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Pretty sure she's trying to be satirical but can definitely see how this would be read wrong
My impression is she is very serious, but also trying to be a little 'joshing'/funny
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The pick-me energy is strong
Mods please lock this thread after such a highly political post
Totally satirical. Did you see the rest of the people commenting?
Meet Donald Trump, the oncologist https://www.washingtonpost.com/news...candidate-once-referred-to-as-the-famous-one/
H/T to Bishal Gyawali for the share on X
Also thought the other thread wouldve been interesting discussion. Sad to see that things like that are locked.
I discourage locking the thread. It was a legit twitter oriented post (much more on target to the thread origins than most posts). The twitter post was political...and satirical, which is totally fine. Calling out "pick-me" ism is also fine...it will be interesting.
Silence is usually the problem.
Silence is usually the problem.
So meta.
Palex's thread was out of control. Let's not let this thread be as crazy as his/hers.
I had a very pleasant discussion with evilbooyaa, it was helpful for me to understand the specifics of US healthcare policy.
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Aren't you glad to be in Europe now?
Some things are certainly less complicated here.
x.com
x.com
Get in losers we're all calling it SABR now
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This is an old argument
I mean those are probably two of the worst ROs in the entire country in terms of damage to the state of RO as a field
But calling 30Gy in 5 Fx (https://www.sciencedirect.com/science/article/pii/S0360301624025410) ABLATIVE
seems like a bit of a stress.
Should call it SARS if that's our threshold - Stereotactic Ablative RadioSurgery
Let’s improve survival first or at the very least local control!
Who cares about survival? I can make them spend an hour a day showing them my new toy.
MRI linac make sense for LGG but that study would take forever and require a lot of patients. We probably will see IDH inhibitors as standard of care before that study completes.
Very important for the 10+ year GBM survivors
I didn't know him personally, but in reading the NRG oncology obituary, I feel like the bell tolls for thee - a big loss to our field
I briefly met him during an away rotation. His general good nature and excitement about the field kept me from going in another direction to a degree, and I'm not just saying it to be sentimental. The obituary seemed an accurate summation.
Ralph Weichselbaum, MD, appointed University of Chicago Health System leader for Radiation and Cellular Oncology - UChicago Medicine
In his expanded health system role, Ralph Weichselbaum leads efforts to bring radiation therapy to patients at the University of Chicago Medicine, including in Chicago’s suburbs and in Northwest Indiana.
Still going strong
I thought Biden debacle would open some eyesRalph Weichselbaum, MD, appointed University of Chicago Health System leader for Radiation and Cellular Oncology - UChicago Medicine
In his expanded health system role, Ralph Weichselbaum leads efforts to bring radiation therapy to patients at the University of Chicago Medicine, including in Chicago’s suburbs and in Northwest Indiana.www.uchicagomedicine.org
Still going strong
Two different senile septugenarians running didn't open up anyone's eyes apparently
Ralph Weichselbaum, MD, appointed University of Chicago Health System leader for Radiation and Cellular Oncology - UChicago Medicine
In his expanded health system role, Ralph Weichselbaum leads efforts to bring radiation therapy to patients at the University of Chicago Medicine, including in Chicago’s suburbs and in Northwest Indiana.
Still going strong
My God he’s terrible
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Goose?
Rectal?
I was thinking breast + boost at 1.8/day but it’s a male so not likely. Can’t think of what would be 28 vs 35…prostate? 70 in 28 but what prostate dose is in 35 fx? Unless he meant 45 fx or there was some sort of unplanned nodal boost.
35 fx FLAME vs 28 fx for high risk prostate?
I've had that argument before.
(92% bDFS is pretty good in FLAME, especially considering the relatively high proportion of high-risk patients in the trial (84%), not all received hormone therapy, the nodes weren't covered, and the OARs took priority over the PTVs.
