rad onc market

[Dave1980]

What happened to rad-onc in the last 5-10 years?

When I graduated med school in 2010 it was a super competitive field and everyone made tons of money. I thought about it but didn't think I was competitive enough to get a spot. Now it seems like everyone is super down on the field. Is it due to oversupply? decreasing demand for radiation therapy? both? or something else entirely?

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[thecarbonionangle]

This question has been asked, debated, pontificated ad nauseaum. You may as well ask why is sky blue or water wet? Why do i have so many teeth? You know the answer.

 

[Dave1980]

This question has been asked, debated, pontificated ad nauseaum. You may as well ask why is sky blue or water wet? Why do i have so many teeth? You know the answer.

i actually don't. im not a rad-onc and don't really follow the field.

 

[elementaryschooleconomics]

What happened to rad-onc in the last 5-10 years?

When I graduated med school in 2010 it was a super competitive field and everyone made tons of money. I thought about it but didn't think I was competitive enough to get a spot. Now it seems like everyone is super down on the field. Is it due to oversupply? decreasing demand for radiation therapy? both? or something else entirely?

Option E) all of the above!

Doubled the number of graduating residents, clinical trials aimed at reducing or eliminating the need for radiation therapy, reimbursement cuts from CMS, forcing half the country to participate in a poorly designed bundled payment model, the "leaders" in the field actively keeping their head in the sands from their PPS-exempt Ivory Towers making tons of money off cheap resident labor.

 

[TheWallnerus]

What happened to rad-onc in the last 5-10 years?

When I graduated med school in 2010 it was a super competitive field and everyone made tons of money. I thought about it but didn't think I was competitive enough to get a spot. Now it seems like everyone is super down on the field. Is it due to oversupply? decreasing demand for radiation therapy? both? or something else entirely?

You have no frame of reference, like a child who wanders in...

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[OTN]

They doubled the number of residents. Everything else is a negative, but small in comparison to the massive residency expansion that no one wanted or needed.

 

[TheWallnerus]

They doubled the number of residents. Everything else is a negative, but small in comparison to the massive residency expansion that no one wanted or needed.

Massively untapped amounts of hypofractionation that are still possible will give overexpansion a run for its money. I saw where no one... no woman, or man... gets more than 15 fractions for any stage of breast cancer now in the UK. Not even needs-a-boost patients.

 

[Mandelin Rain]

Double supply, halve demand.

The maths don't work.

 

[OTN]

Massively untapped amounts of hypofractionation that are still possible will give overexpansion a run for its money. I saw where no one... no woman, or man... gets more than 15 fractions for any stage of breast cancer now in the UK. Not even needs-a-boost patients.

Stage-for-stage, across all studied cancer types, cancer survival with treatment is better in the US than the UK, and has been for many years. They are not the system we should be emulating.

 

[medgator]

Stage-for-stage, across all studied cancer types, cancer survival with treatment is better in the US than the UK, and has been for many years. They are not the system we should be emulating.

You get what you pay for (sometimes).

The NICE determines what is covered over there, probably could use a little dose of that here but they sometimes go overboard

 

[jondunn]

Stage-for-stage, across all studied cancer types, cancer survival with treatment is better in the US than the UK, and has been for many years. They are not the system we should be emulating.

are you suggesting that hypofrac is the reason?

 

[TheWallnerus]

Stage-for-stage, across all studied cancer types, cancer survival with treatment is better in the US than the UK, and has been for many years. They are not the system we should be emulating.

True broadly for cancer, but not for breast. Survival has been taking huge strides forward last quarter century in breast both here and across pond. Tweaks in radiotherapy fractionation don't affect breast cancer survival one way or the other. Almost two-thirds of breast cancer patients in UK now get 5 fx. As bad as I hate to say it... I think we should emulate that. Of course if we did it would cause a Great Depression type crash in American rad onc.

 

[deleted941485]

True broadly for cancer, but not for breast. Survival has been taking huge strides forward last quarter century in breast both here and across pond. Tweaks in radiotherapy fractionation don't affect breast cancer survival one way or the other. Almost two-thirds of breast cancer patients in UK now get 5 fx. As bad as I hate to say it... I think we should emulate that. Of course if we did it would cause a Great Depression type crash in American rad onc.

Seems almost fraudulent to milk CMS money for 4 years (one of which is actually research) to train someone to do this especially when it’s on the verge of irrelevance.

