Rad Onc Twitter

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Is it really an open question?
 
TheWallnerus said:
5x5.2 would be even better than Livi though. IMPORT-LOW and FAST-Forward were designed to be taken together so that's why 5x5.2 (instead of 5x6 Gy) is the UK standard. (It's also usually 2-field IMRT vs VMAT/multifield.)

And.... 10x3.85Gy bid was just a regimen made by a radiobiological know-nothing.
Click to expand...
I don't like how close to the knifes edge 5.2x5 ended up being when 5.4x5 turned out to be inferior.
 


- So, Stiles said on his slide:

* "Selection of pts for SBRT should be guided by surgeons".

* "SBRT is associated with an inadequate pCR rate and with failure rates of ~ 40%".

I am just sitting here shaking my head at the pure stupidity...

1. Sorry Stiles, but the selection of SBRT comes from either pts themselves or from
multiD recommendation.

2. SBRT 40% failure rates?
 
Radonc90 said:


- So, Stiles said on his slide:

* "Selection of pts for SBRT should be guided by surgeons".

* "SBRT is associated with an inadequate pCR rate and with failure rates of ~ 40%".

I am just sitting here shaking my head at the pure stupidity...

1. Sorry Stiles, but the selection of SBRT comes from either pts themselves or from
multiD recommendation.

2. SBRT 40% failure rates?
Click to expand...

If you factor in all locoregional failures there have been some reports where that rate approaches 40%, that’s true (he likes to hammer this selectively, admittedly)
 
TheWallnerus said:
If you factor in all locoregional failures there have been some reports where that rate approaches 40%, that’s true (he likes to hammer this selectively, admittedly)
Click to expand...
I think that is from reports of late biopsies, which are probably showing intact cells that have no proliferation potential.
 
TheWallnerus said:
Honest answer: 15 fx of partial breast opposed tangent IMRT beams. This will have ~99% 5y LC and significantly lower side effects than whole breast/partial axillary treatment (of whatever sort), and based on "apples to orange" comparisons versus contemporary whole breast RT data, better LC (this, I know, is a counterintuitive, but true, statement).

I would love to do 5 fractions of 5.2 Gy each of partial breast, but I would bankrupt the house.

View attachment 377054
Click to expand...
You forgot the boost!!!
 
Radonc90 said:


- So, Stiles said on his slide:

* "Selection of pts for SBRT should be guided by surgeons".

* "SBRT is associated with an inadequate pCR rate and with failure rates of ~ 40%".


2. SBRT 40% failure rates?
Click to expand...

He loves to quote the MISSILE trial that showed PCR of 60%. In gusssing that’s where he is getting that.
 
medgator said:
So many of my SBRT referrals never even get sniffed by a CT surgeon. Such a different dynamic in academics
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Same here. I'm usually the one suggesting it, but so far I can only think of one patient who has agreed to go see a surgeon. Every other one says "But.... my doctor told me this is the right treatment!" Fine by me....
 
Nationally, the number of pts getting sbrt for stage I nsclc per radonc is absurdly low. In really don’t care if my thoracic surgeon wants to take resect a stage I nsclc in an 80yo. If he thinks he can get it out safely, go for it.
Not a big part of what we do, so I really don’t have much interest in this debate. Would hate to to work with either stiles or his radonc counterpart.
 
RickyScott said:
Nationally, the number of pts getting sbrt for stage I nsclc per radonc is absurdly low. In really don’t care if my thoracic surgeon wants to take resect a stage I nsclc in an 80yo. If he thinks he can get it out safely, go for it.
Not a big part of what we do, so I really don’t have much interest in this debate. Would hate to to work with either stiles or his radonc counterpart.
Click to expand...

I do care if a surgeon wants to resect a stage I NSCLC in an 80 year old when there is an equally effective non-invasive treatment that I'm biased toward - that's my problem and why I've made it my battle of choice to fight. I wouldn't want that for my grandparent, parent, friend, relative in that situation. If patient chooses that after weighing both options (and it's actually safe) fine.
Patients need to know there is an alternative and in many places, they are not being offered that choice.
 
RickyScott said:
Nationally, the number of pts getting sbrt for stage I nsclc per radonc is absurdly low. In really don’t care if my thoracic surgeon wants to take resect a stage I nsclc in an 80yo. If he thinks he can get it out safely, go for it.
Not a big part of what we do, so I really don’t have much interest in this debate. Would hate to to work with either stiles or his radonc counterpart.
Click to expand...
That doesn't jive with my experience in the era of LD-CT screening. Definitely feel like the caseload has ramped up over the last few years...
 
medgator said:
That doesn't jive with my experience in the era of LD-CT screening. Definitely feel like the caseload has ramped up over the last few years...
Click to expand...
The number of people getting SBRT is low, and rad onc case loads w/ SBRT for stage I are increasing (on average; individuals will have variability). Both are true. There will be about 500 to 600 stage I NSCLC patients getting SBRT tomorrow, nationally (this roughly equates to 500 to 600 new stage I SBRT consult patients per week, nationally; or 10 to 12 patients per state per week!). There’s a market cap here tho, and that market cap is decreasing. Rad onc case loads will do a “peak oil” thing most likely.

