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

[thecarbonionangle]

No. 327 on the List of Why We Can't Have Nice Things in Rad Onc. The ECG thing is no. 52.

The MLD and MHD will be much lower with protons in a patient who will be possibly dead before any side effects happen. Choose wisely folks!

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[brushbeamscanning]

At the risk of doxxing myself but I wouldn't pass judgement on proton CSI until the phase II trial results are published/announced. It may be difficult to justify the cost but there may be a measurable (?meaningful) benefit.

 

[thecarbonionangle]

At the risk of doxxing myself but I wouldn't pass judgement on proton CSI until the phase II trial results are published/announced. It may be difficult to justify the cost but there may be a measurable (?meaningful) benefit.

i could see some benefit of some end point but the discussion will be is it worth it for the cost? what do you think would be an end point which would justify cost against a 3d or VMAT CSI plan?

For me I could see maybe someone with anthracycline cardiotoxocity who is otherwise doing well and no other sites of disease. Maybe could justify but others would argue this patient has a terrible prognosis anyways. Do med oncs let cost hold them back from a very expensive drug with a few months of PFS benefit? Probably not… interesting discussion.

 

[elementaryschooleconomics]

At the risk of doxxing myself but I wouldn't pass judgement on proton CSI until the phase II trial results are published/announced.

Proton CSI for...leptomeningeal disease in metastatic patients?

The patients treated in the QuadShot study had a median OS of 8 months (the nodular variant).

I definitely don't want to imply I don't think there's efficacy of proton CSI here, there's certainly a signal. My larger point is: why? Does this HAVE to be protons? Couldn't we theoretically do photon CSI?

This specialty is just LASER focused on fractions and cost and we're hyping proton CSI for lepto??

 

[TheWallnerus]

It may be difficult to justify the cost but there may be a measurable (?meaningful) benefit.

I definitely don't want to imply I don't think there's efficacy of proton CSI here, there's certainly a signal

Do we really want rad onc to turn into a specialty where we are "signal-finders" to become achievers of modest toxicity reductions by way of $100 million dollar machines being used on people with terminal cancer illnesses? Dan Spratt would say "you bet your ass."

 

[TheWallnerus]

Do med oncs let cost hold them back from a very expensive drug with a few months of PFS benefit? Probably not… interesting discussion.

One thing I will say about the med onc vs rad onc costs debate. Correct me if I'm wrong. But when a very expensive drug appears in the med onc space, it starts out sky high. Then, with increasing use over many years, the costs come down by order of magnitude or more. We really don't see this in rad onc. We will always have to pay for expensive machines. Drug companies have to pay for R&D. It's always gonna cost $1m to make a linac. It may only cost a penny to produce a single great immunotherapy tablet that the patient just swallowed. Are we engaged in asymmetric warfare in our "battle" against drug costs?

 

[communitydoc13]

I'm not CSI-ing any adults with metastatic disease and leptomeningeal disease period. They can get whole brain and then focal radiation for symptomatic spinal disease. I don't feel bad about this. Should I?

 

[TheWallnerus]

I'm not CSI-ing any adults with metastatic disease and leptomeningeal disease period. They can get whole brain and then focal radiation for symptomatic spinal disease. I don't feel bad about this. Should I?

That's a real good point. Whole brain RT barely/difficultly makes a case for survival prolonging sometimes, or QALY-improving, and that's disease confined to the CNS brain. When disease spreads throughout the whole CNS, do we know CSI is survival prolonging? Large dataset or randomized data only, preferably. Nothing jumps out of the mental rolodex.

EDIT: answered own qu

 

[elementaryschooleconomics]

I'm not CSI-ing any adults with metastatic disease and leptomeningeal disease period. They can get whole brain and then focal radiation for symptomatic spinal disease. I don't feel bad about this. Should I?

If you need to feel bad about this, then so should I, because I totally agree.

I'm just very confused about this study. I would have normally skimmed it, but the combo of proton CSI + lepto really caught my eye.

 

[jondunn]

It’s going to give false hope to many patients

 

[evilbooyaa]

At the risk of doxxing myself but I wouldn't pass judgement on proton CSI until the phase II trial results are published/announced. It may be difficult to justify the cost but there may be a measurable (?meaningful) benefit.

Protons for CSI in LMD patients?

Talk about the haves and the have-nots.

Unreal.

Holy **** @elementaryschooleconomics it's real, published phase I data with proton CSI in LMB patients: Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

I'm glad the article linked talks about how much less toxic protons are compared to photons in CURATIVE INTENT MEDULLOBLASTOMA: Proton beam craniospinal irradiation reduces acute toxicity for adults with medulloblastoma - PubMed

IMO, protons should only be considered to be given for curative intent. But man, there's really no rules, and it's funny to think that some folks look down on IMRT for palliation, when we're OK with MSKCC bilking 50+ patients insurances for hundreds of thousands of dollars for protons for CSI in patients with solid malignancies with leptomeningeal disease.

