Rad Onc Twitter

[OTN]

I would caution those trying this for the first time that there are a lot of nuances that may not be obvious

It is very easy for there to be miscommunication with the EPs as we have very different frames of reference. They do not frequently plan their normal catheter ablation targets based upon cross-sectional imaging --it's more of a procedural approach whereby they use real-time imaging in the lab. This means that they may not be accustomed to pointing to a spot on a CT image even when looking at cardiac views. Furthermore, no human being can look at an axial image of the heart that would come from a CT simulation and know where a target is without first rotating to the cardiac views... and getting the CT scan from standard sim orientation (axial, sag, coronal) those cardiac-specific views takes some practice.

It's important that the EPs understand how the RT works... and also that we understand how they select their target (i.e. knowing the broad strokes of how to interpret the EKG of the clinical VT you are trying to treat so you have a general sense of where you should be targeting in the LV) to avoid miscommunication.

Given the complexity and the dangerous doses used, we have sought the guidance of WashU in most of our cases and are only now starting to feel a little more confident... and I would strongly advise anyone who is new to this do the same.

I agree with all of this. Fortunately for us, the EP docs with whom we worked had done cardiac SBRT several times before and were very experienced. I also by no means tried to recreate the wheel and communicated heavily with the WashU team.

Edit: machine was a Varian iX with CBCT, robotic couch top, with body pro lok and 4d CT sim

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[RadOncDoc21]

I agree with all of this. Fortunately for us, the EP docs with whom we worked had done cardiac SBRT several times before and were very experienced. I also by no means tried to recreate the wheel and communicated heavily with the WashU team.

Edit: machine was a Varian iX with CBCT, robotic couch top, with body pro lok and 4d CT sim

Maybe you can make a little extra teaching us lay folks. I’ll join once we get reimbursed or once I start ending up in the back of a bread line, whichever comes first I guess.

 

[dieABRdie]

I would caution those trying this for the first time that there are a lot of nuances that may not be obvious

It is very easy for there to be miscommunication with the EPs as we have very different frames of reference. They do not frequently plan their normal catheter ablation targets based upon cross-sectional imaging --it's more of a procedural approach whereby they use real-time imaging in the lab. This means that they may not be accustomed to pointing to a spot on a CT image even when looking at cardiac views. Furthermore, no human being can look at an axial image of the heart that would come from a CT simulation and know where a target is without first rotating to the cardiac views... and getting the CT scan from standard sim orientation (axial, sag, coronal) those cardiac-specific views takes some practice.

It's important that the EPs understand how the RT works... and also that we understand how they select their target (i.e. knowing the broad strokes of how to interpret the EKG of the clinical VT you are trying to treat so you have a general sense of where you should be targeting in the LV) to avoid miscommunication.

Given the complexity and the dangerous doses used, we have sought the guidance of WashU in most of our cases and are only now starting to feel a little more confident... and I would strongly advise anyone who is new to this do the same.

Cliff Robinson visited our institution and offered his initial experience. He said before he did it he was fretting about how he would hit such a small target. The EPs said.... "Hey.... can you make it BIGGER?"

Yes, yes we can.

It turns out the problem is they are ablating a very small area each time then waiting to see if it worked. If they didn't get it, they have to go back. So part of the attraction to this method is we can ablate a large area at one time.

He said he was terrified doing the first patient (understandably). He told the patient "Hey, I might kill you." The patient said "Look... I get shocked with electricity about a hundred times a day. I'd rather be dead than go on like this."

 

[TheWallnerus]

Cliff Robinson visited our institution and offered his initial experience. He said before he did it he was fretting about how he would hit such a small target. The EPs said.... "Hey.... can you make it BIGGER?"

Yes, yes we can.

It turns out the problem is they are ablating a very small area each time then waiting to see if it worked. If they didn't get it, they have to go back. So part of the attraction to this method is we can ablate a large area at one time.

He said he was terrified doing the first patient (understandably). He told the patient "Hey, I might kill you." The patient said "Look... I get shocked with electricity about a hundred times a day. I'd rather be dead than go on like this."

Great story. In other words world famous rad onc had to do something medically and to be successful had to quit thinking and behaving like a rad onc. Counter this with rad oncs and physicists who flipped their lid over 1 Gy to the lungs during COVID.

