Rad Onc Twitter

[sirspamalot]

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ADT is as clear as mud to me. I know what we "Do" but I don't know that we truly understand. H/UH risk18-24 months? Sure. UIR prostate 4-6 months? Sure.

I follow the rules. I'm a good radonc.

 

[evilbooyaa]

Is adt and sbrt a thing? I don't really do sbrt outside low risk or favorable intermediate.

SBRT for UIR totally fine, do it with 4 months of ADT all the time.

SBRT for HR that doesn't require LN coverage not unreasonable, IMO, although covering 3cm of SV as I do for HR patients can be a bit more problematic.

SBRT for HR that does require LN coverage (> 15% risk LNI per MSKCC nomogram) I do not offer.

Globally, neoadjuvant ADT not necessary, but not wrong in a larger prostate. Glad to see positive press from the lay-people on radiation!

 

[thesauce]

I have done it for all risk groups. Sbrt is really indicated to capture distant pts or those with severe transportation hardships.

It is to attract patients that don’t know any better

 

[evilbooyaa]

It is to attract patients that don’t know any better

??? What's wrong with prostate SBRT? It's not even unreasonable to do it in HR patients.

 

[sirspamalot]

As for me.. High/UH risk patients I'm giving IMRT P/SV/LN + ADT referral till the cows come home.

 

[deleted1111261]

I find it hard to believe the studies

I have treated much less than people here, but there is an intensity of urinary sx in the 1-3 weeks after treatment that is different than Ebrt pattern

 

[OTN]

I find it hard to believe the studies

I have treated much less than people here, but there is an intensity of urinary sx in the 1-3 weeks after treatment that is different than Ebrt pattern

Intensity of urinary symptoms is higher but the duration of symptoms is shorter. I can't appreciate a difference in long-term urinary symptoms.

Basically zero (0) GI symptoms in either the short- or long-term. I've never used a spacer. I truly believe they are worthless.

 

[Mandelin Rain]

I find it hard to believe the studies

I have treated much less than people here, but there is an intensity of urinary sx in the 1-3 weeks after treatment that is different than Ebrt pattern

This is why you schedule a 4 week follow up.

 

[DoctwoB]

This is why you schedule a 4 week follow up.

Limited N in my patients, but I have seen more GU toxicity in the SBRT patients, both acute and chronic.

I find the neoadjuvant vs adjuvant ADT stuff clear as mud. Seems like adjuvant probably better with XRT. But what about with brachy? New data that 6 months neoadjucant with Trimodal is equivalent to 2 years adjuvant.

 

[RadOncDoc21]

Limited N in my patients, but I have seen more GU toxicity in the SBRT patients, both acute and chronic.

I find the neoadjuvant vs adjuvant ADT stuff clear as mud. Seems like adjuvant probably better with XRT. But what about with brachy? New data that 6 months neoadjucant with Trimodal is equivalent to 2 years adjuvant.

Not sure I care that much about biochemical failure when there is no difference in OS. I don’t think Brachy matters that much for prostate cancer and is not worth the extra amount of side effects in my opinion.

SBRT is a good alternative for many patients but all the side effects equals out eventually over time. The Caesar data did show better side effects outcome with RT alone vs surgery but adding hormones made everything equal over time as far as sexual function. I do think there are too many caveats for me to use any of the data but it’s there for those who want it.

If it was my prostate, I would favor surgery only if I already had significant BPH, underlying bad ED and know that I might be wearing pads for the rest of my life. I would never do brachy and would only receive hormones if I had unfavorable int risk or high risk disease. I would be a hypocrite to how I practice because I would choose a conventional course of RT (most of my patients either receive SBRT or hypofx) because I would prefer to have limited acute symptoms and I don’t see a big issue for me being able to take 30 minutes of my day receiving treatment for cancer.

In regards to Active Surveillance, I understand the rationale to diagnose men earlier at earlier stages, but I’m not sure that I would be a fan of having multiple biopsies and knowing that with the next one, I might end up adding hormones. I also question the anxiety and fear we are contributing by diagnosing more people but not offering definitive treatment.

Prostate cancer is one of the few cancers we strongly consider not treating with any modality if diagnosed at an early stage- maybe this is where HIFU/ablations come in where we burned our bridges. I end my rant!

 

[thesauce]

??? What's wrong with prostate SBRT? It's not even unreasonable to do it in HR patients.

I’m not completely against it, but the marketing for it is nauseating. A group will “compete” for business by telling patients and referring physicians that they do 5-fraction treatments KNOWING FULL WELL that the competing clinics in the region also have the technology and ability to do it. But they are playing on the ignorance of patients and non-radonc-physicians.

