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RickyScott said:
It wouldn’t surprise me if Siemens totally screws up Varian. A lot of people have left and the service guys are really pissed off.
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There's also an ~18 month lag time on getting a new Truebeam (source: me trying to buy a new Truebeam).

In August, the Siemens Q3 earnings call reported Varian margins down a bit from predicted due to "temporary outbound logistics".

Might get real interesting.

However, at this point, "outbound logistics issues" could mean "Varian has a borderline global monopoly on linacs now and it's hard to keep up with demand due to supply chain hiccups from that pesky pandemic".
 
elementaryschooleconomics said:
There's also an ~18 month lag time on getting a new Truebeam (source: me trying to buy a new Truebeam).

In August, the Siemens Q3 earnings call reported Varian margins down a bit from predicted due to "temporary outbound logistics".

Might get real interesting.

However, at this point, "outbound logistics issues" could mean "Varian has a borderline global monopoly on linacs now and it's hard to keep up with demand due to supply chain hiccups from that pesky pandemic".
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Supposedly some used ones finally in the market after several years. If you are willing to go that route
 
medgator said:
Supposedly some used ones finally in the market after several years. If you are willing to go that route
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They have to be from third party sellers right?

I asked Varian about this, they told me if you replace a Varian linac with a new Varian linac, they scrap the old ones and can't/won't sell it.

I've seen some listed on the big medical device reseller sites, but they look like they're shipping from somewhere across the Pacific Ocean...
 
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?
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Yes I agree that they could just smoke a cigar and sip bourbon and watch the whole thing burn and when they get desperate sell them a unity. Alternatively, they could try to help and secure that business. Purely speculating. Will be interesting to see what happens.
 
grenz said:
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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Elekta about 5-7 years behind viewray in terms of capabilities. But that doesn't matter now.
 

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OTN said:
Improvement in CBCT quality and technique quickly rendered this machine obsolete, especially at the ridiculous price point.

(Edited to remove my first sentence, which I ended up disagreeing with)
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I recently was doing some research on pre-op SBRT for sacral chordomas and read the following excellent quote in a 2023 review article. It really highlights the irrelvancy of MR-linacs and protons/carbon too for that matter:

"Advances in radiation technology including micro-multileaf collimators, cone beam CT scans, robotic systems, and real-time image guidance have allowed for progressively more precise delivery of photon therapy utilizing steep dose gradients and the emergence of SBRT. SBRT is increasingly available at many community and academic centers throughout the world, and thus is more readily available than charged particle therapies such as proton and carbon ion therapy, which have been discussed in earlier sections."

Source: Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy - PubMed
 
Gfunk6 said:
I recently was doing some research on pre-op SBRT for sacral chordomas and read the following excellent quote in a 2023 review article. It really highlights the irrelvancy of MR-linacs and protons/carbon too for that matter:

"Advances in radiation technology including micro-multileaf collimators, cone beam CT scans, robotic systems, and real-time image guidance have allowed for progressively more precise delivery of photon therapy utilizing steep dose gradients and the emergence of SBRT. SBRT is increasingly available at many community and academic centers throughout the world, and thus is more readily available than charged particle therapies such as proton and carbon ion therapy, which have been discussed in earlier sections."

Source: Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy - PubMed
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would love to have an mri sim. Not sure what mri linac brings outside of niche indications and research. they were never going to expand beyond large academic centers.
 
RickyScott said:
would love to have an mri sim. Not sure what mri linac brings outside of niche indications and research. they were never going to expand beyond large academic centers.
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Never made any sense to me whatsoever. Who is paying 8m for a machine with no improvement in coding "but vsims daily!" ain't gonna cut it.

The nice breakfast/food they had out was sweet while it lasted.

While the "party invites" for ASTRO used to be pretty good, I prefer the smaller more personable dinners I've had with reps at ACRO.
 
OTN said:
Improvement in CBCT quality and technique quickly rendered this machine obsolete, especially at the ridiculous price point.

