Protons are blowing Rad Onc's boat out the CMS water

[elementaryschooleconomics]

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As with most arguments in America over the last few years, we find ourselves down the whatboutism spiral.

The answer to "where's the data for protons" is not "but what about IMRT!", though many pro-proton folks seem to think it is.

Et tu quoque, Brutus!

 

[ROforbetterorworse]

As with most arguments in America over the last few years, we find ourselves down the whatboutism spiral.

The answer to "where's the data for protons" is not "but what about IMRT!", though many pro-proton folks seem to think it is.

Et tu quoque, Brutus!

I’m overall okay with protons except for when they lie to patients

same as how I don’t like it when MDACC lies about better care for a routine breast case

But the IMRT talk from protons bothers me a lot

Don’t drag us down bc you chose to make 5 proton vaults and are struggling now with reimbursement

 

[Ray D. Ayshun]

I think my patients appreciate sparing their testicular function. It is a good reason to use protons in pelvic RT for men who care about their sexual function. You can definitely shape your IMRT plans differently but then the femoral heads take a beating.


Protons are a very small amount of radiation oncology spending. IMRT takes up a huge portion of radiation oncology spending and there is very little randomized data to support the use of IMRT with IGRT over 3DCRT with weekly port films, and its more expensive and recommended for nearly every disease site.


View attachment 341552

This wasn't showing spending, rather implementation. Combining your chart with this from the same report:

I get that proton beam therapy accounts for 1.3% of technical episodes but 3.3% of technical expenditures. My maff could be wrong.

 

[evilbooyaa]

If I needed my spine treated I would get it done with IMPT. Plan looks like a photon SBRT plan around the target but without the anterior exit dose through the heart, esophagus, liver, kidneys, bowel, bladder, rectum, testis, etc.

That's me thinking about my own body. I'm not interested in penny pinching when it comes to my body. I feel the same way about my patients.

Protons can improve the therapeutic benefit of palliative RT over photons of any form. Plans just look better. Patients experience less toxicity. The closest one can get to that is non-complanar arc photon plans which is what I would use if I didn't have IMPT around.

I can also turn around proton plans just as fast as x-ray plans so I don't have an issue with time.

If patient needs treatment faster than what it takes to get a CT scan and a plan made then I just put them on the linac and do a clinical setup like an old time cowboy.

 

[evilbooyaa]

I'm not a clinical trialist but I can tell you that we enroll on a number of clinical trials comparing protons to IMRT. So they are ongoing, but they are very difficult to make and even more difficult to enroll/randomize patients. Patients on clinical trials will get randomized to protons and then their insurance will refuse to pay for the treatment - this happens all the time.

All of these difficulties in phase III randomized trials are why there are also so few Phase III RCT for IMRT. Most disease sites treated with IMRT are done without RCT backing, they are done because "the dosimetry is better". Well IMPT does even better than that in most cases.

Multiple trials have shown clinical toxicity benefit to IMRT or better ability to cover the disease without breaking dose constraints. RTOG 0617 for lung. PARSPORT for H&N. RTOG 0529 showing better toxicity outcomes than 9811 for anal.

The esophageal data for protons actually looks somewhat reasonable and I offer proton referral to a place that had IMPT for all my esophageal cases. I do think it has value in limiting V5 as well in these difficult cases, cases where even with static IMRT we really struggle to meet dose constraints.

I do sympathize with proton users that insurance SHOULD cover protons if on a randomized clinical trial (and not just an institutional registry). I am aware of the ongoing lung

Maybe IMPT for H&N will work out as well, but using it for chip shot tonsil + unilateral neck in HPV+ Tonsil cancer is NOT the answer. Show me it's going to have a clinical toxicity benefit in a T3N2c oropharynx or larynx tumor and I'm happy to discuss that with patients.

But, the lack of robustness and the potential for severe toxicity that is WORSE than what IMRT would provide (as seen in old proton for prostate data) is not acceptable. Do a retrospective analysis convincing us that the pretty pictures and numbers on the computer translate to a clinical toxicity benefit. I'm happy to be educated even with comparative effectiveness data looking at toxicity in retrospective series.

