pay off your house, save save save.

That's actually a very likely outcome. While CMS does pay for some pathology training spots in each program, my anecdotal experience that most of the pathology spots are paid for by some combination of the department itself, the parent institution, or the VA. Even for an academic program, these cuts are going to hurt the bottom line and they'll probably have to cut some bloat.
 

path24

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So CAP is using this to push for more members and more contributions. Will they push for more over training so they can get even more members? I'll pass on an organization that supports overtraining, a crappy job market, and gets laughed out of rooms with insurance companies. They have proved over decades they are not the answer to the problems in this field.

As always med students, stay away from pathology. It will get worse.
 
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Vicinal

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That's actually a very likely outcome. While CMS does pay for some pathology training spots in each program, my anecdotal experience that most of the pathology spots are paid for by some combination of the department itself, the parent institution, or the VA. Even for an academic program, these cuts are going to hurt the bottom line and they'll probably have to cut some bloat.
No chairman or department head would take department money and hand it over to residents unless it was just crushing it fiscally. This isn’t about educational altruism.... not in this market. It’s all about being at least somewhat profitable. Everyone who can will get subsidized money provided by CMS or the VA which is From CMS anyway. The hospital might pay but it has to make sense fiscally. There is no way a department or a medical center would lose money every single year just to keep an over supply of residents that are not actually working. There has to be free money in there somewhere that’s being hidden or some incentive. The reason resident labor worked in the past because you worked so hard for your pay that it made sense. Now you get paid to predominantly hang out. This is unsustainable. Eventually there has to be a reset. Less residents doing much more actual work and/or closing spots etc. Or residents paying to get trained .....The Old school Ackerman derm model. Hmmmmmmm pay to play.
 
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Vicinal

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why are people in the age of molecular path even doing cyto??

Everyone needs to just accept cyto is dead. Standing around a procedure room while a patient is prepped and you do 5 sec adequacy assessement or a ROSE that bills a single 30 buck code for an 30-45 of work is best way to end up bankrupt.

Im already trying to save too many private practices where I am with my mad biz skillz, I dont have time to save more. Please stop doing cyto.
Cyto could have been the savior of pathology if the leaders weren’t so short sided. There was a great push for pathologists to see the patients and control the tissue flow with US-guided FNA and even performing core biopsies. A combination of crappy leadership, short sightedness by departments destroyed this possibility. As usual the CAP and USCAP train people to do these procedures but never pushed through the infrastructure to make it a tenable and profitable modality. It is heart breaking. But life goes on... eventually there will be the liquid biopsy and NGS with some magic pseudo-AI algorithm out of Palo Alto to contend with. It will be BS but will be shoved down everyone throats by slick smooth talking sales people.
 
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WEBB PINKERTON

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A lot of pathologists don't want to see patients. There is just too many semi-autistic people in the field.

The field definitely needed to go interventional though. I admire those that did try to set up FNA clinics and found a way to make it profitable.
 

Vicinal

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A lot of pathologists don't want to see patients. There is just too many semi-autistic people in the field.

The field definitely needed to go interventional though. I admire those that did try to set up FNA clinics and found a way to make it profitable.
Exactly. Unfortunately the main issue is that the field of diagnostics is too broad. Pulmonary, GI, and radiology went interventional and are paid handsomely. The best interventional pathologists are amazing brilliant people but the support infrastructure and short sighted leadership made it impossible to activate in any reasonable way. Too bad some billionaire does not see the obvious benefits of this and sets it up in the private sector. Path should have had interventional centers and had all interventionalists working for us. We are the ones that should have always controlled the tissue and qualified/quantified it for optimal downstream testing and reporting. Patient is sent to the interventional center run by pathologists in which all other interventional docs procure tissue. Especially if there is NGS etc etc. the upfront investment is huge but the potential for banking tissue properly and having the highest quality standards would be natural. But as the man said “how about fantasy land”
 
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mikesheree

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Everything is supply and demand. CMS can get away with paying so low because someone will do it for that price. If you have paid attention to price erosion the last few decades or LISTENED to anyone detail the story, you would see how CMS and other payers have slowly cooked us.