lung-revised.jpg
 
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metallica81788 said:
I do care if a surgeon wants to resect a stage I NSCLC in an 80 year old when there is an equally effective non-invasive treatment that I'm biased toward - that's my problem and why I've made it my battle of choice to fight. I wouldn't want that for my grandparent, parent, friend, relative in that situation. If patient chooses that after weighing both options (and it's actually safe) fine.
Patients need to know there is an alternative and in many places, they are not being offered that choice.
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I save my outrage for cystectomies.
 
RickyScott said:
I save my outrage for cystectomies.
Click to expand...
That would be an excellent band name. „The cystectomy outrage“

or perhaps an album name?

The cystectomy outrage

Track list:
1. (I can't get no) Neoadjuvant chemo
2. Tripping over my Foley
3. Incontinent
4. Avelumab Calling
5. Ooops, I recurred again

EDIT: Track lick order adjusted (makes more sense now)
 
Last edited:
TheWallnerus said:
Honest answer: 15 fx of partial breast opposed tangent IMRT beams. This will have ~99% 5y LC and significantly lower side effects than whole breast/partial axillary treatment (of whatever sort), and based on "apples to orange" comparisons versus contemporary whole breast RT data, better LC (this, I know, is a counterintuitive, but true, statement).

I would love to do 5 fractions of 5.2 Gy each of partial breast, but I would bankrupt the house.

View attachment 377054
Click to expand...
I can't wait until data from the single fraction whole breast trial FAST-AF.
 
Radonc90 said:
In the mean time, Stiles showed this slide...

Click to expand...

Surgeons plainly declare their modality superior to radiation.

Radiation's largest professional society charges $40 for a 7AM breakfast to hear about their goofy legislative proposal.

2023: great or greatest year for radiotherapy?
 
elementaryschooleconomics said:
Surgeons plainly declare their modality superior to radiation.

Radiation's largest professional society charges $40 for a 7AM breakfast to hear about their goofy legislative proposal.

2023: great or greatest year for radiotherapy?
Click to expand...
This presentation was his half of a pro-con debate. I wonder what the title for the pro radiation talk was. Can't find it easily on the website though
 
elementaryschooleconomics said:
Surgeons plainly declare their modality superior to radiation.

Radiation's largest professional society charges $40 for a 7AM breakfast to hear about their goofy legislative proposal.

2023: great or greatest year for radiotherapy?
Click to expand...

Sameer, no worries, I got this!

The $40 was for a food ticket, but the event is open. It was always this way, they just forgot to announce that part. Give them some grace please.

Now, this might be confusing but... the other events are not open, there are tickets. That ticket is for the event, not the food. If you want food, you will have to bring your own and pay the corkage fee of $425 per item. It does seem steep, but ASTRO is still trying to pay off their loan for that keynote speaker a few years back. Rates are super high now! Grace pleaaaase. Gimme.

ESE, all you have to do is just listen to ASTRO is saying right now today, forget what they said yesterday, don't ask any questions, and maybe praise them a little bit. Or a lot. This is not hard, they do so much for the boa... uh, field. Yes. The whole field. What is not clear? Maybe ol' Wallner was right about decreasing quality young radiation oncologists. Jeez.

Separate from all that, why are you so negative? Do you want ASTRO to die? Stop bullying ASTRO with follow up questions, just give them your money and be thankful they are trying to engage you.
 
NotMattSpraker said:
Sameer, no worries, I got this!

The $40 was for a food ticket, but the event is open. It was always this way, they just forgot to announce that part. Give them some grace please.

Now, this might be confusing but... the other events are not open, there are tickets. That ticket is for the event, not the food. If you want food, you will have to bring your own and pay the corkage fee of $425 per item. It does seem steep, but ASTRO is still trying to pay off their loan for that keynote speaker a few years back. Rates are super high now! Grace pleaaaase. Gimme.

ESE, all you have to do is just listen to ASTRO is saying right now today, forget what they said yesterday, don't ask any questions, and maybe praise them a little bit. Or a lot. This is not hard, they do so much for the boa... uh, field. Yes. The whole field. What is not clear? Maybe ol' Wallner was right about decreasing quality young radiation oncologists. Jeez.

Separate from all that, why are you so negative? Do you want ASTRO to die? Stop bullying ASTRO with follow up questions, just give them your money and be thankful they are trying to engage you.
Click to expand...
This is art.
 
TheWallnerus said:
ViewRay a complete goner

Guess people will still keep using their machines until the machines break, but I find that risky

Essentially when the ViewRay breaks or needs service, you’ve got the world’s most technologically advanced paperweight
Click to expand...
This is okay for 21c/genesis as many of their other machines are Siemens. Time to open a linac junkyard.
 
