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

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elementaryschooleconomics said:
Just to stir the pot:

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This has been consistent with my anecdotal experience. I think you trade less low dose lung/heart dose for worse fibrosis/cosmesis . One of our plastic reconstructive breast surgeons has expressed this to our breast tumor board as well (photon better on tissues than proton).

It's hard to look at this report and my colleagues and think that unless there's some really bad dosimetry (which can happen in certain anatomies), if you've got a lady with bilateral reconstruction (where I feel comfortable "spilling" some more contralateral dose to get a good angle in the IM's/spare heart, and do a good DIBH plan) it seems you'd really favor photons here. ,

I haven't taken a deep dive into the radiobiology, but my experience, this publication, and then the twitter thread from urologists operating on post proton prostates saying it's more fibrotic in there leads me to believe that there is not enough talk about how much LET is in that Bragg Peak.

I *think* we're going to figure out which patients proton will benefit (I do think there will be some...maybe even a big chunk of patients), but there are some signals out there (pediatric brainstem necrosis, breast fibrosis/skin toxicity/rib toxicity) that make me think....
 
TheWallnerus said:
I am not a statistician but I think "OR, 15.3" is pretty high??

In all seriousness the proton data keep telling us that one can not simply take a Gy and prescribe a cobalt gray equivalent and expect to see less side effects. And more importantly: the radiobiology of protons is sometimes really, really different than photons. It's almost like protons are experimental (gasp).
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180907100732-elon-musk-smokes-marijuana-podcast-1-large-169.jpg
 
TheWallnerus said:
I am not a statistician but I think "OR, 15.3" is pretty high??

In all seriousness the proton data keep telling us that one can not simply take a Gy and prescribe a cobalt gray equivalent and expect to see less side effects. And more importantly: the radiobiology of protons is sometimes really, really different than photons. It's almost like protons are experimental (gasp).
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"We'll probably just keep treating."
 
TheWallnerus said:
I am not a statistician but I think "OR, 15.3" is pretty high??

In all seriousness the proton data keep telling us that one can not simply take a Gy and prescribe a cobalt gray equivalent and expect to see less side effects. And more importantly: the radiobiology of protons is sometimes really, really different than photons. It's almost like protons are experimental (gasp).
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That guy from NYP centre would disagree with you!
 
I will give MDACC some tiny credit......in that at least when it comes to protons, NYProton makes MDACC looks like good stewards

NY Proton Center is a TOTAL, unabashed, shilling for protons, money making venture.

Chuck Simone is a smart man, and he is becoming a RICH man.
 
jondunn said:
I will give MDACC some tiny credit......in that at least when it comes to protons, NYProton makes MDACC looks like good stewards

NY Proton Center is a TOTAL, unabashed, shilling for protons, money making venture.

Chuck Simone is a smart man, and he is becoming a RICH man.
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You know what they say about someone understanding something when their salary depends on them not understanding it!
 
'I've been a poor man, and I've been a rich man. And I choose rich every f***ing time.'
 
RickyScott said:
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Glad to see it.

But what is "on study" in the proton world? Registry? Single institution phase I/II?

We need randomized data with assessment of cosmesis, local control, cardiac endpoints, etc. It's the most common treated site. We can do it, right?

Does the PCORI trial have contracture/cosmesis endpoints in the trial?
 
I reflected more on my flippant comment and it occurred to me: why would you do a proton/photon RTC if you can already use the “experimental” therapy, reap the marketing advantages, and bill higher for it? A positive outcome would have marginal gains with respect to any of those things. Possible reasons I can come up with:

Academic purism. I think this is real and I respect it. I am sure there are plenty of folks that genuinely believe in the broad superiority of protons and want to prove it to validate their belief. Are there enough of them in the right positions? I doubt it. I think I have a great chair but I assure you, if we had protons there is no chance they would support me doing something to risk that cash cow.

