Rad Onc Twitter

[TheWallnerus]

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.

Over time I have realized one of the key ulterior (unspoken) motives of admin is never to let MD pay float too high. It would be far too cognitively dissonant to admin to have an MD being super efficient and covering 5 sites… it would send off too many “We need to give this guy a huge raise” vibes. So it’s much more pleasing to admin (and probably a chairman) to have the doctor relatively underutilized so they can have logical ground to stand on to keep MD pay low. In other words, the ultra efficient one-doctor-for-many-sites thing may never happen in the US, even though technology is increasingly making it highly logical and safe.

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[Fpg1245]

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.”

Rad onc is born to lose

It’s more likely they efficiency gains will continue to make the remainder of the RO physician workforce redundant. You’ll still be employed but the issue is that admin still keep a large underemployed underpaid workforce that can easily step in when needed.

 

[TheWallnerus]

Hypofractionation for nodes too! Nice!

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

In the UK prior to COVID, no breast ENI patient got more than 15 fractions. After COVID, about 35% of all breast ENI patients get 5 fractions. The FAST Forward nodal sub study results should be out any day now.

Right now in the US most insurers let early stage breast patients get up to 21 fractions and ENI patients get up to 33 fractions. I predict this is headed to 15 fractions for both in near future.

 

[Palex80]

A 129-patient randomized trial was supposed to demonstrate that it‘s safe to give tamoxifen parallel to RT.

I still do it, but the trial is clearly underpowered.

 

[metallica81788]

Seems like a lot more doom and gloom about the future lately around these parts

Or is that just standard course after a relevant (i.e. non ASTRO) oncologic meeting?

 

[Mandelin Rain]

A 129-patient randomized trial was supposed to demonstrate that it‘s safe to give tamoxifen parallel to RT.

I still do it, but the trial is clearly underpowered.

Like what was the absolute best case scenario of this study?

A tiny (2-3%) statistically significant reduction in clinically insignificant radiographic changes?

This is where we are?

 

[TheWallnerus]

Like what was the absolute best case scenario of this study?

A tiny (2-3%) statistically significant reduction in clinically insignificant radiographic changes?

This is where we are?

Yes.

 

[Fpg1245]

Yes.

Meanwhile over at ASCO

 

[deleted1111261]

Okay so it’s not a “game change” study but it’s a good question! It comes to a lot - how to sequence. I’d rather have a study that’s practical like that. Now we know - it doesn’t matter.

 

[Fpg1245]

Okay so it’s not a “game change” study but it’s a good question! It comes to a lot - how to sequence. I’d rather have a study that’s practical like that. Now we know - it doesn’t matter.

All these physiologic justifications I’ve heard iver the years for doing all the things we do. it doesn’t surprise me that a lot of it has no real basis

 

[TheWallnerus]

Okay so it’s not a “game change” study but it’s a good question! It comes to a lot - how to sequence. I’d rather have a study that’s practical like that. Now we know - it doesn’t matter.

Yeah but we had a lot of data it didn’t matter before this!

 

[communitydoc13]

clinically insignificant radiographic changes

Where we are. If you want to reduce fibrosis (breast), you can always treat longer and slower as well.

 

[Fpg1245]

Where we are. If you want to reduce fibrosis (breast), you can always treat longer and slower as well.

How dare you even suggest this.

 

[TheWallnerus]

How dare you even suggest this.

It is a mathematical and clinical certainty that 50.4/28 whole breast will produce more breast fibrosis than 26/5 partial breast, and a mathematical certainty that 50.4/28 whole breast will produce more breast fibrosis than 26/5 whole breast. Adding a breast boost to the 50.4/28 will take those certainties to something past totality.

 

[sirspamalot]

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

Noooooooooooo.... (anguished screams)

 

[thecarbonionangle]

Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT

 

[Fpg1245]

Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT

Community hospitals not yet acquired will basically hand over their RO Dept to remote mega hospital criminal academic RO cogs at that point who will be signing off on NP/AI generated notes while the attending frantically writes his next manuscript on RTT midlevels and the prognostic factors of head and neck outcomes on stool samples.

I really hate that this is what I wasted my time fighting to get into.

 

[thecarbonionangle]

Community hospitals not yet acquired will basically hand over their RO Dept to remote mega hospital criminal academic RO cogs at that point who will be signing off on NP/AI generated notes while the attending frantically writes his next manuscript on RTT midlevels and the prognostic factors of head and neck outcomes on stool samples.

I really hate that this is what I wasted my time fighting to get into.

This has been in works for a while. “ Academics” are also working hard to eliminate radiation from HER2/TNBC. Once the five fx RNI data is out, it will all go to 5 fx except for IBC/+margins/gross disease which must all be treated with protons. Thats what i hear!

