Rad Onc Twitter

[medgator]

Nancy Lee doesn't understand that the converse is also true, i.e. inherent bias to use protons in the absence of any demonstrable benefit...

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[thecarbonionangle]

Here's her context. If the trials are negative, she said it doesn't make sense to demolish machines. Yeah...because they spent MILLIONS on this, as did a lot of other groups.

Also, who is this ProtonStorey guy? He believes in protons, but yet, looking at his group's website, which his title is Medical Director Clinical Operations, there is NO mention of clinical trials involving protons. If this technology works, show it. Tell us why it is worth 3 times more. It better be 3 times better or 3 fold less toxicity. Value = quality / cost. There better be good quality.
View attachment 289022

Storey is an interesting guy. Buy him a beer next time you see him. Very firm handshake.

 

[OTN]

Let them eat APM

Oh, but isn't MSKCC exempt from the RO-APM? Can't put our favored institutions at risk, financial toxicity to patients be damned!

 

[RickyScott]

Here's her context. If the trials are negative, she said it doesn't make sense to demolish machines. [/QUOTE]

she is right about crisis. Even if mskcc was not on board with protons, arms race forced them into getting one. Honestly, what probably makes most sense is 1) fudge clinical trial data vs 2) drag them out over many years and kick can down road to next generation... (medstudents and residents who currently will struggle to find a job)because we all know protons will almost never show significant measurable benefits and in some cases may likely to be harmful.

in randomized proton for lung cancer published in jco, worse toxicity and worse survival!

 

[deleted947887]

Oh, but isn't MSKCC exempt from the RO-APM? Can't put our favored institutions at risk, financial toxicity to patients be damned!

Where's that financial toxicity woman from MSKCC when you need her?

 

[Mandelin Rain]

"Protons cause more toxicity, but... is that a good thing?"

Intellectual honesty.

 

[deleted573262]

exempt from the RO-APM? Can't put our favored institutions at risk, financial tox

it's the good ol' don't bite the hand that feeds you argument. rock solid.

 

[Chartreuse Wombat]

Here's her context. If the trials are negative, she said it doesn't make sense to demolish machines.

she is right about crisis. Even if mskcc was not on board with protons, arms race forced them into getting one. Honestly, what probably makes most sense is 1) fudge clinical trial data vs 2) drag them out over many years and kick can down road to next generation... (medstudents and residents who currently will struggle to find a job)because we all know protons will almost never show significant measurable benefits and in some cases may actually be harmful.
[/QUOTE]
What an elite out of touch ignoramus. "Doesn't make sense to demolish machines"?" Sunk cost fallacy rears its ugly head once again.

What no one is mentioning is how SBRT in prostate cancer and many other contexts is the real disruptor. Really hard to make the economics work if you are delivering only 1-5 fractions with your fancy proton machine.

Why should prudent people that decided to wait for proof be bailing out reckless spendthrifts? But alas it is always so...

 

[medgator]

Here's her context. If the trials are negative, she said it doesn't make sense to demolish machines. Yeah...because they spent MILLIONS on this, as did a lot of other groups.

@Chartreuse Wombat nailed the moral hazard issue quite well with his post. The academic RadOnc emperors have no clothes

 

[bergonieandtribondeau]

Nancy Lee doesn't understand that the converse is also true, i.e. inherent bias to use protons in the absence of any demonstrable benefit...

I've got to give a hand to Spratt on that one. The notion that those without an institutional proton center somehow harbor an inherent bias against the modality is a preposterous double-standard. The burden of proof lies with those who champion the superiority of proton therapy, not those who criticize it. I suppose everyone without carbon ions is inherently biased against carbon ions as well? Everyone without a new Tesla cybertruck is biased against Tesla cybertrucks? I am all for a healthy debate about the indication for proton therapy, but come on.

 

[medgator]

I've got to give a hand to Spratt on that one. The notion that those without an institutional proton center somehow harbor an inherent bias against the modality is a preposterous double-standard. The burden of proof lies with those who champion the superiority of proton therapy, not those who criticize it. I suppose everyone without carbon ions is inherently biased against carbon ions as well? Everyone without a new Tesla cybertruck is biased against Tesla cybertrucks? I am all for a healthy debate about the indication for proton therapy, but come on.

Cybertruck starts at $39.9k. Not sure I see the analogy, now the roadster....

 

[RadOncDoc21]

I don’t have syphilis, doesn’t mean I want it!

