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evilbooyaa said:
It's not (and never has been) about the money for me - with capitated I would still offer conventional. Same with offering 30/10 for complex bone mets in metastatic patients not approaching hospice.
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I cannot get myself to ever give 30 in 10 any more. Ever ever.

But, my payors very good about conformal tech

So, I do a ton of 12-16/1 or 25-30/5
 
RealSimulD said:
I cannot get myself to ever give 30 in 10 any more. Ever ever.

But, my payors very good about conformal tech

So, I do a ton of 12-16/1 or 25-30/5
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If I was confident I could do IMRT/SBRT routinely I would be happy to do those regimens. Most of my palliative targets are not nice little circles than DCA makes sense. Bone met in an extremity or lateral pelvis or rib, yeah 25/5 is fine...
 
None of it is wrong!

Just not a fan of two weeks for palliation, and meta shows a little higher tox. But people swear by it and have for decades.

I’ve been pretty Taleb-ized. Stuff that works, well, it works. And no reason to always change for change’s sake. 30/10 3D is a super cheap and effective regimen and the most data. I’ve just always preferred as short as possible for bone mets, which doesn’t always translate to cheaper.
 
RealSimulD said:
meta shows a little higher tox
Click to expand...

30/10 has higher tox than 8/1 ?

You Dont Know Me Jason Sudeikis GIF by Saturday Night Live
 
UAB should never have gone with Varian's large footprint and hugely expensive model. Proton International was just a finance arm of Varian and the sales team was happy to make comforting promises they couldn't help the board of trustees and ego-centric clinical leadership docs keep. Small footprints and affordable evolutionary tech solutions would have made sense for tons of reasons. This is just another cliched example of the idiocracy of corporatized healthcare. And as a result, it will be another black eye for the proton community and rad onc community.
 
PrdgmShift said:
UAB should never have gone with Varian's large footprint and hugely expensive model. Proton International was just a finance arm of Varian and the sales team was happy to make comforting promises they couldn't help the board of trustees and ego-centric clinical leadership docs keep. Small footprints and affordable evolutionary tech solutions would have made sense for tons of reasons. This is just another cliched example of the idiocracy of corporatized healthcare. And as a result, it will be another black eye for the proton community and rad onc community.
Click to expand...
Curious..what is the leading small footprint and affordable evolutionary tech in protons?
 
RealSimulD said:
None of it is wrong!

Just not a fan of two weeks for palliation, and meta shows a little higher tox. But people swear by it and have for decades.

I’ve been pretty Taleb-ized. Stuff that works, well, it works. And no reason to always change for change’s sake. 30/10 3D is a super cheap and effective regimen and the most data. I’ve just always preferred as short as possible for bone mets, which doesn’t always translate to cheaper.
Click to expand...

I totally agree. The idea of keeping someone in my clinic for two weeks for palliation just not my style, and I don’t like the higher acute tox.

My main approach is 20-25/5 for most palliative things

I do 30/10 for non-whole brain like once a year
 
NotMattSpraker said:
If that's not a message the battle for evidence based implementation is lost, I dont know what is.
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This is one way to look at it.

The counterargument is that if we restrict proton solutions to only facilities that cost hundreds of million of dollars, then those facilities will never produce the evidence we want, because they will simply be busy treating prostate cancer patients with 44 x 1.8 Gy with protons in order to pay back those investments.

If on the other hand, cheap solutions become available, then the whole pressure to treat nonsense will disappear and we may end up actually treating those cases, where common sense says protons may be good (like meningiomas and lymphomas) or even some tough re-irradiation cases (even if the intention is palliative!).
 
Palex80 said:
This is one way to look at it.

The counterargument is that if we restrict proton solutions to only facilities that cost hundreds of million of dollars, then those facilities will never produce the evidence we want, because they will simply be busy treating prostate cancer patients with 44 x 1.8 Gy with protons in order to pay back those investments.
Click to expand...

The NAPT counter argument 🙂 we are in an access crisis!

Who is "restricted"?

Most proton centers treat majority breast, prostate, and head and neck where there is zero evidence of benefit.

I thought the S250 article was interesting.

