Rad Onc Twitter

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Lamount said:
Perhaps I will become more nihilistic when I have a few more years under my belt, but I am still of the mindset at 2 to 5 mm differences matter in some cases (but clearly not all)
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I think we all probably think this pre-treatment.

How often have we had a case where we thought "If only I had changed my volume (or contour) by 2 millimeters" post-treatment. Maybe we never think this because we are all perfect and get the volumes/contours right pre-treatment 100% of the time. Or maybe when there is an infaust outcome our brains don't thoroughly recall all that well the 40 structures we contoured/volumized pre-treatment.

There was an ESTRO abstract this year, a randomized trial IIRC, of adaptive replanning in HNSCC. The volumes must frequently change in the 2-5mm range (or more) w/ adaptive replanning in HNSCC chemoRT. My impression of the study is that it was negative for benefits from implementing "2 to 5 mm differences" in volumes!
 
TheWallnerus said:
I think we all probably think this pre-treatment.

How often have we had a case where we thought "If only I had changed my volume (or contour) by 2 millimeters" post-treatment. Maybe we never think this because we are all perfect and get the volumes/contours right pre-treatment 100% of the time. Or maybe when there is an infaust outcome our brains don't thoroughly recall all that well the 40 structures we contoured/volumized pre-treatment.

There was an ESTRO abstract this year, a randomized trial IIRC, of adaptive replanning in HNSCC. The volumes must frequently change in the 2-5mm range (or more) w/ adaptive replanning in HNSCC chemoRT. My impression of the study is that it was negative for benefits from implementing "2 to 5 mm differences" in volumes!
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There is only one good reason for this kind of "adaptive treatment": you can charge for it. You can in the US, can't you?
 
TheWallnerus said:
I think we all probably think this pre-treatment.

How often have we had a case where we thought "If only I had changed my volume (or contour) by 2 millimeters" post-treatment. Maybe we never think this because we are all perfect and get the volumes/contours right pre-treatment 100% of the time. Or maybe when there is an infaust outcome our brains don't thoroughly recall all that well the 40 structures we contoured/volumized pre-treatment.

There was an ESTRO abstract this year, a randomized trial IIRC, of adaptive replanning in HNSCC. The volumes must frequently change in the 2-5mm range (or more) w/ adaptive replanning in HNSCC chemoRT. My impression of the study is that it was negative for benefits from implementing "2 to 5 mm differences" in volumes!
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1652638259565.png


Chunky volumes; less likely to show a benefit. Primary endpoint of parafilm stimulation was ns superior, but secondary endpoint of scintigraphy was positive. PROs were the same, so patients probably didn't notice.
 
TheWallnerus said:
I think we all probably think this pre-treatment.

How often have we had a case where we thought "If only I had changed my volume (or contour) by 2 millimeters" post-treatment. Maybe we never think this because we are all perfect and get the volumes/contours right pre-treatment 100% of the time. Or maybe when there is an infaust outcome our brains don't thoroughly recall all that well the 40 structures we contoured/volumized pre-treatment.

There was an ESTRO abstract this year, a randomized trial IIRC, of adaptive replanning in HNSCC. The volumes must frequently change in the 2-5mm range (or more) w/ adaptive replanning in HNSCC chemoRT. My impression of the study is that it was negative for benefits from implementing "2 to 5 mm differences" in volumes!
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I had one marginal recurrence with NSCLC that made me second guess my volumes but that is arguably less than 1% incidence. I think it is more relevant in toxicity. If you are off by 5 mm in contouring the esophagus with a central met getting hypofractionated tx… well, it’s hard to pretend that doesn’t matter.
 
RickyScott said:
2 fractions of hdr worked out so well that this trial was a given. True equipoise.These kind of trials are what make our field so special. Let’s get prostate sbrt down to 2!
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Isn’t there a horror movie where the guy has to start eating part of his body to survive
 
BobbyHeenan said:
When they figured out you can get treatment done in one week off of work away from your home. Your catchment area just went to infinity.
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Lot of lies there about cost and convenience. Could stay at home and continue work while getting 5 fractions of sbrt at home. I am sure New York Presbyterian charges a s load for sbrt prostate.
 
RickyScott said:
Lot of lies there about cost and convenience. Could stay at home and continue work while getting 5 fractions of sbrt at home. I am sure New York Presbyterian charges a s load for sbrt prostate.
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I can’t hate too much - at least they’re doing it on trial.

I’m interested to see PACE and GU -005 report though.

I feel like we’re still trying to figure out optimal 5 fraction dosing too. And do you escalate an mri detected nodule of interest? A lot of moving parts.
 