 

[evilbooyaa]

I'm not CSI-ing any adults with metastatic disease and leptomeningeal disease period. They can get whole brain and then focal radiation for symptomatic spinal disease. I don't feel bad about this. Should I?

No you should not. Those who are CSI'ing LMD from a solid tumor in anything but the rarest of clinical situations should feel bad, IMO.

 

[elementaryschooleconomics]

Protons for CSI in LMD patients?

Talk about the haves and the have-nots.

Unreal.

Holy **** @elementaryschooleconomics it's real, published phase I data with proton CSI in LMB patients: Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

I'm glad the article linked talks about how much less toxic protons are compared to photons in CURATIVE INTENT MEDULLOBLASTOMA: Proton beam craniospinal irradiation reduces acute toxicity for adults with medulloblastoma - PubMed

IMO, protons should only be considered to be given for curative intent. But man, there's really no rules, and it's funny to think that some folks look down on IMRT for palliation, when we're OK with MSKCC bilking 50+ patients insurances for hundreds of thousands of dollars for protons for CSI in patients with solid malignancies with leptomeningeal disease.

I don't feel like looking at MSKCC terrible "price transparency" CSV file right now, so I'll just go to this paper:

This is just wild to me.

Why is this wild to me?

Well, from the same institution today:

SO HELP ME GOD, QUADSHOT, IF YOU PUT ERIN'S STUDY IN YOUR EMAIL THIS WEEK AFTER SENDING OUT PROTONS FOR CSI TODAY...

 

[radiation]

Protons for CSI in LMD patients?

Talk about the haves and the have-nots.

Unreal.

Holy **** @elementaryschooleconomics it's real, published phase I data with proton CSI in LMB patients: Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

I'm glad the article linked talks about how much less toxic protons are compared to photons in CURATIVE INTENT MEDULLOBLASTOMA: Proton beam craniospinal irradiation reduces acute toxicity for adults with medulloblastoma - PubMed

IMO, protons should only be considered to be given for curative intent. But man, there's really no rules, and it's funny to think that some folks look down on IMRT for palliation, when we're OK with MSKCC bilking 50+ patients insurances for hundreds of thousands of dollars for protons for CSI in patients with solid malignancies with leptomeningeal disease.

The actual data from the paper is pretty reasonable, median survival 8 months with some long term survivors. I think trying to improve quality of life in someone living 6 months or more is not something that should be dismissed and I am huge proton skeptic. Their quality of life data is hard to argue, I have done plenty of VMAT CSI and it is hard to pts through especially with counts bottoming out where they can't continue systemic therapy. MSKCC definitely has selection bias and it shows, but if you can reliably pick out a population that is not going to immediately die its far from an unreasonable thing to consider (especially if you can pick out the winners with CTCs).

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

AbstractBackground. Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effecti

academic.oup.com

As a comparison, look at the curves for CC-001. Is hippocampal avoidance a waste in this mostly terminal population? @Neuronix says he does protons for meningiomas, would be curious what his thoughts are

 

[medgator]

No you should not. Those who are CSI'ing LMD from a solid tumor in anything but the rarest of clinical situations should feel bad, IMO.

About as bad as the med oncs trying to push IT chemo on them?

 

[elementaryschooleconomics]

The actual data from the paper is pretty reasonable, median survival 8 months with some long term survivors. I think trying to improve quality of life in someone living 6 months or more is not something that should be dismissed and I am huge proton skeptic. Their quality of life data is hard to argue, I have done plenty of VMAT CSI and it is hard to pts through especially with counts bottoming out where they can't continue systemic therapy. MSKCC definitely has selection bias and it shows, but if you can reliably pick out a population that is not going to immediately die its far from an unreasonable thing to consider (especially if you can pick out the winners with CTCs).

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

AbstractBackground. Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effecti

academic.oup.com

View attachment 348480

As a comparison, look at the curves for CC-001. Is hippocampal avoidance a waste in this mostly terminal population? @Neuronix says he does protons for meningiomas, would be curious what his thoughts are
View attachment 348477

This is a totally reasonable opinion.

However, why is it OK for us to consider quality of life by utilizing proton CSI for lepto but not OK for us to prefer conventional fractionation for prostate, which has a lower incidence of GU/GI toxicity compared to moderate hypofrac?

I know I'm painting in unfairly broad strokes, and the people publishing protons for lepto are probably not the same people publishing on the evils of conventional fractionation for prostate, but this concept feels very hypocritical.

