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Hilariou$
$omebody $top me from laughing my a$$ off at this $hilling for proto$
$omebody $top me from laughing my a$$ off at this $hilling for proto$
Protons are blowing Rad Onc's boat out the CMS water
- Thread starter scarbrtj
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I want to see actual numbers though.
a partial arc VMAT (or 4-6 field IMRT) versus protons.
5 fractions.
If someone gives me the proton cpt codes I can get it myself...
Most (all?) bill 5 fractions or less of protons as SBRT.
Here is another proton study in the latest issue of PRO, this time for breast cancer, chest wall irradiation following implants. The side effects are shocking to me.
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Protons in breast cancer is toeing the line of malpractice, IMO.
We get it. You bought the expensive machine and have to pay for it. But you're out here hurting patients. Look in the mirror. Please.
We get it. You bought the expensive machine and have to pay for it. But you're out here hurting patients. Look in the mirror. Please.
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I didn't know they would bill as SBRT.
I don't bill photon 30/5 as SBRT (though I have no major issues with those that do).
===
My experience with proton breast for implants/expanders is congruent with that report. We have plastics in town that will only do photon cases due to issues with proton cases. Not all but some. Skin toxicity is worse with proton for breast. I know this isn't news to you, but heart, lung, and contralateral breast dosimetry can certainly be better though in left sided cases, especially with challenging anatomy/slight pectus.
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I can only speak to my experience, but that's what we did.
Im no breast expert and don't even have a proton center in town, but it seems insane to recommend it. We have copious trial data that shows a very good toxicity profile for all organs. It should be a strong message that cosmetic outcome has been prioritized as a trial outcome. It makes no sense to take on a substantially worse toxicity profile in the "highest risk" tissue for toxicity in order to have better dosimetry for organs that have low rates of even mild-moderate toxicity with photons.
I do agree that it seems like the only way a patient would agree is if an RO is misleading about the data. Troubling.
D
deleted1116990
Lets go back to basics,
What's the problem we are trying to solve by going from 5 fraction IMRT to 5 fraction proton? Serious question.
It's absurd, an enormous waste of resources, undermines legitimate uses of protons, and wastes researcher effort that should be focused on things that have the potential to improve patient care.
What's the problem we are trying to solve by going from 5 fraction IMRT to 5 fraction proton? Serious question.
It's absurd, an enormous waste of resources, undermines legitimate uses of protons, and wastes researcher effort that should be focused on things that have the potential to improve patient care.
The problem is that some patients are not getting their care at the large, corrupt academic center which is fleecing all of us.
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How’s IMRT for breast looking now?
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You sound like a money grubbing private practitioner IMO.
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This can be generalized to all external beam treatments. Where do protons factor into a "solution"?
When I first heard about protons (circa 2006), there was some messaging that protons allowed for meaningful dose escalation. Example would be base of skull tumor that is fairly radioresistant and where you wanted to avoid temporal lobe necrosis.
It is very hard in the modern era to think of a circumstance where protons provide an opportunity for meaningful dose escalation. So it's down to solving "the low dose bath problem" with its associated small risks of 2nd malignancies, low dose threshold late effects (pneumonitis, hepatitis, CAD?) and per some acolytes, lymphopenia (clinically of uncertain significance).
But, protons have great dosimetric uncertainty. They do, they do, they do. This is an interesting scientific problem, but an unsolved one. It means that in low dose situations (lymphoma, many pediatric tumors) they may be more "safe" but just marginally. In other situations (dose on the order of 50 Gy EQD2 or higher and any adjacent or embedded OAR where hot spots equal toxicity) they are almost certainly less "safe".
Proton treatment takes longer, it is more resource intensive, it is more expensive.
I can only attribute the continued proton enthusiasm to a couple things.
