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

[TheWallnerus]

Ackerman Cancer Center, world's first private practice proton center

They will treat your Dupuytren's contracture better than anybody (not with protons it appears, thank the Lord)

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[deleted314957]

Ackerman Cancer Center, world's first private practice proton center

They will treat your Dupuytren's contracture better than anybody (not with protons it appears, thank the Lord)

This just cannot be real. Maybe this is heresy or flat-out bs
but as a former rad rx patient and subsequent pelvic GI surgery ( unrelated to rad rx purpose) and decades as a pathologist, I’m pretty sure rad tx causes a hell of a lot more fibrosis than it removes. And Dupuytren’s is a fibromatosis for goodness sake. But i’m from the Co-60 days and may be all wet.

 

[madchemist89]

Doses for inflammatory conditions are far lower.

 

[deleted314957]

Doses for inflammatory conditions are far lower.

As I said, I may be (am) all wet! But is it considered an inflammatory condition? I don’t believe it is. It is certainly a fibroblastic proliferation with a really, really low growth rate( very very low Ki- 67 labeling/low proliferative index). Can the low doses cause tissue death in something that has very very low mitotic activity? And if it can, is the dead tissue eventually replaced by fibrous tissue ( a scar)? I would love to know the theory behind how this is supposed to work or achieve a better result than surgery. Like with Peyronie, maybe the hand surgeons will start injecting microbial liquifactive necrosis toxins. Everyone has a gimmick.

 

[madchemist89]

I don't know much about duptryens as I have never treated it, but radiation has been successfully used in several inflammatory conditions as cells that mediate the inflammatory response are very radiosensitive. We are talking about doses that would be homeopathic for a cancer. Randomized data are lacking in this area though.

 

[deleted314957]

I don't know much about duptryens as I have never treated it, but radiation has been successfully used in several inflammatory conditions as cells that mediate the inflammatory response are very radiosensitive. We are talking about doses that would be homeopathic for a cancer. Randomized data are lacking in this area though.

They are indeed very radiosensitive. Now the question is, does inflammation act IN SOME WAY as a promoter, because when you look at them histologically they are notably bereft of an inflammatory component, much like a mature scar. Abundant collagen with scattered mitotically inactive fibroblast nuclei. Bland, bland, bland.

 

[Ray D. Ayshun]

As I said, I may be (am) all wet! But is it considered an inflammatory condition? I don’t believe it is. It is certainly a fibroblastic proliferation with a really, really low growth rate( very very low Ki- 67 labeling/low proliferative index). Can the low doses cause tissue death in something that has very very low mitotic activity? And if it can, is the dead tissue eventually replaced by fibrous tissue ( a scar)? I would love to know the theory behind how this is supposed to work or achieve a better result than surgery. Like with Peyronie, maybe the hand surgeons will start injecting microbial liquifactive necrosis toxins. Everyone has a gimmick.

Radiation only works in the proliferative phase. It can cause cell death acutely, or sabacutely through DNA damage, and it can cause terminal differentiation. Additionally, a split course is delivered, 6-12 weeks from the first half of treatment, which allows for a new group of cells to be affected. The goal of rt is certainly regression, but halting progression is also the aim. Rt doesn't work once terminal differentiation, scar formation has occurred.

 

[TheWallnerus]

As I said, I may be (am) all wet! But is it considered an inflammatory condition? I don’t believe it is. It is certainly a fibroblastic proliferation with a really, really low growth rate( very very low Ki- 67 labeling/low proliferative index). Can the low doses cause tissue death in something that has very very low mitotic activity? And if it can, is the dead tissue eventually replaced by fibrous tissue ( a scar)? I would love to know the theory behind how this is supposed to work or achieve a better result than surgery. Like with Peyronie, maybe the hand surgeons will start injecting microbial liquifactive necrosis toxins. Everyone has a gimmick.