“I have seen the clinical benefits of proton therapy for the past 20 years, especially for pediatric patients, and the idea that proton therapy could be accessible to all pediatric patients has always been my dream. I am so excited to hear of this innovation. This product could be a game changer,” said Nancy Tarbell, MD, a world-renowned pediatric radiation oncologist, and CC Wang Professor emerita at Harvard Medical School and Mass General Hospital.
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I do not know Nancy at all, but does she really believe this? The cost of a single S250 unit would buy a lot of plane tickets and hotel rooms in Boston. I just don't think we can assume that lack of vaults is the access issue we have in the US. This only makes sense if you area true believer... someone who thinks better dosimetry = better outcomes in all cases. We know these people are out there, they've published it, but clinical trials prove them wrong.

Canada's current approach to proton therapy access proves them wrong too.

What am I missing?

If on the other hand, cheap solutions become available, then the whole pressure to treat nonsense will disappear and we may end up actually treating those cases, where common sense says protons may be good (like meningiomas and lymphomas) or even some tough re-irradiation cases (even if the intention is palliative!).
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I don't understand this part, but I'm not an economist so wont come at it from that angle.

But logically, it doesn't make sense. Many centers already have ubiquitous access to IMRT, which is very good. This is not the year 2000.

IMRT could be equal or better for most indications. Why do I need to swap out what I am already doing for something that is more expensive and labor intensive with no benefit? This is totally backwards in my opinion. What happened to EBM?
 
NotMattSpraker said:
The NAPT counter argument 🙂 we are in an access crisis!

Who is "restricted"?

Most proton centers treat majority breast, prostate, and head and neck where there is zero evidence of benefit.

I thought the S250 article was interesting.



I do not know Nancy at all, but does she really believe this? The cost of a single S250 unit would buy a lot of plane tickets and hotel rooms in Boston. I just don't think we can assume that lack of vaults is the access issue we have in the US. This only makes sense if you area true believer... someone who thinks better dosimetry = better outcomes in all cases. We know these people are out there, they've published it, but clinical trials prove them wrong.

Canada's current approach to proton therapy access proves them wrong too.

What am I missing?



I don't understand this part, but I'm not an economist so wont come at it from that angle.

But logically, it doesn't make sense. Many centers already have ubiquitous access to IMRT, which is very good. This is not the year 2000.

IMRT could be equal or better for most indications. Why do I need to swap out what I am already doing for something that is more expensive and labor intensive with no benefit? This is totally backwards in my opinion. What happened to EBM?
Click to expand...
EBM? PBM. Profit based medicine
 
I did not say that we are in an access crisis, I think you misunderstood my point.
The US likely has more than enough proton centers and we do not have access issues in Europe to treat what makes most sense with protons.
The problem with protons is the cost.

If you are going to spend hundreds of millions to build a facility and need millions per year to keep it running, you will have to treat prostates and breasts to pay it off. Because those are the cases, with which most of the radoncs make their money. Little effort, yet high pay.

5 prostate proton patients indirectly pay for 1 medulloblastoma proton treatment for a 5 year old.

So, if we are able to get proton solutions that are cheap, both in installation and operation, we may end up treating stuff which may make more sense. And that is where the S250 may fill a gap. If it costs 15 millions to set up, 1 million per year to operate and you can put it in an old department without having to build a new vault, then a center which now has 3-4 linacs and is thinking of swapping one of their C-arm linacs for a cyberknife, may actually buy one S250. The price likely has to come down more, I think the sweet spot is around the MR-linac or fully upgraded Cyberknife price, roughly worth two C-arm Linacs.

Have any of you seen a proton treatment for repeat RT of a bone met, which has already had considerable dose to the cord or perhaps a repeat RT for a nasty rectal cancer recurrence where the plexus and the small bowel are troublesome for photons? I haven‘t.
Because those treatments generally do not pay well, regardless if it‘s photons or protons.

It‘s a bit like the MR Linac argument. Many centers used/use those machines to treat prostate, where the clinical benefit is likely small (we‘ve been over Mirage). There‘s a reason those machines were not running 24/7 with NSCLC SBRT (where data is also compelling) or pancreas.
 
Palex80 said:
I did not say that we are in an access crisis, I think you misunderstood my point.
The US likely has more than enough proton centers and we do not have access issues in Europe to treat what makes most sense with protons.
The problem with protons is the cost.

