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jondunn said:
How does the lung v20 look with your VMAT plans?
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IMRT does not have to be VMAT. In fact, it probably isn't very good for what people are using it for here. Tangential IMRT, efluence, etc. Breast "IMRT" or IMRT.

And, MROQC group published showing inverse planned breast did better than FiF. I'm getting more convinced for IMRT for breast. Can pay me the 3D amount, that's fine, I just want to do what's best.
 
RealSimulD said:
IMRT does not have to be VMAT. In fact, it probably isn't very good for what people are using it for here. Tangential IMRT, efluence, etc. Breast "IMRT" or IMRT.

And, MROQC group published showing inverse planned breast did better than FiF. I'm getting more convinced for IMRT for breast. Can pay me the 3D amount, that's fine, I just want to do what's best.
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Truth always wins out. And every time the last couple decades someone phIII, or large retrospective, tests IMRT in breast it wins. Breast contains the best documented literature track record of success for IMRT versus any other disease site.
 
RealSimulD said:
IMRT does not have to be VMAT. In fact, it probably isn't very good for what people are using it for here. Tangential IMRT, efluence, etc. Breast "IMRT" or IMRT.

And, MROQC group published showing inverse planned breast did better than FiF. I'm getting more convinced for IMRT for breast. Can pay me the 3D amount, that's fine, I just want to do what's best.
Click to expand...

Yes. I compare partial arc vmat vs. static field IMRT. Often teh static field IMRT is a little better.

The lung V20's on the IMRT/VMAT almost always are better than the 3D. It's the lung V5 that's worse than 3D typically.
 
RealSimulD said:
i was good until, clinically. you think 60/30 to a bone met is worse than protons for breast?
bro. bro... bro.
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durable palliation. curious what the difference in billing 60Gy/30Fx 2D vs. 35Gy/5Fx SBRT? In oligomet type situation of course.
 
medgator said:
It's going to cause fatigue and financial toxicity, no doubt, but you aren't fracturing bone with that
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i find the fraction shaming to be ridiculous if you are pushing protons for prostate.
A lot of this goes back to little vs. big rad onc.
I have verbatim seen attendings advocate for patients to drive 4 hrs to get whole breast at the ivory tower instead of locally. i am honest with patients and disagree. probably won't help my rotation evals but yolo.
 
radoncftw said:
i find the fraction shaming to be ridiculous if you are pushing protons for prostate.
A lot of this goes back to little vs. big rad onc.
I have verbatim seen attendings advocate for patients to drive 4 hrs to get whole breast at the ivory tower instead of locally. i am honest with patients and disagree. probably won't help my rotation evals but yolo.
Click to expand...
It’s incredible whet these centers will do to hold on to 16 fx of 3D
 
jondunn said:
For people that ask why our field should do hypofrac trials, Join Luh has this to say :

Click to expand...


How. What. How. Just...

His plan is what, exactly, throw a Tomo or a Halcyon on a truck, put a couple of therapists in a chase car like some roadies, give a couple of treatments in one town early in the morning, drive it a few hours down the road to next feedlot town, give a couple more there, finish off the day on a highway east of Omaha when the truck driver collides with a loaded cattle truck in a spectacular conservation of momentum demonstration from physics I lab. I guess Varian will just fly another Halcyon out on a 747 as a downtime contingency in that case because at that point sure why not that makes just about as much sense.

I have a better idea. Let the market place linacs where they are needed. Pay rad oncs what it takes to move to rural North Dakota and staff them.
 
Moonbeams said:
How. What. How. Just...

His plan is what, exactly, throw a Tomo or a Halcyon on a truck, put a couple of therapists in a chase car like some roadies, give a couple of treatments in one town early in the morning, drive it a few hours down the road to next feedlot town, give a couple more there, finish off the day on a highway east of Omaha when the truck driver collides with a loaded cattle truck in a spectacular conservation of momentum demonstration from physics I lab. I guess Varian will just fly another Halcyon out on a 747 as a downtime contingency in that case because at that point sure why not that makes just about as much sense.

I have a better idea. Let the market place linacs where they are needed. Pay rad oncs what it takes to move to rural North Dakota and staff them.
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I wrote about this in my fan fiction about KHE88 and Todd Scarborough. Join must be a fan!
 
