Rad Onc Twitter

[Fpg1245]

We are in a pickle of sorts.

I strongly believe that protons have been oversold since the mid 2000s and their further adoption has been strictly cultural and economic and not based on good science.

But, if a new radonc intervention was developed, which was appreciably better than the standard of care, yet required the type of high capital investment and physics expertise that a community practice isn't gonna have, I would also probably want to crap on it.

If only we were developing pills, and the care model was in general community practice with academic expertise reserved for clinical trial type work.

And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)

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[sirspamalot]

Meat on the Machine

I heard that was, ironically, the next album title from Metallica.

 

[thecarbonionangle]

Meat on the Machine

I heard that was, ironically, the next album title from Metallica.

Back in high school, a friend of mine had a band called “smile in the ice machine”. Similar concept. The meat has to be moved. Plenty of slime in our field. You betcha!

 

[NotMattSpraker]

And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)

At least medical oncology and pharma runs the trials. They aren't good trials, but they go through the motions to generate a piece of evidence.

In 2008, two guys from Harvard and MDACC literally wrote an editorial that we do not need RCTs for protons, the benefit is self-evident. It is embarrassing.

 

[medgator]

And it won’t be. The best you can hope for is becoming a cog in the academic profit machine under the guise of quality.

I’m post EBM at this point. I don’t care about the science anymore. I only care about job security and putting meat on the machine. If it means endorsing proton or MRIL without the most rigorous of tests fine. You want precedent for this type of behavior? (See literally every other field)

Modality shaming needs to become a thing like fraction shaming, esp given the shameless push by protonistas in ASTRO with this most recent statement being put out.

ASTRO was happy to push less fractions to screw over community centers, but ignore costs of cares and financial toxicity at many of their member centers that were delivering shorter courses of treatment.

The emperor has no clothes

 

[sirspamalot]

And so in the great book of academic radonc.. another chapter closed. I hope I retire long before FLASH puts the final dagger in and twists.

 

[Lamount]

I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense

 

[Fpg1245]

I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense

So they get an extra 2K a year in their paycheck for all this ****. If I remember Neha is at Penn and they are more than keen on using extenders for all kinds of stuff (see radiology)

 

[NotMattSpraker]

I don’t know about anyone else, but I don’t think this can translate into any REAL changes…

“they can lead image review, specific technical and/or clinical procedures, patient education and follow-up, clinical markup of treatment sites, care coordination, knowledge translation, research, and participate in clinical leadership”

…aren’t they doing that stuff already?

“Limited prescribing” sounds suspiciously like giving patients moisturizer

Seems more like they are trying to dress up the RTT role with a whole load of jibberish to entice more people train as RTTs. The RTTs I know are too bright to fall for this nonsense

The best use I have personally seen was an RTT doing OAR contours for on-table adaptive cases. I worked with and without them and my ability to be happy covering adaptive cases went off a cliff without the ARTT. A supportive leadership would encourage departments to create a Rad Onc FTE to support implementation of on-table adaptive, but you know, ASTRO gonna ASTRO. So, that is one single use of an RTT that I think is outside their usual scope and deserves extra pay.

I bet there are a lot of interesting uses in countries that are either resource or bandwidth constrained that make a lot of sense.

My sense is we need more RTTs in the US and we need to encourage hospitals to treat them better. Maybe more than we need Penn to become more profitable. But what do I know. This is why I will never be ASTRO president or Red J EIC.

 

[medgator]

 

[Fpg1245]

A 40 percent discount and still not low enough? What do they think RO APM will bring?

 

[elementaryschooleconomics]

A 40 percent discount and still not low enough? What do they think RO APM will bring?

RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.

It's why the GAO report from 2015, showing a half a billion dollars in savings if PPS-exempt status was ended...fell by the wayside in favor of pursuing this boondoggle with a potential savings of only $40 million....but all on the backs of the community.

Do I think there's some nefarious, overarching plot here?

Nah.

But ASTRO is really "it" in terms of American RadOnc professional societies, and it's run mostly by folks from PPS-exempt centers with protons.

No one votes against their own interests.

 

[grenz]

RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.

It's why the GAO report from 2015, showing a half a billion dollars in savings if PPS-exempt status was ended...fell by the wayside in favor of pursuing this boondoggle with a potential savings of only $40 million....but all on the backs of the community.

Do I think there's some nefarious, overarching plot here?

Nah.

But ASTRO is really "it" in terms of American RadOnc professional societies, and it's run mostly by folks from PPS-exempt centers with protons.

