Rad Onc Twitter

[RickyScott]

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.

It depends what you mean by unresectable. 3c due to nodal involvement, but a small primary is very “resectavle” but traditionally surgey was avoided because the prognosis was poor. When the prognosis changes (pdl1>50 has high cr rate), the role of surgery will change as well.

Surgeons have a different mentality than us. When they start seeing 50% high pdl1+ pts having path cr, a lot of them will jump in and start operating. Minimally invasive lobectomy is not a very morbid procedure- probably less than 60-70 gy of radiation. I recall one survey by chest surgeons where 25% thought they should be the ones giving the immunotherapy.

I think radoncs get too focused on the studies. We can opine all we want on the flaws in a hodgkins study ommitting radiation, but at the end of the day xrt will still go bye-bye in that disease.

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[Doctorer]

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.

The pace of trial accrual in the US is pretty stunning in comparison to the European/Asian groups. I don't see it changing.

 

[elementaryschooleconomics]

I think radoncs get too focused on the studies. We can opine all we want on the flaws in a hodgkins study ommitting radiation, but at the end of the day xrt will still go bye-bye in that disease.

Trial data to your average RadOnc is like garlic to a vampire.

To everyone else in medicine, it's a flavor you can choose to use in a meal, based on the pairing and your personal tastes.

To us...well, you get the idea.

 

[Fpg1245]

Trial data to your average RadOnc is like garlic to a vampire.

To everyone else in medicine, it's a flavor you can choose to use in a meal, based on the pairing and your personal tastes.

To us...well, you get the idea.

May have something to do with where you reside in the referral chain.

If you control the patient, you can play fast and loose with the data if not you’re stuck encyclopedically reciting studies down to the subgroup analysis at tumor board just to compel a referral. Jokes on us.

When I was coming up, it was always be the smartest oncologist in the room and people will respect you. Which is pretty much like the old troupe about working hard to make your dreams come true. A lot of it is bull****, some people have the luxury of doing what they want and others have to stick to the letter of the law.

 

[sirspamalot]

 

[RickyScott]

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.

 

[TheWallnerus]

 

[Lamount]

View attachment 367374

My question to any surgeon convinced that you can turn unressectable to ressectable…

If a CR is really a CR, can’t we just omit surgery? *Ruh Roh*

 

[TheWallnerus]

My question to any surgeon convinced that you can turn unressectable to ressectable…

If a CR is really a CR, can’t we just omit surgery? *Ruh Roh*

Why does this strike me as an “If a tree falls in the forest and no one is around, does it make a sound” question. You can’t really know it’s a CR until you do the surgery, I hear them saying. “Nuke it/operate on it from orbit… it’s the only way to be sure.”

 

[Lamount]

Why does this strike me as an “If a tree falls in the forest and no one is around, does it make a sound” question. You can’t really know it’s a CR until you do the surgery, I hear them saying. “Nuke it/operate on it from orbit… it’s the only way to be sure.”

You really can’t know it’s ressectable than either 🤔

 

[NotMattSpraker]

"Almost all tumors are technically resectable" is like a Glaucomflecken line.

 

[TheWallnerus]

"Almost all tumors are technically resectable" is like a Glaucomflecken line.

All bleeding stops.

Everything is technically resectable.

We all have a terminal disease (life). And it’s sexually transmitted.

 

[communitydoc13]

Median age at diagnosis of stage III lung cancer from trials is 65-79 years old.

What is the life expectancy of this group independent of their NSCLCA diagnosis?

At what time point is it likely that OS curves are going to deviate between chemorads then IO vs whatever plus surgery?

We know that the initial survival curves are going to favor the non-surgical approach. They always do.

Surgery in the elderly should be limited to:

1. Procedures that are addressing an imminent threat to life (as in days to weeks): aortic dissection, active CAD, GB on the verge of sepsis

2. Procedure that will immediately improve quality of life: (ortho, TURP).

3. Oncologic procedures where reasonable alternatives are not available (see below).

How sh*%ty is even a chest tube in an elderly patient?

