Rad Onc Twitter

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WildRivers said:
It's fine, but when you have a reputation of fighting every little battle against "the haters", when you're saying getting standard of care is sus ... idk. I think SBRT would have been fine, but it's not SOC for that unless medically inoperable or patient declines. Presume pontiff is a guy that listens to his doctors. Similar to if a patient had a rad cys for T2 bladder cancer. Of course we can say CRT would have preserved his bladder, but SOC is SOC. It's an odd battle, in my opinion, particularly without reviewing the case in detail.
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SOC for bladder cancer in Europe is CRT however. What say you, Pope? Are you Italian now?

When it comes to surgery vs SBRT for early-stage lung ca, I'd be willing to bet the data from the VA study will show postop mortality is worse with surgery but local control may be a bit better. However, I do think survival will be better with SBRT overall due to the postop mortality and ability to salvage local failure. What I am 100% sure about is the trial will set off a firestorm of about 14,000 tweets between Dr. Stiles and Dr. Moghanaki.
 
OTN said:
SOC for bladder cancer in Europe is CRT however. What say you, Pope? Are you Italian now?

When it comes to surgery vs SBRT for early-stage lung ca, I'd be willing to bet the data from the VA study will show postop mortality is worse with surgery but local control may be a bit better. However, I do think survival will be better with SBRT overall due to the postop mortality and ability to salvage local failure. What I am 100% sure about is the trial will set off a firestorm of about 14,000 tweets between Dr. Stiles and Dr. Moghanaki.
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They have already mentioned that Moghanaki's hardcore advocacy for SBRT raises questions about his impartiality as the PI of a surgery versus SBRT trial.
 
OTN said:
When it comes to surgery vs SBRT for early-stage lung ca, I'd be willing to bet the data from the VA study will show postop mortality is worse with surgery but local control may be a bit better. However, I do think survival will be better with SBRT overall due to the postop mortality and ability to salvage local failure. What I am 100% sure about is the trial will set off a firestorm of about 14,000 tweets between Dr. Stiles and Dr. Moghanaki.
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Correct.

They're also going to say the trial used "substandard" surgery since some of the recent randomized surgical studies suggested sub-lobar resection may be appropriate.

Outside of academia, in the community our CT surgeons have been extremely sbrt-friendly over the years. I see more "threat" to lung SBRT volume from pulm/IR and these new ablative bronch technologies - their advertising is ridiculous and they are espousing all this "synergy" with immunotherapy.
 
BobbyHeenan said:
Correct.

They're also going to say the trial used "substandard" surgery since some of the recent randomized surgical studies suggested sub-lobar resection may be appropriate.

Outside of academia, in the community our CT surgeons have been extremely sbrt-friendly over the years. I see more "threat" to lung SBRT volume from pulm/IR and these new ablative bronch technologies - their advertising is ridiculous and they are espousing all this "synergy" with immunotherapy.
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The local control outcomes are bad enough for RFA that I told my medoncs I would treat with SBRT anyway even if IR had done something after they biopsied it. We treat breast cancer adjuvantly for less.
 
TheWallnerus said:
But personally I think Evan’s post was fine. The news piece was like Pope got out of hospital 4 days after surgery. It is very true to observe if he’d got SBRT he’d be out the clinic in 5 mins. If that can offend anyone’s delicate sensibilities I fail to see why.
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The problem is that EMT’s tweet was in response to a thoracic surgeon who goes by “latinamd” and saying negative things in response to what ethnic minorities post (though in Miami that is a 😂) constitutes a hate crime in ASTRO adjacent circles.

Also I would take SBRT > surgery. I’ve seen tons of people with chronic post op rib pain even in robotic assisted VATS.
 
Gfunk6 said:
The problem is that EMT’s tweet was in response to a thoracic surgeon who goes by “latinamd” and saying negative things in response to what ethnic minorities post (though in Miami that is a 😂) constitutes a hate crime in ASTRO adjacent circles.

Also I would take SBRT > surgery. I’ve seen tons of people with chronic post op rib pain even in robotic assisted VATS.
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Yeah this is what someone who is way too obsessed with DEI would say. I think the problem is you not her.

Snowflake behavior, respectfully
 
If I had stage 1 lung cancer as myself - under 50, nonsmoker, healthy, top 10% I’d wager for my age group in cardiovascular fitness, and with access to and knowledge of the top thoracic surgeons, then yes I’d get surgery. However, most patients do not fall into these buckets, and age, other health issues, quality of local surgeons, those would all sway me towards sbrt.

I’m not on X but I’d say we need firebrands in the modern era and it’s better to be cringe sometimes, than the other extreme, which is to roll over and be deferential to competing specialists or overly PC.
 