BobbyHeenan said:
When they figured out you can get treatment done in one week off of work away from your home. Your catchment area just went to infinity.
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That plus APM. A lot of people are preparing for a world of doing as little as possible to collect a fixed payment.
 
Neuronix said:
That plus APM. A lot of people are preparing for a world of doing as little as possible to collect a fixed payment.
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Lumpectomy cavity is a lot more foregiving than prostate. Should see 2 or single fraction. I think someone had preliminary data at estro for single fraction.
 
RickyScott said:
Lumpectomy cavity is a lot more foregiving than prostate. Should see 2 or single fraction. I think someone had preliminary data at estro for single fraction.
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Single fraction post-lump RT is a hot, trendy topic. It was hotter than DEI at ACRO. The cool kids do it with MRgRT, natch. I think they reported one local failure in 200+ patients at many years.
 
RickyScott said:
2 fractions of hdr worked out so well that this trial was a given. True equipoise.These kind of trials are what make our field so special. Let’s get prostate sbrt down to 2!
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I’m going to run a trial that will get it down to 0. Oh wait PROTECT…
 
RickyScott said:
2 fractions of hdr worked out so well that this trial was a given. True equipoise.These kind of trials are what make our field so special. Let’s get prostate sbrt down to 2!
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The equipoise question is the interesting one here, as I do not understand how they can say there is true equipoise between those two arms.
 
OTN said:
The equipoise question is the interesting one here, as I do not understand how they can say there is true equipoise between those two arms.
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My understanding is that the hdrx2 experience was both more toxic and less effective. Maybe they will try to claim that space oar reduces toxicity despite hdr dosimeteric advantage, but how can it possibly be more effective than hdrx2?
 
RickyScott said:
My understanding is that the hdrx2 experience was both more toxic and less effective. Maybe they will try to claim that space oar reduces toxicity despite hdr dosimeteric advantage, but how can it possibly be more effective than hdrx2?
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Someone is going to need to explain to me how HDR = SBRT, then, if that's their hypothesis.

Plus, as we've mentioned before ad nauseum here, you don't need SpaceOAR for 5 fractions. So, if you're placing it for 2 fractions, then we already have one of the arms of the trial with 100% grade 1 toxicity.
 
OTN said:
Someone is going to need to explain to me how HDR = SBRT, then, if that's their hypothesis.

Plus, as we've mentioned before ad nauseum here, you don't need SpaceOAR for 5 fractions. So, if you're placing it for 2 fractions, then we already have one of the arms of the trial with 100% grade 1 toxicity.
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I really don’t think they have a legitimate clinical hypothesis. This is marketing.
 
jondunn said:
I mean this exact statement could be made of anyone, wherever they work. It doesn't have anything to do with 'experts' or non-experts

the point is anybody anywhere should do more than the bare minimum of meeting the scorecard, if they can.
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Oh man

At risk of doxing myself, we recently implemented an automated breast tangent process. I was not in the initial pilot, but in the regular roll out

I rejected every single left heart dose that it auto planned for me. The computer planned to what was met the constraint, but not clinically acceptable given the circumstance. It was one frustration among many.
 
taserlaser said:
Oh man

At risk of doxing myself, we recently implemented an automated breast tangent process. I was not in the initial pilot, but in the regular roll out

I rejected every single left heart dose that it auto planned for me. The computer planned to what was met the constraint, but not clinically acceptable given the circumstance. It was one frustration among many.
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Hmmm your computers must have been trained by my Dosimetrists...
 
agreed, he really does some wild stuff, very interesting tweets
 
Palex80 said:
This guy's tweets are actually kind of fun to read...



What kind of a needle is that? 2 feet long?
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Wowsers. It almost looks like the poor patient had an industrial related accident and was speared with a long, hollow tube.
 
There is huge proton lobby money behind this , I have no doubt

However maybe it’s like APM - the proton lobby protects their interest but helps everyone else accidentally

 
One day he will have a tweet that sounds like it came from a normal person

 
udrag14 said:
I'm for this. Prior authorization are so stupid. Let's make more barriers for cancer patients who need urgent treatment.
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No one likes prior auth. With health care costs and prices already out of control, I doubt we could sustain a system without prior auth. At least when it comes to radiation, conventionally fractionated proton radiation would quickly be recommended for everything. Prior authorization is not the root of the issue. Upenn charging 300k to Pennsylvania employers for prostate proton is.
 
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My biggest problem with all of this "value-based" stuff is who decides what is "valuable" and how is it measured?

There are already enough factors out of our control impacting our patients' outcomes, our career satisfaction, and our salaries - let's just throw some more in there and be completely powerless!
 
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