Rad Onc Twitter

[sirspamalot]

CTCA went from a multi-billion dollar darling to... a cratered shell at 390m.

The pathetic nature of the radoncs that worked at CTCA were... amazing. And the shill and fringe nonsense that CTCA pushed was incredible. The founder (who was, by news reports, staunchly conservative) went thru a nasty divorce and got smoked. Double putz.

All in all, good riddance. Hopefully Hope will clean the mess up... maybe they bought an empty shell at pennies on the dollar..

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[Fpg1245]

CTCA went from a multi-billion dollar darling to... a cratered shell at 390m.

The pathetic nature of the radoncs that worked at CTCA were... amazing. And the shill and fringe nonsense that CTCA pushed was incredible. The founder (who was, by news reports, staunchly conservative) went thru a nasty divorce and got smoked. Double putz.

All in all, good riddance. Hopefully Hope will clean the mess up... maybe they bought an empty shell at pennies on the dollar..

I remember back in 97 when they were advertising on television and thinking wow that’s cool….****ing crooks

 

[pikachu]

I remember back in 97 when they were advertising on television and thinking wow that’s cool….****ing crooks

'97? I remember seeing their ads within the past 2 or 3 years. they seem to target ... low-information demos
(you might ask what i was doing watching fox news late at night, and the answer is elderly parents)

 

[communitydoc13]

they seem to target ... low-information demos

I never worked there, but there used to be a regional CTCOA and I shared some patients.

Their model was standard of care with lots of superficial, service type extras or fluffy stuff. (Booking plane tickets, transpo from airport, snacks, smiles, Disney model of excellent service, excellent telephone availability, massage, yoga, etc.). Of course, positive wallet biopsy required (right insurance or cash). Radoncs that I spoke to from CTCOA were not ridiculous or anything.

Never had them provide meaningful experimental therapy for a patient or enroll patient on clinical trial to my knowledge.

Many patients love this stuff BTW. Admins will be on docs tail regarding PG scores, but often, when you get granular, it's your front office staff or a terrible telephone service that's bringing scores down. (Not that PG very meaningful).

 

[sirspamalot]

Free coffee, quality snacks and a pleasant front desk person goes a VERY LONG WAY and yet.. how many places do this despite making MILLIONS in profit every year?

Can we get coffee service?

"Can't do it bro, COVID"

 

[medgator]

Free coffee, quality snacks and a pleasant front desk person goes a VERY LONG WAY and yet.. how many places do this despite making MILLIONS in profit every year?

Can we get coffee service?

"Can't do it bro, COVID"

We do the same for staff... Cases of coke zero, coke, Frito lays, cookies etc

 

[sirspamalot]

We have zero competition in the area, and I'm at (checks notes) about 20 people on treatment (highest: 24, lowest: 2) and we're busy. I am flat paid so it makes no difference financially to me but.... Staff get zinged out or shuffled elsewhere when volumes are low and its unfortunate, but they have no recourse as they either accept or move away. Feels bad man. Hospital is gonna Hospital. They stay, so it is what it is.

Patients are happy to not drive 100 miles to the next center. So, I guess no coffee and donuts it is..

 

[pikachu]

Many patients love this stuff BTW. Admins will be on docs tail regarding PG scores, but often, when you get granular, it's your front office staff or a terrible telephone service that's bringing scores down. (Not that PG very meaningful).

This is so true and so many places ignore it.

CTCA charged cash for all the fluffy stuff (massage, aromatherapy, etc.), correct?

 

[sirspamalot]

Some CTCA docs have migrated to Genesis. One particularly egregious one I can think of.. a total clown show. Uncertain training history. Bizarre personality issues. Pure crazy (I know the entire story), also.. saw it up close, not. good. Maybe Hope booted him, dunno. Genesis will take anyone who complies.

There are some true weirdo's in our field.

 

[metallica81788]

There are some true weirdo's in our field.

This cannot be understated enough, in all generations of our field (although I think it's slowly improving)

I always found it strange that we are dealing with a vulnerable patient population yet seemingly >75% of our doctors cannot even have a normal human conversation in or out of medicine

 

[sirspamalot]

I believe you meant overstated. I'm here to help.