 

[FrostyHammer]

That trial was not an actual randomized trial, but rather a Bayesian randomized trial. Not the same.

 

[BobbyHeenan]

We've had proton machines for many years at a number of centers....

They had the chance to run the trials and they were never done. Prostate RCT should have been done 10 years ago.

Astro never took a stance ...they should have lobbied for insurance mandated coverage for a Phase 3 prostate trial and taken a strong stance against off protocol protons for prostate....instead we got an Astro seal of approval in choosing wisely for BS “registry trials” for proton prostate.

===

Spratt going hard in the paint. Good for him.

I actually think the head neck proton trial will show benefit but in his prostate world I’ll thibk he’ll be vindicated.

 

[scarbrtj]

I've got to give a hand to Spratt on that one. The notion that those without an institutional proton center somehow harbor an inherent bias against the modality is a preposterous double-standard. The burden of proof lies with those who champion the superiority of proton therapy, not those who criticize it. I suppose everyone without carbon ions is inherently biased against carbon ions as well? Everyone without a new Tesla cybertruck is biased against Tesla cybertrucks? I am all for a healthy debate about the indication for proton therapy, but come on.

dude (or lady) you have a great name btw

 

[PhotonBomb]

No quid pro quo

 

[thecarbonionangle]

I don’t have syphilis, doesn’t mean I want it!

important point here. There used to be an entire medical specialty dedicated to treating syphilis. They were out of the job like nuclear medicine. we may be out of a job one day, similarly.

 

[PhotonBomb]

important point here. There used to be an entire medical specialty dedicated to treating syphilis. They were out of the job like nuclear medicine. we may be out of a job one day, similarly.

No quid pro quo

 

[RadOncMegatron]

That trial was not an actual randomized trial, but rather a Bayesian randomized trial. Not the same.

Are you and I the only people on earth that noticed this?

 

[FrostyHammer]

Are you and I the only people on earth that noticed this?

Probably...stats seems to elude most people I suppose.

 

[BobbyHeenan]

Probably...stats seems to elude most people I suppose.

Hopefully we get more robust data with RTOG 1308.

Though they selected 70 Gy as the dose (?maybe trial written before 0617 published). Would have thought 60-66 Gy would have been the dose.

May also be clouded by durvalumab. Not sure how that is integrated in the trial as it become more standard after the trial initially started enrolling if I have my timeline right.

 

[seper]

Durvalumab will cloud a lot of upcoming NSCLC data.

 

[fiji128]

Saw this posted on Redit as response to that other post, seems to be in line with what a lot of folks are dealing with:

I'm a rad onc attending. I graduated three years ago into this bad job market. I looked for jobs all over the country after I couldn't find a job within 100 miles of my target city. My "academic" job straight up lied to me about my position, and I've I ended up in a hellish network of academic satellites where I make crap money working 60 hours a week with little support, plenty of disrespect, and will probably never move above "assistant professor". My colleagues and I all have a saying "the only way out is retirement". Our current residents either graduate unemployed, into a fellowship, or go to rural positions like the one described by tjpath86 for 200-300k.

I wish I had done radiology instead. Every doctor in just about every other specialty I'm aware of makes more than I do for similar or less work. I've been looking for a new job for two years and can't find a job that pays or will eventually pay even remotely close to what "average" is supposed to be for this specialty. I've pretty much called every friend I have, applied to every job ad I see, and I've gotten basically nowhere. I did get an interview where the pay was about 250k/year. "Well we thought you were miserable in your current position..." COOL THANKS FOR THE OPPORTUNITY dinguses!

I was an extremely well qualified residency and attending applicant with absolutely no red flags. My residency program did nothing to help find me a job, refused to make phone calls for me, and then offered me a non-ACGME accredited fellowship if I wanted to stay on board. This was after plenty of hard work and writing them a bunch of papers. These academic programs are a scam. Where I work now and where I trained are both actively expanding into more satellites and trying to expand their residency programs to put more residents and their own grads into general practice at their satellites at well less than private practice rates.