 

[OTN]

True broadly for cancer, but not for breast. Survival has been taking huge strides forward last quarter century in breast both here and across pond. Tweaks in radiotherapy fractionation don't affect breast cancer survival one way or the other. Almost two-thirds of breast cancer patients in UK now get 5 fx. As bad as I hate to say it... I think we should emulate that. Of course if we did it would cause a Great Depression type crash in American rad onc.

It is true for breast:

Cancer survival rates

We explore how cancer survival varies by cancer type and how it compares across countries.

www.nuffieldtrust.org.uk

And I'm not saying that fractionation schedules are the reason, but I disagree very strongly that we should be modeling what we do after the UK.

Finally, I don't like at all how the 5-fraction regimen is on the "very steep" part of the toxicity curve, at least with the single trial that has evaluated it. For my patients who are still interested in the best possible cosmesis after treatment and underwent an oncoplastic lumpectomy, I believe 16 fractions + 5 fraction boost offers the best chance at good long-term cosmesis. It's what I would want for myself or a family member.

 

[Mandelin Rain]

It is true for breast:

Cancer survival rates

We explore how cancer survival varies by cancer type and how it compares across countries.

www.nuffieldtrust.org.uk

And I'm not saying that fractionation schedules are the reason, but I disagree very strongly that we should be modeling what we do after the UK.

Finally, I don't like at all how the 5-fraction regimen is on the "very steep" part of the toxicity curve, at least with the single trial that has evaluated it. For my patients who are still interested in the best possible cosmesis after treatment and underwent an oncoplastic lumpectomy, I believe 16 fractions + 5 fraction boost offers the best chance at good long-term cosmesis. It's what I would want for myself or a family member.

Very steep is almost an understatement. 1 Gy divided over 5 fractions is apparently the crucial difference maker.

 

[deleted941485]

Very steep is almost an understatement. 1 Gy divided over 5 fractions is apparently the crucial difference maker.

I’m sure nobody in the UK really cares that much. Just move the meat and get back to being clinical oncologists is probably the motto.

 

[jondunn]

It is true for breast:

Cancer survival rates

We explore how cancer survival varies by cancer type and how it compares across countries.

www.nuffieldtrust.org.uk

And I'm not saying that fractionation schedules are the reason, but I disagree very strongly that we should be modeling what we do after the UK.

Finally, I don't like at all how the 5-fraction regimen is on the "very steep" part of the toxicity curve, at least with the single trial that has evaluated it. For my patients who are still interested in the best possible cosmesis after treatment and underwent an oncoplastic lumpectomy, I believe 16 fractions + 5 fraction boost offers the best chance at good long-term cosmesis. It's what I would want for myself or a family member.

Do a few 5 fraction partial breast and you will never even ever begin to think anything is better cosmesis and overall patient experience wise.

If i had a breast cancer that was appropriate for partial breast, I would demand Livi 5 fraction partial breast

 

[dieABRdie]

Do a few 5 fraction partial breast and you will never even ever begin to think anything is better cosmesis and overall patient experience wise.

If i had a breast cancer that was approached for partial breast, I would demand Livi 5 fraction partial breast

I'm about to start handing it out like candy once I get the senior partners to agree.

Then I'm really going to enjoy being done by noon every day... and being in crushing debt the rest of my life 😢

 

[deleted941485]

I'm about to start handing it out like candy once I get the senior partners to agree.

Then I'm really going to enjoy being done by noon every day... and being in crushing debt the rest of my life 😢

I guess you can hold out until Astro makes inroads with Med onc...NOT

 

[BobbyHeenan]

Do a few 5 fraction partial breast and you will never even ever begin to think anything is better cosmesis and overall patient experience wise.

If i had a breast cancer that was appropriate for partial breast, I would demand Livi 5 fraction partial breast

I'm with you here. This regimen is amazing. Patients love it, I love it. I have had patients have literally zero acute toxicity...like I can't even find erythema. Now most go on to get minor skin thickening/volume loss focally, but overal cosmesis in my experience has been superior to my usual 40-42.6/15-16.

I really wish we'd quit making 70+ year old's miserable with an AI and just give them 5 fraction Livi instead. I hope the ongoing trial (I *think* it exists) shows breast APBI adequate and consider quick omission of AI at first adverse side effect.

