Rad Onc Twitter

[thecarbonionangle]

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it really is crazy that over the years i have met more patients than i should who come to me and:

1) i am the first person telling they have cancer. Usually it is because med onc uses words like “mass”, “lump”, “malignancy” or another euphemism

2) i am the first person to tell them their cancer is incurable

3) first person who tells them their prognosis is very poor

4) first person to tell them something super important about their disease like positive margins (surgeon said they “got it all”), or something else

5) first person to spend over 30 minutes with them and hear often you are first to ever explain this

6) first person to tell them their stage

 

[medgator]

I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.

ADT is a different beast, esp in low volume high risk disease. And esp when a patient comes in with obesity/metabolic syndrome/CAD etc before your decide to add years of ADT into the mix

 

[Chartreuse Wombat]

I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.

I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years

 

[medgator]

I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years

Not only not worth it, would argue detrimental both in terms of health as well as qol to some of these pts

 

[metallica81788]

Not only not worth it, would argue detrimental both in terms of health as well as qol to some of these pts

You could argue the majority of prostate patients on ADT would take a 5% (maybe even 10%) increase in risk of cancer recurrence for improved QOL off of ADT

 

[deleted1180461]

I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years

I’m aware but at the time 4k was very toxic I assure you, and I don’t give out ADT without consideration. You’re missing the point. If you’ve confirmed GS8 with random samples, even if it’s not a lot, it’s a signal you shouldn’t ignore and if you do, you are taking on significant risk to the downside.

Surveillance in this scenario is insane for anybody not in a nursing home IMO.

 

[deleted1180461]

Not only not worth it, would argue detrimental both in terms of health as well as qol to some of these pts

You know what’s really detrimental to quality of life? Not having one.

 

[Palex80]

I do not give 24 months of ADT for high-risk patients with only one high-risk feature. There is good data for 18 months.

Duration of Androgen Deprivation Therapy in High-risk Prostate Cancer: A Randomized Phase III Trial - PubMed

In this study, we report outcomes from high-risk prostate cancer patients treated with radiotherapy and either 36 or 18 mo of androgen deprivation therapy. There was no difference in survival between the two groups, with the 18-mo group experiencing a better quality of life.

pubmed.ncbi.nlm.nih.gov

Also, bear in mind the Will Rogers effect.
Today’s high-risk patients staged with PSMA-PET-CT are likely more truly N0M0 than those in the past staged with CT & bone scan. The net benefit in these patients from prolonged ADT, esp. in the context of dose escalation and ENI of the pelvis (if you do that), may be even lower.

 

[Ray D. Ayshun]

I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.

Generally, 4+4 gets 18 months from me

 

[drowsy12]

Being upset with someone misrepresenting what we do on x? He made an untrue statement, no? Does each gs 4+4 patient you treat get 24 months adt? Essentially none of mine do.

I don’t think this was an attack on rad oncs at all. I realize that many of us feel the need to be aggrieved but this was not one of them in my opinion.

1) he’s talking about urologists too
2) he’s generally speaking about the SOC for high risk and the fact is it’s a reality that despite your practice most people are not as discerning as you and treat high risk with long term ADT, full stop.
3) this urologist often is pretty favorable to rad onc in general
4) I posted it initially thinking the AS for GS8 would be the controversial part

 

[Mandelin Rain]

This happens to me all the time as well.

Like what are you doing in that room?

Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”

 

[Ray D. Ayshun]

I don’t think this was an attack on rad oncs at all. Not one iota. I realize that many of us feel the need to be aggrieved but this was not one of them in my opinion.

1) he’s talking about urologists too
2) he’s generally speaking about the SOC for high risk and the fact is it’s a reality that despite your practice most people are not as discerning as you and treat high risk with long term ADT, full stop.
3) this urologist often is pretty favorable to rad onc in general
4) I posted it initially more on the active surveillance part, not the ADT part.

I understand. My issue isn't a product of feeling aggrieved. Rather, id simply like people to stop saying things that are wrong, however peripheral to their larger point. Perhaps I overstated his attack on radonc, but it is indicative of an absolute ignorance of the thought we put into the use of adt and anti androgens in pca. I spend as much or more time talking about testosterone with many guys.

 

[medgator]

Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”

Be grateful he sent you the patient pre vs post op. Damn good GU, bro

 

[deleted1180461]

Be grateful he sent you the patient pre vs post op. Damn good GU, bro

Yep.