(Edited to remove my first sentence, which I ended up disagreeing with)
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While there are other ways to do the same treatment, MR based real time tracking was IMO a cleaner way to do SBRT (eg prostate or lung). The adaptive promise wasn't fully realized but to the company's credit they were funding a large number of trials to create evidence, even for new/potential indications, that we all crave. I'd rather a MR Linac than other niche machines like tomo or cyberknife. But none of these make sense unless probably 4 vaults plus.
 
temujim said:
While there are other ways to do the same treatment, MR based real time tracking was IMO a cleaner way to do SBRT (eg prostate or lung). The adaptive promise wasn't fully realized but to the company's credit they were funding a large number of trials to create evidence, even for new/potential indications, that we all crave. I'd rather a MR Linac than other niche machines like tomo or cyberknife. But none of these make sense unless probably 4 vaults plus.
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The pictures/movies looked beautiful on screen

They made the cockles of the rad onc’s heart so warm

But there was not any clinical proof for side effects or cure that real time tracking made a difference… only a MIRAGE
 
temujim said:
While there are other ways to do the same treatment, MR based real time tracking was IMO a cleaner way to do SBRT (eg prostate or lung). The adaptive promise wasn't fully realized but to the company's credit they were funding a large number of trials to create evidence, even for new/potential indications, that we all crave. I'd rather a MR Linac than other niche machines like tomo or cyberknife. But none of these make sense unless probably 4 vaults plus.
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The "adaptive promise wasn't fully realized" because it doesn't work. I don't know what "cleaner way to do SBRT" means, but I know MRlinacs generated no data suggesting they were "cleaner" than anything else.
 
OTN said:
The "adaptive promise wasn't fully realized" because it doesn't work
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I am not yet sure I agree. I really do think with the way the speed of automation and AI is improving, adaptation will be fast AF in the future and will be standard way to treat people. not sure when, but likely in most of our careers, adaptation in real time, along with real time gating possibly, will be normal. It is likely to be CT based for most of us. Many patients will likely start treatment within 1-2 days from sim, if not the same day.

but to the post - I am not sure LUNG sbrt or even prostate would be where I would be focusing my efforts, but rather most abdominal things.

for standard 30 fraction chemoRT lung - I agree, it will be a a cinch to quickly generate a new plan within 10 minutes for a lung CA that has been responding
 
drowsy12 said:
I am not yet sure I agree. I really do think with the way the speed of automation and AI is improving, adaptation will be fast AF in the future and will be standard way to treat people. not sure when, but likely in most of our careers, adaptation in real time, along with real time gating possibly, will be normal. It is likely to be CT based for most of us

but to the post - I am not sure LUNG sbrt or even prostate would be where I would be focusing my efforts, but rather most abdominal things.

for standard 30 fraction chemoRT lung - I agree, it will be a a cinch to quickly generate a new plan within 10 minutes for a lung CA that has been responding
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H+N was the lowest-hanging fruit for adaptive, and the trial was negative.
 
OTN said:
H+N was the lowest-hanging fruit for adaptive, and the trial was negative.
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In my opinion it was likely never going to significantly change much in delivered dose in HN, with the way they did it in the trial. the main reason I even bother adapting massively responding head and neck patients (meaning resin and replan) is to get dose off skin by large nodes that are now gone, but more importantly, to make sure that with significant contour changes of external contour, that the tumor is getting what it is supposed to get.

personally I did not think it was possible for adaptation to do much in HN in terms of noticeable toxicity. same thing btw has been seen in unilateral HN vs bilateral HN treatments. patients are going to get the same mucosal toxicities that drives things.

I guess my bigger point is that in the future, it may be so easy to do it that it's going to be done just because we can, like many things we do.
 
The premise of ViewRay is a sign of the dismal state of innovation in radiation oncology

We will invest $8M in an expensive machine, hire more staff to...

shorten pancreatic treatment from 25 fractions to 5? or
shorten prostate treatment from 20 to 28 to 5?

At what point do we say that the 25 fraction Crane regimen, 20 fraction prostate or CT-based adaptive is 'non-inferior'. I guess 10.25.23 is the official answer.
 
theradiator said:
The premise of ViewRay is a sign of the dismal state of innovation in radiation oncology

We will invest $8M in an expensive machine, hire more staff to...

shorten pancreatic treatment from 25 fractions to 5? or
shorten prostate treatment from 20 to 28 to 5?

At what point do we say that the 25 fraction Crane regimen, 20 fraction prostate or CT-based adaptive is 'non-inferior'. I guess 10.25.23 is the official answer.
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and then from 5 to 2 in prostate. Viewray was pushing this trial at cornell and some other sites.
 
theradiator said:
The premise of ViewRay is a sign of the dismal state of innovation in radiation oncology

We will invest $8M in an expensive machine, hire more staff to...

shorten pancreatic treatment from 25 fractions to 5? or
shorten prostate treatment from 20 to 28 to 5?