Cornering the market on a disease site. If you could show clear superiority it is not far fetched to see guidelines recommending protons preferred for that disease and current users would potentially gain a competitive advantage. But how realistic is that? Many people who have the means to travel already do. And how superior would they have to be for photon centers to start referring out en mass? Considering how hard it’s been to even find a signal this seems very unlikely to happen.

Venders could boost sales. No. Just. No. They have almost zero incentive. Could they maybe get a small boost? I guess. But think about the downside. Bad results could decrease reimbursement which could hurt demand.

Bottom line, I think a lot of people on both sides would love to see the RCTs for different reasons. But at the end of the day, the potential downsides seem to far outweigh the theoretical upsides. These are technically hard to do for a lot of reasons. So, why bother?

Again, none of this is specific to protons. I am quite confident you won’t be seeing any MR vs CT IGRT RCTs anytime soon…
 
NY proton center doing well financially I guess?
 
What does it mean that speculators and bond-buyers (and foreign interests) try and profit off of proton centers' treatment of cancer patients? Wouldn't it mean something is wrong with radiation oncology—who speaks out one side of its mouth that a ~$50m/year cut nationally for all doctors and centers is bad yet with the other side of its mouth lures folks to invest in single, local facilities costing double or triple this amount—and that something is wrong with the people who would build the centers?

Proton Therapy Center Bonds - Not A Pretty Picture​

 
TheWallnerus said:
What does it mean that speculators and bond-buyers (and foreign interests) try and profit off of proton centers' treatment of cancer patients? Wouldn't it mean something is wrong with radiation oncology—who speaks out one side of its mouth that a ~$50m/year cut nationally for all doctors and centers is bad yet with the other side of its mouth lures folks to invest in single, local facilities costing double or triple this amount—and that something is wrong with the people who would build the centers?

Proton Therapy Center Bonds - Not A Pretty Picture​

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What the heck is this?? Every time I think I have a handle on all the strings tugging on American Medicine, I realize how wrong I am.

These final two paragraphs are interesting, speculating that proton centers failing can make a lot of money for some people (probably not doctors or patients...):

1636982892354.png
 
TheWallnerus said:
What does it mean that speculators and bond-buyers (and foreign interests) try and profit off of proton centers' treatment of cancer patients? Wouldn't it mean something is wrong with radiation oncology—who speaks out one side of its mouth that a ~$50m/year cut nationally for all doctors and centers is bad yet with the other side of its mouth lures folks to invest in single, local facilities costing double or triple this amount—and that something is wrong with the people who would build the centers?

Proton Therapy Center Bonds - Not A Pretty Picture​

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That Georgia/Emory bond size is MASSIVE.

Bet Curran sleeps better at night with that off his ledger now.
 
elementaryschooleconomics said:
What the heck is this?? Every time I think I have a handle on all the strings tugging on American Medicine, I realize how wrong I am.

These final two paragraphs are interesting, speculating that proton centers failing can make a lot of money for some people (probably not doctors or patients...):

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OPC is not owned by ProCure. It's a group of former Provision execs who split off to specifically purchase the center. This article has a very strong bias.
 
What are these bonds are going to yield? It's hard to get any kind of return besides stocks, so probably a good bet by OPF
 
elementaryschooleconomics said:
What the heck is this?? Every time I think I have a handle on all the strings tugging on American Medicine, I realize how wrong I am.

These final two paragraphs are interesting, speculating that proton centers failing can make a lot of money for some people (probably not doctors or patients...):

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This also sounds a lot like the story behind the Emory proton center which I have only heard third hand.

It was literally a hole in the ground when it went “bankrupt”
 
It looks like the “proton international” twitter page was hacked and they are now selling knock off Raybans. Very sad stuff that it has come to this for some of these ventures folks!
 
seper said:
What are these bonds are going to yield? It's hard to get any kind of return besides stocks, so probably a good bet by OPF
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Sounds to me like bonds are sold to suckers to finance the center. When center goes belly up, company (or it’s hidden agent) comes in and buys it out of bankruptcy for pennies on the dollar, basically aquires proton center for next to nothing.
 
