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TheWallnerus said:
How about this math.
Reported deaths in literature from SpaceOAR insertion: N≥1
Reported deaths in literature from prostate IMRT: N=0

You can't fool a Norwegian!

Or attorneys.
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No offense, and I generally agree everything you post and respect you a lot, but you are really shifting the goalposts here.

Doing all the no-nos: comparing across trials/databases, compiling anecdotes together to make data, scouring patient reviews online to inform decision making (interestingly enough the third comment on that site... "My stinking radiologist from the so called number 4 in the country cancer care didn't want to use the space Orr ..now I hsve rectal damage .thry say it should resolve in a month or 2")

The reality is that we have a phase 3 randomized trial of 222 patients that showed a statistically significant improvement in graded toxicity and quality of life metrics (large difference in the latter) without any reported serious adverse events. Which leads me to believe the rare adverse events that are happening via anecdote may have other factors involved other than spaceOAR just sucking in general. And the response is that we don't have good data that it works and it is safe, but we have a lot of "data" apparently that patients are embolizing and dropping dead. Hmm.. I don't think so!

If you want to talk about costs, then we need to be honest and also include in the conversation why we are routinely doing 45 fractions instead of 20 fractions for most intact prostate. The cost of the spaceOAR (which interestingly comes out to about $1600 USD in Norway) is a drop in the bucket compared to an extra 25 fractions of IMRT. Yet the argument that is typically used to justify more than doubling the treatment time is that it is "gentler" and less likely to cause toxicity. Hmm........
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FrostyHammer said:
I'm sure it'll get accepted by the top urological journal which will use that as high quality evidence to withhold RT referrals even more than they already do. Everyone loves to hear what they want to hear, journals are no exception, and surgical journals are certainly no exception.
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No, his n=2 series will only get into a mid-tier journal. To get on the top shelf, he will have to find a med student to emulate a clinical trial.
 
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How many authors on the SpaceOAR phase III received 6-figure/high 5-figure payments from Augmenix and/or Boston Scientific? The disclosures on that trial always caught my eye, then I looked it up on Open Payments and it blew me away. If that doesn’t make you skeptical of the G2+/QOL endpoints used on the trial, and how much rectal spacers are pushed in general, don’t know what else will.

SpaceOAR is a useful tool, but by no means is it SOC. Patients do absolutely fine without it with modern IMRT/SBRT planning. For FLAME and retreats - it’s a great product. My patients, however, are exposed to all of the intense marketing and think I’m going to burn up their rectum without the spacer. I must say, those reps know how to sell (and throw a good party). But, at the end of the day they have been very helpful when I have chosen to use their product.
 
Turaco said:
The reality is that we have a phase 3 randomized trial of 222 patients that showed a statistically significant improvement in graded toxicity and quality of life metrics (large difference in the latter) without any reported serious adverse events.
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If you put it that way...

Can we have level 1 evidence out there from a phase III trial showing SpaceOAR is the superior approach and it NOT be standard of care? If it is "reality" that SpaceOAR leads to lower rectal toxicity in (a group of) all patients (and that would be the logical conclusion of the trial's results, and your arguments)... who can argue with reality? Not me. Not anyone.

You have just proven that not using SpaceOAR is not the standard of care.
{Must be (real) Can’t be} #existence
 
TheWallnerus said:
If you put it that way...

Can we have level 1 evidence out there from a phase III trial showing SpaceOAR is the superior approach and it NOT be standard of care? If it is "reality" that SpaceOAR leads to lower rectal toxicity in (a group of) all patients (and that would be the logical conclusion of the trial's results, and your arguments)... who can argue with reality? Not me. Not anyone.

You have just proven that not using SpaceOAR is not the standard of care.
{Must be (real) Can’t be} #existence
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giphy.gif


I had to read this 5 times and all I can say is never go full Ralph Weichselbaum. I agree that phase 3 trials are not necessarily the word of God ala Exodus 11:5. The breast literature and the cult that surrounds it comes to mind. I think we'll just leave it at, you really, really, really hate spaceOAR. Fair?
 