 

[elementaryschooleconomics]

Alright, so based on this paper posted earlier in the thread:

Those just seemed like tremendously high doses. It's important to note this was published in 2004, and while it was using IMRT, I imagine we're better than that now.

Thus, I decided to test my imagination. I happened to be reviewing a prostate plan today (high risk with terrible urinary function, so going to 79.2), and told my physicist about this discussion. I contoured the testicles (quickly and without breaking it down into left/right) and we re-ran the plan. We put no weight on the testicles or changed the plan in any way:

I whopping mean of 27.3 cGy and a max of 58.1 cGy. Sure, this is an N=1, but everything about this patient's case and anatomy was very average, so I have to think that this is a representative dose wash.

Again, I'm pro-proton, but testicle dose/serum testosterone drop as a justification for IMPT over IMRT seems like murky water to swim in.

(also, I think the staff here are looking at me sideways after I started the day with a discussion about how I want to see something about testicle dose based on an internet message board)

 

[RickyScott]

Alright, so based on this paper posted earlier in the thread:

View attachment 341586
Those just seemed like tremendously high doses. It's important to note this was published in 2004, and while it was using IMRT, I imagine we're better than that now.

Thus, I decided to test my imagination. I happened to be reviewing a prostate plan today (high risk with terrible urinary function, so going to 79.2), and told my physicist about this discussion. I contoured the testicles (quickly and without breaking it down into left/right) and we re-ran the plan. We put no weight on the testicles or changed the plan in any way:

View attachment 341587

View attachment 341588

I whopping mean of 27.3 cGy and a max of 58.1 cGy. Sure, this is an N=1, but everything about this patient's case and anatomy was very average, so I have to think that this is a representative dose wash.

Again, I'm pro-proton, but testicle dose/serum testosterone drop as a justification for IMPT over IMRT seems like murky water to swim in.

(also, I think the staff here are looking at me sideways after I started the day with a discussion about how I want to see something I about testicle dose based on an internet message board)

the inferior border of prostate in the 90s was lower than it is generally set today. Fields in Perez were at inferior border of ischial tuberosities and saw a lot of contouring base of penis as prostate

 

[DoctwoB]

Alright, so based on this paper posted earlier in the thread:

View attachment 341586
Those just seemed like tremendously high doses. It's important to note this was published in 2004, and while it was using IMRT, I imagine we're better than that now.

Thus, I decided to test my imagination. I happened to be reviewing a prostate plan today (high risk with terrible urinary function, so going to 79.2), and told my physicist about this discussion. I contoured the testicles (quickly and without breaking it down into left/right) and we re-ran the plan. We put no weight on the testicles or changed the plan in any way:

View attachment 341587

View attachment 341588

I whopping mean of 27.3 cGy and a max of 58.1 cGy. Sure, this is an N=1, but everything about this patient's case and anatomy was very average, so I have to think that this is a representative dose wash.

Again, I'm pro-proton, but testicle dose/serum testosterone drop as a justification for IMPT over IMRT seems like murky water to swim in.

(also, I think the staff here are looking at me sideways after I started the day with a discussion about how I want to see something about testicle dose based on an internet message board)

It's a feature, not a bug. Build in ADT!

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

 

[RickyScott]

It's a feature, not a bug. Build in ADT!

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

Could you link to that twitter thread? I am really curious as I have heard this as well.

 

[medgator]

It's a feature, not a bug. Build in ADT!

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

Have heard same from a high volume salvage RP surgeon in my neck of the woods as well.... Worse than cryo, hifu or IMRT salvage

 

[RickyScott]

It's a feature, not a bug. Build in ADT!

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

From a radiobiological standpoint: 80 gy of protons in the center of the prostate is less damaging to tissue than 80 gy at the edge of the prostate. We call this rbe or relative biological effect. Per unit dose near the Bragg peak, there is a greater degree of damage to both cancer and normal tissues. This does not happen with photons. Dose is only part of the story.

 

[SubserviantToABR]

From a radiobiological standpoint: 80 gy of protons in the center of the prostate is less damaging to tissue than 80 gy at the edge of the prostate. We call this rbe or relative biological effect. Per unit dose near the Bragg peak, there is a greater degree of damage to both cancer and normal tissues. This does not happen with photons. Dose is only part of the story.

