Rad Onc Twitter

  • Thread starter Thread starter deleted1002574
  • Start date Start date
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
NotMattSpraker said:
I like vmat but I agree. Lots of ways to get a good plan.
Click to expand...
I actually prefer old school sbrt for lung. You can find data that Imrt /vmat are just as good but there is conflicting data that the increased inhomogeneity with 3D Sbrt is superior in terms of tumor control. From my standpoint if I can make a good portion of the tumor get 110 percent (or more ) of dose without exceeding any normal tissue tolerance, I think that is preferable. Kind of like why brachy may be beneficial in other disease sites.
I’ll use vmat if close to plexus or some critical central structure but only if needed
 
24 Gy x 1 to the femoral neck. Haha. That's funny.

I once took heat for giving 24 Gy x 1 to a small spot in the ilium.

Why do we do chart rounds/peer review anyway? Primary care doctors don't have another doctor reviewing every ABx prescription. Surgeons don't have a group of others in the surgical theatre watching their every cut. Even radiologists only have a tiny percentage (<1%) of their reads randomly audited for quality review.

Yet we want to spend a few hours ever week going over every single case in a power flex where people argue and nobody ever changes their original plan anyway (rarely). Nobody has the guts to stand up and say this is stupid and a quirk of our field to even logistically allow it. People have been practicing solo with NO peer review forever and delivering fine care as it ultimately falls back on the individual physician. It is possible to have a culture of safety with a single doctor. It's not even hard.

Is 24 Gy in a single fraction an ablative dose (as in kills 100% of the cancer cells in the volume)? Who knows. Probably not. Really, almost certainly not. 30 Gy in 5 isn't. The whole thing, from 24 Gy x 1, to arguing about it in chart rounds, to even having chart rounds in the first place is a cluster of stupid and personality disorder.

Also, mobile bones... It's not mobile bones. It's mobile (knee) vs. semi-mobile (vertebrae) vs. rigid (skull) JOINTS, not bones. Bones are just bones. Clusters of calcium and stuff. They are all technically mobile as we move through time and space (or I guess all stationary as time and space moves through us?).
 
RadRadRad said:
I actually prefer old school sbrt for lung. You can find data that Imrt /vmat are just as good but there is conflicting data that the increased inhomogeneity with 3D Sbrt is superior in terms of tumor control. From my standpoint if I can make a good portion of the tumor get 110 percent (or more ) of dose without exceeding any normal tissue tolerance, I think that is preferable. Kind of like why brachy may be beneficial in other disease sites.
I’ll use vmat if close to plexus or some critical central structure but only if needed
Click to expand...
I agree with you from a step-by-step, logical standpoint.

However, having experimented with this myself: how long are your 3D SBRT patients on the table, compared to VMAT?

You might be using different techniques than what I've tried, but 3D SBRT is a significantly slower treatment, which is very difficult for elderly patients to tolerate. You can have the perfect plan in the computer, but if your patient wiggles from discomfort during their 20 minute treatment sessions, it doesn't really matter.

Currently, I use VMAT with a planned hotspot of ~135%-145% to get both "3D-esque" inhomogeneity and fast treatment times.

I'm always looking for ways to do it better, though.
 
Lamount said:
Too lazy to crunch the numbers, but I would imagine there are more men with prostate cancer in the NHS than vets in the US with stage 1 lung cancer.
Click to expand...
it’s probably a difference in culture. Much more complacent and compliant population in NHS eg brits love waiting in long lines.
 
Last edited:
Palex80 said:
The Brits randomized 1500 men in 10 years to undergo surgery, radiotherapy or surveillance for prostate cancer...

That's a tripple coin flip.
Click to expand...
although to be complete, the Brits also tried to tee up a randomized surgery vs SBRT study and were completely unable to recruit for it

Something especially nettlesome about trying to run these lung surgery vs SBRT trials
 
1705428256548.png
 
drowsy12 said:
What would be the point of this?

Click to expand...

Someone doesn't seem to understand the point of the OLA questions is to confirm ongoing bare minimal competency working knowledge. You should be getting near 100%. It's a fluke of our field that a few people have eidetic memories and can recall every kaplan meier curve from every study they've ever seen. If you want to retake the written exam every 5 years instead to show that off, I say go for it.
 
