Rad Onc Twitter

  • Thread starter Thread starter deleted1002574
  • Start date Start date
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Members don't see this ad.
1600101983848.png


Amen
 
RadsWFA1900 said:
Workforce reduction?? We need to train more international grads so that they can learn these highly complex highly valuable 5fx regimens.

Good to see Vargo and Beriwal joining the circular firing squad.
Click to expand...

The only way I can rationalize their institutions allowing this is they they probably get the same reimbursement for a 5fx regimen that most non acavdemic institutions and free standings get for a 25fx regimen. Otherwise their handlers (MBA type practice managers) would have fired their staff and probably most of the attendings a while back.

I mean how long do you think this will go on for until the bean counters say “you know what you aren’t that important” here’s a pay cut you can leave if you don’t like it.
 
elementaryschooleconomics said:
View attachment 318285

Amen
Click to expand...

Drew left out the word "some," which was pretty clearly stated in the article.

Breast:
Consistent with the evidence, COVID-19 breast radiation therapy guidelines have recommended 30 Gy in 5-fraction partial breast or 26 Gy in 5-fraction whole breast radiation therapy as the preferred standard in suitable patients. Post-COVID, new standard nomenclature should refer to 15 to 16 fractions of 2.66 to 2.67 Gy per fraction as “conventional fractionation” and be considered standard of care for all patients after breast-conserving surgery. Five fractions at 5.2 to 6.0 Gy per fraction should be referred to as the new “hypofractionation” and should be used for suitable patients.

Rectal:
Yet, even in a postpandemic world, for appropriate patients with resectable upper to midrectal cancers, short-course radiation can be a new standard of care and preferred option in many cases, given that it is oncologically noninferior to long-course radiation and has potentially less acute toxicity, as backed by multiple randomized trials, and imposes a smaller burden on both health care systems and patients.

Prostate was a bit more confusing.
 
RadsWFA1900 said:
The only way I can rationalize their institutions allowing this is they they probably get the same reimbursement for a 5fx regimen that most non acavdemic institutions and free standings get for a 25fx regimen. Otherwise their handlers (MBA type practice managers) would have fired their staff and probably most of the attendings a while back.

I mean how long do you think this will go on for until the bean counters say “you know what you aren’t that important” here’s a pay cut you can leave if you don’t like it.
Click to expand...
What's funny is that those authors' employing institution is very famous for really whipping their docs to generate revenue. Writing an editorial is easy...but actually practicing what they preach given who their employer is? Not gonna happen
 
FrostyHammer said:
What's funny is that those authors' employing institution is very famous for really whipping their docs to generate revenue. Writing an editorial is easy...but actually practicing what they preach given who their employer is? Not gonna happen
Click to expand...

I’m confident I won’t be doing this especially because the day we start doing this is the day I get a pink slip or make as much as my kids kindergarten teacher. I say this as an employed cog.

Toilet paper is in short supply here at the satellite in the midst of COVID scarce resources and all, I guess I know where I can put my latest IJROBP
 
RadsWFA1900 said:
The only way I can rationalize their institutions allowing this is they they probably get the same reimbursement for a 5fx regimen that most non acavdemic institutions and free standings get for a 25fx regimen. Otherwise their handlers (MBA type practice managers) would have fired their staff and probably most of the attendings a while back.

I mean how long do you think this will go on for until the bean counters say “you know what you aren’t that important” here’s a pay cut you can leave if you don’t like it.
Click to expand...
For certain institutions, hypofractionation may improve margins by increasing pts throughput and allowing them to treat pts from out of town. Like mskcc? Goes without saying that these places price gouge.
 
RickyScott said:
For certain institutions, hypofractionation may improve margins by increasing pts throughput and allowing them to treat pts from out of town. Like mskcc? Goes without saying that these places price gouge.
Click to expand...
Five fractions is better than zero fractions. Academic centers increasingly using extreme hypo to attract patients who live a distance away who wouldn't opt to get standard fractionation at the academic center. They won't travel 4 hours for 6-8 weeks but for 4-5 treatments-maybe.
 
Chartreuse Wombat said:
Five fractions is better than zero fractions. Academic centers increasingly using extreme hypo to attract patients who live a distance away who wouldn't opt to get standard fractionation at the academic center. They won't travel 4 hours for 6-8 weeks but for 4-5 treatments-maybe.
Click to expand...