If there were too few of us, they would have been paying us extra to do the work.

Everything in life is SUPPLY AND DEMAND. Even when someone tells you it isn’t!!!

Supply and demand exactly. Look what has happened with shrinks! Perhaps, in 15-20 years path will be in vogue again.
 

Alteran

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No chairman or department head would take department money and hand it over to residents unless it was just crushing it fiscally. This isn’t about educational altruism.... not in this market. It’s all about being at least somewhat profitable. Everyone who can will get subsidized money provided by CMS or the VA which is From CMS anyway. The hospital might pay but it has to make sense fiscally. There is no way a department or a medical center would lose money every single year just to keep an over supply of residents that are not actually working. There has to be free money in there somewhere that’s being hidden or some incentive. The reason resident labor worked in the past because you worked so hard for your pay that it made sense. Now you get paid to predominantly hang out. This is unsustainable. Eventually there has to be a reset. Less residents doing much more actual work and/or closing spots etc. Or residents paying to get trained .....The Old school Ackerman derm model. Hmmmmmmm pay to play.

To the contrary, plenty of chairmen would hire or fire residents or fellows based on what the department's bottom line and needs are. You have to keep a few things in mind though.

A lot of academic department's finances aren't their own. Yes they have to earn, but even if you're totally unprofitable but necessary like pediatrics, you don't have to worry because the institution will just skim the profitable departments to keep yours afloat. Also, faculty salaries at most institutions are fixed and capped - which is to say that a chair earning $650K won't make any more or less depending on how the department does financially. Of the academic institutions that I know of, all salary changes have to be approved by the higher ups beyond the chairman. Some departments do annual bonuses as a revenue sharing type thing, but from what I'm told they're rather measly.

So as a chair, and I could be wrong about this, you only have to meet your expenses for the year and after that it's all extra money that may or may not stay in the department depending on the overall needs of the institution. So therefore it stands to reason if they're approved for more residents, why not get more residents because if you don't the money will leave your department's control and go somewhere else to fund someone else's department. And, if you can get 2 residents for the price of a PA who are on annual renewal contracts rather than an actual employment contract, that's even better. And if you can magically create non-ACGME accredited fellowship positions where most of the time the fellow actually signs out cases on a salary that is a fraction of an associate professor's salary but yet has equal responsibilities, that's the goose that lays the golden egg.

Successful departments will be able to bankroll these kinds of positions even after the cuts. Mediocre to poorly run departments will not be able to, and will try to find the savings somewhere unless their home institution wants to prop them up. Given pathology is universally at the bottom rung of any ladder, anywhere, that's not likely.
 
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KeratinPearls

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A lot of pathologists don't want to see patients. There is just too many semi-autistic people in the field.

The field definitely needed to go interventional though. I admire those that did try to set up FNA clinics and found a way to make it profitable.

I certainly wouldn’t mind it. Yeah there are plenty of awkward pathologists who shouldn’t talk to patients.
 

Vicinal

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To the contrary, plenty of chairmen would hire or fire residents or fellows based on what the department's bottom line and needs are. You have to keep a few things in mind though.

A lot of academic department's finances aren't their own. Yes they have to earn, but even if you're totally unprofitable but necessary like pediatrics, you don't have to worry because the institution will just skim the profitable departments to keep yours afloat. Also, faculty salaries at most institutions are fixed and capped - which is to say that a chair earning $650K won't make any more or less depending on how the department does financially. Of the academic institutions that I know of, all salary changes have to be approved by the higher ups beyond the chairman. Some departments do annual bonuses as a revenue sharing type thing, but from what I'm told they're rather measly.

So as a chair, and I could be wrong about this, you only have to meet your expenses for the year and after that it's all extra money that may or may not stay in the department depending on the overall needs of the institution. So therefore it stands to reason if they're approved for more residents, why not get more residents because if you don't the money will leave your department's control and go somewhere else to fund someone else's department. And, if you can get 2 residents for the price of a PA who are on annual renewal contracts rather than an actual employment contract, that's even better. And if you can magically create non-ACGME accredited fellowship positions where most of the time the fellow actually signs out cases on a salary that is a fraction of an associate professor's salary but yet has equal responsibilities, that's the goose that lays the golden egg.