It is -particularly- awful in academic radiation oncology. Raging narcissists who couldn't last a day in the surgical environment. Abusers having been abused, carrying on the tradition. Total psychopaths some of them. The stories..

Beware the 'small shop' looking for a replacement radonc in a smaller area "you can run the place as you see fit, I'm stepping away." Etc. All that matters is who owns what, and who really has control. If you can't get the bad apple out, the apple sauce will always be bad. The fun variant: the existing alpha looking for his biyatch. AVOID. Unless you know, you're into that sorta thing, which is fine. Everybody's fine..nothing wrong with that (ducks)..

 

[medgator]

CTCA charged cash for all the fluffy stuff (massage, aromatherapy, etc.), correct?

Yeah that's what I've heard. A lot of CAM in addition to standard radiation and chemotherapy

 

[radiaterMike]

feisty conversation going down on Twitter

 

[medgator]

feisty conversation going down on Twitter

Nice of EMT call out the boomerage going on over there...

 

[communitydoc13]

feisty conversation going down on Twitter

I'm as far out of the loop as can be. No connection to MSKCC whatsoever.

However, I'm going to go out on a limb, based on this work and some cryptic remarks about their phase II prophylactic bone met trial, and infer that they are going to publish soon some dose finding immunomodulatory work that tells us that somewhere in the 7-10 Gy/fraction is ideal for stimulating an immunologic response. (Throw in their CURB trial oligoprogressive breast and lung paper for good measure).

MSKCC doing good work on the RT in metastatic disease front.

 

[Fpg1245]

Nice to EMT call out the boomerage going on over there...

Ralph’s pathological need to be right even in cyberspace. When is the vascular dementia gonna kick in? That’s the Ralph I wanna hear.

 

[TheWallnerus]

Nice to EMT call out the boomerage going on over there...

Admins … thinking about changing my name from TheWallnerus to Mouth. Lemme know.

 

[RickyScott]

Frontal lobe dementia

 

[Palex80]

So, which NSCLCs do you want to resect?

TCs be like:

 

[medgator]

So, which NSCLCs do you want to resect?

TCs be like:

So dumb

 

[RickyScott]

So dumb

Already implemented at my hospital

 

[TheWallnerus]

Things are changing so fast in lung cancer. I always hypothesized that a shift toward Stage I at diagnosis (and epidemiologically this shift is totally happening) would mean less SBRT (after an initial growth spurt and once and if SBRT tech gets widespread uptake) for rad oncs. And, lo, we are losing steam in Stage III what with immuno and things like LungART. I’m just happy when I get a consult now.

 

[medgator]

Already implemented at my hospital

Aggressive ent and CT surgeons are ruining things for patients as bad as aggressive urologists have been....

 

[communitydoc13]

And, lo, we are losing steam in Stage III

I remain skeptical of the value of surgery in the vast majority of stage III lung CA in the community. My stage III pts are 10 years older than median for Pacific trial. Mediastinal failure remains a problem after surgery and IO helps remarkably with locoregional failure after chemoXRT.

Are we really going to push a 74 y/o (or 68 with marginal lungs) with gross mediastinal adenopathy to surgery with the knowledge of outcomes for concurrent chemoXRT and adjuvant IO? Never mind that these folks grow additional cancers with significant frequency.

We could even apply PIVOT prostate data to this type of insane thinking.

For my money, the two most impressive multimodality IO trials in solid tumors I can think of are Pacific and Checkmate 577 for esophagus. Those are some curves worth looking at.

 

[RickyScott]

Aggressive ent and CT surgeons are ruining things for patients as bad as aggressive urologists have been....

No one asks my input, but they have operated on 2 stage 3c patients with high pdl1 and tmb. Path was negative in both cases.

 

[RickyScott]

I remain skeptical of the value of surgery in the vast majority of stage III lung CA in the community. My stage III pts are 10 years older than median for Pacific trial. Mediastinal failure remains a problem after surgery and IO helps remarkably with locoregional failure after chemoXRT.

