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

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thecarbonionangle said:
When you guys get them it will all of a sudden be a fantastic modality with many applications. I have spoken.
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Right, it will be another one of those videos with the doc in his white coat talking about how this fancy machine is the latest and greatest weapon in the fight against cancer and how it can target the tumor and that there is absolutely no dose given to anything… blah blah blah. Because only at this institution, we give personalized care… blah blah blah.

I know this script because I’ve said this a bunch of times at multiple institutions.
 
ramsesthenice said:
I doubt it comes to pass and i hope I don't end up doxing myself here…
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I think this request is happening in at least half of RO academic departments. I knew it was the subject of many meetings where I trained, and the real draw was getting patients in the door. Once there, maybe their commercial insurance would decline PBT, but hey, that’s ok, because the negotiated rate for IMRT would make just about any community RO blush.

In a sense, the proposed single room proton center was just a really expensive billboard for the cancer center.
 
GapCalc said:
I think this request is happening in at least half of RO academic departments. I knew it was the subject of many meetings where I trained, and the real draw was getting patients in the door. Once there, maybe their commercial insurance would decline PBT, but hey, that’s ok, because the negotiated rate for IMRT would make just about any community RO blush.

In a sense, the proposed single room proton center was just a really expensive billboard for the cancer center.
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The elder Simone way back when essentially wrote a public editorial in a throwaway journal that the reason to get protons is it makes the rad onc department's IMRT business a lot better, in part by thrashing the competitors. (Too lazy to find it.)
 
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TheWallnerus said:
The elder Simone way back when essentially wrote a public editorial in a throwaway journal that the reason to get protons is it makes the rad onc department's IMRT business a lot better, in part by thrashing the competitors. (Too lazy to find it.)
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Is that charles simone’s dad? Looks similar
 
GapCalc said:
I think this request is happening in at least half of RO academic departments. I knew it was the subject of many meetings where I trained, and the real draw was getting patients in the door. Once there, maybe their commercial insurance would decline PBT, but hey, that’s ok, because the negotiated rate for IMRT would make just about any community RO blush.

In a sense, the proposed single room proton center was just a really expensive billboard for the cancer center.
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Same reason many practices bought CKs back in the day...
 
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The way I see it if America becomes awash in proton centers, proton centers have only a few viable paths forward (if the peds angle is taken out):

1) Keep bringing more XRT business in due to that swanky "Proton Cachet"
2) Keep collecting 10x (or more) per patient than XRT would for the same diagnosis
3) Keep making society believe that protons are the state-of-art tx for prostate
4) Make protons happen in breast or lung
 
TheWallnerus said:
e22ipOZ.png



The way I see it if America becomes awash in proton centers, proton centers have only a few viable paths forward (if the peds angle is taken out):

1) Keep bringing more XRT business in due to that swanky "Proton Cachet"
2) Keep collecting 10x (or more) per patient than XRT would for the same diagnosis
3) Keep making society believe that protons are the state-of-art tx for prostate
4) Make protons happen in breast or lung
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My prediction is that the proton game is short-sighted. It’s mainly used for marketing as there will be no clinical evidence to support it in disease sites such as breast, lung or prostate. As fraction numbers continue to go down, adaptive planning will be the future. Instead of focusing on how to get more patients on the machine, I think we should be focusing on how to keep our current patients like what med onc is doing with maintenance chemotherapy/immunotherapy.

I rather treat one patient 2-3 times with SRS, SBRT vs seeing 10 new breast patients regarding reimbursement rates. This is why I believe MRI-Linacs are worth the investment when everyone will be getting 5 or less fractions regardless of disease site.
 
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RadOncDoc21 said:
My prediction is that the proton game is short-sighted. It’s mainly used for marketing as there will be no clinical evidence to support it in disease sites such as breast, lung or prostate. As fraction numbers continue to go down, adaptive planning will be the future. Instead of focusing on how to get more patients on the machine, I think we should be focusing on how to keep our current patients like what med onc is doing with maintenance chemotherapy/immunotherapy.

I rather treat one patient 2-3 times with SRS, SBRT vs seeing 10 new breast patients regarding reimbursement rates. This is why I believe MRI-Linacs are worth the investment when everyone will be getting 5 or less fractions regardless of disease site.
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IF everyone, including all payors and self-righteous rad oncs, can agree we get an IMRT replan (and calcs, and IMRT device, etc) per fraction, for 5 fx MRgRT, you'd be stupid NOT to get MRgRT.
 