My urologist referring does not do prostatectomies at all. I am nice to him!

 

[radoncftw]

it really is crazy that over the years i have met more patients than i should who come to me and:

1) i am the first person telling they have cancer. Usually it is because med onc uses words like “mass”, “lump”, “malignancy” or another euphemism

2) i am the first person to tell them their cancer is incurable

3) first person who tells them their prognosis is very poor

4) first person to tell them something super important about their disease like positive margins (surgeon said they “got it all”), or something else

5) first person to spend over 30 minutes with them and hear often you are first to ever explain this

6) first person to tell them their stage

>80% of my encounters

 

[radoncftw]

Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”

lol i don't send too much shade.
i just do my thing and explain things to the patient and thank the urologist for referring the patient.

 

[RadOncDoc21]

lol i don't send too much shade.
i just do my thing and explain things to the patient and thank the urologist for referring the patient.

Our med oncs are so busy and handle so much of the medical issues so I understand why they can’t sometimes spend as much time with the patient as I do in regards to the “cancer discussion.”

In regards to the surgeons, I don’t mind as long as I get the referrals.

 

[StIGMA]

Our med oncs are so busy and handle so much of the medical issues so I understand why they can’t sometimes spend as much time with the patient as I do in regards to the “cancer discussion.”

In regards to the surgeons, I don’t mind as long as I get the referrals.

I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.

 

[RadOncDoc21]

I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.

Well that’s another story!

 

[madchemist89]

I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.

Gotta be stage 4 to get the immunotherapy

 

[temujim]

Gotta be stage 4 to get the immunotherapy

Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.

 

[BobbyHeenan]

Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.

Same here.

They just start Libtayo for huge tumors and then send to me …but often they’ve already had a few cycles before I see them. So it’s challenging to know how long to run the IO before jumping to XRT. And do you stop it and add a platinum for sensitizing, etc.

 

[temujim]

Same here.

They just start Libtayo for huge tumors and then send to me …but often they’ve already had a few cycles before I see them. So it’s challenging to know how long to run the IO before jumping to XRT. And do you stop it and add a platinum for sensitizing, etc.

Biased bc only see once they've progressed. So not much of a question of IO anymore, just RT +/- chemo, though most of these older skin patients can't tolerate the cisplatin.

But once derm figures out what has been happening with their referrals (ie IO rather than standard surgery or RT), they won't send anymore and set up an infusion bay right next to the SGRT. Many of the local derms are prescribing vismodegib; med oncs never see.

 

[thesauce]

Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.

Gawd what a nightmare

 

[medgator]

Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.

Why are Derms referring to med onc first?

Traditionally they try to resect aggressively or send to us if they can't, not med onc.

 

[BobbyHeenan]

Why are Derms referring to med onc first?

Traditionally they try to resect aggressively or send to us if they can't, not med onc.

My cases have been ER to inpatient (neglected, indigent patients). Admitted by hispitalist. ENT sees as inpatient, biopsies, says can’t resect and then hospitalist consults the med onc service…,and then libtayo gets started.

 

[madchemist89]

While not standard of care, libtayo can be very effective in skin cancer. NEJM phase two study showed a 50% pathCR rate in unresectable disease.

 

[drowsy12]

Im okay with med oncs starting with cemiplimab in advanced cases, but rad onc should follow along and should be able to consolidate, patients should not be on the drug forever in the locally advanced setting

And the decision should happen in coordination with rad onc as well. I trust my med oncs for these cases, but they also discuss the cases with me. Cemiplimab is an amazing drug for cutaneous SCC.

 

[medgator]

My cases have been ER to inpatient (neglected, indigent patients). Admitted by hispitalist. ENT sees as inpatient, biopsies, says can’t resect and then hospitalist consults the med onc service…,and then libtayo gets started.

Maybe they are getting drug free from the company... A thought.

I guess if you're rvu based you don't care that they are indigent but maybe med onc thinks they aren't getting surgery or try RT otherwise.

Very few skin ca if any come to me through the hospital...95%+ are outpt and insured and see me from derm. From there I refer to med onc for IO if it looks appropriate to do so

 

[temujim]

While not standard of care, libtayo can be very effective in skin cancer. NEJM phase two study showed a 50% pathCR rate in unresectable disease.