Successful departments will be able to bankroll these kinds of positions even after the cuts. Mediocre to poorly run departments will not be able to, and will try to find the savings somewhere unless their home institution wants to prop them up. Given pathology is universally at the bottom rung of any ladder, anywhere, that's not likely.
I get the non ACGME fellow sign out thing and the programs where residents gross thing so you need less PAs but what percentage of programs actually run this way? It seems that this has become less common. Not at the fellowship level but at the residency spots being offered level. If programs were not supported by CMS and other funds for resident salary as much as they are wouldn’t there be a reassessment of number needed to perform necessary labor. Pathology may be a bottom rung, but it generates significant revenue for departments that are run well. Whenever entities get guaranteed federal funding it is difficult to figure out what Is truly required.
 
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LADoc00

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Does anyone believe "circulating cell free DNA" in plasma and "liquid biopsies" is even a thing?

I dont believe it for one second. Its a marketing gimmick lead by questionable science at best in the real world.

NGS companies get QNS results for FFPE tissue WITH MASSIVE QUANTITIES of tumoral DNA present all the time but somehow their sensitivity and specificity are magnified by 10,000x when they are looking at plasma?

Its like we had Theranos and nobody learned a damn thing.

And I hate to tell people half the allegedly pathogenic translocations like t(14;18) are found in a vast majority of all humans! In fact in one study, 97%+ of random healthy Japanese people!! Hahaha.


detection of clinically significant genetic aberrations in circulating cell free DNA is like something sold to idiots over cocktails at an ASCO meeting when everyone is 10 drinks in.
 
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bauber

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I know you like to be hyperbolic, but comparing ctDNA to Theranos is wrong. It's absolutely not settled science yet but I've sat in on several talks at molecular meetings on it and it's real and it works (especially with ddPCR and in patients with large tumor burden). Of course folks in biotech like to claim all kinds of stuff, but there is actual science there.
 

Vicinal

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Tissue agnostic therapeutics will likely drive the whole liquid biopsy paradigm. I foresee a push toward using liquid biopsies to stratify “incipient” malignancies and to come up with recommended treatments even if a definitive tumor is not detected. This will be dangerous and without definitive value. Also data from liquid biopsy results will be banked and connected to individuals forever. This will be a huge problem if testing becomes population based screening using liquid biopsy. It will be driven by informatics and “AI” based stratification that is foundationally flawed. They are pushing this liquid biopsy thing hardcore and it is a serious Pandora’s box.
 
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LADoc00

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I know you like to be hyperbolic, but comparing ctDNA to Theranos is wrong. It's absolutely not settled science yet but I've sat in on several talks at molecular meetings on it and it's real and it works (especially with ddPCR and in patients with large tumor burden). Of course folks in biotech like to claim all kinds of stuff, but there is actual science there.

Yes liquid biopsies ARENT Theranos.

Liz Holmes had to overcome the roadblock of defying the laws of microfluidics, a single unsurmountable scientific hurdle.

Liquid biopsies has to overcome unsurmountable hurdles in 1.) molecular genetics 2.) cell biolology AND 3.) biophysics.

I would actually rather bet on Theranos than Guardant OR Grail OR Exosome Diagnostics or any of 12+ biotech sham start ups pumping VC and Fintech fools at the moment.


This is like reading some article that scientists have "proved teleportation" and starting a travel company based on it:

What about optical biopsies? Anyone remember that? Hyperspectral multi-modal imaging capable of resolution to subcellular detail?? Optical biopsies were gonna make everything obsolete 25 years ago...hahaha.

Theranos was Theranos because of the hype around and the SJW push given the first female biotech founder but "Theranos" is a very old and well played biotech song that has been on repeat for centuries.
 
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LADoc00

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"Tissue agnostic" diagnosis isnt a thing.

This is like watching the movie GATTACA and thinking we can now somehow predict to the minute the manner of someone's death.

This sounds like Sci-Fi because it IS Sci-Fi.