 

[deleted1111261]

I’m not completely against it, but the marketing for it is nauseating. A group will “compete” for business by telling patients and referring physicians that they do 5-fraction treatments KNOWING FULL WELL that the competing clinics in the region also have the technology and ability to do it. But they are playing on the ignorance of patients and non-radonc-physicians.

Ability doesn’t imply the will to do it

There is a center in Oregon that literally says on their website that they don’t hypo anything

 

[RadOncDoc21]

I’m not completely against it, but the marketing for it is nauseating. A group will “compete” for business by telling patients and referring physicians that they do 5-fraction treatments KNOWING FULL WELL that the competing clinics in the region also have the technology and ability to do it. But they are playing on the ignorance of patients and non-radonc-physicians.

I’ve seen other rad oncs claim their trubeam is better and more “state of the art” than mine when we literally have the exact same thing. I can only imagine what the academics are claiming, especially when there are proton commercials and billboards all around the area. I have absolutely no faith in us!

 

[medgator]

I’ve seen other rad oncs claim their trubeam is better and more “state of the art” than mine when we literally have the exact same thing. I can only imagine what the academics are claiming, especially when there are proton commercials and billboards all around the area. I have absolutely no faith in us!

 

[Palex80]

Med oncs

 

[TheWallnerus]

Med oncs

“No excuses or illusions please.” Data isn’t enough to make a person’s point in medicine anymore. Gotta throw an admonishment or two in there.

 

[Fpg1245]

Med oncs

Still gonna order it lol. Won’t change a thing

 

[NotMattSpraker]

“No excuses or illusions please.” Data isn’t enough to make a person’s point in medicine anymore. Gotta throw an admonishment or two in there.

Sadly, I think data is actually not enough these days. Pretty much every week on twitter I see some version of "this data doesn't apply to my practice" from a practitioner in every discipline of oncology. See it from Rad Oncs all the time.

 

[Gfunk6]

Sadly, I think data is actually not enough these days. Pretty much every week on twitter I see some version of "this data doesn't apply to my practice" from a practitioner in every discipline of oncology. See it from Rad Oncs all the time.

Thanks mostly to the current political climate we live in a world that can be termed "post truth" or "alternative facts."

 

[OTN]

Thanks mostly to the current political climate we live in a world that can be termed "post truth" or "alternative facts."

I remember seeing the "not in my hands" argument way back in the halcyon days of the 90s

 

[evilbooyaa]

I’m not completely against it, but the marketing for it is nauseating. A group will “compete” for business by telling patients and referring physicians that they do 5-fraction treatments KNOWING FULL WELL that the competing clinics in the region also have the technology and ability to do it. But they are playing on the ignorance of patients and non-radonc-physicians.

If other centers have the technological capability but not the willingness, does that really matter?

Now if the offending center is saying other centers don't do it (when they do) then I guess that's a problem. I do see a fair number of consults from far (2-3 hours) who have a local Rad Onc, but the urologist didn't refer them (and the urologist at my institution did refer them to me) so if you're not hearing of these patients at all, may be worth a discussion with your local referring Urologist.

If you're seeing the patients and not offering 5Fx, then... yeah. Back in the heyday it was 'Cyberknife SBRT' which was marketed aggressively.

I’ve seen other rad oncs claim their trubeam is better and more “state of the art” than mine when we literally have the exact same thing. I can only imagine what the academics are claiming, especially when there are proton commercials and billboards all around the area. I have absolutely no faith in us!

Shysters gonna shyste - I make no claims (as an 'academic attending') that my TrueBeam is better than anyone else's. I always say it's the doctor and the therapists behind the Linac, much more than the Linac itself.

Proton marketing is the worst, will allow full blame on (mostly) academics on that one...

 

[IonsAreOurFuture]

Should be quick to contour and plan. Set iso. Select golfball tool. Click once. Use a single arc with pretty much no constraints. What is this?

Pretty soon, if not already, AI will auto-contour the PET avid tumor, auto-contour all the normal organs, select the optimal arc angles, optimize, plan, align, treat, and sign off.

Oh wait, I still do that last step.

 

[Radonc90]

Here you go, Wifi radiation opens BBB so the toxins can enter the brain.
He might as well said "chemo drugs enter the brain" lol...

 

[thesauce]

Now if the offending center is saying other centers don't do it (when they do) then I guess that's a problem.

Exactly - this is what I’m talking about. They KNOW the centers have this and offer it, but market as if they don’t.

 

[Palex80]

 

[Fpg1245]

I don’t get it. I think most residents with a brain have asked this very question.

 

[TheWallnerus]

I don’t get it. I think most residents with a brain have asked this very question.

He’s saying “everyone actually wants protons” I think

 

[Ray D. Ayshun]

I don’t get it. I think most residents with a brain have asked this very question.

