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

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IonsAreOurFuture said:
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.
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I am participating. SBRT is not allowed which of late has hampered accrual.
 
Proton therapy represents maybe 1-2% of radiation treatments in the US. I also do SBRT for many Xray patients, but nationwide not everyone can or does. There is no shortage of prostate IMRT being done in the US. Every month could fill up 1,000 patients on a clinical trial. Please don't claim there is no data comparing protons and IMRT and then refuse to generate such data.
 
IonsAreOurFuture said:
Proton therapy represents maybe 1-2% of radiation treatments in the US. I also do SBRT for many Xray patients, but nationwide not everyone can or does. There is no shortage of prostate IMRT being done in the US. Every month could fill up 1,000 patients on a clinical trial. Please don't claim there is no data comparing protons and IMRT and then refuse to generate such data.
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What are you hoping to accomplish with protons in prostate CA that isn't happening with imrt/vmat? Honest question
 
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IonsAreOurFuture said:
Proton therapy represents maybe 1-2% of radiation treatments in the US. I also do SBRT for many Xray patients, but nationwide not everyone can or does. There is no shortage of prostate IMRT being done in the US. Every month could fill up 1,000 patients on a clinical trial. Please don't claim there is no data comparing protons and IMRT and then refuse to generate such data.
Click to expand...
Tbh, I think any enthusiasm for protons have significantly waned from the general radiation oncology community. This apathy is fueled by the greediness of those with protons, with their widespread, hyperbolic marketing. Let’s be honest, many of those patients with breast or prostate cancer who wants protons and are willing to go to a proton center under the false, unfounded assumption that it is better, are not likely to be willing to randomize to photons versus protons.

After all of these years and lies, it is now up to those with protons to demonstrate its utility and convince everyone else with photons, not vice versa.
 
IonsAreOurFuture said:
Proton therapy represents maybe 1-2% of radiation treatments in the US. I also do SBRT for many Xray patients, but nationwide not everyone can or does. There is no shortage of prostate IMRT being done in the US. Every month could fill up 1,000 patients on a clinical trial. Please don't claim there is no data comparing protons and IMRT and then refuse to generate such data.
Click to expand...
Also, if there are plenty of patients that are willing to enroll every month, then why don’t you generate that data? You would have a first author NEJM paper, plenary at ASCO and ASTRO with survival and PRO endpoints, and your name in history as the savior of proton therapy, complete with an ASTRO gold medal.

But we know why those with protons don’t do these studies, because if they were to find out that protons were no better (or even worse perhaps!) that they are stuck with an 8 figure hunk of crap, regretting that they should’ve bought an off the shelf Halcyon for sub-2 mil.
 
SubserviantToABR said:
Also, if there are plenty of patients that are willing to enroll every month, then why don’t you generate that data? You would have a first author NEJM paper, plenary at ASCO and ASTRO with survival and PRO endpoints, and your name in history as the savior of proton therapy, complete with an ASTRO gold medal.

But we know why those with protons don’t do these studies, because if they were to find out that protons were no better (or even worse perhaps!) that they are stuck with an 8 figure hunk of crap, regretting that they should’ve bought an off the shelf Halcyon for sub-2 mil.
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Nancy Lee already told us what happens if the proton data isn't spectacular
 
I stepped away for a bit and didn’t expect to see this still going on. Anyway, someone above brought up accrual to a randomized trial and they are spot on. Randomizing patients to an experimental therapy is one thing. Randomizing them between 2 approved therapies when the lay press is already singing the praises of the other? That can be problematic. Not insurmountable, but problematic nonetheless. And who is most likely to refuse randomization in favor of protons? Probably people with the means to travel to a proton center in the first place and above average medical IQ. And that starts to introduce bias. I would like to see the pro-proton crowd bring on the randomized data as much as the next but these trials would not be quite as easy as you might think to complete.

