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

[medgator]

---

Members do not see this ad.

Mevion Selected to Equip Compact Proton Therapy Center in Kansas City

Mevion Medical Systems is pleased to announce it has signed a contract with Kansas City Urology Care (KCUC) for the purchase of a MEVION S250i Proton Therapy...

www.businesswire.com

Urorads getting in on the proton scam. Kinda surprised honestly. Most urologists I've met are very anti pretty proton

 

[thecarbonionangle]

Urorads getting in on the proton scam. Kinda surprised honestly. Most urologists I've met are very anti pretty proton

You’re against it until you are for it when you gonna make tons of cheese!

 

[ramsesthenice]

Urorads getting in on the proton scam. Kinda surprised honestly. Most urologists I've met are very anti pretty proton

Everyone hates Tom Brady…until he is your QB.

There are good reasons to question protons for PRCa. But let’s face it, on the whole, protons and photons for prostate are pretty comparable (tox and efficacy). Depending on how they affect your market share/revenue, you could argue either way. No one should be surprised to see anyone opening a proton center anymore. Disappointed sure. But not surprised.

 

[TheWallnerus]

Ken Olivier says proton cost a drop in the bucket in RO. Nothing to worry about. Every time a proton unit is purchased an angel gets its wings and a RO grad gets a job.

 

[RickyScott]

Everyone hates Tom Brady…until he is your QB.

There are good reasons to question protons for PRCa. But let’s face it, on the whole, protons and photons for prostate are pretty comparable (tox and efficacy). Depending on how they affect your market share/revenue, you could argue either way. No one should be surprised to see anyone opening a proton center anymore. Disappointed sure. But not surprised.

Difference is that I know close colleagues who treat proatate with protons, but wouldn’t use them on themselves or family.

 

[deleted1111261]

Seems like a really, really risky venture.

 

[Radonc 2013]

Didn't expect a proton center to show up in central Illinois but here you go!

A $237M cancer care center offering proton-beam therapy is coming to Illinois

A comprehensive cancer care center offering the second proton-beam therapy location in Illinois was approved by a state health board Tuesday.

www.usatoday.com

 

[fiji128]

While some talk about fraction shaming or choosing wisely there has been a gold rush in ultra high cost proton therapy over the past 10 years.

5/40 (12.5%) of centers are PPS Exempt Cancer Hospitals.

11/40 (27.5%) of centers are in APM Participant Zip Codes.