That was all resectable, though the phase I NEJM in R/M has ~50% ORR. Not sure I see the difference in outcomes between lancet oncology follow up paper, admittedly with only 18 mo follow up and the TROG surg+RT data. But as usual med oncs out there doing whatever based on phase II data, never mind the 11% that didn't make it to surgery/ progressed to unresectable.

 

[Palex80]

I have been seeing the same pattern in the (rare) locally/regionally advanced merkel cell carcinomas.

The patients get avelumab up front, then resection and then the fight ensuits (esp. in those with favorable response), whether or not they should get adjuvant RT. Someone should think about running a trial on primary RT+IO for larger / nodal-positive MCC.

 

[thesauce]

While not standard of care, libtayo can be very effective in skin cancer. NEJM phase two study showed a 50% pathCR rate in unresectable disease.

ok so about half as effective as RT?

 

[BobbyHeenan]

Im okay with med oncs starting with cemiplimab in advanced cases, but rad onc should follow along and should be able to consolidate, patients should not be on the drug forever in the locally advanced setting

And the decision should happen in coordination with rad onc as well. I trust my med oncs for these cases, but they also discuss the cases with me. Cemiplimab is an amazing drug for cutaneous SCC.

Yes, in the cases scenarios as above they get me involved and are not on the cemiplimab indefinitely. I've had I think 3 cases and two of them responded really well, we rode it out 6 months then switched to radiation. One had minimal response. Not sure what the best answer is in these cases, but indefitive cemiplimab doesn't seem to be a good plan.

 

[Palex80]

ok so about half as effective as RT?

But did you see that tumor melt away on IO? 😛😛😛

 

[BobbyHeenan]

I wonder if he’ll be screened for PACE-A?

https://x.com/royalfamily/status/1754565735655887066?s=46&t=ywK8R-mkFzwr4B1EWwRSvA

 

[OTN]

I wonder if he’ll be screened for PACE-A?

https://x.com/royalfamily/status/1754565735655887066?s=46&t=ywK8R-mkFzwr4B1EWwRSvA

Apparently it's not prostate cancer. Bladder maybe?

 

[CaesarRO]

I wonder if he’ll be screened for PACE-A?

https://x.com/royalfamily/status/1754565735655887066?s=46&t=ywK8R-mkFzwr4B1EWwRSvA

One of the other articles I Read explicitly said not Prostate Cancer.

I'm thinking colorectal or bladder...

 

[Palex80]

One of the other articles I Read explicitly said not Prostate Cancer.

I'm thinking colorectal or bladder...

Bladder makes sense. He likely had a TUR-B and needs to go "regularly" back to the clinic for instillations.

 

[TheWallnerus]

Apparently it's not prostate cancer. Bladder maybe?

Or it could be Gleason 3+3

And we are having metaphysics arguments, is it cancer or no

 

[drowsy12]

My money is on rectal

 

[TheWallnerus]

My money is on rectal

It is my sincerest hope that the Royal Rectum is cancer free

 

[Ray D. Ayshun]

Anal?

 

[Fpg1245]

It is my sincerest hope that the Royal Rectum is cancer free

all I know is his royal behind will not be waiting in an NHS queue even if they have to use the service to keep up appearances.

 

[thecarbonionangle]

all I know is his royal behind will not be waiting in an NHS queue even if they have to use the service to keep up appearances.

King will end up getting protons on his behind?

 

[TheWallnerus]

King will end up getting protons on his behind?

Gives “annus horribilis” a very different spin

 

[RickyScott]

This was sent to me. I guess Ron can’t use RTT after his name?

 

[TheWallnerus]

PopcornThis was sent to me. I guess Ron can’t use initials RTT after his name?


View attachment 382228

Wow I have known doctors allegedly to have committed massive fraud and nothing ever happened to their license. This must be salacious.

 

[medgator]

This was sent to me. I guess Ron can’t use initials RTT after his name?


View attachment 382228

He didn't find the grifter life, it found him?

 

[RickyScott]

Wow I have known doctors allegedly to have committed massive fraud and nothing ever happened to their license. This must be salacious.

I was told that it was on the rtt proffesional site but then taken down after Ron called because it had been up for 10 years. Easy to call and verify.

 

[RickyScott]

Wow I have known doctors allegedly to have committed massive fraud and nothing ever happened to their license. This must be salacious.

Docs usually loose their license for sex,drugs or theft