I also though someone seemed to imply that we could complete accrual very quickly because of how many IMRT cases we do a month as a whole. I disagree. Only centers that can offer both therapies should be involved in RCTs. I believe the RTOG esophageal trial is allowing photon only centers to participate but I think that is a bad design that is just opening the door to bias and unnecessary variance. The whole point of a randomized trial is that patients should be able to randomly receive either treatment.
 
just gonna drop this here for you folks. I am hearing that NY proton centre is saying that there will be an OS benefit to protons soon. Stay tuned folks!

www.healio.com

Amid questions about cost and access, proton therapy set for ‘big moment of change’

Hemonc Today | More than 3 decades after receiving FDA approval, proton beam radiation therapy has failed to find a footing as a go-to treatment for many cancers in the United States.About three dozen proton therapy facilities are in operation nationwide — fewer than one per state — limiting...
www.healio.com www.healio.com
 
thecarbonionangle said:
just gonna drop this here for you folks. I am hearing that NY proton centre is saying that there will be an OS benefit to protons soon. Stay tuned folks!

www.healio.com

Amid questions about cost and access, proton therapy set for ‘big moment of change’

Hemonc Today | More than 3 decades after receiving FDA approval, proton beam radiation therapy has failed to find a footing as a go-to treatment for many cancers in the United States.About three dozen proton therapy facilities are in operation nationwide — fewer than one per state — limiting...
www.healio.com www.healio.com
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If proton therapy saves the field because it’s become “much more developed and accurate than before,” I don’t know if a single person who was ever a radiation oncology resident (much less Holman pathway) has been directly involved with that development.

Protons will show a survival advantage by… having less fatal toxicity rates versus photons? Makes you think: how many people have you killed with photons/IMRT.
 
thecarbonionangle said:
just gonna drop this here for you folks. I am hearing that NY proton centre is saying that there will be an OS benefit to protons soon. Stay tuned folks!

www.healio.com

Amid questions about cost and access, proton therapy set for ‘big moment of change’

Hemonc Today | More than 3 decades after receiving FDA approval, proton beam radiation therapy has failed to find a footing as a go-to treatment for many cancers in the United States.About three dozen proton therapy facilities are in operation nationwide — fewer than one per state — limiting...
www.healio.com www.healio.com
Click to expand...
Color me skeptical. Pretty sure no randomized comparison with OS as endpoint. Can you say selection bias? OS is > with RP compared to XRT for the same reason
 
Chartreuse Wombat said:
Color me skeptical. Pretty sure no randomized comparison with OS as endpoint. Can you say selection bias? OS is > with RP compared to XRT for the
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“In 2021, I believe that proton therapy planning and delivery technologies have advanced to the point where they now match photon therapy planning and delivery technologies,” Chen said in an interview with HemOnc Today. “This means that we can now do meaningful clinical trials to determine the potential benefit of proton therapy in different cancers.”


WTF? 10 years ago proton centers were claiming superiority, but this time we should believe them.
 
RickyScott said:
“In 2021, I believe that proton therapy planning and delivery technologies have advanced to the point where they now match photon therapy planning and delivery technologies,” Chen said in an interview with HemOnc Today. “This means that we can now do meaningful clinical trials to determine the potential benefit of proton therapy in different cancers.”


WTF? 10 years ago proton centers were claiming superiority, but this time we should believe them.
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Proton guy totally throws shade on proton treatment 10 years ago.

There are so many unverifiable opinion-y things in this article it makes your head spin.

Of course as usual everyone is unbothered.
 
It's called towing the party line. Everyone in academics or corporate is expected to follow the party line. Don't have protons? Protons suck. We have protons? Protons are amazing. Didn't have protons in the past? Well they're amazing now due to advances over the years. Now at place without protons where you were with protons before? Protons aren't very helpful, only maybe in very rare cases. Repeat this for any technology.

If you work at one of these places, this sort of promotion is heavily encouraged or enforced.

My mother had a saying: money talks and bull**** walks.
 
TheWallnerus said:
Protons and lack of hypofx biggest bubbles in our specialty right now. Maybe APM is not the hero we want but the hero we need?
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Protons are currently part of the APM (but that could change) and remember on 30-40% of practices were "lucky" enough to be choses for APM. I wonder how many proton centers are IN and how many are OUT of the APM.
 
Proton fellowship in a day?
 

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Everything proton + breast RT in October's Red Journal.

Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials’ cost-effectiveness analyses and key areas for future research.


 
fiji128 said:
Everything proton + breast RT in October's Red Journal.

Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials’ cost-effectiveness analyses and key areas for future research.


Click to expand...
Haha. The number one proton money maker is breast. Makes sense as almost 1:1 in rad onc is breast:everything else.
 
In my experience proton cosmesis is worse than photon for breast, at least at the skin (both in terms of acute and late skin thickening cosmesis).

I have sent some young left sided challenging anatomy cases for protons though for adjuvant chest wall/RNI.

