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I'm not sure I would call what we are in a "mismanaged decline." As we have seen from Dr. Dennis Hallahan's missive in The Red Journal, increasing residency spots in order to decrease bargaining power of physicians and decrease reimbursement was a feature, not a bug, of residency expansion.

Combined with predatory/monopolistic billing practices by academic medical centers, which has allowed them to go on a buying spree of practices over the last decade, we have a situation where academic centers have not been declining, but rather have seen relatively steady growth.

So, by using predatory billing to buy up competing private practices while simultaneously increasing the supply of their future employees, academic radiation oncology departments have created a perfect situation wherein they control both the supply and an increasingly-large portion of the demand for radiation oncologists. By paying radoncs only a portion of their professional fees (and none of the technical, of course), these academic practices have been facilitating a rather large transfer of money which previously would have gone to their own program graduates back into their own pockets. This was by design, of course, and will continue unabated unless influenced by legislation. There is zero incentive for any radonc program to decrease their resident compliment- the incentives all point in the other direction.
 
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sloh

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It's sobering reading how RadOnc's well-intentioned focus on evidence based care and clinical endpoints that matter (e.g. overall survival) end up detracting from their own employment/careers/earning potential while MedOnc chugs along with their "game changer" drugs that at best usually only improve surrogate markers (e.g. PFS). World is truly unfair.
 
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I'm not sure I would call what we are in a "mismanaged decline." As we have seen from Dr. Dennis Hallahan's missive in The Red Journal, increasing residency spots in order to decrease bargaining power of physicians and decrease reimbursement was a feature, not a bug, of residency expansion.
It's sobering reading how RadOnc's well-intentioned focus on evidence based care and clinical endpoints that matter (e.g. overall survival) end up detracting from their own employment/careers/earning potential while MedOnc chugs along with their "game changer" drugs that at best usually only improve surrogate markers (e.g. PFS).
I tend to agree that things have been managed perfectly.

Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)

I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.

I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.

Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.

I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.

Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.

Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.
 
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I tend to agree that things have been managed perfectly.

Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)

I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.

I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.

Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.

I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.

Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.

Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.
PREACH
 
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scarbrtj

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I tend to agree that things have been managed perfectly.

Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)

I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.

I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.

Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.

I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.

Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.

Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.
Ugh.
 

RadOncMegatron

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I tend to agree that things have been managed perfectly.

Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)

I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.

I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.

Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.

I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.

Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.

Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.
Truth.
 

RadOncDoc21

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I tend to agree that things have been managed perfectly.

Radonc is not a synthetic field. Even paradigm changing technological advancements will only replace existing practices, not augment them. If FLASH works, its replacing standard XRT. Elite centers actively try to convince the public and the radonc community that protons should replace standard XRT. What are "brilliant minds" going to study when there is no synthesis? De-escalation, value based care and disparities research. (All valuable BTW)

I got to interview the best medical students in the country in the relatively early 2010s. I would not have gotten an interview at the place that I matched 5 years earlier (still peak radonc and significantly fewer spots). At that time radonc had widely entered medical students consciousness and had accomplished a triumvirate of sorts (money, lifestyle and cachet). The third pillar being the most important. A little like derm, which has been the repository of brilliant med students who will contribute very little to medicine as a whole for decades, radonc became "the place to go" for really exceptional students who were interested in lifestyle. Many of the candidates had been goal directed to the field since before med school. It didn't matter that you didn't work as hard as medicine or surgery, people knew you were smart if you went into the field.

I can only speak of my own program, but when confronted with this glut of talent, the powers that be (high profile academics, chairs) didn't blanch at all. They did however drop any pretense of selecting candidates who would "make good doctors". They expanded their spots and selected for academic ambition. I literally watched as the chair and another physician scientist culled the list strictly based on commitment to academic medicine. The absolutely best candidate that I have ever seen (based on grades, boards, pedigree, LORs, meaningful research output and interview) was ranked low as there was an inkling that they might not do academics. The mission of the department was clear, to produce academics. And, they were going to expand their residency numbers to produce more.