Bingo. It's about keeping all the 'second opinion' folks treatment in-house rather than referring back out to 'inept community docs' who apparently can't treat a prostate, a breast, or a rectal cancer.
 
Ray D. Ayshun said:
Drew left out the word "some," which was pretty clearly stated in the article.

Breast:
Consistent with the evidence, COVID-19 breast radiation therapy guidelines have recommended 30 Gy in 5-fraction partial breast or 26 Gy in 5-fraction whole breast radiation therapy as the preferred standard in suitable patients. Post-COVID, new standard nomenclature should refer to 15 to 16 fractions of 2.66 to 2.67 Gy per fraction as “conventional fractionation” and be considered standard of care for all patients after breast-conserving surgery. Five fractions at 5.2 to 6.0 Gy per fraction should be referred to as the new “hypofractionation” and should be used for suitable patients.

Rectal:
Yet, even in a postpandemic world, for appropriate patients with resectable upper to midrectal cancers, short-course radiation can be a new standard of care and preferred option in many cases, given that it is oncologically noninferior to long-course radiation and has potentially less acute toxicity, as backed by multiple randomized trials, and imposes a smaller burden on both health care systems and patients.

Prostate was a bit more confusing.
Click to expand...

So all it took was a respiratory virus harmful to end of life octogenarians and morbidly obese people to elucidate some of the burning questions in radiation oncology.
Post-pandemic world implies virus is gone. Wouldn't this be the same as the pre-pandemic world? Something else happened!

2.66 OR 2.67 Gy? Dear Lord. If I say 2.69 or even really go nuts and say 2.7 Gy on boards will I fail for sure? Glad we got that one figured out down to the precise centigray +/- 1 centigray. That's a remarkable achievement. Really. 15 or 16 fractions. Is that +/- 267 centigray or +/- 268 centigray. Regardless. Solved.

"Can be a new standard" This doesn't undermine the definition of the word standard at all, does it? As in something else "could" (subjunctive mood noted) could be a standard as well? After all, in a post-pandemic world where words have no meaning, the science is settled because the mob says it is, and we can redefine words and science however we want. I guess it "can" be a new standard in that case after all.
 
evilbooyaa said:
Bingo. It's about keeping all the 'second opinion' folks treatment in-house rather than referring back out to 'inept community docs' who apparently can't treat a prostate, a breast, or a rectal cancer.
Click to expand...
It’s about the $. UPitt is one of worst in terms of monopoly and price gouging. Featured on 60 minutes! Had something like 30+ executives with salaries over 1 million!
 
medgator said:


7:30 mark
Click to expand...


Literally if you take down upmc you’ll just make Pittsburgh just another burnt out city in the middle of the rust belt.

I also couldn’t stop laughing at these idiots as they formed over 50K for an evaluation. If there’s one group I don’t feel sorry for it’s them...the well to do.
 
KHE88 said:
2.66 OR 2.67 Gy? Dear Lord. If I say 2.69 or even really go nuts and say 2.7 Gy on boards will I fail for sure? Glad we got that one figured out down to the precise centigray +/- 1 centigray. That's a remarkable achievement. Really. 15 or 16 fractions. Is that +/- 267 centigray or +/- 268 centigray. Regardless. Solved.
Click to expand...
Hahahaha. Where does one even start. I'm laughing because I have had a fair number of rad oncs in the past when they saw I was doing the "Canadian fractionation" seem totally perplexed with dividing 42.5 by 16, and look at me like a heretic for using 2.65 Gy a day (but never even look at other things, like, normalization). And if 15 to 16 fractions is "conventional," the 16 fx whole breast plus 5 fx cavity boost done in most academic centers is...
 
UPMC is an institution which puts PPs out of business and hires docs at these “satellites” for much lower pay, while padding salaries for admins at the top. They are precisely what is ruining the field, and this sort of thing is ruining medicine, overall. I have not been shy here with my distaste for this institution and their residency program history.
 
thecarbonionangle said:
UPMC is an institution which puts PPs out of business and hires docs at these “satellites” for much lower pay, while padding salaries for admins at the top. They are precisely what is ruining the field, and this sort of thing is ruining medicine, overall. I have not been shy here with my distaste for this institution and their residency program history.
Click to expand...
And yet med students, who don't really seem dumb at all, are still filling every seat at the table offered by rad onc. Crazy.
 
scarbrtj said:
And yet med students, who don't really seem dumb at all, are still filling every seat at the table offered by rad onc. Crazy.
Click to expand...
There is always a seat for every butt. Unfortunately for us, the butts in rad onc will get stinkier year after year as our specialty fails to match even people with a decent CV. The quality of applicants is dropping dramatically.
 
