Rad Onc Twitter

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I treated prostate mostly. We hosted all the on-treats at Ruth's Chris for appetizers and wine and a talk every Wednesday night. Drinks, snacks, shake everyone's hand, 77427s in one fell swoop. And it was all tax deductible. The dessert was "Enticement Lava Cake."
Why does contouring common sites like prostate and breast take more time than 10-15 years ago?
 
This song is in honor of Dan Spratt and in honor of his tweet which I feel has a limited lifespan

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Who talks about impact factor like that?

a) he doesn't seem to understand that primary brachy is different than a brachy boost
b) also doesn't seem to remember that ADT has no benefit in prostatectomy patients. it may be that brachy clearly works in a different mechanism than standard EBRT does
c) this is a **** ton of patients. there's something to be said about high volume retrospective looks. this question would take YEARS to get this many patients in a randomized trial, with patients treated in all sorts of ways in all sorts of places. this is a clean dataset

@Dan Spratt, I hope you read this.
 


what a sad sad sad total clown Dan Spratt is. Who talks about impact factor like that? he's a weird guy.

a) he doesn't seem to understand that primary brachy is different than a brachy boost
b) also doesn't seem to remember that ADT has no benefit in prostatectomy patients. it may be that brachy clearly works in a different mechanism than standard EBRT does
c) this is a **** ton of patients. there's something to be said about high volume retrospective looks. this question would take YEARS to get this many patients in a randomized trial, with patients treated in all sorts of ways in all sorts of places. this is a clean dataset

@Dan Spratt, I hope you read this. you seem low IQ.

Is anyone else a little surprised at the intensity of this debate, on both sides?
 
c) this is a **** ton of patients. there's something to be said about high volume retrospective looks. this question would take YEARS to get this many patients in a randomized trial, with patients treated in all sorts of ways in all sorts of places. this is a clean dataset

This is the retrospective study that pretty much let me know that you can never, ever, ever account for selection bias. Big ass data (the 2 biggest Whipple centers I believe), matched pair analysis and apparently overwhelming evidence of benefit to adjuvant chemorads (which has never been replicated in an actual clinical trial).

I don't have access to the whole brachy paper tonight, but I will read it. The pancreatic paper had some famously peculiar curves. (Curves that deviated within months of assignment of start time and almost certainly represented selection bias).

In the same way, that patients selected to get ADT with brachy in an aggregate group made of of 75% UIR patient with a median f/u of less than 5 years shows no benefit compared to those selected to not get ADT is well....nothing. Both selection bias and short f/u limit any meaningful conclusions IMO.

That Spratt is so angry is another matter.
 

This is the retrospective study that pretty much let me know that you can never, ever, ever account for selection bias. Big ass data (the 2 biggest Whipple centers I believe), matched pair analysis and apparently overwhelming evidence of benefit to adjuvant chemorads (which has never been replicated in an actual clinical trial).

I don't have access to the whole brachy paper tonight, but I will read it. The pancreatic paper had some famously peculiar curves. (Curves that deviated within months of assignment of start time and almost certainly represented selection bias).

In the same way, that patients selected to get ADT with brachy in an aggregate group made of of 75% UIR patient with a median f/u of less than 5 years shows no benefit compared to those selected to not get ADT is well....nothing. Both selection bias and short f/u limit any meaningful conclusions IMO.

That Spratt is so angry is another matter.


He should have just said selection bias! I agree. Though that’s true of every single RR paper ever written but yeah I agree.

The problem I have other than his anger is his examples he uses. Using data from BRACHY BOOSTS is not the same thing, at all. I’m offended by him trying to pretend it is.
 
I think it depends on how he practices. If he treats as if it is 1989, take him out back. If he stays up to date and treats with appropriate levels of competence, then he can practice until he is deemed incompetent.

The problem is that a lot of these older docs are grandfathered in. How does one person on the outside able to assess his competence and knowledge base? Is MOC appropriate enough?