But the dosimetry pictures are pretty! 🙄

 

[MegaVoltagePhoton]

I'm pretty sure the radiation to the balls thing has been debunked, both in conventional RT and in SBRT. I think fairly recently there were papers in Advances and even in the Red J.

It never ceases to amaze me how a tiny drop in T might justify millions of dollars of expense. Yet if I got a T1 breast cancer I would be told to go on hormonal therapy for 5 years and dinged for being a bad patient if I didn't comply 😉

 

[RickyScott]

I'm pretty sure the radiation to the balls thing has been debunked, both in conventional RT and in SBRT. I think fairly recently there were papers in Advances and even in the Red J.

It never ceases to amaze me how a tiny drop in T might justify millions of dollars of expense. Yet if I got a T1 breast cancer I would be told to go on hormonal therapy for 5 years and dinged for being a bad patient if I didn't comply 😉

Just looking for an angle to make the sale…

 

[evilbooyaa]

It's a feature, not a bug. Build in ADT!

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

Relatively simplistic way to think about it for those not in RO is to think that where the Bragg peak sits (which is at the edges of the treatment volume, so the lateral, anterior, posterior, and superior edges of the prostate) has the potential to deliver higher doses (Some of the proton proponents here have suggested 1.3 to 1.5 RBE, which equates to 30%-50% higher) of radiation than throughout the entirety of the prostate. This is, thus far to my knowledge, unable to well modeled on our computer screens (which is mostly how ROs think about treatment planning).

Thus the periprostatic tissue, anterior rectal wall, and bladder, are potentially getting higher doses than the remainder of prostate. This was more of an issue with 'old school' passive scatter proton as opposed pencil beam, and is less of an issue with multi beam angle pencil beam (called IMPT).

This effect is not seen with photon radiation or with brachytherapy dose drop off.

 

[TheWallnerus]

Again, I'm pro-proton, but testicle dose/serum testosterone drop as a justification for IMPT over IMRT seems like murky water to swim in

I didn't see that there was a paper that said the family jewels can get >>1 Gy with prostate RT. That is ridiculoballs. Thanks for your wonderful dosimetric testes test. It is what I would expect.

Saw an interesting twitter thread amongst uros about salvage prostatectomy after protons. namely that it is hell on earth, with incredible fibrosis throughout the periprostatic tissues forming cement that often involves the anterior rectal wall. Significantly worse then post IMRT or even brachytherapy. It was a lot of small Ns, but multiple people chiming in that they noticed that as well. Any particular reason that would be from a radbio/dosimetric standpoint?

What protons do to matter would scare you if it was doing it to your own matter. And I'm scared enough of photons as is. Protons are matter, and X-rays are not.

X-rays ("6MV," which is really ~2MeV, photon IMRT e.g.) can only perform a covalent bond breaking chemistry in the body.

Protons (>200 MeV protons e.g.) can perform a nuclear chemistry in the body. The number of protons in an atom solely determines what that atom is. Knock a proton out of a carbon atom, it becomes boron. And so on. The alchemists dreamed of transmutation; proton beam therapy makes it real.

Protons and neutrons "weigh" almost the same. (Electrons are matter too, and we use them in the clinic all the time; they weigh 2000 times less than protons. Velocity affects mass. 200 MeV protons move about 60% light speed; 20 MeV electrons move 99% light speed.) Neutrons are uncharged though and thus interact FAR more with atomic nuclei than protons do (protons like interacting with electrons... that is not nuclear chemistry). That said, neutron radiation has a sad history. Neutrons have insanely high relative biological effectiveness (RBE). Depending on what person you talk to or paper you read, proton beams in patients' bodies have 1.1-1.5 RBE. Read one patient's story about the perils of high RBE here:

Roger Ebert: 'I'm happy I don't look worse'

Roger Ebert is regarded as one of the greatest film critics in the world. But after being diagnosed with thyroid cancer in 2002, he was left unable to speak, eat or drink. In an extract from his new book, Life Itself, he explains how his life has been changed

www.theguardian.com

 

[Lamount]

What about charging IMRT rates until there is proof of superiority?

