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drowsy12 said:
The proton lobby wrote the Astro proton guidelines. They are very well acquainted.

The mafia analogy earlier was germane.
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LOL I cant believe this is still online.
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drowsy12 said:
The proton lobby wrote the Astro proton guidelines. They are very well acquainted.

The mafia analogy earlier was germane.
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...sure.

Like I'm acquainted with my neighbor's dog.

I know the dog exists. The neighbor seems to like the dog. I'm happy they have each other.

So help me God, if I start seeing dog dumps on my side of the fence...
 
elementaryschooleconomics said:
...sure.

Like I'm acquainted with my neighbor's dog.

I know the dog exists. The neighbor seems to like the dog. I'm happy they have each other.

So help me God, if I start seeing dog dumps on my side of the fence...
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Once, one time, I had like 2 minutes of useful conversation with a guy that works for ASTRO on policy stuff.

He tried explaining the "proton lobby" is not a thing. What he meant was that theres not a shadowy conspiracy group pulling strings. Yes, I understand our real life is not a Scooby Doo cartoon.

I tried to talk about the foundational issue with equipoise in the US proton therapy roll out... and that was the end of our 2 minutes of useful conversation.

The problem is diffuse, but not insurmountably so. Watch NAPT, look at their board and ASTROs board. All of these folks would LOVE for you to accept that protons are too powerful, there is nothing that can be done now to try to bring science back in to the field. Its not true.
 
NotMattSpraker said:
Once, one time, I had like 2 minutes of useful conversation with a guy that works for ASTRO on policy stuff.

He tried explaining the "proton lobby" is not a thing. What he meant was that theres not a shadowy conspiracy group pulling strings. Yes, I understand our real life is not a Scooby Doo cartoon.

I tried to talk about the foundational issue with equipoise in the US proton therapy roll out... and that was the end of our 2 minutes of useful conversation.

The problem is diffuse, but not insurmountably so. Watch NAPT, look at their board and ASTROs board. All of these folks would LOVE for you to accept that protons are too powerful, there is nothing that can be done now to try to bring science back in to the field. Its not true.
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Totally agree - but I don't think ASTRO themselves know that.

The proton lobby is doing what they think is best for the proton lobby. They aren't "checking in" with ASTRO before making any decisions.

Likewise, ASTRO assumes the "proton lobby is too powerful". I would bet...so much money they didn't even approach the proton lobby before authoring ROCR.

They're operating in a mutual space, making decisions independently, making assumptions about what the other will do should certain events take place.

Like me, my neighbor, and the dog.

POST-POST EDIT:

I just re-read this...and uh, did this ASTRO policy person think that a "lobby group" is like...an official, organized entity? Did this policy person not understand that...a "lobby" is often people/groups with shared interest loosely engaged in activities for their own benefit?

Actually...please don't answer that.
 
elementaryschooleconomics said:
POST-POST EDIT:

I just re-read this...and uh, did this ASTRO policy person think that a "lobby group" is like...an official, organized entity? Did this policy person not understand that...a "lobby" is often people/groups with shared interest loosely engaged in activities for their own benefit?

Actually...please don't answer that.
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My guess is it’s more like he thought I didn’t understand.

Politics are very complicated though. It’s an honest mistake for an overconfident person “in healthcare” that has no clinical experience and treats physicians like a commodity.
 
NotMattSpraker said:
My guess is it’s more like he thought I didn’t understand.

Politics are very complicated though. It’s an honest mistake for an overconfident person “in healthcare” that has no clinical experience and treats physicians like a commodity.
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Sometimes I wonder if it’s a mistake or a feature. Would love to think it’s a mistake that can be corrected.
 
NotMattSpraker said:
I floated some proposed changes and you will hear more from me. My biggest thing is Id like to see SOME discussion of including breast and prostate proton therapy for patients >40 years old. Their reason for excluding is not strong and I dont think they should be let off the hook on this very solvable issue.

I really, really do not like the accreditation requirement. Im doing a podcast on this aspect, out soon.

Jason Beckta has floated a number of changes in his podcast, or maybe more like questions that remain unanswered. He has talked a lot about their $500 transportation benefit and supporting rural practices, or large academic practices... not actually sure what this supports haha.