Where I work they are telling the faculty to get out there and help recruit medical students from the medical school and twitter because applications are down. We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. Our chair salivates at getting more highly qualified people he can lie to and pay **** money with no chance of them fleeing and being replaced every year. Every year at least one person quits and never works in clinical medicine again because they can't find a new job in rad onc. Some people do actually find different jobs in rad onc. One guy looked over 5 years before just finally giving up and leaving unemployed. It's impossible to find a new local job with non-competes basically the size of the state (I'm exaggerating but they are HUGE and LONG). And why would anyone take a chance on your non-compete when there's a long line of new grads looking for jobs? Oh you're unhappy? Go ahead and leave, we'll replace you for an even more lowly paid new grad. If you're willing to go *anywhere* as a rad onc you might find a rural job or another abusive academic satellite job, but even the rural jobs don't pay well anymore. Everyone is just looking to take advantage of you, and you have no bargaining power.
Get out while you can. The party in rad onc is dead and it's getting worse every year.

 

[theradiator]

It's all a Ponzi scheme but at least Madoff paid out 10% per year until it all came crashing down.

 

[seper]

This sounds a bit like Duke

Saw this posted on Redit as response to that other post, seems to be in line with what a lot of folks are dealing with:

I'm a rad onc attending. I graduated three years ago into this bad job market. I looked for jobs all over the country after I couldn't find a job within 100 miles of my target city. My "academic" job straight up lied to me about my position, and I've I ended up in a hellish network of academic satellites where I make crap money working 60 hours a week with little support, plenty of disrespect, and will probably never move above "assistant professor". My colleagues and I all have a saying "the only way out is retirement". Our current residents either graduate unemployed, into a fellowship, or go to rural positions like the one described by tjpath86 for 200-300k.

I wish I had done radiology instead. Every doctor in just about every other specialty I'm aware of makes more than I do for similar or less work. I've been looking for a new job for two years and can't find a job that pays or will eventually pay even remotely close to what "average" is supposed to be for this specialty. I've pretty much called every friend I have, applied to every job ad I see, and I've gotten basically nowhere. I did get an interview where the pay was about 250k/year. "Well we thought you were miserable in your current position..." COOL THANKS FOR THE OPPORTUNITY dinguses!

I was an extremely well qualified residency and attending applicant with absolutely no red flags. My residency program did nothing to help find me a job, refused to make phone calls for me, and then offered me a non-ACGME accredited fellowship if I wanted to stay on board. This was after plenty of hard work and writing them a bunch of papers. These academic programs are a scam. Where I work now and where I trained are both actively expanding into more satellites and trying to expand their residency programs to put more residents and their own grads into general practice at their satellites at well less than private practice rates.

Where I work they are telling the faculty to get out there and help recruit medical students from the medical school and twitter because applications are down. We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. Our chair salivates at getting more highly qualified people he can lie to and pay **** money with no chance of them fleeing and being replaced every year. Every year at least one person quits and never works in clinical medicine again because they can't find a new job in rad onc. Some people do actually find different jobs in rad onc. One guy looked over 5 years before just finally giving up and leaving unemployed. It's impossible to find a new local job with non-competes basically the size of the state (I'm exaggerating but they are HUGE and LONG). And why would anyone take a chance on your non-compete when there's a long line of new grads looking for jobs? Oh you're unhappy? Go ahead and leave, we'll replace you for an even more lowly paid new grad. If you're willing to go *anywhere* as a rad onc you might find a rural job or another abusive academic satellite job, but even the rural jobs don't pay well anymore. Everyone is just looking to take advantage of you, and you have no bargaining power.
Get out while you can. The party in rad onc is dead and it's getting worse every year.

 

[scarbrtj]

Saw this posted on Redit as response to that other post, seems to be in line with what a lot of folks are dealing with:

I'm a rad onc attending. I graduated three years ago into this bad job market. I looked for jobs all over the country after I couldn't find a job within 100 miles of my target city. My "academic" job straight up lied to me about my position, and I've I ended up in a hellish network of academic satellites where I make crap money working 60 hours a week with little support, plenty of disrespect, and will probably never move above "assistant professor". My colleagues and I all have a saying "the only way out is retirement". Our current residents either graduate unemployed, into a fellowship, or go to rural positions like the one described by tjpath86 for 200-300k.

I wish I had done radiology instead. Every doctor in just about every other specialty I'm aware of makes more than I do for similar or less work. I've been looking for a new job for two years and can't find a job that pays or will eventually pay even remotely close to what "average" is supposed to be for this specialty. I've pretty much called every friend I have, applied to every job ad I see, and I've gotten basically nowhere. I did get an interview where the pay was about 250k/year. "Well we thought you were miserable in your current position..." COOL THANKS FOR THE OPPORTUNITY dinguses!