A quick search on ABR's verification page shows that this particular doc has a lifetime certificate:
View attachment 344706

Unfortunately, for these people grandfathered in, maintenance of certification is only voluntary:
View attachment 344707

Is he good or is he bad? I don't know, but given the pace advances, especially in the everchanging treatment paradigm and advent of IMRT, I would imagine that one would have to work hard to stay on top of things. I think I read something some time ago that showed that rad oncs now spend more time contouring and planning than ever before.
I won’t go after anybody individually unless you are PW or similar clown bully. Every solution has some casualties. These guys will be alright. They have millions in the bank. i say put them out to pasture out back and end all “grandfathered” certificates. I’d love to see these guys sit for boards again if they want to remain practicing. My overall experience with these old guys, has been mostly negative. These granddaddies can relax and let the youngsters fix this field
 
"We have the lowest impact factor and will publish anything!!!"

I agree - odd comment on the impact factor.

Aren't there other studies like this? I feel like Greg what's his face from West Virginia and the Seattle guys published really good outcomes with brachytherapy alone in high risk patients. I don't feel like googling.

Not sure of the wisdom of these types of attacks, which are quite common. "Dangerous" "Very harmful" etc.

It is not really surprising. I don't engage any more with that crew. There's a harshness and lack of curiosity when interacting that makes it hard to enjoy or learn anything.

My new boss, the head of out cancer center, really pushes the "questioning mindset". She would want me to ask Rahul, probably via text/email - "Do you actually not give ADT to UIR / HR patients that get treated with brachy?" "Are you going to study this is a prospective fashion?" "What's the algorithm there at CCF?" etc. instead of just blasting away. It's more effective to be Ted Lasso rather than Logan Roy, though being Logan would be pretty fun with all the private jets and yachts and castles.
 
Dan Spratt is an SDN member who does engage with our community from time to time. As such, please refrain from personally attacking him with insults and such. You are welcome to strongly disagree with the content of his posts, but you are not allowed to call SDN members names, etc


Also... lol at people criticizing each other's database reviews. Cleveland Clinic has a large internal database. Dan Spratt has a large external database called NRG. Hooray, we're all datamining and getting our academic merit badges called publications. You gotta get promoted somehow. Calm down folks.
 
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My new boss, the head of out cancer center, really pushes the "questioning mindset". She would want me to ask Rahul, probably via text/email - "Do you actually not give ADT to UIR / HR patients that get treated with brachy?" "Are you going to study this is a prospective fashion?" "What's the algorithm there at CCF?" etc. instead of just blasting away. It's more effective to be Ted Lasso rather than Logan Roy, though being Logan would be pretty fun with all the private jets and yachts and castles.
Argh Simul, why aren't you guys in the geographic area I'm interested in? I would be emailing you every month asking if you had an opening, if so.
 
Dan Spratt is an SDN member who does engage with our community from time to time. As such, please refrain from personally attacking him with insults and such. You are welcome to strongly disagree with the content of his posts, but you are not allowed to call SDN members names, etc
Agree that ad hominems and name-calling not the greatest. (@jondunn has a way with words.) Now that Dan has deleted his tweet though, I would point out that any time someone tweets "You don't follow the standard of care" (maybe the worst insult you can give a rad onc!) or that you're "dangerous," "harmful," or "irresponsible," that too is a form of ad hominem and/or insult albeit dressed up in a more high falutin' phraseology. There's an idea in psychology that we become what we hate. The only way to avoid that is: don't hate. A doctor publicly tweeting that other doctors/institutions, or publications (oh brother), are harmful actually makes the tweeting doctor harmful. Irony! If I were Rahul, I would forgive Dan, shake his hand, and try to work with him. If I were Dan, I'd "focus on the positive."
 
I would point out that any time someone tweets "You don't follow the standard of care" (maybe the worst insult you can give a rad onc!) or that you're "dangerous," "harmful," or "irresponsible,"

I agree with your post. We have Lee Burnett's law on SDN; so called after our SDN founder.

That is, any time someone posts that another user shouldn't be a doctor or are a bad doctor, that someone automatically loses the argument.

This is based on an old message board tradition rooted in Godwin's law where whenever someone calls someone else a nazi, they lose the argument.
 