1) Seattle Cancer Care Alliance. Seattle, WA 98133. (PPS Exempt Cancer Hospital).
2) James M. Slater, MD Proton Treatment and Research Center. Loma Linda, CA 92354
3) California Protons Cancer Therapy Center. San Diego, CA 92121.
4) Huntsman Cancer Institute. Salt Lake, UT 84112.
5) The Mayo Clinic Proton Beam Therapy Center. Phoenix, AZ 85054.
6) Oklahoma Proton Center. Oklahoma City, OK 73142.
7) Stephenson Cancer Center. Oklahoma City, OK 73104.
8) Texas Center for Proton Therapy. Irving, TX 75063.
9) MD Anderson Cancer Center Proton Therapy Center. Houston, TX. 77504. (PPS Exempt Cancer Hospital).
10) Proton Therapy at the University of Kansas Cancer Center. Kansas City, KS 66160
11) Willis-Knighton Cancer Center. Shreveport, LA 71103. (APM Participant Zip Code).
12) The Mayo Clinic Proton Beam Therapy Center. Rochester, MN. 55901. (APM Participant Zip Code).
13) Red Frog Proton Therapy Center. Memphis, TN. 38105. (APM Participant Zip Code).
14) S. Lee Kling Center for Proton Therapy Center. St. Louis, MO. 63110.
15) David C. Pratt Cancer Center. St. Louis, MO. 63141.
16) Northwestern Medicine Proton Center. Wheaton, IL. 60555.
17) Provsion CARES Proton Therapy Center. Franklin, TN. 37067.
18) Provsion CARES Proton Therapy Center. Knoxville, TN. 37909.
19) Proton International. Birmingham, AL. 35233.
20) Emory Proton Therapy Center. Atlanta, GA. 30308.
21) Proton Therapy at University of Cincinnati Medical Center. Liberty Township, OH. 45044.
22) James Cancer Hospital and Solove Research Institute. Columbus, OH. 43210. (PPS Exempt Cancer Hospital).
23) University Hospital Proton Therapy Center. Cleveland, OH. 44106.
24) Beaumont Proton Therapy Center. Royal Oak, MI. 48073. (APM Participant Zip Code).
25) McLaren Proton Therapy Center. Flint, MI. 48532.
26) Miami Cancer Institute Proton Therapy Center. Miami, FL. 33176. (APM Participant Zip Code).
27) Dwoskin Proton Therapy Center. Miami, FL. 33125. (PPS Exempt Cancer Hospital).
28) South Florida Proton Therapy Institute. Delray Beach, FL. 33484. (APM Participant Zip Code).
29) The Marjorie and Leonard Williams Center for Proton Therapy. Orlando, FL. 32806.
30) Ackerman Cancer Center Proton Therapy Center. Jacksonville, FL. 32223. (APM Participant Zip Code).
31) University of Florida Health Proton Therapy Institute. Jacksonville, FL. 32206. (APM Participant Zip Code).
32) Hampton University Proton Therapy Institute. Hampton, VA. 23666.
33) Inova Mather Proton Therapy Center. Falls Church, VA. 22031. (APM Participant Zip Code).
34) MedStar Georgetown University Hospital Proton Therapy Center. Washington, DC. 20007. (APM Participant Zip Code).
35) Maryland Proton Treatment Center. Baltimore, MD. 21201.
36) Roberts Proton Therapy Center. Philadelphia, PA. 19104. (APM Participant Zip Code).
37) The Laurie Proton Therapy Center. New Brunswick, NJ. 08901.
38) ProCure Proton Treatment Center. Somerset, NJ. 08873.
39) The New York Proton Center. New York, NY. 10035.
40) Francis Burr Proton Therapy Center. Boston, MA. 02114. (PPS Exempt Cancer Hospital).

 

[thecarbonionangle]

NM proton center in works, just announced. The grift continues folks!

Proton therapy to fight cancer in ABQ

Center to build $43M facility bringing technology to New Mexico for the first time

www.abqjournal.com

 

[TheWallnerus]

NM proton center in works, just announced. The grift continues folks!

Proton therapy to fight cancer in ABQ

Center to build $43M facility bringing technology to New Mexico for the first time

www.abqjournal.com

We can laugh but this is ruining our field. And no one is willing to speak up. It doesn't have to be a riot; the change could come from logic and even kindness. Protons are a money-making machine not a make-lives-better machine. I become more and more convinced APM will save rad onc in ways no leader in rad onc could.

 

[thecarbonionangle]

We can laugh but this is ruining our field. And no one is willing to speak up. It doesn't have to be a riot; the change could come from logic and even kindness. Protons are a money-making machine not a make-lives-better machine. I become more and more convinced APM will save rad onc in ways no leader in rad onc could.

Pretty soon many will agree with following statements:

1) PW was way ahead of his time and CLEARLY onto something big/yuge
2) APM will save this field (anti grift) along with 1) (keep as many out of workforce as possible)

 

[communitydoc13]

APM will save rad onc in ways no leader in rad onc could.

Agree. Wondering if these recently announced centers are strategically located away from APM zips. A non-apm Zip code with surrounding APM codes would be ideal for short term gain.

 

[Chartreuse Wombat]

Agree. Wondering if these recently announced centers are strategically located away from APM zips. A non-apm Zip code with surrounding APM codes would be ideal for short term gain.

Protons could be exempt...wait for last minute sentence or two added to the ginormous spending bills

 

[lyltothend]

Agree. Wondering if these recently announced centers are strategically located away from APM zips. A non-apm Zip code with surrounding APM codes would be ideal for short term gain.

Also it states the facility will take 3 years to build, not much time to game the apm zip code distribution.

 

[communitydoc13]

Also it states the facility will take 3 years to build, not much time to game the apm zip code distribution.

I agree. That timeline to total implementation a bit fuzzy to me. (5 years?). I did check zips. Albuquerque center not in APM zip but Peoria is (of course Peoria announcement was in early 2020).

