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the breast trial just shows even more so why more people should adopt 5 fraction APBI. if you make your treatment as attractive as possible, it's easy for the multiD team to buy in to RT. anyone can tolerate daily 5 fraction Livi APBI. done in a week. counting the simulation it's like 2 hours total time in a dept.

5 fraction RT is better than 0 fractions.
 
jondunn said:
the breast trial just shows even more so why more people should adopt 5 fraction APBI. if you make your treatment as attractive as possible, it's easy for the multiD team to buy in to RT. anyone can tolerate daily 5 fraction Livi APBI. done in a week. counting the simulation it's like 2 hours total time in a dept.

5 fraction RT is better than 0 fractions.
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I agree with you but even 5 fraction will really hurt our field as breast is the number one definitive diagnosis and majority are early. This is not something I want to get ahead of.
 
RickyScott said:
I agree with you but even 5 fraction will really hurt our field as breast is the number one definitive diagnosis and majority are early. This is not something I want to get ahead of.
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Exactly and it wont stop the med oncs or surgeons trying to get rid of it anyway. You wont be rewarded for capitulating. Nothing will stop the trend of RO becoming pretty much a non contributor at all tumor boards.

If Astro is really concerned about peoples access to cancer care, rad onc should cease to be a stand alone specialty.
 
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RadsWFA1900 said:
Exactly and it wont stop the med oncs or surgeons trying to get rid of it anyway.
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I think this is highly dependent on your actual team. I started doing 5fx APBI when I started at my current job and the med oncs and surgeons have completely bought in. They even send me the >70 crowd who are technically candidates for omission to at least discuss with them based on how easy it is.
 
HolySmokes said:
I think this is highly dependent on your actual team. I started doing 5fx APBI when I started at my current job and the med oncs and surgeons have completely bought in. They even send me the >70 crowd who are technically candidates for omission to at least discuss with them based on how easy it is.
Click to expand...

5fx is already the SOC for all early stage. If I have to depend on my “team” for their buy in then it really isn’t a battle worth fighting.

How much “buy in” does the team need to give immuno or a few more cycles of folfox in a pancreas case?
 
pikachu said:
Can an uninsured patient even get through the door at Sloan?
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HolySmokes said:
I think this is highly dependent on your actual team. I started doing 5fx APBI when I started at my current job and the med oncs and surgeons have completely bought in. They even send me the >70 crowd who are technically candidates for omission to at least discuss with them based on how easy it is.
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I think wallnerus had made some modeling of what happens to volume when you go 5 fraction. Not good.
 
‘Exactly and it wont stop the med oncs or surgeons trying to get rid of it anyway’

Has not been my experience or many I know. Surgeons LOVE Livi. Omission discussions never happen now. 5 frac IMRT pays less but not that much less than 15 fx 3D.

Therapy staffing is an issue tho.

For now if you don’t I would offer it to anyone that meets omission critieria to nip that in bud
 
Re: getting these breast patients sent to you at all - there should be a multiD breast discussion where the patient sees surgery, medonc, radonc.

Yes it's annoying, but you tell the patient personally the value of what we offer instead of letting someone else drive the ship. I've been able to capture much more breast volume this way even at my community-ish satellite. With any regional/local competition, these are things patients care about when deciding where to go - it's a marketing tool.

If you have terrible surgeons you can only do so much, but I've seen improvement just over a few years with this model. Once you discuss the role even of 5fx vs omission, most patients will not opt for nothing.
 
It’s not both. Surgeon sees the patient and makes the call. If the surgeon doesn’t see the value in it then why would the patient?

It’s already happening where I am with med onc.

The discussion is irrelevant anyway because if you think about it even if you get to treat the patient or even increase your volume your center is still in worse financial shape with less therapists anyway. So end up getting stuck in a self destructive loop.

Then what happens, Radiation starts losing money which means it needs a subsidy from elsewhere. Subsidies become something for admin to minimize.
 
RadsWFA1900 said:
It’s not both. Surgeon sees the patient and makes the call. If the surgeon doesn’t see the value in it then why would the patient?

It’s already happening where I am with med onc.
Click to expand...

