Rad Onc Twitter

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MidwestRadOnc said:
Another question is at what point is nodal disease “incurable”

I recently was lead into chasing nodes down near into the pelvis.
Do I treat them to 50.4 or 60+? They aren’t coming out at surgery. So any other adeno we are going to boost these nodes as high as bowel tolerance will allow. That’s what I did. But we stop the primary at 50.4? Cause esophageal is special. Ok. Makes zero sense.
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Personally, I don't take the nodes higher than the primary if genuinely treating definitively. That doesn't strike me as ethical. I don't do it in any other situation where I'm treating definitively. Unresectable nodes in neoadjuvant rectum, sure. I tell the patient up-front in definitive attempts that this probably won't cure you. Definitive chemorads works 100% of the time 20% of the time.
 
Ray D. Ayshun said:
Personally, I don't take the nodes higher than the primary if genuinely treating definitively. That doesn't strike me as ethical. I don't do it in any other situation where I'm treating definitively. Unresectable nodes in neoadjuvant rectum, sure. I tell the patient up-front in definitive attempts that this probably won't cure you. Definitive chemorads works 100% of the time 20% of the time.
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So my decision to boost an unresectable node to 60+ in esophageal was unethical even though the same node would have been boosted that high by anybody else in any other adeno?

Am I crazy?

I’ve got a prostate guy im taking multiple nodes to 80+ right now. Bowel constraints met.
 
i'm out game of thrones GIF by Amanda
 
MidwestRadOnc said:
So my decision to boost an unresectable node to 60+ in esophageal was unethical even though the same node would have been boosted that high by anybody else in any other adeno?

Am I crazy?

I’ve got a prostate guy im taking multiple nodes to 80+ right now. Bowel constraints met.
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I don't know what to tell you. It's all a risk/benefit calculation. Doesn't make sense to treat gross disease to different doses. Not sure what to say about what you're doing with the prostate but sounds like you're treating gross nodes to a definitive dose. Hope it goes well. For stage iii esophagus, my approach is 50.4 will work unless it doesn't. I'll admit to taking big lung primaries to 66/30 while taking nodes to 60.
 
MidwestRadOnc said:
We might have a new contender for stupidest disease site. Hold my beer, breast.
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Seems straightforward. Chemorads cures some people. 50 gy is the dose. Maybe it's just me. I'll let the folks know next time I see em that despite being 4 yrs out with ned, they've got not shot. I'll write em a check for the unnecessary otv.
 
(Pokes head in the door, sees the discussion, throws the following grenade, shuts the door and runs away):

I've cured a patient with locally-advanced gastric aca with XRT alone. 50.4. We are now 5 years out.
 
OTN said:
(Pokes head in the door, sees the discussion, throws the following grenade, shuts the door and runs away):

I've cured a patient with locally-advanced gastric aca with XRT alone. 50.4. We are now 5 years out.
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Your pathologist:

1714424249817.png


MidwestRadOnc said:
I recently was lead into chasing nodes down near into the pelvis.
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Why are you treating a patient with esophageal cancer with a definitive dose if he has "nodes down near into the pelvis"???
 
drowsy12 said:
I am speaking more on the interpretation of the trial. If there is a big OS benefit, I don't think there's much of a case to be made that the outcomes would have been different if the dose was 50.4 and not 41.4.
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1714424817994.png

Especially in a multicenter setting and if RT-QA is not great or surgeons not very experienced, delivering a higher dose to lungs & heart in the preoperative setting may indeed impair outcomes.
 
thesauce said:
The reason we have a new drug every week is that pCR is now used as a surrogate for PFS for FDA approval. Somehow this doesn’t work for RT?
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genuine question - any good recent examples of this? the main recent neoadjuvant regimens I am aware of are things like resectable lung cancer, where EFS is the endpoint.

second point - yes, pathologic response of a drug reflects what it is doing systemically, this is more relevant than a pCR in a local field.
 
I think the good thing about Europe having more centralized care is we can actually get answers to big data questions with a lot better data integrity than NCDB


x.com

x.com x.com
 

x.com

x.com x.com

Agree. Part of the concern some have with potential for corporate rad onc to use more extenders rather than hiring docs, in future.
 
drowsy12 said:

x.com

x.com x.com

Agree. Part of the concern some have with potential for corporate rad onc to use more extenders rather than hiring docs, in future.
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You think pts will want to see an extender when they have newly dxed cancer? MA and medicaid HMO pts may not care/have a choice, but those with good insurance will balk.

I've seen a breast surgeon lose business when they started trying to use an extender for new patient consults
 
medgator said:
You think pts will want to see an extender when they have newly dxed cancer? MA and medicaid HMO pts may not care/have a choice, but those with good insurance will balk.

I've seen a breast surgeon lose business when they started trying to use an extender for new patient consults
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I’m just worried about what we have seen happen in EM and anesthesia, but I hope you are right.
 
drowsy12 said:

x.com

x.com x.com

Agree. Part of the concern some have with potential for corporate rad onc to use more extenders rather than hiring docs, in future.
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Any RO practice that routinely uses NPs for new patient consults should be expected to lose out on a portion of their business.
 
drowsy12 said:


Another new chair who only took about a decade to get there. Good for WashU
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Amazing. I remember before she had grants and was struggling, much like I was. Her rise is fantastic, and it couldn't happen to a better person. I hope she improves the culture at WashU.
 