All moot if a blanket proton exemption comes to pass.

 

[TheWallnerus]

I agree. That timeline to total implementation a bit fuzzy to me. (5 years?). I did check zips. Albuquerque center not in APM zip but Peoria is (of course Peoria announcement was in early 2020).

All moot if a blanket proton exemption comes to pass.

You have to think.

Either you're really really stupid to put protons in Peoria, or you have inside information.

Given the players and amount of money we're talking about, my money's on the latter.

As a follow-on, please check out "DOPESICK" on Hulu.

 

[Lamount]

We can laugh but this is ruining our field. And no one is willing to speak up. It doesn't have to be a riot; the change could come from logic and even kindness. Protons are a money-making machine not a make-lives-better machine. I become more and more convinced APM will save rad onc in ways no leader in rad onc could.

What is your position on proton therapy from a clinical perspective? Do you think that the Bragg peak has any utility or is it merely a nice parlor trick?

I contend that it is extremely unlikely that protons wouldn’t have a better therapeutic ratio than photons in many cases where low intermediate dose is relevant… if planned appropriately taking into account uncertainty/motion/heterogeneity (which really is just STARTING to happen).

From my perspective, relevant issues are
1) doing it right -IMPT with robust optimization, incorporating IGRT into adaptive planning
2) finding appropriate clinical indications by doing RCT with protons DONE RIGHT
3) decreasing cost of equipment and cost to the system

I think there is likely a lot of value to protons. The problem is that protons became more expensive before they ever had a chance to attain this higher value. The money came before the science… but that doesn’t mean the science is useless.

 

[OTN]

What is your position on proton therapy from a clinical perspective? Do you think that the Bragg peak has any utility or is it merely a nice parlor trick?

I contend that it is extremely unlikely that protons wouldn’t have a better therapeutic ratio than photons in many cases where low intermediate dose is relevant… if planned appropriately taking into account uncertainty/motion/heterogeneity (which really is just STARTING to happen).

From my perspective, relevant issues are
1) doing it right -IMPT with robust optimization, incorporating IGRT into adaptive planning
2) finding appropriate clinical indications by doing RCT with protons DONE RIGHT
3) decreasing cost of equipment and cost to the system

I think there is likely a lot of value to protons. The problem is that protons became more expensive before they ever had a chance to attain this higher value. The money came before the science… but that doesn’t mean the science is useless.

[citations needed]

 

[Lamount]

[citations needed]

Which part? Where I say what my opinion is, or that we should do more trials with protons planned correctly?

 

[jondunn]

You have to remember that some people will have an opposition no matter what because they don’t have proton, and some will love it no matter what because they do have proton

The rest of us are in some spectrum of the space in between.

 

[Chartreuse Wombat]

What is your position on proton therapy from a clinical perspective? Do you think that the Bragg peak has any utility or is it merely a nice parlor trick?

I contend that it is extremely unlikely that protons wouldn’t have a better therapeutic ratio than photons in many cases where low intermediate dose is relevant… if planned appropriately taking into account uncertainty/motion/heterogeneity (which really is just STARTING to happen).

From my perspective, relevant issues are
1) doing it right -IMPT with robust optimization, incorporating IGRT into adaptive planning
2) finding appropriate clinical indications by doing RCT with protons DONE RIGHT
3) decreasing cost of equipment and cost to the system

I think there is likely a lot of value to protons. The problem is that protons became more expensive before they ever had a chance to attain this higher value. The money came before the science… but that doesn’t mean the science is useless.

One can use the same argument about any technology.

The proton industry is making claims. In scientific enterprises the burden of proof is on the claimant.

My simple request is prove it... instead of adding to the unsustainable medical spending

 

[communitydoc13]

where low intermediate dose is relevant

...and where robustness of high dose gradient regions is not critical.

The question I have is, in the absence of wide field applications and developmentally immature patients (see pediatric cranial spinal, Wilms, CNS), where is low/intermediate dose that relevant? You may spare the rare cancer. It is unclear if lymphocyte sparing means much.