When I think of solid tumors where the evidence for the addition of surgery in terms of OS benefit is nil relative to alternative therapies, I think H&N (exempting OC and salivary), esophagus, cervical and anal CA, prostate and lung cancer.

Surgical disease? Melanoma (XRT helps almost none), colorectal, upper GI exempting gus, sarcoma and endometrial CA.

 

[TheWallnerus]

Median age at diagnosis of stage III lung cancer from trials is 65-79 years old.

What is the life expectancy of this group independent of their NSCLCA diagnosis?

At what time point is it likely that OS curves are going to deviate between chemorads then IO vs whatever plus surgery?

We know that the initial survival curves are going to favor the non-surgical approach. They always do.

Surgery in the elderly should be limited to:

1. Procedures that are addressing an imminent threat to life (as in days to weeks): aortic dissection, active CAD, GB on the verge of sepsis

2. Procedure that will immediately improve quality of life: (ortho, TURP).

3. Oncologic procedures where reasonable alternatives are not available (see below).

How sh*%ty is even a chest tube in an elderly patient?

When I think of solid tumors where the evidence for the addition of surgery in terms of OS benefit is nil relative to alternative therapies, I think H&N (exempting OC and salivary), esophagus, cervical and anal CA, prostate and lung cancer.

Surgical disease? Melanoma (XRT helps almost none), colorectal, upper GI exempting gus, sarcoma and endometrial CA.

I think I can argue signals for surgery adding to survival in lung and esophagus. Perhaps even prostate. We shouldn’t underestimate how much new targeted immunotherapies are going to change all our “old rules” though.

 

[communitydoc13]

I can argue signals for surgery adding to survival in lung and esophagus. Perhaps even prostate

There are signals, and the young should be considered for surgery for early stage lung and intermediate (some high risk) prostate cancer, as well as triple modality therapy for esophageal CA.

Competing risks are competing risks however, and 85% of our lung patients are one big competing risk.

Also, what are the targeted therapies and IO doing? What does effective systemic therapy do?

In prostate (I know I keep mentioning this), the best data for local therapy improving survival is in low burden metastatic disease with 55 Gy.

Do we need to surgerize these same patients?

But you and @RickyScott are right about clinical trials and the synergy of surgery and improved systemics in trialists minds.

I'm already seeing my future role in lung CA as treating oligoprogressive stage IV disease.

But, on a population based level, I think this is wrong in the present day. Lots of OR time spent, unnecessary treatment related M&M and rare benefit as we push for more oncologic surgery in the 75+ yo crowd.

 

[NotMattSpraker]

There are signals, and the young should be considered for surgery for early stage lung and intermediate (some high risk) prostate cancer, as well as triple modality therapy for esophageal CA.

Competing risks are competing risks however, and 85% of our lung patients are one big competing risk.

Also, what are the targeted therapies and IO doing? What does effective systemic therapy do?

In prostate (I know I keep mentioning this), the best data for local therapy improving survival is in low burden metastatic disease with 55 Gy.

Do we need to surgerize these same patients?

But you and @RickyScott are right about clinical trials and the synergy of surgery and improved systemics in trialists minds.

I'm already seeing my future role in lung CA as treating oligoprogressive stage IV disease.

But, on a population based level, I think this is wrong in the present day. Lots of OR time spent, unnecessary treatment related M&M and rare benefit as we push for more oncologic surgery in the 75+ yo crowd.

I think we will treat more and more stage I, but not enough to have a significant impact on most clinic volumes. While lung cancer is going down, Americans are aging and more sick, and lung screening is picking up.

 

[TheWallnerus]

Virtual Tumor Board: Resectable Stage III NSCLC | IASLC

In this Virtual Tumor Board episode of Lung Cancer Considered, host Dr. Stephen Liu and his guests discuss the dynamic topic of managing resectable stage III NS ...

www.iaslc.org

 

[TheWallnerus]

https://www.astrazeneca.com/media-centre/press-releases/2023/imfinzi-improved-efs-in-resectable-lung-cancer.html

 

[communitydoc13]

https://www.astrazeneca.com/media-centre/press-releases/2023/imfinzi-improved-efs-in-resectable-lung-cancer.html

Yes, yes, a million of these trials coming down the pipe. But what does the trial say about the value of surgery?