Last night Case finally realized wealthy prostate patients are going to CCF no matter who Case’s chair is

It’s okay though, at least Case only publishes in IF 3 and above
CCF is top urology and uro-onc center. No one is going to take prostate away from them. Dans best strategy would be to lie about the benefits of protons.
 
I don't know about SERO specifically, but I know for a fact that a few physician-owned RO mega-groups in the country have stopped offering technical partnership for years. The best new grads can get is straight salary with RVU bonuses/incentives.

"Partner" implies that all the partners are invested in the business with the same incentive structure, potential for salary growth, and potential for ownership of the company (with fair valuations).

Such "partner" positions are rare nowadays unless

1) It's a high risk startup practice.
or
2) It's not a good partnership because the business model is bad for some reason.

Yes there are exceptions. Good for you if you've found such a unicorn. There are places offering a real sounding "partnership" with a long track, but nobody actually makes partner, or the place folds or gets bought out before that track is up. I think we all know people who have been in this position.

Most of the time when I hear partner, an equal position within a practice at some point in the future is not actually the arrangement. I've discussed plenty of "partnership" positions where I would not have the same potential for growth as the person trying to hire me.

A lot of new grads choose the safety of employed positions for these reasons. I don't want to make it sound like that's better--less risk less potential reward maybe. I like the phrase "it's not paranoia if they're all out to get you."
 
"Partner" implies that all the partners are invested in the business with the same incentive structure, potential for salary growth, and potential for ownership of the company (with fair valuations).

Such "partner" positions are rare nowadays unless

1) It's a high risk startup practice.
or
2) It's not a good partnership because the business model is bad for some reason.

Yes there are exceptions. Good for you if you've found such a unicorn. There are places offering a real sounding "partnership" with a long track, but nobody actually makes partner, or the place folds or gets bought out before that track is up. I think we all know people who have been in this position.

Most of the time when I hear partner, an equal position within a practice at some point in the future is not actually the arrangement. I've discussed plenty of "partnership" positions where I would not have the same potential for growth as the person trying to hire me.

A lot of new grads choose the safety of employed positions for these reasons. I don't want to make it sound like that's better--less risk less potential reward maybe. I like the phrase "it's not paranoia if they're all out to get you."
partnership as an "equal" is very rare
 
CCF is top urology and uro-onc center. No one is going to take prostate away from them. Dans best strategy would be to lie about the benefits of protons.

That’s hilariously accurate!

Dan should also remember maybe only 10 people actually read Brachytherapy

Nobody is changing their practice based on this RR 🤣
 
There is a really fun sock puppet account on Twitter that is trying to make friends and influence people! Give her a follow! Go Buckeyes!



I am very sad that I missed this.
This song is in honor of Dan Spratt and in honor of his tweet which I feel has a limited lifespan

bEgJLEC.png

Thank you for saving for posterity. This is a no good, very bad twitter post. He attacks it with the same vitriol as the RP > RT for localized prostate cancer database studies (which are trash and should stop being published), which is excessive.

@Dan Spratt , don't be like Icarus and fly too close to the sun. If you argue against other specialties doing stupid ****, Rad Onc will (usually) back you. If you attack others within Rad Onc, it divides this house.
 
"Partner" implies that all the partners are invested in the business with the same incentive structure, potential for salary growth, and potential for ownership of the company (with fair valuations).

Such "partner" positions are rare nowadays unless

1) It's a high risk startup practice.
or
2) It's not a good partnership because the business model is bad for some reason.

Yes there are exceptions. Good for you if you've found such a unicorn. There are places offering a real sounding "partnership" with a long track, but nobody actually makes partner, or the place folds or gets bought out before that track is up. I think we all know people who have been in this position.

Most of the time when I hear partner, an equal position within a practice at some point in the future is not actually the arrangement. I've discussed plenty of "partnership" positions where I would not have the same potential for growth as the person trying to hire me.

