Message in a bottle to Academic Rad Onc - Focus on Defining Narrative

[theradiator]

Interesting conversation with a medical oncologist from a highly ranked medical school. According to this full professor, kyphoplasty even to multiple bones with either deferred or omitted radiation is now a standard treatment approach for symptomatic bone metastases. As explained by this program director, there is fear of 'fracture' related to radiation. This was particularly concerning to me because doesn't radiation actually reduce the risk of skeletal-related events? After a cordial but firm adult conversation there is now multidisciplinary consensus to proceed with standard of care palliative radiation.

As everyone on this board knows, there are no randomized trials investigating kyphoplasty (thus no non-inferiority studies omitting), interventional radiology is excellent at asserting that their modality is standard without high level evidence (see HCC/liver metastasis experience and also the lenient FDA approval processes for medical devices) and they do not obsessively inform the public of their complications like extruding cement into the spinal cord. Finally, do we really need to push reducing fractionation for everything when the medical oncologists just want safety so they can give their highly priced drugs in peace.

I suggest the following opportunities for improvement:

1) Stop wasting time on trying to drive up your H index on DEI, non-inferiority trials and being the 10th paper to document vertebral body fracture after RT especially when the incidence of fracture without RT is unknown.

2) Sit down with your medical oncologists and educate them on the safety and efficacy of radiation ideally using narrative or even pictures in addition to charts and graphs. When data is used it much be done in a strategic fashion see recent JCO editorial by Nina Sanford.

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[RadRadRad]

I’ve seen 2-3 patients in last 6 months with horrible outcomes after not getting post op rt for bone mets

-Femur fracture that got rod. Renal cell met. Radonc not consulted
Several months later had 20+ cm soft tissue met in that leg around the bone/rod and non functional leg

-spine met that got decompressed and stabilized but radonc never consulted. Back in hospital several months later with cord compression (thankfully only radiographically ) from extensive soft tissue disease in the canal at site of decompression.

Definitely a teaching moment to see what happens when you don’t treat appropriately

 

[mheat3]

Absolutely asinine how our specialty presents itself to the public and within the medical community. Trying to pick up the pieces and clean up after all of these clown shows that were practicing previously mixed with the lovely messages from our field leaders and the complete acquiescence to medical oncology instead of working on collaborative indications.

"Hey Mr. MO did you know that if I treat this bone met they will be functioning better and have better QOL while you give your drugs?" framework usually works pretty well and once they see enough of thoughtful RT courses with great tolerance suddenly practice patterns can change.

Undoing the damages of the past RO mindset and current leadership/direction is more than 1.0 FTE for most of us I would imagine.

 

[NotMattSpraker]

If you are a new and well trained radiation oncologist starting at a new place, consider giving some talks or meet and greets to teach your colleagues. Buy them lunch, same as that other discussion. Kyphoplasty is not a cancer therapy and solves the mechanical issue that can't be solved by RT in the case of a pathologic fracture. Any doctor with half a brain will understand why that patient needs both kyphoplasty and radiotherapy. Just teach them.

People want to learn and it seems like a lot of Rad Oncs I have replaced hid from their colleagues or just don't care to engage. Totally agree, stop with the DEI pubs and start correcting the mistakes of the last generation.

 

[medgator]

If you are a new and well trained radiation oncologist starting at a new place, consider giving some talks or meet and greets to teach your colleagues. Buy them lunch, same as that other discussion. Kyphoplasty is not a cancer therapy and solves the mechanical issue that can't be solved by RT in the case of a pathologic fracture. Any doctor with half a brain will understand why that patient needs both kyphoplasty and radiotherapy. Just teach them.

People want to learn and it seems like a lot of Rad Oncs I have replaced hid from their colleagues or just don't care to engage. Totally agree, stop with the DEI pubs and start correcting the mistakes of the last generation.

Bingo. I use the analogy of radiation killing the termites in a wood house while kypho tries to support the remaining structure.

Good relationship with the Ortho spine locally who does kypho.