 

[TheWallnerus]

Yes, yes, a million of these trials coming down the pipe. But what does the trial say about the value of surgery?

It says the slope of the line plotting the incidence of using the words “resectable” and “stage III lung cancer” together in the same sentence versus time in oncology is positive.

 

[medgator]

Yes, yes, a million of these trials coming down the pipe. But what does the trial say about the value of surgery?

Rad oncs with a spine need to be speaking up at TB. Albain study pretty clear

 

[sirspamalot]

Rad oncs with a spine need to be speaking up at TB. Albain study pretty clear

Spine? Lol. Yeah maybe in academia they can do that without repercussion. But they won't. Meanwhile in PP land..

It takes the referral and it rubs it all over its bank account. What goes on in the basement is of no concern upstairs at most places.

 

[medgator]

Spine? Lol. Yeah maybe in academia they can do that without repercussion. But they won't. Meanwhile in PP land..

It takes the referral and it rubs it all over its bank account. What goes on in the basement is of no concern upstairs at most places.

Out in the real world, most CT surgeons aren't stupid enough to operate on bulky n2/n3 disease

 

[Mandelin Rain]

Out in the real world, most CT surgeons aren't stupid enough to operate on bulky n2/n3 disease

Academic Thoracic Surgeons ^^^

 

[deleted1111261]

Rad oncs with a spine need to be speaking up at TB. Albain study pretty clear

Clear that giving 45 Gy pre op is a joke and that pneumonectomies are bad.

 

[medgator]

Clear that giving 45 Gy pre op is a joke and that pneumonectomies are bad.

Overall survival benefit to surgery very unclear

 

[deleted1111261]

After 60-66 Gy, there aren’t good studies. This is the second place where I’ve worked where people still like to operate after full dose.

I think the people doing trimodality are not stopping at 45 Gy. And selecting better - avoiding pneumonectomies. I don’t know that surgery is dead. I think more to be learned. And hanging on to Albain is a little Boomerish.

Well selected patients randomized to 60 Gy with chemo + / - surgery and everyone gets Durva. That would be interesting.

 

[medgator]

After 60-66 Gy, there aren’t good studies. This is the second place where I’ve worked where people still like to operate after full dose.

I think the people doing trimodality are not stopping at 45 Gy. And selecting better - avoiding pneumonectomies. I don’t know that surgery is dead. I think more to be learned. And hanging on to Albain is a little Boomerish.

Well selected patients randomized to 60 Gy with chemo + / - surgery and everyone gets Durva. That would be interesting.

I think in large t3/t4 pts, absolutely a role, we aren't controlling those with chemorads. Bulky n2/n3 pts, no role imo

 

[NotMattSpraker]

I think in large t3/t4 pts, absolutely a role, we aren't controlling those with chemorads. Bulky n2/n3 pts, no role imo

This is true but I dont know that surgery does a better job than RT as a local modality. Look at Lung ART.

Today, Albain should do nothing but motivate people to want to run IO-surgery versus Pacific.

 

[sirspamalot]

Clear that giving 45 Gy pre op is a joke and that pneumonectomies are bad.

But 1+1 = 3 says the CT surgeon

aka 2 wrongs make a right

 

[medgator]

But 1+1 = 3 says the CT surgeon

aka 2 wrongs make a right

Nothing is worse than giving 45gy and then having +disease that has to be treated post op

 

[sirspamalot]

(Prostatic bed nods mournfully)

 

[Lamount]

Out in the real world, most CT surgeons aren't stupid enough to operate on bulky n2/n3 disease

Most referrals for lung on coming from CT surg... they are coming from pulm.