If you are going to spend hundreds of millions to build a facility and need millions per year to keep it running, you will have to treat prostates and breasts to pay it off. Because those are the cases, with which most of the radoncs make their money. Little effort, yet high pay.

5 prostate proton patients indirectly pay for 1 medulloblastoma proton treatment for a 5 year old.

So, if we are able to get proton solutions that are cheap, both in installation and operation, we may end up treating stuff which may make more sense. And that is where the S250 may fill a gap. If it costs 15 millions to set up, 1 million per year to operate and you can put it in an old department without having to build a new vault, then a center which now has 3-4 linacs and is thinking of swapping one of their C-arm linacs for a cyberknife, may actually buy one S250. The price likely has to come down more, I think the sweet spot is around the MR-linac or fully upgraded Cyberknife price, roughly worth two C-arm Linacs.

Have any of you seen a proton treatment for repeat RT of a bone met, which has already had considerable dose to the cord or perhaps a repeat RT for a nasty rectal cancer recurrence where the plexus and the small bowel are troublesome for photons? I haven‘t.
Because those treatments generally do not pay well, regardless if it‘s photons or protons.

It‘s a bit like the MR Linac argument. Many centers used/use those machines to treat prostate, where the clinical benefit is likely small (we‘ve been over Mirage). There‘s a reason those machines were not running 24/7 with NSCLC SBRT (where data is also compelling) or pancreas.
Click to expand...

Thanks for explaining. I did misunderstand but I dont agree with this rationale to justify people buying cheaper machines in the US. Things are just so money driven here. I suspect people learn that they can be paid a lot more for proton treatments, so they open a center. Once you have that center, you have to pay for it, so you treat as much as you can. I agree it will continue to get cheaper, but its still extremely expensive in absolute dollars. No administration is going to let it sit empty to treat a few kids a year.

The number of patients that have known benefit from proton therapy is very, very small. This is why you start to see people slide. Just today I saw a person on twitter go from saying CSI with protons is better to now... extended PA fields with protons are better. I disagree. I do PA fields all the time on an edge or truebeam and people do great. The reason this matters is because there just aren't that many CSI cases a year.

We have so many proton treatment slots available each day in the US. Soooo many.

I've actually treated in independent practice with protons and both MR and CT adaptive platforms. I think all of these have their uses. It was cool to have access to those machines when I felt they would help.

Now I am in a community generalist practice and somehow I manage to treat basically all my patients with an Edge. My 1-5 referrals a year of pelvic re-irradiation or CSI, those can go out. Our practice is way more healthy that way, at least in my opinion.

See what happens with the PET-Linac, which just got codes today that apparently allow like 10K more per patient compared to standard SBRT. I still do not understand the clinical justification for this machine, but would bet people will start buying them now.

Because the justification is just money...
 
NotMattSpraker said:
Thanks for explaining. I did misunderstand but I dont agree with this rationale to justify people buying cheaper machines in the US. Things are just so money driven here. I suspect people learn that they can be paid a lot more for proton treatments, so they open a center. Once you have that center, you have to pay for it, so you treat as much as you can. I agree it will continue to get cheaper, but its still extremely expensive in absolute dollars. No administration is going to let it sit empty to treat a few kids a year.

The number of patients that have known benefit from proton therapy is very, very small. This is why you start to see people slide. Just today I saw a person on twitter go from saying CSI with protons is better to now... extended PA fields with protons are better. I disagree. I do PA fields all the time on an edge or truebeam and people do great. The reason this matters is because there just aren't that many CSI cases a year.

We have so many proton treatment slots available each day in the US. Soooo many.

I've actually treated in independent practice with protons and both MR and CT adaptive platforms. I think all of these have their uses. It was cool to have access to those machines when I felt they would help.

Now I am in a community generalist practice and somehow I manage to treat basically all my patients with an Edge. My 1-5 referrals a year of pelvic re-irradiation or CSI, those can go out. Our practice is way more healthy that way, at least in my opinion.

See what happens with the PET-Linac, which just got codes today that apparently allow like 10K more per patient compared to standard SBRT. I still do not understand the clinical justification for this machine, but would bet people will start buying them now.

Because the justification is just money...
Click to expand...
It's always about the money.
 