MidwestRadOnc said:
Someone doesn't seem to understand the point of the OLA questions is to confirm ongoing bare minimal competency working knowledge. You should be getting near 100%. It's a fluke of our field that a few people have eidetic memories and can recall every kaplan meier curve from every study they've ever seen. If you want to retake the written exam every 5 years instead to show that off, I say go for it.
Click to expand...

View attachment 381119

You are right. The part that is hard to understand is why we do this at all. They have already certified your competency and explicitly say you should not study for OLA.

🙂
 
MidwestRadOnc said:
Someone doesn't seem to understand the point of the OLA questions is to confirm ongoing bare minimal competency working knowledge. You should be getting near 100%. It's a fluke of our field that a few people have eidetic memories and can recall every kaplan meier curve from every study they've ever seen. If you want to retake the written exam every 5 years instead to show that off, I say go for it.
Click to expand...

He missed 4? I haven’t missed one in 2 years. Just change the pass rate to 98% and fail this guy.

I have worked with people that would have failed OLA though.
 
The fact that The Establishment™ cannot grasp that you NEVER USE AVERAGES to consider salary data is absolutely perfect. It's the apex parable for helping outsiders understand what happened to Radiation Oncology.

Of course, Kent Wallner, the author of that post, would do well to note some details behind the AVERAGE salary he's celebrating:

1705456502481.png


This data is borderline irrelevant now. 2005-2017 is not only pre-CMS crackdown, it's also from the pre-consolidation era (capturing just the dawn of the acceleration). The majority of doctors are W2 employees now.

Table 2:

1705456523569.png


Hilarious.

This is neat too:

1705456539130.png


What a time to be alive, if you managed to have your peak career years in Radiation Oncology from 2005-2017, and you were private practice with technical revenue (owned the linac) in the Midwest.

Maybe Kent will lend the ASTRO PAC his time machine?
 
elementaryschooleconomics said:
I agree with you from a step-by-step, logical standpoint.

However, having experimented with this myself: how long are your 3D SBRT patients on the table, compared to VMAT?

You might be using different techniques than what I've tried, but 3D SBRT is a significantly slower treatment, which is very difficult for elderly patients to tolerate. You can have the perfect plan in the computer, but if your patient wiggles from discomfort during their 20 minute treatment sessions, it doesn't really matter.

Currently, I use VMAT with a planned hotspot of ~135%-145% to get both "3D-esque" inhomogeneity and fast treatment times.

I'm always looking for ways to do it better, though.
Click to expand...
The driver of treatment time is motion management. Non gated/ non breathhold treatments take minimal beam time regardless of technique. (Way less than 20 min)

I’ve not found anything that makes a gated treatment “fast”. Having used vmat, static field 3D, and modulated static field.

Like your vmat hot spot
 
RadRadRad said:
The driver of treatment time is motion management. Non gated/ non breathhold treatments take minimal beam time regardless of technique. (Way less than 20 min)

I’ve not found anything that makes a gated treatment “fast”. Having used vmat, static field 3D, and modulated static field.

Like your vmat hot spot
Click to expand...
Hmmmm. It's been a few years now since I played around with all this. What's your preferred beam arrangement?

I think the last non-VMAT version I tried was similar to this:


I'd have to see if I still have it somewhere, but I once went through and measured the time from CBCT acquisition to delivery of last MU and 3D was consistently longer...

Though that could have been the therapists I was working with at the time.
 
The difference in time between dynamic conformal arcs and a VMAT plan is going to be very small. Monitor units will be less for the DCA plan but if the arc arrangement is more complicated, this can add a little time.

DCA can still be inverse planned and with dynamic MLCs. You are just not modulating across the target. In principle, this takes away some dosimetric uncertainty.

I have to admit, the modulation of stereotactic, small field VMAT plans enters into the realm of absurdity. There is no longer any intuition and I am sure there are compounding risks of dose uncertainty...however, it works.

You can get any hotspot you want with VMAT by applying proper planning objectives. The hotter plans are not limited to DCA.

What has bothered me is how we should prescribe these heavily modulated plans, because you don't need to have a very hot center and the prescription paradigm is really a volumetric one (e.g. 95% PTV gets 100% prescription dose as opposed to prescribing to the 60-80% IDL). Should we mimic old 3D plans and try to make the center very hot. Should we try to cover the ITV at 125% the periphery of the PTV (as some have suggested)...this makes for much hotter plan.