Im not saying molecular isnt the future, it is but people have gone from identification of actionable mutations TO--> creation of genetically enhanced super soldiers known as space marines and conquering the galaxy thinking that is somehow logical progression.

Listen folks I know people love science fiction and tales of high adventure, I do as well. I love Star Wars, I AM a Trekky with the convention badges to prove it. But that isnt us, it isnt real. We are merely apes who struggle through the day to not burn down our own cities now.
We are a modern society:
1.) INCAPABLE OF STOPPING FOREST FIRES
2.) INSTANTLY CRIPPLED BY THE COLD WHICH HAS KILLED LESS THAN A MILLION IN A CIVILIZATION 9000 TIMES (!!) THAT LOSS

In my estimate we are actually REGRESSING. I would bet in 5 years we will be using leeches again, diagnosing cancer based on the movement of tea leaves in a cauldron after sacrificing a crow and using goat horns again for erectile dysfunction....
 
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Spikebd

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Tissue agnostic therapeutics will likely drive the whole liquid biopsy paradigm. I foresee a push toward using liquid biopsies to stratify “incipient” malignancies and to come up with recommended treatments even if a definitive tumor is not detected. This will be dangerous and without definitive value. Also data from liquid biopsy results will be banked and connected to individuals forever. This will be a huge problem if testing becomes population based screening using liquid biopsy. It will be driven by informatics and “AI” based stratification that is foundationally flawed. They are pushing this liquid biopsy thing hardcore and it is a serious Pandora’s box.
Does this mean you treat every clonal hematopoiesis of indeterminate potential patient for a heme malignancy based off of a couple of actionable mutations found in a blood sample? I understand the desire to find actionable mutations to give a patient a drug, but obviously only for patients with an actual malignancy.
 

WEBB PINKERTON

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All this talk made me remember a company we worked with MANY years ago called Cellvizio that was supposed to reduce biopsies.

 

Vicinal

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I know you like to be hyperbolic, but comparing ctDNA to Theranos is wrong. It's absolutely not settled science yet but I've sat in on several talks at molecular meetings on it and it's real and it works (especially with ddPCR and in patients with large tumor burden). Of course folks in biotech like to claim all kinds of stuff, but there is actual science there.
The large tumor burden use is reasonable but it seems that there is a push to use this technology for screening of “incipient” cancer. Or first time diagnosis.
 
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Vicinal

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Does this mean you treat every clonal hematopoiesis of indeterminate potential patient for a heme malignancy based off of a couple of actionable mutations found in a blood sample? I understand the desire to find actionable mutations to give a patient a drug, but obviously only for patients with an actual malignancy.
Exactly. When you test for something it is extremely important to first fully flesh out what you intend to do with the result. The field is expanding faster than thought leaders really understanding what the data means and could mean. We are getting better and better at detecting signals in smaller and smaller partitions but have not worked out what the signals truly represent. It has to be scrutinized before Palo Alto “VC”runs with it.
 
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Vicinal

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"Tissue agnostic" diagnosis isnt a thing.

This is like watching the movie GATTACA and thinking we can now somehow predict to the minute the manner of someone's death.

This sounds like Sci-Fi because it IS Sci-Fi.

Im not saying molecular isnt the future, it is but people have gone from identification of actionable mutations TO--> creation of genetically enhanced super soldiers known as space marines and conquering the galaxy thinking that is somehow logical progression.

Listen folks I know people love science fiction and tales of high adventure, I do as well. I love Star Wars, I AM a Trekky with the convention badges to prove it. But that isnt us, it isnt real. We are merely apes who struggle through the day to not burn down our own cities now.
We are a modern society:
1.) INCAPABLE OF STOPPING FOREST FIRES
2.) INSTANTLY CRIPPLED BY THE COLD WHICH HAS KILLED LESS THAN A MILLION IN A CIVILIZATION 9000 TIMES (!!) THAT LOSS

In my estimate we are actually REGRESSING. I would bet in 5 years we will be using leeches again, diagnosing cancer based on the movement of tea leaves in a cauldron after sacrificing a crow and using goat horns again for erectile dysfunction....
Tissue agnostic therapy is trying to become a thing. I hope tissue agnostic diagnosis does not become a thing.
 