No one votes against their own interests.

APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.

 

[RickyScott]

Medicare cuts primarily affect independent centers and small community hospitals. Big centers leverage their size to negotiate increasing prices anyway. Astro will pay lip service to Medicare cuts but at the end of the day, the large universities still take in 10x cms.

 

[Fpg1245]

APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.

Bundled payments won’t help rad onc despite decreasing fractions. It just won’t. If it did they wouldn’t be asking for a proton exemption. They’ll hold you to a number and then continue to ratchet it down for the same reason. They’ve already bled RO over the last 10 years. “Stabilizing” payments is completely meaningless in this environment. They aren’t stable they just continue to fall.

Increasing PCP reimbursements is a distraction. Makes it sound like they are doing something noble with the money by helping out lowly underpaid front line medicine. The reality is there are too many providers out there (MD DNPs PAs) to appreciably move the needle for them and the hospital networks most of them work for will never make up declines in procedural income with extra time billing codes.

 

[sirspamalot]

No one votes against their own interests.

 

[NotMattSpraker]

APM as proposed by ASTRO was good policy and would have stabilized payments. Medicare’s version was terrible and they weren’t willing to listen to any stakeholders. I don’t know how it gets done, but we need a bundled payment system as fx inevitably go down and Medicare remains revenue neutral while also increasing primary care reimbursement.

What do you think would have happened if ASTRO went in and offered to include proton therapy? I'm just curious. The fact is, it's very expensive for medicare among Rad Onc costs.

I've spent a lot of time talking to ASTRO reps about their APM proposal and what they were unhappy about. It never really matched what doctors were unhappy about, see Join Luh's editorial for an example. No one ever brought up protons. 🤷‍♂️

 

[sirspamalot]

Those who have take from those who don't, cause those that don't have.. can't take from those that have.

-Protons, 2023

ps. Bragg that ass up let me see whatchu got!

 

[Gfunk6]

RO-APM was performative and meant to further consolidate power among the PPS-exempt centers.

It's why the only clinical advisor for CMS was from Anderson.

This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.

 

[Fpg1245]

This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.

I don’t like to gloat but serious Medicare drug negotiation (unlike in current form) would bring down drug costs but it is likely to be disappointing to those who thought radical savings were just around the corner

The problem I’ve noticed is that the big spenders rarely get touched. It’s the smaller less powerful and costly ones that get squeezed the most.

 

[Mandelin Rain]

The problem I’ve noticed is that the big spenders rarely get touched. It’s the smaller less powerful and costly ones that get squeezed the most.

...and this is how capitalism works.

 

[Fpg1245]

...and this is how capitalism works.

The thing about capitalism is that it tends to destroy itself.

 

[dieABRdie]

If the upcoming external beam boost trial can replicate the endocavitary brachytherapy boost data, then I would argue organ preservation with chemoRT will become the SOC in rectal ca.

It certainly will in our area..... I spend quite a bit of time convincing patients that they should get surgery as "standard of care."

Many who need APR and have cCR are just saying no.

 

[sirspamalot]

Instajoke:

"no, I like my assh0le and I'm not talking about my (insert your fav= ex wife, wife, husband, boss)"

 

[sirspamalot]

What do you think would have happened if ASTRO went in and offered to include proton therapy? I'm just curious. The fact is, it's very expensive for medicare among Rad Onc costs.

I've spent a lot of time talking to ASTRO reps about their APM proposal and what they were unhappy about. It never really matched what doctors were unhappy about, see Join Luh's editorial for an example. No one ever brought up protons. 🤷‍♂️

The grift is alive... in the drive to 2025...

Fern Nibauer-Cohen on LinkedIn: #napt2023

Penn Radiation Oncology team representing strong at #NAPT2023 The National Association for Proton Therapy. Having a great conference in Salt Lake City!

www.linkedin.com

 

[RickyScott]

This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.

Hospital Prices are a bigger contribution to out of control health care costs than drug prices.

 

[medgator]

Hospital Prices are a bigger contribution to out of control health care costs than drug prices.