One other "thing" I've seen for left sided proton whole breast cases....is that when they do a plan comparison photon versus proton they are covering literally every last voxel of breast tissue. For things like small-ish lobular cancers or other cases I'm going whole breast on, I will sometimes skimp on some very far medial breast tissue coverage (especially if tumor UOQ many many cm's away) to get better heart/lung dosimetry. Does this push the needle clincially that they "can" cover that area with protons? I doubt it.

I just see such good dosimetry/tolerance with DIBH photon plans, it's hard to imagine protons moves the needle much. With that said, I can buy regional nodal irradiation proton benefit over prostate only proton benefit.

Would love to hear others experience.
 
Idiot's guide to ASTRO's position on protons in breast cancer: We don't have enough data to say protons >= photons. However, there is a lot of heterogeneity in proton planning so please send all such patients to academic centers only where they may be enrolled in useless single arm or registry trials. The main benefit of protons would be reduced risk of secondary malignancy which has a latency of 15-30 years so we will get back to you then.
 
BobbyHeenan said:
In my experience proton cosmesis is worse than photon for breast, at least at the skin (both in terms of acute and late skin thickening cosmesis).

I have sent some young left sided challenging anatomy cases for protons though for adjuvant chest wall/RNI.

One other "thing" I've seen for left sided proton whole breast cases....is that when they do a plan comparison photon versus proton they are covering literally every last voxel of breast tissue. For things like small-ish lobular cancers or other cases I'm going whole breast on, I will sometimes skimp on some very far medial breast tissue coverage (especially if tumor UOQ many many cm's away) to get better heart/lung dosimetry. Does this push the needle clincially that they "can" cover that area with protons? I doubt it.

I just see such good dosimetry/tolerance with DIBH photon plans, it's hard to imagine protons moves the needle much. With that said, I can buy regional nodal irradiation proton benefit over prostate only proton benefit.

Would love to hear others experience.
Click to expand...
British data shows you can cheat to avoid the heart with zero consequences. No reason for that kind of coverage whatsoever.
 
BobbyHeenan said:
In my experience proton cosmesis is worse than photon for breast, at least at the skin (both in terms of acute and late skin thickening cosmesis).

I have sent some young left sided challenging anatomy cases for protons though for adjuvant chest wall/RNI.

One other "thing" I've seen for left sided proton whole breast cases....is that when they do a plan comparison photon versus proton they are covering literally every last voxel of breast tissue. For things like small-ish lobular cancers or other cases I'm going whole breast on, I will sometimes skimp on some very far medial breast tissue coverage (especially if tumor UOQ many many cm's away) to get better heart/lung dosimetry. Does this push the needle clincially that they "can" cover that area with protons? I doubt it.

I just see such good dosimetry/tolerance with DIBH photon plans, it's hard to imagine protons moves the needle much. With that said, I can buy regional nodal irradiation proton benefit over prostate only proton benefit.

Would love to hear others experience.
Click to expand...
Treating breast with protons should make everyone mad. Brook the protonists no quarter for RNI concerns. The theoretically best case, lowest number-needed-to-harm for photons instead of protons is already so high... in the 1 in 30 range... that proton use for RNI in breast cancer is insanity. And if that's insanity, using protons in Stage I breast cancer is venal anencephaly.
 
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TheWallnerus said:
Treating breast with protons should make everyone mad. Brook the protonists no quarter for RNI concerns. The theoretically best case, lowest number-needed-to-harm for photons instead of protons is already so high... in the 1 in 30 range... that proton use for RNI in breast cancer is insanity. And if that's insanity, using protons in Stage I breast cancer is venal anencephaly.
Click to expand...

Protons for stage I breast cancer absolutely goes on, including whole breast and partial breast.

The MDA single arm APBI proton trial is used as justification. Thanks, Ben Smith.
 
I don't know where they're at with the PCORI breast trial (randmozed photon vs. proton). That might help.
 
BobbyHeenan said:
Protons for stage I breast cancer absolutely goes on, including whole breast and partial breast.

The MDA single arm APBI proton trial is used as justification. Thanks, Ben Smith.
Click to expand...
There are some seriously malevolent actors poisoning the field who simultaneously try to come off as thought and department leaders. This guy comes to mind and so does LK who graciously temporarily limited expansion of her hellpit program by one resident.
 
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RickyScott said:
There are some seriously malevolent actors wrecking the field who was simultaneously try to come off as thought and department leaders. This guy comes to mind and so does LK who gratuitously temporarily limited expansion of her hellpit program by one resident.
Click to expand...