I was an extremely well qualified residency and attending applicant with absolutely no red flags. My residency program did nothing to help find me a job, refused to make phone calls for me, and then offered me a non-ACGME accredited fellowship if I wanted to stay on board. This was after plenty of hard work and writing them a bunch of papers. These academic programs are a scam. Where I work now and where I trained are both actively expanding into more satellites and trying to expand their residency programs to put more residents and their own grads into general practice at their satellites at well less than private practice rates.

Where I work they are telling the faculty to get out there and help recruit medical students from the medical school and twitter because applications are down. We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. Our chair salivates at getting more highly qualified people he can lie to and pay **** money with no chance of them fleeing and being replaced every year. Every year at least one person quits and never works in clinical medicine again because they can't find a new job in rad onc. Some people do actually find different jobs in rad onc. One guy looked over 5 years before just finally giving up and leaving unemployed. It's impossible to find a new local job with non-competes basically the size of the state (I'm exaggerating but they are HUGE and LONG). And why would anyone take a chance on your non-compete when there's a long line of new grads looking for jobs? Oh you're unhappy? Go ahead and leave, we'll replace you for an even more lowly paid new grad. If you're willing to go *anywhere* as a rad onc you might find a rural job or another abusive academic satellite job, but even the rural jobs don't pay well anymore. Everyone is just looking to take advantage of you, and you have no bargaining power.
Get out while you can. The party in rad onc is dead and it's getting worse every year.

Can almost hear the non-rad onc choosing med students, and other specialty MDs, saying “Our thoughts and prayers are with you rad oncs in this difficult time.” Of course my granddad used to say 90% of folks couldn’t care less about the problems you’ve got and the other 10% are glad you’ve got ‘em. Rad oncs will be the only ones who can help themselves... or they won’t.

 

[PhotonBomb]

That sounds like DukeNukem

sad!

 

[w00tz]

Maybe they work in the same place?

 

[Chartreuse Wombat]

This sounds a bit like Duke

Can't be Dook as they have no non-competes.

 

[medgator]

Can't be Dook as they have no non-competes.

Situation is probably more common than anyone would like to admit.

Having an excess labor supply will do that to a specialty

 

[Lamount]

This is ridiculous. For a field that prides itself on being data-driven, having Nancy Lee stand up there and say that even if randomized controlled trials are negative, that they would still use proton beam. These academics are a joke. They built these machines and facilities and started treating without opening any good trials. Off of the top of my head, there's probably only one study that MD Anderson published (not just presented, like their esophageal experience) looking at photons versus protons, which showed modest (?) benefit.

Nancy Lee states that the proton naysayers have an inherent bias. But doesn't the bias go the other way? She's on the one with this brand new facility at New York Proton Center. They are already invested into it, so that's why she put on her slide, in the face of negative data, they would still treat. Nancy, it is YOUR crisis, not the whole radiation oncology community. Surely, there are hospital systems out there who would not hesitate at the chance of building a proton facility if the data shows a benefit in major disease sites, such as breast and prostate. These proton people argue that it is good for pediatrics, but fortunately, there is not that many pediatric cases as there are breast and prostate, but yet, they fill their machines with breast and prostate patients. The English don't do that. They send their pediatric cases to the United States because it is cheaper than building a facility. So, why, in the United States, have there been a proliferation of proton facilities? Is the pediatric cancer endemic that bad that we need a proton facility on every corner?

Where's the data?!?! Some of these facilities have had protons for two decades and did not run the trials to look at the value of proton therapy. This is not a new problem! If we have a new technology, generate the data. It costs money, but clearly, the NY group had no problem dropping 9 figures for a new facility.

So, Nancy, why are we the naysayers? Isn't the burden on proof with those who have it to show the clinical benefit? You say that that it is not about money, but it really is. Your group spent $300 million dollars to build this facility in East Harlem. That's not trivial money. The only way to get that money back is to treat everything and bilk insurers and patients for everything they can, like a broken ATM. You should be a leader and run the trials to show the value of protons. This is your chance to be a trailblazer as you did for IMRT in nasopharyngeal cancer. Get off of your high horse and do some science. We will follow you to the promised land, if the data is good.

FYI, the Brits have at least 2 private proton centers up and running, and at least 1 NHS one (with several more under construction)

Randomized trials in this arena are very difficult because few patients are willing to be randomized to photons when protons are an option...

But more importantly for adult patients, protons are most beneficial in situations where we wouldn't even try to use photons (i.e. chordoma/chondrosarcoma, difficult re-irradiation cases, HCC with borderline liver status, N3 lung cases where you can't meet V20 metrics with photons etc...). Maybe protons will never be standard in all lung cancer, or breast cancer or even head and neck cancer (Nancy Lee would likely agree) ... but there are certainly cases where they are clearly indicated.