NotMattSpraker said:
Thanks for explaining. I did misunderstand but I dont agree with this rationale to justify people buying cheaper machines in the US. Things are just so money driven here. I suspect people learn that they can be paid a lot more for proton treatments, so they open a center. Once you have that center, you have to pay for it, so you treat as much as you can. I agree it will continue to get cheaper, but its still extremely expensive in absolute dollars. No administration is going to let it sit empty to treat a few kids a year.

The number of patients that have known benefit from proton therapy is very, very small. This is why you start to see people slide. Just today I saw a person on twitter go from saying CSI with protons is better to now... extended PA fields with protons are better. I disagree. I do PA fields all the time on an edge or truebeam and people do great. The reason this matters is because there just aren't that many CSI cases a year.

We have so many proton treatment slots available each day in the US. Soooo many.

I've actually treated in independent practice with protons and both MR and CT adaptive platforms. I think all of these have their uses. It was cool to have access to those machines when I felt they would help.

Now I am in a community generalist practice and somehow I manage to treat basically all my patients with an Edge. My 1-5 referrals a year of pelvic re-irradiation or CSI, those can go out. Our practice is way more healthy that way, at least in my opinion.

See what happens with the PET-Linac, which just got codes today that apparently allow like 10K more per patient compared to standard SBRT. I still do not understand the clinical justification for this machine, but would bet people will start buying them now.

Because the justification is just money...
Click to expand...
Very valid arguments, thank you!
 
Bequerel said:
Who makes a PET-Linac and what does it cost?
Click to expand...
Reflexxion
reflexion.com

Home Page - RefleXion

SCINTIX® technology is a novel therapy for patients with tumors in the lung or bone arising from primary and metastatic cancer. This breakthrough technology uses live, continuously updated data throughout the entire treatment session to determine where to deliver radiotherapy.
reflexion.com reflexion.com

Speaking of which...
I saw their video on the website, where they claim.

1699602488993.png


How is that supposed to work? Will the resection cavity in the breast show up in FDG-PET or will the Reflexxion just shoot at the heart?
 
NotMattSpraker said:
PET-Linac, which just got codes today that apparently allow like 10K more per patient compared to standard SBRT. I still do not understand the clinical justification for this machine
Click to expand...
I too am confused. Poorer spatial resolution, not appropriate for adaptive work, the worst modality for motion management.

Now as a platform to move to fully automated real time target delineation without human input? Probably some advantages, as I imagine PET provides easier threshold data for this sort of thing.

Not that I'm really interested in that sort of thing.
 
communitydoc13 said:
I too am confused. Poorer spatial resolution, not appropriate for adaptive work, the worst modality for motion management.

Now as a platform to move to fully automated real time target delineation without human input? Probably some advantages, as I imagine PET provides easier threshold data for this sort of thing.

Not that I'm really interested in that sort of thing.
Click to expand...
Mike Judge Applause GIF by Idiocracy


A machine for future cancer Care....
 
mheat3 said:
Playing a dangerous game buying an expensive machine with C code as justification. A C code by definition is not permanent and may be changed at any time. I certainly will not be recommending that for our practice from a financial perspective.
Click to expand...
Yeah, I'm sure when CMS discovers that it triples the cost of care, that code can disappear quickly.
 
OTN said:
Once again I am begging - BEGGING - someone to tell me how the Reflexion unit allows us to do anything different compared with PET/CT fusion --> CT simulation --> treatment. Please. Someone. Anyone.
Click to expand...
1. The images that guide treatment are taken in real time. The PETs we use for fusion purposes can be days or weeks old.
2. Targets are tracked and treated in real-time as they move (e.g. in the lung/liver). With FDG-PET based Reflexion treatments, the only target you can't yet treat is brain as they haven't figure out how to quiet the background "noise" of normal brain.
3. You can treat many more targets simultenaously than with a conventional linac.
4. The unit has a Tomo like design but at a rotation speed which is far faster than a standard Radixact. It is therefore uniquely suited to treat the whole body.
5. As I understand it, there is no convetional planning as we currently do it. It is done on the fly by the machine's AI although you can obviously see what it is doing and adjust the parameters.

Caveat: I don't have a Reflexion, nor do I intend to buy one (yet) but I've visited their factory and listened to numeours talks with Q&A.
 