I've done some 5 fraction whole breast and I see more toxicity than the 5 fraction APBI I think. LOok at the 5 fraction whole breast trial, the ever so slighlty higher dose arm had worse cosmesis. I find it hard to believe that 27 Gy was that much different than 26 Gy. If you need a boost you're already up to 10 fractions....so are we sure it's worth it to do 10 and not a more established 19-20?

 

[evilbooyaa]

I'm with you here. This regimen is amazing. Patients love it, I love it. I have had patients have literally zero acute toxicity...like I can't even find erythema. Now most go on to get minor skin thickening/volume loss focally, but overal cosmesis in my experience has been superior to my usual 40-42.6/15-16.

I really wish we'd quit making 70+ year old's miserable with an AI and just give them 5 fraction Livi instead. I hope the ongoing trial (I *think* it exists) shows breast APBI adequate and consider quick omission of AI at first adverse side effect.

I've done some 5 fraction whole breast and I see more toxicity than the 5 fraction APBI I think. LOok at the 5 fraction whole breast trial, the ever so slighlty higher dose arm had worse cosmesis. I find it hard to believe that 27 Gy was that much different than 26 Gy. If you need a boost you're already up to 10 fractions....so are we sure it's worth it to do 10 and not a more established 19-20?

I am eagerly awaiting results of EUROPA (ExclUsive endocRine Therapy Or Partial Breast Irradiation for Women Aged ≥70 Years Early Stage Breast Cancer - Full Text View - ClinicalTrials.gov) so we can start doing 5Fx APBI instead of 5 years AI for all these women that are (likely) getting the wrong treatment as a result of CALGB, PRIME-II, and the ongoing DEBRA trials. It's supported in theory by NSABP B-21 where RT alone had a larger effect than Tam alone at preventing local recurrence.

 

[OTN]

Do a few 5 fraction partial breast and you will never even ever begin to think anything is better cosmesis and overall patient experience wise.

If i had a breast cancer that was appropriate for partial breast, I would demand Livi 5 fraction partial breast

Nearly every lumpectomy I see is oncoplastic, and I’m just not comfortable doing APBI in that setting, even though I have seen one small study. That small bit of retrospective data wasn’t enough to convince me that it’s reasonable to do APBI after breast tissue has been rearranged, so it’s whole breast for most of my patients.

Getting the breast surgeons do to a non-oncoplastic lumpectomy is a non-starter, and I do have to admit the cosmetic outcomes have been great with oncoplastic lumpectomy + 16 whole breast +\- boost.

 

[BobbyHeenan]

Nearly every lumpectomy I see is oncoplastic, and I’m just not comfortable doing APBI in that setting, even though I have seen one small study. That small bit of retrospective data wasn’t enough to convince me that it’s reasonable to do APBI after breast tissue has been rearranged, so it’s whole breast for most of my patients.

Getting the breast surgeons do to a non-oncoplastic lumpectomy is a non-starter, and I do have to admit the cosmetic outcomes have been great with oncoplastic lumpectomy + 16 whole breast +\- boost.

Im lucky our breast surgeons haven’t gone to do much oncoplastic lumpectomies….but I’m hearing more about this.

In my limited experience I’ve seen little difference between a close but negative margin lumpectomy (ie you don’t take massive chunk of tissue) and an oncoplastic lump.

What has been your experience?

 

[evilbooyaa]

Nearly every lumpectomy I see is oncoplastic, and I’m just not comfortable doing APBI in that setting, even though I have seen one small study. That small bit of retrospective data wasn’t enough to convince me that it’s reasonable to do APBI after breast tissue has been rearranged, so it’s whole breast for most of my patients.

Getting the breast surgeons do to a non-oncoplastic lumpectomy is a non-starter, and I do have to admit the cosmetic outcomes have been great with oncoplastic lumpectomy + 16 whole breast +\- boost.

Can you get them to put some clips on the outskirts of the cavity before tissue rearrangement starts to help guide APBI? I've had two breast surgeons locally who do oncoplastic willing to place clips to allow their patients access to APBI.

Certainly nothing wrong with 16Fx WBI, but I also like the convenience of 5Fx IMRT (or SBRT, see thread in private forum) APBI in these scenarios.

 

[fiji128]

I’m in a community clinic. No way I can keep up with what every referring breast surgeon is doing or not doing. Sometimes lumpectomy cavity is obvious other times not. Everyone basically get whole breast RT or near whole breast RT in 15 fractions for that reason driven by lung and heart doses. Cosmetic outcomes are overwhelmingly excellent. My average patient is probably 60 mins from the time they walk out their front door to the time their back home.

