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jondunn said:
This argument isn’t founded in data
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There isn't much of a difference in local control, but I'm pretty sure there is some. Look at all the partial breast trials, the raw data, the sensoring, the fact that almost no ER+ tumors come back within the 5 year standard adjuvant endocrine therapy time line without XRT. All strategies a little different. Agree with @Ray D. Ayshun that IMPORT-LO is an almost whole breast strategy, which is pretty much how I do left sided whole breast now anyway, and likely very, very little difference in local control. I like the Livi stuff and will adopt it, but in a 50 year old with a 30 year life expectancy, I'm going to expect an extra 2-5% local recurrences.
 
No difference in ten year outcomes but sure I totally get if someone doesn’t want to do Livi in a 50 year old. Most of my patients are 60 and above.

Most importantly - it’s a fantastic option in patients that would otherwise be not getting sent to me because they are omission candidates. The surgeons LOVE 5 fractions. Business is booming. For those of you afraid to get on at all, you’re going to be on the wrong side of history.
 
jondunn said:
No difference in ten year outcomes but sure I totally get if someone doesn’t want to do Livi in a 50 year old. Most of my patients are 60 and above.

Most importantly - it’s a fantastic option in patients that would otherwise be not getting sent to me because they are omission candidates. The surgeons LOVE 5 fractions. Business is booming. For those of you afraid to get on at all, you’re going to be on the wrong side of history.
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The reason 16 or 15 or 13 fraction worked versus ~5 week radiotherapy is that alpha/beta predicted it would. It was tested, and it worked.

The reason 5 fraction worked versus 15 is that alpha/beta predicted it would. It was tested, and it worked.

But because the alpha/beta of breast cancer seems to be the same as normal tissue, the number of fractions has not yet been optimized to the lowest number.

Which is one. Five fraction will be on the wrong side of history by, say, 2030 or 2035. Let's bet a dollar!
 
jondunn said:
No difference in ten year outcomes but sure I totally get if someone doesn’t want to do Livi in a 50 year old. Most of my patients are 60 and above.

Most importantly - it’s a fantastic option in patients that would otherwise be not getting sent to me because they are omission candidates. The surgeons LOVE 5 fractions. Business is booming. For those of you afraid to get on at all, you’re going to be on the wrong side of history.
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Yup.... new breast surgeon called me a couple of weeks ago like "Um.... isn't there a 5 fraction regimen these patients can get?" Send em here, I'm on it 🙂
 
TheWallnerus said:
The reason 16 or 15 or 13 fraction worked versus ~5 week radiotherapy is that alpha/beta predicted it would. It was tested, and it worked.

The reason 5 fraction worked versus 15 is that alpha/beta predicted it would. It was tested, and it worked.
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I will challenge this (because I like to challenge you so much, you know that!):

5 fractions worked, because:

- Recurrence rates even without any RT are considerably lower than what we think. Even the effect of the boost we hypothesize based on 30 year old boost-trials is vastly overestimated bearing in mind modern systemic therapy and accurate treatment planning of WBRT, which does not underdose critical areas of the breast.

- 25 x 2 or 15 x 2.66 are overdosed anyway. You could run a non-inferiority trial of 20x2 / 12x2.66 vs. 25x2 / 15x2.66 and it would have shown that the lower dose was still fine.
 
TheWallnerus said:
The reason 16 or 15 or 13 fraction worked versus ~5 week radiotherapy is that alpha/beta predicted it would. It was tested, and it worked.

The reason 5 fraction worked versus 15 is that alpha/beta predicted it would. It was tested, and it worked.

But because the alpha/beta of breast cancer seems to be the same as normal tissue, the number of fractions has not yet been optimized to the lowest number.

Which is one. Five fraction will be on the wrong side of history by, say, 2030 or 2035. Let's bet a dollar!
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You may be right....but alpha/beta for prostate is well studied yet somehow hypofrac isn't better for cure. The math says it should cure more.

That's a lot of faith in alpha/beta you have. More than me. Does that make me a bad rad onc? Maybe?