1. An ideological notion that protons are necessarily superior due to exit dose and brag peak. (weak thinking)
2. A sincere enthusiasm for ion research (some on this board, a minority of proton practitioners).
3. Cynical financial considerations in the near term. (I suspect smaller and community places investing in protons).
4. Cynical financial and global healthcare consolidation considerations long term. (Big academic places. They leverage their protons through direct to patient advertising, dubious clinical trial design and even consolidation of physics services. Big places may put small places out simply by hiring all the physicists.)
Wasn't my best work that's for sure
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The answer to all of life's why questions (I teach my kids this): its always the same homie..
ps. if you're "not sure its about the money" .. then its.. definitely about the damn money
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For admin sure. For physician owners, sure. For underpaid and prestige hungry academic radoncs doing the work, this doesn't explain it. They must believe that they are doing the right thing.The answer to all of life's why questions (I teach my kids this): its always the same homie..
ps. if you're "not sure its about the money" .. then its.. definitely about the damn money
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They are just trying to make more money for their chair, so their chair in turn might pay them more money.
Ehh idk about that. Some of those faculty members are questioning the wisdom of a proton center and I’m talking about high power places
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Well damn. Can we get a faculty member on here to speak to this? Clear the air so to speak? Let us know what financial incentives they have to treat with protons in academia?
My guess is they never get more for it but they’ll use it to generate papers etc.
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If you have a proton center, and more $ coming in, and that shiny new building and office.. and the prestige keeps the junior ranks full.. then.. yeah.. of course.. its about the damn money..
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I don't much about the academic life. But, I do know from personal experience that there is little worse you can do than publish honest research that undermines a lucrative initiative of your chair or department.
I'm guessing this is why we see less incisive and clear papers regarding proton dosimetry than I would hope.
I'm guessing this is why we see less incisive and clear papers regarding proton dosimetry than I would hope.
If you have a proton center, and more $ coming in, and that shiny new building and office.. and the prestige keeps the junior ranks full.. then.. yeah.. of course.. its about the damn money..
Nobody is disputing that but to suggest the faculty are actually seeing it in their paychecks is a joke.
The second-easiest type of research in radonc to do is to just use your fancy new technology on something novel, whether or not it makes sense. I'm guessing this ease has a lot to do with it. Why make hard trials when easy trials do fine?
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Mdacc has to first disclose their prices. You can probably rely on upenn’s as a floor.I want to see actual numbers though.
a partial arc VMAT (or 4-6 field IMRT) versus protons.
5 fractions.
If someone gives me the proton cpt codes I can get it myself...
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No fuzzy math. Mdacc just won’t release their Prices.
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I was just thinking Medicare fee schedule prices as a first look.
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Mdacc doesn't bill or collect standard Medicare hopps rates
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Reading this thread and the forum in general is unsurprising but still disappointing from a patient perspective.
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Care to elaborate? What exactly is disappointing or unsurprising?
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The influence of money/ROI in clinical decision making. Not unique to rad onc.
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Docs allowed all the clinical decision making to go to the MBA’s and MHA’s.
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It's a microcosm of what happens with big pharma
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Hard to cure cancer if your clinic's closed. This is America not heaven.
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What is unique to radonc is the virtue signalling, imrt, and fraction shaming by the very institutions pimping protons and price gouging with 10x cms rates. (Eg ben smith, Aileen Chen) . The robber barons love to shame the community!
There was not widespread shaming in the surgical community when the robot came out (despite lack of data that it had any benefit over conventional laparascopic approaches). I think it is still very controversial if the robot has much of a benefit over open prostatectomies? (And prostatectomies can be performed laparoscopically much cheaper without the robot)Did the American college of surgeons ever release a choose wisely to consider conventional laparoscopic or open vs robot?
Mdacc dipShts still spew convoluted flat out lies that protons are actually cost saving without referencing mdaccs actual prices reimbursed by payors. ! Eg Steve frank. Didn’t Mayo just release some garbage on 3 fraction partial breast with protons. I am sure they will also lie about cost savings, and withhold (against the law) actual prices paid by insurance.
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Keeping the doors open and employees paid and happy are all very important and vital to survival, but not very inspiring.