 

[metallica81788]

Yeah I'm just not going to do all of that cardiac stuff...

 

[medgator]

Yeah I'm just not going to do all of that cardiac stuff...

Arthritis and cardiac SBRT helping us metamorphosize into therapeutic radiologists....

 

[TheWallnerus]

I am guessing you are right...

I think of it like SRS or SBRT anywhere else: it may be that there are a lot of ways to do it safely and effectively... and also a lot of ways to hurt people and/or burn a bridge with an ineffective treatment.

But unlike SRS for brain mets or SBRT for lung cancer, we just don't know which aspects of the treatment approach can be changed without causing a problem yet. We know the existence of one safe approach... so it may be best to follow that approach until there are more data.

That is true. It's really pretty astounding that for something so dangerous and lethal and that no one essentially knew what they were doing beforehand (I mean they had "an idea") it turned out to be so safe and effective. Better to be lucky than good.

 

[mheat3]

Arthritis and cardiac SBRT helping us metamorphosize into therapeutic radiologists....

So true, although I feel comfortable only delivering one of them at the moment...

 

[Lamount]

That is true. It's really pretty astounding that for something so dangerous and lethal and that no one essentially knew what they were doing beforehand (I mean they had "an idea") it turned out to be so safe and effective. Better to be lucky than good.

Think about the first lunatic that gave 80 Gy x 1 CN V right next to the brain stem for trigeminal neuralgia.

"Not only is the patient still breathing, but their face feels better too!"

 

[RickyScott]

Think about the first lunatic that gave 80 Gy x 1 CN V right next to the brain stem for trigeminal neuralgia.

"Not only is the patient still breathing, but their face feels better too!"

Lars leskell Without mri and probably without ct - in Sweden in 1960s

 

[TheWallnerus]

Radiation Oncology's Plight,
In Three Acts

I. A senator sponsors a bill that has nothing to do with radiation oncology (except exceedingly tangentially)
II. A physician thinks the bill has to do with radiation therapy and that "HemeOncs" Rx radiation
III. Everyone starts fighting for the HemeOncs and their ability to prescribe RT

 

[RadOncDoc21]

Radiation Oncology's Plight,
In Three Acts

I. A senator sponsors a bill that has nothing to do with radiation oncology (except exceedingly tangentially)
II. A physician thinks the bill has to do with radiation therapy and that "HemeOncs" Rx radiation
III. Everyone starts fighting for the HemeOncs and their ability to prescribe RT

Lol, if it means getting some form of justice, I’ll take it. Maybe having med oncs appear to be radiation oncologists gets more done than having our current “leaders” fight for us.

In a field where we don’t receive recognition anyway and the catfish of all specialties, maybe this is a good thing... can’t get any worse in my opinion. Maybe med oncs will appreciate us more, society, who knows.

Do I feel disrespected? Of course, but that’s not new. Maybe this gets people to think about radiation more, I’m grasping for anything these days.

 

[Mandelin Rain]

I think hemeoncs trying to deliver radiation therapy would lead to a whole new level of appreciation for radiation oncologists.

 

[TheWallnerus]

I think hemeoncs trying to deliver radiation therapy would lead to a whole new level of appreciation for radiation oncologists.

The hemeoncs that employ rad oncs and get a good chunk of their global have a level of appreciation even above that.

 

[Bearstronaut]

Radiation Oncology's Plight,
In Three Acts

I. A senator sponsors a bill that has nothing to do with radiation oncology (except exceedingly tangentially)
II. A physician thinks the bill has to do with radiation therapy and that "HemeOncs" Rx radiation
III. Everyone starts fighting for the HemeOncs and their ability to prescribe RT

They mention in a later tweet they mistyped radonc as hemeonc here.

 

[TheWallnerus]

They mention in a later tweet they mistyped radonc as hemeonc here.

They “mistyped” it a few times lol

 

[emt409]

Question for the cardiac literati from the cardiac illiterati.

Before WashU did this for the first time, no one really had done it. So they theorized a way that would work, and I'll be darned it worked. But it was maybe one out of tens of different ways of doing this. So what are the chances that the WashU way is the only way? Did they just nail it on the first time by sheer force of latent cardiac know-how resting in the RO's brain or could it be that there might be actually numerous roads to Rome. Our man in the arena @OTN seems to have nailed it on his first try/tries too. My guess is that there's a panoply of approaches which will be minor variations on a theme that can (and will) be used to "blast" a big bolus of X-rays into the cardium and all of them work.