77 Gy in 2.2s to the whole prostate is a pretty good whole prostate dose in addition to the SIB to 95 Gy.
FLAME is my go-to for high-risk now after this data came out. I refer to my medical oncologist who does a lot of GU to discuss hormone and other systemic therapy.)
The Dutch FLAME trial
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Definitely prostate / FLAME thing here
Keep in mind folks. When the insurance company denies 7 extra treatments... you are more than able to go ahead and treat the patient those 7 extra. And not bill the patient. When the insurance company denies IMRT, go ahead and do the IMRT. Just bill as 3D. This is accepted, legal, kosher, all the things, etc.
In a modern practice, admins won't let you prescribe 35 fx of you have preauth for 28. Patient will not be simulated.
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Sure, it's legal, but it's also capitulating and letting them win. We should not do that.
Admins typically react like I am some sort of criminal when I bring this up. I get vibes of traitor to God and country.
Of course they won’t. And it’s absurd. That it’s wrong to sim and treat and do the the extra 7 for free, etc, is a boogeyman story.
You could also go for DELINEATE, if you want to perform focal dose escalation in the prostate.
20 fractions only, up to 67 Gy focal boost.
Standard and Hypofractionated Dose Escalation to Intraprostatic Tumor Nodules in Localized Prostate Cancer: 5-Year Efficacy and Toxicity in the DELINEATE Trial - PubMed
The DELINEATE trial has shown safety, tolerability, and feasibility of focal boosting in 20 or 37 fractions. Efficacy results indicate a low chance of prostate cancer recurrence 5 years after radiation therapy. Evidence from ongoing phase 3 randomized trials is awaited.
pubmed.ncbi.nlm.nih.gov
A Pioneering Journey in Radiation Oncology Inspired by Multidisciplinary Collaboration | OncLive
Fueled by wanting to carry on his father’s legacy, Ralph R. Weichselbaum, MD, created his own mark on radiation therapy in oncologic care.
In 1995, Weichselbaum worked with Hellman to coin the term oligometastasis. Together, they proposed the spectrum theory of metastasis, suggesting an intermediate state between localized, curable cancers and lethal, widespread disease, whereby some patients develop only limited metastatic disease. “There wasn’t much study of it at all then,” Weichselbaum said. “[When we talk about metastatic cancer, it’s not always widely spread]. This is really a way to think about cancer and...cancer therapy.” This practice-altering concept led to the administration of curative regional therapy for patients with oligometastatic disease.
What's wild to me... maybe not wild to anyone else... is that Hellman and Ralph staked their oligometastatic theory (and the "spectrum theory," which sounds autistic I'm sorry) on breast cancer.
Other prominent rad oncs picked up on this idea... without much data. In fact, maybe ignoring the data.
Later, Bernie Fisher said, essentially, when it comes to this spectrum theory/oligometastasis stuff for breast cancer, it's all bunk. (It probably took a lot to dishearten Bernie Fisher).
Fast forward to now. Bernie was right (NRG BR002, CURB, e.g.). Ralph was wrong.
In a way, Ralph's a leader in our field for being proven wrong about the theory for which he's famous. To paraphrase the late great Don King... "Only in rad onc!"
If the consensus is the "alternative hypothesis" is correct and that locoregional treatment is unlikely to affect overall survival, why are there still papers about nodal radiation in 2025A Pioneering Journey in Radiation Oncology Inspired by Multidisciplinary Collaboration | OncLive
Fueled by wanting to carry on his father’s legacy, Ralph R. Weichselbaum, MD, created his own mark on radiation therapy in oncologic care.www.onclive.com
In 1995, Weichselbaum worked with Hellman to coin the term oligometastasis. Together, they proposed the spectrum theory of metastasis, suggesting an intermediate state between localized, curable cancers and lethal, widespread disease, whereby some patients develop only limited metastatic disease. “There wasn’t much study of it at all then,” Weichselbaum said. “[When we talk about metastatic cancer, it’s not always widely spread]. This is really a way to think about cancer and...cancer therapy.” This practice-altering concept led to the administration of curative regional therapy for patients with oligometastatic disease.