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LADoc00

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I love the "Ive sat through talks and it's real and it works". Where is the skepticism? Where is the natural SDN cynicism?

I sat through a talk and absolutely believe this new empowerment movement is the wave of the future, its called NXIVM.

How has medicine fallen to what is a giant Nigerian prince scam yet again?

Hydroxychloroquine! Remdesivir! Convalescent plasma!

I have a tonic that will cure small penis size! Make your hair grow! Make you younger!!
snakesalesmancrop_8328.jpg
 
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LADoc00

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Regrow hair? I could use that.

Some of us have made millions off Guardant stock. I believe.

No Im sure people have made millions off Gaurdtonic.

Funny, 110 years after the Flexner report Medical Charlatanism is not only alive and well but bigger than ever.

Sometimes when I get really bored, I start thinking maybe I will just give up and be grifter like the rest of them. Come up with some hand waving scientific concept based on a recent media clip and just run with it. Maybe drones that can detect viral DNA fragments in ambient air. Or better yet a drug specifically for COVID depression..something with cocaine benzoate in it.
 
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gbwillner

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Does anyone believe "circulating cell free DNA" in plasma and "liquid biopsies" is even a thing?

I dont believe it for one second. Its a marketing gimmick lead by questionable science at best in the real world.

NGS companies get QNS results for FFPE tissue WITH MASSIVE QUANTITIES of tumoral DNA present all the time but somehow their sensitivity and specificity are magnified by 10,000x when they are looking at plasma?

Its like we had Theranos and nobody learned a damn thing.

And I hate to tell people half the allegedly pathogenic translocations like t(14;18) are found in a vast majority of all humans! In fact in one study, 97%+ of random healthy Japanese people!! Hahaha.


detection of clinically significant genetic aberrations in circulating cell free DNA is like something sold to idiots over cocktails at an ASCO meeting when everyone is 10 drinks in.
Yes, it is definitely a thing.
 
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mikesheree

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Old timer here. What tumoral DNA is all going to come down to is: 1. can it detect curable and/or stage 1 cancer?
2. can it be highly sensitive. ( hi specif would certainly be nice).

Once you reproducibly have those two; Bob’s your Uncle.
 

Vicinal

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Old timer here. What tumoral DNA is all going to come down to is: 1. can it detect curable and/or stage 1 cancer?
2. can it be highly sensitive. ( hi specif would certainly be nice).

Once you reproducibly have those two; Bob’s your Uncle.
That’s the goal supposedly but the devils in the details.

There are detectable mutations that are “nothing burgers” and part of the body shedding aberrant cells And are essentially inert.

Translocations , Point mutations... some of these detectable molecular features have a magical targeted therapy (small molecule or monoclonal antibody).

There is an incentive for companies to develop specific targeted therapies while also developing the detection modality.
(Roche, Genentech)

liquid biopsy sounds great on paper but rife with issues in the real world.

There are dumb ****s purporting that it can already do much more than is possible and getting funded.

I understand this technology and am more concerned about the hype, especially having listened to oncologists and intelligent clinicians including some clinical pathologists discuss this as “the future”.
 
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LADoc00

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Old timer here. What tumoral DNA is all going to come down to is: 1. can it detect curable and/or stage 1 cancer?
2. can it be highly sensitive. ( hi specif would certainly be nice).

Once you reproducibly have those two; Bob’s your Uncle.

the answer to both those is essentially no.

This is the case because although someone MIGHT be able to look at genetic aberrations in retrospect of a patient already tissue diagnosed with malignancy and say "look! I could have predicted that!", the prospective use of such tests is akin to giving someone a prostatectomy for a PSA of 9.0 WITHOUT A CONFIRMATION Bx. You will be right like 1/2 the time, the other 1/2 time you will lose your medical license on a coin flip.

This is how medical charlatanism works: it mixes just enough science to sound scientific and just enough evidence to seem like they have achieved proof of concept but in reality the laws of our known universe and current technological level of innovation of the human race guarantees failure.