I understand your point of “well, IMRT didn’t have to do that.” That was then, this is now. It’s experimental, so it shouldn’t be a higher charge than standard of care. I think that isn’t unreasonable. It’s why I was never annoyed with Maryland’s proton center which in addition was open to anyone that wanted training. You’d send patients for treatment, and see your own OTVs.

I think this a reasonable argument but from an ethical perspective it is not practical for many proton centers, especially those who have financed the construction and are still paying off these expenses.

It's fair to say that many shouldn't have opened in the first place, but I don't think you can expect them to deliberately go broke.

APM may force this on some... we shall see.

 

[Chartreuse Wombat]

I think this a reasonable argument but from an ethical perspective it is not practical for many proton centers, especially those who have financed the construction and are still paying off these expenses.

It's fair to say that many shouldn't have opened in the first place, but I don't think you can expect them to deliberately go broke.

APM may force this on some... we shall see.

So the American taxpayer should bail out those who unwisely financed construction? Most of the VC have already got there money and some centers have "gone broke". APM will be difficult for the proton centers "in" the zipcodes but those "out" of the zipcodes will thrive.

 

[evilbooyaa]

I think this a reasonable argument but from an ethical perspective it is not practical for many proton centers, especially those who have financed the construction and are still paying off these expenses.

It's fair to say that many shouldn't have opened in the first place, but I don't think you can expect them to deliberately go broke.

APM may force this on some... we shall see.

I think it's interesting you talk about ethics in this situation. Not ethics to the patients, the country, insurers, about paying more for the same treatment, but ethics to a proton center.

A corporation built a business around a flawed idea (that charging 5-10x IMRT or whatever was worth it and that insurers would continue to pay for it) and because that idea was flawed, we (the US population) all are now required to subsidize these bloated, exceedingly expensive proton centers who went for size (4+ vaults) rather than practicality (like the Mevion single vault system)?

Nah, don't think so. I have no problem with some of these proton centers going bankrupt. Either let the technology get cheaper or have a large enough encatchment area that you can use it for just the things it's actually necessary/better for.

Lots of proton centers going bankrupt. Scripps did. IU is dead. Provision going bankrupt too. There will be more casualties in the old proton center world, and eventually rebirth with the advent of cheaper and cheaper proton units.

 

[HardenedBeam]

Protons are a terrible investment. If anyone reading this wants to make money - don't build a proton center. Much better to use an old vault somewhere, buy a used LINAC, undercut for insurance contracts, and fill the place with volume. Much better ROI. The $$$$$ is in photon centers.

 

[RickyScott]

I think this a reasonable argument but from an ethical perspective it is not practical for many proton centers, especially those who have financed the construction and are still paying off these expenses.

It's fair to say that many shouldn't have opened in the first place, but I don't think you can expect them to deliberately go broke.

Protons are a terrible investment. If anyone reading this wants to make money - don't build a proton center. Much better to use an old vault somewhere, buy a used LINAC, undercut for insurance contracts, and fill the place with volume. Much better ROI. The $$$$$ is in photon centers.

Protons can be a great investment depending on the situation. For a large center with very high negotiated rates for imrt, protons are a must to keep pts coming through the door even if most of them don’t get protons.
Regarding apm, it may not affect protons at such centers. Places like UPenn still have enormous leverage with insurance. Medicare may pay less but centers may just demand that the secondary make up the difference, nor will they agree to commercial insurances entering into an apm.

 

[Lamount]

So the American taxpayer should bail out those who unwisely financed construction?

This gets to the ethical question and is another issue altogether. I am not commenting about what "should" happen, but FWIW, I am on your side of the fence on this issue.

...rather I am pointing out the fallacy in one expecting someone to act against their own self interest, especially when lots of money is involved. Many departments/hospitals/(whoever else) invested a lot money expecting an ROI, and they likely took out loans to do it. In your experience, how often do people who invest 7-8 figures in a project spontaneously decide to leave revenue on the table?