Mark Storey has a nice write up of ROCR and has some super interesting ideas in there on all the controversial aspects. ROCR: ASTRO's New Payment Direction

Finally, Id recommend watching the ACRO town hall. It was an actual town hall with audience questions, there are a lot of comments there from their policy folks. I got the sense that they do not agree with ROCR as defined today and I think yesterdays letter may imply that ASTRO is finally open to feedback at least from ACRO (I am not sure how much the ACR or ASCO is weighing in?).

ACRO also are running a survey on how the field feels about many of these controversial aspects of ROCR. They said they plan to report it out publicly. I strongly suggest you fill it out, especially if you don't agree with ROCR!

Everyone seems to agree that change will only work with universal support, and ACRO are the only ones who are working to understand the opinions of the field.
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Link to the ACRO town hall? I was unable to atten dthat one (instead, wasted my time at the ASTRO advertisement dressed up as a town hall)
 
NotMattSpraker said:
A root cause analysis of what?



Im sooooo interested in this but afraid to talk online because that U-word makes people unhinged ha
MidwestRadOnc said:
There is nothing more frustrating than having to deliver a 3DCRT plan because insurance refuses IMRT and watch the patient have noticeably worse acute toxicity. Anything in the pelvis non-palliative needs IMRT IMO. 4 and 3 field plans for GYN and GI stuff? Get out of here.

It's like purposely driving around in a 30 year old Toyota with a blown head gasket, the heat stuck on HI, and mismatched tires vs. buying a new Tesla with gas at $5/gal. Sure, it gets you there. If that's all you care about I guess.
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RealSimulD said:
So, a friend of mine had a patient that had early stage lung CA and it was on top of PBT, so he didn't want to do 1-5 fx. He recommended 70/10 per MDACC. Evicore denies it without P2P and tells him to do ... 3D.

He blasted them on SoMe, they called him, want to do root cause analysis, etc.

But, hypothetical question -

If the doc said, "fine, I guess I'll do 3D" and the patient got a horrendous toxicity, who would actually be at fault?

You damn straight shouldn't be doing 3D to that dose for ablation, but the payor said to do it and they said it based on "medical necessity", that IMRT/SBRTlite was not approvable. And, many institutions feel that if he had treated with IMRT when approved for 3D, that would be fraud and they would not allow it.

From MD perspective (not PA perspective), this seems very dangerous. If they want to practice medicine remotely without touching the patient there should be some liability transfer away from doctor.

I would hope that when this happens, if the PA company denies something that is NCCN/ASTRO SOC, all liability should go on to the 3rd party or payor and potentially some to the hospital for not allowing physician to treat with IMRT (despite what auth said).
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This sounds suspect... I've never had 10 fraction IMRT for central lesion not approved by any PA. It's in NCCN. Sounds like a friend's office may have not submitted request correctly, which is almost 90% of all of our preauth P2P calls or cases.
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TheWallnerus said:
I have no idea how you can propel a massive charged particle through a magnetic field without it undergoing beam path deflection. Will be neat to learn how they overcome this.
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Agreed.

I laughed a little while and then double checked to make sure this wasnt an onion article.

Very interesting funding story though, quite different than the approach VR took.
 
TheWallnerus said:
I have no idea how you can propel a massive charged particle through a magnetic field without it undergoing beam path deflection. Will be neat to learn how they overcome this.
Click to expand...

Low field MRI on those systems I believe. Not a huge interaction or change in path for protons at those lower magnetic field strengths over those sorts of distances to my knowledge. I'm sure the interactions are built into the planning system.
 
Neuronix said:
Low field MRI on those systems I believe. Not a huge interaction or change in path for protons at those lower magnetic field strengths over those sorts of distances to my knowledge. I'm sure the interactions are built into the planning system.
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We had one of the physicists who designed this system give us a rounds talk about it. I’m pretty sure it’s modelled.
 
Neuronix said:
Low field MRI on those systems I believe. Not a huge interaction or change in path for protons at those lower magnetic field strengths over those sorts of distances to my knowledge. I'm sure the interactions are built into the planning system.
Click to expand...
taserlaser said:
We had one of the physicists who designed this system give us a rounds talk about it. I’m pretty sure it’s modelled.
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Great. More proton uncertainties 😉
 
drowsy12 said:
People complain when studies are designed to finish quickly and then don’t give the proper answer. They should be commended for committing to such a large expensive trial for a difficult to randomize population.
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Of course it‘s great that the trial is running.

