Rad Onc Twitter

[BobbyHeenan]

---

Members don't see this ad.

Supposedly optum/UH is getting into the proton game i am hearing so they might be playing ball in multiple ways. CVS was bought by Aetna and they have a former penn RO as rad onc medical director. There might be a lot more to the iceberg tip folks!

United has been in the proton game. They own Pro Health Proton Mgmt as a subsidiary...and is a major investor in the NY proton center.

Protons are blowing Rad Onc's boat out the CMS water

Ackerman Cancer Center, world's first private practice proton center They will treat your Dupuytren's contracture better than anybody (not with protons it appears, thank the Lord)

forums.studentdoctor.net

 

[TheWallnerus]

Hate the games, not the players. APM/payment bundles would kill the business model for Optum and evilcore, HealthHell overnight

Would love that!

 

[thecarbonionangle]

United has been in the proton game. They own Pro Health Proton Mgmt as a subsidiary...and is a major investor in the NY proton center.

Protons are blowing Rad Onc's boat out the CMS water

Ackerman Cancer Center, world's first private practice proton center They will treat your Dupuytren's contracture better than anybody (not with protons it appears, thank the Lord)

forums.studentdoctor.net

So now that UH is a player in protons does anyone know if they are approving protons for IMRT indications? Say prostate, lung, esophagus? Or are they only approving it at their centre? 😉

 

[jondunn]

So now that UH is a player in protons does anyone know if they are approving protons for IMRT indications? Say prostate, lung, esophagus? Or are they only approving it at their centre? 😉

Some dummies may bite on a UH job but it’s a clear okey doke and bait/switch!

 

[TheWallnerus]

So now that UH is a player in protons does anyone know if they are approving protons for IMRT indications? Say prostate, lung, esophagus? Or are they only approving it at their centre? 😉

From what I hear they are increasing proton approval for protons!

 

[BobbyHeenan]

From what I hear they are increasing proton approval for protons!

Not sure if joking or not but this is how I came to find out about UH and protons. A couple of colleagues had mentioned UH had become much more proton approval friendly, but they said off the cuff something like "probably because they are involved in the NY proton center."

Then others confirmed it as posted above.

 

[TheWallnerus]

Not sure if joking or not but this is how I came to find out about UH and protons. A couple of colleagues had mentioned UH had become much more proton approval friendly, but they said off the cuff something like "probably because they are involved in the NY proton center."

Then others confirmed it as posted above.

I am not joking

I am hearing from rad oncs in the United system that farther up the chain past the initial denial they are reversing proton denials more frequently with gusto; all the proton places need do is appeal the denial

 

[medgator]

I am not joking

I am hearing from rad oncs in the United system that farther up the chain past the initial denial they are reversing proton denials more frequently with gusto; all the proton places need do is appeal the denial

Heaven forbid they actually let you do a 3D plan or IGRT on a spine met between the kidneys, though

 

[thecarbonionangle]

Heaven forbid they actually let you do a 3D plan or IGRT on a spine met between the kidneys, though

But would they approve protons to avoid low dose kidney bath? You wouldnt want to bathe the kidneys, would you?

 

[jondunn]

But would they approve protons to avoid low dose kidney bath? You wouldnt want to bathe the kidneys, would you?

You’re very handy with the grift language

 

[communitydoc13]

Hot bath for the treatment of chronic renal failure​

Ting Ye 1, Weiping Tu, Gaosi Xu
Affiliations expand

• PMID: 24060101
• DOI: 10.3109/0886022X.2013.832318

Hells yeah I want to "bathe the kidneys"

 

[A_DeMichele]

This is a new one

that is so depressing

 

[jondunn]

 

[medgator]

Man u such a big rad onc fan, bro

 

[jondunn]

Man u such a big rad onc fan, bro

I more thought the step brothers comparison was funny. I’m imagining simul and like chirag shah double teaming interviews with Harvard

 

[Mandelin Rain]

Did medgator and jondunn just become best friends? YUP!!!!

 

[CurbYourExpectations]

Simul about radonc future:

Also Simul about radonc future:

 

[deleted1111261]

That's good, Larry!

 

[temujim]

me making 100k per year in rural idaho in 10 years:

100k in 10 years gonna be minimum wage. Sounds about right.