 

[Lamount]

I think it's interesting you talk about ethics in this situation. Not ethics to the patients, the country, insurers, about paying more for the same treatment, but ethics to a proton center.

A corporation built a business around a flawed idea (that charging 5-10x IMRT or whatever was worth it and that insurers would continue to pay for it) and because that idea was flawed, we (the US population) all are now required to subsidize these bloated, exceedingly expensive proton centers who went for size (4+ vaults) rather than practicality (like the Mevion single vault system)?

Nah, don't think so. I have no problem with some of these proton centers going bankrupt. Either let the technology get cheaper or have a large enough encatchment area that you can use it for just the things it's actually necessary/better for.

Lots of proton centers going bankrupt. Scripps did. IU is dead. Provision going bankrupt too. There will be more casualties in the old proton center world, and eventually rebirth with the advent of cheaper and cheaper proton units.

You and I are referring to the same ethics, and I agree with you. I am also not saying that it was wise for all of these proton centers to open.

...but if someone really thought that protons were no more valuable and deserve no more compensation than IMRT, they wouldn't have opened a proton center. To expect people who did open a proton center to -only then- question their value... belies a misunderstanding of human nature.

There is right and wrong... and there is what I expect of people based upon their past activity.

I don't know what protons should cost... but I am sure some are charging too much. That is wrong... but it is also entirely predictable.

 

[Mandelin Rain]

What kind of men y’all treating that you’re “shaping IMRT plans” around testicles, that somehow live betwixt the femoral heads?

 

[TheWallnerus]

Did you guys catch this pre-print in RedJ ("Mechanisms and review of clinical evidence for variations in relative biological effectiveness in proton therapy"). Makes me not wanna touch a proton with a ten foot pole. My physicist fails an IMRT plan QA where dose varies >5% versus expected. We are talking much greater % than this with protons. A dose is the RBE and the RBE is the dose; who cares the Gy or cobalt gray equivalents written on the page. With this much uncertainty re: proton RBE, how is it ethical to treat anyone with proton therapy unless they're in a randomized trial comparing to standard photon based approaches. They should put the paragraphs below on these proton center websites and see if their patient volumes go down as a result of giving patients more information.

 

[RickyScott]

Did you guys catch this pre-print in RedJ ("Mechanisms and review of clinical evidence for variations in relative biological effectiveness in proton therapy"). Makes me not wanna touch a proton with a ten foot pole. My physicist fails an IMRT plan QA where dose varies >5% versus expected. We are talking much greater % than this with protons. A dose is the RBE and the RBE is the dose; who cares the Gy or cobalt gray equivalents written on the page. With this much uncertainty re: proton RBE, how is it ethical to treat anyone with proton therapy unless they're in a randomized trial comparing to standard photon based approaches. They should put the paragraphs below on these proton center websites and see if their patient volumes go down as a result of giving patients more information.

“A dose is the rbe, and the rbe is the dose”.

 

[Gfunk6]

A dose is a dose of course of course
And everyone understands dose of course.
That is of course unless the dose
Is delivered by proton beam!

 

[Lamount]

A dose is a dose of course of course
And everyone understands dose of course.
That is of course unless the dose
Is delivered by proton beam!

Something that I found interesting when I was doing research on heavy ions a few years ago... RBE is so hard to derive not because of the weirdness of particles, but rather because photons are a terrible index

With photons... 2+2 does not = 4. We live and breath the LQ-model, so we forget how weird it is...

With high LET radiation, things that don't effect radiation effectiveness include:
1) Fractionation (10 Gy x 1 is similar to 5 Gy x 2)
2) Hypoxia
3) Cell cycling
4) Intrinsic radio sensitivity
5) alpha/beta -----> infinity for every tissue/tumor

Most of the magnitude of the RBE of protons is dependent on LET... but this relationship is pretty simple to model. The real tricky (though less impactful) stuff has to do fractionation, hypoxia, radiosensitivity, alpha/beta ratio... and these only matter because they affect the crappy rubber band photon yardstick we are using.