 

[lyltothend]

The actual data from the paper is pretty reasonable, median survival 8 months with some long term survivors. I think trying to improve quality of life in someone living 6 months or more is not something that should be dismissed and I am huge proton skeptic. Their quality of life data is hard to argue, I have done plenty of VMAT CSI and it is hard to pts through especially with counts bottoming out where they can't continue systemic therapy. MSKCC definitely has selection bias and it shows, but if you can reliably pick out a population that is not going to immediately die its far from an unreasonable thing to consider (especially if you can pick out the winners with CTCs).

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

AbstractBackground. Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effecti

academic.oup.com

View attachment 348480

As a comparison, look at the curves for CC-001. Is hippocampal avoidance a waste in this mostly terminal population? @Neuronix says he does protons for meningiomas, would be curious what his thoughts are
.

The actual data from the paper is pretty reasonable, median survival 8 months with some long term survivors. I think trying to improve quality of life in someone living 6 months or more is not something that should be dismissed and I am huge proton skeptic. Their quality of life data is hard to argue, I have done plenty of VMAT CSI and it is hard to pts through especially with counts bottoming out where they can't continue systemic therapy. MSKCC definitely has selection bias and it shows, but if you can reliably pick out a population that is not going to immediately die its far from an unreasonable thing to consider (especially if you can pick out the winners with CTCs).

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases

AbstractBackground. Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effecti

academic.oup.com

View attachment 348480

As a comparison, look at the curves for CC-001. Is hippocampal avoidance a waste in this mostly terminal population? @Neuronix says he does protons for meningiomas, would be curious what his thoughts are
View attachment 348477

Excellent, The Norwegians are going to be thrilled when they do the math and find that there actually is an intervention with a lower QALY than SpaceOar.

 

[Neuronix]

I do CSI for LMD in selected cases. I just don't really have time to post right now to argue my case.

 

[elementaryschooleconomics]

I do CSI for LMD in selected cases. I just don't really have time to post right now to argue my case.

"In select cases", I could see a point in doing it.

Of note, I see you just said "CSI", not "proton CSI".

I think in cases of nodular lepto (NOT carcinomatosis), photon-based (VMAT) CSI is something that's on the table.

If you, or anyone else, can present a compelling argument for proton-based CSI over photon-based CSI in the scenario of young, high KPS, low burden of disease, etc - my mind is open!

 

[TheWallnerus]

"In select cases", I could see a point in doing it.

Of note, I see you just said "CSI", not "proton CSI".

I think in cases of nodular lepto (NOT carcinomatosis), photon-based (VMAT) CSI is something that's on the table.

If you, or anyone else, can present a compelling argument for proton-based CSI over photon-based CSI in the scenario of young, high KPS, low burden of disease, etc - my mind is open!

I wish I could say my mind is open.

I spent too much time hanging around the psychiatrists in med school who said “Always keep a dirty mind.”

 

[Tsigolonco noitaidar]

This is a totally reasonable opinion.

However, why is it OK for us to consider quality of life by utilizing proton CSI for lepto but not OK for us to prefer conventional fractionation for prostate, which has a lower incidence of GU/GI toxicity compared to moderate hypofrac?

I know I'm painting in unfairly broad strokes, and the people publishing protons for lepto are probably not the same people publishing on the evils of conventional fractionation for prostate, but this concept feels very hypocritical.

Speaking of hypocritical, I think it’s hypocritical to admonish the use of protons without data and then get all in a tizzy when a proton study in Quadshot shows actual data...

 

[communitydoc13]

a compelling argument for proton-based CSI over photon-based CSI in the scenario of young, high KPS, low burden of disease, etc - my mind is open

As is clear from my prior posts on this thread, I'm convinced proton dosimetry is ****e for detailed work (any target close to an OAR where the prescription dose is associated with significant toxicity or is near threshold for severe toxicity). However, I don't have a problem with patients as you describe getting proton CSI.

The data here is just a feasibility study. It's not very helpful and does not establish value over other approaches. Heck, I don't think there is data establishing value of CSI over WBRT with XRT of symptomatic spinal disease only in this setting. I'm happy to be proven wrong.

I would never ever compare MSKCC outcomes with mine. Our patients are from different planets. My lung patients are 10 years older than average on Pacific Trial. I suspect that my younger patients are much more likely to be poor, have severe medical comorbidities and unhealthy lifestyles.

However, CSI prescriptions are low dose, where 130% hot spots unlikely to harm patient. They also have a nice buffer to dump dose into vertebral bodies. Cytopenias probably matter in these patients and as we learned from rad-bio, hematologic toxicity is a low dose, high volume phenomenon.