 

[Mandelin Rain]

100k in 10 years gonna be minimum wage. Sounds about right.

We'll be making median 350k and people will be saying how good we have it.

 

[Palex80]

Interesting! Just like Avelumab in JAVELIN, a further checkpoint inhibitor fails to improve outcomes when given together with RT+CT in unresectable LAHNSCC.

 

[TheWallnerus]

Interesting! Just like Avelumab in JAVELIN, an further checkpoint inhibitor fails to improve outcomes when given together with RT+CT in unresectable LAHNSCC.

Lots of fancy graphics and diagrams from very smart people have been shown to me and the world that radiation and IO was supposed to work and be very good.

Was I lied to? The graphics were very pretty and contained lots of alphabet soup.

It is funny now to see the “IO and RT works, but we are giving too much radiation to nodes” crowd. How many times have there been arguments on here that you MUST irradiate the nodes. Except, now you must not?

Cigarettes and tuna fish

 

[Palex80]

How many times have there been arguments on here that you MUST irradiate the nodes.

Only in breast, my friend. Only in breast.

 

[Fpg1245]

Interesting! Just like Avelumab in JAVELIN, a further checkpoint inhibitor fails to improve outcomes when given together with RT+CT in unresectable LAHNSCC.

It’s RTs fault that it didn’t work. Looking forward to them pushing the IO/CT —-> surg paradigm.

 

[TheWallnerus]

Only in breast, my friend. Only in breast.

It's all so intellectually specious and internally inconsistent.

To wit: again, how many times on here (and in life!) have people said IO, by itself, doesn't cure solid tumors. So that's one idea. Another widespread idea: doses of 50 Gy or so to normal appearing regions/nodes cure subclinical (ie less than "microscopic" amounts) solid tumor reservoirs. This is why people love irradiating so much normal tissue... er, I'm sorry, normal appearing nodes... in breast cancer e.g. Or in head/neck cancer!

Now... these two ideas can not mutually co-exist if all of a sudden you are saying RT to nodes that contain subclinical disease is bad, and we must instead let IO "carry that water." This is not too far off, for me, of "EndTimes" people who keep setting a date for the end of the world and when the end of the world doesn't arrive on cue they come up with a new explanation as why the End of the World was calculated incorrectly. You can never be wrong if you keep being wrong and have good explanations of why you're still right; Ralph "Oligomet" W, in my opinion, has become a poster child for this tactic.

 

[RickyScott]

It's all so intellectually specious and internally inconsistent.

To wit: again, how many times on here (and in life!) have people said IO, by itself, doesn't cure solid tumors. So that's one idea. Another widespread idea: doses of 50 Gy or so to normal appearing regions/nodes cure subclinical (ie less than "microscopic" amounts) solid tumor reservoirs. This is why people love irradiating so much normal tissue... er, I'm sorry, normal appearing nodes... in breast cancer e.g. Or in head/neck cancer!

Now... these two ideas can not mutually co-exist if all of a sudden you are saying RT to nodes that contain subclinical disease is bad, and we must instead let IO "carry that water." This is not too far off, for me, of "EndTimes" people who keep setting a date for the end of the world and when the end of the world doesn't arrive on cue they come up with a new explanation as why the End of the World was calculated incorrectly. You can never be wrong if you keep being wrong and have good explanations of why you're still right; Ralph "Oligomet" W, in my opinion, has become a poster child for this tactic.

Dont worry, FLASH will save us.

 

[Fpg1245]

Dont worry, FLASH will save us.

No that’s your career FLASHing

 

[thecarbonionangle]

The proton overlords have your back with FLASH, doncha worry folks!

 

[TheWallnerus]

The proton overlords have your back with FLASH, doncha worry folks!

There are many fancy graphics and diagrams put up on the projection screen by the FLASHers in their talks on FLASHing, too

 

[RickyScott]

It's all so intellectually specious and internally inconsistent.

To wit: again, how many times on here (and in life!) have people said IO, by itself, doesn't cure solid tumors. So that's one idea. Another widespread idea: doses of 50 Gy or so to normal appearing regions/nodes cure subclinical (ie less than "microscopic" amounts) solid tumor reservoirs. This is why people love irradiating so much normal tissue... er, I'm sorry, normal appearing nodes... in breast cancer e.g. Or in head/neck cancer!