Do you ever use IMRT in diseases were there aren't randomized phase III data that specifically tested 3D vs IMRT and proved IMRT yields superior outcomes (e.g. NSCLC)? If so, are you bilking your insurers?... or can you appropriately infer that the treatment with a V20 of 20% is better than the one with a V20 of 45%?

 

[deleted1002574]

Bad argument, @Lamount

She said two things that are notable:

1) She will disregard RCTs showing no benefit or even showing harm

2) Those that don’t have proton centers are inherently biased against them.

Respond to those arguments. Those are relevant, and would love to hear opinions regarding that.

 

[SubserviantToABR]

FYI, the Brits have at least 2 private proton centers up and running, and at least 1 NHS one (with several more under construction)

Randomized trials in this arena are very difficult because few patients are willing to be randomized to photons when protons are an option...

But more importantly for adult patients, protons are most beneficial in situations where we wouldn't even try to use photons (i.e. chordoma/chondrosarcoma, difficult re-irradiation cases, HCC with borderline liver status, N3 lung cases where you can't meet V20 metrics with photons etc...). Maybe protons will never be standard in all lung cancer, or breast cancer or even head and neck cancer (Nancy Lee would likely agree) ... but there are certainly cases where they are clearly indicated.

Do you ever use IMRT in diseases were there aren't randomized phase III data that specifically tested 3D vs IMRT and proved IMRT yields superior outcomes (e.g. NSCLC)? If so, are you bilking your insurers?... or can you appropriately infer that the treatment with a V20 of 20% is better than the one with a V20 of 45%?

I think a lot of would agree that there are potential roles in difficult cases such as chordoma or re-irradiation cases. But, those are far rare than what a proton center would treat, unless there's a chordoma epidemic that I don't know about. Should we have as many proton centers as we do? In all honesty, I would not mind having a few proton centers to address these tough cases where there may never be a phase III, randomized controlled trial.

However, there is wayyyy more breast and prostate cancer than there are chordomas. A study to look at the value of protons should be pretty easy to accrue to. And don't tell me it is about money, not being able to fund a trial. MILLIONS of dollars have been thrown in to build this center. In fact, Nancy Lee's shop cost $300 million dollar to construct (New York’s First Proton Therapy Center to Open in July). Just a quick look at their website state that they can treat the following sites: brain, breast, esophageal, gastrointestinal, genitourinary, gynecologic, head and neck, lung/thoracic, lymphomas, pediatric, prostate, recurrent, sarcoma, skull base, and spinal tumors (What Types of Cancers Can Be Treated with Proton Therapy?). That's a lot of tumor sites where high-level data does not exist.

Just a quick look at clinicaltrials.gov at the currently recruiting phase III trials with proton compared to another treatment modality (no phase I, II, IIR and only recruiting):

• Photons versus protons for liver cancer: NCT03186898 (NRG GI003)
• Hypofractionation versus standard with protons: NCT01230866
• Protons versus RFA for HCC: NCT02640924
• Protons versus carbon for chordoma: NCT01182779
• Protons versus carbon for chondrosarcoma: NCT01182753
• Photon versus proton for lung cancer: NCT01993810 (RTOG 1308)
• Photon versus proton for esophageal cancer: NCT03801876 (NRG GI006)
• Photon versus proton for head and neck: NCT01893307 (Steven Frank's study)

Out of all the listed studies, comparing protons to something, there are only FOUR studies comparing photons to protons. You can't say that it is difficult to accrue to these studies because these studies are not available everywhere there are protons. Out of all of the conditions that is treated by NY Proton Center, are they accruing to each available study that is out there?

Plus, as alluded to earlier, a true, blue randomized trial is the only way to go. I don't care if protons were shown to be "effective" in a single arm phase II. Single arm studies won't move the needle, unlike a phase III...so let's accrue to these studies!

 

[BobbyHeenan]

Don’t give me that hard to accrue talk...

Lung, breast, and prostate are so common. You make it your institutional policy to only treat protons for these cases on a randomized protocol. None of this registry BS. There. It’s done.

We have phase 3 trials now for all these sites (and it’s shameful they haven’t been open for many years prior).

 

[Lamount]

Bad argument, @Lamount

She said two things that are notable:

1) She will disregard RCTs showing no benefit or even showing harm

2) Those that don’t have proton centers are inherently biased against them.