Is proton CSI a high value intervention? Of course not. I'm sure any QOLY calculation would demonstrate miniscule benefit.

Does the aggregate incidence of high performance status, good systemic control, relatively young patients with leptomeningeal disease, including spinal leptomeningeal disease, justify more than a handful of proton centers nationally? Of course not.

Is proton CSI within reason for the 40 year old mother with reasonably well controlled systemic disease and leptomeningeal disease, including definitive spinal disease? I think so, but it is also true that I have had patient's like this with Her2 positive breast CA, who got WBRT, were thrown on TDM-1 therapy and are now years out and doing well.

 

[TheWallnerus]

Speaking of hypocritical, I think it’s hypocritical to admonish the use of protons without data and then get all in a tizzy when a proton study in Quadshot shows actual data...

Aw cmon man. We want data that didn’t take bribing a dosimetrist with donuts.

That’s Don’t Look Up data. I don’t even know what means but it sounds funny. That data will cross an informational event horizon in short order and never have meaningful interaction with the rad onc universe again.

 

[elementaryschooleconomics]

Speaking of hypocritical, I think it’s hypocritical to admonish the use of protons without data and then get all in a tizzy when a proton study in Quadshot shows actual data...

???

To be crystal clear, I am absolutely not saying I don't believe the data. Also, I think the point of the data is more about the CTC-CSF component than the radiation modality.

My larger point: it is my perception that for at least the last 10-15 years, a major focus of Radiation Oncology has been on cost. We have been accused, both from within and without, of doing things "just for money" because American medicine reimburses procedures highly, and each fraction of radiation is considered a procedure.

Our most "groundbreaking" clinical data in this timeframe has been the adoption of moderate hypofractionation or SBRT for common disease sites. It is either implied or stated outright that using longer courses, which costs more money, is bad. Concurrently, we have seen the rise of proton centers, which generally cost more money than their photon counterparts.

Ironically, a significant percentage of the work published on how "costly" radiation therapy is comes from PPS-exempt centers (that may or may not be very selective about which type of patients they take - try having Medicaid and going to Anderson), who derive, on average, significantly more reimbursement than other institutions and practices. Over the past couple years, the faculty at Sloan have been particularly visible in the "financial toxicity" space.

Leptomeningeal disease, especially leptomeningeal carcinomatosis, has a dismal prognosis. I think most physicians who work with patients with that diagnosis pivot towards best supportive care, as is appropriate. While, as @communitydoc13 points out, there are therapies and patients which can exceed expectations, this is not the norm. Lepto often carries a prognosis of weeks-to-months. Even in this CTC-CSF paper with protons, median OS was 8 months in the best case scenario. Proton-based CSI for lepto is, by definition, "non-concordant with guidelines".

All of this culminates in a paradox on my Twitter feed: Sloan trumpets a paper decrying the inappropriate use of XRT at the end of life, then presents us with a paper using proton CSI for lepto within the same week.

I know it doesn't seem that way, but I actually like this paper.

That's not my point. What has "gotten me into a tizzy" is how hypocritical this all is. Sloan is held up as one of the best/most influential institutions on the planet. However, on a granular level, leadership is forced to resign after not disclosing millions of dollars in COI, or an active KOL in the GU space advocates the use of a gel after receiving $500k+ from the company making that gel, or a group publishes yet another paper about the evils of extended fractionation at the end of life while simultaneously another group from the same institution publishes another paper using proton CSI for leptomeningeal disease.

Individually at Sloan, there are a lot of people who I really respect and find their work excellent. On a macro level, the institution is driven by greed, and engages in publications and practices which has a negative effect on the rest of us. If physicians think using proton CSI for lepto is beneficial, then great, those physicians should practice medicine the way they think is best. However, please don't turn around and finger wag because someone else used 15 fractions on a bone met.

(note: I personally don't use protons for lepto or 15 fractions on bone mets, and am not advocating for either)

 

[Lamount]

???

To be crystal clear, I am absolutely not saying I don't believe the data. Also, I think the point of the data is more about the CTC-CSF component than the radiation modality.

My larger point: it is my perception that for at least the last 10-15 years, a major focus of Radiation Oncology has been on cost. We have been accused, both from within and without, of doing things "just for money" because American medicine reimburses procedures highly, and each fraction of radiation is considered a procedure.

Our most "groundbreaking" clinical data in this timeframe has been the adoption of moderate hypofractionation or SBRT for common disease sites. It is either implied or stated outright that using longer courses, which costs more money, is bad. Concurrently, we have seen the rise of proton centers, which generally cost more money than their photon counterparts.