Now... these two ideas can not mutually co-exist if all of a sudden you are saying RT to nodes that contain subclinical disease is bad, and we must instead let IO "carry that water." This is not too far off, for me, of "EndTimes" people who keep setting a date for the end of the world and when the end of the world doesn't arrive on cue they come up with a new explanation as why the End of the World was calculated incorrectly. You can never be wrong if you keep being wrong and have good explanations of why you're still right; Ralph "Oligomet" W, in my opinion, has become a poster child for this tactic.

Io/xrt is Rapidly evolving in breast cancer?

 

[TheWallnerus]

Io/xrt is Rapidly evolving in breast cancer?

"...the potential abscopal effect makes radio-immunotherapy a potentially powerful combination."

Promising abscopal in a paper makes it potentially powerful toilet tissue.

 

[Mandelin Rain]

Io/xrt is Rapidly evolving in breast cancer?

Depends on who's asking.

 

[Palex80]

Io/xrt is Rapidly evolving in breast cancer?

Yes. IO displaces XRT.
That's evolution.

 

[Ray D. Ayshun]

calling the use of io in X cancer an evolving issue is like saying the eye as we know it was just there one day in some prehistoric animal.

 

[jondunn]

 

[Lamount]

Lots of fancy graphics and diagrams from very smart people have been shown to me and the world that radiation and IO was supposed to work and be very good.

Was I lied to? The graphics were very pretty and contained lots of alphabet soup.

It is funny now to see the “IO and RT works, but we are giving too much radiation to nodes” crowd. How many times have there been arguments on here that you MUST irradiate the nodes. Except, now you must not?

Cigarettes and tuna fish

6+ weeks of RT destroys local immune response.

I think this is why 0617 showed worse control with dose escalation

 

[jondunn]

 

[GapCalc]

Cool for this med student but I literally cannot imagine this level of groveling except for the fact that we are The Least Desired Specialty.

 

[thecarbonionangle]

Would any of these “leaders” shill for warm bodies 10 years ago? They did not even know your name back then. You know the answer folks!

 

[grenz]

6+ weeks of RT destroys local immune response.

I think this is why 0617 showed worse control with dose escalation

Wouldn’t you then have expected the 60/15 arm to have better local control in the UTSW trial?

 

[Palex80]

6+ weeks of RT destroys local immune response.

I think this is why 0617 showed worse control with dose escalation

So, 74 Gy destroy it „more“ than 60 Gy?

 

[TheWallnerus]

6+ weeks of RT destroys local immune response.

I think this is why 0617 showed worse control with dose escalation

A few extra fractions of RT dinged the immune system versus all the concurrent systemic chemo? Like, 6+ weeks is bad but 6 weeks is good? What is the cell kill power of the immune system in tandem with radiation? Is it 2+2=4, or 5? If the dose is too high evidently it’s 2+2=3. Is there a Goldilocks dose where the RT is not too hot for the nodes/immune system, not too cold for the tumor… if so, please tell me what that dose is 😉

 

[Mandelin Rain]

A few extra fractions of RT dinged the immune system versus all the concurrent systemic chemo? Like, 6+ weeks is bad but 6 weeks is good? What is the cell kill power of the immune system in tandem with radiation? Is it 2+2=4, or 5? If the dose is too high evidently it’s 2+2=3. Is there a Goldilocks dose where the RT is not too hot for the nodes/immune system, not too cold for the tumor… if so, please tell me what that dose is 😉

Per the MRC in 1952, "it is generally agreed that in respect of immediate damage the lymphocytes are the most radiosensitive cells in the mammalian body."