 

[RickyScott]

We have a

Most referrals for lung on coming from CT surg... they are coming from pulm.

i think it is very institutionally dependent. Ours perform a lot of interventional pulm such as ion bronch, lasers and stents etc. in last few years almost all our biopsies are coming from ion bronch

 

[NotMattSpraker]

Great results here. Im looking forward to the immuno SBRT studies resulting out.

 

[Radonc90]

Coming from a neurosurgeon (the Accuray man)...

 

[Mandelin Rain]

Coming from a neurosurgeon (the Accuray man)...

"Heels"?

Lars Leksell DIED in 1986. He invent radiosurgery in the latter 1940's I believe.

 

[TheWallnerus]

"Heels"?

Lars Leksell DIED in 1986. He invent radiosurgery in the latter 1940's I believe.

Radiosurgical outcomes sucked (vs now) until 3D planning became possible though; ie the advent of computerized TPSs using CT and MRI data (below: perils of biplanar angiography). And that didn’t happen until the 1990s. So kind of on heels

 

[Mandelin Rain]

We measure rapid medical advancement in DECADES

 

[Ray D. Ayshun]

Pretty soon an app will be doing SRS. And potentially even delivering it from an iPhone.

 

[RadOncDoc21]

Pretty soon an app will be doing SRS. And potentially even delivering it from an iPhone.

The iPhone won’t exist in the future… trust me I am 100% sure of this.

 

[Ray D. Ayshun]

The iPhone won’t exist in the future… trust me I am 100% sure of this.

Should I short Apple stock, or are you basing this on the Buddhist principle of impermanence?

 

[taserlaser]

Courtesy of Spraker and Reddit - good laugh

Diary of a Radiation Oncology Resident

 

[deleted1111261]

That was so good. I feel like I recognize the writing style, but cannot place it.

 

[Gfunk6]

Courtesy of Spraker and Reddit - good laugh

Diary of a Radiation Oncology Resident

This is awesome, thanks for posting

 

[medgator]

Courtesy of Spraker and Reddit - good laugh

Diary of a Radiation Oncology Resident

"4 days of clinic and drawing your own OARs? Sounds like a malignant program"

Comments are gold too

 

[Neuronix]

HAHAHAHAHAAHAHAH

I mean I am in academics, and this is accurate for some of the residents I've worked with.

I know SDN loves to hate on academics and academic attendings, but if I ever ask a resident to do more than they want to do there is hell to pay.

Also the Instragram part is golden.

"I wake up, go on a run by the water, making sure to post pictures to Instagram and twitter to remind everyone how my life is better than theirs." -- I literally have docs in other specialties asking me why our residents are posting from the gym/beach/wherever in the middle of the day. Amazing satire!

 

[RickyScott]

HAHAHAHAHAAHAHAH

I mean I am in academics, and this is accurate for some of the residents I've worked with.

I know SDN loves to hate on academics and academic attendings, but if I ever ask a resident to do more than they want to do there is hell to pay.

Also the Instragram part is golden.

"I wake up, go on a run by the water, making sure to post pictures to Instagram and twitter to remind everyone how my life is better than theirs." -- I literally have docs in other specialties asking me why our residents are posting from the gym/beach/wherever in the middle of the day. Amazing satire!

In all seriousness, that description was not too far off from my residency.

 

[CaesarRO]

Clearly I went to the wrong residency.

Needed to go somewhere with water.

 

[medgator]

HAHAHAHAHAAHAHAH

I mean I am in academics, and this is accurate for some of the residents I've worked with.

I know SDN loves to hate on academics and academic attendings, but if I ever ask a resident to do more than they want to do there is hell to pay.

Also the Instragram part is golden.

"I wake up, go on a run by the water, making sure to post pictures to Instagram and twitter to remind everyone how my life is better than theirs." -- I literally have docs in other specialties asking me why our residents are posting from the gym/beach/wherever in the middle of the day. Amazing satire!

During peak rad onc, there was hell to pay if you didn't staff every boomer attendings fu/clinic pt, also inpatients etc. Things have changed i guess with this buyers market