This is also being created by big pharma, the father of all medical charlatans as the poster above me is saying. Big pharma and companion diagnostics including cfDNA based platforms are working hand in glove to create the narrative in order to achieve billions in profit.

Did you know Merck the company that owns the patent for Keytruda also owns Ventana, the company which has the patent for the only companion diagnostic antibody to assess for PDL-1 for this med?

Just think about that.

I am a free market, capitalist 100%, but I am also 100% against the rampant medical charlatanism we now face.
 
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Vicinal

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the answer to both those is essentially no.

This is the case because although someone MIGHT be able to look at genetic aberrations in retrospect of a patient already tissue diagnosed with malignancy and say "look! I could have predicted that!", the prospective use of such tests is akin to giving someone a prostatectomy for a PSA of 9.0 WITHOUT A CONFIRMATION Bx. You will be right like 1/2 the time, the other 1/2 time you will lose your medical license on a coin flip.

This is how medical charlatanism works: it mixes just enough science to sound scientific and just enough evidence to seem like they have achieved proof of concept but in reality the laws of our known universe and current technological level of innovation of the human race guarantees failure.

This is also being created by big pharma, the father of all medical charlatans as the poster above me is saying. Big pharma and companion diagnostics including cfDNA based platforms are working hand in glove to create the narrative in order to achieve billions in profit.

Did you know Merck the company that owns the patent for Keytruda also owns Ventana, the company which has the patent for the only companion diagnostic antibody to assess for PDL-1 for this med?

Just think about that.

I am a free market, capitalist 100%, but I am also 100% against the rampant medical charlatanism we now face.
I thought the unholy trinity was Roche, Genentech, and Ventana as the example you stated but I 100% agree with you. I am more concerned with the data that is generated from these tests and how it may impact what may part of the medical record of future generations. I just don’t want population based screening analogous to 23 and me. Starting out as a slickly marketed test for fringe primary care practitioners as a blood test to just see “what could be a potential problem.” I mean just doing NGS on a blood sample during a routine physical when it becomes cheap enough and finding **** that has not been vetted in any meaningful way.

Even when there is solid tumor these technologies with targeted therapy and “individualized medicine” seem to be less effective as purported ultimately.

Tumor boards can be so frustrating at times. So often a Hail Mary pass situation.
 
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mikesheree

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I thought the unholy trinity was Roche, Genentech, and Ventana as the example you stated but I 100% agree with you. I am more concerned with the data that is generated from these tests and how it may impact what may part of the medical record of future generations. I just don’t want population based screening analogous to 23 and me. Starting out as a slickly marketed test for fringe primary care practitioners as a blood test to just see “what could be a potential problem.” I mean just doing NGS on a blood sample during a routine physical when it becomes cheap enough and finding **** that has not been vetted in any meaningful way.

Even when there is solid tumor these technologies with targeted therapy and “individualized medicine” seem to be less effective as purported ultimately.

Tumor boards can be so frustrating at times. So often a Hail Mary pass situation.

I can just see all the marginal and/ or greedy practitioners having access to a “screening” blood test for “cancer, n.o.s.” The unnecessary pain, expense and human misery that would follow is scary.
 
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WEBB PINKERTON

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I thought the unholy trinity was Roche, Genentech, and Ventana as the example you stated but I 100% agree with you. I am more concerned with the data that is generated from these tests and how it may impact what may part of the medical record of future generations. I just don’t want population based screening analogous to 23 and me. Starting out as a slickly marketed test for fringe primary care practitioners as a blood test to just see “what could be a potential problem.” I mean just doing NGS on a blood sample during a routine physical when it becomes cheap enough and finding **** that has not been vetted in any meaningful way.

Even when there is solid tumor these technologies with targeted therapy and “individualized medicine” seem to be less effective as purported ultimately.

Tumor boards can be so frustrating at times. So often a Hail Mary pass situation.

Unfortunately oncologists and corporations are going to bankrupt the health care system chasing a few extra months. "Personalized medicine" still a con for most folks.
 
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mikesheree

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Unfortunately oncologists and corporations are going to bankrupt the health care system chasing a few extra months. "Personalized medicine" still a con for most folks.