 

[RickyScott]

A few extra fractions of RT dinged the immune system versus all the concurrent systemic chemo? Like, 6+ weeks is bad but 6 weeks is good? What is the cell kill power of the immune system in tandem with radiation? Is it 2+2=4, or 5? If the dose is too high evidently it’s 2+2=3. Is there a Goldilocks dose where the RT is not too hot for the nodes/immune system, not too cold for the tumor… if so, please tell me what that dose is 😉

And volume is going to be more important than dose for lymphocytes

 

[TheWallnerus]

View attachment 357486

You and I both know radiation kills white cells. How many lymphocytes does 60 Gy in 30 fx thoracic RT kill. If we did blood counts pre and post RT how much does lymphocyte count drop. Is lymphocyte count drop from definitive RT correlated with local control; you hypothesize yes, so why wouldn’t 50 Gy/25fx of thoracic RT be better than the current 60 Gy/30 fx. How much does lymphocyte count drop from 6 weeks of chemo; I think it’s more than RT, but yet adding lymphocyte-killing chemo with RT improves local control. So this “lymphocyte hypothesis” you have has some negating data going against it. More RT gives more LC seems to be a more reproducible thing versus less RT (allowing more lymphocytes) giving more LC. You and I also know RTOG 0617 is a bit of an outlier in the pantheon of NSCLC and RT dose trends.

 

[jondunn]

You and I also know RTOG 0617 is a bit of an outlier in the pantheon of NSCLC and RT dose trends.

Same thing seen in RTOG 1106

dose escalation in conv fractionation schemes does not work. Same thing seen in 60/15 vs 60/30 as well.

not an outlier.

 

[CaesarRO]

It's all so intellectually specious and internally inconsistent.

To wit: again, how many times on here (and in life!) have people said IO, by itself, doesn't cure solid tumors. So that's one idea. Another widespread idea: doses of 50 Gy or so to normal appearing regions/nodes cure subclinical (ie less than "microscopic" amounts) solid tumor reservoirs. This is why people love irradiating so much normal tissue... er, I'm sorry, normal appearing nodes... in breast cancer e.g. Or in head/neck cancer!

Now... these two ideas can not mutually co-exist if all of a sudden you are saying RT to nodes that contain subclinical disease is bad, and we must instead let IO "carry that water." This is not too far off, for me, of "EndTimes" people who keep setting a date for the end of the world and when the end of the world doesn't arrive on cue they come up with a new explanation as why the End of the World was calculated incorrectly. You can never be wrong if you keep being wrong and have good explanations of why you're still right; Ralph "Oligomet" W, in my opinion, has become a poster child for this tactic.

I think the dostarlimab data in locally advanced rectal cancer suggests that we may have been wrong assuming immunotherapy was like chemotherapy. It certainly seems like immunotherapy may have more ablative potential than previously realized. I don't think it's unreasonable to propose ways that radiation as done in the RT-alone era may impede the IO and work towards testing models of IO+RT that are complementary.

As new data comes in, it's worthwhile updating your prior assumptions.

 

[CaesarRO]

You and I both know radiation kills white cells. How many lymphocytes does 60 Gy in 30 fx thoracic RT kill. If we did blood counts pre and post RT how much does lymphocyte count drop. Is lymphocyte count drop from definitive RT correlated with local control; you hypothesize yes, so why wouldn’t 50 Gy/25fx of thoracic RT be better than the current 60 Gy/30 fx. How much does lymphocyte count drop from 6 weeks of chemo; I think it’s more than RT, but yet adding lymphocyte-killing chemo with RT improves local control. So this “lymphocyte hypothesis” you have has some negating data going against it. More RT gives more LC seems to be a more reproducible thing versus less RT (allowing more lymphocytes) giving more LC. You and I also know RTOG 0617 is a bit of an outlier in the pantheon of NSCLC and RT dose trends.

I think this is also being actively looked at as a previously unexplored area for RT.

Neutrophil-to-Lymphocyte Ratio predictive for outcomes in NSCLC Value of neutrophil-to-lymphocyte ratio for predicting lung cancer prognosis: A meta-analysis of 7,219 patients
Rationale for Lymphocyte Sparing RT in NSCLC Lymphocyte-Sparing Radiotherapy: The Rationale for Protecting Lymphocyte-rich Organs When Combining Radiotherapy With Immunotherapy - PubMed

 

[CaesarRO]

6+ weeks of RT destroys local immune response.

I think this is why 0617 showed worse control with dose escalation

I think it has more to do with compromising margins with the techniques used on that trial, but I do think there is much to explore re: RT effect on blood and systemic response

 

[RickyScott]

Btw neutrophil to lymphocyte ratio is basically a general predictor of health/inflammation in an aging population ie predicts heart attacks and stroke, so associating it with any health outcome is quite worthless. It’s like saying pts with better performance status do better.