IIRC, Billy Loo at Stanford did it first. Basically an EP knocked on his door and ask if he thought RT could homogenize heterogeneous distributions of mixed scar/myocardium from prior MI. He tried it, it worked. A few other EP's got wind and started asking their rad oncs to try it.

Cliff and Phil were the first to protocolize it, and systematically test it.

There are a LOT of open questions, and Cliff & Phil are very open when they discuss the practice that there might be other ways to do it. Everything is cookie cutter right now to satisfy the cardiac division of the FDA, who is monitoring developments VERY closely, and has jurisdiction over trials, and device labeling indications.

I have treated a few of these patients with our team, and we opened a dose de-escalation trial at our institution, and I'm taking it with me to my next center (who is already treating a fairly decent volume), which will hopefully shed some insight onto whether 25Gy/1fx is really necessary, because that dose is obvious high risk to ultra-central tissues as well as gastric tissue (e.g. gastro-pericardial fistula that developed in one patient in the ENCORE-VT study), which is at risk if you don't gate.

@OTN is correct that from a rad onc perspective, the delivery is not nearly as challenging as the target delineation, which should never be done without an EP. The target delineation is made more challenging by the fact that EP's do not think about anatomy the way we do (slice by slice in one of the three cardinal axes). They think about anatomy from an endocardial structural point of view, so they are lost looking at anatomy the way we do, and vice versa.

The Wash U team puts on a phenomenal 2 day seminar/workshop every year, with hands-on practical sessions. If you're interested and have an interested EP, the best thing you can do is take them to this workshop.

 

[TheWallnerus]

IIRC, Billy Loo at Stanford did it first. Basically an EP knocked on his door and ask if he thought RT could homogenize heterogeneous distributions of mixed scar/myocardium from prior MI. He tried it, it worked. A few other EP's got wind and started asking their rad oncs to try it.

Cliff and Phil were the first to protocolize it, and systematically test it.

There are a LOT of open questions, and Cliff & Phil are very open when they discuss the practice that there might be other ways to do it. Everything is cookie cutter right now to satisfy the cardiac division of the FDA, who is monitoring developments VERY closely, and has jurisdiction over trials, and device labeling indications.

I have treated a few of these patients with our team, and we opened a dose de-escalation trial at our institution, and I'm taking it with me to my next center (who is already treating a fairly decent volume), which will hopefully shed some insight onto whether 25Gy/1fx is really necessary, because that dose is obvious high risk to ultra-central tissues as well as gastric tissue (e.g. gastro-pericardial fistula that developed in one patient in the ENCORE-VT study), which is at risk if you don't gate.

@OTN is correct that from a rad onc perspective, the delivery is not nearly as challenging as the target delineation, which should never be done without an EP. The target delineation is made more challenging by the fact that EP's do not think about anatomy the way we do (slice by slice in one of the three cardinal axes). They think about anatomy from an endocardial structural point of view, so they are lost looking at anatomy the way we do, and vice versa.

The Wash U team puts on a phenomenal 2 day seminar/workshop every year, with hands-on practical sessions. If you're interested and have an interested EP, the best thing you can do is take them to this workshop.

I foresaw that there would be “rad oncs” doing only heart in the future and got some guff. If this happens, to mis paraphrase Simul, “I left oncology; it didn’t leave me.”

 

[Conn Seannery]

 

[TheWallnerus]

Tw

Jack Dorsey already flagging it as “offensive content.” He must have some friends at Stanford.

 

[seper]

There is probably just one RadOnc troll on Twitter, but gotta say, he is hitting where it hurts )

 

[TheWallnerus]

There is probably just one RadOnc troll on Twitter, but gotta say, he is hitting where it hurts )

Is it really trolling when it's accurate

 

[medgator]

Is it really trolling when it's accurate

 

[medgator]

 

[FrostyHammer]

Because the solution to all problems in life is to throw money at it and hope the problem goes away. WTF Duke.

 

[randomname2018]

Because the solution to all problems in life is to throw money at it and hope the problem goes away. WTF Duke.