One great hospital CEO whom I greatly admire once shared with me, "No margin, no mission. Even the sisters of mercy will tell you that." But he then went on to teach me how laser focus on the mission is what creates margin.
Nimbus reminded me why I went into healthcare, part of which was to do well financially, by doing good for others. The margin isn't the mission, and if we as a field confuse the two, or allow our administration to, we are at risk of selling our souls, so to speak.
The CEO above who taught me related how GM was once a good car company that made cars people wanted to buy, and they led in market share. Then their CEO who loved cars was replaced by an accountant who wanted to cut costs to improve margin and shareholder value. It worked temporarily, but then failed. Why? They lost sight of their reason for existence. They lost the ability to inspire customers and employees who want to buy and make great cars.
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Well that’s because they have protons
I’m anesthesia, not urology, so I don’t know if robot offers much if any long term benefit. That may still be controversial. But I’ve been practicing long enough to remember open radical prostatectomies. In terms of visualization and magnification, robot offers a huge benefit. Open prostatectomy was operating on the far wall at end of a deep bloody cave trying to see what’s going on through the entrance. We used to put in big lines and always have blood available because when the urologists got into the dorsal venous plexus, the blood loss was fast and furious, commonly 500-1000ml in 5min. When we first started robotic prostatectomies, there was a learning curve and they could be 6-9hr ordeals for some surgeons. Nowadays they are 90-120min cases with no blood loss and the patients go home the next day so it doesn’t seem controversial to me. The short term outcomes alone (blood loss, pain, length of stay) are much better than open.
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The mission hasn't really changed if I give 20 frac whole breast instead of 5. Otoh, if I give 5 for everyone, the therapists get flexed. If the therapists get flexed, the therapists leave. If the therapists leave, I can't treat people/it becomes a miserable plac to be with locums everything and no cohesiveness etc. It would be nice if the c-suite folk recognized that hiring traveling anyone is significantly more expensive than In house, but they do not. In turn, I have to sometimes consider that treating one patient a certain way will allow me to better treat other patients. It doesn't make me happy that this is the case, but it clearly is. I conventionally fractionate 1 prostate yearly, fwiw, but there are many instances where I err on the side of more when it's a judgement call.
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Our ceo quoted this to me as well. Must have been at some seminar for hospital execs.
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It seems intuitive robot would be better, but at least of 10 years ago, there were not really any proven benefits.Well that’s because they have protons
I’m anesthesia, not urology, so I don’t know if robot offers much if any long term benefit. That may still be controversial. But I’ve been practicing long enough to remember open radical prostatectomies. In terms of visualization and magnification, robot offers a huge benefit. Open prostatectomy was operating on the far wall at end of a deep bloody cave trying to see what’s going on through the entrance. We used to put in big lines and always have blood available because when the urologists got into the dorsal venous plexus, the blood loss was fast and furious, commonly 500-1000ml in 5min. When we first started robotic prostatectomies, there was a learning curve and they could be 6-9hr ordeals for some surgeons. Nowadays they are 90-120min cases with no blood loss and the patients go home the next day so it doesn’t seem controversial to me. The short term outcomes alone (blood loss, pain, length of stay) are much better than open.
Comparing traditional and robotic-assisted surgery for prostate cancer - Harvard Health
Today, most surgeries to remove the prostate gland in men with prostate cancer are performed with robotic assistance, which ostensibly offers quality-of-life advantages. But how does this me...
www.health.harvard.edu
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Haha I see what you did there. And it would be hard to conduct a trial nowadays because nobody does open prostatectomies any more.
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Here is another editorial that clarifies the lack of known vs trivial benefit. Radonc is driven by profit just like every other specialty. Our problem is disproportionate number of backstabbing and arrogant academics- many of whom graduated at the dead bottom of their medical school class, and now have some sort of complex.
Robotic-Assisted Radical Prostatectomy: Who Is Benefiting?
How should oncologists advise patients about the best surgical approach to use to treat their prostate cancer? Quite simply, it is the surgeon, not the approach. The self-fulfilling prophecy about surgery is that the best surgeons tend to do the most surgeries, so an easy metric is volume.