JS1987 said:
How many authors on the SpaceOAR phase III received 6-figure/high 5-figure payments from Augmenix and/or Boston Scientific? The disclosures on that trial always caught my eye, then I looked it up on Open Payments and it blew me away. If that doesn’t make you skeptical of the G2+/QOL endpoints used on the trial, and how much rectal spacers are pushed in general, don’t know what else will.
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Neil Mariados 1, John Sylvester 2, Dhiren Shah 3, Lawrence Karsh 4, Richard Hudes 5, David Beyer 6, Steven Kurtzman 7, Jeffrey Bogart 8, R Alex Hsi 9, Michael Kos 10, Rodney Ellis 11, Mark Logsdon 12, Shawn Zimberg 13, Kevin Forsythe 14, Hong Zhang 15, Edward Soffen 16, Patrick Francke 17, Constantine Mantz 18, Peter Rossi 19, Theodore DeWeese 20, Daniel A Hamstra 21, Walter Bosch 22, Hiram Gay 22, Jeff Michalski 22

Neil Mariados received $100,000.
John Sylvester received $210,000.
Dhiren Shah received $100,000.
David Beyer received $2500.
Steven Kurtzman received $25,000.
Rodney Ellis $7,000.
Edward Soffen $56,000.
Peter Rossi $220,000.
Daniel Hamstra $100,000.
Jeff Michalski received $9000.

TOTAL: ~$830K to all the SpaceOAR authors.

First, I would like to nominate JS1987 for the SDN Oscar, 2021. Best post of year. Not even close.

Second, I have changed my opinion on SpaceOAR. It sucks. It's awful. In a game of F, marry, kill between SpaceOAR, Paul Wallner, and Hitler, I would F Paul Wallner, marry Hitler, and kill SpaceOAR. I reward SpaceOAR no points. I fart in its general direction. GOOD NITE.
 
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TheWallnerus said:
Neil Mariados 1, John Sylvester 2, Dhiren Shah 3, Lawrence Karsh 4, Richard Hudes 5, David Beyer 6, Steven Kurtzman 7, Jeffrey Bogart 8, R Alex Hsi 9, Michael Kos 10, Rodney Ellis 11, Mark Logsdon 12, Shawn Zimberg 13, Kevin Forsythe 14, Hong Zhang 15, Edward Soffen 16, Patrick Francke 17, Constantine Mantz 18, Peter Rossi 19, Theodore DeWeese 20, Daniel A Hamstra 21, Walter Bosch 22, Hiram Gay 22, Jeff Michalski 22

Neil Mariados received $100,000.
John Sylvester received $210,000.
Dhiren Shah received $100,000.
David Beyer received $2500.
Steven Kurtzman received $25,000.
Rodney Ellis $7,000.
Edward Soffen $56,000.
Peter Rossi $220,000.
Jeff Michalski received $9000.

TOTAL: ~$730K to all the SpaceOAR authors.

First, I would like to nominate JS1987 for the SDN Oscar, 2021. Best post of year. Not even close.

Second, I have changed my opinion on SpaceOAR. It sucks. It's awful. In a game of F, marry, kill between SpaceOAR, Paul Wallner, and Hitler, I would F Paul Wallner, marry Hitler, and kill SpaceOAR. I reward SpaceOAR no points. I fart in its general direction. GOOD NITE.
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If you really want to get to the heart of the matter look at Boston Scientific payments to individuals in 2018 after Augmenix was purchased by Boston Scientific.
 
TheWallnerus said:
Neil Mariados 1, John Sylvester 2, Dhiren Shah 3, Lawrence Karsh 4, Richard Hudes 5, David Beyer 6, Steven Kurtzman 7, Jeffrey Bogart 8, R Alex Hsi 9, Michael Kos 10, Rodney Ellis 11, Mark Logsdon 12, Shawn Zimberg 13, Kevin Forsythe 14, Hong Zhang 15, Edward Soffen 16, Patrick Francke 17, Constantine Mantz 18, Peter Rossi 19, Theodore DeWeese 20, Daniel A Hamstra 21, Walter Bosch 22, Hiram Gay 22, Jeff Michalski 22

Neil Mariados received $100,000.
John Sylvester received $210,000.
Dhiren Shah received $100,000.
David Beyer received $2500.
Steven Kurtzman received $25,000.
Rodney Ellis $7,000.
Edward Soffen $56,000.
Peter Rossi $220,000.
Jeff Michalski received $9000.

TOTAL: ~$730K to all the SpaceOAR authors.

First, I would like to nominate JS1987 for the SDN Oscar, 2021. Best post of year. Not even close.