I just saw a 70-year-old prostate patient of mine prior to Sim with a T1c N0 M0 Gleason 3+4=7 in 2/10 cores with no high risk disease on mpMRI and a PSA of 4.5 ng/mL. My non ivory tower "community" plan is for 70 Gy in 28 fractions. Prior to the sim, the patient said he went for a second opinion at Fox Chase rad onc and they recommended 8 weeks of RT. I was shocked to hear that given what they promote in the literature and conference circuit. Maybe us community docs need to publish a paper purposing a network of academics centers that can be certified as "safe" for second opinions.
 
Same experience here. We have a locums RTT that also works part time at a satellite of the local academic center, staffed by the mothership docs. As of 6-12 months ago, I was told that the center had never hypofractionated a breast. My clinic was the first she'd heard of it. May still be the case, I just haven't cared enough to get an update.
 
I was recently thinking to do 1 fraction SBRT to a small spine melanoma met. Patient had brain mets in the past which were controlled, so we were following that.

I held off because the bone met was less than 1 cm in size, very anterior in the vertebral body, and the disease was shrinking plus there were 4 other sites of disease, all of which were shrinking, and some of which were in places that would be tough to SBRT. Patient also contacted me soon after the consult and was found to have serious cardiac issues.

Certainly a borderline case, but I figured what's the benefit if I'm not going to SBRT everything and disease is shrinking with no current threat in a reliable elderly patient with medical co-morbidities?

Soon thereafter, patient went for proton opinion at an academic center far from home. They gave 5 fraction SBRT to that spine level only, ignoring the 4 other sites of disease, one of which was 4 mm in the spinal level immediately above.
 
Neuronix said:
I was recently thinking to do 1 fraction SBRT to a small spine melanoma met. Patient had brain mets in the past which were controlled, so we were following that.

I held off because the bone met was less than 1 cm in size, very anterior in the vertebral body, and the disease was shrinking plus there were 4 other sites of disease, all of which were shrinking, and some of which were in places that would be tough to SBRT. Patient also contacted me soon after the consult and was found to have serious cardiac issues.

Certainly a borderline case, but I figured what's the benefit if I'm not going to SBRT everything and disease is shrinking with no current threat in a reliable elderly patient with medical co-morbidities?

Soon thereafter, patient went for proton opinion at an academic center far from home. They gave 5 fraction SBRT to that spine level only, ignoring the 4 other sites of disease, one of which was 4 mm in the spinal level immediately above.
Click to expand...
Gotta leave those other 4 spots for 91 days later, IMO.
 
radiation said:
Won't APM obviate these fractionation debates by changing to lump sum reimbursement by diagnosis/indication? The worst thing we did for ourselves is to fixate all our billing by fractions, IMO
Click to expand...
Apm is only for cms. It will not address problem of price gouging. Centers with leverage will still just negotiate bundled rates with insurers that are 3-5x cms rates. Almost nobody has straight up Medicare, and if you do a place like Mayo Clinic won’t see you! Insurers love the high rates because in many cases they are just middle men who take a commission.
Capitated/ medicare advantage plans will almost never include mskcc/ mdacc types in network.
 
RickyScott said:
Apm is only for cms. It will not address problem of price gouging. Centers with leverage will still just negotiate bundled rates with insurers that are 3-5x cms rates. Almost nobody has straight up Medicare, and if you do a place like Mayo Clinic won’t see you! Insurers love the high rates because in many cases they are just middle men who take a commission.
Capitated/ medicare advantage plans will almost never include mskcc/ mdacc types in network.
Click to expand...
Bingo. Don't forget Medicaid which is almost never accepted at any NCI designated CC
 
The hypocrisy of those who work at academic centers and either decry cost to patients or rag on community doctors is stunning. Intellectual consistency means absolutely nothing to them.
 
There are good and bad actors on both sides. This is not a black and white issue.

I trained and practice in the same state. Both are NCI designated cancer centers, and both take medicaid. I've seen patients who had to travel 1 hour or more to those centers past private practices that do not take medicaid.
 