Actually RT works really well in Dupuytrens. I just thought it was kind of funny that at the Ackerman CANCER Center, with the worlds most expensive cancer treating gizmo, they’re advertising treating Dupuytrens. I think this means they’re not flush with (proton) cancer business but I could be wrong

Also RT works for Peyronies (and Morbus lederhose, and keloids, and Castlemans, and Vtach of the heart, and pterygium, and arthritis, and plantar fasciitis, and pneumonia, I could go on!)

 

[deleted314957]

Actually RT works really well in Dupuytrens. I just thought it was kind of funny that at the Ackerman CANCER Center, with the worlds most expensive cancer treating gizmo, they’re advertising treating Dupuytrens. I think this means they’re not flush with (proton) cancer business but I could be wrong

Also RT works for Peyronies (and Morbus lederhose, and keloids, and Castlemans, and Vtach of the heart, and pterygium, and arthritis, and plantar fasciitis, and pneumonia, I could go on!)

I just wonder “how” it works on , for what is for all intents and purposes, an architecturally disordered, hypocellular, non inflamed, mitotically ( as measured by Ki-67 proliferation index) inactive/hypoactive scar?

 

[Ray D. Ayshun]

I just wonder “how” it works on , for what is for all intents and purposes, an architecturally disordered, hypocellular, non inflamed, mitotically ( as measured by Ki-67 proliferation index) inactive/hypoactive scar?

doesn't work on the scar, works on the growing nodule:

Frontiers | Basics of Radiation Biology When Treating Hyperproliferative Benign Diseases

For decades, low- and moderate-dose radiation therapy (RT) has been shown to exert a beneficial therapeutic effect in a multitude of non-malignant conditions...

www.frontiersin.org

 

[Lamount]

I just wonder “how” it works on , for what is for all intents and purposes, an architecturally disordered, hypocellular, non inflamed, mitotically ( as measured by Ki-67 proliferation index) inactive/hypoactive scar?

I believe the mechanism has to do with low dose RT inhibiting fibroblasts…. I am sure someone here with time on their hands can dig up a pub.

 

[deleted314957]

I believe the mechanism has to do with low dose RT inhibiting fibroblasts…. I am sure someone here with time on their hands can dig up a pub.

That would be the along the lines i would be thinking. There are buckets of different kind of collagens. Perhaps xrt somehow can alter , let’s say type whatever collagen to a structurally different much softer and far less clinically apparent collagen like elastin? Who knows?

As re “the nodule” not “the scar”, the surgically excised specimen which is the nodule histologically looks like a scar as I previously described.

 

[Ray D. Ayshun]

That would be the along the lines i would be thinking. There are buckets of different kind of collagens. Perhaps xrt somehow can alter , let’s say type whatever collagen to a structurally different much softer and far less clinically apparent collagen like elastin? Who knows?

As re “the nodule” not “the scar”, the surgically excised specimen which is the nodule histologically looks like a scar as I previously described.

Myofibroblast distribution in Dupuytren's cords: correlation with digital contracture - PubMed

We found that two thirds of digital cords were nodular. Nodules were hypercellular, the majority being alpha-SMA-positive cells. Nodules varied in size and co-localized with the PIP joint. Cord was relatively cellular throughout; a proportion of these cells were alpha-SMA-positive and cells...

pubmed.ncbi.nlm.nih.gov

from NIH definition:
Dupuytren contracture progresses through three phases: (1) proliferative, (2) involution, and (3) residual. The proliferative phase has a characteristically high concentration of immature myofibroblasts and fibroblasts arranged in a whorled pattern. In the involution phase, fibroblasts become aligned in the longitudinal axis of the hand following lines of tension. In the residual phase, relatively acellular collagen-rich chords remain causing contracture deformity.

 

[RadRadRad]

I’ve treated 2 dupuytrens and 2 plantar fibromatosis in last few years. First patient was a dupuytrens that called all over the region and couldn’t get anyone to treat her (I must have been at bottom of her list 😂). Best data I found was 15 gy in 5 fx, 6 week break, then another 15 in 5 fx.