RealSimulD said:
I wrote about this in my fan fiction about KHE88 and Todd Scarborough. Join must be a fan!
Click to expand...
This needs to be expanded.

I see KHE painting an « In this we trust » sign on the side of the LINAC trailer with an AR15 and LINAC underneath. He finds out that Walmart is his sweet spot for dating.

Meanwhile, Scarborough periodically flies in from alternating junkets to the Caribbean, wearing nothing but board shorts and a bow tie. He works his wizardry with sophisticated time dépendent BED calcs, exotic conedowns and common sense. Despite his 90 minute consults detailing the theoretical basis of treatment, clinic days are efficient because he never gives regional nodal irradiation.
 
communitydoc13 said:
Meanwhile, Scarborough periodically flies in from alternating junkets to the Caribbean, wearing nothing but board shorts and a bow tie. He works his wizardry with sophisticated time dépendent BED calcs, exotic conedowns and common sense. Despite his 90 minute consults detailing the theoretical basis of treatment, clinic days are efficient because he never gives regional nodal irradiation.
Click to expand...
Maybe he finally perfected the art of IGRT checks from his iPhone out of the country?
 
jondunn said:
For people that ask why our field should do hypofrac trials, Join Luh has this to say :

Click to expand...

Ok, so I think Join has a point here. In theory, yes, this is an incredibly not-practical plan and has way to many potential logistical failures, but there is a serious unmet need for rural healthcare. Maybe an alternative way to tackle this is providing more funding for patients who live rurally to come and stay where there is a linac and then the financial burden is eased for this rural population. I would argue we still need hypofrac in this situation because often times a patient needs a caregiver to accompany them and that means time out of work for said caregiver.
 
RO28 said:
but there is a serious unmet need for rural healthcare
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Yes, but it starts with being able to pay and with having access to good primary care. Trying to solve rural health care disparities with a traveling LINAC is sort of like sending a bunch of us to Ukraine to perform battlefield XRT.
 
communitydoc13 said:
Yes, but it starts with being able to pay and with having access to good primary care. Trying to solve rural health care disparities with a traveling LINAC is sort of like sending a bunch of us to Ukraine to perform battlefield XRT.
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oh for sure. I completely agree.
 
RealSimulD said:
It’s incredible whet these centers will do to hold on to 16 fx of 3D
Click to expand...

jondunn said:
For people that ask why our field should do hypofrac trials, Join Luh has this to say :

Click to expand...


Makes no sense.

In order for this to work logistically, the hypofractionation would have to be extreme- say 1 or 2 fractions. If it approaches 3-5 fractions, then you essentially have a linac in a remote location for a week at a time. How on Earth would you staff it? Which physicians, therapists, and physicists would want to work in a different rural location every week? You would have to recalibrate the isocenter each and every time something was set up to account for the traveling nature of the linac, so good physics support would be a must.

So, we'll just hypofractionate to the extreme, maybe down to 1-2 fractions, which could take care of the staffing issue. Ok, so then in that situation a patient should be able to travel to receive a treatment or two, even if the distance is substantial, to take advantage of the better tech you would expect at a main cancer center.
 
communitydoc13 said:
This needs to be expanded.

I see KHE painting an « In this we trust » sign on the side of the LINAC trailer with an AR15 and LINAC underneath. He finds out that Walmart is his sweet spot for dating.

Meanwhile, Scarborough periodically flies in from alternating junkets to the Caribbean, wearing nothing but board shorts and a bow tie. He works his wizardry with sophisticated time dépendent BED calcs, exotic conedowns and common sense. Despite his 90 minute consults detailing the theoretical basis of treatment, clinic days are efficient because he never gives regional nodal irradiation.
Click to expand...
Literal LOL
 
Moonbeams said:
How. What. How. Just...

His plan is what, exactly, throw a Tomo or a Halcyon on a truck, put a couple of therapists in a chase car like some roadies, give a couple of treatments in one town early in the morning, drive it a few hours down the road to next feedlot town, give a couple more there, finish off the day on a highway east of Omaha when the truck driver collides with a loaded cattle truck in a spectacular conservation of momentum demonstration from physics I lab. I guess Varian will just fly another Halcyon out on a 747 as a downtime contingency in that case because at that point sure why not that makes just about as much sense.