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There is a lot of grift that happens around bankrupcies. Vulture capitalist firms come in and acquire a ton of debt, pay themselves, then declare “bankrupcy”. It is essentially publicizing loses and privatizing gains.
 
thecarbonionangle said:
Emory has to keep feeding the beast and pay their debts!
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Something really shady went on with that center. I haven’t got the time to really deep dive into it, but Advanced Particle Therapy was the original developer.

There’s tons of articles from the time period where it got into trouble and eventually went bankrupt. Just use the Google.

The hard part is reconciling what was reported in the media, what is officially written as the history of the center on both their website and Emory websites, and what actually happened.

 
From Quora of all places: In describing use of bankruptcy laws by high wealth entities (aka private equity)

I create two companies A and B. Company A borrows heavily in order to pay for goods and services to B. When it becomes clear that A cannot borrow any longer, it declares bankruptcy and is dissolved. I lose all my equity in A but keep all revenues in B.

maxxor said:
It was literally a hole in the ground when it went “bankrupt”
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I'm guessing Zeitgeist (these names) felt that adequate early borrowing had occurred and it was time to stick it to bond holders et al? To what degree Zeitgeist and all are holders of the functional proton center? Who knows.

Such is the zeitgeist of this era of Radiation Oncology.
 
Fun facts:

The Loma Linda proton center was made possible, partly, by a US DOE grant shepherded via Lindy Boggs (whose daughter had died of choroidal melanoma) and Congressman Jerry Lewis, both of whom were impressed by a presentation James Slater gave them on the potential power of proton therapy. MGH would later boast in a book that it didn't need "pork barrel monies" to get its proton center off the ground.

Jerry Slater, current chair at Loma Linda, is James Slater's son. James Slater's other son became President of Optivus, a proton therapy company still in operation (evidently handling Loma Linda's proton operations?), in 1993.

news.llu.edu

In Memoriam: James M. Slater, pioneer of proton therapy, transformed cancer treatment | News

Founded proton treatment center at Loma Linda University Medical Center
news.llu.edu news.llu.edu
 
TheWallnerus said:
Fun facts:

The Loma Linda proton center was made possible, partly, by a US DOE grant shepherded via Lindy Boggs (whose daughter had died of choroidal melanoma) and Congressman Jerry Lewis, both of whom were impressed by a presentation James Slater gave them on the potential power of proton therapy. MGH would later boast in a book that it didn't need "pork barrel monies" to get its proton center off the ground.

Jerry Slater, current chair at Loma Linda, is James Slater's son. James Slater's other son became President of Optivus, a proton therapy company still in operation (evidently handling Loma Linda's proton operations?), in 1993.

news.llu.edu

In Memoriam: James M. Slater, pioneer of proton therapy, transformed cancer treatment | News

Founded proton treatment center at Loma Linda University Medical Center
news.llu.edu news.llu.edu
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Loma linda is a hellpit place. Hellpit terrible proton machine. Hellpit program. Hellpit place which is too busy hiring their own sons and daughters. Disgusting filth!
 
It is a strange strange place indeed.

Gives me the creeps!
 
TheWallnerus said:
all proton places now SpaceOAR their prostate patients. Which if true is pretty telling.
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Alas! The Germans figured out that the spacer was the actual cause of the fistulas they were seeing! Of course it could never ever be the protons. Had the Germans just waited until Boston Scientific owned SpaceOAR...



1639009830801.jpeg
 
SneakyBooger said:
Alas! The Germans figured out that the spacer was the actual cause of the fistulas they were seeing! Of course it could never ever be the protons. Had the Germans just waited until Boston Scientific owned SpaceOAR...



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Dang...

Not sure how much this plays a role, in our locality the spaceOAR reps are with you for every gel placement until they and you feel confident doing it alone. If there is ever a real concern we abort. 2 consecutive occurrences might have more to do more with user than product here. Per methods the "Department of Urology of the Heidelberg University Hospital" placed the gel...
 