At what point do we say that the 25 fraction Crane regimen, 20 fraction prostate or CT-based adaptive is 'non-inferior'. I guess 10.25.23 is the official answer.
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A great example of smart people really sucking at simple economics. Maybe they don’t suck at economics, they just suck at billing and coding and rad onc reimbursement knowledge
 
OTN said:
The "adaptive promise wasn't fully realized" because it doesn't work. I don't know what "cleaner way to do SBRT" means, but I know MRlinacs generated no data suggesting they were "cleaner" than anything else.
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To each his own. Wasn't right for your practice and that's fine. Of course, that was the fatal flaw in their business plan -- a niche machine only big centers would invest in. Maybe tops they could install 80-100 across the world, not enough to support their pricing and spend.

And not saying it was better (bc we'll never know -- if you think running a phase 3 definitive radiation superiority trial in any disease site in the clinical lifetime of VR was possible, don't know what to tell you). It was certainly cleaner in the sense that one did not have to rely on invasive or non-invasive surrogates of tumor position -- actually could see the tumor during treatment at 8 frames (I think this was the last software update, may have been 16) per second.
 
OTN said:
H+N was the lowest-hanging fruit for adaptive, and the trial was negative.
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Terrible trial; 5 mm margins focused only on parotid while they ignored submandibulars and oral cavity for a primary endpoint of total stimulated saliva. However, their isolated parotid scintigraphy was positive. I don't think adaptive dead yet in this site.
 
sirspamalot said:
who buys 8m machines without a clear path to reimbursement?

No one, and you'll go bankrupt (phrase I uttered long ago).

Chickens be roostin' yo
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Know of more than a few centers with 2 (whether VR or Elekta or combo) and a few centers with one planning on a second. Seems like they paid their machines off quick and well enough?
 
TheWallnerus said:
A great example of smart people really sucking at simple economics. Maybe they don’t suck at economics, they just suck at billing and coding and rad onc reimbursement knowledge
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Huge academic center (and especially PPS exempt) is fantasy land. They are so far removed from the normal reimbursement paradigms and challenges they have no clue. Their economics are not my economics.
 
radiaterMike said:
Huge academic center (and especially PPS exempt) is fantasy land. They are so far removed from the normal reimbursement paradigms and challenges they have no clue. Their economics are not my economics.
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...which is precisely why they should NOT be involved in any way whatsoever in designing reimbursement schemes for the rest of us. Why they're even allowed in the same room as the discussions is beyond me.
 
sirspamalot said:
who buys 8m machines without a clear path to reimbursement?

No one, and you'll go bankrupt (phrase I uttered long ago).

Chickens be roostin' yo
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We tried to get protons from our govt… the MRL’s were the ‘consolation prize’. We are now rediscussing protons with the govt now that prices have come down more.
 
HolySmokes said:
optimization on Monaco is powerful but no more so imo than Eclipse or Raystation and every other part of using it is a truly unpleasant experience
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I think it’s very slick since there’s no need for opti structures and it’s multi oar focused from start. Can push plans beyond what I thought was possible. Also easily templated to similar anatomies
 
Ray D. Ayshun said:
Hmmm. All us private practice docs getting criticized for factoring in lifestyle. If lifestyle's not a big deal, the Fri afternoon coverage shouldn't be.
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In a lot of academic depts, everything from office space to call schedule to inpt consults is heavily politicized. I remember some faculty who would put so much more effort and time into avoiding a simple inpt bone met than just treating the pt.
 
RickyScott said:
In a lot of academic depts, everything from office space to call schedule to inpt consults is heavily politicized. I remember some faculty who would put so much more effort and time into avoiding a simple inpt bone met than just treating the pt.
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Oh, I know. I'm quick to respond to anything with a smile in practice. This isn't necessarily what I was taught to do.
 
Dan is super polarizing.

But, if this is true, and I have no reason to believe it isn't, it is a good look and the right thing to do.

The fact that it is celebrated is an indictment of all the other chairman who do so little.

He's a tough personality at times, but he is doing a lot of good in our world. Faculty getting paid properly. Growing research infrastructure. Taking interest in resident education.

Sometimes the good leaders aren't the ones you want to get a beer with or be friends with. He's relentlessly singleminded, we've spoken a fair amount. Two completely different human beings. We are never gonna share biryani together or high five at at Wolverines game, but I respect a chairman that sees patients and takes call.

My chairman in residency doing any of the above? HAHAHAHAHAHAHHAHAHAHAHAHHA, I cannot type enough laughter.
 
RealSimulD said:
it is a good look and the right thing to do
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Agree. All chairs should do something like this.