Lots of variability in terms of how to prescribe and define objectives for these sorts of plans.
 
elementaryschooleconomics said:
Hmmmm. It's been a few years now since I played around with all this. What's your preferred beam arrangement?

I think the last non-VMAT version I tried was similar to this:


I'd have to see if I still have it somewhere, but I once went through and measured the time from CBCT acquisition to delivery of last MU and 3D was consistently longer...

Though that could have been the therapists I was working with at the time.
Click to expand...
Are we talking fixed beam 3D, or DCA? DCA is way fewer MUs than VMAT and slightly faster in our experience. We do 1 half arc sweep that is comprised of a few partial arc beams. They mode up pretty quickly and are at worst no slower than 2 VMAT arcs.
 
grenz said:
Are we talking fixed beam 3D, or DCA? DCA is way fewer MUs than VMAT and slightly faster in our experience. We do 1 half arc sweep that is comprised of a few partial arc beams. They mode up pretty quickly and are at worst no slower than 2 VMAT arcs.
Click to expand...
I’ll add that I really like DCA for targets that move a lot. Has to be the right shape though.
 
Man I love SDN, where else can you find a simultaneous discussion about PACs, policy, and SBRT treatment times based on technique...

All in a silly Twitter thread?

Never forget everyone, we're anonymous misanthropes and no one can be sure we're even doctors, let alone Radiation Oncologists!

(VMAT FFF SBRT for the win)
 
MidwestRadOnc said:
Be careful. I had another account on here in the past and somehow got doxxed at work. Literally no idea how.
Here I am, back for more punishment. A degenerate addict.
Click to expand...
I have a lot of comments about this that I'll just...mostly keep to myself...

Internet shenanigans need to stay internet shenanigans.

If anyone feels inclined to take an SDN argument into real life, especially contacting employers - that is literally the saddest, weakest thing you could possibly do.

The best thing about the internet is YOU CAN WALK AWAY. In an argument? Close your browser. Put notifications for that conversation on mute. Never think about it again.

It's literally impossible for me to consider ever respecting someone again once they pull the "find you in real life" move. It tells me everything I need to know about who they are as a person.
 
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?
Click to expand...

Those who can't get surgery OR SBRT. But IRs don't masturbate over data and trials the way ROs do and thus they've started doing it nationwide. Also see the nonsense about RFA or even Y-90 or TACE in HCC over SBRT. Jeff Ryckman with a lot of good tweetorials about the lack of beneficial randomized data with IR techniques vs some form of EBRT (SBRT, proton RT, etc.) which has positive randomized data.
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...
Great space for a RO NP dependent on your volume - CT chest a few days prior to NP visit, NP sees patient, reads report (reviewing imaging personally can be problematic), lets doc know PRN, otherwise continues the q3-6 month CT surveillance (based on time from previous RT).

RadRadRad said:
I actually prefer old school sbrt for lung. You can find data that Imrt /vmat are just as good but there is conflicting data that the increased inhomogeneity with 3D Sbrt is superior in terms of tumor control. From my standpoint if I can make a good portion of the tumor get 110 percent (or more ) of dose without exceeding any normal tissue tolerance, I think that is preferable. Kind of like why brachy may be beneficial in other disease sites.
I’ll use vmat if close to plexus or some critical central structure but only if needed
Click to expand...
Links?

elementaryschooleconomics said:
I agree with you from a step-by-step, logical standpoint.

However, having experimented with this myself: how long are your 3D SBRT patients on the table, compared to VMAT?

You might be using different techniques than what I've tried, but 3D SBRT is a significantly slower treatment, which is very difficult for elderly patients to tolerate. You can have the perfect plan in the computer, but if your patient wiggles from discomfort during their 20 minute treatment sessions, it doesn't really matter.

Currently, I use VMAT with a planned hotspot of ~135%-145% to get both "3D-esque" inhomogeneity and fast treatment times.

I'm always looking for ways to do it better, though.
Click to expand...

Shouldn't be longer... it's less MUs since you're not modulating. Are you using 6MV beams for 3D vs 6MV-FFF for VMAT? The increase in dose rate possible w/ FFF may make up for the increased MUs. 6MV-FFF w/ DCA would hypothetically be fastest, no? This assumes same number of arcs across both plans.

communitydoc13 said:
The difference in time between dynamic conformal arcs and a VMAT plan is going to be very small. Monitor units will be less for the DCA plan but if the arc arrangement is more complicated, this can add a little time.