I have a better idea. Let the market place linacs where they are needed. Pay rad oncs what it takes to move to rural North Dakota and staff them.
Click to expand...
Does the market really work for underserved areas?

I wouldn’t go there full time for double or triple what I make, and I’m not making near @OTN or @medgator money.

It’s more than money. Job share agreements, work from home opportunity, possibility of ownership/entrepreneurial activity.

As the field gets younger, non-heterosexual, URM and more likely to be single and cosmopolitan in tastes, it will take more than money to get someone to Avera or wherever the **** in SD keeps getting posted.
 
jondunn said:
For people that ask why our field should do hypofrac trials, Join Luh has this to say :

Click to expand...

I have heard tell that the linac tech used on the Cyberknife was failed research by the army to develop a backpack sized linear accelerator that could be carried by a human being.
RickyScott said:
Are there medoncs in trailers hanging bags of chemo in cornfields?
Click to expand...
No. But it would be a-maize-ing!
 
thecarbonionangle said:
You better believe it. I recently hears from a buddy about a med onc who drove around with chemo and gave it in a bus/car set up with an NP
Click to expand...
Yeah, todd and khe tried to go into business with said MedOnc. She was very spirited and entrepreneurial. She was known for sharpness - both wit and features, and there was nary a fellow (or a fella) that hadn’t taken a tongue lashing from her at some point. Many of the quad state regions community hospitals had worked with her in the past, but “playing well in the sandbox” was not in her toolbox. She did her best work alone - and that’s speaking about both oncology and in the bedroom. I interacted with her once at the Great American Beer Festival, in my drinking days). The women knew her way around Hops and HOPs, she was the first one that told me that direct supervision was for the birds. We shared a drink and some intimacy, but we just didn’t connect in the way I had hoped, and went our separate ways. I think about her from time to time. Glad she got her Mobile Juice business going - she has earned it.
 
RealSimulD said:
Yeah, todd and khe tried to go into business with said MedOnc. She was very spirited and entrepreneurial. She was known for sharpness - both wit and features, and there was nary a fellow (or a fella) that hadn’t taken a tongue lashing from her at some point. Many of the quad state regions community hospitals had worked with her in the past, but “playing well in the sandbox” was not in her toolbox. She did her best work alone - and that’s speaking about both oncology and in the bedroom. I interacted with her once at the Great American Beer Festival, in my drinking days). The women knew her way around Hops and HOPs, she was the first one that told me that direct supervision was for the birds. We shared a drink and some intimacy, but we just didn’t connect in the way I had hoped, and went our separate ways. I think about her from time to time. Glad she got her Mobile Juice business going - she has earned it.
Click to expand...
Sometimes KHE and her would get in a spirited debate, and he would say “Hoo boy the Juice is loose!” Todd would say, “Don’t know if you can really use that phrase in polite conversation my bro.” KHE would then launch into some undeniably funny but very un-woke jokes.
 
RealSimulD said:
Does the market really work for underserved areas?

I wouldn’t go there full time for double or triple what I make, and I’m not making near @OTN or @medgator money.

It’s more than money. Job share agreements, work from home opportunity, possibility of ownership/entrepreneurial activity.

As the field gets younger, non-heterosexual, URM and more likely to be single and cosmopolitan in tastes, it will take more than money to get someone to Avera or wherever the **** in SD keeps getting posted.
Click to expand...

As long as the Dakotas or similar pay ($$$$$$), there will always be the thirsty new grads to come in 3-4 year spurts to make their money and head to greener pastures elsewhere. While not ideal, that's better than some alternatives. At least the job gets done that way.
 
metallica81788 said:
As long as the Dakotas or similar pay ($$$$$$), there will always be the thirsty new grads to come in 3-4 year spurts to make their money and head to greener pastures elsewhere. While not ideal, that's better than some alternatives. At least the job gets done that way.
Click to expand...
Are those jobs still paying what they did a decade ago?
 