Ironically, a significant percentage of the work published on how "costly" radiation therapy is comes from PPS-exempt centers (that may or may not be very selective about which type of patients they take - try having Medicaid and going to Anderson), who derive, on average, significantly more reimbursement than other institutions and practices. Over the past couple years, the faculty at Sloan have been particularly visible in the "financial toxicity" space.

Leptomeningeal disease, especially leptomeningeal carcinomatosis, has a dismal prognosis. I think most physicians who work with patients with that diagnosis pivot towards best supportive care, as is appropriate. While, as @communitydoc13 points out, there are therapies and patients which can exceed expectations, this is not the norm. Lepto often carries a prognosis of weeks-to-months. Even in this CTC-CSF paper with protons, median OS was 8 months in the best case scenario. Proton-based CSI for lepto is, by definition, "non-concordant with guidelines".

All of this culminates in a paradox on my Twitter feed: Sloan trumpets a paper decrying the inappropriate use of XRT at the end of life, then presents us with a paper using proton CSI for lepto within the same week.

I know it doesn't seem that way, but I actually like this paper.

That's not my point. What has "gotten me into a tizzy" is how hypocritical this all is. Sloan is held up as one of the best/most influential institutions on the planet. However, on a granular level, leadership is forced to resign after not disclosing millions of dollars in COI, or an active KOL in the GU space advocates the use of a gel after receiving $500k+ from the company making that gel, or a group publishes yet another paper about the evils of extended fractionation at the end of life while simultaneously another group from the same institution publishes another paper using proton CSI for leptomeningeal disease.

Individually at Sloan, there are a lot of people who I really respect and find their work excellent. On a macro level, the institution is driven by greed, and engages in publications and practices which has a negative effect on the rest of us. If physicians think using proton CSI for lepto is beneficial, then great, those physicians should practice medicine the way they think is best. However, please don't turn around and finger wag because someone else used 15 fractions on a bone met.

(note: I personally don't use protons for lepto or 15 fractions on bone mets, and am not advocating for either)

To be fair, MSKCC is an institution, not a person. It's tricky to argue that an institution is 'hypocritical'. Should the scientists who did the CSI study have checked with the scientists who did the cost-effectiveness study before they published? Should all MSKCC rad onc research be "coordinated" to be "on message"? Should the fact that they all work for the same health system affect which questions they are allowed to investigate?

 

[RadOncDoc21]

To be fair, MSKCC is an institution, not a person. It's tricky to argue that an institution is 'hypocritical'. Should the scientists who did the CSI study have checked with the scientists who did the cost-effectiveness study before they published? Should all MSKCC rad onc research be "coordinated" to be "on message"? Should the fact that they all work for the same health system affect which questions they are allowed to investigate?

Yes… that’s the pros and cons of being an institution. Logistically challenging but you have to take the good with the bad.

Do all 21c docs suck… of course not!

 

[thesauce]

One thing I will say about the med onc vs rad onc costs debate. Correct me if I'm wrong. But when a very expensive drug appears in the med onc space, it starts out sky high. Then, with increasing use over many years, the costs come down by order of magnitude or more. We really don't see this in rad onc. We will always have to pay for expensive machines. Drug companies have to pay for R&D. It's always gonna cost $1m to make a linac. It may only cost a penny to produce a single great immunotherapy tablet that the patient just swallowed. Are we engaged in asymmetric warfare in our "battle" against drug costs?

But they are always coming out with new drugs and variations on those older drugs to keep the costs high. Yes, Keytruda is expensive now and will drop over time but Keytruda won’t be used in 5 years (hell probably 3 years) and we’ll have a new immunotherapy that costs billions to replace it.

 

[elementaryschooleconomics]

To be fair, MSKCC is an institution, not a person. It's tricky to argue that an institution is 'hypocritical'. Should the scientists who did the CSI study have checked with the scientists who did the cost-effectiveness study before they published? Should all MSKCC rad onc research be "coordinated" to be "on message"? Should the fact that they all work for the same health system affect which questions they are allowed to investigate?

Completely agree - they don't deserve to be painted as a monolith, like I'm doing.

However, we also shouldn't be painting the use of, let's say, conventional fractionation for prostate as universally bad, for the same reason.

And I certainly don't mean to imply anyone is doing that. However, all these studies have consequences. The ASTRO white papers or breast and prostate drive insurance reimbursement.

I read these papers and think about potential butterfly effects - we now have justification in the literature for proton CSI for lepto, and more ammo for CMS to come after us with reimbursement cuts because of "inappropriate use of XRT at the end of life".

Perhaps I'm being pessimistic.

 

[Mandelin Rain]

But they are always coming out with new drugs and variations on those older drugs to keep the costs high. Yes, Keytruda is expensive now and will drop over time but Keytruda won’t be used in 5 years (hell probably 3 years) and we’ll have a new immunotherapy that costs billions to replace it.