**Edited to fix a few typos

 

[TheWallnerus]

Mayo Clinic to build $200 million proton beam expansion​

In November, Mayo Clinic plans to start construction of a $200 million, 110,000-square-foot expansion of its proton beam therapy program in downtown Rochester. The expansion will add two new treatment rooms to the four Mayo now uses to treat patients dealing with prostate cancer, breast cancer, neck and throat cancers as well as pediatric cancers. Work on the massive project is expected to begin in November.

 

[StIGMA]

Mayo Clinic to build $200 million proton beam expansion​

In November, Mayo Clinic plans to start construction of a $200 million, 110,000-square-foot expansion of its proton beam therapy program in downtown Rochester. The expansion will add two new treatment rooms to the four Mayo now uses to treat patients dealing with prostate cancer, breast cancer, neck and throat cancers as well as pediatric cancers. Work on the massive project is expected to begin in November.

Did they link the companion article that the Saudi Royal family and friends now have completely private proton gantry access for their full course of treatment?

 

[evilbooyaa]

Mayo Clinic to build $200 million proton beam expansion​

In November, Mayo Clinic plans to start construction of a $200 million, 110,000-square-foot expansion of its proton beam therapy program in downtown Rochester. The expansion will add two new treatment rooms to the four Mayo now uses to treat patients dealing with prostate cancer, breast cancer, neck and throat cancers as well as pediatric cancers. Work on the massive project is expected to begin in November.

Lmao. From the article (bolded my emphasis):

From the start in 2015, Mayo Clinic’s proton beam program faced criticism due the limited amount of clinical research into proton beam treatment versus less expensive options. Mayo Clinic leaders say that is one aspect that has changed in the past five years.

Mayo researchers have published an estimated 300 articles studying the effects of proton beam treatment that have found it less toxic than traditional radiation as well as more cost effective with fewer treatments required.

While the equipment is more expensive, Mayo Clinic has kept the patient cost of proton beam radiation treatment equal to the cost of intensity modulated photon radiotherapy cancer treatment. The per-treatment cost of proton beam treatment, according to Mayo Clinic’s online cost estimator, was $5,904 at the end of 2020.

Jacobson’s $100 million donation covered much of the cost of launching the program, so that made it easier for Mayo Clinic to keep the cost down. Despite no donors or other external financing source for the $200 million expansion, Laack said Mayointends to continue the practice of pricing proton beam treatment at the same level of traditional radiation treatment.

“The plan is still to keep the pricing equal, so that the cost is not a consideration, either for the Mayo physicians or the insurers. We want to be able to choose the right treatment for the patient, because it's the right treatment for the patient, regardless of the cost or reimbursement,” said Laack.

Most insurance plans do not automatically cover proton treatment. Mayo Clinic is required to make a special request for each patient. Since the price tag is the same as the covered photon treatment, Laack said about 95 percent of insurance requests are approved.

$5,904 PER fraction. And this is apparently the same as their (I presume) IMRT costs. $5,904 PER fraction. My ****ing goodness.
Aren't there diagnoses in the proposed APM that folks will get ~$5k for an entire course of treatment for a certain diagnosis?

 

[deleted1111261]

Lmao. From the article (bolded my emphasis):



$5,904 PER fraction. And this is apparently the same as their (I presume) IMRT costs. $5,904 PER fraction. My ****ing goodness.
Aren't there diagnoses in the proposed APM that folks will get ~$5k for an entire course of treatment for a certain diagnosis?

Wow

 

[fiji128]

Lmao. From the article (bolded my emphasis):



$5,904 PER fraction. And this is apparently the same as their (I presume) IMRT costs. $5,904 PER fraction. My ****ing goodness.
Aren't there diagnoses in the proposed APM that folks will get ~$5k for an entire course of treatment for a certain diagnosis?

Astounding. Every academic article published from that place needs to have that on their COI disclaimer.

 

[Chartreuse Wombat]

Wow

RO Base Rates attached

 

[TheWallnerus]

RO Base Rates attached

There are going to be some VERY interesting fractionation trends happening in the US in certain locales come 2022.

 

[brushbeamscanning]

Not that it's a competition other proton centers charge up to 10k per fraction.