Treat the abdomen to high doses with 3D and probably no real IGRT and that **** is gonna suck. Being totally lazy about a site I never treat and not having looked at the paper, I would guess that toxicity from old techniques would lead to bad pt outcomes, early discontinuation, missing surgery, and a poor comparison. One of the few sites that probably truly requires real IMRT imho.

Now, unfortunately, this trial will likely only cause all the snake oil salesman peddling MRI linacs to tell us we *really* just need their device. *sigh*
 
RollTideRadOnc said:
Treat the abdomen to high doses with 3D and probably no real IGRT and that **** is gonna suck. Being totally lazy about a site I never treat and not having looked at the paper, I would guess that toxicity from old techniques would lead to bad pt outcomes, early discontinuation, missing surgery, and a poor comparison. One of the few sites that probably truly requires real IMRT imho.

Now, unfortunately, this trial will likely only cause all the snake oil salesman peddling MRI linacs to tell us we *really* just need their device. *sigh*
Click to expand...

95% of patients got IMRT. Would attempt to not be lazy and at least glance at the paper. Takes 2-5 minutes to skim through relevant details.

But, yes, 25% had protocol violations and 25% had some prolongation of treatments.

Probably no utility of it in UPFRONT RP sarcoma patients. Extrapolating this to recurrent RP sarcoma is a fool's errand. The abstract suggested a potential benefit in liposarcoma histology, but published results were different.
 
evilbooyaa said:
95% of patients got IMRT. Would attempt to not be lazy and at least glance at the paper. Takes 2-5 minutes to skim through relevant details.

But, yes, 25% had protocol violations and 25% had some prolongation of treatments.

Probably no utility of it in UPFRONT RP sarcoma patients. Extrapolating this to recurrent RP sarcoma is a fool's errand. The abstract suggested a potential benefit in liposarcoma histology, but published results were different.
Click to expand...

I use preop RT in RP sarcoma selectively where surgeons are concerned about the possibility of margins. I still feel comfortable with this approach, even given this data.
 
It seems like 50.4 gy is generally inadequate in this scenario. There's a multi institution trial headed by delaney concerning the use of an sib to the area that will be the surgical margin that should give us a better idea of our role, or lack thereof, in this setting.
 
OTN said:
I use preop RT in RP sarcoma selectively where surgeons are concerned about the possibility of margins. I still feel comfortable with this approach, even given this data.
Click to expand...

That sounds reasonable, although this trial will maybe curtail places that were doing it routinely for every single case.

If surgeon asks for RT, give them the RT.
 
Zahramar said:
As you said, another one bites the dust. And with the most common ones being 5-5-5 hopefully the oral boards will be a cinch
Click to expand...
On radonc review dot org I saw where they have 115 single spaced, small fonted pages on "breast." It's beautiful and fantastically organized and intimidating and a testament to its creators. I don't think any ordinary human has hope of REALLY knowing even half this data, in detail, over the span of even a 40y career. If a tree falls in the forest and no one is around, does it make a sound? If 5-5-5 is most of what we do in rad onc, does stuff like knowing the minutiae of "TEXT-SOFT [Pagani NEJM '14, JCO '19]: Adjuvant tamox vs. exemestane + ovarian suppression in early br ca" (directly copied/pasted) help make one a better/worse rad onc?
 
I like the concept of rad onc review but will never read it start to finish. Maybe treat it more like the old rad onc wiki as a resource to go look up summaries of things for a quick reference.

I would not expect Rad Oncs to be able to know RadOncReview cold in prep for oral boards.
 
evilbooyaa said:
I like the concept of rad onc review but will never read it start to finish. Maybe treat it more like the old rad onc wiki as a resource to go look up summaries of things.

I would not expect Rad Oncs to be able to know RadOncReview cold in prep for oral boards.
Click to expand...

When I first heard about RadOncReview, I thought it would be like First Aid.

Then I saw RadOncReview, and realized they're using the word "review" as in, "Cochrane Review".

It's a tremendous source of information, and I have the utmost respect for the authors. But ain't nobody got time for that.
 
elementaryschooleconomics said:
When I first heard about RadOncReview, I thought it would be like First Aid.

Then I saw RadOncReview, and realized they're using the word "review" as in, "Cochrane Review".

It's a tremendous source of information, and I have the utmost respect for the authors. But ain't nobody got time for that.
Click to expand...
Holy ****. I never knew about this. Now I know what I'm doing with my free time, which hasn't changed one bit.
 