Half the time it’s just repackaging the same drug as an injectable, or depot, or pill, or whatever

 

[evilbooyaa]

To be fair, MSKCC is an institution, not a person. It's tricky to argue that an institution is 'hypocritical'. Should the scientists who did the CSI study have checked with the scientists who did the cost-effectiveness study before they published? Should all MSKCC rad onc research be "coordinated" to be "on message"? Should the fact that they all work for the same health system affect which questions they are allowed to investigate?

Every MSKCC published study that lands up on twitter, that suggests that people who do 10Fx or higher for bone mets is a problem due to direct or indirect "money grubbing", should have a reply from someone asking if this is the same MSKCC that does PROTON CSI for LEPTOMENINGEAL disease without any data.

 

[deleted941485]

Every MSKCC published study that lands up on twitter, that suggests that people who do 10Fx or higher for bone mets is a problem due to direct or indirect "money grubbing", should have a reply from someone asking if this is the same MSKCC that does PROTON CSI for LEPTOMENINGEAL disease without any data.

If they were paid what a freestanding or even a community center was paid, I suspect their self righteous indignation would evaporate.

They are only as noble as their financial situation allows them to be.

 

[communitydoc13]

But they are always coming out with new drugs and variations on those older drugs to keep the costs high.

In terms of value based care, I really have to question even NCI based entities like NRG. NRG-GU008 and GU-009 are classic examples and I know I harp on them, but I've never gotten a good explanation why the expensive drug apalutamide was included, when abiraterone alone in these patient populations is not well studied. (To my knowledge, the non-metastatic cohort on Stampede is why many of us (I do) incorporate abiraterone for very high risk localized patients). Both trials should have been just +/- abiraterone IMO.

When they modified GU008 from combo apa/abi to single agent, they chose to keep apa? Why? Hard for me not to be cynical about this and not believe long arm of pharma at play.

Instead of defining the scope of the now cheap abiraterone's utility in the salvage/high risk cohorts of patients, we are trying to establish a new de-factor SOC where apa is included here?

 

[deleted1111261]

Wasn’t there another proton palliation study they had? Sarcoma or something ?

 

[RickyScott]

I have given csi with vmat to 2 hormone naïve breast pts at diseas presentation and both tolerated treatment well and lived about 2 years. Not sure what protons would really add.

 

[OTN]

I have given csi with vmat to 2 hormone naïve breast pts at diseas presentation and both tolerated treatment well and lived about 2 years. Not sure what protons would really add.

That has been my exact experience as well.

 

[communitydoc13]

ClinicalTrials.gov

clinicaltrials.gov

Credit to MSKCC here. Doesn't address proton vs photon CSI, but does address CSI vs targeted RT

 

[RSAOaky]

"You're not wrong Walter, you're just an *sshole."

This Gillespie study is just yet another example of people doing low value work and picking low hanging fruit that puts everyone else in the crosshairs of CMS for inappropriate utilization of resources for the purpose of advancing their CVs. She has the backing, voice, and recognition of a world renowned institution so her SEER study makes it into JAMA and Medscape and opens all of us up to more scrutiny.

It's all just so disingenuous. Fumiko Chino and Erin Gillespie publish articles about overutilization of radiation and financial toxicity of cancer treatment using fraction number as surrogates for cost, coming from an institution that charges more for 1 fraction than most of us do for 20. If they really gave a **** about either of those things as more than just a notch on their CV they'd do some actual MEANINGFUL work and show us what their institution charges for these courses and the amount of money spent on "high quality end of life care" at MSKCC. I've heard that 80% of the money spent on protons at certain CMS exempt institutions is spent in the last year of patients' lives. Unfortunately they have the voice to make the rules we all have to play by while simultaneously playing by a completely different set of them.

As an aside, as an employed physician I get an extra OTV and an extra port film for 30 in 10 vs 20 in 5. That's ~4 wRVU's total, or $200 in my pocket, $120 after taxes. It's an irrelevant amount of money and it's not my motivation. I just feel that it's a better regimen for patients so it's my go to.

 

[evilbooyaa]

Wasn’t there another proton palliation study they had? Sarcoma or something ?

Recurrent H&N tx w/ proton QUAD-SHOT. B/c the photon treatment that was built to have zero toxicity requires protons. I suppose maybe some theoretical benefit for those receiving a lot of QUAD-SHOT (in fairness, 65% of the cohort)

Proton Radiotherapy for Recurrent or Metastatic Head and Neck Cancers with Palliative Quad Shot - PubMed

The proton quad-shot regimen demonstrates favorable palliative response and toxicity profile, even in patients that received prior RT.

pubmed.ncbi.nlm.nih.gov

Oops, one for recurrent sarcoma as well. Protons for palliative QUAD-SHOT seems to be ALL over the place at MSKCC

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[deleted1111261]

Jeez. I want to post these, but don’t really want to be so inflammatory…

But impulse control isn’t really my strong suit, I guess !