Unlike a big field or synthetic field, where most of the docs are by definition in the community doing the hard work of providing clinical care, radonc can and has effectively consolidated care over time. Whereas new pharmaceuticals are generally quickly adapted by the community and are priced in a way that there is very little barrier to community administration, new radonc tech is prohibitively expensive and compensation is disparate with remarkable institutional leverage regarding payment. The academics have no interest in a healthy community radonc market. They have an interest in consolidating care and maintaining advantageous payment to themselves in order to continue their de-escalation, value based care, disparities and basic science research, almost none of which will result in new XRT indications and much of which will result in less radiation administration.

I'm sure that the academic leadership also knew during peak-peak radonc that most of those applicants just wanted a good job, liked taking care of cancer patients and eventually would want to spend a reasonable amount of time with their family. They knew that those applicants might suffer but were not sympathetic. They would be able to get them on the cheap at their ever expanding satellite practices. They also knew that med students would respond as they have.

Radiation oncology has enough academic talent from the last 10 years to see the field into it's total demise roughly 30 years from now. In my opinion, it will become an increasingly niche and academic field with fewer indications for treatment. New indications will go the way of brain SRS with academic collaboration with outside departments that will become the high volume practitioners. Eventually the academics will function as thought leaders for integrating the field into medical oncology or radiology. Thousands of papers will be written on this. Their unfortunate contemporaries in the community will be rushing to retire.

Is radonc still a good opportunity for some? Sure. If you have an established onc research background and are elite, you can make a run at a rare physician scientist job. It may be a better opportunity for elite candidates only interested in academics now than 7-10 years ago as the meritocracy is less brutal and all those comparable candidates who thought they might like to live close to their family are gone.
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ramsesthenice

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I'm getting a lot of patients for the sake of "getting more mileage" out of immunotherapy. New spot but everything else is negative? Zap it and keep going with immuno instead of switching to the next line that won't work.

Im getting loads of this too. We also have good med oncs that, this is going to sound crazy, think RT is better for oligo Mets than systemic therapy for select diseases. RCC is a big money maker for me. TKIs are basically water and they generally prefer to send RCC oligomets patients my way than waste time on bad systemic therapy.

Before Scar says anything, no, oligo Mets patients do not outweigh what we use to treat in terms of breast. The net change is still negative.
 
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RadsWFA1900

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It's sobering reading how RadOnc's well-intentioned focus on evidence based care and clinical endpoints that matter (e.g. overall survival) end up detracting from their own employment/careers/earning potential while MedOnc chugs along with their "game changer" drugs that at best usually only improve surrogate markers (e.g. PFS). World is truly unfair.

No good deed goes unpunished
 
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DoctwoB

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Im getting loads of this too. We also have good med oncs that, this is going to sound crazy, think RT is better for oligo Mets than systemic therapy for select diseases. RCC is a big money maker for me. TKIs are basically water and they generally prefer to send RCC oligomets patients my way than waste time on bad systemic therapy.

Before Scar says anything, no, oligo Mets patients do not outweigh what we use to treat in terms of breast. The net change is still negative.
You still seeing that stream with Ipi/Nevo first line?

I would proceed with caution though. If cytoreductive NX for patients with 90% of their disease in the kidney didn’t improve survival compared to sutent I wouldn’t expect ablating a few oligomets to move the needle.
 
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You still seeing that steam with Ipi/Nevo first line?

I would proceed with caution though. If cytoreductive NX for patients with 90% of their disease in the kidney didn’t improve survival compared to sutent I wouldn’t expect ablating a few oligomets to move the needle.
It’s all about hitting the disease that is resistant to the systemic therapy. The RCC patients I see rarely are progressing in the intact primary, but usually at metastatic sites. My hypothesis (admittedly unproven) is it is the mutated resistant disease that is more likely to drive mortality and could allow SBRT to help with “hard” outcomes like survival. Although sometimes it is the primary progressing and I’ll be asked to go ahead and SBRT that too!
 
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ramsesthenice

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You still seeing that steam with Ipi/Nevo first line?

I would proceed with caution though. If cytoreductive NX for patients with 90% of their disease in the kidney didn’t improve survival compared to sutent I wouldn’t expect ablating a few oligomets to move the needle.

The goal isn't to cure but to kick the can down the line as long as possible. Ipi/Nivo can be very toxic. They typically prefer to hold that back if the disease is low volume and otherwise behaving indolent. We are not talking about folks who present with a couple mets and a huge intact primary. We are talking about the folks who had a nephrectomy 5 years ago and present with a solitary adrenal met that has been very slowly growing over the last few months.
 