Okay
 
jondunn said:
Has not been my experience or many I know. Surgeons LOVE Livi. Omission discussions never happen now. 5 frac IMRT pays less but not that much less than 15 fx 3D.
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This has been my talking point in tumor board that I hit hard.

I bring up the "real world data" (haha couldn't resist) about poor compliance with 5 years of endocrine therapy, say something like "it would be awful if she recurs when she's 90, are we taking a 90 year old to the OR", and tell them Florence APBI or FAST is just an "absolute breeze" and even if she declines endocrine therapy or stops it early, the "benefit of radiation is hers for life".

It helps that I STRONGLY believe in this, and if it was my Mom, and she was 85 herself, I would encourage one of the 5-fraction regimens for her. The people pushing omission over ANY radiation...have they actually seen a local recurrence in a very elderly person? It's terrible. I wouldn't wish that on my worst enemy.

The majority of my breast patients are still getting 15 fractions to the whole breast, and then I "capture" a lot of patients with APBI or FAST, including the younger women who are seeing me as a second opinion and other docs in my region aren't offering it.

Now, obviously this is somewhat regional, because I'm not in a big city with 10 other departments I need to compete with. But with these various SBRT and hypofrac regimens (across all disease sites), my on-beam conversion rate is astronomical. I still have admin periodically making noise because our budget is built around the classic "number on beam" metric, but our "new start" number is 15% higher compared to a couple of years ago.
 
RadsWFA1900 said:
Is it really value to the patient we are demonstrating or to the surgeon?
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as jd said, both. if you don't think you should treat these patients, don't. I'm simply talking about the idea that a med onc is going to start telling 55 yos they don;t need RT. There's already a process in place in my neck of the woods to prevent this until after i retire should the data end up showing this is reasonable.
 
elementaryschooleconomics said:
This has been my talking point in tumor board that I hit hard.

I bring up the "real world data" (haha couldn't resist) about poor compliance with 5 years of endocrine therapy, say something like "it would be awful if she recurs when she's 90, are we taking a 90 year old to the OR", and tell them Florence APBI or FAST is just an "absolute breeze" and even if she declines endocrine therapy or stops it early, the "benefit of radiation is hers for life".

It helps that I STRONGLY believe in this, and if it was my Mom, and she was 85 herself, I would encourage one of the 5-fraction regimens for her. The people pushing omission over ANY radiation...have they actually seen a local recurrence in a very elderly person? It's terrible. I wouldn't wish that on my worst enemy.

The majority of my breast patients are still getting 15 fractions to the whole breast, and then I "capture" a lot of patients with APBI or FAST, including the younger women who are seeing me as a second opinion and other docs in my region aren't offering it.

Now, obviously this is somewhat regional, because I'm not in a big city with 10 other departments I need to compete with. But with these various SBRT and hypofrac regimens (across all disease sites), my on-beam conversion rate is astronomical. I still have admin periodically making noise because our budget is built around the classic "number on beam" metric, but our "new start" number is 15% higher compared to a couple of years ago.
Click to expand...

all that sounds nice but at the end of the day it’s revenues versus expenses that matter
 
Ray D. Ayshun said:
as jd said, both. if you don't think you should treat these patients, don't. I'm simply talking about the idea that a med onc is going to start telling 55 yos they don;t need RT. There's already a process in place in my neck of the woods to prevent this until after i retire should the data end up showing this is reasonable.
Click to expand...
Okay…glad to see you’ve worked out a process at your center in your particular state in your particular region with your referral base that probably won’t be widely applicable.
 
Sounds like you need to work with navigation and surgery to make things happen ensuring you see these patients upfront.
The hard work is getting them in - you can do whatever you wish from there.

Like I said, if the surgeon is terrible you're screwed, but don't hate on the whole process that others have established. 5fx > 0fx
 
metallica81788 said:
Sounds like you need to work with navigation and surgery to make things happen ensuring you see these patients upfront.
The hard work is getting them in - you can do whatever you wish from there.