 

[evilbooyaa]

RO Base Rates attached

Oops, I was wrong. With technical added in (which I'm sure the 5.9k is including) per fraction is similar to APM.

One fraction of 8Gy x 1 palliation of bone met with Mayo Protons still puts them ahead of APM compensation for bone mets, nice.

 

[Ray D. Ayshun]

Oops, I was wrong. With technical added in (which I'm sure the 5.9k is including) per fraction is similar to APM.

One fraction of 8Gy x 1 palliation of bone met with Mayo Protons still puts them ahead of APM compensation for bone mets, nice.

6k/fraction? As in, ~200k global for a prostate course?

 

[TheWallnerus]

6k/fraction? As in, ~200k global for a prostate course?

There’s data (somewhere) that the average proton prostate is in the $200-300K range. Some proton cases reimburse nearly a half million.

 

[deleted941485]

There are going to be some VERY interesting fractionation trends happening in the US in certain locales come 2022.

You lose either way. You hypofrac...theyll just cut theyll argue oh less effort from staff and doc. You don't hypo theyre getting extra fxs for free. Either way gonna alot of layoffs in those zip codes.

 

[deleted941485]

There’s data (somewhere) that the average proton prostate is in the $200-300K range. Some proton cases reimburse nearly a half million.

Sounds awesome. Wish more PPs could get in on the bull**** fest. At this point, Im just fighting to keep my job and the lights on

 

[medgator]

You lose either way. You hypofrac...theyll just cut theyll argue oh less effort from staff and doc. You don't hypo theyre getting extra fxs for free. Either way gonna alot of layoffs in those zip codes.

Wonder how things will look in the centers just outside those zips....

 

[deleted941485]

Wonder how things will look in the centers just outside those zips....

My guess is they know whatever happens in those zips will eventually happen to them. I don't see how this little experiment doesn't fail. It saves money because it literally cuts all the fat out of RO and leaves you with bare bones. There is no upside.

 

[SneakyBooger]

Low dose bath has been accused of so many things over the years (like killing lung cancer patients) yet none of it has ever panned out.

Low dose radiotherapy has been shown to decrease inflammation (arthritis), aid in healing bone, aid in healing nerve damage, increase sperm counts.

When I get my prostate radiated I will say, "Give me the low dose koolaid bath!" (instead of that range uncertainty proctitis).

 

[SneakyBooger]

Alright, so based on this paper posted earlier in the thread:

View attachment 341586
Those just seemed like tremendously high doses. It's important to note this was published in 2004, and while it was using IMRT, I imagine we're better than that now.

Thus, I decided to test my imagination. I happened to be reviewing a prostate plan today (high risk with terrible urinary function, so going to 79.2), and told my physicist about this discussion. I contoured the testicles (quickly and without breaking it down into left/right) and we re-ran the plan. We put no weight on the testicles or changed the plan in any way:

View attachment 341587

View attachment 341588

I whopping mean of 27.3 cGy and a max of 58.1 cGy. Sure, this is an N=1, but everything about this patient's case and anatomy was very average, so I have to think that this is a representative dose wash.

Again, I'm pro-proton, but testicle dose/serum testosterone drop as a justification for IMPT over IMRT seems like murky water to swim in.

(also, I think the staff here are looking at me sideways after I started the day with a discussion about how I want to see something about testicle dose based on an internet message board)

The study below suggests that man may have increased spermatogenesis.

"These results suggest that enhanced spermatogenesis occurred in large Japanese field mice living in and around the FNPP exevacuation zone."

 

[TheWallnerus]

The study below suggests that man may have increased spermatogenesis.

"These results suggest that enhanced spermatogenesis occurred in large Japanese field mice living in and around the FNPP exevacuation zone."

View attachment 342403

Gives new insight into this:

You, sir, have the balls of a stud field mouse.

American Crime Story (2016) - S01E07 clip with quote You, sir, have the balls of a stud field mouse. Yarn is the best search for video clips by quote. Find the exact moment in a TV show, movie, or music video you want to share. Easily move forward or backward to get to the perfect clip.

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[fiji128]

Hopefully they will also be disclosing the huge financial conflicts of interest that come with the non data when pushing protons.

