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It has always surprised me the healthplans don't have some kind of language embedded in a contract or a signed document that goes along with the plan comparison stating the 3d plan is truly a "best effort" plan. I did reviews back in the day, and I was assigned many for a famous academic center with multiple satellites that seemed to do imrt on every breast case including t1a 80 year olds. Every comparison plan was exactly the same with tangents intentionally shooting through the heart, no fif optimization, etc. I guess the healthplans figure they'll just get us in the end by not paying either way 🙃 People here talk a lot about the pre auth process but if you followed the post treatment claims process, you'd see that's where the real shenanigans happen.
 
FWIW - its not clear that Mantz didnt plan the treatment. The prior MD consented the patient for the incorrect side and Mantz saw the patient under treatment, but from what I can gather, it is not specified who simmed and planned the patient.
 
TheWallnerus said:
In essence

In my opinion

This is what being a good modern rad onc is all about, in toto

(P.S. this is the lure of LDRT)
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I have practiced with boomers who intentionally undertreat to avoid side effects. Stuff like unilateral neck or worse gross disease only on an oral cavity case, 1mm margins on lung, prostate bed covering only the inferior 1 cm of bladder, inappropriately hypofractionate GI stuff (grade 4-5 toxicity is LATE, not acute), etc.

Seems common in locums Drs. Therapists say you suck and Dr. So-and-so was great, his patients never had any problems! (patients never follow-up, so and so flies off to another town a month later), complain to admin about how terrible you are because of toxicity and other ridiculousness.
 
MidwestRadOnc said:
I have practiced with boomers who intentionally undertreat to avoid side effects. Stuff like unilateral neck or worse gross disease only on an oral cavity case, 1mm margins on lung, prostate bed covering only the inferior 1 cm of bladder, inappropriately hypofractionate GI stuff (grade 4-5 toxicity is LATE, not acute), etc.

Seems common in locums Drs. Therapists say you suck and Dr. So-and-so was great, his patients never had any problems! (patients never follow-up, so and so flies off to another town a month later), complain to admin about how terrible you are because of toxicity and other ridiculousness.
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The best evidence I can give that there is general over treatment is that less than 1% of breast cancer patients in America get 5 fractions, and less than 10% of bone mets patients get single fraction.

And it’s not always just the boomers that do odd things. Here’s a stage zero glottic case I audited recently. Rad onc is about 5 years out of training.
 
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TheWallnerus said:
The best evidence I can give that there is general over treatment is that less than 1% of breast cancer patients in America get 5 fractions, and less than 10% of bone mets patients get single fraction.

And it’s not always just the boomers that do odd things. Here’s a stage zero glottic case I audited recently. Rad onc is about 5 years out of training.
View attachment 387922
View attachment 387920
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If you don't use the GD shoulder-pulls you gotta do weird ****. It's crazy how little set-up strategy is taught in res. Obv, there are other issues, but this is how not to setup shoulders and chin in true glottic.
 
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TheWallnerus said:
The best evidence I can give that there is general over treatment is that less than 1% of breast cancer patients in America get 5 fractions, and less than 10% of bone mets patients get single fraction.

And it’s not always just the boomers that do odd things. Here’s a stage zero glottic case I audited recently. Rad onc is about 5 years out of training.
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Gee, what would happen if 50% of breast got 5 fractions under ROCR? (even if billing stayed the same, job market would be hammered)
 
Ray D. Ayshun said:
If you don't use the GD shoulder-pulls you gotta do weird ****. It's crazy how little set-up strategy is taught in res. Obv, there are other issues, but this is how not to setup shoulders and chin in true glottic.
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I guess we can be happy the doc is sparing the mandible, parotids, and oral tongue in this case
 
TheWallnerus said:
The best evidence I can give that there is general over treatment is that less than 1% of breast cancer patients in America get 5 fractions, and less than 10% of bone mets patients get single fraction.

And it’s not always just the boomers that do odd things. Here’s a stage zero glottic case I audited recently. Rad onc is about 5 years out of training.
View attachment 387922
View attachment 387920
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What is the scenario in which you "audited" this?

Internal peer review?

Expert witness? If so, what was the complaint?
 
OTN said:
Long-term cosmesis would be worse in that population that if they had received UK/Canadian fractionation for one thing
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giphy.gif
 
MidwestRadOnc said:
I have practiced with boomers who intentionally undertreat to avoid side effects. Stuff like unilateral neck or worse gross disease only on an oral cavity case, 1mm margins on lung, prostate bed covering only the inferior 1 cm of bladder, inappropriately hypofractionate GI stuff (grade 4-5 toxicity is LATE, not acute), etc.