As noted above, results thought to be better during proliferative phase. 3/4 patients had improvement. 1 was particularly impressive with near resolution of cording on foot.

 

[SubserviantToABR]

I treat about 1-2 cases of Dupuytren or Ledderhose per month, and it is a great treatment, especially when they're in the early proliferative phases before contracture begins (stage N patients). I have a superficial x-ray machine, so really easy and cost-effective treatment for them (although not too entirely complex for planning and delivery so not many RVUs). It also gives me a break from treating crazy cancer cases that I tend to get (mainly single site specific service at an academic shop).

It seems that the durability of response is quite on par with what is described in the literature. I tend to do 21 Gy in 7 fractions but have done the 30 Gy in 10 fractions, split course, both studied in the Seegenschmiedt study.

 

[deleted314957]

View attachment 353815

Myofibroblast distribution in Dupuytren's cords: correlation with digital contracture - PubMed

We found that two thirds of digital cords were nodular. Nodules were hypercellular, the majority being alpha-SMA-positive cells. Nodules varied in size and co-localized with the PIP joint. Cord was relatively cellular throughout; a proportion of these cells were alpha-SMA-positive and cells...

pubmed.ncbi.nlm.nih.gov

from NIH definition:
Dupuytren contracture progresses through three phases: (1) proliferative, (2) involution, and (3) residual. The proliferative phase has a characteristically high concentration of immature myofibroblasts and fibroblasts arranged in a whorled pattern. In the involution phase, fibroblasts become aligned in the longitudinal axis of the hand following lines of tension. In the residual phase, relatively acellular collagen-rich chords remain causing contracture deformity.

Just like a scar. I looked at the darned things for decades as a pathologist. Same with a desmoid. Scars and fibromatoses, anywhere, all, at one point look just like the others. Small, “early” fibromatoses look more cellular(at least more nuclei to cytoplasm ratio of area). At some point of their evolution, so do scars. They all end up as virtually mature collagen with inconspicuous nuclei. n.b. scars very early on have a more capillary and mixed inflammatory component but it is early and transitory.

 

[Ray D. Ayshun]

Just like a scar. I looked at the darned things for decades as a pathologist. Same with a desmoid. Scars and fibromatoses, anywhere, all, at one point look just like the others. Small, “early” fibromatoses look more cellular(at least more nuclei to cytoplasm ratio of area). At some point of their evolution, so do scars. They all end up as virtually mature collagen with inconspicuous nuclei. n.b. scars very early on have a more capillary and mixed inflammatory component but it is early and transitory.

Sounds like you looked at the one's that were resected and sent to you.

 

[deleted314957]

Sounds like you looked at the one's that were resected and sent to you.

That and visceral processes observed at autopsy(1977 med school grad, used to be LOTS of autopsies).

 

[ramsesthenice]

This will get confusing real quick, real fast and frankly requires a lot hand waving. Low to medium doses of RT should have an activating effect on fibroblasts, not inhibitory. But…they can inhibit immune cells which stimulate the conversion of resident fibroblasts into myofibroblasts. This is actually near and dear to one of the major areas my lab researches (fibrosis in general, not DC) and the technical term for all of this is “context-dependent” which roughly translates into 🤷🏻‍♂️

 

[IonsAreOurFuture]

I have no clue. Heard it around 2020ish from someone in the know on proton insurance issues.

I *think* it was in relation to a major market (?NY or Chicago? ) proton center.

Probably wouldn’t be hard to verify or refute. Of course the funder wouldn’t be listed as “United health” on the documents, but could be figured out.

It’s obviously tin foil hat material, but would not surprise me either way.

You're not paranoid, it's true.

United Healthcare is trying to make money from protons. It is listed by the SEC as owning "ProHealth Proton Center Management, LLC" and is one of the major investors of the NYPC, along with Mount Sinai, MSKCC, and Montefiore:

New York State’s first Proton Therapy Center reaches completion

www.stantec.com

"New York Proton Management, LLC" is another subsidiary on this SEC document regarding UnitedHealthcare.