 

[Fpg1245]

This has been in works for a while. “ Academics” are also working hard to eliminate radiation from HER2/TNBC. Once the five fx RNI data is out, it will all go to 5 fx except for IBC/+margins/gross disease which must all be treated with protons. Thats what i hear!

Their treatment recommendations are garbage. They’ll still be charging these people 150K per treatment and paying the attendings dog****.

 

[thecarbonionangle]

Their treatment recommendations are garbage. They’ll still be charging these people 150K per treatment and paying the attendings dog****.

This is the way.

 

[Palex80]

Anal cancer on it's way to become the next 5 fractions indication.

5 x 4 Gy for ENI
5 x 5 Gy for cN+
5 x 6 Gy for primary and call it a day?

 

[medgator]

Anal cancer on it's way to become the next 5 fractions indication.

5 x 4 Gy for ENI
5 x 5 Gy for cN+
5 x 6 Gy for primary and call it a day?

28 to 23 fractions? 5 fractions didn't work out so well in rectal. Anything organ preserving like anal or h&n will continue to get long-course chemoRT imo

 

[radoncftw]

28 to 23 fractions? 5 fractions didn't work out so well in rectal. Anything organ preserving like anal or h&n will continue to get long-course chemoRT imo

I think the 5 fraction regimen is here to stay. May be some areas where long-course is a better option, but most patients will probably do fine with 5 fraction. RAPIDO wasn't designed to compare LC + SC. Prior studies that were show equivalence.

 

[Palex80]

5 x 6 Gy gives a BED of 48 Gy (a/b=10 Gy)
28 x 1.8 Gy gives a BED of 59.5 Gy (a/b=10 Gy)

a/b for anal cancer cells is however perhaps lower than 10 Gy?

 

[communitydoc13]

Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT

We were wrong. We use the wrong tools. Would you want to offer 5 fraction whole breast to a 45-55 y/o after reading the appendices to the five fraction whole breast trials?

5 fraction is a bit worse that 13-16 fraction for long term cosmetic and fibrotic outcomes.

I love APBI for the right patient. However, have you felt the lumpectomy bed 2 years out from XRT in these patients? Cosmesis is good for APBI because of volumes alone.

Like many things, we have used EBM tools to advance the field to shorter, more convenient care that is in some ways a little bit worse, but is much easier to consolidate in a few large centers.

Meanwhile, in my experience, academics with captive metastatic patients are the most likely to offer prolonged or expensive palliative radiation.

Whatever, I have adopted moderate hypofractionation for many things as it is now national standard of care.

Why are we not seeing articles like, "The radiation oncologist as comprehensive solid tumor oncologist in rural America: accounting for distribution of care crises by expanding the scope of practice of available board certified physicians"

 

[TheWallnerus]

5 x 6 Gy gives a BED of 48 Gy (a/b=10 Gy)
28 x 1.8 Gy gives a BED of 59.5 Gy (a/b=10 Gy)

a/b for anal cancer cells is however perhaps lower than 10 Gy?

You didn’t correct for time

 

[OTN]

50.4 Gy is worse for cosmesis than UK/Canadian
5 fraction whole breast is worse for cosmesis than UK/Canadian
5 fraction partial breast is not worse for cosmesis than UK/Canadian

For my patients who get non-oncoplastic lumpectomies and are eligible for APBI, I treat with Livi APBI. If they cared about cosmesis enough to get an oncoplastic lumpectomy, then UK/Canadian it is. If they don't care about cosmesis, didn't get an oncoplastic lumpectomy, and aren't eligible for partial breast RT, then 5-fraction whole breast. I haven't seen any of the latter yet, but that's probably because the vast majority of the lumpectomies I see are oncoplastic.

 

[grenz]

50.4 Gy is worse for cosmesis than UK/Canadian
5 fraction whole breast is worse for cosmesis than UK/Canadian
5 fraction partial breast is not worse for cosmesis than UK/Canadian

For my patients who get non-oncoplastic lumpectomies and are eligible for APBI, I treat with Livi APBI. If they cared about cosmesis enough to get an oncoplastic lumpectomy, then UK/Canadian it is. If they don't care about cosmesis, didn't get an oncoplastic lumpectomy, and aren't eligible for partial breast RT, then 5-fraction whole breast. I haven't seen any of the latter yet, but that's probably because the vast majority of the lumpectomies I see are oncoplastic.

Something that isn’t talked about much is Livi’s control arm was conventional frac. So unless I missed something, we don’t know for sure how it compares to UK/canadian

 

[Palex80]

Something that isn’t talked about much is Livi’s control arm was conventional frac. So unless I missed something, we don’t know for sure how it compares to UK/canadian

Indeed, and there was also a 10Gy-boost in the conventional arm.

To me, the Livi regime was more of a way to prove that APBI is safe in terms of toxicity and without an excessive risk for recurrences, as long as you picked the patients right.