Seems common in locums Drs. Therapists say you suck and Dr. So-and-so was great, his patients never had any problems! (patients never follow-up, so and so flies off to another town a month later), complain to admin about how terrible you are because of toxicity and other ridiculousness.
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More evidence we're all living similar lives of existential torture.

I have absolutely, positively, 1000% witnessed this as well.
 
TheWallnerus said:
The best evidence I can give that there is general over treatment is that less than 1% of breast cancer patients in America get 5 fractions, and less than 10% of bone mets patients get single fraction.

And it’s not always just the boomers that do odd things. Here’s a stage zero glottic case I audited recently. Rad onc is about 5 years out of training.
View attachment 387922
View attachment 387920
Click to expand...

Oof. I could see that if you do VMAT routinely for glottic and don't really pay attention to the chin/shoulder positioning you won't notice anything problematically wrong.

Although, if the patient is in a S-frame and can't move (meaning shoulder and chin position are pretty consistent), is it really *bad* as opposed to just maybe 'suboptimal'? The shoulder pull down and neck hyperextension was only really necessary in the era where you were bringing in opposed lateral fields to treat this disease..

As an aside - Posts regarding skin care (including ESE's extremely informative write-up on how he/she/it/they do(es) it) has been moved to a new thread
 
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[QUOTE="@AtlanticHealth
and Mevion Medical Systems are thrilled to announce plans to bring the latest in proton therapy technology to the Carol G. Simon Cancer Center at Morristown Medical Center! Learn more: https://hubs.la/Q02BrCL90
[/QUOTE]

The carbon savings from patients being able to get treated locally in NJ instead of having to drive all the way into NYC for each fraction is going to be substantial.
 
I think we are past the point of being surprised. We are going to see a bunch of new centers over the next decade. This isn’t going away. The momentum is in proton lobby’s favor
 
drowsy12 said:
I think we are past the point of being surprised. We are going to see a bunch of new centers over the next decade. This isn’t going away. The momentum is in proton lobby’s favor
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Eventually payors are going to wonder where the data is to support this higher priced "drug"

Protons have no big pharma money and rcts backing them up.

Will end badly imo. Already is, plenty of bankruptcies and "restructurings" already occurring
 
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medgator said:
Eventually payors are going to wonder where the data is to support this higher priced "drug"

Protons have no big pharma money and rcts backing them up.

Will end badly imo. Already is, plenty of bankruptcies and "restructurings" already occurring
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Mevion single room is probably one of the most economic ways of opening a proton gantry, and so maybe they'll contract for IMRT rates.

Or they'll just treat Medicare folks prostates for straight cash, who knows.
 
evilbooyaa said:
Mevion single room is probably one of the most economic ways of opening a proton gantry, and so maybe they'll contract for IMRT rates.

Or they'll just treat Medicare folks prostates for straight cash, who knows.
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Not a financially viable strategy imo. Medicare is the only payor without an auth requirement. They don't pay the best. And eventually Medicare may wonder about it too

Only time will tell
 
Insurance companies have gotten sued and lost. Some states have passed laws making it harder for companies to deny approval for proton.

Not going away in my view and it’s only a matter of time before some of us haters have it on our centers.
 
1718450666316.png



A wonderful misinterpretation of the study results…



Results Thirty-nine publications were included, comprising 85 comparisons of trial participants and routine care patients. The meta-analysis revealed a statistically significant overall survival benefit for trial participants (HR, 0.76 [95% CI, 0.69-0.82]) when all studies were pooled, regardless of design or quality. However, survival benefits diminished in study subsets that matched trial participants and routine care patients for eligibility criteria (HR, 0.85 [95% CI, 0.75-0.97]) and disappeared when only high-quality studies were pooled (HR, 0.91 [95% CI, 0.80-1.05]). They also disappeared when estimates were adjusted for potential publication bias (HR, 0.94 [95% CI, 0.86-1.03]).

Conclusions and Relevance Many studies suggest a survival benefit for cancer trial participants. However, these benefits were not detected in studies using designs addressing important sources of bias and confounding. Pooled results of high-quality studies are not consistent with a beneficial effect of trial participation on its own.
 
is momentum really in PBT’s favor? I don’t see major insurers or Evicore expanding approved indications. No new Medicare LCD on PBT either
 
As # of fractions decreases, it actually reduces the financial upside of protons. If ROCR passes and all photon centers start using short courses more, proton centers will probably feel pressure from referrings to also shorten courses
 
grenz said:
As # of fractions decreases, it actually reduces the financial upside of protons. If ROCR passes and all photon centers start using short courses more, proton centers will probably feel pressure from referrings to also shorten courses
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Sort of a cut off your nose to spite your face

We can kill protons with rocr and probably also kill your photon center at the same time!
 