The vast majority of our low/intermediate dose volumetric constraints are derived from the 3D era and are often proxies for larger tumor volume and higher dose plans period. ENI is going away regardless.

Are you going the dose escalate pancreas with IMPT with just as robust dose falloff at the duodenum but lower integral dose to the other small bowel and find meaningful improvement in the therapeutic ratio? Are you going to dose escalate brain or find marked cognitive benefits to IMPT in 70 year olds with GBM and not risk necrosis?

But none of this is the point. All these things could be explored at 4 national proton centers or even 10. Peoria and Albuquerque are doing this for marketing and reimbursement purposes only. If you want to concentrate the minds of proton industry leaders, make them float a few research centers; make them get it technically correct; make them get early clinical data that makes all the practitioners involved say woah! (not what I'm hearing from folks who use them now) and then do straightforward clinical trials.

You can clinically believe in protons and not believe in massive, present day proton expenditures.

 

[Lamount]

One can use the same argument about any technology.

The proton industry is making claims. In scientific enterprises the burden of proof is on the claimant.

My simple request is prove it... instead of adding to the unsustainable medical spending

I share concerns about cost... but the question of 'the science' is entirely distinct.

I also agree that the onus is on folks like (those who believe protons will have an important role in our field) to put up or shut up. However, I take issue with the confident assertion that protons are a dead end... unless someone can demonstrate that one of the following two statements are true.

1) Protons don't form a Bragg peak.
2) Dose deposited by an X-ray beam distal to the tumor is never clinically relevant.

 

[Lamount]

...and where robustness of high dose gradient regions is not critical.

The question I have is, in the absence of wide field applications and developmentally immature patients (see pediatric cranial spinal, Wilms, CNS), where is low/intermediate dose that relevant? You may spare the rare cancer. It is unclear if lymphocyte sparing means much.

The vast majority of our low/intermediate dose volumetric constraints are derived from the 3D era and are often proxies for larger tumor volume and higher dose plans period. ENI is going away regardless.

Are you going the dose escalate pancreas with IMPT with just as robust dose falloff at the duodenum but lower integral dose to the other small bowel and find meaningful improvement in the therapeutic ratio? Are you going to dose escalate brain or find marked cognitive benefits to IMPT in 70 year olds with GBM and not risk necrosis?

But none of this is the point. All these things could be explored at 4 national proton centers or even 10. Peoria and Albuquerque are doing this for marketing and reimbursement purposes only. If you want to concentrate the minds of proton industry leaders, make them float a few research centers; make them get it technically correct; make them get early clinical data that makes all the practitioners involved say woah! (not what I'm hearing from folks who use them now) and then do straightforward clinical trials.

You can clinically believe in protons and not believe in massive, present day proton expenditures.

To name a few...
-Stage III lung where we live and die by V20 and MLD, and LAD dose become more important.
-I am also going to take a look at lung SBRT for oligomets, as I find myself treating these folks over and over again.
-HCC/liver mets in folks with poor liver function.
-Esophagus.
-RP sarcoma.

 

[Chartreuse Wombat]

I share concerns about cost... but the question of 'the science' is entirely distinct.

I also agree that the onus is on folks like (those who believe protons will have an important role in our field) to put up or shut up. However, I take issue with the confident assertion that protons are a dead end... unless someone can demonstrate that one of the following two statements are true.

1) Protons don't form a Bragg peak.
2) Dose deposited by an X-ray beam distal to the tumor is never clinically relevant.

DVH idolatry. Most toxicity is threshhold sinusoidal

Prove that clinical outcomes are superior in human beings. If you can do this then good on you.

 

[OTN]

"I contend that it is extremely unlikely that protons wouldn’t have a better therapeutic ratio than photons in many cases where low intermediate dose is relevant… if planned appropriately taking into account uncertainty/motion/heterogeneity"

No data supports this statement outside of peds, ocular melanoma, and skull base chordomas.

Finally, It is simply not fair to paint those of us who are asking for actual clinical data showing clinically significant outcomes as proton "have nots". Not only it is an obvious ad hominem attack, some of us may have protons in our group and might not want to doxx ourselves. Some of us might not have protons and don't want to doxx ourselves by admitting that.