 

[IonsAreOurFuture]

I think we can all agree that there are a lot of unanswered questions surrounding proton therapy, especially for prostate cancer.

Fortunately, there is an open clinical trial that needs thoughtful and opinionated doctors like you to enroll prostate cancer patients using the modality you think is best. Neither X-rays or protons are going to disappear any time soon, but at least we'll have a better understanding of what it's like for patients going through treatment with them, in terms of safety, quality of life, and 10-year cure rate.

The COMPPARE trial is still open and accruing patients to both the proton and IMRT arms. See: comppare.org There is still time to participate. To enroll a patient on the IMRT arm, you don't have to change the way you practice at all, but the patient has to be willing to complete quality of life surveys (like the IPSS and SHIM on steroids) before, during and after radiation, and agree to be followed for 10 years. They get paid around $250 for their time. You and the patient are in control of his treatment.

Protons don't have to be available at your site, just IMRT. You can treat low, intermediate or high risk patients, but not Very High Risk (patients must have at least a 10 year life expectancy). You can treat nodes if you feel it's needed. You can use SpaceOAR, or not. You can use whatever IMRT fractionation and total dose you normally would. It's a very pragmatic comparison of how patients fare with the way things are currently being done with protons and IMRT nationwide. Some sites offer both IMRT and protons and enroll in both arms, many sites offer a single modality.

If you'd like to contribute in a meaningful way, please reach out to Dr. Nancy Mendenhall, she's the nationwide PI of this federally-funded trial. Proton patients are accruing well; IMRT patients are not enrolling as quickly. There seems to be either a lack of awareness or reluctance on the part of IMRT-based physicians to generate this type of data. If your site isn't already participating, please email her, it's: [email protected]. She's always been very helpful with my questions about the trial.

 

[RickyScott]

I think we can all agree that there are a lot of unanswered questions surrounding proton therapy, especially for prostate cancer.

Fortunately, there is an open clinical trial that needs thoughtful and opinionated doctors like you to enroll prostate cancer patients using the modality you think is best. Neither X-rays or protons are going to disappear any time soon, but at least we'll have a better understanding of what it's like for patients going through treatment with them, in terms of safety, quality of life, and 10-year cure rate.

The COMPPARE trial is still open and accruing patients to both the proton and IMRT arms. See: comppare.org There is still time to participate. To enroll a patient on the IMRT arm, you don't have to change the way you practice at all, but the patient has to be willing to complete quality of life surveys (like the IPSS and SHIM on steroids) before, during and after radiation, and agree to be followed for 10 years. They get paid around $250 for their time. You and the patient are in control of his treatment.

Protons don't have to be available at your site, just IMRT. You can treat low, intermediate or high risk patients, but not Very High Risk (patients must have at least a 10 year life expectancy). You can treat nodes if you feel it's needed. You can use SpaceOAR, or not. You can use whatever IMRT fractionation and total dose you normally would. It's a very pragmatic comparison of how patients fare with the way things are currently being done with protons and IMRT nationwide. Some sites offer both IMRT and protons and enroll in both arms, many sites offer a single modality.

If you'd like to contribute in a meaningful way, please reach out to Dr. Nancy Mendenhall, she's the nationwide PI of this federally-funded trial. Proton patients are accruing well; IMRT patients are not enrolling as quickly. There seems to be either a lack of awareness or reluctance on the part of IMRT-based physicians to generate this type of data. If your site isn't already participating, please email her, it's: [email protected]. She's always been very helpful with my questions about the trial.

Do you know of anyone delivering protons without balloons or space oar?

 

[OTN]

I think we have a pretty good chunk of data already which shows us the rates of toxicity for prostate cancer with both PBT and IMRT are very low. For example: A Pooled Toxicity Analysis of Moderately Hypofractionated Proton Beam Therapy and Intensity Modulated Radiation Therapy in Early-Stage Prostate Cancer Patients - PubMed

Other smaller trials confirm this data.

Given this, along with the (substantial) increased financial toxicity of PBT in the treatment of prostate cancer (both to the patient and society), in my opinion this trial does not have equipoise. So, this "IMRT-based physician" will not be participating.