*ducks head* because I'm out of my element here. Haven't cracked open Hall in years.
 
BobbyHeenan said:
You may be right....but alpha/beta for prostate is well studied yet somehow hypofrac isn't better for cure. The math says it should cure more.

That's a lot of faith in alpha/beta you have. More than me. Does that make me a bad rad onc? Maybe?

*ducks head* because I'm out of my element here. Haven't cracked open Hall in years.
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1635520557403.png
 
jondunn said:
No difference in ten year outcomes but sure I totally get if someone doesn’t want to do Livi in a 50 year old.
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jco.20.00650f2.jpeg

They are not statistically significant but are they real? Is our Bayesian prior that these are no different? The wrong statistical tool is being used here for what is a rare event. Among the patients evaluable at 10 years the absolute difference in local recurrence was 3%. Would this play out with 1000 evaluable patients? I'm guessing yes.

I'm down with the five fraction regimen. I'm down with zero fractions in many patients. Just saying that MROGA, if his absolute goal is to minimize salvage breast surgery, is not data free in his argument.
 
communitydoc13 said:
jco.20.00650f2.jpeg

They are not statistically significant but are they real? Is our Bayesian prior that these are no different? The wrong statistical tool is being used here for what is a rare event. Among the patients evaluable at 10 years the absolute difference in local recurrence was 3%. Would this play out with 1000 evaluable patients? I'm guessing yes.

I'm down with the five fraction regimen. I'm down with zero fractions in many patients. Just saying that MROGA, if his absolute goal is to minimize salvage breast surgery, is not data free in his argument.
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statistical power and testing is done for a reason.

at ten years there were 6 events in the WBI arm and 9 events in the APBI arm. that could have easily been reversed and I wouldnt blink or think that WBI was worse lol. come on.
 
Palex80 said:
- Recurrence rates even without any RT are considerably lower than what we think.
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YES.

15 vs 33 and 5 vs 15 also worked because of that. Quite convenient!

Which is why I have supreme confidence that a single drop of Tc-99m on the nipple at the time of lumpectomy will be non-inferior to 5 or 15 fractions. If the trial is ran "correctly."
 
TheWallnerus said:
YES.

15 vs 33 and 5 vs 15 also worked because of that. Quite convenient!

Which is why I have supreme confidence that a single drop of Tc-99m on the nipple at the time of lumpectomy will be non-inferior to 5 or 15 fractions. If the trial is ran "correctly."
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You're probably right here.

But the play I *think* is taking dead aim at an AI. The breast onc community should be trying to omit that, not 5 fraction radiation.

My patients hate it. Hair loss, zometa, bone density tests, vaginal issues, joint aches. This is worse than 5 fraction breast. I really hope the radiation makes up for the lack of AI in these favorable patients. I'm a little afraid though of the microscopic estrogen + disease, so we'll see if distant mets pile up on the trial. Sure hope not.
 
BobbyHeenan said:
You may be right....but alpha/beta for prostate is well studied yet somehow hypofrac isn't better for cure. The math says it should cure more.

That's a lot of faith in alpha/beta you have. More than me. Does that make me a bad rad onc? Maybe?

*ducks head* because I'm out of my element here. Haven't cracked open Hall in years.
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Not "faith" per se. Don't judge me! I am just telling you the base underlying logic and hypothesis for fraction reduction in breast cancer. So far that logic and hypothesis have not been proven incorrect.

Direct quote from START-A, 2008:

Normal and malignant tissues vary in their responses to radiotherapy fraction size, termed fractionation sensitivity. Responses are described by a model in which the sensitivity (measured by the degree of tissue damage for normal tissues, and tumour recurrence rates for malignant tumours) to fraction size is represented by the ratio of two constants α and β.3 The lower the ratio of α to β (expressed in Gy), the greater the effect on normal and malignant tissues of changes in fraction size. Healthy tissues of the breast and ribcage are sensitive to fraction size, with α/β values 5 Gy or less,4 so small changes in fraction size can produce relatively large changes in the effects of radiotherapy on these tissues. This sensitivity is typical of so-called late-reacting normal tissues that take months or years to develop atrophy or fibrosis after radiotherapy. By contrast, squamous carcinomas of the lung and the head and neck area have high α/β values (≥10 Gy), indicating low sensitivity to fraction size. In head and neck cancer, radiotherapy delivered in small fractions (≤2·0 Gy) to a high total dose spares late-responding normal tissues relative to tumour.5 Breast cancer has previously been thought to be insensitive to fraction size and best treated with fractions of 2·0 Gy or less. However, some trials have tested the hypothesis that breast cancer is as sensitive to fraction size as the normal tissues of the breast and underlying rib cage.6, 7, 8 If confirmed, these findings could indicate that small fraction sizes of 2·0 Gy or lower offer no therapeutic advantage, and that a more effective strategy would be to deliver fewer, larger fractions to a lower total dose.
 
jondunn said:
statistical power and testing is done for a reason.
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That's the rub. Do a sample size calculation for a dichotomous outcome with expected incidence of 6% vs 3% and a 5% tolerance of Type I error.

~1500 patients. (Don't let Wallnerus convice you otherwise)

But yes, the absolute risk is always low, which is the big point. We will continue to creatively do less down to zero as we have nothing else to study.
 
fiji128 said:
For you all on here that love 5 fraction breast just wait until your not asked to do 0 fraction breast!

Just a reminder that BR007 is still enrolling. >50 yo with pT1N0 ER/PR positive Her2 negative disease with oncotype DX =<18. RT+AI vs AI.
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Stop the trial now and add an RT only arm. Tell Varian (?seimens?) to fund it.
 
ROforbetterorworse said:
I would have thought that until the Asian attacks in Bay Area this year
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I don't know anything about Mahal or Cooperberg, but it's highly unlikely a Jewish academic living in SF is some hard core right wing racist. It's like suggesting the attacks on Asians in one of the most liberal cities in the world were perpetrated by right wingers. This sounds more like a personal thing between these two.
 
fiji128 said:
For you all on here that love 5 fraction breast just wait until your not asked to do 0 fraction breast!

Just a reminder that BR007 is still enrolling. >50 yo with pT1N0 ER/PR positive Her2 negative disease with oncotype DX =<18. RT+AI vs AI.
Click to expand...
horrifying, but a new reality
 
Reaganite said:
I don't know anything about Mahal or Cooperberg, but it's highly unlikely a Jewish academic living in SF is some hard core right wing racist. It's like suggesting the attacks on Asians in one of the most liberal cities in the world were perpetrated by right wingers. This sounds more like a personal thing between these two.
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I am not sure one has to be right wing to be racist?
 
medgator said:
I joke around about wanting to cure prostate cancer at 8 am rather than 630 am when it came down to picking specialties but it hasn't quite worked out that way in practice sometimes
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If you're trying to attract med students, you could do worse then a motto of "Radiation Oncology: Curing cancer 15 minutes at a time from 9 to 5, Tuesday-Friday excluding holidays"
 
If I had to guess (pure conjecture) the established, well-published urologist did not appreciate some upstart radiation oncologist performing similar (maybe better ?) research than him. Whether that disdain was exacerbated by racial bias, dislike of the faculty mentor, being an overall despicable person, insecurity or a combination of factors is not clear, but seemingly resulted in unprofessional behavior. Kudos to Dr Mahal for calling him out.
 
radiaterMike said:
If I had to guess (pure conjecture) the established, well-published urologist did not appreciate some upstart radiation oncologist performing similar (maybe better ?) research than him. Whether that disdain was exacerbated by racial bias, dislike of the faculty mentor, being an overall despicable person, insecurity or a combination of factors is not clear, but seemingly resulted in unprofessional behavior. Kudos to Dr Mahal for calling him out.
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That is also my read as well. Urologist probably thinks SEER prostate studies are his personal property. Doubt it has anything to do with race or sexual orientation or whatever else
 
radiaterMike said:
If I had to guess (pure conjecture) the established, well-published urologist did not appreciate some upstart radiation oncologist performing similar (maybe better ?) research than him. Whether that disdain was exacerbated by racial bias, dislike of the faculty mentor, being an overall despicable person, insecurity or a combination of factors is not clear, but seemingly resulted in unprofessional behavior. Kudos to Dr Mahal for calling him out.
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I'm a fan of calling out abuses of power, but perhaps unclear on how to interpret this:
1635528556722.png