They should start by asking why we accept a higher mean heart dose for stage III breast cancer than for stage I? Then, maybe they'll realize it's a product of volume treated and proximity to the heart. They could also ask how the findings of partial breast trials are relevant in this context, and then ask an attending if there's a partial lung tumor trial they could design for their academic year. After doing those things, they can delete their tweet.

 

[Palex80]

He’s saying “everyone actually wants protons” I think

 

[TheWallnerus]

Someone needs to explain to me one day why in some of these proton isodose plans the absorbed dose doesn't seem to mind if it's in the patient or the air outside of the patient; almost like the patient ('s matter's attenuation behavior) is superfluous to the dose distribution.

 

[Palex80]

Someone needs to explain to me one day why in some of these proton isodose plans the absorbed dose doesn't seem to mind if it's in the patient or the air outside of the patient; almost like the patient ('s matter's attenuation behavior) is superfluous to the dose distribution.

There's so much money involved in proton therapy, the air itself acquires stopping power.

 

[deleted1111261]

There's so much money involved in proton therapy, the air itself acquires stopping power.

View attachment 373323

you're on fire palex. haven't seen this level since Lin-Sanity in 2011

 

[sirspamalot]

Meanwhile over in the SPF forum, fringe right highlights be like..

 

[Palex80]

Let’s toast to that! 🥂

 

[deleted1111261]

I cannot type enough vomit emojis

 

[Ray D. Ayshun]

One other thing he'll learn is that Stage I breast is the worst while stage III lung is the best.

 

[evilbooyaa]

I cannot type enough vomit emojis

Aww, c'mon grumpy pants! It's a heartwarming story about the physician/patient relationship!

 

[thecarbonionangle]

don’t forget to vote for ASTRO elections. I endorse Sameer!

 

[SneakyBooger]

I have heard of places still doing 4 field box with a subsequent cone down even today. I'd expect a lot more toxicity with something like that vs IMRT all the way through.

This paper states 3DCRT is just fine for prostate (maybe not plain 4 field box? But maybe):

Practical considerations for prostate hypofractionation in the developing world

Practical considerations for prostate hypofractionation in the developing world - Nature Reviews Urology

Conventionally fractionated external beam radiotherapy is an effective treatment for localized prostate cancer, but long treatment programmes result in a substantial burden to patients and the health-care system, which is particularly problematic in low-income and middle-income countries (LMICs)...

www.nature.com

“3D-CRT is associated with acceptable toxicity rates and oncological outcomes if IMRT is not available”

“moderate hypofractionation can be safely and effectively delivered without strict IGRT requirements”

An ASCO 2022 poster on RTOG 0415 toxicity analysis found less GU toxicity with 3DCRT vs IMRT.

Given this, one could make an argument that everyone doing IMRT for prostate is greedy. 3DCRT is clearly less toxic, so why let anyone have IMRT?

And taking weekly MV's is "image guidance". 😉

Hypofractionation in prostate cancer has been shown to be more toxic yet it is "acceptable". So why allow IMRT and IGRT!

You want to discuss SpaceOAR! HAHAHAHAHA!!! Fat chance!

I am preparing for a future gig with Evilcore. When I do, I plan to be the most Evil 😈, so no more IGRT or IMRT for you (collectively) if I am doing your peer to peer!

😵 🤣🖤

 

[SneakyBooger]

Pretty soon, if not already, AI will auto-contour the PET avid tumor, auto-contour all the normal organs, select the optimal arc angles, optimize, plan, align, treat, and sign off.

Oh wait, I still do that last step.

I expect centers are selling (or hope to sell) your contours to an AI firm for just this reason.

Same for eContour...

 

[evilbooyaa]

This paper states 3DCRT is just fine for prostate (maybe not plain 4 field box? But maybe):

Practical considerations for prostate hypofractionation in the developing world

Practical considerations for prostate hypofractionation in the developing world - Nature Reviews Urology

Conventionally fractionated external beam radiotherapy is an effective treatment for localized prostate cancer, but long treatment programmes result in a substantial burden to patients and the health-care system, which is particularly problematic in low-income and middle-income countries (LMICs)...

www.nature.com

“3D-CRT is associated with acceptable toxicity rates and oncological outcomes if IMRT is not available”

“moderate hypofractionation can be safely and effectively delivered without strict IGRT requirements”

An ASCO 2022 poster on RTOG 0415 toxicity analysis found less GU toxicity with 3DCRT vs IMRT.

Given this, one could make an argument that everyone doing IMRT for prostate is greedy. 3DCRT is clearly less toxic, so why let anyone have IMRT?

And taking weekly MV's is "image guidance". 😉

Hypofractionation in prostate cancer has been shown to be more toxic yet it is "acceptable". So why allow IMRT and IGRT!

You want to discuss SpaceOAR! HAHAHAHAHA!!! Fat chance!