SneakyBooger said:
Alas! The Germans figured out that the spacer was the actual cause of the fistulas they were seeing! Of course it could never ever be the protons. Had the Germans just waited until Boston Scientific owned SpaceOAR...



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What a misleading ("spun") abstract. Again, I come from the standpoint of being pro-proton and pro-SpaceOAR in appropriately selected patients, but to clarify IN THE ABSTRACT about the SpaceOAR-fistula hypothesis without also clarifying (in the abstract) how many patients received SpaceOAR...this reeks of agenda.

Since it's not in this screenshot, and I don't have the full PDF in front of me - I assume 2 out of 46 proton patients prescribed a relatively vanilla treatment scheme developed Grade 3 fistulas? If someone told me one out of every 20 of their prostate patients developed a fistula, I would be concerned about their technique.
 
elementaryschooleconomics said:
What a misleading ("spun") abstract. Again, I come from the standpoint of being pro-proton and pro-SpaceOAR in appropriately selected patients, but to clarify IN THE ABSTRACT about the SpaceOAR-fistula hypothesis without also clarifying (in the abstract) how many patients received SpaceOAR...this reeks of agenda.

Since it's not in this screenshot, and I don't have the full PDF in front of me - I assume 2 out of 46 proton patients prescribed a relatively vanilla treatment scheme developed Grade 3 fistulas? If someone told me one out of every 20 of their prostate patients developed a fistula, I would be concerned about their technique.
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Presumably all patients got spaceOAR, per their protocol (Ion Prostate Irradiation (IPI) – a pilot study to establish the safety and feasibility of primary hypofractionated irradiation of the prostate with protons and carbon ions in a raster scan technique - BMC Cancer)

Also, 8% of patients having urinary retention requiring a Foley during treatment sounds pretty high. I didn't realize this was classified as a grade 2, always thought grade 3.
 
Radonky said:
Presumably all patients got spaceOAR, per their protocol (Ion Prostate Irradiation (IPI) – a pilot study to establish the safety and feasibility of primary hypofractionated irradiation of the prostate with protons and carbon ions in a raster scan technique - BMC Cancer)

Also, 8% of patients having urinary retention requiring a Foley during treatment sounds pretty high. I didn't realize this was classified as a grade 2, always thought grade 3.
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Well that makes it even more interesting - I grabbed the whole paper, I think you're right:

1639051255818.png

1639051291477.png

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So:

1) All patients got SpaceOAR
2) No carbon patients developed fistulas
3) 2 out of 46 proton patients developed fistulas
4) The authors blamed SpaceOAR

I...don't think the author's conclusion is supported by evidence.
 
elementaryschooleconomics said:
Well that makes it even more interesting - I grabbed the whole paper, I think you're right:

View attachment 346626
View attachment 346627
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So:

1) All patients got SpaceOAR
2) No carbon patients developed fistulas
3) 2 out of 46 proton patients developed fistulas
4) The authors blamed SpaceOAR

I...don't think the author's conclusion is supported by evidence.
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Maybe not, but added to the collective evidence out there, what is net benefit/risk use of spaceOAR in the average patient esp getting photons?

They felt the need to use it in every pt getting particle therapy and that should say something about the therapy itself imo....
 
im not even super anti proton, but the use of it for prostate cancer confuses the hell out of me. worse than requiring a spacer are the folks who put a rectal balloon for all 39 fractions or whatever. nuts
 
jondunn said:
worse than requiring a spacer are the folks who put a rectal balloon for all 39 fractions or whatever. nuts
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Call it "The Anality of Evil."