I am not saying there is any utility to this - but it is the only machine that can track PET signal day to day. So every treatment (or the ones chosen by the physician) the patient is given a PET tracer. Can also be used without this added 'feature'
 
OTN said:
Once again I am begging - BEGGING - someone to tell me how the Reflexion unit allows us to do anything different compared with PET/CT fusion --> CT simulation --> treatment. Please. Someone. Anyone.
Click to expand...
I treated a prostate patient with 5 Mets to all sites of disease and the planning was incredibly painful and costly in terms of dosimetry time. And add to that we got paid the exact same amount as if I had treated one site in 5 fractions. If there was some automated solution, it would make me much more open to treating the patients with 4-5 mets compared to 1-3.
 
Gfunk6 said:
1. The images that guide treatment are taken in real time. The PETs we use for fusion purposes can be days or weeks old.
2. Targets are tracked and treated in real-time as they move (e.g. in the lung/liver). With FDG-PET based Reflexion treatments, the only target you can't yet treat is brain as they haven't figure out how to quiet the background "noise" of normal brain.
3. You can treat many more targets simultenaously than with a conventional linac.
4. The unit has a Tomo like design but at a rotation speed which is far faster than a standard Radixact. It is therefore uniquely suited to treat the whole body.
5. As I understand it, there is no convetional planning as we currently do it. It is done on the fly by the machine's AI although you can obviously see what it is doing and adjust the parameters.

Caveat: I don't have a Reflexion, nor do I intend to buy one (yet) but I've visited their factory and listened to numeours talks with Q&A.
Click to expand...
Got it - that was helpful. Here are my thoughts.

1. I need evidence that a week-old PET compared with day-of-treatment PET shows any meaningful difference. I am skeptical, mostly because an SUV threshold which defines tumor does not exist and because image fusion --> treatment a week or two later is the standard in our field and I don't think it causes any problems.
2. Real-time target tracking has not been shown (yet) to have benefit. Maybe this machine will show it does, but until there's good data that proves it I'm still skeptical for the vast majority of tumors. I can't imagine a scenario where PET planning for brain disease makes any sense.
3. Throughput benefit, but does not expand treatment capability.
4. You can do VMAT for TBI on a TrueBeam, so this is not a unique capability.
5. Not a benefit, just a difference in planning. Maybe a slight benefit in throughput, but, again, it doesn't allow me to do anything I can't currently do. Adaptive planning data hasn't been impressive.

edit: in response to grenz's comment above, I treat a ton of oligometastatic disease with 5-fraction SBRT. It can be cumbersome. We can still get it done, however, and any efficiency benefit with Reflexion doesn't justify the super high cost.
 
If the main incentive for a treatment modality is because it reimburses better (in any field) rather than for tangible clinical benefit, it is suspect.

FDG highlights inflammation that radiation induces. There are also obvious contrast-enhancing cancers (or spread) in areas that are not FDG-avid. I don't foresee how this concept makes any sense over current practice. However I think the concept sells well to naïve investors.
 
StIGMA said:
If the main incentive for a treatment modality is because it reimburses better (in any field) rather than for tangible clinical benefit, it is suspect.

FDG highlights inflammation that radiation induces. There are also obvious contrast-enhancing cancers (or spread) in areas that are not FDG-avid. I don't foresee how this concept makes any sense over current practice. However I think the concept sells well to naïve investors.
Click to expand...

"You can bill for adaptive plans, so the machine is easily profitable" - MR linac salesmen to me a decade ago. We see how that story went.
 
grenz said:
I treated a prostate patient with 5 Mets to all sites of disease and the planning was incredibly painful and costly in terms of dosimetry time. And add to that we got paid the exact same amount as if I had treated one site in 5 fractions. If there was some automated solution, it would make me much more open to treating the patients with 4-5 mets compared to 1-3.
Click to expand...
i treat sequentially now (if reasonable i.e. not delaying systemic therapy).
if i am doing the work, i wanna get paid. i do a lot of 2 fx for bone/spine SBRT now a days though
 
grenz said:
I just can’t believe they got a code so quick, but viewray had years to do it and never did
Click to expand...
Per the current** ASTRO ROCR FAQ:

1699760735498.png


Great news, Reflexion has the honor of getting included in ROCR, I assume that was the plan all along because ROCR is clearly the savior of everything.