I am merely criticising the fact that merely one patient per week is included in this multicenter, super-expensive trial which is addressing a quite common scenario (T1 NSCLC).

What are the barriers here?

Surgeons?
Patients‘ wish?
 
drowsy12 said:
People complain when studies are designed to finish quickly and then don’t give the proper answer. They should be commended for committing to such a large expensive trial for a difficult to randomize population.
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VA has had some decent studies come out in that regard
 
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Palex80 said:
Of course it‘s great that the trial is running.

I am merely criticising the fact that merely one patient per week is included in this multicenter, super-expensive trial which is addressing a quite common scenario (T1 NSCLC).

What are the barriers here?

Surgeons?
Patients‘ wish?
Click to expand...
Compared to the 2013 or so timeframe, there are now about 85K stage ones per year instead of about 50K per year. So stage one is way up. It is the most common presenting stage among non Hispanic whites and in highest educated regions. But… the overall incidence of lung cancer is really dropping.
 
Palex80 said:
Of course it‘s great that the trial is running.

I am merely criticising the fact that merely one patient per week is included in this multicenter, super-expensive trial which is addressing a quite common scenario (T1 NSCLC).

What are the barriers here?

Surgeons?
Patients‘ wish?
Click to expand...

the STARS and ROSEL trials both failed to accrue. Surgery vs non surgery trials are hard, whether in the US or Europe. Patients have preferences.

The VA is the only place this could be done in the US.
 
Palex80 said:
Of course it‘s great that the trial is running.

I am merely criticising the fact that merely one patient per week is included in this multicenter, super-expensive trial which is addressing a quite common scenario (T1 NSCLC).

What are the barriers here?

Surgeons?
Patients‘ wish?
Click to expand...

Huge barriers. I’m in a very friendly system and I’m not sure my surgeon would enroll to this trial. I don’t think he believes SBRT is as good (reasonable).

This is still much slower than they expected.
 
NotMattSpraker said:
Huge barriers. I’m in a very friendly system and I’m not sure my surgeon would enroll to this trial. I don’t think he believes SBRT is as good (reasonable).

This is still much slower than they expected.
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I've found this to be extremely interesting over the course of my career, though I guess I technically shouldn't, because it's just normal human behavior. I've worked with surgeons/Pulmonologists who run the entire spectrum from "SBRT is fake" to "SBRT is God".

Currently, I work with a Pulmonologist who, based on her referral patterns to me, thinks SBRT is amazing.

But then the patients show up and are terrified, because she's verbally telling them something to the effect of "well you should have surgery, but here's Plan B".

I mean...in the nuanced nature of medicine, of course, in this moment, SBRT is indeed "Plan B". But there's a way to phrase that so you don't terrify patients. This could also just be a side effect of my rural/low health literacy patients who rarely go to the doctor.

Of course I'm biased myself, but I still think SBRT is like...casting a spell out of Merlin's grimoire. It's the epitome of why I thought radiotherapy was cool when I was in med school.
 
NotMattSpraker said:
Huge barriers. I’m in a very friendly system and I’m not sure my surgeon would enroll to this trial. I don’t think he believes SBRT is as good (reasonable).

This is still much slower than they expected.
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Out in the community my CT surgeon calls me with cases. But it's a symbiotic relationship, I will get referrals to radiate things and the pt hasn't even had a pulm/eval or pfts and no point in a bx if I know they can go to the OR and get it taken care from a dx and tx standpoint. A lot of cross referring creates mutual respect for both modalities, on net, I probably send him a little more just because I really hate radiating things without tissue if I can help it and the patient can just get it wedged or segmented out.

Like anything else in this specialty, cross referring/referral relationships are the best way to practice build if the environment permits.

I usually will get at least 1-2 lung sbrt referrals a week, usually pulmonary, sometimes med onc and quarterly at least 1/2 of the CT surgeons I work the closest with.
 
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elementaryschooleconomics said:
I've found this to be extremely interesting over the course of my career, though I guess I technically shouldn't, because it's just normal human behavior. I've worked with surgeons/Pulmonologists who run the entire spectrum from "SBRT is fake" to "SBRT is God".