 

[deleted1111261]

5 fx APBI FTW

 

[Krukenberg]

I'm with you here. This regimen is amazing. Patients love it, I love it. I have had patients have literally zero acute toxicity...like I can't even find erythema. Now most go on to get minor skin thickening/volume loss focally, but overal cosmesis in my experience has been superior to my usual 40-42.6/15-16.

I really wish we'd quit making 70+ year old's miserable with an AI and just give them 5 fraction Livi instead. I hope the ongoing trial (I *think* it exists) shows breast APBI adequate and consider quick omission of AI at first adverse side effect.

I've done some 5 fraction whole breast and I see more toxicity than the 5 fraction APBI I think. LOok at the 5 fraction whole breast trial, the ever so slighlty higher dose arm had worse cosmesis. I find it hard to believe that 27 Gy was that much different than 26 Gy. If you need a boost you're already up to 10 fractions....so are we sure it's worth it to do 10 and not a more established 19-20?

Is there a cup size at which you’ve consistently been unable to meet the constraints? Considering doing this more, but I tend not to even try in small breasted women

 

[BobbyHeenan]

Is there a cup size at which you’ve consistently been unable to meet the constraints? Considering doing this more, but I tend not to even try in small breasted women

I've had one lady with a small cup size/big seroma that I didn't go for it. IMO you really don't know until you start planning.

Off the top of my head I *think* the constraint is no more than 50% of normal breast (I think trial defined as breast minus CTV maybe) getting > 15 Gy.

I can usually meet that. There is wiggle room tough in the text of the trial it says something like "if can't meet constraints then physicians used discretion." In particular, I have violated the contralateral breast constraint to get better dosimetry elsewhere...especially in ladies over 70. I'm OK with a contralateral breast max a little more than what trial designed for.

 

[evilbooyaa]

I’m in a community clinic. No way I can keep up with what every referring breast surgeon is doing or not doing. Sometimes lumpectomy cavity is obvious other times not. Everyone basically get whole breast RT or near whole breast RT in 15 fractions for that reason driven by lung and heart doses. Cosmetic outcomes are overwhelmingly excellent. My average patient is probably 60 mins from the time they walk out their front door to the time their back home.

I get referrals from about 5-6 unique breast surgeons. Do you have more datapoints than that? Most would be very interested in setting patients up with the ability to offer a 5fx regimen if they had to make minor changes to their practice.

I've had one lady with a small cup size/big seroma that I didn't go for it. IMO you really don't know until you start planning.

Off the top of my head I *think* the constraint is no more than 50% of normal breast (I think trial defined as breast minus CTV maybe) getting > 15 Gy.

I can usually meet that. There is wiggle room tough in the text of the trial it says something like "if can't meet constraints then physicians used discretion." In particular, I have violated the contralateral breast constraint to get better dosimetry elsewhere...especially in ladies over 70. I'm OK with a contralateral breast max a little more than what trial designed for.

Agree with this. V15 < 50% is accurate as ipsi breast constraint. I will allow contralateral breast point dose < 1Gy to meet heart/lungs, as necessary, in most women.

 

[Krukenberg]

I get referrals from about 5-6 unique breast surgeons. Do you have more datapoints than that? Most would be very interested in setting patients up with the ability to offer a 5fx regimen if they had to make minor changes to their practice.



Agree with this. V15 < 50% is accurate as ipsi breast constraint. I will allow contralateral breast point dose < 1Gy to meet heart/lungs, as necessary, in most women.

I’ve wondered about applying FAST-FORWARD dose and fractionation to Livi APBI technique to further drive down toxicity/increase patient satisfaction. In fact the FAST FORWARD authors endorse using it with PBI in the Discussion section.

 

[deleted1111261]

I’ve wondered about applying FAST-FORWARD dose and fractionation to Livi APBI technique to further drive down toxicity/increase patient satisfaction. In fact the FAST FORWARD authors endorse using it with PBI in the Discussion section.

Logically, yes.

I do a SIB. It’s based on MDACC in house protocol (OPAL II). I do a 2cm CTV expansion on seroma+clips and 0.5cm PTV and that goes to 26/5. Then I do 1cm expansion/0.5cm PTV and take that to 30/5. DIBH and CBCT each fraction. The SIB per protocol is for patients that require a boost, but I just boost everyone.

 

[Krukenberg]

Logically, yes.