Like I said, if the surgeon is terrible you're screwed, but don't hate on the whole process that others have established. 5fx > 0fx
Click to expand...


agree
 
RadsWFA1900 said:
Okay…glad to see you’ve worked out a process at your center in your particular state in your particular region with your referral base that probably won’t be widely applicable.
Click to expand...
I wouldn't say an official system. Surgeons are involved in the care of breast cancer patients, and generally they are the docs whose opinions carry the most weight with patients. In turn, med oncs convincing themselves that RT isn't beneficial in this population is infinitely less consequential than med oncs convincing surgeons, who tend to think more about LC and what it means wrt their surgical acumen.
 
jondunn said:
the breast trial just shows even more so why more people should adopt 5 fraction APBI. if you make your treatment as attractive as possible, it's easy for the multiD team to buy in to RT. anyone can tolerate daily 5 fraction Livi APBI. done in a week. counting the simulation it's like 2 hours total time in a dept.

5 fraction RT is better than 0 fractions.
Click to expand...

We’re just circling the drain. It’ll be 1 pretty quickly and then 0.
 
metallica81788 said:
Sounds like you need to work with navigation and surgery to make things happen ensuring you see these patients upfront.
The hard work is getting them in - you can do whatever you wish from there.

Like I said, if the surgeon is terrible you're screwed, but don't hate on the whole process that others have established. 5fx > 0fx
Click to expand...

Wow.

Clearly we view this problem very differently.

I think I realized something more important. None of this is gonna stop the train wreck that is rad onc or even slightly alter it. At this point, coming to terms with the fact that the knowledge I acquired is pretty much superfluous and being relegated to more of a car salesman than an oncologist is something I’m just going to have to accept if I want to stay in the field. You all seem very content with the referrings sending you scraps perhaps it just doesn’t sit well with me.

At this point, I have said all I’ve wanted to say on the subject of breast cancer and radiation oncology in general. My own short career in it has been nothing but a spectacular disappointment and a colossal waste of time.

Good luck to all of you as you navigate the shark infested waters of oncology! My writings on this forum have been a completely futile exercise.

And with that I say, good bye.
 
Medonc in the community is overwhelmed. Baby boomers hitting 75 with PCPs that no longer manage abnormal CBCs themselves means that heme consults can take 40-60% of new patient volume. Armies of APPs are needed. Maintaining patient satisfaction in a community medonc clinic is difficult. Cancer incidence increases into a person's 80s.

One of the easiest sites for us to manage definitively is low risk (Luminal A or similar) breast CA. Oncotype-DX could be used to indicate if a medical (heme-onc) consult is required at all or all further management could be through radonc (call it clinical oncology).

If I were in academic Radonc leadership, I would be looking at societal needs, medonc undersupply, radonc oversupply and gradual implementation of more comprehensive care by our field.

I don't think you would get much push back from community medonc (academics a different story) by offering this service. If you were to offer to workup an 80 y/o with anemia for them (which would be totally inappropriate) they probably wouldn't mind either.

Given the unique mindset radonc offers in terms of progressive oncology, the research opportunities are limitless: (AI q.o.d vs daily. You know, big science stuff).
 
Wow back.

If you've interpreted my experiences as saying everything is fine with radonc you're reading the wrong stuff. I'm just trying to make hay while the sun shines. If you're that discontent, enjoy retraining.

Certainly the field is not going in a good direction, but I'll do whatever I can to improve my situation and expect others to do the same. Unfortunately most of us will have little to no influence on the bigger picture and it's hard to change that.
 
Surgeons and med oncs here leave the omission discussion up to us. Do med oncs elsewhere argue that endocrine alone is better than RT alone for efficacy reasons (eg reduction of contralateral recurrence)?
 
thesauce said:
We’re just circling the drain. It’ll be 1 pretty quickly and then 0.
Click to expand...
The data for one fraction look very good. That data certainly look better than RT omission data.

There are various possible outcomes from here. None of them are good for the health of our specialty. Five fraction is very bad for the health of the specialty. I have “modeled” it, but it’s not rocket science. It means about 60-80% less breast cancer patients on beam per day. Breast cancer patients make up on average about 40 to 50% of all definitive patients under beam per day. Do people realize what an absolute death blow 5 fraction will be to smaller departments? They can not and will not survive. And one fraction will decrease your breast patient load by 80% versus 5 fraction…

So, again, possibilities/choices… Under APM, one and five fraction breast will become standards. If APM doesn’t happen, there will be slow continued resistance to 5 fraction. But there will be growing competition as larger centers bite the bullet and make it their standard, thereby slowly making it the standard everywhere. Which again means closures/job difficulties etc. (One percent of all breast patients/all stages get more than 15 fractions in the UK now, and 60% get five fraction… and ~none of the five fx pts get >26 Gy.)