Second, I have changed my opinion on SpaceOAR. It sucks. It's awful. In a game of F, marry, kill between SpaceOAR, Paul Wallner, and Hitler, I would F Paul Wallner, marry Hitler, and kill SpaceOAR. I reward SpaceOAR no points. I fart in its general direction. GOOD NITE.
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Knowing this, is it surprising how quickly rectal spacers made it into the NCCN guidelines?

I wish there was the same urgency for SBRT, oligometastases, RCC, HCC...the list goes on. Better representation of our specialty in guidelines simply comes down to better leadership.
 
TheWallnerus said:
Neil Mariados 1, John Sylvester 2, Dhiren Shah 3, Lawrence Karsh 4, Richard Hudes 5, David Beyer 6, Steven Kurtzman 7, Jeffrey Bogart 8, R Alex Hsi 9, Michael Kos 10, Rodney Ellis 11, Mark Logsdon 12, Shawn Zimberg 13, Kevin Forsythe 14, Hong Zhang 15, Edward Soffen 16, Patrick Francke 17, Constantine Mantz 18, Peter Rossi 19, Theodore DeWeese 20, Daniel A Hamstra 21, Walter Bosch 22, Hiram Gay 22, Jeff Michalski 22

Neil Mariados received $100,000.
John Sylvester received $210,000.
Dhiren Shah received $100,000.
David Beyer received $2500.
Steven Kurtzman received $25,000.
Rodney Ellis $7,000.
Edward Soffen $56,000.
Peter Rossi $220,000.
Daniel Hamstra $100,000.
Jeff Michalski received $9000.

TOTAL: ~$830K to all the SpaceOAR authors.

First, I would like to nominate JS1987 for the SDN Oscar, 2021. Best post of year. Not even close.

Second, I have changed my opinion on SpaceOAR. It sucks. It's awful. In a game of F, marry, kill between SpaceOAR, Paul Wallner, and Hitler, I would F Paul Wallner, marry Hitler, and kill SpaceOAR. I reward SpaceOAR no points. I fart in its general direction. GOOD NITE.
Click to expand...

As always.... follow the money.
 
TheWallnerus said:
Neil Mariados 1, John Sylvester 2, Dhiren Shah 3, Lawrence Karsh 4, Richard Hudes 5, David Beyer 6, Steven Kurtzman 7, Jeffrey Bogart 8, R Alex Hsi 9, Michael Kos 10, Rodney Ellis 11, Mark Logsdon 12, Shawn Zimberg 13, Kevin Forsythe 14, Hong Zhang 15, Edward Soffen 16, Patrick Francke 17, Constantine Mantz 18, Peter Rossi 19, Theodore DeWeese 20, Daniel A Hamstra 21, Walter Bosch 22, Hiram Gay 22, Jeff Michalski 22

Neil Mariados received $100,000.
John Sylvester received $210,000.
Dhiren Shah received $100,000.
David Beyer received $2500.
Steven Kurtzman received $25,000.
Rodney Ellis $7,000.
Edward Soffen $56,000.
Peter Rossi $220,000.
Daniel Hamstra $100,000.
Jeff Michalski received $9000.

TOTAL: ~$830K to all the SpaceOAR authors.

First, I would like to nominate JS1987 for the SDN Oscar, 2021. Best post of year. Not even close.

Second, I have changed my opinion on SpaceOAR. It sucks. It's awful. In a game of F, marry, kill between SpaceOAR, Paul Wallner, and Hitler, I would F Paul Wallner, marry Hitler, and kill SpaceOAR. I reward SpaceOAR no points. I fart in its general direction. GOOD NITE.
Click to expand...

Ok am i on the only person whose actual question is ... how do i get hooked up?
 
TheWallnerus said:
I would. Maybe we should start squirting the hydrogel at the prostate base too. In reality, it may take full prostatic hydrogel entombment for adequate normal tissue protection.
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Holy hydrogel. I was being facetious (shocker).

MdQgPJ0.png

The heck is this guy talking about. "Low Teal" prostate cancer? Surely he's saying something else.

Agewawz.png

 
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elementaryschooleconomics said:
Five different specialties?!?