Document

I think this could be construed as a conflict of interest pretty easily.

 

[BobbyHeenan]

You're not paranoid, it's true.

United Healthcare is trying to make money from protons. It is listed by the SEC as owning "ProHealth Proton Center Management, LLC" and is one of the major investors of the NYPC, along with Mount Sinai, MSKCC, and Montefiore:

New York State’s first Proton Therapy Center reaches completion

www.stantec.com

"New York Proton Management, LLC" is another subsidiary on this SEC document regarding UnitedHealthcare.

Document

I think this could be construed as a conflict of interest pretty easily.

Well there you go. I thought I remembered hearing this, but then started second guessing myself.

 

[ramsesthenice]

You're not paranoid, it's true.

United Healthcare is trying to make money from protons. It is listed by the SEC as owning "ProHealth Proton Center Management, LLC" and is one of the major investors of the NYPC, along with Mount Sinai, MSKCC, and Montefiore:

New York State’s first Proton Therapy Center reaches completion

www.stantec.com

"New York Proton Management, LLC" is another subsidiary on this SEC document regarding UnitedHealthcare.

Document

I think this could be construed as a conflict of interest pretty easily.

Nothing would surprise me with these people. I mean nothing. If you told me UHC had a 70% stake in Phillip Morris I would be 0% surprised. Whatever’s good for business.

 

[temujim]

Nothing would surprise me with these people. I mean nothing. If you told me UHC had a 70% stake in Phillip Morris I would be 0% surprised. Whatever’s good for business.

UHC has been a 5 bagger since obamacare. With that kinda juice most everything else is a rounding error.

 

[TheWallnerus]

Firmly believe were it not for protons Medicare RO spending would have fallen more than it did (about 20% according to ASTRO) over the last 10 years

 

[thecarbonionangle]

Is the future they want one where if you don’t have protons you don’t deserve to exist? Many would say so!

 

[deleted1111261]

Is the future they want one where if you don’t have protons you don’t deserve to exist? Many would say so!

Totally

 

[deleted941485]

Firmly believe were it not for protons Medicare RO spending would have fallen more than it did (about 20% according to ASTRO) over the last 10 years

Literally the only thing that keeps us on the front page. If you were able to Wack 20% off RT costs in the last 10 years. I really think it just would have invited more cuts not less.

In the US HC, the real crime isn’t stealing it’s not stealing enough.

Seriously Long live protons.

 

[thecarbonionangle]

Literally the only thing that keeps us on the front page. If you were able to Wack 20% off RT costs in the last 10 years. I really think it just would have invited more cuts not less.

In the US HC, the real crime isn’t stealing it’s not stealing enough.

Seriously Long live protons.

You get those bills and loans paid,buddy!

 

[evilbooyaa]

Literally the only thing that keeps us on the front page. If you were able to Wack 20% off RT costs in the last 10 years. I really think it just would have invited more cuts not less.

In the US HC, the real crime isn’t stealing it’s not stealing enough.

Seriously Long live protons.

Would love your COI disclaimer

Of course all proton shills should post their COI disclaimer, but lord knows we ain't gonna see that

 

[deleted941485]

Would love your COI disclaimer

Of course all proton shills should post their COI disclaimer, but lord knows we ain't gonna see that

I could care less. If you’re health system has a proton center, you’re part of the scam. But evidently the only way to make in RO is the shill and scam, i embrace it

 

[Lamount]

I could care less. If you’re health system has a proton center, you’re part of the scam. But evidently the only way to make in RO is the shill and scam, i embrace it

Ha!

PP thinks academics are greedy because of protons... academics think PP is greedy because frequently make >25% more. Everyone hates the player because no one thinks they ARE the player. Truth is... we all play just fine

 

[RickyScott]

Ha!

PP thinks academics are greedy because of protons... academics think PP is greedy because frequently make >25% more. Everyone hates the player because no one thinks they ARE the player. Truth is... we all play just fine

Anecdotally, don’t see pay gap between pp and academics for hospital employed docs.