Sharks and sea monsters, @RadsWFA1900
 
No question - if you are reliant on breast cases for your department/livelihood, you’re in big trouble.

One thing we have learned from the APM fiasco and really a multitude of examples over the years is that you cannot give someone an inch on you or they will take 50 miles. If you offer up a reduction in fractions, they (medonc, etc) will just capitalize on that and want fewer fractions or none. This has not been about the data for some time.
 
TheWallnerus said:
The data for one fraction look very good. That data certainly look better than RT omission data.

There are various possible outcomes from here. None of them are good for the health of our specialty. Five fraction is very bad for the health of the specialty. I have “modeled” it, but it’s not rocket science. It means about 60-80% less breast cancer patients on beam per day. Breast cancer patients make up on average about 40 to 50% of all definitive patients under beam per day. Do people realize what an absolute death blow 5 fraction will be to smaller departments? They can not and will not survive. And one fraction will decrease your breast patient load by 80% versus 5 fraction…

So, again, possibilities/choices… Under APM, one and five fraction breast will become standards. If APM doesn’t happen, there will be slow continued resistance to 5 fraction. But there will be growing competition as larger centers bite the bullet and make it their standard, thereby slowly making it the standard everywhere. Which again means closures/job difficulties etc. (One percent of all breast patients/all stages get more than 15 fractions in the UK now, and 60% get five fraction… and ~none of the five fx pts get >26 Gy.)

Sharks and sea monsters, @RadsWFA1900
Click to expand...
Yeah, I think this is "inevitable" as well. My breast solution, for example, of "15 fractions normally, 5 fractions to get patients I wouldn't otherwise get" - how long can I keep that going? 10 years? 30 years? 2 years? I don't know.

This also works for me because my Elder Partners established a culture of strong RadOnc influence in my hospital in particular. I'm not simultaneously fighting the battle of having my Zoom on permanent-mute at tumor board like I know happens elsewhere.

We're still in this weird transformation phase with academic (and corporate) entities gobbling up private practices as Boomer RadOncs decide to cash out the gravy train one last time. Turning what used to be one private practice doc making "classic" private practice money into two (or three!) docs making "academic satellite" money is giving us artificial elasticity.

Unfortunately, no one cared enough to get an accurate measurement of how many RadOncs are practicing out of how many departments (the best in the modern era mostly stems from a single dude making chaotic graphics in his free time on Twitter and SDN). We'll see what the "independent workforce analysis" says.

It's a race against competing factors: what will win?

Unless something changes, when you have all of our bread-and-butter patients getting significantly fewer treatments (or none at all) while we get reimbursed significantly less for the treatments they do get while we're producing a huge surplus of new RadOncs per year (200 new grads to 100 people leaving per best available data) while academic medical centers transform former private practices into "satellites" and pay people half (or less than half) of what used to be earned in that exact same location...where is the explosion?
 
TheWallnerus said:
The data for one fraction look very good. That data certainly look better than RT omission data.

There are various possible outcomes from here. None of them are good for the health of our specialty. Five fraction is very bad for the health of the specialty. I have “modeled” it, but it’s not rocket science. It means about 60-80% less breast cancer patients on beam per day. Breast cancer patients make up on average about 40 to 50% of all definitive patients under beam per day. Do people realize what an absolute death blow 5 fraction will be to smaller departments? They can not and will not survive. And one fraction will decrease your breast patient load by 80% versus 5 fraction…
Click to expand...
You just need to recommend more RNI. No 5 fractions when doing RNI (yet). 🙂
 
Huge numbers of breast patients needing RT and high utilization of RT in breast cancer didn’t become a thing until the early 90s. And it was all 6 week treatment. But when it came to be, it meant we needed a lot more rad oncs and the market kind of responded accordingly. The “demand pendulum” is rapidly swinging the other way… not back to pre-90s but about 80% of the way there.