Respond to those arguments. Those are relevant, and would love to hear opinions regarding that.

This post is confusing. Best I can tell, you don't want to have a debate about the points I raised, rather you would like me to play along in your imaginary argument with NL. When you are asking me to "respond to those arguments", I can only presume you are asking me to defend what you think she said. Sure, I'll bite.

1) I don't think she actually said she would use protons despite trials showing harm (granted, I am not extremely proficient in twitter, so perhaps I just missed that post). Nonetheless, consider in 1994, almost every randomized trial of PORT in NSCLC demonstrated worse survival. However, many knew that those trials were flawed: volumes and fraction sizes were unreasonable... and that PORT was supported by first principals so long it was done in a reasonable way. As such, 25% of the patients who enrolled on ANITA received, PORT which provided us will enough data to figure out that PORT is helpful in N2 disease. Now we are testing that specific question in a well-designed RTC, because we know which question to ask.

NL's point (I presume) was that, when IMRT was first developed, we didn't really know how to use it... we didn't know how to harness it's strengths and avoid the pitfalls. But despite the lackluster data, the concept made too much sense for people to abandon it... now it is employed in most definitive treatments at many centers.

We can make protons stop where we want them to... this provides another degree of freedom as compared to photons. There are bound to be times when this property is clinically advantageous (and I would say it is unreasonable to argue otherwise). But we really don't know what we are doing yet. We mostly don't account for range uncertainties, higher RBE in the distal Bragg peak, and the failure of analytical algorythms in regions of heterogeneity etc... and protons can certainly be dangerous if these issues are not appropriately considered.

We also don't necessarily now which questions to ask in trials. Like I said above, maybe it isn't that protons are better in bread-and-butter cases of a given disease... maybe protons simply let you safely treat more patients than you could with photons. How do you test that? Like PORT and IMRT, it's likely that the indications for protons will first be found through retrospective reviews and unplanned secondary analyses. From what I can tell, she is simply saying don't break out the wrecking balls quite yet.

2) She said that people who are biased tend not to have protons, not the converse (as you stated). Is she wrong?

 

[deleted941485]

Protons: Why I stopped worrying about evidenced based medicine and learned to love the particle beam!

 

[medgator]

.

NL's point (I presume) was that, when IMRT was first developed, we didn't really know how to use it... we didn't know how to harness it's strengths and avoid the pitfalls. But despite the lackluster data, the concept made too much sense for people to abandon it... now it is employed in most definitive treatments at many centers.

Are you really going to be that disingenuous regarding the cost differential of protons vs IMRT/3D where there was a much smaller jump, financially?

 

[Lamount]

Are you really going to be that disingenuous regarding the cost differential of protons vs IMRT/3D where there was a much smaller jump, financially?

No argument here. Costs are ridiculous and need to come down.

 

[bluebubbles]

Protons = magic pixie dream dust

RCT's unnecessary in the face of the proton power ranger

Bragg peak, swag peak

In protons we trust, all others bring data

Adding target volume delineation for particle therapy to my Amazon Wish List

 

[medgator]

No argument here. Costs are ridiculous and need to come down.

And that should require a commensurate higher bar in terms of adoption as a result compared to IMRT

 

[CaesarRO]

Bad argument, @Lamount

She said two things that are notable:

1) She will disregard RCTs showing no benefit or even showing harm

2) Those that don’t have proton centers are inherently biased against them.

Respond to those arguments. Those are relevant, and would love to hear opinions regarding that.

I think it's pretty obvious this was a slide in a talk in which she is highlighting the "crisis of protons" as Mimi Knoll emphasizes in subsequent replies.

Nancy Lee is highlighting the fact that with the capital investment that goes into building proton centers, if proton trials are negative then many centers would be hard pressed to give up their centers and just close up shop. Thus, many centers will treat regardless if results are negative. *She's highlighting this scenario as a crisis.* I take the "we" to mean we radiation oncologists.

I didn't see the talk, so not sure if she presented solutions.

Also, from what I know, the problem with randomizing photons vs protons is that pts still need insurance auth to get protons, so thats a prerequisite to enroll on trial. For many pts, if they are enrolled on trial and get randomized to photons, they will withdraw from trial and all for the protons since they've already got approval. Many _patients_ don't have equipoise when it comes to photons vs protons.