 

[Lamount]

DVH idolatry. Most toxicity is threshhold sinusoidal

Prove that clinical outcomes are superior in human beings. If you can do this then good on you.

Will hopefully be able to meet this challenge.

“Idolatry” is a bit dismissive, unless of course, you never check your DVH. A better question with protons is whether the DVH you calculated is the DVH you deliver.

I would ask if you can be skeptical of a research hypothesis while still be supportive of the endeavor

 

[communitydoc13]

To name a few...
-Stage III lung where we live and die by V20 and MLD, and LAD dose become more important.
-I am also going to take a look at lung SBRT for oligomets, as I find myself treating these folks over and over again.
-HCC/liver mets in folks with poor liver function.
-Esophagus.
-RP sarcoma.

I like the list. I’ll start with HCC, the most likely winner in my opinion. Although, it is notable that one of the most cited recent retrospective series only demonstrated survival benefit for pts treated with protons off of protocol (lol) and that the difference in distant progression was bonkers in the MDACC series….I am happy to send every Medicaid having cirrhotic out for protons when proven superior. Please take them, treat them well and don’t bankrupt them….but I agree, whole liver dose tolerance is pretty well established and some HCCs are pretty big. A great research project and an ongoing prospective trial I believe.

Thoracic malignancies? I’m not hung ho but prove me wrong. V20, MLD etc. are strictly contextual. So much room to play with with volumes alone, we can go back and forth forever.

RP sarcoma? You have better things to do. If you want to try to dump 90Gy into an unresectable RP be my guest. Next to impossible to run a trial on this in today’s sarcoma environment.

 

[Lamount]

"I contend that it is extremely unlikely that protons wouldn’t have a better therapeutic ratio than photons in many cases where low intermediate dose is relevant… if planned appropriately taking into account uncertainty/motion/heterogeneity"

No data supports this statement outside of peds, ocular melanoma, and skull base chordomas.

Finally, It is simply not fair to paint those of us who are asking for actual clinical data showing clinically significant outcomes as proton "have nots". Not only it is an obvious ad hominem attack, some of us may have protons in our group and might not want to doxx ourselves. Some of us might not have protons and don't want to doxx ourselves by admitting that.

There are plenty of data that low/intermediate dose matter outside of CNS/Peds (I.e lung V20). If protons can yield a safe V20 in certain patients when photons do not, it is my opinion that this is a compelling reason to use protons. 1308 will hopefully provide an answer.

I am not painting you as a “have not”… but I am a little frustrated by the lack of support many have for even RESEARCHING protons.

 

[Chartreuse Wombat]

Will hopefully be able to meet this challenge.

“Idolatry” is a bit dismissive, unless of course, you never check your DVH. A better question with protons is whether the DVH you calculated is the DVH you deliver.

I would ask if you can be skeptical of a research hypothesis while still be supportive of the endeavor

Idolatry is essentially to worship something as a God.

I don't intend to be dismissive; in just about every clinical scenario the proton DVH will "look better". In most scenarios this "improvement" has not resulted in improved clinical outcomes.

 

[Chartreuse Wombat]

There are plenty of data that low/intermediate dose matter outside of CNS/Peds (I.e lung V20). If protons can yield a safe V20 in certain patients when photons do not, it is my opinion that this is a compelling reason to use protons. 1308 will hopefully provide an answer.

I am not painting you as a “have not”… but I am a little frustrated by the lack of support many have for even RESEARCHING protons.

I have no problem with researching protons but registry studies don't count. Do the rigorous comparisons (which I wholeheartedly support). I have equipoise about the superior of protons in most clinical scenarios but my equipoise is wasted since I don't have access to protons. I am strong accruer to COMMPARE

 

[OTN]

There are plenty of data that low/intermediate dose matter outside of CNS/Peds (I.e lung V20). If protons can yield a safe V20 in certain patients when photons do not, it is my opinion that this is a compelling reason to use protons. 1308 will hopefully provide an answer.

I am not painting you as a “have not”… but I am a little frustrated by the lack of support many have for even RESEARCHING protons.

As was mentioned above, I'm not anti-proton research, I'm just anti- the proton research which has been done up to this point. It should be a source of incredible embarrassment for the field that we have yet to produce a myriad of RCTs looking into the issues. Registry studies are B.S. and everyone knows it.