Thoughtful analyses like this WILL NOT be in the ASTRO workforce analysis.
 
TheWallnerus said:
Huge numbers of breast patients needing RT and high utilization of RT in breast cancer didn’t become a thing until the early 90s. And it was all 6 week treatment. But when it came to be, it meant we needed a lot more rad oncs and the market kind of responded accordingly. The “demand pendulum” is rapidly swinging the other way… not back to pre-90s but about 80% of the way there.

Thoughtful analyses like this WILL NOT be in the ASTRO workforce analysis.
Click to expand...
2 million dollar a year Lou Potters says we should worry about patients not fractions.
 
TheWallnerus said:
Subjectively speaking, Stage I SABR has exploded. Stage IIi chemoRT has imploded. Stage III patients reimburse higher than stage I and utilize about 6 times as much linac time. The explosion and implosion are about equal in patient number intensity though. So rad onc is getting reimbursed less for lung cancer care, and the whole of rad oncs are working quite a bit less on treating lung cancer (the oversupply and dilution of labor force makes up a lot of this too).
Click to expand...
Imploded?

I am reluctant to be a naysayer as many concerns expressed on this forum have been borne out, however this has NOT been my experience at all. Firstly, the thoracic surgeons in my group are not particularly excited about operating following neoadjuvant IO because the mediastinum is a fibrotic mess... and I have heard others bring this up at meetings. Maybe there is some more excitement in the adjuvant setting, but neoadjuvant may be harder to implement than the data would suggest. Second, there is a HUGE jump from single station stage III -> multi-station and/or N3 disease. Third... there is no evidence that stage III patients getting neoadjuvant IO + surgery, or surgery + adjuvant actually do better than similar patients getting PACIFIC. Fourth... lung cancer is common, radiation oncologists are common... thoracic surgeons that are capable of competently performing lobectomy + MLND are not.

In my neck of the woods, I am begging my leadership to add another thoracic rad onc. Volumes never went down during COVID and have exploded since. Maybe it's just n = 1, but my personal experience suggests that your assertions are a bit hasty.
 
Lamount said:
Imploded?

I am reluctant to be a naysayer as many concerns expressed on this forum have been borne out, however this has NOT been my experience at all. Firstly, the thoracic surgeons in my group are not particularly excited about operating following neoadjuvant IO because the mediastinum is a fibrotic mess... and I have heard others bring this up at meetings. Maybe there is some more excitement in the adjuvant setting, but neoadjuvant may be harder to implement than the data would suggest. Second, there is a HUGE jump from single station stage III -> multi-station and/or N3 disease. Third... there is no evidence that stage III patients getting neoadjuvant IO + surgery, or surgery + adjuvant actually do better than similar patients getting PACIFIC. Fourth... lung cancer is common, radiation oncologists are common... thoracic surgeons that are capable of competently performing lobectomy + MLND are not.

In my neck of the woods, I am begging my leadership to add another thoracic rad onc. Volumes never went down during COVID and have exploded since. Maybe it's just n = 1, but my personal experience suggests that your assertions are a bit hasty.
Click to expand...

Your reasoning is sound and gives me hope on not losing out on stage III lung

Hopefully the people I work with will use similar reasoning...
 
Lamount said:
Imploded?

I am reluctant to be a naysayer as many concerns expressed on this forum have been borne out, however this has NOT been my experience at all. Firstly, the thoracic surgeons in my group are not particularly excited about operating following neoadjuvant IO because the mediastinum is a fibrotic mess... and I have heard others bring this up at meetings. Maybe there is some more excitement in the adjuvant setting, but neoadjuvant may be harder to implement than the data would suggest. Second, there is a HUGE jump from single station stage III -> multi-station and/or N3 disease. Third... there is no evidence that stage III patients getting neoadjuvant IO + surgery, or surgery + adjuvant actually do better than similar patients getting PACIFIC. Fourth... lung cancer is common, radiation oncologists are common... thoracic surgeons that are capable of competently performing lobectomy + MLND are not.