Fpg1245 said:
Sort of a cut off your nose to spite your face

We can kill protons with rocr and probably also kill your photon center at the same time!
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Why would it kill a photon center? Of all the criticisms of ROCR I’ve heard, financial insolvency of photon centers isn’t one of them.
 
I still haven’t heard what case based payments are going to do to doctors who are paid per RVU. Are the pro codes just going to go away and all we have left is a single prostate pro code that is worth 50 wRVU or something?
 
medgator said:
Does Evilcore or aim specialty health limit protons at all? Seems a lot more lucrative than going after extra breast and prostate fractions
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I mean… is it? From an insurance perspective, is there more utility in focusing on protons or IMRT? Protons cost a more per patient, but changing IMRT policy impacts quite a few more patients.
 
What is cheapest proton machine available? 15M? How many prostates you need on treat to make it profitable? I’m guessing 30 Medicare prostates on treat doesn’t make it profitable or some urorads would open them. How many on treats would you need to make it work?
 
Bequerel said:
What is cheapest proton machine available? 15M? How many prostates you need on treat to make it profitable? I’m guessing 30 Medicare prostates on treat doesn’t make it profitable or some urorads would open them. How many on treats would you need to make it work?
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Financials are only going to work for centers that can leverage something like 3x cms prices. 30 Medicare prostates won’t cut it.
 
Bequerel said:
What is cheapest proton machine available? 15M? How many prostates you need on treat to make it profitable? I’m guessing 30 Medicare prostates on treat doesn’t make it profitable or some urorads would open them. How many on treats would you need to make it work?
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There is a Urorad proton center going into St Louis, I believe.

The Mevion-FIT machine, if it will fit in your larger empty vault, is a potential game changer in terms of adoption.
 
IonsAreOurFuture said:
There is a Urorad proton center going into St Louis, I believe.

The Mevion-FIT machine, if it will fit in your larger empty vault, is a potential game changer in terms of adoption.
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Could you explain the pros and cons of the FIT? I’ve only ever seen the marketing materials, but there’s always more to the story.
 
grenz said:
Could you explain the pros and cons of the FIT? I’ve only ever seen the marketing materials, but there’s always more to the story.
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It's self-shielded and can therefore fit into a convenional linac vault. I presume it will cost more than a non-shielded proton unit, but you will not have to configure an entirely new proton vault either.

If you are angling to replace a conventional linac with a proton unit, choosing FIT will probably be cheaper.

mevion.com

mevion-s250-fit-proton-therapy-system

MEVION S250-FIT PROTON THERAPY SYSTEM Enabled by the world’s smallest self-shielded proton accelerator, the MEVION S250-FIT Proton Therapy System™ is the first and only full proton therapy system t…
mevion.com mevion.com
 
Gfunk6 said:
It's self-shielded and can therefore fit into a convenional linac vault. I presume it will cost more than a non-shielded proton unit, but you will not have to configure an entirely new proton vault either.

If you are angling to replace a conventional linac with a proton unit, choosing FIT will probably be cheaper.

mevion.com

mevion-s250-fit-proton-therapy-system

MEVION S250-FIT PROTON THERAPY SYSTEM Enabled by the world’s smallest self-shielded proton accelerator, the MEVION S250-FIT Proton Therapy System™ is the first and only full proton therapy system t…
mevion.com mevion.com
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Oh… correction… every proton unit, no matter the manufacturer, is highly shielded.

Shielded from ROCR 🙂
 
Stanford is getting the Mevion

The number of major academic centers without proton falls by the day.
 
Just saw this, and I do wonder a couple things.
1718802074012.png

1718802152983.png

1718802118783.png

Firstly, how can gender be collected from publicly available department websites? Isn't that sex that's being collected? Secondly, is this an indictment of patients and not the specialty? My impression is that women prefer female doctors in this scenario in general and men males.
 
Ray D. Ayshun said:
Just saw this, and I do wonder a couple things.View attachment 388197
View attachment 388199
View attachment 388198
Firstly, how can gender be collected from publicly available department websites? Isn't that sex that's being collected? Secondly, is this an indictment of patients and not the specialty? My impression is that women prefer female doctors in this scenario in general and men males.
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Why does it have to be an indictment? Can't it just be a preference?
 
OTN said:
Why does it have to be an indictment? Can't it just be a preference?
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I don't disagree, but society at large feeds on indicting other groups. If you're going to write a paper proving that more men treat prostate and more women treat gyn, there must be some greater evil you are trying to right. Otherwise, this is just common knowledge, and inconsequential.
 
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