TheWallnerus said:
IF everyone, including all payors and self-righteous rad oncs, can agree we get an IMRT replan (and calcs, and IMRT device, etc) per fraction, for 5 fx MRgRT, you'd be stupid NOT to get MRgRT.
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Doesn't sound very "APM" like to me. Almost the antithesis of it
 
Theres multiple open or recently accrued proton breast and lung studies.

for me the most interesting studies I’m looking forward to reading is NRG GI006 and RTOG 1308. I think the thorax could lead to interesting results.
 
ramsesthenice said:
I doubt it comes to pass and i hope I don't end up doxing myself here, but the powers that be have us (mostly physics and admin) doing a deep dive into the logistics generating a detail pro forma into putting in a proton unit. Why? Because a few major donors feel like we should be able to offer anything our regional competitors are able to offer and are willing to pony up see it happen (though just how much they want to pony up remains to be seen). For me as a provider would it be cool to be able to offer basically everything under the sun (protons, MR linac, GK, HDR, etc)? Sure. In the bigger picture, is there a logistical reason for a mid-sized Midwest program to have all those toys? Probably not. But this is the reality of how these things proliferate sometimes 🙁
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Makes sense to have ONE in any relevant midwest city. I'm more OK with UAMS getting a proton unit to service the entire state of Arkansas than building another in a city where there is already multiple proton therapy options.
 
FrostyHammer said:
Dude read my posts. When did I ever say protons have less GI tox. If you actually read the posts, you'll see that I didn't contend that people used less SpaceOAR with protons, I said it's not logical that that'd be the case. I'm questioning the logical validity. That's OK to do without data, right? I didn't get any data when I asked. I then replied with my own "anecdotal evidence" which proved my point that a battle of anecdotal evidence doesn't do a damn thing for anyone. I'm sure, by your misinterpretation of that thread, that you think I'm pro protons for prostate...I'm sure if people didn't understand my posts they'd think that, but it couldn't be farther from the truth. Let's interpret things like radoncs, not like surgeons.
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First I’m not a dude so check your privilege 🙂; jk)

You did first raise this idea of less spaceoar with protons. I don’t think anyone other than you has this experience.

sorry if I was overly harsh
 
MegaVoltagePhoton said:
First I’m not a dude so check your privilege 🙂; jk)

You did first raise this idea of less spaceoar with protons. I don’t think anyone other than you has this experience.

sorry if I was overly harsh
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- Well in that case, #WomenWhoCurie #RadOncRocks

- I know many people (like dozens) who work at some of the most well known proton centers and none of them have those experiences either. That was the point of the whole "anecdotal evidence" thing. Maybe the proton centers in others' neck of the woods push for SpaceOAR but that's hardly generalizable to those in other areas.

- It's all good
 
FrostyHammer said:
- Well in that case, #WomenWhoCurie #RadOncRocks

- I know many people (like dozens) who work at some of the most well known proton centers and none of them have those experiences either. That was the point of the whole "anecdotal evidence" thing. Maybe the proton centers in others' neck of the woods push for SpaceOAR but that's hardly generalizable to those in other areas.

- It's all good
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Harvard and penn used to be into balloons. Have they transitioned to space oar?
 
SubserviantToABR said:


Proton quad shot for recurrent or metastatic sarcomas? Using protons seem like an expensive proposition for palliation.
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Yikes. But even if randomized data is eventually published that doesn't support protons for palliation, I'm sure the senior author will still keep using protons per a famous comment she's made in the past...
 

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some great tidbits here:

pubmed.ncbi.nlm.nih.gov

Towards Achieving the Full Clinical Potential of Proton Therapy by Inclusion of LET and RBE Models - PubMed

Despite increasing use of proton therapy (PBT), several systematic literature reviews show limited gains in clinical outcomes, with publications mostly devoted to recent technical developments. The lack of randomised control studies has also hampered progress in the acceptance of PBT by many...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


3.3. Two Clinical Examples Where PBT can be Suboptimal​

In addition to the clinical example already given in Figure 2, the following two clinical entities are relevant.