RealSimulD said:
Does the market really work for underserved areas?
Click to expand...
Exactly!

Markets don't work for a lot of things and unchecked markets create monopolies or monopsonies. This is what is happening in medicine. Imagine if med schools responded to the distribution problem by just pumping out more docs? (Many radonc power players seemed to justify residency expansion on these grounds). Competitiveness for med school would go down dramatically (as it has for radonc residency). Urban medical jobs will just pay less.

Docs will already take 1/2 to 1/3 to live where they want.

You can't make docs go where they don't want to live.

....and the demographic issues are huge. My med school was a state school with an externship program for rural practices, a conscious emphasis on primary care and well known diversity driven admissions, even when I went there. (Diversity driven admissions didn't just mean getting racial URM representation but also rural white kids). Still, the med school class looked like med school classes look and almost no one went on to practice rural medicine.

Loan forgiveness and playing the visa game is what keeps rural or even semirural hospitals afloat. Unless you are from there and did well, or have a magnet school in your rural county (which you won't) or the rare country day school, or you are comfortable sending your kids to boarding school, you are going to feel pressure to bail when you realize that your kid isn't doing any homework.

There are nursing schools at small hospitals and community colleges. These definitely help with nursing staffing. Maybe time for some small (20 person class) rural medical schools? I actually think this is the solution. Preferential admissions for locals.
 
medgator said:
Are those jobs still paying what they did a decade ago?
Click to expand...

jondunn said:
800k? yeah.
Click to expand...

I don't know - probably depends on the particular job

But it was much more than that just in the past 5 years via personal knowledge, so I would hope at bare bare minimum 800k+
 
RealSimulD said:
Yeah, todd and khe tried to go into business with said MedOnc. She was very spirited and entrepreneurial. She was known for sharpness - both wit and features, and there was nary a fellow (or a fella) that hadn’t taken a tongue lashing from her at some point. Many of the quad state regions community hospitals had worked with her in the past, but “playing well in the sandbox” was not in her toolbox. She did her best work alone - and that’s speaking about both oncology and in the bedroom. I interacted with her once at the Great American Beer Festival, in my drinking days). The women knew her way around Hops and HOPs, she was the first one that told me that direct supervision was for the birds. We shared a drink and some intimacy, but we just didn’t connect in the way I had hoped, and went our separate ways. I think about her from time to time. Glad she got her Mobile Juice business going - she has earned it.
Click to expand...
How did you go from a guy who knows about and went to GABF to no drinking? Health?
 
Palex80 said:
Tangential VMAT is also an option. Two mini-arcs, around 30° each, in tangential configuration so to say.
I can post a screenshot tomorrow.
Click to expand...
1649311643235.png

Not saying it's superior to other techniques, but here's one plan with partial VMAT arcs.
 
OTN said:
In order for this to work logistically, the hypofractionation would have to be extreme- say 1 or 2 fractions. If it approaches 3-5 fractions, then you essentially have a linac in a remote location for a week at a time. How on Earth would you staff it? Which physicians, therapists, and physicists would want to work in a different rural location every week? You would have to recalibrate the isocenter each and every time something was set up to account for the traveling nature of the linac, so good physics support would be a must.
Click to expand...
I agree. This sounds improbable.

We have mammography trucks in some European countries. They travel from village to village for mammographies during the whole year.
There also used to be a truck mounted PET-CT that was parked on the parking lot of a small hospital for a couple of days, then moved to the next location for the next feew days and so on... So basically even smaller hospitals had PET-CT slots every other week.
 
RadOncDoc21 said:
Maybe have a Linac housed out of a Dollar General?
Click to expand...
Buck a Rad?

Maybe $1.25 nowadays.


EDIT: I just realized that you likely have to be >40 yo to remember the buck-a-rad days. When surgeons looked at us with jealousy and disgust and would use that term in a vain attempt to denigrate the specialty. I remember these days only as a medical student. By the time I graduated residency, those gilded days were over. The bubble had popped. But damn if it wasn't funny at the time.
 
Last edited:
OTN said:
That would be a great solution for clinics who are upgrading their machine. (The Alliance truck)
Click to expand...
That's the main purpose I believe. We looked into it, but it was quite expensive.