The people in RO leadership now wouldn't have matched during peak rad onc and in some cases were likely in the bottom of their class when RO used to go unfilled routinely in the 70s and 90s

 

[elementaryschooleconomics]

Interesting conversation with a medical oncologist from a highly ranked medical school. According to this full professor, kyphoplasty even to multiple bones with either deferred or omitted radiation is now a standard treatment approach for symptomatic bone metastases. As explained by this program director, there is fear of 'fracture' related to radiation. This was particularly concerning to me because doesn't radiation actually reduce the risk of skeletal-related events? After a cordial but firm adult conversation there is now multidisciplinary consensus to proceed with standard of care palliative radiation.

As everyone on this board knows, there are no randomized trials investigating kyphoplasty (thus no non-inferiority studies omitting), interventional radiology is excellent at asserting that their modality is standard without high level evidence (see HCC/liver metastasis experience and also the lenient FDA approval processes for medical devices) and they do not obsessively inform the public of their complications like extruding cement into the spinal cord. Finally, do we really need to push reducing fractionation for everything when the medical oncologists just want safety so they can give their highly priced drugs in peace.

I suggest the following opportunities for improvement:

1) Stop wasting time on trying to drive up your H index on DEI, non-inferiority trials and being the 10th paper to document vertebral body fracture after RT especially when the incidence of fracture without RT is unknown.

2) Sit down with your medical oncologists and educate them on the safety and efficacy of radiation ideally using narrative or even pictures in addition to charts and graphs. When data is used it much be done in a strategic fashion see recent JCO editorial by Nina Sanford.

Wow I was just talking about this yesterday.

I'm in a resource-challenged hospital/area, so my experiences can't be widely generalized, but it I've gotten the impression that over the last year or two, the volume of bone mets (especially post-op) patients seemed lower than I would have expected.

Maybe it's a coincidence, as volumes for a particular diagnosis wax and wane, but that MedOnc you talked to wouldn't have pulled that statement out of thin air.

It will take us a generation to repair the damage done to our specialty over the last 15 years.

 

[grenz]

Interesting conversation with a medical oncologist from a highly ranked medical school. According to this full professor, kyphoplasty even to multiple bones with either deferred or omitted radiation is now a standard treatment approach for symptomatic bone metastases. As explained by this program director, there is fear of 'fracture' related to radiation. This was particularly concerning to me because doesn't radiation actually reduce the risk of skeletal-related events? After a cordial but firm adult conversation there is now multidisciplinary consensus to proceed with standard of care palliative radiation.

As everyone on this board knows, there are no randomized trials investigating kyphoplasty (thus no non-inferiority studies omitting), interventional radiology is excellent at asserting that their modality is standard without high level evidence (see HCC/liver metastasis experience and also the lenient FDA approval processes for medical devices) and they do not obsessively inform the public of their complications like extruding cement into the spinal cord. Finally, do we really need to push reducing fractionation for everything when the medical oncologists just want safety so they can give their highly priced drugs in peace.

I suggest the following opportunities for improvement:

1) Stop wasting time on trying to drive up your H index on DEI, non-inferiority trials and being the 10th paper to document vertebral body fracture after RT especially when the incidence of fracture without RT is unknown.

2) Sit down with your medical oncologists and educate them on the safety and efficacy of radiation ideally using narrative or even pictures in addition to charts and graphs. When data is used it much be done in a strategic fashion see recent JCO editorial by Nina Sanford.

Do you know if the patient got RFA and kypho combined in one procedure for the bone Mets? I have seen this done and worried a bit. That could be what the med onc was talking about.

 

[theradiator]

Do you know if the patient got RFA and kypho combined in one procedure for the bone Mets? I have seen this done and worried a bit. That could be what the med onc was talking about.

And they can throw a biopsy in with molecular testing for good measure

 

[RickyScott]

Wow I was just talking about this yesterday.

I'm in a resource-challenged hospital/area, so my experiences can't be widely generalized, but it I've gotten the impression that over the last year or two, the volume of bone mets (especially post-op) patients seemed lower than I would have expected.

Maybe it's a coincidence, as volumes for a particular diagnosis wax and wane, but that MedOnc you talked to wouldn't have pulled that statement out of thin air.