3.3.1. Prostate Cancer​

Most American proton centres have based their business cases on treating high numbers of prostate cancer patients. There are some concerns about reports of enhanced side effects, but the outcomes are difficult to establish from small numbers in uncontrolled studies [35,36]. The following list of techniques and assumptions could contribute to enhanced toxicity and have been used in some/all treatment Centres:
  • (a)
    Use of one field per day treatments to save gantry sweep time, and only two field plans, which inevitably increase the dose per fraction outside the high dose treatment volume.
  • (b)
    Reduced beam shaping and conformity indices, especially with passive scattering, when compared to best photon techniques; this may be improved by scanned beams.
  • (c)
    Late complication RBE values are likely to exceed 1.1, so the biological doses to relevant volumes of small bowel and parts of rectum adjacent to the prostate can be higher than for photons.

It remains to be determined if better results emerge with scanned beams from all portals per day and using a higher RBE allocation of say 1.2 for normal tissues.

3.3.2. Paediatric Cancers and Other Radiosensitive Tumours such as Lymphomas​

Here, the tumour α radiosensitivity parameter is high, leading to low RBEs, sometimes less than the 1.1 used for protons [37]. In such cases, where RBEs may be as low as for example 1.03–1.07, the use of 1.05 or no RBE at all would respectively reduce or eliminate the chance of under-dosage. Such an approach would require careful assessment of the normal tissues close to the tumours, since they might then be overdosed, but in many cases of radiosensitive tumours this should be acceptable, since the relatively low curative doses are within normal tissue tolerance for severe late effects. Proposals for a clinical trial based on these concepts are shown diagrammatically in Figure 7. Random sampling simulations of tumour control probabilities, including numbers of patients required to reach significance are given elsewhere [38].
 
FrostyHammer said:
I said "or", not "and". I don't think you got my point. I'm not supportive of protons for prostate, but I'm saying that the SEER study that was quoted isn't a good way to justify that point. I'm also saying that protons for prostate are much more palatable if they are used as a means to hypofractionate or SBRT. In other words...in general for prostate, protons SBRT >>> IMRT conventional fractionation.
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Hi from the path board. Are they offering patients( i know, ya gotta have good insurance) these choices. I had prostate CA bio recurrence in 2019( maybe 2018) and was only offered , and given, 20 fractions of 350 rads IMRT ( protons not at this place). Bad, bad side effect had to stop at 5500 rad total. Too bad I missed out on hypofractionation. This place was brand new and the docs were newly boarded hotshots. They can do anything they want as long as I have ZERO bone pain!

Ya pays your money, ya takes your chances.
 
mikesheree said:
Hi from the path board. Are they offering patients( i know, ya gotta have good insurance) these choices. I had prostate CA bio recurrence in 2019( maybe 2018) and was only offered , and given, 20 fractions of 350 rads IMRT ( protons not at this place). Bad, bad side effect had to stop at 5500 rad total. Too bad I missed out on hypofractionation. This place was brand new and the docs were newly boarded hotshots. They can do anything they want as long as I have ZERO bone pain!

Ya pays your money, ya takes your chances.
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5500/350 = 15.714....

maybe it was not 350 a day...

“too bad I missed out on hypofractionation”... but wait...
 
They were newly boarded hotshots, so perhaps wanted to try blending 70/28 and 60/20. On fraction 16, someone said, "how nice, it smells like someone's roasting chestnuts..."

Edit: Oops, didn't notice there was no chestnut to roast. Sounds like there was a lot at play here.
 
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mikesheree said:
Hi from the path board. Are they offering patients( i know, ya gotta have good insurance) these choices. I had prostate CA bio recurrence in 2019( maybe 2018) and was only offered , and given, 20 fractions of 350 rads IMRT ( protons not at this place). Bad, bad side effect had to stop at 5500 rad total. Too bad I missed out on hypofractionation. This place was brand new and the docs were newly boarded hotshots. They can do anything they want as long as I have ZERO bone pain!

Ya pays your money, ya takes your chances.
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1)never had to stop patient early in my life for post-prost xrt side effects. something went badly wrong.
 
TheWallnerus said:
5500/350 = 15.714....

maybe it was not 350 a day...

“too bad I missed out on hypofractionation”... but wait...
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25-26 x 250 is a regimen in this setting, which would allow for 55 gy stopping point. As others have said, not aware of toxicity having caused early end to treatment.
 