Sent from my Pixel 2 XL using Tapatalk

 

[medgator]

I think it's pretty obvious this was a slide in a talk in which she is highlighting the "crisis of protons" as Mimi Knoll emphasizes in subsequent replies.

Nancy Lee is highlighting the fact that with the capital investment that goes into building proton centers, if proton trials are negative then many centers would be hard pressed to give up their centers and just close up shop. Thus, many centers will treat regardless if results are negative. *She's highlighting this scenario as a crisis.* I take the "we" to mean we radiation oncologists.

A good reason why so many shouldn't have been built in the first place considering cost and lack of data. So Nancy is trying to give a free pass to the moral hazard of those decisions.

Probably didn't more than 5-10 centers until the data matured and proved we needed more. Not even sure I can keep count of how many are open at this point

 

[xrthopeful]

Saw this posted on Redit as response to that other post, seems to be in line with what a lot of folks are dealing with:

I'm a rad onc attending. I graduated three years ago into this bad job market. I looked for jobs all over the country after I couldn't find a job within 100 miles of my target city. My "academic" job straight up lied to me about my position, and I've I ended up in a hellish network of academic satellites where I make crap money working 60 hours a week with little support, plenty of disrespect, and will probably never move above "assistant professor". My colleagues and I all have a saying "the only way out is retirement". Our current residents either graduate unemployed, into a fellowship, or go to rural positions like the one described by tjpath86 for 200-300k.

I wish I had done radiology instead. Every doctor in just about every other specialty I'm aware of makes more than I do for similar or less work. I've been looking for a new job for two years and can't find a job that pays or will eventually pay even remotely close to what "average" is supposed to be for this specialty. I've pretty much called every friend I have, applied to every job ad I see, and I've gotten basically nowhere. I did get an interview where the pay was about 250k/year. "Well we thought you were miserable in your current position..." COOL THANKS FOR THE OPPORTUNITY dinguses!

I was an extremely well qualified residency and attending applicant with absolutely no red flags. My residency program did nothing to help find me a job, refused to make phone calls for me, and then offered me a non-ACGME accredited fellowship if I wanted to stay on board. This was after plenty of hard work and writing them a bunch of papers. These academic programs are a scam. Where I work now and where I trained are both actively expanding into more satellites and trying to expand their residency programs to put more residents and their own grads into general practice at their satellites at well less than private practice rates.

Where I work they are telling the faculty to get out there and help recruit medical students from the medical school and twitter because applications are down. We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. Our chair salivates at getting more highly qualified people he can lie to and pay **** money with no chance of them fleeing and being replaced every year. Every year at least one person quits and never works in clinical medicine again because they can't find a new job in rad onc. Some people do actually find different jobs in rad onc. One guy looked over 5 years before just finally giving up and leaving unemployed. It's impossible to find a new local job with non-competes basically the size of the state (I'm exaggerating but they are HUGE and LONG). And why would anyone take a chance on your non-compete when there's a long line of new grads looking for jobs? Oh you're unhappy? Go ahead and leave, we'll replace you for an even more lowly paid new grad. If you're willing to go *anywhere* as a rad onc you might find a rural job or another abusive academic satellite job, but even the rural jobs don't pay well anymore. Everyone is just looking to take advantage of you, and you have no bargaining power.
Get out while you can. The party in rad onc is dead and it's getting worse every year.

haha there is no doubt in my mind that this DukeNukem

I feel bad for him, I truly hope he fixes whatever the issue is and finds a better job soon.

one quote here - 'We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. ' - I think this is important to underline what medical students already know, but this is proof of concept, DON'T GO TO A BAD PROGRAM, even if you think the location is good for you, or you got tricked on interview day blah blah, just don't do it. Duke went to a bad program, and it set him up for a bad job.

 

[medgator]

Duke went to a bad program, and it set him up for a bad job.

Probably more "bad" ones than good ones at this point in the expansion game.

 

[deleted1002574]

Yes, because the points you’re making are fine.

But, my issue is with the “Trust me kids, we got this” attitude from her and others. At least Dr. Storey wants evidence and (pretend) cares about EBM. I have no disagreement with him or many others that are pro - protons. I am, as well. This started with Nancy Lee’s comment.

1. Yes, she said she would still treat with protons if the RCTs were negative

2. To claim that anyone without protons is inherently biased is a point so illogical, paternalistic, and makes me think she isn’t the thinker people believe her to be. That means that only Harvard and Loma Linda saw the promise of protons. Until of course, Indiana and Penn got them. Then, they knew and the others were still blind. Then MDACC got them, and now they were the all knowing seers. On and on and on.