It will take us a generation to repair the damage done to our specialty over the last 15 years.

our irs kypho and rfa everything. dont really care what I have to say.

 

[NotMattSpraker]

our irs kypho and rfa everything. dont really care what I have to say.

If there is extra-osseous extension, you should consider adding 8x1. Thoughtful IRs will agree with you especially if the extension is into the canal.

This all might seem a little silly, but it is a way to collaborate. SBRT literature argues there is some benefit to therapeutic escalation in fit patients with low disease burden or "radioresistant" disease (man I hate that term).

If you follow that thought, it might make sense to kypho and/or ablate then follow with RT in some cases.

 

[CaesarRO]

Bingo. I use the analogy of radiation killing the termites in a wood house while kypho tries to support the remaining structure.

Good relationship with the Ortho spine locally who does kypho.

The people in RO leadership now wouldn't have matched during peak rad onc and in some cases were likely in the bottom of their class when RO used to go unfilled routinely in the 70s and 90s

Seeing this too.

The IR reps had the audacity to come to my clinic and ask if I'd send patients with bone mets for Kypho+RFA

I told them to make sure any patient RFA'd comes my way for evaluation

ETA: to be clear though, these were low level reps, I have a half-decent relationship with IR docs themselves

 

[ramsesthenice]

If you are a new and well trained radiation oncologist starting at a new place, consider giving some talks or meet and greets to teach your colleagues.

Couldn't agree more. When I was newer (and had time, haha) I took the opportunity to present at other departments including grand rounds for palliative care and urology. But you have to be smart about it. For urology, I didn't try to convince them why radiation is better than surgery or blabber on about fractionation. Instead, I talked about the evolution of radiation planning and image guidance. Most of them came up and learned about radiation toxicity in the 2D era. I showed them pictures, CBCTs, etc. Explained in very simple terms what IMRT is. Understanding why we don't see as many catastrophic complications anymore really did help some of them engage more with us.

Speaking of being smart...at my institution, I wouldn't waste time talking to IR. Nice folks, but data is an inconvenience that is secondary to their conceptual framework. Much better to engage further up the referral chain.

 

[TheWallnerus]

Interesting conversation with a medical oncologist from a highly ranked medical school. According to this full professor, kyphoplasty even to multiple bones with either deferred or omitted radiation is now a standard treatment approach for symptomatic bone metastases. As explained by this program director, there is fear of 'fracture' related to radiation. This was particularly concerning to me because doesn't radiation actually reduce the risk of skeletal-related events? After a cordial but firm adult conversation there is now multidisciplinary consensus to proceed with standard of care palliative radiation.

As everyone on this board knows, there are no randomized trials investigating kyphoplasty (thus no non-inferiority studies omitting), interventional radiology is excellent at asserting that their modality is standard without high level evidence (see HCC/liver metastasis experience and also the lenient FDA approval processes for medical devices) and they do not obsessively inform the public of their complications like extruding cement into the spinal cord. Finally, do we really need to push reducing fractionation for everything when the medical oncologists just want safety so they can give their highly priced drugs in peace.

I suggest the following opportunities for improvement:

1) Stop wasting time on trying to drive up your H index on DEI, non-inferiority trials and being the 10th paper to document vertebral body fracture after RT especially when the incidence of fracture without RT is unknown.

2) Sit down with your medical oncologists and educate them on the safety and efficacy of radiation ideally using narrative or even pictures in addition to charts and graphs. When data is used it much be done in a strategic fashion see recent JCO editorial by Nina Sanford.

Brutal.

I think there's somehow a lesson on entropy in here. Like we only have so much energy in our professional lives, and it's important to know where to spend your professional energy because every place you're NOT spending that energy can get quite disordered.

In the meantime, the total fund of knowledge in oncology is expanding at a brutal pace! There is an order of magnitude more treatment options now in stage III/IV lung cancer than ~20 years ago... and many other disease sites.... but is there an order of magnitude more radiotherapeutic options for the same? As time goes by, I fear entropy is increasing in rad onc. Like a friend of mine who once said about obtaining his PhD: the march of knowledge from BS to master's to PhD is like learning more and more about less and less, until one day you realize you know absolutely everything about almost nothing.