Palex80 said:

View attachment 377342
Click to expand...

TheWallnerus said:
ViewRay a complete goner

Guess people will still keep using their machines until the machines break, but I find that risky

Essentially when the ViewRay breaks or needs service, you’ve got the world’s most technologically advanced paperweight
Click to expand...
I'm guessing that's what the tweet is about? You don't think third party companies will move in and try to fill an aftermarket niche like they do with varian machines?
 
medgator said:
I'm guessing that's what the tweet is about? You don't think third party companies will move in and try to fill an aftermarket niche like they do with varian machines?
Click to expand...
That's definitely possible, however, ViewRay is the biggest player by far in the US (maybe global?) for MR-Linacs.

There were ultimately no buyers while they were in bankruptcy. The deadline is passed. They basically have to rapidly close up shop.

For another MR-Linac player to spin up will take a lot of time, and won't help anyone who currently owns a ViewRay machine.

The next month should be fairly chaotic.
 
medgator said:
I'm guessing that's what the tweet is about? You don't think third party companies will move in and try to fill an aftermarket niche like they do with varian machines?
Click to expand...
I wonder how easy it will be for a third party company to service Viewray machines. Are there any IP issues or do the IP rights of Viewray dissolve once the company has to close shop?
 
Palex80 said:
I wonder how easy it will be for a third party company to service Viewray machines. Are there any IP issues or do the IP rights of Viewray dissolve once the company has to close shop?
Click to expand...
i would think it would be quite difficult given the complexities and software
 
RickyScott said:
i would think it would be quite difficult given the complexities and software
Click to expand...

I always assumed the techs start their own service company off shoot....I guess getting parts is a big problem though. But there are probably a ?dozen? people out there who can work on these machines, right?
 
BobbyHeenan said:
I always assumed the techs start their own service company off shoot....I guess getting parts is a big problem though. But there are probably a ?dozen? people out there who can work on these machines, right?
Click to expand...
Even if this happened, which it won’t for ViewRay, how long would you want to limp through life like this as a clinic.

Katie Couric where are you

IMG_3461.png
 
BobbyHeenan said:
I always assumed the techs start their own service company off shoot....I guess getting parts is a big problem though. But there are probably a ?dozen? people out there who can work on these machines, right?
Click to expand...
True, but they can’t really produce new parts, right? Viewray still holds IP rights on several of these parts, I would presume…
 
I know for certain that one of the big academic systems that owns more than one ViewRay machine was considering poaching the employees who can perform service/maintenance.

This was a month or two ago, before doom was absolutely certain, and I don't have a more recent update as to where that stands.

But best case scenario would be some startup forms which the IP/patent owners license stuff to for servicing existing equipment. That wouldn't be an overnight thing though.
 
elementaryschooleconomics said:
I know for certain that one of the big academic systems that owns more than one ViewRay machine was considering poaching the employees who can perform service/maintenance.

This was a month or two ago, before doom was absolutely certain, and I don't have a more recent update as to where that stands.

But best case scenario would be some startup forms which the IP/patent owners license stuff to for servicing existing equipment. That wouldn't be an overnight thing though.
Click to expand...
Will the big academic center hire a PhD Viewray person to work on the machine then have a meeting and deem that person’s work not of faculty quality
 
elementaryschooleconomics said:
That's definitely possible, however, ViewRay is the biggest player by far in the US (maybe global?) for MR-Linacs.

There were ultimately no buyers while they were in bankruptcy. The deadline is passed. They basically have to rapidly close up shop.

For another MR-Linac player to spin up will take a lot of time, and won't help anyone who currently owns a ViewRay machine.

The next month should be fairly chaotic.
Click to expand...
A lawyer friend once told me that bankruptcy law is the Wild West of US law and anything can happen. The tech IP has definite value, and at some point viewray will have to sell the IP to pay its creditors. I bet other companies are waiting for that fire sale rather than opting to buy the company outright. It might make more sense for a company to buy the IP and start fresh rather than buy the company and all its debt
 
Palex80 said:
Would that be in their interest, though?
I mean, every clinic with a MRidian would want to keep this capability. So, would they not simply buy an Elekta Unity instead?
Click to expand...
At one point Elekta actually had ownership stake in ViewRay IIRC.
Crazy news if its true.
I have heard from many people that for those interested in the MR-linac platform, ViewRay was a "better system" in terms of capability, user interface, et.c
 
radoncftw said:
At one point Elekta actually had ownership stake in ViewRay IIRC.
Crazy news if its true.
I have heard from many people that for those interested in the MR-linac platform, ViewRay was a "better system" in terms of capability, user interface, et.c
Click to expand...
I also heard that viewray was the better product, partly due to the software. If you’ve ever experienced the POS that is Mosaiq you wouldn’t be surprised.
 
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