Currently, I work with a Pulmonologist who, based on her referral patterns to me, thinks SBRT is amazing.

But then the patients show up and are terrified, because she's verbally telling them something to the effect of "well you should have surgery, but here's Plan B".

I mean...in the nuanced nature of medicine, of course, in this moment, SBRT is indeed "Plan B". But there's a way to phrase that so you don't terrify patients. This could also just be a side effect of my rural/low health literacy patients who rarely go to the doctor.

Of course I'm biased myself, but I still think SBRT is like...casting a spell out of Merlin's grimoire. It's the epitome of why I thought radiotherapy was cool when I was in med school.
Click to expand...

I agree that patient perceptions of SBRT should not hinge on the bedside manner of pulmonologists and surgeons.

It would be interesting to take sites that have below benchmark surgical outcomes and randomize people to SBRT.

It’s also hard to think about this nationally if you are a well trained rad onc, recently grad, and does a lot of SBRT. This procedure is not routine for some rad oncs and some clinics are really bad at it. My first locums experience was changing what might have been a fatal SBRT lung plan (20x3 to mediastinum).

We always talk about how some surgeons are overly aggressive with patient selection but we also do basically nothing to evaluate our outcomes.

medgator said:
Like anything else in this specialty, cross referring/referral relationships are the best way to practice build if the environment permits
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Agree. I have a more well rounded view of this problem in my current surgeons and I think part of it is that my surgeons are nice, pretty balanced, and appreciate SBRT haha
 
NotMattSpraker said:
We always talk about how some surgeons are overly aggressive with patient selection but we also do basically nothing to evaluate our outcomes.
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Best thing is to follow your patients, gets hard with the clinic flow, I've basically tried to alternate with pulm or med onc to space it out, I usually let them go 3-5 years out though. Definitely have gotten some add-on cases through the years, certain pts seem to win that unlucky lottery more than once
 
medgator said:
Best thing is to follow your patients, gets hard with the clinic flow, I've basically tried to alternate with pulm or med onc to space it out, I usually let them go 3-5 years out though. Definitely have gotten some add-on cases through the years, certain pts seem to win that unlucky lottery more than once
Click to expand...

Personally, yea. I like to follow with pulm too.

I meant more at a systems level.
 
thesauce said:
I personally do think that surgery is better than SBRT.

What I don’t understand are the other ablation techniques like RFA etc. Who would be appropriate for that?
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Also unclear about is the natural history of slowly growing, pet negative lung adenocarcinomas.
 
Palex80 said:
Of course it‘s great that the trial is running.

I am merely criticising the fact that merely one patient per week is included in this multicenter, super-expensive trial which is addressing a quite common scenario (T1 NSCLC).

What are the barriers here?

Surgeons?
Patients‘ wish?
Click to expand...
How many patients do you know who would be comfortable leaving surg vs SBRT to a coin flip?

with treatments so different, it’s hard not to think that one MUST be the wrong choice.
 
NotMattSpraker said:
It’s also hard to think about this nationally if you are a well trained rad onc, recently grad, and does a lot of SBRT. This procedure is not routine for some rad oncs and some clinics are really bad at it. My first locums experience was changing what might have been a fatal SBRT lung plan (20x3 to mediastinum).
Click to expand...
Yeah, that part...I still struggle to remember that.

I love seeing an SBRT consult on my schedule. It's a lot "easier" for me than say, definitive head and neck or like, post-op vulvar.

But...yeah. I've seen exactly what you're talking about in real life. Multiple, multiple times.

It's hard to appreciate how rapidly radiation technology changed, and we're currently in an era where you have docs who finished residency in the 90s being "self taught" for VMAT/SBRT working side by side with more recent grads who were learning SBRT planning on Day 1 of PGY-2.

Wild times.
 
elementaryschooleconomics said:
Yeah, that part...I still struggle to remember that.

I love seeing an SBRT consult on my schedule. It's a lot "easier" for me than say, definitive head and neck or like, post-op vulvar.

But...yeah. I've seen exactly what you're talking about in real life. Multiple, multiple times.

It's hard to appreciate how rapidly radiation technology changed, and we're currently in an era where you have docs who finished residency in the 90s being "self taught" for VMAT/SBRT working side by side with more recent grads who were learning SBRT planning on Day 1 of PGY-2.