A lot of new grads choose the safety of employed positions for these reasons. I don't want to make it sound like that's better--less risk less potential reward maybe. I like the phrase "it's not paranoia if they're all out to get you."
The other thing that's worth mentioning - if you're interesting in getting a job in one of the unicorn practices (physician-owned with a real partnership track), you've got to be prepared to decide early. These groups hire LONG before academia or hospital-employed community gigs. There's a misconception out there that if you can't land the "desired" academic gig, then you can fall back on private practice. While that might be true in other specialties, it's not true for Radiation Oncology.

The "good" private groups, which have been brought up a lot on SDN in the past couple days, have already locked kids up for this year.
 
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Trying to interpret Ralph's unintelligible "Weichselbaum-ese", I believe he's claiming RadOnc is particularly egregious in pushing non-evidenced based treatments?

I'll throw a lot of critiques at our specialty, but I definitely don't think we win the snake oil crown. HIFU in prostate cancer, RFA in lung cancer, virtually every Orthopedic Surgeon I know (as well as half the medical students) have some kind of patent for some sort of bone device...I think in this area, we're definitely not the Kings, I don't even know if we have a seat in the court.

Can someone at Chicago open the blinds in Ralph's office so he can yell at the clouds?
 
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Trying to interpret Ralph's unintelligible "Weichselbaum-ese", I believe he's claiming RadOnc is particularly egregious in pushing non-evidenced based treatments?

I'll throw a lot of critiques at our specialty, but I definitely don't think we win the snake oil crown. HIFU in prostate cancer, RFA in lung cancer, virtually every Orthopedic Surgeon I know (as well as half the medical students) have some kind of patent for some sort of bone device...I think in this area, we're definitely not the Kings, I don't even know if we have a seat in the court.

Can someone at Chicago open the blinds in Ralph's office so he can yell at the clouds?
I really hate it when I don't know WTF Ralph's saying because he leaves no effective way to argue with him.

Wait a sec...
 
I am assuming it is ccf practice to offer adt; these were just pts who declined?
I don't know for sure but I know Eric Klein and Jay Czieski (sp?) felt that for intermediate risk disease the findings of 9408 (66.6 Gy 2D with no image guidance) were not relevant to contemporary dose-escalated XRT and they routinely recommended XRT alone (brachy) in patients with UIR disease.

The results of 0815 will be presented at ASTRO Plenary next week. I won't reproduce them here but the ARR of OS is very small. 95% of deaths were due to something other than prostate cancer and based on the update from 9408 the OS curves are not likely to converge further as follow-up continues. Competing comorbidities...
 
I don't know for sure but I know Eric Klein and Jay Czieski (sp?) felt that for intermediate risk disease the findings of 9408 (66.6 Gy 2D with no image guidance) were not relevant to contemporary dose-escalated XRT and they routinely recommended XRT alone (brachy) in patients with UIR disease.

The results of 0815 will be presented at ASTRO Plenary next week. I won't reproduce them here but the ARR of OS is very small. 95% of deaths were due to something other than prostate cancer and based on the update from 9408 the OS curves are not likely to converge further as follow-up continues. Competing comorbidities...
So, not only was the tone wrong, but the substance was incorrect?
 
I don't know for sure but I know Eric Klein and Jay Czieski (sp?) felt that for intermediate risk disease the findings of 9408 (66.6 Gy 2D with no image guidance) were not relevant to contemporary dose-escalated XRT and they routinely recommended XRT alone (brachy) in patients with UIR disease.

The results of 0815 will be presented at ASTRO Plenary next week. I won't reproduce them here but the ARR of OS is very small. 95% of deaths were due to something other than prostate cancer and based on the update from 9408 the OS curves are not likely to converge further as follow-up continues. Competing comorbidities...
Would also assume that brachy pts younger and healthier and care abt sexual function. I have plenty of pts who decline adt, when I tell them small os benefit, although I offer it to all uir. Been years since I looked at d Amico and Australian studies. I don’t know if orgovyx changes anything because supposedly testosterone recovers faster. In any case if cc docs have nuanced discussion with pt and they decline adt, that is a very reasonable.
 