I do a SIB. It’s based on MDACC in house protocol (OPAL II). I do a 2cm CTV expansion on seroma+clips and 0.5cm PTV and that goes to 26/5. Then I do 1cm expansion/0.5cm PTV and take that to 30/5. DIBH and CBCT each fraction. The SIB per protocol is for patients that require a boost, but I just boost everyone.

Interesting. What’s the per-protocol criteria for the SIB? Guessing cautionary criteria?

 

[deleted1111261]

Interesting. What’s the per-protocol criteria for the SIB? Guessing cautionary criteria?

Yeah, I think margins, grade, age- etc.

 

[Splenda88]

Lol

 

[medgator]

Lol

Totally kosher for igrt coverage in the hospital as long as Andy has been "trained"

 

[TheWallnerus]

Lol

And I looked, and behold a pale horse. And his name that sat on him was FNP-C, and Hell followed with him.

 

[TheWallnerus]

Lol

I like "Latinx" ... if the "x" means X-ray

 

[Splenda88]

I like "Latinx" ... if the "x" means X-ray

Well, he speaks Spanish.

 

[jondunn]

This is the future many want !

 

[jondunn]

We ain’t seen nuttin in rad onc yet. Talk to your friends in derm and ophtho to see what happens when private equity goes full board

 

[elementaryschooleconomics]

And I looked, and behold a pale horse. And his name that sat on him was FNP-C, and Hell followed with him.

Man, this dude gets more press from his hospital than I do at mine. Next time my admin starts talking about our target numbers, I'm whipping this out and asking when they think they'll be ready to play hardball to get those numbers.

 

[Gfunk6]

Given oversupply, it is far more likely we will see Rad Oncs cross train as FNPs rather than the other way around.

 

[seper]

Given oversupply, it is far more likely we will see Rad Oncs cross train as FNPs rather than the other way around.

Or perhaps salaries of employed RadOncs and NP's will converge faster than we may think

 

[OTN]

We should be more upset than we currently are about this guy being described as a "radiation oncologist" by a health system. What does ASTRO think of this? Does our professional society have any opinion on who gets to call themselves a "radiation oncologist"? Have they pursued any legal action against this dude or the hospital? Has the California Medical Board been alerted that this guy is practicing as a radiation oncologist without any training? Does anyone other than this board care?

Can I hire 4 NPs to cover all our centers once our other docs retire, then just stick around to supervise them? Would that also be ok? If ASTRO allows this clinic in California to get away with this, what's stopping me from doing that?

 

[Neuronix]

It's spooky that heme onc in a big city pays better than rad onc in the middle of nowhere.

 

[jondunn]

We should be more upset than we currently are about this guy being described as a "radiation oncologist" by a health system. What does ASTRO think of this? Does our professional society have any opinion on who gets to call themselves a "radiation oncologist"? Have they pursued any legal action against this dude or the hospital? Has the California Medical Board been alerted that this guy is practicing as a radiation oncologist without any training? Does anyone other than this board care?

Can I hire 4 NPs to cover all our centers once our other docs retire, then just stick around to supervise them? Would that also be ok? If ASTRO allows this clinic in California to get away with this, what's stopping me from doing that?

Private equity is listening, early and often! Supervision relaxation is a BOON for big business, bad for the individual

 

[jondunn]

if I worked for Genesis and was a new grad, I would not get too comfortable!

 

[TheWallnerus]

If ASTRO allows this clinic in California to get away with this, what's stopping me from doing that?

I am not a fan of whataboutism ... but is it worse that ASTRO allows a clinic in the middle of almond country with a 50+% Hispanic population be staffed with NPs who, as far as we know, provide good rad onc care... or allows proton centers' #1 treated diagnosis be Stage 1 breast cancer.

ASTRO lets a lot of weird s**t go down. But when there are randomized trials showing whole breast IMRT is superior, they're against that.

 

[medgator]

View attachment 344192

It's spooky that heme onc in a big city pays better than rad onc in the middle of nowhere.

Not the same hours, interesting they put that in there

 

[OTN]

UPDATE: I just couldn’t believe that an NP was delivering radiation and being marketed as a radonc, so I looked into the center online.

The main website of cancer care at the hospital talks about a doctor who is indeed an MD: https://www.enloe.org/services-and-treatments/cancer-care/radiation-oncology/radiation-oncology

I think someone in marketing got a little too enthusiastic, which as we all know happens more often than not. I will sheath the pitchfork and retreat back to my misanthropic corner.