 

[theradiator]

"You're not wrong Walter, you're just an *sshole."

This Gillespie study is just yet another example of people doing low value work and picking low hanging fruit that puts everyone else in the crosshairs of CMS for inappropriate utilization of resources for the purpose of advancing their CVs. She has the backing, voice, and recognition of a world renowned institution so her SEER study makes it into JAMA and Medscape and opens all of us up to more scrutiny.

It's all just so disingenuous. Fumiko Chino and Erin Gillespie publish articles about overutilization of radiation and financial toxicity of cancer treatment using fraction number as surrogates for cost, coming from an institution that charges more for 1 fraction than most of us do for 20. If they really gave a **** about either of those things as more than just a notch on their CV they'd do some actual MEANINGFUL work and show us what their institution charges for these courses and the amount of money spent on "high quality end of life care" at MSKCC. I've heard that 80% of the money spent on protons at certain CMS exempt institutions is spent in the last year of patients' lives. Unfortunately they have the voice to make the rules we all have to play by while simultaneously playing by a completely different set of them.

As an aside, as an employed physician I get an extra OTV and an extra port film for 30 in 10 vs 20 in 5. That's ~4 wRVU's total, or $200 in my pocket, $120 after taxes. It's an irrelevant amount of money and it's not my motivation. I just feel that it's a better regimen for patients so it's my go to.

I agree with these comments. It is important to highlight prior research from that research group.

Replacing 30 Gy in 10 fractions with stereotactic body radiation therapy for bone metastases: A large multi-site single institution experience 2016–2018

Bone metastases cause significant morbidity in patients with cancer, and radiation therapy (RT) is an effective treatment approach. Indications for more complex ablative techniques are emerging. We sought to evaluate RT trends at a large multi-site tertiary ...

www.ncbi.nlm.nih.gov

It appears that not only does MSKCC charge exorbitant amounts for 1 or 5 fractions of palliative RT, they are frequently charging for 1 to 5 fractions of SBRT at their famously elevated rates. The aggressive use of SBRT in the palliative setting is notably absent from their JAMA Oncology paper.

So to summarize, exorbitantly expensive dose escalation at MSKCC using SBRT is good for patients who may have travelled very far is good but dose escalation at a low cost local center that may not have access to SBRT capable equipment is very bad.

 

[radiaterMike]

wow !

How many of the non-SBRT treatments were simply due to insurance denials ??? and how are ~50% of patients' insurer's authorizing SBRT for bone mets ??

 

[RSAOaky]

I agree with these comments. It is important to highlight prior research from that research group.

Replacing 30 Gy in 10 fractions with stereotactic body radiation therapy for bone metastases: A large multi-site single institution experience 2016–2018

Bone metastases cause significant morbidity in patients with cancer, and radiation therapy (RT) is an effective treatment approach. Indications for more complex ablative techniques are emerging. We sought to evaluate RT trends at a large multi-site tertiary ...

www.ncbi.nlm.nih.gov

It appears that not only does MSKCC charge exorbitant amounts for 1 or 5 fractions of palliative RT, they are frequently charging for 1 to 5 fractions of SBRT at their famously elevated rates. The aggressive use of SBRT in the palliative setting is notably absent from their JAMA Oncology paper.

So to summarize, exorbitantly expensive dose escalation at MSKCC using SBRT is good for patients who may have travelled very far is good but dose escalation at a low cost local center that may not have access to SBRT capable equipment is very bad.

A remarkable body of work. I particularly like this line:

"Importantly, SBRT reduces the number of patient visits for patients otherwise receiving 30 Gy in 10 fractions, which could reduce financial toxicity to the patient [23] and limit time off systemic therapy [24]."

[23] Lee A., Shah K., Chino F. Assessment of parking fees at national cancer institute-designated cancer treatment centers. JAMA Oncol. 2020 [PMC free article] [PubMed] [Google Scholar]

It's just such an absurd level of gaslighting. So MSKCC treats 50% of their bone mets with 5 fractions of SBRT instead of 10 fractions of 2D. This alone makes the treatment several multiples more expensive, but then you throw in the fact that they are CMS exempt charging several multiples more for the same treatment, raising the palliative treatment cost exponentially, and your justification is that 5 days of treatment is better than 10 days of treatment because it could reduce financial toxicity, AND YOU CITE YOUR COLLEAGUE'S F*CKING PARKING FEE STUDY.