Not a lot of cancer Care happening in hospitals but you are right. The whole point of OCM/eom etc is to keep med onc patients out of those high-cost money sinks, to be sure

 

[RickyScott]

Not a lot of cancer Care happening in hospitals but you are right. The whole point of OCM/eom etc is to keep med onc patients out of those high-cost money sinks, to be sure

In our system, I believe the satellites still bill hospital rates for radiation, radiology etc? I know pps exempt systems use the pps exemption at satellites up to 25-50 miles? I thought mskcc charges same in Brooklyn as at main campus for an infusion of keytuda

 

[Mandelin Rain]

In our system, I believe the satellites still bill hospital rates for radiation, radiology etc? I know pps exempt systems use the pps exemption at satellites up to 25-50 miles? I thought mskcc charges same in Brooklyn as at main campus for an infusion of keytuda

Such a ridiculous situation.

 

[sirspamalot]

It sure is... what it is..

 

[RickyScott]

 

[RadOncDoc21]

2 rad oncs for every person 😂

 

[Fpg1245]

2 rad oncs for every person 😂

Clearly a paucity that needs fixing

 

[Palex80]

Cross-fertilisation???

Do I have to sleep with my physicist to achieve that? 😱😱😱

 

[RadOncMegatron]

Cross-fertilisation???

Do I have to sleep with my physicist to achieve that? 😱😱😱

What are you guys doing in Europe?!? 😆 lol

 

[TheWallnerus]

Cross-fertilisation???

Do I have to sleep with my physicist to achieve that? 😱😱😱

Ha. Maybe a more Mendelian thing. Although I am pretty allergic to pollen.

 

[Palex80]

MR-Linac for GBM treatment. Choosing wisely!

 

[Fpg1245]

MR-Linac for GBM treatment. Choosing wisely!

I’m checking myself into the psych ward now.

 

[Lamount]

MR-Linac for GBM treatment. Choosing wisely!

Just in case it moves…

 

[Doctorer]

MR-Linac for GBM treatment. Choosing wisely!

Legitimately embarrassing that this qualifies for an oral presentation at a conference.

 

[elementaryschooleconomics]

I feel like GBM is Radiation Oncology's white whale.

GBM? Better dose escalate.

GBM? Better combine with [insert drug here].

GBM? Better dose escalate with [insert drug here].

GBM? Better do some giant margins.

GBM? Whoa, better dial back those margins.

GBM? Better omit radiation.

GBM? Better hypofrac.

GBM? Better dial back those margins and hypofrac.

2023:
GBM? Better dial back those margins and hypofrac...BUT WITH THE MRI.

Since we're doing this, can I be the first to suggest "no sham arm"? I'm playing bingo.

 

[Gfunk6]

MR-Linac for GBM treatment. Choosing wisely!

100 Gy to GBMs didn’t improve survival. Using an MRI linac on a fixed target so that you can achieve a 1 mm margin reduction probably ain’t doing squat.

 

[sirspamalot]

$quat $quat you problem$ away today..

 

[FindMeOnTheLinks]

I’m checking myself into the psych ward now.

lol
Such a microcosm of all the effed up aspects of our field

Seeing that tweet honestly makes me depressed

 

[Palex80]

 

[Palex80]

Trend for better PFS if you treat the macroscopic oligometastasis on top of systemic treatment.

 

[elementaryschooleconomics]

This is the area I struggle most with, in terms of predicting the future. Although it's not like any of us can be great at forecasting the future in the first place.

But: if I were given complete control to build a department from absolute scratch, I could definitely deploy tools and platforms and regulations/policies in such a way that I could be the solo doc staffing a very busy practice that spans multiple sites, operating 5 days a week.

The issue is...that world doesn't exist. Right now, for example, I'm several months into trying to "fix" a department that was ignored for years and years. I have almost cheerleader-level support from admin - not quite "blank check" but...close.

Even with this setup, where many key admin/executives are backing me to a weird degree, and I have the knowledge and ability to drag this department into the modern era - the systems and inertia AROUND this department mean this will likely take me several years.

I'm very "techno optimist" for AI in RadOnc, but I recognize I might be wrong. My optimism comes from me being in places where I'm the only one that really understands it, and can use it to make myself more efficient.

One day I'll encounter an executive who understands what is possible on a high level.

Perhaps I'll feel differently after that happens.

 

[Palex80]

Hypofractionation for nodes too! Nice!

 

[TheWallnerus]

Contouring is mostly from where we get our self worth right now. But that is so easily malleable. It’s like becoming a paraplegic. One day you realize “I don’t get my self worth from walking” and you have a mindset change and get your self worth from some other new psychological well. I predict it will be as something as hokey as “Rad oncs are the only physicians trained to monitor the AI contours.”

 

[OTN]

Hypofractionation for nodes too! Nice!

I've been doing UK/Canadian hypofx for nodes for years now, it works just fine