Ive seen a few of these URM med student rad onc scholarship opportunities now. Fundamentally, it is a good idea. It's an opportunity for students and departments to enter into a mutual beneficial arrangement. Student gets experience and exposure to the department and the department gets an opportunity to build a strong resident applicant and some research. However, the timing and optics of these could not be worse and that's the most damning evidence. Offering up a couple grand they poached off of junior faculty is transparent and unethical with the job market concerns.

 

[CurbYourExpectations]

If programs were committing to cutting spots to a healthy amount and still offering URMs some opportunities like this it would be outstanding.

 

[RickyScott]

Didn’t duke just expand their program?

 

[medgator]

Ive seen a few of these URM med student rad onc scholarship opportunities now. Fundamentally, it is a good idea. It's an opportunity for students and departments to enter into a mutual beneficial arrangement. Student gets experience and exposure to the department and the department gets an opportunity to build a strong resident applicant and some research. However, the timing and optics of these could not be worse and that's the most damning evidence. Offering up a couple grand they poached off of junior faculty is transparent and unethical with the job market concerns.

I've never seen URM outreach until the last year or so. Hell, Louis potters didn't exactly try to keep it a secret in his recent op-ed in the red journal.

It's as shameless as it is disgusting

 

[RickyScott]

It’s not like increasing urm in radonc increases urm in medicine. They are just being diverted from fields where they are needed and would thrive and and shunted into a dead end speciality with no jobs.

 

[RickyScott]

Railing on 30 Gy in 10 fractions for palliation, while meanwhile on the Emory proton therapy web page, they claim benefit for breast cancer, prostate cancer, rectal cancer, etc...

Emory Proton Therapy Center

Advanced proton therapy—extreme precision, less radiation—at the Southeast's largest center: Emory Proton Therapy Center

winshipcancer.emory.edu

just wanted to post what emory has in terms of maximum prices:

Tab Summary A B 1 Machine Readable Disclosure File 2 3 ...​

Level 1 Therapeutic Radiation Treatment Preparation	119
Level 2 Therapeutic Radiation Treatment Preparation	8055
Level 3 Therapeutic Radiation Treatment Preparation	22129
Level 2 Radiation Therapy	12759
Level 3 Radiation Therapy	27808
Level 4 Radiation Therapy	5313
Level 6 Radiation Therapy	41082
Level 7 Radiation Therapy	41082

 

[elementaryschooleconomics]

It’s not like increasing urm in radonc increases urm in medicine. They are just being diverted from fields where they are needed and would thrive and and shunted into a dead end speciality with no jobs.

Exactly. Truly altruistic action towards helping foster diversity in medicine includes mentoring/sponsoring students to succeed IN GENERAL while in medical school without regard for whichever specialty suits their individual goals.

US MD/DO applications to RadOnc are down =/= "time to increase diversity". The pool of available "diverse" applicants at the residency level remains constant; recruiting someone into RadOnc so they can struggle to find a job in a geographic area of their choice doesn't seem like you're recruiting them for THEIR benefit...

This whole thing feels so disingenuous to me. Where were these people currently beating the diversity drum 5 years ago when the average Step 1 score was >250? While the Twitter anonymous accounts can sometimes get a little aggressive, they do hit certain points with utter clarity: would you want to increase diversity on the Titanic?

 

[Lamount]

Exactly. Truly altruistic action towards helping foster diversity in medicine includes mentoring/sponsoring students to succeed IN GENERAL while in medical school without regard for whichever specialty suits their individual goals.

US MD/DO applications to RadOnc are down =/= "time to increase diversity". The pool of available "diverse" applicants at the residency level remains constant; recruiting someone into RadOnc so they can struggle to find a job in a geographic area of their choice doesn't seem like you're recruiting them for THEIR benefit...

This whole thing feels so disingenuous to me. Where were these people currently beating the diversity drum 5 years ago when the average Step 1 score was >250? While the Twitter anonymous accounts can sometimes get a little aggressive, they do hit certain points with utter clarity: would you want to increase diversity on the Titanic?

Is it possible that everyone is being just a little too cynical here?

 

[medgator]

Is it possible that everyone is being just a little too cynical here?

Care to show us all the URM outreach and MS scholarships being offered by Stanford, Duke, UCLA etc 5-10 years ago?

I'm all ears

 

[Lamount]

Care to show us all the URM outreach and MS scholarships being offered by Stanford, Duke, UCLA etc 5-10 years ago?