What's wild to me... maybe not wild to anyone else... is that Hellman and Ralph staked their oligometastatic theory (and the "spectrum theory," which sounds autistic I'm sorry) on breast cancer.
Other prominent rad oncs picked up on this idea... without much data. In fact, maybe ignoring the data.
Later, Bernie Fisher said, essentially, when it comes to this spectrum theory/oligometastasis stuff for breast cancer, it's all bunk. (It probably took a lot to dishearten Bernie Fisher).
Fast forward to now. Bernie was right (NRG BR002, CURB, e.g.). Ralph was wrong.
In a way, Ralph's a leader in our field for being proven wrong about the theory for which he's famous. To paraphrase the late great Don King... "Only in rad onc!"
I think pretty premature to say the idea of oligometastases has been proven wrong. I think what has been proven wrong is probably the definition of what we are calling oligometastatic based on current imaging technology
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The reason there are still papers on nodal (ir)radiation in 2025 (do you have a time machine 😉) is hidden within this equivocating apologia. There are some twists and turns, for sure, but...
1) Under usual scientific method principles, it takes just one invalidating piece of data to invalidate an entire theory. That has now happened with NRG BR002 and CURB vis-à-vis Ralph's oligomet theory. They're randomized trials; supposedly we use these to prove/disprove things in medicine, science, etc. (We have even ASCO lit "saying" don't use ablative therapies on M1 breast cancer patients outside of trials... "off-protocol use of [SBRT for breast oligomets], which could have significant toxicity, should probably stop.") The standard of care for M1 breast cancer was never SBRT until one, we had the oligometastatic theory which was mostly "feelings based," and two, we had the tech, and three, probably a sprinkle of SABR-COMET (which was arguably itself a poor reason to use SBRT in M1 breast as N<20 for breast patients there iirc).
2) Re: https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(24)00329-6/fulltext,
a) not a randomized trial
b) the Danish data has always been an "IMN benefit outlier"
c) The DBCG IMN2 data is population data from ~5000 patients suggesting right sided patients who got IMN RT had a better survival than left sided patients who did not get IMN RT, suggesting OS "causality" linked to IMN RT. What if I had population data from ~7 million patients showing that right sided breast patients already have a built-in survival advantage versus left sided patients; i.e., the IMN RT may very well be a red herring for OS benefit in this "study."
d) Not a single randomized nodal irradiation trial has shown an OS benefit for nodal RT. Not a single randomized IMN RT trial has shown an OS benefit to IMN RT. Both of these findings "fit" much better with the alternative hypothesis versus the oligomet hypothesis.
Plenty of other reasons to throw shade on Ralph
Likely because back in those days (90s) >90% of patients with stage IV NSCLC, colorectal, ovarian, melanoma died within a year or so, irrelevant if oligometastatic or not. Renal cell might have been the exception due to sometimes very benign course of disease, but it's a rare disease anyhow.
Breast cancer on the other hand was a whole different ball game. Patients with metachronous metastatic breast cancer with favorable biology (luminal A) with bone mets could even back then live for a decade or longer, sometimes only on endocrine therapy. I guess this is what drove the idea behind oligometastasis in breast cancer: Suggesting that aggressive local treatment of mets in oligometastatic breast cancer could enhance survival. 30 years later we now understand that it was likely not the local therapy, but the biology of the disease itself.
And it is the biology that we still do not understand today. We do not really know which stage IV NSCLC, colorectal, ovarian, melanoma patients will benefit from aggressive treatment of mets, or not. Solely a few trials were run in biology-defined subgroups. We have for instance randomized evidence that oligomets treatment enhances OS in EGFRm NSCLC. But we don't decide which melanoma or CRC patient get's oligometastatic treatment based on the biology of the tumor.
Isn’t he big on residency expansion?