Lemme tell ya, it’s pretty personalized in uro oncology for prostate ca.

They ask you if you want a 3 month or 6 month course of chemical castration after your radiation therapy for a “biochemical recurrence” ( PSA 0.2 x2 post radical prostatectomy.). I guess that’s kinda personalized.
 
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WEBB PINKERTON

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Lemme tell ya, it’s pretty personalized in uro oncology for prostate ca.

They ask you if you want a 3 month or 6 month course of chemical castration after your radiation therapy for a “biochemical recurrence” ( PSA 0.2 x2 post radical prostatectomy.). I guess that’s kinda personalized.

That is one cancer I will never be treated or screened for. I gotta be locked and loaded when I need to be.
 
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mikesheree

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That is one cancer I will never be treated or screened for. I gotta be locked and loaded when I need to be.

Well, as you know , there’s prostate carcinoma and then there’s prostate F****** CANCER If it was not treated i would be dead. Thankfully, all the plumbing works fine.
 
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doctor313

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CAP president worried about the cuts. Hope there is enough room under the bridge for all you guys.


Hope everyone on here reads the article and does their part to help avert those cuts. CAP president explains the reason for the cuts, and has links to things we can do to help stop the cuts.
 
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Does anyone believe "circulating cell free DNA" in plasma and "liquid biopsies" is even a thing?

I dont believe it for one second. Its a marketing gimmick lead by questionable science at best in the real world.

I am a board-certified molecular pathologist and I sign out both tissue-based NGS and liquid biopsy/ctDNA NGS. The findings on ctDNA actually correlate well with those from tissue-based NGS.

Just because you don't understand something does not make it less real.
 
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WEBB PINKERTON

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Guardant is already leading to less repeat biopsies in our practice. It will only get worse I am afraid. FLEE PATHOLOGY NOW!
 

Vicinal

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I am a board-certified molecular pathologist and I sign out both tissue-based NGS and liquid biopsy/ctDNA NGS. The findings on ctDNA actually correlate well with those from tissue-based NGS.

Just because you don't understand something does not make it less real.
It seems you are doing liquid biopsy NGS on a patient with solid tumor since there is a comparison(tumor to biopsy).
I get the whole validation thing.

Trust me I understand what you are doing. It’s not rocket science. Worked in fields that developed NGS platforms. The issue I’m concerned about is the eventual touting of NGS as a screening tool for incipient cancers. It seems this is already being whispered in the inner rooms

I hope you board certified molecular pathologists don’t take diagnostic medicine down that primrose path.

People have been dicking around with minimal residual disease for 25 years. CTCs etc.... It’s not a big deal to enrich DNA from a tumor that has been detected and biopsied. The biopsy releases tons of DNA into the circulation anyway.... So does surgery.

Performing post therapeutic liquid biopsy NGS to determine remission/cure/recurrence makes sense. However circulating DNA may not be meaningful without detected and sampled tumor. It’s not really quantitative...

Possibly in a few years NGS’s true efficacy will be determined from the hype. It is nice to have one test lay out all therapeutic targets. But will there be definitive relationship to protein expression, promoter methylation etc.
One way NGS may be helpful is the labeling and stratifying all entities by their NGS profile related to oncotherapeutic potential.

But that’s probably never going to happen because there is too much overlap and blurring of categories. Human brains capacity for histomorphologic pattern recognition has stood the test of time.
 
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Vicinal

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“These tests fuel development of its LUNAR program, which aims to address the needs of early stage cancer patients with neoadjuvant and adjuvant treatment selection, cancer survivors with surveillance, asymptomatic individuals eligible for cancer screening and individuals at a higher risk for developing cancer with early detection.