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radiation

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You still seeing that stream with Ipi/Nevo first line?

I would proceed with caution though. If cytoreductive NX for patients with 90% of their disease in the kidney didn’t improve survival compared to sutent I wouldn’t expect ablating a few oligomets to move the needle.

harder to find a survival benefit when you add on 5% mortality risk with CN

plus delays in systemic therapy from recovery etc.
 
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evilbooyaa

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You still seeing that stream with Ipi/Nevo first line?

I would proceed with caution though. If cytoreductive NX for patients with 90% of their disease in the kidney didn’t improve survival compared to sutent I wouldn’t expect ablating a few oligomets to move the needle.

Patient selection is critical in this clinical situation, and I think *most* rad oncs get it, while I'd say the jury is mostly out for both med oncs and surgeons. I'd wager 33-50% of each.
 

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harder to find a survival benefit when you add on 5% mortality risk with CN

plus delays in systemic therapy from recovery etc.

True, (didn’t see full text, so with caveats), but I expect a large percentage of those CNs with mortality are big, nasty, symptomatic tumors (plus or minus IVC involvement) that are resected mostly palliatively. For simple lap nephrectomies 30d mortality will be <1%.

I do agree that CN should be offered judiciously and typically as more consolidative after systemic tx, or up front in Good risk category patients with low volume Mets amenable to resection or SBR.

I do also agree with the treatment (SBR or resection) of low volume isolated recurrences as there’s good data for reasonably durable responses.
 
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DoctwoB

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Patient selection is critical in this clinical situation, and I think *most* rad oncs get it, while I'd say the jury is mostly out for both med oncs and surgeons. I'd wager 33-50% of each.
I do think Carmena, caveats and limitations notwithstanding (most notably being done in the TKI setting and not the Ipi/Nevo setting) was a wake up call. Most Uro Oncs I know will still offer CN, but are much more selective about patients and much more likely to do so after rather then before systemic tx. Before, we (probably over-)used the randomized IFN data to whack out a lot of kidneys.
 

ramsesthenice

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Patient selection is critical in this clinical situation, and I think *most* rad oncs get it, while I'd say the jury is mostly out for both med oncs and surgeons. I'd wager 33-50% of each.

What Ivory tower did you train at? Im glad you have largely witnessed thoughtful medicine but I think you grossly under estimate many of your colleagues willingness to treat anything that walks in the door. I also like to think we are a bit more thoughtful than some other disciplines but I don't think its as good as you do.

I do think Carmena, caveats and limitations notwithstanding (most notably being done in the TKI setting and not the Ipi/Nevo setting) was a wake up call. Most Uro Oncs I know will still offer CN, but are much more selective about patients and much more likely to do so after rather then before systemic tx. Before, we (probably over-)used the randomized IFN data to whack out a lot of kidneys.

This was always going to be the case. Surgery, like radiation,, is a focal therapy. There are reasons to suspect both modalities will play a role in select metastatic patients with relatively indolent diseases but you/we always have to weed out the more aggressive cases to have any chance of success. Let biology declare it's self if you will.
 
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evilbooyaa

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What Ivory tower did you train at? Im glad you have largely witnessed thoughtful medicine but I think you grossly under estimate many of your colleagues willingness to treat anything that walks in the door. I also like to think we are a bit more thoughtful than some other disciplines but I don't think its as good as you do.



This was always going to be the case. Surgery, like radiation,, is a focal therapy. There are reasons to suspect both modalities will play a role in select metastatic patients with relatively indolent diseases but you/we always have to weed out the more aggressive cases to have any chance of success. Let biology declare it's self if you will.
That's fair I suppose, since I have not seen the full gamut of practice patterns. I just know where I did residency, and a little bit now as an attending (but not enough to make any determination of whether folks 'get it' or not). That's my N=1 - I saw off protocol prostatectomies for metastatic prostate cancer. Saw no referrals for prostate primary RT (or oligomet RT) in oligometastatic prostate cancer from med-onc. I saw attendings, when sent the patient with RCC and with 5-10 new spots, progressing on maintenance nivo, say "hey maybe RT isn't the best thing here". Not all of them, and not in every scenario. But probably 75%-80% of the time that are as aggressive/conservative as I, and national trials (ie SABR-COMET that didn't allow 3 lesions in the same organ) feel are reasonable.
 
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