Wild times.
Click to expand...
Still remember the 3D non coplanar lung sbrt plans from residency
 
elementaryschooleconomics said:
Yeah, that part...I still struggle to remember that.

I love seeing an SBRT consult on my schedule. It's a lot "easier" for me than say, definitive head and neck or like, post-op vulvar.

But...yeah. I've seen exactly what you're talking about in real life. Multiple, multiple times.

It's hard to appreciate how rapidly radiation technology changed, and we're currently in an era where you have docs who finished residency in the 90s being "self taught" for VMAT/SBRT working side by side with more recent grads who were learning SBRT planning on Day 1 of PGY-2.

Wild times.
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I have to say learning how to draw a circle around a circle that’s moving isn’t really that complicated.

In regards to old school rad oncs- I have no clue how to do some of those old school brachy cases.
 
grenz said:
If his threshold to request a nail is lower for single fraction, then whatever cost and patient convenience gains you get from single fx goes completely out the window.
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I assume he is basing his treatment recommendation on this study for highly selected patients?

pubmed.ncbi.nlm.nih.gov

Phase 3 Multi-Center, Prospective, Randomized Trial Comparing Single-Dose 24 Gy Radiation Therapy to a 3-Fraction SBRT Regimen in the Treatment of Oligometastatic Cancer - PubMed

The study confirms SDRT as a superior ablative treatment, indicating that effective ablation of oligometastatic lesions is associated with significant mitigation of distant metastatic progression.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
grenz said:
If his threshold to request a nail is lower for single fraction, then whatever cost and patient convenience gains you get from single fx goes completely out the window.
Click to expand...

theradiator said:
I assume he is basing his treatment recommendation on this study for highly selected patients?

pubmed.ncbi.nlm.nih.gov

Phase 3 Multi-Center, Prospective, Randomized Trial Comparing Single-Dose 24 Gy Radiation Therapy to a 3-Fraction SBRT Regimen in the Treatment of Oligometastatic Cancer - PubMed

The study confirms SDRT as a superior ablative treatment, indicating that effective ablation of oligometastatic lesions is associated with significant mitigation of distant metastatic progression.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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"While the present study was designed as a prospective, randomized, phase III trial, several study limitations should be highlighted. These include the relatively small sample size of the study arms; the restriction of metastatic deposits to non-mobile bone and lymph nodes"

Just wow. Neither doctorate gave him any common sense it seems
 
medgator said:
"While the present study was designed as a prospective, randomized, phase III trial, several study limitations should be highlighted. These include the relatively small sample size of the study arms; the restriction of metastatic deposits to non-mobile bone and lymph nodes"

Just wow. Neither doctorate gave him any common sense it seems
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What are mobile vs non-mobile bones? I feel like all bones are non mobile but then all bones are also mobile sometimes.
 
RadOncDoc21 said:
What are mobile vs non-mobile bones? I feel like all bones are non mobile but then all bones are also mobile sometimes.
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Femoral neck mobile and weight-bearing.

Sternum or skull? Nope.

Can Google it as well:

Which is the non movable bone of the body?


Immovable – the two or more bones are in close contact, but no movement can occur – for example, the bones of the skull. The joints of the skull are called sutures. Slightly movable – two or more bones are held together so tightly that only limited movement is permitted – for example, the vertebrae of the spine.
Click to expand...
 
medgator said:
Femoral neck mobile and weight-bearing.

Sternum or skull? Nope.

Can Google it as well:
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Makes sense, could have just outlined the limited bones they targeted. Sometimes leaving room for interpretation can be dangerous. I’ll continue to be a chicken and use boomer “SBRT” and not this new “SDRT” I just learned about 2 min ago!

I also tried using google but didn’t have much luck. After 2-3 failed links, I gave up trying.
 
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RadOncDoc21 said:
Makes sense, could have just outlined the limited bones they targeted. Sometimes leaving room for interpretation can be dangerous. I’ll continue to be a chicken and use boomer “SBRT” and not this new “SDET” I just learned about 2 min ago!

I also tried using google but didn’t have much luck. After 2-3 failed links, I gave up trying.
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Fairly certain fem neck is the last bone met site in the body I would ever use single fraction RT
 
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