 

[jondunn]

Anecdotally, don’t see pay gap between pp and academics for hospital employed docs.

True

 

[deleted941485]

Anecdotally, don’t see pay gap between pp and academics for hospital employed docs.

Anecdotally in many areas the lines are so blurred because everyone in the mega hospital academic abomination system is "faculty".

 

[RickyScott]

Anecdotally in many areas the lines are so blurred because everyone in the mega hospital academic abomination system is "faculty".

Pay may diverge among junior faculty vs employed hospital. Take it with a grain of salt, but it can be exceptionally difficult to get raises in academic systems vs community for new grads over the last 5 years. Chairmen probably think “why should I raise x’s salary, when I have the next great resident graduating who will do the job for less.”
Most community hospitals on the other hand often don’t want to loose a known quantity.

 

[jondunn]

Pay may diverge among junior faculty vs employed hospital. Take it with a grain of salt, but it can be exceptionally difficult to get raises in academic systems vs community for new grads over the last 5 years. Chairmen probably think “why should I raise x’s salary, when I have the next great resident graduating who will do the job for less.”
Most community hospitals on the other hand often don’t want to loose a known quantity.

not sure why you think hospital admins would be any more attached to the doc themselves than a chairman?

I think the opposite would be true, and from my experience with community hospitals, is true.

 

[RickyScott]

not sure why you think hospital admins would be any more attached to the doc themselves than a chairman?

I think the opposite would be true, and from my experience with community hospitals, is true.

Because chairman has yearly graduating residents, and knows which are good.

 

[Neuronix]

Employed rad onc is becoming like any other job--you have to jump ship or negotiate with other offers to get a pay raise.

 

[jondunn]

Because chairman has yearly graduating residents, and knows which are good.

Hospital admins have yearly grads as well that they can pick from.

There is a sunk cost and risk for anyone to play musical chairs with their employees. With some exception maybe in rural hospitals where they truly don’t care - it really is the same thing whether it’s big community hospital or big community hospital with an academic name - no one wants to let go of a bird in hand; but they also have options to likely find someone to replace them, especially if the location is decent

 

[deleted1111261]

Hospital admins have yearly grads as well that they can pick from.

There is a sunk cost and risk for anyone to play musical chairs with their employees. With some exception maybe in rural hospitals where they truly don’t care - it really is the same thing whether it’s big community hospital or big community hospital with an academic name - no one wants to let go of a bird in hand; but they also have options to likely find someone to replace them, especially if the location is decent

Yeah, it’s all the same pressures.

At the same time, exiting a physician is very hard, and admin at community vs university both hate recruiting and onboarding and ramp up. It’s painful for everyone.

I think the idea is to steadily increase hospital salaries to a reasonable amount as a floor, some bonuses to set us into a narcotized stupor repeating - “4 day work week and median salary”

 

[jondunn]

another one bites the dust

 

[RickyScott]

another one bites the dust

I guess he will have to do a 360 on space oar. Can’t deliver protons without it.

Considering benefit and risk before routinely recommending SpaceOAR

www.ncbi.nlm.nih.gov

 

[Mandelin Rain]

another one bites the dust

Not to be outdone.

 

[TheWallnerus]

another one bites the dust

Not to be outdone.

Tulip mania!

 

[Mandelin Rain]

Tulip mania!

Wide scale adoption of protons will HAVE to lead to a steep price correction like IMRT, right??? Right???

 

[Ray D. Ayshun]

Tulip mania!

This was also meant to be a Duke/UNC scenario. Only to be outdone by SERO.

 

[thecarbonionangle]

Harari showed us he was one upright fella by matching his son and doing nothing about expansion under president tenure. Now he is going all in on an upright proton machine. What could go wrong folks?

 

[Mandelin Rain]

 

[Mandelin Rain]

 

[jondunn]

Nancy Lee has the higher ground