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Thank God CMS is cracking down on us Snake Oil RadOncs though.
Believe it or not if you look at all the drugs CMS pays for in terms of annual growth rate in spending per unit 2015-2019, at the top of the list for a drug which is mostly oncology-specific, the drug with the biggest growth rate (26% per yr) is:

Amifostine.

XL8BdFk.png


375 Americans received the drug in 2019 at a cost of about $4m to CMS.
 
Believe it or not if you look at all the drugs CMS pays for in terms of annual growth rate in spending per unit 2015-2019, at the top of the list for a drug which is mostly oncology-specific, the drug with the biggest growth rate (26% per yr) is:

Amifostine.

XL8BdFk.png


375 Americans received the drug in 2019 at a cost of about $4m to CMS.
Amifostine is a pain... but willing to get back in the saddle for this reimbursement
 
Definitely had some reps stop by and try to pimp it. Thought it was pretty much dead in the IMRT era?

In the era of APM, extreme hypofractionation, surplus workforce, and decreasing jobs we will see a worsening "the tail wagging the dog" phenomenon in Rad Onc. Anything that can increase revenue will be ruthlessly pursued.
 
In the era of APM, extreme hypofractionation, surplus workforce, and decreasing jobs we will see a worsening "the tail wagging the dog" phenomenon in Rad Onc. Anything that can increase revenue will be ruthlessly pursued.
Time to look up the pro fees for amifostine I guess.

With fee splitting being illegal, maybe I can get the hospital to issue me a company Maserati instead?
 
Good thing I love my job, because an opportunity to work with Simul the Great in that part of the country would be amazing. Congrats to whoever ends up there!
 
Would also assume that brachy pts younger and healthier and care abt sexual function. I have plenty of pts who decline adt, when I tell them small os benefit, although I offer it to all uir. Been years since I looked at d Amico and Australian studies. I don’t know if orgovyx changes anything because supposedly testosterone recovers faster. In any case if cc docs have nuanced discussion with pt and they decline adt, that is a very reasonable.

have you used orgovyx at all? I'm 0/1 on getting it approved by insurance and this was in a patient with a possible depot injection (PEG) allergy.

Apparently reduced cardiovascular events compared to lupron as well, though that makes my skepticism alarm go off a bit
 
have you used orgovyx at all? I'm 0/1 on getting it approved by insurance and this was in a patient with a possible depot injection (PEG) allergy.

Apparently reduced cardiovascular events compared to lupron as well, though that makes my skepticism alarm go off a bit
I haven't even tried to go down that road yet - the insurance companies keep me on my toes enough as it is with existing treatments.

If anyone has the secret formula, I'd like to hear it as well.
 
have you used orgovyx at all? I'm 0/1 on getting it approved by insurance and this was in a patient with a possible depot injection (PEG) allergy.

Apparently reduced cardiovascular events compared to lupron as well, though that makes my skepticism alarm go off a bit
I think it's only indicated if pts need it for at least 12 months right? Basically eliminates using it except in high risk
 
I think it's only indicated if pts need it for at least 12 months right? Basically eliminates using it except in high risk

I wouldn't say that's true. The trial followed patients for 48 weeks so only included patients that would need ADT for that long, but that seems to be an arbitrary distinction. The trial included a mix of advanced local disease, biochemically recurrent, or metastatic hormone sensative patients.
 
have you used orgovyx at all? I'm 0/1 on getting it approved by insurance and this was in a patient with a possible depot injection (PEG) allergy.

Apparently reduced cardiovascular events compared to lupron as well, though that makes my skepticism alarm go off a bit
Maybe its regional? We've used it on a handful of patients and its never been denied. But depending on insurance they might get hit with a hefty copay so have to check that first.
 
have you used orgovyx at all? I'm 0/1 on getting it approved by insurance and this was in a patient with a possible depot injection (PEG) allergy.

Apparently reduced cardiovascular events compared to lupron as well, though that makes my skepticism alarm go off a bit
no, my practice can’t handle drug approvals so we refer back to medonc or urology. Have had a few pts get 2 months free from company.
 
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