It's great what he overcame, but how do we get to this post-racial Shangri La when we can't stop bringing it up? Maybe he wasn't suggesting the bullying was related to his skin color, but it seems like it.
 
Ray D. Ayshun said:
I'm a fan of calling out abuses of power, but perhaps unclear on how to interpret this:
View attachment 345118
It's great what he overcame, but how do we get to this post-racial Shangri La when we can't stop bringing it up? Maybe he wasn't suggesting the bullying was related to his skin color, but it seems like it.
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Not a fan of that. Also, objectively he is about as "brown" as anyone from Greece, Spain, Italy, or Israel of Ted Cruz for that matter. Does a second or third generation southern European from latin america get to refer to themselves as "brown"
 
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Ray D. Ayshun said:
Wasn't me, but I think the other poster was talking about the absurdity of it all.
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Yip. I had no idea whether he is Hispanic or not, and probably the same goes for the bully urologist. It is race baiting to reduce all conflict to race. “He hates me because I am brown”? Is that what he is going to say when his chair refuses to give him a raise or promotion because of the bad job market? Racism is the new pedophilia. Would think real hard before accusing someone personally.
 
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I don't know... while I think there are a lot of times that race is awkwardly inserted where it doesn't belong, I don't think Dr. Mahal's post is one of them.

Underrepresented minorities are, indeed, underrepresented. Socio-economic barriers are hard to overcome, and I've got no issue with someone patting themselves on the back for some impressive achievements.

Pride and gratitude are powerful deterrents of burnout
 
Lamount said:
I don't know... while I think there are a lot of times that race is awkwardly inserted where it doesn't belong, I don't think Dr. Mahal's post is one of them.

Underrepresented minorities are, indeed, underrepresented. Socio-economic barriers are hard to overcome, and I've got no issue with someone patting themselves on the back for some impressive achievements.

Pride and gratitude are powerful deterrents of burnout
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I think he was initially targeted for pointing out in his article draft that urologists are operating far more often in the current day on high risk disease after active surveillance was adopted for low risk disease. I'm not sure it's that different than the Vanderbilt Rad Onc who let urology shade fly on twitter and got swift backlash. I doubt race has anything to do with this.
 
elementaryschooleconomics said:
View attachment 345145

Here's the paper.

Wow. 89% huh. I didn't know APM cut estimates could surprise me anymore, but I guess I was wrong.
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Need to get on twitter and post what is hidden between the lines of seeing a negative 89% reimbursement for lung.

Neutral global payment for lung in RO-APM is about $13,000.

So this means Moffitt must get ~$130K for lung from Medicare w/ MRgRT, if an 89% cut takes them to ~$13K.

On the accelerators today Connie Mantz (and he's a freestanding guy) said freestandings bill Medicare more than academic places.

I think a devil is the details, somewhere. It is true that the top 10 out of ~4500 (0.2%) entities in Medicare RO account for 6.6% of all RO spending, and they are all freestanding. But 7/10 are protons and 2/10 are UroRads.
 
TheWallnerus said:
Need to get on twitter and post what is hidden between the lines of seeing a negative 89% reimbursement for lung.

Neutral global payment for lung in RO-APM is about $13,000.

So this means Moffitt must get ~$130K for lung from Medicare w/ MRgRT, if an 89% cut takes them to ~$13K.

On the accelerators today Connie Mantz (and he's a freestanding guy) said freestandings bill Medicare more than academic places.