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Here is another editorial that clarifies the lack of known vs trivial benefit. Radonc is driven by profit just like every other specialty. Our problem is disproportionate number of backstabbing and arrogant academics- many of whom graduated dead bottom of their medical school class, and now have some sort of complex.
Robotic-Assisted Radical Prostatectomy: Who Is Benefiting?
How should oncologists advise patients about the best surgical approach to use to treat their prostate cancer? Quite simply, it is the surgeon, not the approach. The self-fulfilling prophecy about surgery is that the best surgeons tend to do the most surgeries, so an easy metric is volume.www.cancernetwork.com
Completely agree with that article. It is the surgeon that matters. However, that article was written in 2012. Now it would be very hard to find a high volume prostate surgeon who does not use robot.
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Yip, so we won’t ever answer the question. Likely analogous outcome with protons unless protons can be shown to actually be worse. Some of the older surgeons at mskcc and Harvard use minimally invasive laparoscopic approaches. Very hard to see how the robot would be superior.
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Surprised to hear they are doing prostatectomy using conventional laparoscopy anywhere.
Conventional laparoscopy-surgeon stands at the operating table contorting their body to hold and manipulate long-armed instruments with 2 hands and an assistant holding the camera trying to guess what the surgeon wants to see. The challenge is trying to manipulate and control what happens at one end of a long instrument while holding the other end. With davinci the surgeon sits at a console, controls their own camera, gets magnified 3D visualization of the surgical field and has precise control of instruments that articulate at their distal ends. The robot holds the camera and the long arms of the instruments in a static, stable position so the surgeon only has to worry about what happens at the distal business end.
I was a skeptic when davinci emerged, the first few cases were torture, people didn’t know how to set it up, surgeons didn’t know how to use it, etc, etc. It took a while to see its advantages. There are some minimally invasive cases (mitral valve repair, single port colectomy) being done with it now that would be impossible without it.
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I think most people don't do it lap... It's either robot or open/retropubic, the open guys swear they can still do it pretty fast.
Even saw a few perineal cases in med school during my GU rotation which requires situation incision for the LNs.... Had considered gu before I did RO. In 2022+ as a competitive ms4, i would do gu or ENT any day over rad onc if so inclined
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I’m sure they can do it fast. But the reason they still do it open is because they couldn’t be bothered to learn robot. The urologists in my city who haven’t learned robot just refer out their prostate cancer cases. They still have busy surgical practices treating BPH and stones, plus all their office stuff.
And I agree with you that urology is a good specialty.
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In 1996 mayo did thousands of open RP. You were considered a stud if you could do it in 45 minutes flat. No joke. It was the highest volume RP center in the world.
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I'll weigh in from the urologist side of things.
Firstly, I don't know if protons to photons is a fair comparison to robot vs. open prostate. In protons vs. photons, the fundamental treatment modality is different in how the cancer is treated in ways you all understand far better then I. In open vs. robotic surgery, the surgery and it's end goal is almost exactly the same, just using a different approach/machine.
Next lets dispense with any talk of robotic vs. lap for prostates. Lap prostates are ridiculously technically difficult to the point where only a few surgeons ever really did them in volume, and I suspect their outcomes weren't fantastic. It had already been described for over a decade and never caught on before robotics really took hold.
It is true that data does not show a big benefit to robotics over open for prostatectomies, though there is a clear signal for benefit in terms of blood loss and length of stay in meta analysis. Long term PROs seem similar, but with the caveat that this data is coming out of centers like MSKCC, Mayo, Hopkins, etc. where the world's highest volume and most renowned open prostatectomists practice. And I do believe that is true. In the best hands, open prostatectomy is just as good as robotic. But that is the caveat, I think that is true only in the best hands, and that is a much more difficult skillset to develop with a much steeper learning curve then robotics, even before you take into account that no one trained in the last decade had anything approaching the surgical volume to become as skilled as the last generation in open prostatectomy. Robotics improves visualization, dexterity, training, and standardization in prostatectomy which IMO really balances the learning curve. I believe a decent urology graduate from a decent program can do a good prostatectomy right out of residency with excellent outcomes. Without tooting my own horn, that was true for me, as well as most of (but not all) of my coresidents. That definitely was not true for open prostatectomy.
