Rad Onc Twitter

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metallica81788 said:
This is me currently. I have a decent setup but still face outward pressure for another doctor when it's not even remotely needed. Only question is how long can I hold out on my own. My guess is <2 years. I was hoping for 5.
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yeah, we managed to get a decent contract with the recent renegotiation but I'm REALLY REALLY hoping that one of the geri-boomer decides to retire before we need to renegotiate again. I don't believe our current target is sustainable.
 
RO28 said:
yeah, we managed to get a decent contract with the recent renegotiation but I'm REALLY REALLY hoping that one of the geri-boomer decides to retire before we need to renegotiate again. I don't believe our current target is sustainable.
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Well, since the government can't go two days without finding something else to pointlessly throw tens of billions at and tanked geri-boomer's retirement accounts, the 20 million balance isn't cutting it like the 25 million balance used to. Scary times for them. So don't anticipate a wave of geri-boomer retirements with a prolonged economic downturn. Transition to semi-sentient octolocums is about the best you can hope for.

Bill Maher has a segment on his show called New Rules.
I like that show, So, New Rule: When a rental car agency will no longer rent a car to a rad onc because the actuaries have determined that it is too dangerous to do so, we should do the same when we hire out vacation coverage of our patients.
 
Moonbeams said:
Well, since the government can't go two days without finding something else to pointlessly throw tens of billions at and tanked geri-boomer's retirement accounts, the 20 million balance isn't cutting it like the 25 million balance used to. Scary times for them. So don't anticipate a wave of geri-boomer retirements with a prolonged economic downturn. Transition to semi-sentient octolocums is about the best you can hope for.

Bill Maher has a segment on his show called New Rules.
I like that show, So, New Rule: When a rental car agency will no longer rent a car to a rad onc because the actuaries have determined that it is too dangerous to do so, we should do the same when we hire out vacation coverage of our patients.
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oh no, I'm not expecting geri boomer to retire, its just ya know those wishful thinking day dreams. How is geri-boomer going to pay for remodeling the second vacation home they bought if they don't keep the 37/15 bone met reel going.
 
What is the general opinion on posting about one’s personal life on Twitter? It feels odd, but I don’t know if it’s just because I only follow people who use it professionally.
 
jondunn said:
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I have never done IMRT for a T1-T2 glottic cancer. In fact, I can count on one hand how many of them I've seen through a decade of training and practice. It's not my hill to die on, but I'd much rather receive a highly conformal/homogeneous plan with tissue sparing and daily CBCT rather than just using an ancient technique because it works.

I get the point Bates is trying to make, but while this may be considered an experimental indication, IMRT is far from an experimental technique. Protons are an experimental technique with significant uncertainties. There is a non-zero risk of causing catastrophic esophageal perforations/bleeding/TE fistulas/strictures due to range uncertainties with protons that I wouldn't worry about with IMRT.

Again, not saying I am pro IMRT for early glottics, but I'm not going to poo-poo the community doc for doing it either.
 
RSAOaky said:
Again, not saying I am pro IMRT for early glottics, but I'm not going to poo-poo the community doc for doing it either.
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Idk if they were poo-pooing the community doctor but OTOH it's a glaring sin of omission not picking on/poo-pooing a much bigger target (ie MDACC). (It's possible the community doctor might have invented 3-field IMRT and MDACC copied the technique. Who knows.)

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I have treated 2 t1 glottics this year with imrt. No problems with insurance. Planning a 3rd right now. We will see what happens. Imrt allows for great sparing of the carotids, and these patients are smokers with a very good cancer prognosis. I really don't know why anyone would poopoo imrt in this case. It would be my choice if I had the same diagnosis.
 
madchemist89 said:
I really don't know why anyone would poopoo imrt in this case
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Appears to come down to: with laterals, we treat some involved LNs, and if you don't do that patients have recurrences. It is one of the stupider arguments to use an old technique vs IMRT technique I have heard in a long time... one I didn't even know existed. Appealing to the fear of laryngeal motion seems a smarter tack. Either way, anti-IMRT rants always boil down to fear-stoking: fear of motion, fear of missing erstwhile covered targets (magical thinking!), fear of billing, etc. Not a single, solitary clinical anti-IMRT rant of the past or present has ever been borne out to be true. Who thinks that the evidence for IMRT in breast cancer is "weak" still? If you think this you are an unserious person at best or have an agenda at worst; and you'd better stop IMRT for everything else because the evidence for IMRT is weaker for every other disease site versus breast. The evidence for IMRT in glottic is good. Yet even if there were ZERO evidence, why would you aim beams directly into normal carotid arteries if you didn't have to? I need a trial for that?

Will American rad onc ever quit embarrassing itself over anti-IMRTism? Probably not.

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So based off of "this is just how we do things, IMRT bad" and potential recurrence for an area we don't even contour or care if it gets dose in this particular scenario... let's continue to use 3D in a disease site we use IMRT for everything else
I don't care about carotids, honestly, it's just a better plan

Anecdotally I've been extremely happy with my few IMRT early glottic plans vs prior lateral plans, so much less toxicity
 
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I dont mind IMRT for glottic, but it's not for carotid sparing reasons. We never care about carotid dose in the other 99 percent of our head and neck cases! I think it's sort of dramatic to make a big deal about it for these cases.