 

[jondunn]

There are plenty of data that low/intermediate dose matter outside of CNS/Peds (I.e lung V20). If protons can yield a safe V20 in certain patients when photons do not, it is my opinion that this is a compelling reason to use protons. 1308 will hopefully provide an answer.

I am not painting you as a “have not”… but I am a little frustrated by the lack of support many have for even RESEARCHING protons.

1308 is the wrong trial to do this, though.

they should have stuck with 60 gy. information from this trial will not help support the idea that patients treated to the standard dose need proton to help facilitate that

huge whiff.

 

[jondunn]

we have yet to produce a myriad of RCTs looking into the issues.

im no proton guy, but this is not true. there is an ongoing RCT in like nearly every major disease site.

 

[TheWallnerus]

Idolatry is essentially to worship something as a God.

I don't intend to be dismissive; in just about every clinical scenario the proton DVH will "look better". In most scenarios this "improvement" has not resulted in improved clinical outcomes.

Proton DVH improvement associated with worse outcomes in prostate vs IMRT. I do stress "associated." That said, I have heard that almost all proton places now SpaceOAR their prostate patients. Which if true is pretty telling.

 

[jondunn]

\ That said, I have heard that almost all proton places now SpaceOAR their prostate patients. Which if true is pretty telling.

this blows my mind whenever i remember this. im open minded but prostate is simply not the place where proton can help at all, and we all know this.

 

[RickyScott]

There are plenty of data that low/intermediate dose matter outside of CNS/Peds (I.e lung V20). If protons can yield a safe V20 in certain patients when photons do not, it is my opinion that this is a compelling reason to use protons. 1308 will hopefully provide an answer.

I am not painting you as a “have not”… but I am a little frustrated by the lack of support many have for even RESEARCHING protons.

Protons trial for Lung trended to worse outcomes?

 

[medgator]

this blows my mind whenever i remember this. im open minded but prostate is simply not the place where proton can help at all, and we all know this.

It's the only disease site along with breast that can possibly pay for having a proton center in a smaller city.

The issue we all have with protons is that they put the cart before the horse to the tune of tens to hundreds of millions of dollars per facility

 

[TheWallnerus]

-Stage III lung where we live and die by V20 and MLD, and LAD dose become more important.

Do you think in a trial of proton vs photon for Stage III lung that the rate of "radiotherapeutic feasibility" will be higher for photon vs proton? This would be an exceedingly easy trial to run and accrue a bunch of patients for as it would be entirely in silico. Has this been done? Personally for me the rate of radiotherapeutic infeasibility for 60 Gy/30 fx is in the neighborhood of 1 out 100 (total guess). And for these hugely-tumor-burdened people you really wonder if radiation, photon or proton, would accomplish much.

 

[jondunn]

Do you think in a trial of proton vs photon for Stage III lung that the rate of "radiotherapeutic feasibility" will be higher for photon vs proton? This would be an exceedingly easy trial to run and accrue a bunch of patients for as it would be entirely in silico. Has this been done? Personally for me the rate of radiotherapeutic infeasibility for 60 Gy/30 fx is in the neighborhood of 1 out 100 (total guess). And for these hugely-tumor-burdened people you really wonder if radiation, photon or proton, would accomplish much.

its really irritating

 

[Lamount]

Idolatry is essentially to worship something as a God.

I don't intend to be dismissive; in just about every clinical scenario the proton DVH will "look better". In most scenarios this "improvement" has not resulted in improved clinical outcomes.

I think part of the problem with proton “DVHs looking better” is that they weren't actually better, when uncertainties were properly modeled. Time will tell

 

[Lamount]

Do you think in a trial of proton vs photon for Stage III lung that the rate of "radiotherapeutic feasibility" will be higher for photon vs proton? This would be an exceedingly easy trial to run and accrue a bunch of patients for as it would be entirely in silico. Has this been done? Personally for me the rate of radiotherapeutic infeasibility for 60 Gy/30 fx is in the neighborhood of 1 out 100 (total guess). And for these hugely-tumor-burdened people you really wonder if radiation, photon or proton, would accomplish much.