I'm all ears

Honestly, would be happy to when I am not quite so busy.

I would also make the point that society has evolved in the past 1-2 years and diversity has become a greater priority in a lot of facets of medicine (i.e. departments now have 'Director of Diversity' positions). Perhaps this is more reflective of THAT trend rather than some nefarious plot lure URM into a world-class research lab.

 

[CurbYourExpectations]

It is unfortunate timing as many people are still frustrated with the job outlook and over expansion, but if an URM is interested and still wants to pursue inspite of the issues then at least they’re getting paid to do some research.

 

[Ray D. Ayshun]

just wanted to post what emory has in terms of maximum prices:

Tab Summary A B 1 Machine Readable Disclosure File 2 3 ...​

Level 1 Therapeutic Radiation Treatment Preparation	119
Level 2 Therapeutic Radiation Treatment Preparation	8055
Level 3 Therapeutic Radiation Treatment Preparation	22129
Level 2 Radiation Therapy	12759
Level 3 Radiation Therapy	27808
Level 4 Radiation Therapy	5313
Level 6 Radiation Therapy	41082
Level 7 Radiation Therapy	41082

So max cost for a single sbrt fraction is $41K?

 

[w00tz]

True that society as a whole is pushing for more diversity and I think more so in the last year with BLM revival. Could it just be unfortunate timing that these programs are just now popping up? I think plausible...We've been hating on super SJW Jagsi since before rad onc officially fell off the wagon in 2019/2020, so I know there was already interest in recruiting URM for some years. The Dare you to reply thread was started in 10/2017. I guess you could argue at that point, rad onc was already knee deep, but from the perspective of a lot of academic programs, everything was fine in rad onc until 3/2019, lol....

Here's something from 2015 DEFINE_ME

I definitely remain skeptical about these new programs. Some may have good intentions, but are probably rare. It doesn't change that fact that until job prospects improve, URMs are highly likely to be in a bad spot and going into the job hunt. I think one thing that would change my skeptical mind is if:

If programs were committing to cutting spots to a healthy amount and still offering URMs some opportunities like this it would be outstanding.

But if you're a program that's opening up a BS fellowship or expanding residency and recruiting URM, then F U.

 

[RadOncG]

It is unfortunate timing as many people are still frustrated with the job outlook and over expansion, but if an URM is interested and still wants to pursue inspite of the issues then at least they’re getting paid to do some research.

Why would anyone waste their time doing research to match the least competitive specialty?

You do research to show interest in competitive fields.

 

[TheWallnerus]

Honestly, would be happy to when I am not quite so busy.

I would also make the point that society has evolved in the past 1-2 years and diversity has become a greater priority in a lot of facets of medicine (i.e. departments now have 'Director of Diversity' positions). Perhaps this is more reflective of THAT trend rather than some nefarious plot lure URM into a world-class research lab.

There's no nefarious plot. Nefariousness usually implies a kind of Gru, Dr. No, Count Dooku underlying intelligence, and I do not give that much credit. It's laziness. It's a dog-ate-my-homework excuse. It's yet another example of radiation oncology('s leaders) failing and not dealing with the underlying problem. Diversity is a foil which is being used to cover the embarrassment/the fact that medical students aren't choosing radiation oncology anymore. What is bad, of course, is now this makes it even harder to reduce residency spots because a call to reduce residency spots may elide into somehow being an attack on trying to increase URMs in RO. Oh you want to reduce residency spots? You must be a real big Piers Morgan fan, huh? That will be a blow to the decrease residency spot movement if it happens that way.

 

[elementaryschooleconomics]

Honestly, would be happy to when I am not quite so busy.

I would also make the point that society has evolved in the past 1-2 years and diversity has become a greater priority in a lot of facets of medicine (i.e. departments now have 'Director of Diversity' positions). Perhaps this is more reflective of THAT trend rather than some nefarious plot lure URM into a world-class research lab.

To be clear, I absolutely do not think that anyone is doing anything nefarious. Honestly, I think virtually everyone, on every side of the argument, is really doing what they believe is "best" (though I'm sure there are a handful of bad actors, as with anything).

My concern with recruiting for diversity is twofold:

1) The same concern I have with recruiting ANYONE into RadOnc right now. I think we're producing too many Radiation Oncologists which is leading to a difficult job market and has a realistic chance of causing increased physician unemployment in the near future.