I am preparing for a future gig with Evilcore. When I do, I plan to be the most Evil 😈, so no more IGRT or IMRT for you (collectively) if I am doing your peer to peer!

😵 🤣🖤

Links for the ASCO 2022 poster?

 

[Chartreuse Wombat]

Links for the ASCO 2022 poster?

Radiation technique and outcomes following moderately hypofractionated treatment of low risk prostate cancer: a secondary analysis of RTOG 0415 - Prostate Cancer and Prostatic Diseases

While moderately hypofractionated radiotherapy (MHRT) for prostate cancer (PC) is commonly delivered by intensity modulated radiation therapy, IMRT has not been prospectively compared to three-dimensional conformal radiotherapy (3D-CRT) in this context. We conducted a secondary analysis of the...

www.nature.com

 

[Fpg1245]

Radiation technique and outcomes following moderately hypofractionated treatment of low risk prostate cancer: a secondary analysis of RTOG 0415 - Prostate Cancer and Prostatic Diseases

While moderately hypofractionated radiotherapy (MHRT) for prostate cancer (PC) is commonly delivered by intensity modulated radiation therapy, IMRT has not been prospectively compared to three-dimensional conformal radiotherapy (3D-CRT) in this context. We conducted a secondary analysis of the...

www.nature.com

Wow even less of a motivation to use it.
3D? Are you kidding me? I swear these people have made it their life’s mission to ruin my practice

 

[RickyScott]

Radiation technique and outcomes following moderately hypofractionated treatment of low risk prostate cancer: a secondary analysis of RTOG 0415 - Prostate Cancer and Prostatic Diseases

While moderately hypofractionated radiotherapy (MHRT) for prostate cancer (PC) is commonly delivered by intensity modulated radiation therapy, IMRT has not been prospectively compared to three-dimensional conformal radiotherapy (3D-CRT) in this context. We conducted a secondary analysis of the...

www.nature.com

Toxicity was very low w/ 3d xrt 78 Gy in rtog study. The big improvements in toxicity came when docs learned how to contour the prostate and then later employed image guidance. I was a resident back then and a lot of senior well published radoncs did not know how to contour the prostate. They were not the cream of their medschool class.

Toxicity after three-dimensional radiotherapy for prostate cancer on RTOG 9406 dose Level V - PubMed

Tolerance to three-dimensional conformal radiotherapy with 78 Gy in 2-Gy fractions remains better than expected compared with historical controls. The magnitude of any effect from fraction size and treatment volume requires additional follow-up.

pubmed.ncbi.nlm.nih.gov

 

[Ray D. Ayshun]

Well, didn't they get prostate only rt in this trial? Which is to say, no proximal seminal vesicles, no full seminal vesicles, no pelvis. I'm not surprised that planning technique isn't vital in a population of patients I pretty much don't treat...tbh, I can't think of a single patient I've treated in my career who wouldve met trial criteria.

Also, what were the ptv expansions?

Edit: Per protocol, PTV expansions 4-10 mm.

 

[sirspamalot]

What's more insane: finding another reason to tout eliminating xrt based on a hash of gene data OR crowing about treating a 103 yo for breast cancer with xrt?

Breast Cancer Recurrence Score Predicts Benefits of Radiation Therapy

A Houston Methodist study is the first to use recurrence score testing to predict which early-stage breast cancer patients will benefit from radiation therapy.

www.houstonmethodist.org

 

[Fpg1245]

What's more insane: finding another reason to tout eliminating xrt based on a hash of gene data OR crowing about treating a 103 yo for breast cancer with xrt?

Breast Cancer Recurrence Score Predicts Benefits of Radiation Therapy

A Houston Methodist study is the first to use recurrence score testing to predict which early-stage breast cancer patients will benefit from radiation therapy.

www.houstonmethodist.org

Wait they found people with early stage BC they have a survival benefit with radiotherapy? That’s a first

Also if people have so many negative misconceptions, the solution to that is? Drop the RT

 

[sirspamalot]

Carlin said it best

100% All America Vegan Organic Hand Crafted Custom Deluxe Pure ... BULL****

 

[RickyScott]

Well, didn't they get prostate only rt in this trial? Which is to say, no proximal seminal vesicles, no full seminal vesicles, no pelvis. I'm not surprised that planning technique isn't vital in a population of patients I pretty much don't treat...tbh, I can't think of a single patient I've treated in my career who wouldve met trial criteria.

Also, what were the ptv expansions?

Edit: Per protocol, PTV expansions 4-10 mm.

Proximal sv are almost always covered whether intended or not, especially in this era when mri was not used. During training, about half pts had 3d and I did not notice any toxicity differences.

 

[Radonc90]

Sounds familiar with ABR MOC?