"Making patients come in twice a day for three weeks of lung RT? I can't get a single patient to accept that. Too inconvenient. But shoving a foreign object up my patients' butts for every fraction of RT for nine weeks? All my patients accept it, no questions."
 
elementaryschooleconomics said:
Well that makes it even more interesting - I grabbed the whole paper, I think you're right:

View attachment 346626
View attachment 346627
View attachment 346628

So:

1) All patients got SpaceOAR
2) No carbon patients developed fistulas
3) 2 out of 46 proton patients developed fistulas
4) The authors blamed SpaceOAR

I...don't think the author's conclusion is supported by evidence.
Click to expand...
www.sciencedirect.com

Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy

To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cance…
www.sciencedirect.com www.sciencedirect.com

51 proton patients had spaceOAR, no fistula.

You don't think its more likely user placement (urology placed spaceOAR within the rectal wall, not reported to trialists, who found out after the fact)?
 
Radonky said:
www.sciencedirect.com

Assessment of Polyethylene Glycol Hydrogel Spacer and Its Effect on Rectal Radiation Dose in Prostate Cancer Patients Receiving Proton Beam Radiation Therapy

To assess the efficacy of placing a polyethylene glycol (PEG) spacing hydrogel in patients undergoing proton beam radiation therapy for prostate cance…
www.sciencedirect.com www.sciencedirect.com

51 proton patients had spaceOAR, no fistula.

You don't think its more likely user placement (urology placed spaceOAR within the rectal wall, not reported to trialists, who found out after the fact)?
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Given the information, as presented, in that paper - I don't know.

Out of professional courtesy, I doubt they would have explicitly thrown a colleague under the bus, with something along the lines of "a new Urologist joined the hospital and had zero SpaceOAR experience and messed it up so we stopped". Perhaps that was why they used the phrasing "two consecutive patients", leaving us to interpret human error as the culprit, but that requires heavy "reading between the lines", which is not usually a component of the scientific method (haha).

The only objective statements we can make about the data is that all patients got SpaceOAR, half of the patients got protons and the other half got carbon, 2 of the 46 proton patients got fistulas, zero of the carbon patients got fistulas, the authors concluded SpaceOAR was to blame and discontinued the use for all patients thereafter.

I, personally, am certainly not saying "the use of protons in prostate radiation has a higher incidence of rectal fistula compared to photon or carbon ion radiation", as a general statement. However, to me, in this singular Phase II trial, the data suggests protons are just as likely - perhaps more likely - to be the cause of the fistula formation instead of SpaceOAR.

While 4.3% of the proton patients developed fistula in this study, in terms of absolute numbers it's still a relatively small number, so I wouldn't be comfortable stating anything confidently based on this data alone.
 
elementaryschooleconomics said:
Given the information, as presented, in that paper - I don't know.

Out of professional courtesy, I doubt they would have explicitly thrown a colleague under the bus, with something along the lines of "a new Urologist joined the hospital and had zero SpaceOAR experience and messed it up so we stopped". Perhaps that was why they used the phrasing "two consecutive patients", leaving us to interpret human error as the culprit, but that requires heavy "reading between the lines", which is not usually a component of the scientific method (haha).

The only objective statements we can make about the data is that all patients got SpaceOAR, half of the patients got protons and the other half got carbon, 2 of the 46 proton patients got fistulas, zero of the carbon patients got fistulas, the authors concluded SpaceOAR was to blame and discontinued the use for all patients thereafter.

I, personally, am certainly not saying "the use of protons in prostate radiation has a higher incidence of rectal fistula compared to photon or carbon ion radiation", as a general statement. However, to me, in this singular Phase II trial, the data suggests protons are just as likely - perhaps more likely - to be the cause of the fistula formation instead of SpaceOAR.

While 4.3% of the proton patients developed fistula in this study, in terms of absolute numbers it's still a relatively small number, so I wouldn't be comfortable stating anything confidently based on this data alone.
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I feel comfortable telling a patient that SpaceOAR or protons are associated with higher rates of fistula. There’s no p value I can give except for that one retrospective analysis that showed higher rates of GI toxicity with protons. But I don’t find the data neutral, or falsifying, otherwise.
 
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