Forward-looking Statements
This press release contains forward-looking statements within the meaning of federal securities laws, including statements regarding any regulatory approval to be pursued by Guardant Healthunder its collaboration with Radius Health, Inc. and the potential benefits and advantages of the Guardant360 test, which involve risks and uncertainties that could cause the actual results to differ materially from the anticipated results and expectations expressed in these forward-looking statements. Such risks and uncertainties include those discussed under the caption “Risk Factors” in Guardant Health’s Annual Report on Form 10-K for the year ended December 31, 2019, its Quarterly Report on Form 10-Q for the period ended March 31, 2020, and in its other reports filed with the Securities and Exchange Commission. These forward-looking statements are based on current expectations, forecasts, assumptions and information available to Guardant Health as of the date hereof, and actual outcomes and results could differ materially from these statements due to a number of factors, and Guardant Health disclaims any obligation to update any forward-looking statements provided to reflect any change in its expectations or any change in events, conditions, or circumstances on which any such statement is based, except as required by law. These forward-looking statements should not be relied upon as representing Guardant Health’s views as of any date subsequent to the date of this press release. Investors are urged not to rely on any forward-looking statement in reaching any conclusion or making any investment decision about any securities of Guardant Health.“
 

gbwillner

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It seems you are doing liquid biopsy NGS on a patient with solid tumor since there is a comparison(tumor to biopsy).
I get the whole validation thing.

Trust me I understand what you are doing. It’s not rocket science. Worked in fields that developed NGS platforms. The issue I’m concerned about is the eventual touting of NGS as a screening tool for incipient cancers. It seems this is already being whispered in the inner rooms

I hope you board certified molecular pathologists don’t take diagnostic medicine down that primrose path.

People have been dicking around with minimal residual disease for 25 years. CTCs etc.... It’s not a big deal to enrich DNA from a tumor that has been detected and biopsied. The biopsy releases tons of DNA into the circulation anyway.... So does surgery.

Performing post therapeutic liquid biopsy NGS to determine remission/cure/recurrence makes sense. However circulating DNA may not be meaningful without detected and sampled tumor. It’s not really quantitative...

Possibly in a few years NGS’s true efficacy will be determined from the hype. It is nice to have one test lay out all therapeutic targets. But will there be definitive relationship to protein expression, promoter methylation etc.
One way NGS may be helpful is the labeling and stratifying all entities by their NGS profile related to oncotherapeutic potential.

But that’s probably never going to happen because there is too much overlap and blurring of categories. Human brains capacity for histomorphologic pattern recognition has stood the test of time.

It's easy to conflate issues and talk past each other when discussing a new technology. There definitive and proven use cases of ctDNA right now. They include predictive testing for targeted therapeutics and minimal residual disease testing. Then there are future use cases that are being developed, like cancer screening.

Let's make sure we are speaking the same language.
 
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Vicinal

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It's easy to conflate issues and talk past each other when discussing a new technology. There definitive and proven use cases of ctDNA right now. They include predictive testing for targeted therapeutics and minimal residual disease testing. Then there are future use cases that are being developed, like cancer screening.

Let's make sure we are speaking the same language.
The former I understand.... this makes perfect sense and has been demonstrated in other modalities. I am suspicious of the latter (future use cases that are being developed, like cancer screening) but let’s see how things progress.
 

gbwillner

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The former I understand.... this makes perfect sense and has been demonstrated in other modalities. I am suspicious of the latter (future use cases that are being developed, like cancer screening) but let’s see how things progress.
As stated, these future use cases are in development. It is only right to be both hopeful and critical about their success. The only way to convert a "future" use case to a "present" use case is "evidence". When talking about cancer screening, that means demonstrating the validity of detecting cancer signatures in advance of actual development of cancer. That means screening a lot of people, and then waiting for some of them to get cancer, and identifying the predictive sensitivity and specificity of your signal. This is a normal part of developing any new test.
 

Vicinal

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As stated, these future use cases are in development. It is only right to be both hopeful and critical about their success. The only way to convert a "future" use case to a "present" use case is "evidence". When talking about cancer screening, that means demonstrating the validity of detecting cancer signatures in advance of actual development of cancer. That means screening a lot of people, and then waiting for some of them to get cancer, and identifying the predictive sensitivity and specificity of your signal. This is a normal part of developing any new test.
I get it. Let’s see how this goes with lots and lots and lots of data. Let’s not rush into things with “Champaign wishes and caviar dreams”
 

LADoc00

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That's the funny thing about medicine, we can have Theranos and then a dozen Theranos-like companies and no one learns the lesson.
 
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