This RadOncReview website has been very eye opening. I see a critical deficiency in hypofractionation for head and neck. This cannot and will not stand. We need more hypofractionation. There's this PORT SBRT study mentioned with 6 fractions. 6?! why not 5?! how do they expect people to bill for this nonsense?
 
Zahramar said:
This RadOncReview website has been very eye opening. I see a critical deficiency in hypofractionation for head and neck. This cannot and will not stand. We need more hypofractionation. There's this PORT SBRT study mentioned with 6 fractions. 6?! why not 5?! how do they expect people to bill for this nonsense?
Click to expand...
The fractions are not low enough yet.

We can go lower. We have the technology.

The 5-5-5 thing is totally arbitrary. There is nothing magic about 5, except to eke the maximum $ out of SBRT billing. For example, in breast, if you start out with 50/25 as being the standard, sure something like 42.5/16 etc etc is equivalent if breast ca α/β is about 3.5 and nl tissue about 3. But... three fractions of 7.85 Gy apiece is also equivalent to 50/25. (Calculable.) Three should be the new 5... Yes, I'm saying whole breast 23.55Gy/3fx should work. Since everything else bio-equivalent to it has worked, it's also got high odds of working. When the tumor and nl tissue α/β are equal, or very close, all rad onc fractionation number prescriptions are on a sliding scale of integers which in theory can rationally start at one. And when α/β tumor<tissue, one fraction is theoretically "optimal."

I predict the next decade will see a surge of trials seeking to go lower than 5 fractions... after everyone gets real cozy with 5. The patients deserve as few fractions as we can safely offer.
 
Last edited:
scarbrtj said:
When the tumor and nl tissue α/β are equal, or very close, all rad onc fractionation number prescriptions are on a sliding scale of integers which in theory can rationally start at one. And when α/β tumor<tissue, one fraction is theoretically "optimal."

I predict the next decade will see a surge of trials seeking to go lower than 5 fractions... after everyone gets real cozy with 5. The patients deserve as few fractions as we can safely offer.
Click to expand...

Makes one foresee a possible future in which Rad Onc does only radiosurgery and radiosurgery is much like actual surgery.

Patient schedules OR time, comes in for their single fraction planning and same day treatment, goes home and is done.

If APM really moves us all to per-case billing, having patients actively "on treat" would be all down side
 
Last edited:
kimplera said:
working at a NCI designated center i can say we definately see medicaid patients and in the past 3 months have had patients without coverage (SMH) receive 97 -100% cost writedowns
Click to expand...
Guess it's state dependent. The closest one is in network with only one or two Medicaid plans and that's it. Have heard similar stories from others in the southeast.

Mayo CEO made the waves regarding this a few years ago

www.statnews.com

Mayo Clinic CEO walks back comments on prioritizing privately insured patients

Minnesota regulators are investigating possible civil rights violations based on the CEO's words to staff about caring for people on Medicaid and Medicare.
www.statnews.com www.statnews.com
 
Last edited:
medgator said:
Guess it's state dependent. The closest one is in network with only one or two Medicaid plans and that's it. Have heard similar stories from others in the southeast.

Mayo CEO made the waves regarding this a few years ago

www.statnews.com

Mayo Clinic CEO walks back comments on prioritizing privately insured patients

Minnesota regulators are investigating possible civil rights violations based on the CEO's words to staff about caring for people on Medicaid and Medicare.
www.statnews.com www.statnews.com
Click to expand...
quarterly profits plunged to 154 million.due to covid

 
Last edited:
medgator said:
Guess it's state dependent. The closest one is in network with only one or two Medicaid plans and that's it. Have heard similar stories from others in the southeast.
Click to expand...

Some NCI cancer centers are state safety net hospitals like the University of Minnesota and University of Virginia. Some are better described as for-profit non-for-profits like Duke, Mayo and MSKCC. Nothing more to it then that.
 
You must log in or register to reply here.

Similar threads

uchihastan
Rad Onc vs. Heme/Onc
Replies
18
Views
2K
medgator
M
B
Rad Onc Procedures and RVUs
Replies
35
Views
5K
CurbYourExpectations
CurbYourExpectations
D
Saving Rad Onc
2
Replies
60
Views
7K
RickyScott
R
TheWallnerus
Rad Onc is in a dark place
Replies
13
Views
3K
RickyScott
R
M
Rad Onc Oral Boards: To quote or not quote studies?
Replies
4
Views
544
alwaysbeIMRTing
A
Top