2) Potters' opinion piece where he essentially connects a thread through "RadOnc used to be too competitive for women and minorities, now it's not, this is a good thing". Not to put everything on Potters because he's not alone in expressing variations of this sentiment, he's just the one that put it into writing most recently. I find this sentiment to be insulting.

Sure, it just could be a very unfortunate coincidence that the push for diversity in medicine comes as RadOnc falls from grace, I am definitely on board with that hypothesis. But the tagline of "just take A job" does not seem like the most welcoming strategy for people who might have a preference for what communities they work, live, and raise families in.

 

[RickyScott]

So max cost for a single sbrt fraction is $41K?

they are trying to obscure the data​

ZeaTool – A Healthcare Price Comparison Tool for ...​

https://zeatool.com



ZeaTool is a CMS-compliant price transparency tool that has collected over 5,000 hospitals' CMS Price Transparency Data. If your hospital is not yet compliant

​

​

Tab Summary A B 1 Machine Readable Disclosure File 2 3 ...​

https://www.emoryhealthcare.org › 110010-emory-...

XLS

Jan 1, 2021 — The first Is "gross charge" that relates to the established prices that are billed to all patients ... hospital charges for purposes of enhanced transparency and communication. ... 1, Hospital Name, Emory University Hospital.

 

[TheWallnerus]

they are trying to obscure the data​

ZeaTool – A Healthcare Price Comparison Tool for ...​

https://zeatool.com



ZeaTool is a CMS-compliant price transparency tool that has collected over 5,000 hospitals' CMS Price Transparency Data. If your hospital is not yet compliant

​

​

Tab Summary A B 1 Machine Readable Disclosure File 2 3 ...​

https://www.emoryhealthcare.org › 110010-emory-...

XLS

Jan 1, 2021 — The first Is "gross charge" that relates to the established prices that are billed to all patients ... hospital charges for purposes of enhanced transparency and communication. ... 1, Hospital Name, Emory University Hospital.

The legend goes that Emory charges more for SRS than any other center in the U.S. May be some truth to the legend?!

 

[communitydoc13]

I think radonc remains an outstanding opportunity for medical student research. A lot of departments are really well set-up for med student level projects and I doubt doing research in the radonc department really hurts your chances of matching into medonc down the road or neurosurgery or ENT or any of the other places that these bright young doctors should be going.

Aside from career trajectory, I would argue that doing reasonable clinical research in radonc as a med student will make these docs better at what they end up specializing in. Now, it should be the last time that they do such research (unless there is some meaningful multidisciplinary project where they are the neurosurgeon on the paper years down the road).

 

[Ray D. Ayshun]

I suspect they'll first author a paper on how underserved rural communities need more radoncs, which will help them get a Harvard residency and Hopkins faculty position and allow them to mentor more urim's about underserved communities.

 

[randomname2018]

There is no nefarious plot. However, I do not believe that these offers are a form of genuine altruism either. There have been a number of issues in recent history where the honesty of leadership has been called into question. This should be one of those instances.

 

[GI_RadOnc]

I did a summer program between MS1 and MS2 with two other students. We all learned a ton of clinical oncology and what types of physical exams showed tumors (not something you see in your 'observations'). The other two students ended up in medical oncology and radiology. It was not specifically aimed at any race/ethnicity.

I don't find any such research opportunity a problem or to be hated on.

 

[fiji128]

These guys are the chair and vice chair of the RRC. We will see. Going through other forums I get the impression that the acgme is actively hostile to high training standards for programs (just see ED) and are the root of the “we can’t do anything b/c of anti-trust” big lie.

 

[seper]

Cutting spots, closing entire programs? I’m not holding my breath.
Upenn and Mount Sinai will continue to fill for a few years.
Upenn because it’s a good program and MS because it’s a 4yr job with benefits in NYC.
Those 2 docs have no real pressure for now

 

[Ray D. Ayshun]

View attachment 335302

These guys are the chair and vice chair of the RRC. We will see. Going through other forums I get the impression that the acgme is actively hostile to high training standards for programs (just see ED) and are the root of the “we can’t do anything b/c of anti-trust” big lie.

Name of the game is less high quality programs and no low quality programs.