Do you see the insanity? They are proving the opposite point. They are biased because they have them. Not the other way around.

This post is confusing. Best I can tell, you don't want to have a debate about the points I raised, rather you would like me to play along in your imaginary argument with NL. When you are asking me to "respond to those arguments", I can only presume you are asking me to defend what you think she said. Sure, I'll bite.

1) I don't think she actually said she would use protons despite trials showing harm (granted, I am not extremely proficient in twitter, so perhaps I just missed that post). Nonetheless, consider in 1994, almost every randomized trial of PORT in NSCLC demonstrated worse survival. However, many knew that those trials were flawed: volumes and fraction sizes were unreasonable... and that PORT was supported by first principals so long it was done in a reasonable way. As such, 25% of the patients who enrolled on ANITA received, PORT which provided us will enough data to figure out that PORT is helpful in N2 disease. Now we are testing that specific question in a well-designed RTC, because we know which question to ask.

NL's point (I presume) was that, when IMRT was first developed, we didn't really know how to use it... we didn't know how to harness it's strengths and avoid the pitfalls. But despite the lackluster data, the concept made too much sense for people to abandon it... now it is employed in most definitive treatments at many centers.

We can make protons stop where we want them to... this provides another degree of freedom as compared to photons. There are bound to be times when this property is clinically advantageous (and I would say it is unreasonable to argue otherwise). But we really don't know what we are doing yet. We mostly don't account for range uncertainties, higher RBE in the distal Bragg peak, and the failure of analytical algorythms in regions of heterogeneity etc... and protons can certainly be dangerous if these issues are not appropriately considered.

We also don't necessarily now which questions to ask in trials. Like I said above, maybe it isn't that protons are better in bread-and-butter cases of a given disease... maybe protons simply let you safely treat more patients than you could with photons. How do you test that? Like PORT and IMRT, it's likely that the indications for protons will first be found through retrospective reviews and unplanned secondary analyses. From what I can tell, she is simply saying don't break out the wrecking balls quite yet.

2) She said that people who are biased tend not to have protons, not the converse (as you stated). Is she wrong?

 

[thecarbonionangle]

haha there is no doubt in my mind that this DukeNukem

I feel bad for him, I truly hope he fixes whatever the issue is and finds a better job soon.

one quote here - 'We have a hard time filling our residency program, so fortunately the medical school has forced them to stop expanding, at least for now. ' - I think this is important to underline what medical students already know, but this is proof of concept, DON'T GO TO A BAD PROGRAM, even if you think the location is good for you, or you got tricked on interview day blah blah, just don't do it. Duke went to a bad program, and it set him up for a bad job.

still misrepresents some things clearly though. Always implies he can’t find ANYTHING when you know there are things out there, clearly not as open...

also, there are many BAD no good programs. Some of them still fill year to year. As the ranking approaches if you are thinking about ranking a place pretty high, feel free to message any of us in the know and we can tell you what we think. I do not want anybody to end up in any of these places

 

[theradiator]

Here's her context. If the trials are negative, she said it doesn't make sense to demolish machines. Yeah...because they spent MILLIONS on this, as did a lot of other groups.

Also, who is this ProtonStorey guy? He believes in protons, but yet, looking at his group's website, which his title is Medical Director Clinical Operations, there is NO mention of clinical trials involving protons. If this technology works, show it. Tell us why it is worth 3 times more. It better be 3 times better or 3 fold less toxicity. Value = quality / cost. There better be good quality.
View attachment 289022

Academics used to say that their mission was to put ourselves out of business. This is clearly the opposite. NL cannot say that $$$$$ is not a factor when her job title and thus some unspecified portion of her compensation package is linked to the existence of this $300,000,000 monstrosity/white elephant.

 

[PhotonBomb]

it kind of makes sense to have one proton center in the largest city in the country, so that one I'm more okay with than the 10 in south florida.

 

[medgator]

still misrepresents some things clearly though. Always implies he can’t find ANYTHING when you know there are things out there, clearly not as open...

Gotta say I'm shocked at how many fewer emails I get these days (none honestly) advertising the high % MGMA positions in the middle of nowhere, compared to even 5 years ago

 

[medgator]

it kind of makes sense to have one proton center in the largest city in the country, so that one I'm more okay with than the 10 in south florida.

Should have stopped after the first one at UF. Why was NYC so late to the party again, though?