To be fair, I'm sure the publication of that trial had a hand-waving "more study is needed." But the praxis of that trial is that at tumor boards or when pitching it to the patients/insurers, you show them how MDA had a great experience with the technique so it's the way to go.
 
BobbyHeenan said:
To be fair, I'm sure the publication of that trial had a hand-waving "more study is needed." But the praxis of that trial is that at tumor boards or when pitching it to the patients/insurers, you show them how MDA had a great experience with the technique so it's the way to go.
Click to expand...
More studies are needed for another 30 years…
 
RickyScott said:
There are some seriously malevolent actors poisoning the field who simultaneously try to come off as thought and department leaders. This guy comes to mind and so does LK who gratuitously temporarily limited expansion of her hellpit program by one resident.
Click to expand...
Dr. Benjamin Smith is an incredibly malevolent actor who not only pushes wasteful technology and charges patients near-criminally high prices for his services, he also will routinely talk trash about radonc colleagues who do not work at MDACC.

I would give him yet another chance to say to my face what he said to my patient, but he passed the first time I called him out on it, so I doubt he would take me up on it this time.
 
ramsesthenice said:
Kinda beside the point, but they have 9 faculty. If there is a director of breast radiation oncology, do all of them have director titles?
Click to expand...
They probably do it by laterality and quadrant?

4+4 plus the PMRT medical director
 
medgator said:
They probably do it by laterality and quadrant?

4+4 plus the PMRT medical director
Click to expand...
To be fair, I have a director title at a similar sized institution. But in my mind Brachy is a little different. There are a lot of logistical, safety, and purchasing considerations and it is good to have a point person who actually does the procedures (our chair would rather retire than do Brachy) to make decisions. I’m the only one of us who does Gyn, GU, and endobrochial so by default it fell to me. But let’s not kid ourselves, this is an academic title that = more responsibility without more pay.
 
Protons good?

www.advancesradonc.org

Dosimetry and Acute Toxicity Profile of Patients With Esophageal Cancer Treated With Proton Beam Radiation Therapy: Outcomes From the Proton Collaborative Group REG001-09 Trial

Concurrent chemoradiation plays an integral role in the treatment of esophageal cancer. Proton beam radiation therapy has the potential to spare adjacent critical organs, improving toxicity profiles and potentially improving clinical outcomes.
www.advancesradonc.org

www.advancesradonc.org

Multi-institutional Comparison of Intensity Modulated Photon Versus Proton Radiation Therapy in the Management of Squamous Cell Carcinoma of the Anus

Concurrent chemoradiation therapy is a curative treatment for squamous cell carcinoma of the anus, but patients can suffer from significant treatment-related toxicities. This study was undertaken to determine whether intensity modulated proton therapy (IMPT) is associated with less acute...
www.advancesradonc.org

Protons maybe not so good?
 
Doctorer said:
Protons good?

www.advancesradonc.org

Dosimetry and Acute Toxicity Profile of Patients With Esophageal Cancer Treated With Proton Beam Radiation Therapy: Outcomes From the Proton Collaborative Group REG001-09 Trial

Concurrent chemoradiation plays an integral role in the treatment of esophageal cancer. Proton beam radiation therapy has the potential to spare adjacent critical organs, improving toxicity profiles and potentially improving clinical outcomes.
www.advancesradonc.org

www.advancesradonc.org

Multi-institutional Comparison of Intensity Modulated Photon Versus Proton Radiation Therapy in the Management of Squamous Cell Carcinoma of the Anus

Concurrent chemoradiation therapy is a curative treatment for squamous cell carcinoma of the anus, but patients can suffer from significant treatment-related toxicities. This study was undertaken to determine whether intensity modulated proton therapy (IMPT) is associated with less acute...
www.advancesradonc.org

Protons maybe not so good?
Click to expand...
Even that first paper is nonsense. Dosimetry looked good. 14% grade 3 or worse toxicity. Yum.... okay?
 