In a rural setting though, you can't really send patients to the linac at your sister site 20 minutes away.

Which brings up a lesson. ALWAYS build two vaults during initial construction.
 
Seems like a larger version of what is happening in rad onc with the same root cause. I know people who went to pharmacy school in the early 2000's and admission was at least somewhat rigorous. Now just about anyone with a pulse can get in. Greedy "academics" never seem to want to clean up the messes they create.

Years of Rampant Expansion Have Imposed Darwinian Survival-of-the-Fittest Conditions on US Pharmacy Schools

The number of applicants to US pharmacy schools has been declining since 2013, leading to a national enrollment crisis. Enrollment challenges threaten the viability of many pharmacy programs. Some schools are better equipped than others to confront the risk of having to downsize or close...
www.ajpe.org www.ajpe.org

"Unprecedented academic expansion left in its wake a new era in which the Academy is facing a severe enrollment crisis. The number of verified Pharmacy College Application Service (PharmCAS) applicants has decreased every year since 2013 when it peaked at 17,617. The number had fallen to 15,335 by 2019, and based on a June 2020 PharmCAS update, is poised to fall another 11.0% to about 14,000 during the 2019-2020 admission cycle, which constitutes a drop of 20% since 2017. The average enrollment of an entering class has dropped annually since 2012, from 124 to 102. According to an American Association of Colleges of Pharmacy (AACP) survey completed in March 2020, of the 134 respondent schools, 62% reported not being able to fill the entering class in 2019, with a mean of 15.6 unfilled seats. The Academy has reached an ominous point of critical mass, in which the number of applicants is barely equal to the number of available seats."

"Gone are the days of guaranteed full-time, high-paying positions for graduates straight out of pharmacy school. Many pharmacy graduates are faced with accepting part-time or per diem positions, reduced salaries, difficult working conditions, undesirable locations, and/or unemployment. It is no wonder that fewer students are choosing pharmacy as a career. The value is not what it used to be.

Some pharmacy leaders downplay the role of academic expansion as the primary cause of diminishing enrollment based on the premise that an unstable economy and fewer high school graduates are precipitating factors. However, such inferences are contradicted by the growing number of applicants to some other health profession programs. From 2002 to 2018, enrollment in medical schools increased 31%. Total enrollment of the first-year classes in colleges of osteopathic medicine grew 27% from 2013 to 2018."

"Many current faculty members occupy positions within pharmacy schools that would not exist had it not been for years of academic expansion. Between 2006 and 2018, the number of full-time pharmacy faculty members rose 60%, from 4,121 to 6,574"
 
I’ve noticed the pharmacies have super high turn over these days and bad service. A big national pharmacy just instituted a 12:30-1pm “lunch time” for pharmacists which is ridiculous that up to this point they got nothing and they now only get 30 min. I just see people on their feet all day answering phones and putting people on hold with no time to eat or use the bathroom. Ultimate result of the corporatization of the profession which is now all about working for giant coorporate masters who treat you as a walmart employee, squeezing the life out of you. Same forces at play in medicine, and our field. Greed and explotation is the corporatist’s MO. We are no different than cheap cardboard boxes in an Bezos warehouse, driving down wages and funneling profits to the few.
 
fiji128 said:
Seems like a larger version of what is happening in rad onc with the same root cause. I know people who went to pharmacy school in the early 2000's and admission was at least somewhat rigorous. Now just about anyone with a pulse can get in. Greedy "academics" never seem to want to clean up the messes they create.

Years of Rampant Expansion Have Imposed Darwinian Survival-of-the-Fittest Conditions on US Pharmacy Schools

The number of applicants to US pharmacy schools has been declining since 2013, leading to a national enrollment crisis. Enrollment challenges threaten the viability of many pharmacy programs. Some schools are better equipped than others to confront the risk of having to downsize or close...
www.ajpe.org www.ajpe.org

"Unprecedented academic expansion left in its wake a new era in which the Academy is facing a severe enrollment crisis. The number of verified Pharmacy College Application Service (PharmCAS) applicants has decreased every year since 2013 when it peaked at 17,617. The number had fallen to 15,335 by 2019, and based on a June 2020 PharmCAS update, is poised to fall another 11.0% to about 14,000 during the 2019-2020 admission cycle, which constitutes a drop of 20% since 2017. The average enrollment of an entering class has dropped annually since 2012, from 124 to 102. According to an American Association of Colleges of Pharmacy (AACP) survey completed in March 2020, of the 134 respondent schools, 62% reported not being able to fill the entering class in 2019, with a mean of 15.6 unfilled seats. The Academy has reached an ominous point of critical mass, in which the number of applicants is barely equal to the number of available seats."