It's more just to better control homogeneity of dose, spare skin, ability to better spare constrictors if you want to be tight with it, flexibility if you want to do something more than just treat the glottis (maybe one cord)

I mostly do 3D though but am open to moving over if insurance will pay
 
jondunn said:
I dont mind IMRT for glottic, but it's not for carotid sparing reasons. We never care about carotid dose in the other 99 percent of our head and neck cases! I think it's sort of dramatic to make a big deal about it for these cases.

It's more just to better control homogeneity of dose, spare skin, ability to better spare constrictors if you want to be tight with it, flexibility if you want to do something more than just treat the glottis (maybe one cord)

I mostly do 3D though but am open to moving over if insurance will pay
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If treating nodes, then carotids are in the target volume, making sparing impossible. Plus, many of our head and neck patients are unlikely to survive long enough to develop late sequelae related to treatment.
 
madchemist89 said:
If treating nodes, then carotids are in the target volume, making sparing impossible. Plus, many of our head and neck patients are unlikely to survive long enough to develop late sequelae related to treatment.
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?

Head and neck treatment is mostly for long term cure.
 
TheWallnerus said:
Idk if they were poo-pooing the community doctor but OTOH it's a glaring sin of omission not picking on/poo-pooing a much bigger target (ie MDACC). (It's possible the community doctor might have invented 3-field IMRT and MDACC copied the technique. Who knows.)

7eMaWdb.png
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I have had a great experience with imrt for many years. I think many other large centers like mskcc also use imrt for t1 larynx
 
Seems like there are two questions here:
1) Is IMRT helpful for early stage glottic... I would guess, probably yes. Any time we are using high doses, it's nice to minimize hotspots and make treatment as conformal as possible
2) Can you reasonably spare carotids while treating nodes? This one, I don't really know... as I don't do much H&N. It seems tricky, given that the nodal volumes surround the vessels. For those who do attempt to spare carotids, how do you constrain dose?
 
metallica81788 said:
I don't care about carotids, honestly, it's just a better plan
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jondunn said:
I dont mind IMRT for glottic, but it's not for carotid sparing reasons. We never care about carotid dose in the other 99 percent of our head and neck cases!
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madchemist89 said:
If treating nodes, then carotids are in the target volume, making sparing impossible.
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Here is one head/neck ca scenario where we have the luxury to care about the carotids. Why not indulge it. Head/neck RT is a known risk factor for carotid stenosis; can be increased by as much as 25-30% at 5 to 10 years. It's not a slight risk that carotid RT imparts. People used to talk about carotid RT risks; it's been pretty well studied IMHO. As we all know, some people recommend routine US screening after H&N RT. We know RT in the neck ups the risk of stroke significantly; even lower-than-SCC dose neck RT ups the stroke risk. Non-invasive reversal of RT-related disease doesn't work. The only thing the rad onc has at hand is a technology/technique to lower carotid RT doses. Granted, early glottic+RT is not that common, but carotid avoidance seems (at least potentially) to be very high value care.

SapZvjF.png
 
Lamount said:
Seems like there are two questions here:
1) Is IMRT helpful for early stage glottic... I would guess, probably yes. Any time we are using high doses, it's nice to minimize hotspots and make treatment as conformal as possible
2) Can you reasonably spare carotids while treating nodes? This one, I don't really know... as I don't do much H&N. It seems tricky, given that the nodal volumes surround the vessels. For those who do attempt to spare carotids, how do you constrain dose?
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you would not/could not spare carotids in ENI situations. Glottic is one HN situation where there is no ENI.
 
radiation said:
The nodal recurrence argument is so dumb - if you are worried about nodal recurrence with imrt, then treat the nodes intentionally! I hate the “accidental” nodal coverage technique, the breast people are notorious for this
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Elective nodal coverage dose for T3N1 glottic: 50 Gy/25 fx (or 56 Gy/35 fx)
Elective nodal coverage dose for T1N0 glottic: 63 Gy/28 fx
 
TheWallnerus said:
9LZCO3j.png
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Chera obviously knows substantially more about treating H&N than I do, but this is a bullsh*t argument. I definitely agree that the stroke risk is dramatized but the risk of nodal involvement for a true glottic cancer is <5%. The fact that an antiquated treatment incidentally treats lymph node levels with a <5% risk of involvement doesn't mean that it's the right thing to do. If that was our approach to head and neck we'd be treating BL IB-V for everyone.
 
Speaking of IMRT larynx, has anybody seen laryngeal edema on treatment with 225/fx? I do this all the time but I have a guy on treatment now closing up I'm actually worried about his airway. Put him on a break and steroids with improvement, but nervous about restarting. Never seen this before. Usually people sail through.
 