Are we really going to push a 74 y/o (or 68 with marginal lungs) with gross mediastinal adenopathy to surgery with the knowledge of outcomes for concurrent chemoXRT and adjuvant IO? Never mind that these folks grow additional cancers with significant frequency.

We could even apply PIVOT prostate data to this type of insane thinking.

For my money, the two most impressive multimodality IO trials in solid tumors I can think of are Pacific and Checkmate 577 for esophagus. Those are some curves worth looking at.

Preop is hot. If this holds up in other sites/studies, xrt could take a hit. I know p value does not reflect effect size, but this is still huge. Will see this trialed in esophagus within 5 years?

https://www.nejm.org/doi/full/10.1056/NEJMoa2211437

 

[BobbyHeenan]

I know this is not news and not feasible for all, but tumor boards are helpful for these stage III lungs.

Things I've already seen discussed and had to tell them that this didn't happen in the trial...and I have good med oncs and CT surgeons I work with, but enthusiasm sometimes gets ahead of evidence...:

1. patient's tumor is unresectable, but CT surgeon/med onc want neo to try to convert to resectable. That wasn't a thing on the trial
2. patient has a resectable lung tumor, but a mediastinal node in an area hard to reach/not resectable. It doesn't help us to leave gross disease in there.
3. Keep in mind that reports are now emerging that patient's s/p neoadj chemo/IO that then go on for XRT for whatever reason are showing higher pneumonitis rates. So while I don't think it's crazy to do chemo/IO and then XRT (if surgery is taken off table later)...it's really not ideal.

 

[RickyScott]

I know this is not news and not feasible for all, but tumor boards are helpful for these stage III lungs.

Things I've already seen discussed and had to tell them that this didn't happen in the trial...and I have good med oncs and CT surgeons I work with, but enthusiasm sometimes gets ahead of evidence...:

1. patient's tumor is unresectable, but CT surgeon/med onc want neo to try to convert to resectable. That wasn't a thing on the trial
2. patient has a resectable lung tumor, but a mediastinal node in an area hard to reach/not resectable. It doesn't help us to leave gross disease in there.
3. Keep in mind that reports are now emerging that patient's s/p neoadj chemo/IO that then go on for XRT for whatever reason are showing higher pneumonitis rates. So while I don't think it's crazy to do chemo/IO and then XRT (if surgery is taken off table later)...it's really not ideal.

Recent stage 3c pdl1 >50% in young pt. Surgey argued why not neoadjuvant then med and proceed to lobectomy if negrative. Not that unreasonable.

 

[sirspamalot]

Are you at a location where your referrals are dependent upon your Medonc's whims?

Then I already know how you will ultimately manage these patients. Checkmate, science.

 

[BobbyHeenan]

Recent stage 3c pdl1 >50% in young pt. Surgey argued why not neoadjuvant then med and proceed to lobectomy if negrative. Not that unreasonable.

Yeah, if the primary is especially bulky and nodes that are + are in standard mediastinal dissection procedure, I think surgery makes a lot of sense.

med oncs in my experience more than the surgeons are the ones to be overly enthusiastic about just starting neoadj chemo/IO before thinking it through.

 

[evilbooyaa]

Ralph’s pathological need to be right even in cyberspace. When is the vascular dementia gonna kick in? That’s the Ralph I wanna hear.

What more do you need to see? Clearly it's already in full swing.

 

[deleted1111261]

Jobs analysis is out. Embargoed til 3/8.
PDs apparently have access to the key findings / exec summary.

 

[Lamount]

@RickyScott I wouldn’t support that off trial. We have no data to support doing that… and level 1 data for CRT->IO. There is no reason to think outcomes would be better with surgery, so why do it?

 

[Gfunk6]

Jobs analysis is out. Embargoed til 3/8.
PDs apparently have access to the key findings / exec summary.

Two days to do damage control and spin doctoring is a tall order

 

[OTN]

Jobs analysis is out. Embargoed til 3/8.
PDs apparently have access to the key findings / exec summary.

But why?

 

[RO28]

 

[Fpg1245]

Jobs analysis is out. Embargoed til 3/8.
PDs apparently have access to the key findings / exec summary.