DCA can still be inverse planned and with dynamic MLCs. You are just not modulating across the target. In principle, this takes away some dosimetric uncertainty.

I have to admit, the modulation of stereotactic, small field VMAT plans enters into the realm of absurdity. There is no longer any intuition and I am sure there are compounding risks of dose uncertainty...however, it works.

You can get any hotspot you want with VMAT by applying proper planning objectives. The hotter plans are not limited to DCA.

What has bothered me is how we should prescribe these heavily modulated plans, because you don't need to have a very hot center and the prescription paradigm is really a volumetric one (e.g. 95% PTV gets 100% prescription dose as opposed to prescribing to the 60-80% IDL). Should we mimic old 3D plans and try to make the center very hot. Should we try to cover the ITV at 125% the periphery of the PTV (as some have suggested)...this makes for much hotter plan.

Lots of variability in terms of how to prescribe and define objectives for these sorts of plans.
Click to expand...

Even w/ VMAT, allowing a hotter center will allow for sharper fall off outside the PTV and minimize the intermediate dose bath surrounding the PTV. Relevant in a lung SBRT case for say lung, chest wall, and midline structure DVH metrics allowing treatment of larger lesions, or receiving multiple rounds of treatment without negatively affecting a parallel organ like the lungs.
 
BREAKING NEWS​

ASTRO leadership has been reported missing. Per text messages from friends and family, they embarked on a teambuilding exercise to "find hearts and brains from a wizard in a castle". Police have released this image from social media:

1705799707207.png


In a press release, police have also confirmed that this teambuilding exercise was the result of a recommendation from a $500,000 McKinsey consultant, paid for with member dues.

We'll bring you more information on this developing story tonight at 11.
 
In case anyone has ever wondered, when I point the finger at "the establishment" for causing the mess we're currently in, Ron is a key figure of "the establishment".

Not only does he run the largest agency/company which produces RadOnc-focused coding and billing content, he has co-authored or influenced both the ASTRO and ACRO coding/billing manuals for many, many years.

He has also served as an "expert" witness in at least one qui tam case, probably several.

The guy who is on X posting weird, angry content because...lifting weights...fills him with rage, he's also amplifying this obscure NP-lobby propaganda without any critical thought.

Just extrapolate all this backwards 20 years and everything makes sense.
 
thesauce said:
Even the Astro leaders are no longer saying there is a shortage
Click to expand...

it's got to be at least 6-7 years since that was seriously put forth as an opinion, if not longer. Ron D is a grifter.

Ben Smith published his initial paper in 2010: https://ascopubs.org/doi/full/10.1200/JCO.2010.31.2520

'Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.'

By 2016, he had altered his opinion: Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025 - PubMed

Conclusion: The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.


Ron D is a grifter.
 
drowsy12 said:
it's got to be at least 6-7 years since that was seriously put forth as an opinion, if not longer. Ron D is a grifter.

Ben Smith published his initial paper in 2010: https://ascopubs.org/doi/full/10.1200/JCO.2010.31.2520

'Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.'

By 2016, he had altered his opinion: Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025 - PubMed

Conclusion: The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.


Ron D is a grifter.
Click to expand...
Kendi is a grifter.

This guy appears to be a run of the mill flaming douche bag.

He wants to employ you and strip mine your practice. Future PE vulture written all over him.
 
MidwestRadOnc said:
Kendi is a grifter.

This guy appears to be a run of the mill flaming douche bag.

He wants to employ you and strip mine your practice. Future PE vulture written all over him.
Click to expand...
Oh he's a grifter too. He will happily sell you all kinds of overly onerous and strict CMS compliance advice and scare your hospital admin
 
Last edited:
You must log in or register to reply here.

Similar threads

uchihastan
Rad Onc vs. Heme/Onc
Replies
18
Views
2K
medgator
M
B
Rad Onc Procedures and RVUs
Replies
35
Views
5K
CurbYourExpectations
CurbYourExpectations
D
Saving Rad Onc
2
Replies
60
Views
6K
RickyScott
R
TheWallnerus
Rad Onc is in a dark place
Replies
13
Views
2K
RickyScott
R
D
Future of rad onc job market
2
Replies
58
Views
9K
BobbyHeenan
B
Top