I was supposed to receive a total of 7000 ( I THINK it was 250 x 28 days) for a 1.3 cm 4+4 in one lobe confined to prostate 2 years after radical prostatectomy. There was a question of seminal vesicle involvement, BUT what the paths are describing is involvement of the INTRAPROSTATIC portion of the seminal vesicles which does not count ( i was a path for decades, (U.S grad 1977). Tumor arose at area of root of seminal vesicle. They had to stop tx because i had a hx of severe pan ulcerative colitis. Got total abd colectomy due to hemorrhage with permanent ileostomy. Too risky to remove sigmoid due to prior surgery x 2 and the radiation. So, it really was a T2a, N0, M0 4+4=8. No one would listen to me but it had to be treated one way or another and there is no question there was a recurrence. 0.2ng x 2 at same lab. My pre op PSA was only 4.0 with small palpable) nodule.
The section taken of the seminal vesicle is normal. But there is tumor with the typical seminal vesicles pigment within the prostate. Nada in muscular wall of extraprostatic seminal vesicle. They thought the UC would be ok with IMRT.
 
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mikesheree said:
I was supposed to receive a total of 7000 rads for a 1.3 cm 4+4 in one lobe confined to prostate 2 years after radical prostatectomy. There was a question of seminal vesicle involvement, BUT what the paths are describing is involvement of the INTRAPROSTATIC portion of the seminal vesicles which does not count ( i was a path for decades, (U.S grad 1977). Tumor arose at area of root of seminal vesicle. They had to stop tx because i had a hx of severe pan ulcerative colitis. Got total abd colectomy due to hemorrhage with permanent ileostomy. Too risky to remove sigmoid due to prior surgery x 2 and the radiation. So, it really was a T2a, N0, M0 4+4=8. No one would listen to me but it had to be treated one way or another and there is no question there was a recurrence. 0.2ng x 2 at same lab. My pre op PSA was only 4.0 with small palpable nodule.
The section taken of the seminal vesicle is normal. But there is tumor with the typical seminal vesicles pigment within the prostate. Nada in muscular wall of extraprostatic seminal vesicle. They thought the UC would be ok with IMRT.
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I’m sorry to hear that you went through so much. Without knowing all the history and I understand hindsight is 20/20 but the urologist really should have strongly considered and recommended definitive radiation (with ADT) as complications are more likely with high risk disease, especially after surgery. It would be interesting to see their target volumes and plan.
 
mikesheree said:
They thought the UC would be ok with IMRT.
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/lay

IMRT is not a magic form of radiation. It is exactly the same radiation as the 1980s, but it is... intensity modulated. Which is just a fancier way of saying it is more sculpted. Sculpting is good. Rodin was a good sculptor. You could give me his same "technology" (clay, tools, etc) and I would not give you "The Thinker" though. So the sculptor *can* be more influential than the technology. You can easily make e.g. protons or IMRT more toxic than old style radiation through carelessness or cluelessness, and sometimes even with minor finesse-y deviations more toxicity can happen with "high tech" than without. As another example, if your doctors treated whole pelvis and prostate with IMRT, that can very much be more toxic (and treat MUCH more bowel, regardless the IMRT) than treating prostate alone with non-IMRT.

/lay
 
Hindsight is always 20/20, but in someone with uc history, are there other options here? I know all the data suggests intervening as soon as possible, but all the data was generated pre-modern anti-androgens. There's a ton of bullets in the chamber these days.

*I would've done rt if not recently active uc.
*Hopefully there weren't retained seminal vesicles (that's always an interesting finding)
 
Ray D. Ayshun said:
Hindsight is always 20/20, but in someone with uc history, are there other options here? I know all the data suggests intervening as soon as possible, but all the data was generated pre-modern anti-androgens. There's a ton of bullets in the chamber these days.

*I would've done rt if not recently active uc.
*Hopefully there weren't retained seminal vesicles (that's always an interesting finding)
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Based on the description of pan colitis, I suspect they treated nodes which in this setting I would not have (only high risk feature was GS 8). As a rule when someone has active autoimmune disease or high risk mutations (like an actionable germ line ATM deficit) and you have to treat it’s key to keep the fields as small as reasonably possible.

It’s all about consent and in this case I would have consented the patient for the possibility of a possible colectomy with a permanent ostomy. You could try dual ADT but the downsides to that are it is not curative, it has a lot of bothersome side effects, it would need to be taken long term, and if you have an otherwise good life expectancy your cancer will probably progress eventually. Neither option is particularly inviting and it’s up to the patient to decide. I don’t honestly even know what I would chose for myself if I were in that situation.
 
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