Rad Onc Twitter

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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.
 
Oh No Omg GIF by Curb Your Enthusiasm
 
I have always have disliked SABR as it makes the treatment sounds like some sort of marketing gimmick.
 
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RadOncDoc21 said:
Let’s improve survival first or at the very least local control!
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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.
 
IonsAreOurFuture said:
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
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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.
 
catachip said:
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.
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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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catachip said:
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.
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gmsquid said:
Early stage glottis?? Demanding 63/28 instead of 70/35?
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OTN said:
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
Click to expand...
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.
 
TheWallnerus said:
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.
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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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TheWallnerus said:
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.
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Sure, it's legal, but it's also capitulating and letting them win. We should not do that.
 
TheWallnerus said:
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.
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Admins typically react like I am some sort of criminal when I bring this up. I get vibes of traitor to God and country.
 
OTN said:
Sure, it's legal, but it's also capitulating and letting them win. We should not do that.
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worrying about letting insurance win…

Seems like that scene in Young Frankenstein when Gene Wilder tells Marty Feldman “Damn your eyes!” and he looks in the camera and goes “Too late!”

1734963083563.png
 
OTN said:
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
Click to expand...
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.
pubmed.ncbi.nlm.nih.gov

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 pubmed.ncbi.nlm.nih.gov
 
thesauce said:
My God he’s terrible
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www.onclive.com

A Pioneering Journey in Radiation Oncology Inspired by Multidisciplinary Collaboration

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 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!"
 
TheWallnerus said:
www.onclive.com

A Pioneering Journey in Radiation Oncology Inspired by Multidisciplinary Collaboration

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 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!"
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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 2025

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
 
Treatment of oligomets in breast cancer doesn't work in most cases.

Treatment of oligomets in other diseases (renal cell, NSCLC, colorectal, ovarian, melanoma) works better.

Right concept initially, wrong disease site.
 
radiation said:
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 2025

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.
 
OTN said:
Treatment of oligomets in breast cancer doesn't work in most cases.

Treatment of oligomets in other diseases (renal cell, NSCLC, colorectal, ovarian, melanoma) works better.

Right concept initially, wrong disease site.
Click to expand...
I could have said it this way, but I chose some shade.
 
OTN said:
Treatment of oligomets in breast cancer doesn't work in most cases.

Treatment of oligomets in other diseases (renal cell, NSCLC, colorectal, ovarian, melanoma) works better.

Right concept initially, wrong disease site.
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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.
 
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