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WildRivers said:
It's fine, but when you have a reputation of fighting every little battle against "the haters", when you're saying getting standard of care is sus ... idk. I think SBRT would have been fine, but it's not SOC for that unless medically inoperable or patient declines. Presume pontiff is a guy that listens to his doctors. Similar to if a patient had a rad cys for T2 bladder cancer. Of course we can say CRT would have preserved his bladder, but SOC is SOC. It's an odd battle, in my opinion, particularly without reviewing the case in detail.
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71 I think surgery if he was otherwise fit with a lobectomy is defensible

Not sure a radical cys is in the same boat.

5 year survival is the same with or without the urostomy right? Now with the io trials ongoing I feel like SOC is switching to bladder preservation and it's harder to find GUs that even really want to do this surgery outside of the ivory towers
 
yesmaster said:
.

I’m not on X but I’d say we need firebrands in the modern era and it’s better to be cringe sometimes, than the other extreme, which is to roll over and be deferential to competing specialists or overly PC.
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💯💯

Radonc has been full of catfish and invertebrates for too long esp in many academic centers.
 
TheWallnerus said:
Who needs PORT 😉
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I've done it a handful of times over the years for a positive surgical margin. In the last year I saw two patients who had surgery for Stage III NSCLC after neoadjuvant chemoimmunotherapy whose surgery was aborted after the tumor was deemed unresectable intraoperatively. Is that PORT? Not really but maybe technically? Should that surgery never have been done? Of course.
 
yesmaster said:
If I had stage 1 lung cancer as myself - under 50, nonsmoker, healthy, top 10% I’d wager for my age group in cardiovascular fitness, and with access to and knowledge of the top thoracic surgeons, then yes I’d get surgery. However, most patients do not fall into these buckets, and age, other health issues, quality of local surgeons, those would all sway me towards sbrt.

I’m not on X but I’d say we need firebrands in the modern era and it’s better to be cringe sometimes, than the other extreme, which is to roll over and be deferential to competing specialists or overly PC.
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Same. I lurk on X and sometimes I cringe , but I like Drew or Evan or Dan Spratt mixing it up on there. It’s at least entertaining and gives us some spice which we usually lack.
 
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Palex80 said:
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Are we still trying to make MR Linac happen. Suppose one can argue the MR Linac would save a sim day. Nowadays saving a patient a single extra visit day is of course a total dunk on any center that makes a patient come in that extra day. But also a self dunk on your own reimbursement.

“Direct to unit” has a funny double entendre here.
 
AI is so weird. Even though it has a particular easy to recognize style, it would be quite time consuming for an artist to make something similar. As part of that, it gets so many complex things right. Then it makes little obvious errors like:

The Proton Proponent: "Gleason 6? Perfect time to test a $200K machine!" 🤣 I think it meant $200M

The SDN Supporter: "Midlveels are taking over everything"
 
Neuronix said:
AI is so weird. Even though it has a particular easy to recognize style, it would be quite time consuming for an artist to make something similar. As part of that, it gets so many complex things right. Then it makes little obvious errors like:

The Proton Proponent: "Gleason 6? Perfect time to test a $200K machine!" 🤣 I think it meant $200M

The SDN Supporter: "Midlveels are taking over everything"
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It also left out the evicore medical director sitting on the edge of the bed looking into the mirror.
 
radiaterMike said:
RVU comparison across specialties is kind of meaningless. RVUs are simply a measure of productivity but do not directly reflect reimbursement and pay across different specialties. One could easily double (or half) our RVUs for the same work and leave the pay the same and the data point would on that graph would go way up or way down.
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This is also wRVU. Reimbursement for wRVUs, as it were, only accounts for about 20% of the haul. Profit margins are driven by tech.
 
I think we're conflating RVU production with profitability, and they are not interchangeable. RVUs measure clinical services and physician productivity, not the economic contribution of a physician to the practice.

Medical oncology is a good example. Prescribing expensive chemotherapy, immunotherapy, and biologics does not itself generate work RVUs proportional to the cost of those treatments. However, in a buy-and-bill model, the reimbursement associated with those drugs can generate substantial revenue and potentially significant profit for the practice. Consequently, a physician with relatively modest RVU production may contribute considerably more to practice profitability than their RVU numbers would suggest. If we're evaluating the financial contribution of individual physicians or specialties, we need to examine actual contribution margins, not simply RVU production.
 
Gfunk6 said:
I think we're conflating RVU production with profitability, and they are not interchangeable. RVUs measure clinical services and physician productivity, not the economic contribution of a physician to the practice.

Medical oncology is a good example. Prescribing expensive chemotherapy, immunotherapy, and biologics does not itself generate work RVUs proportional to the cost of those treatments. However, in a buy-and-bill model, the reimbursement associated with those drugs can generate substantial revenue and potentially significant profit for the practice. Consequently, a physician with relatively modest RVU production may contribute considerably more to practice profitability than their RVU numbers would suggest. If we're evaluating the financial contribution of individual physicians or specialties, we need to examine actual contribution margins, not simply RVU production.
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Plus upstream/downstream revenue through work. Surgeons use ORs which is where the hospitals make their money. Medical oncologists send oral drugs to pharmacies, med/rad onc order imaging etc
 
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