Finally, robotics is allowing for even newer variations on the technique that may continue to push outcomes forward in a way that would be impossible open, like Retzius-sparing among others.
TLDR: Robotics isn't better then open in the most skilled hands, but definitely lowers and flattens the learning curve to the point where there are a lot more skilled robotic prostatectomists now then there were open prostatectomists 20 years ago.
Firstly, I don't know if protons to photons is a fair comparison to robot vs. open prostate. In protons vs. photons, the fundamental treatment modality is different in how the cancer is treated in ways you all understand far better then I. In open vs. robotic surgery, the surgery and it's end goal is almost exactly the same, just using a different approach/machine.
Next lets dispense with any talk of robotic vs. lap for prostates. Lap prostates are ridiculously technically difficult to the point where only a few surgeons ever really did them in volume, and I suspect their outcomes weren't fantastic. It had already been described for over a decade and never caught on before robotics really took hold.
It is true that data does not show a big benefit to robotics over open for prostatectomies, though there is a clear signal for benefit in terms of blood loss and length of stay in meta analysis. Long term PROs seem similar, but with the caveat that this data is coming out of centers like MSKCC, Mayo, Hopkins, etc. where the world's highest volume and most renowned open prostatectomists practice. And I do believe that is true. In the best hands, open prostatectomy is just as good as robotic. But that is the caveat, I think that is true only in the best hands, and that is a much more difficult skillset to develop with a much steeper learning curve then robotics, even before you take into account that no one trained in the last decade had anything approaching the surgical volume to become as skilled as the last generation in open prostatectomy. Robotics improves visualization, dexterity, training, and standardization in prostatectomy which IMO really balances the learning curve. I believe a decent urology graduate from a decent program can do a good prostatectomy right out of residency with excellent outcomes. Without tooting my own horn, that was true for me, as well as most of (but not all) of my coresidents. That definitely was not true for open prostatectomy.
Finally, robotics is allowing for even newer variations on the technique that may continue to push outcomes forward in a way that would be impossible open, like Retzius-sparing among others.
TLDR: Robotics isn't better then open in the most skilled hands, but definitely lowers and flattens the learning curve to the point where there are a lot more skilled robotic prostatectomists now then there were open prostatectomists 20 years ago.
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Robotics vs open in any site is not comparable to protons vs photons. Outside of lack of data indicating oncologic benefit for robotics, there are many acute toxicity reasons to do it in multiple sites. I don't believe there is a good acute toxicity rationale for most proton therapy. There certainly isn't a "time under treatment" rationale or diminished hospital recovery rationale.
Now...I believe that there is some data indicating poorer long term oncologic outcomes in some GYN cancers (early stage endometrial) and I have witnessed numerable peculiar regional failures after robot assisted thoracic surgeries (regional pleural based failures as opposed to more traditional suture line failure).
Whether a generation of surgeons is being trained in a technique that is at present oncologically inferior but progressively being used, I don't know. Curious what the thoracic surgeons and gyn/oncs think.
Now...I believe that there is some data indicating poorer long term oncologic outcomes in some GYN cancers (early stage endometrial) and I have witnessed numerable peculiar regional failures after robot assisted thoracic surgeries (regional pleural based failures as opposed to more traditional suture line failure).
Whether a generation of surgeons is being trained in a technique that is at present oncologically inferior but progressively being used, I don't know. Curious what the thoracic surgeons and gyn/oncs think.
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The great thing about being in academics is your TOTAL insulation from economics. You had better believe that the pyramid scheme at big ivory is alive and well, and those at the top are none-to-quick to be dislodged by rational thinking around radeconomics.