One can always argue to do IMPORT-LOW (40/2.66) partial breast, if one is not confident with the Livi regime.

Or, as TheWallnerus will likely agree, simply do FAST-FORWARD to a partial breast volume.
If FAST-FORWARD to the whole breast is non-inferior to START-B to the whole breast, then FAST-FORWARD to a partial breast volume will certainly not be inferior to START-B to the whole breast in terms of cosmesis. Only caveat here is the boost. FAST-FORWARD is one week, but some patients got a boost (delivered in 5 fractions with 2 Gy each). How to compensate for that (provided you want to give the boost)?

 

[sirspamalot]

Round these parts everyone gets 4256/16 unless there is RNI, then regular. Or some other compelling factor.

1, uno, un, echad, etc.. patient demanded APBI with EBRT and so it was done.

Choosing Wisely..or going insane/broke. What'll it be folks?

 

[grenz]

Indeed, and there was also a 10Gy-boost in the conventional arm.

To me, the Livi regime was more of a way to prove that APBI is safe in terms of toxicity and without an excessive risk for recurrences, as long as you picked the patients right.

One can always argue to do IMPORT-LOW (40/2.66) partial breast, if one is not confident with the Livi regime.

Or, as TheWallnerus will likely agree, simply do FAST-FORWARD to a partial breast volume.
If FAST-FORWARD to the whole breast is non-inferior to START-B to the whole breast, then FAST-FORWARD to a partial breast volume will certainly not be inferior to START-B to the whole breast in terms of cosmesis. Only caveat here is the boost. FAST-FORWARD is one week, but some patients got a boost (delivered in 5 fractions with 2 Gy each). How to compensate for that (provided you want to give the boost)?

Since the publication of the DBCG trial, I’ve come around to the thinking that IMPORT-LOW has the best evidence of any PBI regimen, including Livi. I don’t use PBI a lot but when I do, it’s three weeks of two or three fields

 

[TheWallnerus]

Since the publication of the DBCG trial, I’ve come around to the thinking that IMPORT-LOW has the best evidence of any PBI regimen, including Livi. I don’t use PBI a lot but when I do, it’s three weeks of two or three fields

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

 

[sirspamalot]

negative ghostrider, the RVU's are low

 

[Ray D. Ayshun]

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

i do import all the time. to some degree i do it with every breast i treat inasmuch as i dont have my tangents blasting through from wire to wire.

 

[thecarbonionangle]

i do import all the time. to some degree i do it with every breast i treat inasmuch as i dont have my tangents blasting through from wire to wire.

This is how i would look at it, basically tells you it is ok to “cheat” a bit

 

[communitydoc13]

IMPORT-LOW…

So hot in quality and evidence

So cold in the heart and mind of the American MD

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

 

[sirspamalot]

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

 

[grenz]

It's barely partial breast. It's a treat most of the breast protocol, which is what we all do anyway (except for some old folks, who really take 3 cm lung bites and 2 cm inferior margins on their tangents).

It’s enough that it improves cosmesis. Regardless, it definitely has the strongest data behind ir

 

[communitydoc13]

It’s enough that it improves cosmesis. Regardless, it definitely has the strongest data behind ir

Agree. I was just responding to @TheWallnerus regarding why it isn’t exciting to us as a group.

 

[metallica81788]

Isn't the reimbursement for 5fx PBI with IMRT and daily CBCT about the same as 15fx 3D?
I guess only difference is the wRVUs for those two extra OTVs

Import low is not partial breast. Especially if you've seen these seromas out in the community; it's pretty much worthless for most
Florence or 15/16fx or nodes

 

[sirspamalot]

Breast tangents in 16 fx works fine, RNI gets the full monty. IDGAF what the overseas data says: if my patient gets arm edema, and it goes there, then I will get slaughtered in front of jury. It is what it is... hypofrac for RNI is not the USA community standard. If you're going to do it, I hope its for SLN patients only... because round these parts some patients are still getting axillary dissections. Its not like I get to dictate what happens before they get here and neither do you.

APBI? Nah. Think of your patient population. Will they really take their pill every day for 5 years? And if they're high risk otherwise? Just think of it as prophylaxis. For small breasts with big cavity margins its still whole breast anyway.

16fx (rarely boost) is basically where the line is drawn for average patients. Perhaps if you have 40+ on treatment and the linac folks are wilting..

 

[TheWallnerus]

Agree. I was just responding to @TheWallnerus regarding why it isn’t exciting to us as a group.