(** I say "current" because ASTRO will likely edit their FAQ without telling anyone, at any time, to say something entirely different than what it said before. May the odds be ever in your favor.)
 
xrt123 said:
This is how you lose referrals from urologists in the real world. The reason radiation gained traction was that urology could bill for the eligard.
Click to expand...
Well...that used to be true.

Lupron to Urology is like EPO to Nephrology.

From an old OIG report:

1699824478158.png


Now, I don't mean to say there aren't margins to be had for ADT - it's just usually seen in the pharmacy budget.

Gold fiducials are also not exactly a high-dollar procedure these days either, unless you do a lot of them.

Don't get me wrong, you can ABSOLUTELY torpedo the relationship with any referring if you're not careful.

Just like you can run afoul of Stark/AKS if you're...too careful.

In this moment in time, there isn't a clear, generalized version of 2002 Lupron (a drug or procedure that RadOnc could easily do which would hurt the bottom line of a referring), especially since so many American doctors are employed by the same system and are just referring internally anyway.

(note: I don't consider Florida medicine to be "American medicine" in any of my statements. Florida is its own planet. Practice there at your own risk.)
 
xrt123 said:
This is how you lose referrals from urologists in the real world. The reason radiation gained traction was that urology could bill for the eligard.
Click to expand...
Use your skills for good, not evil (or stupidity). Of course.

One day, a skill that may have previously threatened the delicate sensibilities of a urologist could save a rad onc from penury!
 
It’s literally a money loser in my hospital setting, so we don’t do it, but we definitely would. Lot of issues with general ones not knowing how long. They’ll be on for 3, and my note says 6. I see them and they’ll have been off - “does he need more?”
 
RealSimulD said:
It’s literally a money loser in my hospital setting, so we don’t do it, but we definitely would. Lot of issues with general ones not knowing how long. They’ll be on for 3, and my note says 6. I see them and they’ll have been off - “does he need more?”
Click to expand...
Oh my God

This needs to be talked about A LOT more

I love going on MedNet and seeing these eloquent debates about timing and duration of ADT. So much thoughtful hand-wringing.

Out in the rest of the world?

I've seen things. So many things. Almost all the time.

Almost never what it should be.
 
I work with busy community urologists who seem to have fragile egos

My first goal upon starting this job was to gain their trust - they have referred elsewhere if not happy with the care, regardless of right or wrong. They wanted me to do standard fractionation and I wanted them to stop giving 2 years of ADT to literally anybody above Gleason 6. I also found out that my clinic was buying the fiducials that urology placed and I didn't need. The urologists were happy to stop doing those procedures as they are busy enough. Now things are great even if some patients still get an extra 3 months of ADT here or there because uro just feels like or starts before I can even discuss.

Making friends with urology is so important in the community and they have the upper hand. Must tread lightly at first and know what battles are important as you still may lose some.
 
metallica81788 said:
I work with busy community urologists who seem to have fragile egos

My first goal upon starting this job was to gain their trust - they have referred elsewhere if not happy with the care, regardless of right or wrong. They wanted me to do standard fractionation and I wanted them to stop giving 2 years of ADT to literally anybody above Gleason 6. I also found out that my clinic was buying the fiducials that urology placed and I didn't need. The urologists were happy to stop doing those procedures as they are busy enough. Now things are great even if some patients still get an extra 3 months of ADT here or there because uro just feels like or starts before I can even discuss.

Making friends with urology is so important in the community and they have the upper hand. Must tread lightly at first and know what battles are important as you still may lose some.
Click to expand...
Here's my honest tactic for dealing with the psychopath ADT regimens I see every week in my clinic:

"Neat."

There are many hills to die on. If you die on the ADT hill, there is a very real chance that for years and years, patients will not have an opportunity to learn that radiotherapy is an option for them.

Because it's not always about WHICH RadOnc a Urologist sends a prostate cancer patient to: it's about IF that patient gets sent at all.

Join me on this episode of "Stuff No One Ever Prepares You For In Training!"

Next week's episode: "Why does this MedOnc hold chemo for an ANC of 2000?"
 
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