It’s funny you should bring this up because I have plans for something like this. In my population, most stage III is N3 and I am routinely playing games to safely treat

 

[medgator]

Do you think in a trial of proton vs photon for Stage III lung that the rate of "radiotherapeutic feasibility" will be higher for photon vs proton? This would be an exceedingly easy trial to run and accrue a bunch of patients for as it would be entirely in silico. Has this been done? Personally for me the rate of radiotherapeutic infeasibility for 60 Gy/30 fx is in the neighborhood of 1 out 100 (total guess). And for these hugely-tumor-burdened people you really wonder if radiation, photon or proton, would accomplish much.

It'll never happen because they won't like the answers. But like Nancy Lee said, they'll keep using them anyways because there is already a huge sunk cost

 

[Lamount]

Would agree with many of the commenters that the onus is on people like me to make the case…

I would just remind you that not all of us in academics who believe in this are money-grubbing elites… and there are legit reasons to investigate further

Perhaps we can all agree that we need more well designed multi-institution RCTs in the pipeline.

 

[communitydoc13]

Would agree with many of the commenters that the onus is on people like me to make the case…

I would just remind you that not all of us in academics who believe in this are money-grubbing elites… and there are legit reasons to investigate further

Perhaps we can all agree that we need more well designed multi-institution RCTs in the pipeline.

I don't know you from Adam. But, I'm sure you're going to do good work.

Most docs in academics are the furthest thing from money-grubbing. Elitism is unfortunately fairly intrinsic to academic medicine but a good, young doc, who I suspect has landed a good academic gig and is still openly engaged on a platform like this is definitely a mensch.

 

[elementaryschooleconomics]

Would agree with many of the commenters that the onus is on people like me to make the case…

I would just remind you that not all of us in academics who believe in this are money-grubbing elites… and there are legit reasons to investigate further

Perhaps we can all agree that we need more well designed multi-institution RCTs in the pipeline.

I believe most of you aren't, actually. I don't have protons and also believe there are many legit reasons for protons to exist and for additional trials to be run.

I think there are few people "at the top" making decisions for financial reasons, just like in any other sector of the economy. I don't blame the Comcast technician for hiking my monthly internet cost, I blame the C-suite.

 

[jondunn]

I think there are few people "at the top" making decisions for financial reasons, just like in any other sector of the economy. I don't blame the Comcast technician for hiking my monthly internet cost, I blame the C-suite.

this is the best post youll read today, and will apply as true, every day.

 

[RickyScott]

I think there are few people "at the top" making decisions for financial reasons, just like in any other sector of the economy. I don't blame the Comcast technician for hiking my monthly internet cost, I blame the C-suite.

And their useful idiots.

 

[Tsigolonco noitaidar]

Here is my question: if someone was to tell me that there is a more expensive radiation treatment modality that has limited randomized evidence to support it, I would think of IMRT. So I don't understand how folks so easily adopted IMRT when there was little to no randomized evidence comparing 3D to IMRT (currently, there are a few studies, but not many)? Is it because there is a lot of RWD to support IMRT? Are the existing RCTs sufficient enough to support widespread use of IMRT at every radiation oncology center in the country? Surely 3DCRT could be done at a much cheaper cost, so should we be sticking with 3D?

 

[RickyScott]

Here is my question: if someone was to tell me that there is a more expensive radiation treatment modality that has limited randomized evidence to support it, I would think of IMRT. So I don't understand how folks so easily adopted IMRT when there was little to no randomized evidence comparing 3D to IMRT (currently, there are a few studies, but not many)? Is it because there is a lot of RWD to support IMRT? Are the existing RCTs sufficient enough to support widespread use of IMRT at every radiation oncology center in the country? Surely 3DCRT could be done at a much cheaper cost, so should we be sticking with 3D?

Imrt vs 3d is photons to photons. Some parts of the proton dose distribution can have BEDs up to 1.7+ (Effectively biological hot spots of 150%) near the Bragg peak, hence worse rectal toxicity and brain necrosis of kiddies at under 60gy.

Your analogy would have to include imrt that delivered 150% hot spots next to critical organs at risk!