Doctorer said:
Protons good?

www.advancesradonc.org

Dosimetry and Acute Toxicity Profile of Patients With Esophageal Cancer Treated With Proton Beam Radiation Therapy: Outcomes From the Proton Collaborative Group REG001-09 Trial

Concurrent chemoradiation plays an integral role in the treatment of esophageal cancer. Proton beam radiation therapy has the potential to spare adjacent critical organs, improving toxicity profiles and potentially improving clinical outcomes.
www.advancesradonc.org

www.advancesradonc.org

Multi-institutional Comparison of Intensity Modulated Photon Versus Proton Radiation Therapy in the Management of Squamous Cell Carcinoma of the Anus

Concurrent chemoradiation therapy is a curative treatment for squamous cell carcinoma of the anus, but patients can suffer from significant treatment-related toxicities. This study was undertaken to determine whether intensity modulated proton therapy (IMPT) is associated with less acute...
www.advancesradonc.org

Protons maybe not so good?
Click to expand...

First paper:

Single arm evaluation of esophageal cancer suggests its feasible. Any paper evaluating a therapy that gets published, the therapy is always feasible. The dosimetry numbers look good, as always. Maybe esophagus is the saving grace based on Steven Lin's trial with a composite Bayesian endpoint meant to obfuscate beyond just clinical toxicities, either physician graded or patient reported. Maybe the obfuscation won't pan out to anything actually of value.

Second paper:

'Despite dosimetry looking better, we were unable to show any differences in toxicity improvements with IMPT'

For every situation that the above statement is true, it should be mandatory that the conclusion of the abstract contain that exact line. I have no problem with anal cancer IMPT paper - negative results that weren't suppressed are valuable in this space. Props to Mayo and Penn for evaluating. Now it's probably time to not do IMPT for anal cancer routinely anymore.
 
CMS soon catching some big bills coming their way from Florida

www.yahoo.com

Proton Therapy contract finalized with Advocate Radiation Oncology Affiliate in Florida

Louvain-La-Neuve, Belgium, October 24, 2021 – IBA (Ion Beam Applications S.A., EURONEXT), the world leader in particle accelerator technology and the world’s leading provider of proton therapy solutions for the treatment of cancer, today announces that its proton therapy contract with Advocate...
www.yahoo.com www.yahoo.com
 
TheWallnerus said:
CMS soon catching some big bills coming their way from Florida

www.yahoo.com

Proton Therapy contract finalized with Advocate Radiation Oncology Affiliate in Florida

Louvain-La-Neuve, Belgium, October 24, 2021 – IBA (Ion Beam Applications S.A., EURONEXT), the world leader in particle accelerator technology and the world’s leading provider of proton therapy solutions for the treatment of cancer, today announces that its proton therapy contract with Advocate...
www.yahoo.com www.yahoo.com
Click to expand...
All that old 21C founder money had to get invested into something. I could think of a better place to put that money but maybe they know something i dont
 
Doctorer said:
Protons good?

www.advancesradonc.org

Dosimetry and Acute Toxicity Profile of Patients With Esophageal Cancer Treated With Proton Beam Radiation Therapy: Outcomes From the Proton Collaborative Group REG001-09 Trial

Concurrent chemoradiation plays an integral role in the treatment of esophageal cancer. Proton beam radiation therapy has the potential to spare adjacent critical organs, improving toxicity profiles and potentially improving clinical outcomes.
www.advancesradonc.org

www.advancesradonc.org

Multi-institutional Comparison of Intensity Modulated Photon Versus Proton Radiation Therapy in the Management of Squamous Cell Carcinoma of the Anus

Concurrent chemoradiation therapy is a curative treatment for squamous cell carcinoma of the anus, but patients can suffer from significant treatment-related toxicities. This study was undertaken to determine whether intensity modulated proton therapy (IMPT) is associated with less acute...
www.advancesradonc.org

Protons maybe not so good?
Click to expand...
Well the second paper tells you what you need to know. “Despite reducing the volume receiving low dose radiation, IMPT did not reduce the incidence of acute grade 3+ toxicity.” How many more times do we need to learn this to not be surprised anymore. The one thing we have definitively learned so far is reducing the low dose bath does not translate into a crazy reduction in acute toxicity for most diseases (though I still bet it does for some things like CSI).
 
ramsesthenice said:
Well the second paper tells you what you need to know. “Despite reducing the volume receiving low dose radiation, IMPT did not reduce the incidence of acute grade 3+ toxicity.” How many more times do we need to learn this to not be surprised anymore. The one thing we have definitively learned so far is reducing the low dose bath does not translate into a crazy reduction in acute toxicity for most diseases (though I still bet it does for some things like CSI).
Click to expand...
Doesnt take a study to know we dont need a ton of a proton centers to treat peds csi or chordomas
 
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