I talked to an academic dosimetrists. They had their main job and two remote full time jobs. They said they just planned while at work and on weekends. If you are pulling 100-150k per job, you are approaching MD salaries. Way less school and way more flexibility. It is a great gig right now
 
thecarbonionangle said:
I talked to an academic dosimetrists. They had their main job and two remote full time jobs. They said they just planned while at work and on weekends. If you are pulling 100-150k per job, you are approaching MD salaries. Way less school and way more flexibility. It is a great gig right now
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We had a dosimetrist not too long ago and I sat down at her computer to work on a plan. SHe had her laptop open beside it as well and I looked at the screen and it wasn't our planning system and I thought I was stroking out. I put it together and she was remote planning another hospital and forgot to close it out.

With that said, I didn't say anything to admin because she was a fantastic dosimetrist.

She ended up leaving to go be closer to family but I think these new grads that are very tech savvy are pulling double duty a lot. As you all know CT sims often come in waves, I'll go a day or two with maybe just 1 sim a day, then some days have five. On those slower times the dosimetrists certainly could be pulling double duty and I wouldn't know.
 
My dosimetrist has multiple other jobs, w2 and 1099.

As long as the work gets done I don’t care. Funny when other docs get bent out shape because the dosimetrist is hustling and making doctor level income, which has been a concern. Good for them.
 
thecarbonionangle said:
I talked to an academic dosimetrists. They had their main job and two remote full time jobs. They said they just planned while at work and on weekends. If you are pulling 100-150k per job, you are approaching MD salaries. Way less school and way more flexibility. It is a great gig right now
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Maybe rad onc MDs could also get certified in dosimetry as well so we could get in on this double dipping thing.
 
thecarbonionangle said:
I talked to an academic dosimetrists. They had their main job and two remote full time jobs. They said they just planned while at work and on weekends. If you are pulling 100-150k per job, you are approaching MD salaries. Way less school and way more flexibility. It is a great gig right now
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Ditto for med physics. Approaching $300k for chief positions in some markets
 
fiji128 said:
Maybe rad onc MDs could also get certified in dosimetry as well so we could get in on this double dipping thing.
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I've looked into this.

A lot.

Unfortunately, and similar to the Palliative Care cert, there is no longer a "practical pathway" to sit for the exam based on experience.

Now, I stopped short of contacting the AAMD to see if an exception could be made for physicians because I assume no one has asked before...it does remain on my long-term, "potential to-do list".

However, there doesn't really appear to be any regulations around this, other than perhaps something like APEx. There's no overt prohibition on a RadOnc working as a Dosimetrist - and there are, of course, the tales floating around of a solo RadOnc here and there doing their own Dosimetry for their practice.

The real world is the Wild West.
 
fiji128 said:
Things can look much better when demand for specialties' services increase rather then constantly decrease.

View attachment 386133
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Wow! Looks like I’ve chosen the wrong “Rad”😂 is it even possible to pull this kind of money as a rad onc nowadays unless you’re a chair or a boomer with a well-established busy PP?
 
It's actually a pathway to combat the overtraining if you think about it.
Instead of reducing resident numbers, because that would be way too simple, instead have the residents spend a year on dosimetry, so when they get pumped out by the hundreds and only have 5-10 OTVs a week, they will have plenty of time to do their own plans and supplement their income with what dosimetry was being paid.
 
MidwestRadOnc said:
It's actually a pathway to combat the overtraining if you think about it.
Instead of reducing resident numbers, because that would be way too simple, instead have the residents spend a year on dosimetry, so when they get pumped out by the hundreds and only have 5-10 OTVs a week, they will have plenty of time to do their own plans and supplement their income with what dosimetry was being paid.
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I can see this happening and better use of time during residency.
 
DrProtonX said:
Wow! Looks like I’ve chosen the wrong “Rad”😂 is it even possible to pull this kind of money as a rad onc nowadays unless you’re a chair or a boomer with a well-established busy PP?
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Chair? Yes. Do not sell yourself short. There really is no limit to enriching yourself at the expense of the growing junior RO masses. You could be the first chair to get someone to pay you to work for you. A "visiting student-attendingship", or something.
 
MidwestRadOnc said:
It's actually a pathway to combat the overtraining if you think about it.
Instead of reducing resident numbers, because that would be way too simple, instead have the residents spend a year on dosimetry, so when they get pumped out by the hundreds and only have 5-10 OTVs a week, they will have plenty of time to do their own plans and supplement their income with what dosimetry was being paid.
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Yes. It would be a SIGNIFICANTLY better use of time in residency, from just a pure educational perspective - even if someone never ends up opening the Optimizer section of whatever TPS they use for the entire career.

But also, there's the possibility - the unspoken possibility - you end up in a situation without a Dosi/Physics arrangement that can produce minimally competent plans for your patients, and it's either do it yourself or be OK with the plan isocenter being set 7cm off the actual isocenter, etc etc etc
 
DrProtonX said:
Wow! Looks like I’ve chosen the wrong “Rad”😂 is it even possible to pull this kind of money as a rad onc nowadays unless you’re a chair or a boomer with a well-established busy PP?
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It’s possible to pull that money but almost impossible to get that 9-11 weeks PTO with it
 
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