Happy Mayneord's F-factor Friday. Let's not get F'd.

 

[thecarbonionangle]

Our field is “lead” by a bunch of supine protoplasmic invertebrate jellies. The next thing is IR will declare lung met ablation as “SOC” and the dummies who “lead” us will help document low pneumonitis and rib fracture risks. SOC, folks! We are doomed!

 

[thecarbonionangle]

Do you know if the patient got RFA and kypho combined in one procedure for the bone Mets? I have seen this done and worried a bit. That could be what the med onc was talking about.

Yea this is happening at my institution. I have had to fight off IR multiple times who want to do “ablation” while they are there. It is ridiculous.

 

[medgator]

Yea this is happening at my institution. I have had to fight off IR multiple times who want to do “ablation” while they are there. It is ridiculous.

While in reality they should have already lost the lung battle and be fretting about liver Mets/hcc now and possibly early renal in the future

 

[CaesarRO]

Yea this is happening at my institution. I have had to fight off IR multiple times who want to do “ablation” while they are there. It is ridiculous.

I have taken the approach of making sure med onc knows that even if they get ablation I still need to treat afterwards. Are you aware of any harm beyond an unnecessary extra procedure that's caused by it?

 

[theradiator]

Brutal.

I think there's somehow a lesson on entropy in here. Like we only have so much energy in our professional lives, and it's important to know where to spend your professional energy because every place you're NOT spending that energy can get quite disordered.

In the meantime, the total fund of knowledge in oncology is expanding at a brutal pace! There is an order of magnitude more treatment options now in stage III/IV lung cancer than ~20 years ago... and many other disease sites.... but is there an order of magnitude more radiotherapeutic options for the same? As time goes by, I fear entropy is increasing in rad onc. Like a friend of mine who once said about obtaining his PhD: the march of knowledge from BS to master's to PhD is like learning more and more about less and less, until one day you realize you know absolutely everything about almost nothing.

Happy Mayneord's F-factor Friday. Let's not get F'd.

Kudos again to our rectal cancer 'leaders' for making sure that IMRT was not recommended for rectal cancer as we are now specifically being attacked in PROSPECT for increased diarrhea and sexual side effects compared to more upfront FOLFOX (which of course means more FOLFOX overall). More drugs and less radiation always being better according to the NEJM and New York Times.

Using Bayesian inference, if IMRT is beneficial for prostate, anal and gynecologic cancers based on reduced toxicity, IMRT should logically be the standard for rectal cancer until proven otherwise but we all know that is not how it played out.

 

[NotMattSpraker]

Our field is “lead” by a bunch of supine protoplasmic invertebrate jellies. The next thing is IR will declare lung met ablation as “SOC” and the dummies who “lead” us will help document low pneumonitis and rib fracture risks. SOC, folks! We are doomed!

So here is what I dont get. My entire multi-D team is so hyped based on the I-SABR data. Its just 4 cycles of nivo with SOC SBRT for early stage NSCLC. Its not a huge deal. Everyone thinks its a good idea. This seems like an absolute no brainer for these people we call "synchronous" stage I. The ONLY barrier is insurance for my med oncs. If we call them Stage IV then insurance becomes a barrier for me.

I get its a phase II trial and in the pure science world we should wait for phase III data. But that world is imaginary. No one is doing that in the systemic therapy world. We all know of people getting immunotherapy for rectal cancer based on a 12 patient study.

Why is this not in the NCCN already? Why is ASTRO not out there calling this A standard?

This is all really a self-imposed problem. It is so frustrating.

That guy Matt Spraker ran a poll on Twitter (I am not him by the way). Here are the results:

 

[drowsy12]

The FDA has to approve it.

Dostarilab is FDA approved for rectal cancer.

 

[ramsesthenice]

The FDA has to approve it.

Dostarilab is FDA approved for rectal cancer.

Only the MMR deficient subset.

 

[drowsy12]

Only the MMR deficient subset.

Yep, approved because of the rarity and strength of the data

 

[seper]

IR wanted to “own” bone mets since forever.

A RadOnc chairperson is unlikely to oppose a Rads chair in any way. Different weight class.