In my neck of the woods, I am begging my leadership to add another thoracic rad onc. Volumes never went down during COVID and have exploded since. Maybe it's just n = 1, but my personal experience suggests that your assertions are a bit hasty.
Click to expand...
Thoracic surgeons are not common because specialty had the smallest expansion in medicine. Both in the past and present, I have worked with thoracic surgeons comfortable operating after chemo/xrt - fibrosis not a huge issue for them. Ours are very much on board with upfront io. My worry if the generation of io trials is gving 35% path cr, what can we look forward to as this approach is optimized? Astro 2028- pet directed wedge resection after better io w/newer chemo? At the very least, you have to be open minded to a future existential threat.
 
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metallica81788 said:
Your reasoning is sound and gives me hope on not losing out on stage III lung

Hopefully the people I work with will use similar reasoning...
Click to expand...
Med onc told me at last week's tumor board they have no interest in io > surgery. This was unprovoked or maybe in the context of a stage iii lung. They don't really like dealing with the thoracic surgeons. I think that's one thing going against thoracic surgeons. Nobody really likes to talk to them.
 
Lamount said:
Imploded?

I am reluctant to be a naysayer as many concerns expressed on this forum have been borne out, however this has NOT been my experience at all...
In my neck of the woods, I am begging my leadership to add another thoracic rad onc. Volumes never went down during COVID and have exploded since. Maybe it's just n = 1, but my personal experience suggests that your assertions are a bit hasty.
Click to expand...
Just quoting NCDB/SEER data. Don't shoot the messenger.

www.bmj.com

Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study

Objective To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United States. Design Quasi-experimental study using Joinpoint modeling, multivariable...
www.bmj.com www.bmj.com

d0iK4Ky.png
 
TheWallnerus said:
Just quoting NCDB/SEER data. Don't shoot the messenger.

www.bmj.com

Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study

Objective To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United States. Design Quasi-experimental study using Joinpoint modeling, multivariable...
www.bmj.com www.bmj.com

d0iK4Ky.png
Click to expand...
What do you suppose those numbers are going to be from 2020 and beyond? How long do think it will take before we regain the ground we lost in screening? Lastly, how has RT utilization changed since the publication of PACIFIC?
 
Lamount said:
What do you suppose those numbers are going to be from 2020 and beyond? How long do think it will take before we regain the ground we lost in screening? Lastly, how has RT utilization changed since the publication of PACIFIC?
Click to expand...
Hypotheses non fingo

When looking at increasing use of SBRT in Stage I, it's been shown that the majority of this increased utilization has been in patients that would never have gotten any definitive treatment. That well is only so deep.

AEFDwzZ.png
 
Will be interesting to see if/how treatment for early-stage NSCLC changes when VALOR is published. (lobectomy vs SBRT)
 
Aphtalyfe said:
Will be interesting to see if/how treatment for early-stage NSCLC changes when VALOR is published. (lobectomy vs SBRT)
Click to expand...

Pessimistic thought:

If SBRT is equivalent the surgeons will just say the study is out of date because sub lobar is the new standard (see randomized trial from lobectomy vs. sub lobar).

Optimistic thought:
If equivalent a parental pulmonologist will refer directly to rad onc in borderline cases and ignore CT surgeon. This happens sometimes now in my neck of the woods, but typically CT surgery sees them all first. A lot of this depends on your CT surgeon...some just want to do hearts, but ones that are aggressive about cancer surgeries will be just that...aggressive. It's very surgeon/region dependent.
 
Aphtalyfe said:
Will be interesting to see if/how treatment for early-stage NSCLC changes when VALOR is published. (lobectomy vs SBRT)
Click to expand...
BobbyHeenan said:
If equivalent a parental pulmonologist will refer directly to rad onc in borderline cases and ignore CT surgeon.
Click to expand...

As I mentioned, Stage I is "exploding." Of course there are more complex things that can be said beyond that, but that is a fact. Rad oncs--in terms of raw MD numbers and number of RT centers--are well poised to absorb the explosion TBH... enormously unused bandwidth(s) at present. There could be 100% utilization of SBRT in Stage I (fantasy!), and Stage I could climb to 120K pts/yr (fantasy!), and that will wind up being just one new Stage I lung patient consult per rad onc every 3 weeks (by the time that could happen).
 
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