Moonbeams said:
Speaking of IMRT larynx, has anybody seen laryngeal edema on treatment with 225/fx? I do this all the time but I have a guy on treatment now closing up I'm actually worried about his airway. Put him on a break and steroids with improvement, but nervous about restarting. Never seen this before. Usually people sail through.
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hes prob smoking through tx

usually i dont break though, steroids are fine. would only stop if was actually becoming symptomatic

more common to see edema post-tx when people are smoking
 
Moonbeams said:
Speaking of IMRT larynx, has anybody seen laryngeal edema on treatment with 225/fx? I do this all the time but I have a guy on treatment now closing up I'm actually worried about his airway. Put him on a break and steroids with improvement, but nervous about restarting. Never seen this before. Usually people sail through.
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You treating laterals or IMRT
 
Lamount said:
Seems like there are two questions here:
1) Is IMRT helpful for early stage glottic... I would guess, probably yes. Any time we are using high doses, it's nice to minimize hotspots and make treatment as conformal as possible
2) Can you reasonably spare carotids while treating nodes? This one, I don't really know... as I don't do much H&N. It seems tricky, given that the nodal volumes surround the vessels. For those who do attempt to spare carotids, how do you constrain dose?
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How I do it:

Carotids:
Max: 62 if treating to 63, 64 if treating 65.
V35 < 25%
V50 < 5%

Contour GTV, as long as away from Carotids, crop 2mm off PTV extending inside.

Will also constrain thyroid and attempt to keep hotspots off esophagus.
 
RSAOaky said:
Chera obviously knows substantially more about treating H&N than I do,
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Does he???
RSAOaky said:
I definitely agree that the stroke risk is dramatized
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Is it? If the stroke risk is just 1% higher, and it's avoidable.....
RSAOaky said:
risk of nodal involvement for a true glottic cancer is <5%
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If you scrounge around, LN involvement in early glottic is surprisingly >>5%. However the recurrence risk is <5%. There are SO many situations in rad onc where we find the nodal involvement risk is greater than the nodal recurrence risk. I feel there is a deeper lesson from this commonly found thing that we haven't learned/exploited.
 
TheWallnerus said:
Does he???
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I'm flattered you think so highly of me!
...but yes.
TheWallnerus said:
Is it? If the stroke risk is just 1% higher, and it's avoidable.....
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TheWallnerus said:
If you scrounge around, LN involvement in early glottic is surprisingly >>5%. However the recurrence risk is <5%. There are SO many situations in rad onc where we find the nodal involvement risk is greater than the nodal recurrence risk. I feel there is a deeper lesson from this commonly found thing that we haven't learned/exploited.
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Decisions decisions...do I base my treatment technique on the SEER study indicating a a 1.5% increased risk of CVA at 15 years or the NCDB study saying that there is actually a > 5% risk of LN involvement for true glottic larynx?
 
IMRT works great for early-stage glottis cancer.

I switched over a few years ago. Skin reaction better in the short- and long-term. Hotspots out of non-target tissues.

Wanting to cover elective nodes in early stage glottis would be an argument for IMRT, not against.

How would patients feel if they found out their doctor was choosing a cheaper treatment which may have worse side effects in order to save payors/society money? That dog would not hunt in Texas. At all.
 
OTN said:
IMRT works great for early-stage glottis cancer.

I switched over a few years ago. Skin reaction better in the short- and long-term. Hotspots out of non-target tissues.

Wanting to cover elective nodes in early stage glottis would be an argument for IMRT, not against.

How would patients feel if they found out their doctor was choosing a cheaper treatment which may have worse side effects in order to save payors/society money? That dog would not hunt in Texas. At all.
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Haha. Don't disagree. Saying we should stick to lats for this reason is like admitting to not doing much thinking when it comes to target delineation. Basically, saying that sloppy planning let's us sleep better at night as we're covering things we're not targeting and not targeting things that don't "need" to be targeted. We get to be simultaneously liberal and conservative.
 
‘How would patients feel if they found out their doctor was choosing a cheaper treatment which may have worse side effects in order to save payors/society money?’

Some would say you should refer all of your head and neck patients to Dallas or houaton for proton

Why aren’t you? Just to save society money?!!
 
jondunn said:
‘How would patients feel if they found out their doctor was choosing a cheaper treatment which may have worse side effects in order to save payors/society money?’

Some would say you should refer all of your head and neck patients to Dallas or houaton for proton

Why aren’t you? Just to save society money?!!
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Some might say that, but there is no data which has convinced me this is true.
 
Ray D. Ayshun said:
How is sparing the carotids gonna prevent them from dying in a mass shooting?
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Longer time on the treatment couch —> Shorter time outside of it and thus at risk of getting shot at.

Unless a therapist shows up at work with an AR-15 because you promised all your patients they would get a 10:00 am treatment slot. Choose wisely!
 
jondunn said:
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People copying TheWallnerus's fascination w/ futile factoids?

TheWallnerus approves.

This slide tho... it's "literally" a dog whistle.

EDIT: I had an esprit d'escalier... "Do Rhodesian Ridgebacks Have Better Access to Radiotherapy Than Rhodesians?"
 
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SubserviantToABR said:
Oh man, I would love to hear what happened between Dr. Winkfield and ASTRO. I have my suspicions but love to hear the truth.
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Speaking of ASTRO, they are very persistent to get your money but doesn't seem like they're persistent in doing anything but to maintain the status quo:
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