Isn't the reimbursement for 5fx PBI with IMRT and daily CBCT about the same as 15fx 3D?
I guess only difference is the wRVUs for those two extra OTVs

Import low is not partial breast. Especially if you've seen these seromas out in the community; it's pretty much worthless for most
Florence or 15/16fx or nodes

Breast tangents in 16 fx works fine, RNI gets the full monty. IDGAF what the overseas data says: if my patient gets arm edema, and it goes there, then I will get slaughtered in front of jury. It is what it is... hypofrac for RNI is not the USA standard.

APBI if you have a Contura, or a highly educated well taken care of (top 5%) type patient, otherwise, esp in my population who won't reliably take their pillz, why is everyone so worked up about 60+ year old breasts? Just think of it as prophylaxis and all is well.

16fx (rarely boost) is as far as Imma gunna go. If I was incredibly busy (40+ on tx) I'd start seriously thinking about 5 fx... it ain't. gonna. happen.

16 fractions is a way to pay fealty to thine overlords for an extra fraction, whereas 15 fractions works just as well clinically (and offers equal wRVUs to the MD serfs) and would ipso facto offer less side effects than 16 fractions/more dose.

Discuss!

 

[sirspamalot]

I can't wait for the 16 v 15 randomized trial to be published. Why, it will get an oral presentation and put someone on track to be a Department Chair surely.

 

[Mandelin Rain]

I can't wait for the 16 v 15 randomized trial to be published. Why, it will get an oral presentation and put someone on track to be a Department Chair surely.

We got a 26 vs 27 Gy study (with a stat sig difference)

 

[TheWallnerus]

It's barely partial breast. It's a treat most of the breast protocol,

I would call this not true! IMPORT-LOW volumes can prevent hundreds of cc's of normal tissue from seeing any RT at all versus standard tangents, and sometimes 0 cc of lung getting any dose (besides scatter); the latter is typically not achievable with standard tangents. If I had a boob, and a lung, I'd love to get ~0 Gy to my lung during boob RT if possible.

Also keep in mind what IMPORT stands for: intensity modulated partial organ radiotherapy. This trial gives excellent "cover" in my opinion to use IMRT to give 15 fractions of breast RT.

 

[sirspamalot]

Yes. But.. there are caveats littered like a Ukranian Minefield in Bahkrut with regards to that study.
'
Excellent discussion here: Expert Discussion: Hypofractionated Radiation Therapy – Standard for All Indications?

I stand by my original statement (tongue in cheek one was obviously for fun).

 

[TheWallnerus]

Yes. But.. there are caveats littered like a Ukranian Minefield in Bahkrut with regards to that study.
'
Excellent discussion here: Expert Discussion: Hypofractionated Radiation Therapy – Standard for All Indications?

I stand by my original statement (tongue in cheek one was obviously for fun).

We can quibble, now, over whether hypofx is standard for all breast RT indications. As we all know, it is the standard for many rad oncs elsewhere on the planet:

It is as plain as the tusks coming out of my mouth that one day in the not distant future insurance companies will place 15 fractions as the upper limit of fractions for all breast cancer RT patients... and 5 fractions some years after that if FAST-Forward nodal substudy is good.

 

[sirspamalot]

I would call this not true! IMPORT-LOW volumes can prevent hundreds of cc's of normal tissue from seeing any RT at all versus standard tangents, and sometimes 0 cc of lung getting any dose (besides scatter); the latter is typically not achievable with standard tangents. If I had a boob, and a lung, I'd love to get ~0 Gy to my lung during boob RT if possible.

Also keep in mind what IMPORT stands for: intensity modulated partial organ radiotherapy. This trial gives excellent "cover" in my opinion to use IMRT to give 15 fractions of breast RT.

Yes in this highly favorable subset of g1/2 ER+ PR+ patients ( ~90% on trial) who were on a trial and likely therefore religiously taking their endocrine therapy.. seems like it'd be good.

For those not in most favored status.. and who won't take their pillz reliably.. are you still willing to do this regimen?

I've treated breast tangents standard and then mod hypo over a long career. In healthy patients who are not competitive triatheletes (I've never had one) lung damage appears to be irrelevant.

 

[sirspamalot]

When Evilcore/Insurance and the RCS solely determine my patients care, I hope I will be in retirement..

 

[TheWallnerus]

Yes in this highly favorable subset of g1/2 ER+ PR+ patients ( ~90% on trial) who were on a trial and likely therefore religiously taking their endocrine therapy.. seems like it'd be good.

For those not in most favored status.. and who won't take their pillz reliably.. are you still willing to do this regimen?

I've treated breast tangents standard and then mod hypo over a long career. In healthy patients who are not competitive triatheletes (I've never had one) lung damage appears to be irrelevant.

In many Shakespearean plays a character often exclaims "ALARUM!"

"ALARA!" for ~6 years now. So yes totally willing. Peering into the mind of the patient to gauge future endocrine compliance seems illogical, on the basis of RT data we have, on which to base breast PTV decisions for low risk breast cancer.