"Gone are the days of guaranteed full-time, high-paying positions for graduates straight out of pharmacy school. Many pharmacy graduates are faced with accepting part-time or per diem positions, reduced salaries, difficult working conditions, undesirable locations, and/or unemployment. It is no wonder that fewer students are choosing pharmacy as a career. The value is not what it used to be.

Some pharmacy leaders downplay the role of academic expansion as the primary cause of diminishing enrollment based on the premise that an unstable economy and fewer high school graduates are precipitating factors. However, such inferences are contradicted by the growing number of applicants to some other health profession programs. From 2002 to 2018, enrollment in medical schools increased 31%. Total enrollment of the first-year classes in colleges of osteopathic medicine grew 27% from 2013 to 2018."

"Many current faculty members occupy positions within pharmacy schools that would not exist had it not been for years of academic expansion. Between 2006 and 2018, the number of full-time pharmacy faculty members rose 60%, from 4,121 to 6,574"
Click to expand...
It is a mirror image...
 
thecarbonionangle said:
I’ve noticed the pharmacies have super high turn over these days and bad service. A big national pharmacy just instituted a 12:30-1pm “lunch time” for pharmacists which is ridiculous that up to this point they got nothing and they now only get 30 min. I just see people on their feet all day answering phones and putting people on hold with no time to eat or use the bathroom. Ultimate result of the corporatization of the profession which is now all about working for giant coorporate masters who treat you as a walmart employee, squeezing the life out of you. Same forces at play in medicine, and our field. Greed and explotation is the corporatist’s MO
Click to expand...
Yeah, when Wal-Mart finally gave the 30 minute lunch break a decade or so ago, I couldn't believe that this was a new initiative. I don't know that many pharmacists, but atleast 4 of them have left clinical/retail pharmacy. One left entirely and teaches at a grade school now.
 
RealSimulD said:
Yeah, when Wal-Mart finally gave the 30 minute lunch break a decade or so ago, I couldn't believe that this was a new initiative. I don't know that many pharmacists, but atleast 4 of them have left clinical/retail pharmacy. One left entirely and teaches at a grade school now.
Click to expand...
The one I know lives in SoCal. Practiced for about 10 years and has now left the field completely due to no decent/reasonable employment opportunities in the location.
 
jondunn said:
800k? yeah.
Click to expand...

Most of them are not paying 800k. A lot of these ultrarural places are trying to pay somebody to come there for MGMA median, 5 day work week, 6 weeks PTO. They advertise for years. In other words, the same deal they could get in large midwestern city, if not worse. Anybody who takes one of these jobs for a standard salary and benefit package is a fool.

Kearney, Nebraska spams me once every couple of months. They claim 25 patients on treatment. If true, that job should pay 1M. No joke.
I have never been to Kearney, NE. I don't imagine it has a lot going on. I imagine it is hard to recruit to. Rad onc has a problem in that the field self-selected >90% of candidates for over a decade (peak rad onc) who would never go to a place like that for any amount of money. Still, if Kearney would pay a rad onc 100% of pro collections, which should be 1M+ in that practice if those numbers are true, and offered 12 weeks of vacation and an option to cover Fridays from home or something, that job would fill, I am sure of it. And it would almost certainly still be one of the highest revenue centers in the hospital.

The idea of not consolidating the surrounding Nebraska communities into rural linacs in 20k communities (yes, where some patients will have to drive in for an hour or two) and instead putting a linac with limited functionality and a team of support staff on a truck and driving around to each 2000 person town and delivering some ultrahypofractionated treatments is tone deaf and asinine from a logistical and basic common sense perspective.
 
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