I think a devil is the details, somewhere. It is true that the top 10 out of ~4500 (0.2%) entities in Medicare RO account for 6.6% of all RO spending, and they are all freestanding. But 7/10 are protons and 2/10 are UroRads.
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Hmmm...how could that be? Oh, wait:

1635564388412.png
 
jondunn said:
Click to expand...

I wanted to return to this paper since I had a chance to read it. The results:

1635622951897.png


So the range of cost for bone mets XRT is from $297 to $33,411??

I'm begging the authors (who I know read this thread, or at least are told about it): please release the granular data for this manuscript. If they already have and I missed it, could someone post it?

If I could place a bet on who was on the upper end of that range, my money would be on the PPS-exempt centers.

I would love to see a poster at ASTRO next year entitled "Relationship between research output on financial toxicity of radiation and cost to receive radiation therapy at author's institution". I would place a second bet that the institutions with the most publications on the cost of radiation are the same ones who charge the most for their radiation services. I do want to put a disclaimer out there that I think most of the authors on those papers (who are usually residents) have no idea how much their institutions are charging, and most of the folks publishing these papers have good intentions. They're obviously not the ones who negotiated these rates. I don't blame the warehouse workers when Bezos evades taxes.

Does anyone want to bet against me? Let's start the wager at thirty-three thousand, four hundred and eleven dollars, and thirty-four cents.
 
CurbYourExpectations said:
Don't worry about what brown RadOncs are doing. Worry about what rich millionaire "leaders in RadOnc" are doing. I promise you the latter is the more important thing to worry about.
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I, like Larry David, am able to be simultaneously pissed about a number of things.
 
Radonc 2013 said:
Don't disagree on the WBRT take for 30 brain mets, but from a financial toxicity perspective it may depend on the insurer. At least from the medicare reimbursement table from a few posts ago a 2D (10 fractions) global payment is $4921 vs $3638 for SRS.
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Well,

Specialized Tx (SRS, SRT etc.) always costs more than R/L lat field WBRT.

The issue of financial toxicity is on the news today:
www.yahoo.com

Cancer report shows patients face a hardship besides the illness: Zooming financial costs

Cancer deaths are on the decline. But the financial costs borne by patients are skyrocketing. That's the conclusion of the Annual Report to the Nation on the Status of Cancer, which looks at the most recent available statistics from 2019. That year, patients shouldered a whopping $21.09 billion...
www.yahoo.com www.yahoo.com

As a profession, we should:
- be sensitive to the cost of Tx. If indicated (such as IMRT for HN cancer, Gyn cancer etc.), then use the fancy technology.
If not indicated, use the basic technique.
- be ethical.
- be the leader in terms of stewardship in terms of: cure/palliation, pt emotional issues, pt's family issues, financial toxicities.
- not bankrupt the poor pts and/or their families.

Anyway, this profession, esp the academic (I am in academic) is out of control...
 
Radonc90 said:
Well,

Specialized Tx (SRS, SRT etc.) always costs more than R/L lat field WBRT.

The issue of financial toxicity is on the news today:
www.yahoo.com

Cancer report shows patients face a hardship besides the illness: Zooming financial costs

Cancer deaths are on the decline. But the financial costs borne by patients are skyrocketing. That's the conclusion of the Annual Report to the Nation on the Status of Cancer, which looks at the most recent available statistics from 2019. That year, patients shouldered a whopping $21.09 billion...
www.yahoo.com www.yahoo.com

As a profession, we should:
- be sensitive to the cost of Tx. If indicated (such as IMRT for HN cancer, Gyn cancer etc.), then use the fancy technology.
If not indicated, use the basic technique.
- be ethical.
- be the leader in terms of stewardship in terms of: cure/palliation, pt emotional issues, pt's family issues, financial toxicities.
- not bankrupt the poor pts and/or their families.

Anyway, this profession, esp the academic (I am in academic) is out of control...
Click to expand...
While the patient and their family are most visible, the employer and society bear the brunt here. When Ben Smith charges 250k for partial breast protons, so that he can take home a million dollar salary while only 50% clinical, some employer can not hire an extra worker, give out raises/ give back less to investors etc.
 
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