Although I would also argue that all chairs should be rotating positions with 2-3 year terms and not a career goal of academics.

Imagine our field if there were no permanent chairs? If the satellite doc got to (had to) be chair as well as the doc with 2 RO-1 grants.

It would be a better field.
 
RickyScott said:
In a lot of academic depts, everything from office space to call schedule to inpt consults is heavily politicized. I remember some faculty who would put so much more effort and time into avoiding a simple inpt bone met than just treating the pt.
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THIS

I cannot express how much it raises one's QoL to step away from all the political games and just have a regular job and regular life like a regular doc.
 
RealSimulD said:
Dan is super polarizing.

But, if this is true, and I have no reason to believe it isn't, it is a good look and the right thing to do.

The fact that it is celebrated is an indictment of all the other chairman who do so little.

He's a tough personality at times, but he is doing a lot of good in our world. Faculty getting paid properly. Growing research infrastructure. Taking interest in resident education.

Sometimes the good leaders aren't the ones you want to get a beer with or be friends with. He's relentlessly singleminded, we've spoken a fair amount. Two completely different human beings. We are never gonna share biryani together or high five at at Wolverines game, but I respect a chairman that sees patients and takes call.

My chairman in residency doing any of the above? HAHAHAHAHAHAHHAHAHAHAHAHHA, I cannot type enough laughter.
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Great post. I've now recommended two people go work for him while saying "I would never go work for him."

We still have a big problem with prominent academics putting down community medicine and rural medicine. I talk to so many people that come to our conversation defending their desire to do something other than rising in an academic department. My one early career regret is wishing I accepted my own desire to leave academics earlier.

If he became less singleminded and signaled that outward, he would have an even greater impact on the field.
 
TheWallnerus said:
Sounds like doc of the half day 😎
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Very common system in academic institutions where every attending (usually NOT including the chair, FWIW) takes a half day of 'machine coverage', which is variable in responsibilities based on the institution.
 
communitydoc13 said:
Agree. All chairs should do something like this.

Although I would also argue that all chairs should be rotating positions with 2-3 year terms and not a career goal of academics.

Imagine our field if there were no permanent chairs? If the satellite doc got to (had to) be chair as well as the doc with 2 RO-1 grants.

It would be a better field.
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The chairs at Mayo rotate
 
RealSimulD said:
Dan is super polarizing.

But, if this is true, and I have no reason to believe it isn't, it is a good look and the right thing to do.

The fact that it is celebrated is an indictment of all the other chairman who do so little.

He's a tough personality at times, but he is doing a lot of good in our world. Faculty getting paid properly. Growing research infrastructure. Taking interest in resident education.

Sometimes the good leaders aren't the ones you want to get a beer with or be friends with. He's relentlessly singleminded, we've spoken a fair amount. Two completely different human beings. We are never gonna share biryani together or high five at at Wolverines game, but I respect a chairman that sees patients and takes call.

My chairman in residency doing any of the above? HAHAHAHAHAHAHHAHAHAHAHAHHA, I cannot type enough laughter.
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Great post! Without realizing it, Nicholas Zaorsky - who seems like a great guy by the way - was by comparison smearing the former chair at Penn State.
 
communitydoc13 said:
Agree. All chairs should do something like this.

Although I would also argue that all chairs should be rotating positions with 2-3 year terms and not a career goal of academics.

Imagine our field if there were no permanent chairs? If the satellite doc got to (had to) be chair as well as the doc with 2 RO-1 grants.

It would be a better field.
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No different than term limits in Congress....
 
medgator said:
No different than term limits in Congress....
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It's worse than that.

Presumably, congressman are subject to elections q2 years.

Of the chairs I was familiar with during residency (now more than 10 years ago at completion) none returned to ambitious lab heavy research or being the primary thinker regarding clinical research (although some have vanity labs run by other people), most are still chairs and some graduated from radiation oncology to institutional leaderships roles or even perverse gigs like the one Steve Hahn got.

Even worse is the known gatekeeper role that chairs play regarding academic opportunities. In most residencies, there is one person that you need to impress, and that is your chair. You may impress others and an astute chair may value this, but it is also true that a resident or junior faculty who impresses a wide swath of colleagues but not the chair themselves is...screwed.

It's perverse consolidation of power. It leads to all sorts of dumb sycophantic behavior by careerists, and all of it would go away if chairs were just rotating positions.

From what I can tell, MAYO has no problems recruiting.

Maybe SCAROP can insist on rotating chairs? 🤣
 
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