Gotta wait until the lemmings press submit on their match lists for RO.

 

[RickyScott]

@RickyScott I wouldn’t support that off trial. We have no data to support doing that… and level 1 data for CRT->IO. There is no reason to think outcomes would be better with surgery, so why do it?

They didnt ask my opinion. I have no idea if it is better or worse. Wouldn’t surprise me within several years they will be adding and stk11 or some other immune enhancer to the regimen.

 

[TheWallnerus]

They didnt ask my opinion. I have no idea if it is better or worse. Wouldn’t surprise me within several years they will be adding and stk11 or some other immune enhancer to the regimen.

I get the feeling neoadj chemoIO for “unresectable” lung is making thoracic surg “hot” again (their numbers have been pretty stable over last decade… may be getting ready to expand?)

 

[RickyScott]

I get the feeling neoadj chemoIO for “unresectable” lung is making thoracic surg “hot” again (their numbers have been pretty stable over last decade… may be getting ready to expand?)

They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.

 

[medgator]

They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the state 3 game within 10 years.

Totally practice dependent.... Honestly don't see this becoming widespread in community practice but who knows. The big difference between CT surgery vs ent/urology is that they don't control the flow of patients from diagnosis in my experience. Pulmonary does

 

[fiji128]

They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the state 3 game within 10 years.

That’s nonsense, what percentage of IIIa/b patients could even tolerate and or consent to surgical resection, maybe 20% at most 30%?

 

[Fpg1245]

That’s nonsense, what percentage of IIIa/b patients could even tolerate and or constant to surgical resection, maybe 20% at most 30%?

Thought leaders have to say controversial things so that people continue to listen to them. If his institution is consistently operating on these patients, then it says more about him than it does about the surgeons, who will literally cut everything if given the chance.

 

[TheWallnerus]

That’s nonsense, what percentage of IIIa/b patients could even tolerate and or constant to surgical resection, maybe 20% at most 30%?

Last time I was checking on this about 75% of Stage III is managed w/ RT now. Assume 100K new Stage III patients per year. Assume stage shift trends lower this by half over next 10 years and the 75% goes to 50% RT utilization. That means 50,000 less Stage III RT patients per year. Perhaps! (NB: I have no data to back this up but the medical operability rate in lung cancer patients in general should be going up, even in stage III, given the significant changes in stage incidences.)

 

[OTN]

They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.

If only that thought leader would think of doing a Phase III RCT to actually answer the question

 

[Ray D. Ayshun]

Well, perhaps he'll be outta the game bc it entails more than circling the white spiky thing and expanding it by 5 mm, and having to manage toxicities. Oh, the luxury of being a thought leader...

 

[RickyScott]

If only that thought leader would think of doing a Phase III RCT to actually answer the question

by the time it would come out, it would already be outdated by 5 other neoadjuvant pharma trials.

 

[Lamount]

They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.

Hmmm... I hear the concern, but I don't think this is the case.

The ability to run trials with CR as an endpoint doesn't really help T-surg so much as it helps med onc. Additionally 1 million radiation trials testing various sequencing of chemo, RT and IO, as well as second/third generation IO agents (what are we up to... PACIFIC 10?)

This is not pancreatic cancer where there are no cures without surgery. CRT -> IO works pretty well for LA-NSCLC and is the SOC... surgery is NOT SOC for multi station bulky N2 or N3 NSCLC. For surgery to unseat RT for multi station/bulky N2 or N3 NSCLC, they would need to show superiority in in a Phase III trial, testing chemo-IO -> Surg vs. CRT -> IO... and I don't see that happening anytime soon.

 

[Lamount]

by the time it would come out, it would already be outdated by 5 other neoadjuvant pharma trials.

Are you aware of any Pharma trials trying to convert unresectable to resectable? I am not. Nor is there much of an appetite for this in the cooperative groups.

 

[NotMattSpraker]

If only that thought leader would think of doing a Phase III RCT to actually answer the question

Seems like a no-brainer to re-run Albain with the modern regimens, but sadly I don't think we could accrue it in the US. Our biases are pretty embarrassing.