youre approaching this from such an emotional standpoint and as i interpret your post, mixing the issues. it is also simplistic (if morally satisfying) to say that fiscal concerns or issues of balliwick are "irrelevant" if you can show your therapy helps.
Actually, for the beancounters in Congress, fiscal concerns are quite high on the list (dangerously high, given that many want to shortchange health for cost).
And I submit that you should point out the emotional input in my analysis. You simply cannot be dismissive to my argument by nebulously arguing that I'm mixing emotion with policymaking. It's clear that having evidence to support use of therapy X is better versus theoretical justifications. It's also reasonably clear that if one knows therapy X is better than therapy Y, or that therapy X+Y is better than Y alone, then therapy X will become part of the standard of care. However, at least some RadOnc folks believe that the root cause of turf battles isn't the lack of data - it's advertising or perceived institutional conflicts. I submit that without the data, you simply can't win, unless you want to advertise your way to success. It's that point which I find problematic.
You also dont have an understanding of role protons in therapy thus far and therefore realize why our knowledge is limited with regard to long term outcome (therapies have changed so the benefit of higher dose and better local control is of yet undeterminied; with a limited resource (such as protons) there is too much of a selection bias to make good large rct about the issues etc etc).
Well, join the party. MedOnc and SurgOnc are having plenty of the same issues with long-term outcomes and limited resource of either personnel or drug available - selection biases especially with SurgOnc. The key difference is that it's an incredible financial risk to take for chairs throughout the country to beg and obtain $100 million from donors or the state, and for this to be repeated multiple times for each academic center. Is it unfair for a specialty that relies so heavily on equipment for therapy? Maybe so. But like I said above, I could find less risky ways as an institution to spend $100 million, cure more cancers in other patients, and send my pediatric patients to proton centers that already exist, as already suggested above.
as for your "deserving" a response; these are important fundemental issues all right however they are complex ones. Thus they deserve to be less of a challange to an argument rather than an invitation for discussion or enlightenment. as for me, I dont have the time to invest to do justice to such a review.
I'm only speaking from the perspective of a policymaker, which I certainly am not. But I can only imagine that the beancounters will be asking the same questions as I am, and that someone's got to convince John Q. Public that what you're doing is good. Good intentions and theoretical justifications, I submit, are not enough.
If its an important issue to you, I encourage you to do the research. Perhaps others here will be happy to offer what they can. Perhaps such a discussion might be able to begin with the good faith assumption that we as doctors do give a damn about patients and wish to put them above other concerns. This might be the best avenue of approach for anyone interested in exploring the interplay between healthcare, physician roles in a multi-disciplinary world and fiscal concerns.
Sure thing, I'd like to do the retrospective and prospective studies, but I'm not a radiation oncologist!
🙂
A recent meta-analysis was published in JCO this year:
http://jco.ascopubs.org/cgi/reprint/25/8/965
I'm not qualified to evaluate the soundness of the analysis or the biases of authors of the paper, but what I can do is quote from the conclusion:
Proton and other particle therapies need to be explored as potentially more effective and less toxic RT techniques. A passionate belief in the superiority of particle therapy and commercially driven acquisition and running of proton centers provide little confidence that appropriate information will become available. Objective outcome data from prospective studies is only likely to come from fully supported academic activity away from commercial influence. An uncontrolled expansion of clinical units offering as yet unproven and expensive proton therapy is unlikely to advance the field of radiation oncology or be of benefit to cancer patients.
Other reviews of interest:
- doi:10.1016/j.radonc.2007.03.001 (another metanalysis from an Oslo group)
-
http://ej.iop.org/links/rfHYJROL0/4pSD_DQP3BGZCkDMav5vpA/pmb6_13_r26.pdf (Alfred Smith, formerly of Joint Center, now at MDAnderson)
- Point/Counterpoint in recent Medical Physics (I don't have a subscription)
Finally, I don't mean to impugn on the reputation of the field as a whole - only I find the analysis written in Courier font above as problematic as to the implication that in this debate, we should "NOT LET OTHERS DIVIDE AND CONQUER" your field, which frankly should not even come to mind when deciding whether or not building more proton centers is a good or a bad thing, or more importantly in the decision calculus of patients considering radiation of any kind for their treatment. I understand this is quite a controversial topic in the field, but I speak only as an observer and healthcare consumer.