As if this isn't bad enough, the MSKCC satellites have also all increased their utilization of SBRT in this same time frame, creating a PANDEMIC of financial toxicity.

 

[communitydoc13]

exorbitantly expensive dose escalation at MSKCC using SBRT is good for patients who may have travelled very far is good but dose escalation at a low cost local center that may not have access to SBRT capable equipment is very bad

In our field, there is very little expansion of what we do. This is why we have such pathos and academic careers disproportionately studying value based care, de-escalation and equity (mostly a political and not academic issue).

The big centers are not dumb however. They know (or suspect) that aggregate utilization will go down inexorably. Their goal is just to increase market share by any means necessary in this brave new world. Forget being a center of excellence for New Yorkers, MSKCC will be a regional center with sites throughout the north east. PENN is putting protons in Lancaster.

The goal will be high cost, single fraction XRT for everyone, only given at large prestigious centers. That is until all regional competition is eliminated.

The academic radonc is just the useful idiot in this system.

 

[deleted941485]

In our field, there is very little expansion of what we do. This is why we have such pathos and academic careers disproportionately studying value based care, de-escalation and equity (mostly a political and not academic issue).

The big centers are not dumb however. They know (or suspect) that aggregate utilization will go down inexorably. Their goal is just to increase market share by any means necessary in this brave new world. Forget being a center of excellence for New Yorkers, MSKCC will be a regional center with sites throughout the north east. PENN is putting protons in Lancaster.

The goal will be high cost, single fraction XRT for everyone, only given at large prestigious centers. That is until all regional competition is eliminated.

The academic radonc is just the useful idiot in this system.

One of the more insightful posts to be sure

 

[RSAOaky]

One of the more insightful posts to be sure

Very much so. CMS exemption allows these institutions to outmaneuver their competitors, and when their competitors no longer exist and the crosshairs are on them they will all be too big to fail.

 

[Lamount]

Completely agree - they don't deserve to be painted as a monolith, like I'm doing.

However, we also shouldn't be painting the use of, let's say, conventional fractionation for prostate as universally bad, for the same reason.

And I certainly don't mean to imply anyone is doing that. However, all these studies have consequences. The ASTRO white papers or breast and prostate drive insurance reimbursement.

I read these papers and think about potential butterfly effects - we now have justification in the literature for proton CSI for lepto, and more ammo for CMS to come after us with reimbursement cuts because of "inappropriate use of XRT at the end of life".

Perhaps I'm being pessimistic.

I certainly agree vis a vis fraction shaming and the high-handed nonsense. I am not sure I share your concern with "butterfly effects". Don't get me wrong, there are definitely folks at CMS who are out to destroy us. I am just of the mindset that we should do the studies first, and THEN decide if the benefit is worth the expense.

Many think our speciality is paid more than it is worth. We have put a lot of effort into trying to find ways to be more efficient by decreasing costs. However, I also think we should be investing in research on the other side of the equation as well by seeing if we can provide more valuable treatments -that could MAYBE justify a higher pricetag.

 

[deleted941485]

Very much so. CMS exemption allows these institutions to outmaneuver their competitors, and when their competitors no longer exist and the crosshairs are on them they will all be too big to fail.

I certainly agree vis a vis fraction shaming and the high-handed nonsense. I am not sure I share your concern with "butterfly effects". Don't get me wrong, there are definitely folks at CMS who are out to destroy us. I am just of the mindset that we should do the studies first, and THEN decide if the benefit is worth the expense.

Many think our speciality is paid more than it is worth. We have put a lot of effort into trying to find ways to be more efficient by decreasing costs. However, I also think we should be investing in research on the other side of the equation as well by seeing if we can provide more valuable treatments -that could MAYBE justify a higher pricetag.

You can’t even take a step in that direction if all your intellectual capacity is preoccupied with demonstrating the opposite

 

[TheWallnerus]

The big centers are not dumb however. They know (or suspect) that aggregate utilization will go down inexorably.

The academic radonc is just the useful idiot in this system.

I feel like these ... inconvenient truths ... should get tweeted

 

[communitydoc13]

I feel like these ... inconvenient truths ... should get tweeted

Maybe a nascent chair, endowed with muscles, brains, a red pill, game theory and voluntary colostomy...can break down the man made walls that prevent radiation oncologists expanding their scope of practice.

 

[deleted941485]

Maybe a nascent chair, endowed with muscles, brains, a red pill, game theory and voluntary colostomy...can break down the man made walls that prevent radiation oncologists expanding their scope of practice.

Would be a better use of said chairs time than blocking people he doesn’t like a Twitter.

Social media prescence for someone like that will end badly especially when espousing Controversial views.