Sounds financially toxic.
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I mean, according to the article, only 3 of them were able to treat this rib met, SBRT, cryoablation, and nerve block...so far. I'm sure the ortho person is just wringing their hands, getting ready to do an ORIF on that rib me on the next follow up appointment and then the rehab person can do some rib rehabilitation.
 
MegaVoltagePhoton said:
Ok am i on the only person whose actual question is ... how do i get hooked up?
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No. I actually believe in spaceOAR before I knew they were handing out cheese for endorsements. I also don't believe in selling my soul and working for Evicore at any costs so I have to keep my non-existent children in private school somehow (i.e., pay off my blackjack losses). Where does this hungry rad onc rat sign up to get that sweet hydrogel taint cheese?
 
SubserviantToABR said:
Q: How many docs does it take to treat a bone met?

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Do they have a cardiologist there to read the inevitable EKG?

In our private practice, in our building, we have med onc, rad onc, neuro onc, breast surgery, palliative medicine, surgical oncology, urology, and gynecologic oncology. That's more than 5, and you can be 100% sure any of them will see any patient at any time. What do we win?
 
RadOncMegatron said:

Am I reading this right? Dr. Chino saying they merit more money because of inc. survival? Wow, the PP vs academic divide just got larger! Shots fired hurrah for Simul the Great to stand up to this nonsense!
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You know what her answer will be. Shots have been fired especially when it comes down to money.
 
I'm guessing no one actually read this article. Its just a graphic making the rounds on Twitter. Complete joke. Do you need a study that shows that patients treated for whatever category of cancer at lets say Mayo do better then those patients with same category of cancer that are treated at the local county hospital. How does this stuff even get published?

Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage.​


Objective To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information.

Design, Setting, and Participants Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data.

Main Outcomes and Measures Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data.

Results There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease stage information (weighted κ ≥ 0.81).

Conclusions and Relevance Potentially important outcome differences exist between different types of hospitals that treat patients with cancer after risk adjustment using information in Medicare administrative data. This type of risk adjustment may be adequate for evaluating hospital performance, since the additional adjustment for data available only in cancer registries does not seem to appreciably alter measures of performance.
 
From my perch out here in rural America, and having trained at a major academic institution, I can say without question that academicians haven't the slightest idea what it's like out here. Things are on average more advanced, and even if you control for stage, it generally leans to more advanced. Seer analyses are about as close as they ever come to my type of practice unless they're passing through on their way to a national park to get some fomo Instagram pics. People are a whole lot more comfortable dying out here.
 
fiji128 said:
I'm guessing no one actually read this article. Its just a graphic making the rounds on Twitter. Complete joke. Do you need a study that shows that patients treated for whatever category of cancer at lets say Mayo do better then those patients with same category of cancer that are treated at the local county hospital. How does this stuff even get published?

Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage.​


Objective To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information.

Design, Setting, and Participants Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data.

Main Outcomes and Measures Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data.

Results There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease stage information (weighted κ ≥ 0.81).

Conclusions and Relevance Potentially important outcome differences exist between different types of hospitals that treat patients with cancer after risk adjustment using information in Medicare administrative data. This type of risk adjustment may be adequate for evaluating hospital performance, since the additional adjustment for data available only in cancer registries does not seem to appreciably alter measures of performance.
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Can also game numbers by putting up barriers to blacks and Hispanics getting treatment.
 
If nothing else the vast majority of old, frail, advanced stage or very sick patients are completely unwilling to put in the time or endure the cost of traveling to these centers of excellent for treatment. The effects of this on whatever outcome or survival data would seem to be obvious.
 
fiji128 said:
If nothing else the vast majority of old, frail, advanced stage or very sick patients are completely unwilling to put in the time or endure the cost of traveling to these centers of excellent for treatment. The effects of this on whatever outcome or survival data would seem to be obvious.
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They ARE obvious, and to write, publish, or Tweet this study without acknowledging that is academic malpractice. Additionally, the exempt center in my neck of the woods does not see it in their mission to treat the impoverished in our state- that comes straight from their university leadership.
 
Ray D. Ayshun said:
People are a whole lot more comfortable dying out here.
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Great quote. This resonates enormously with me. At major center for training where the wealthy traveled across country and outside. I would refer to the rich and powerful men that I saw as "masters of the universe". They were often oblivious to their mortality even very late in life. In truth, it takes a unique skill set to effectively cater to this group of patients. My chair was great at it, no suprise there!

Compare this to your 61 year old biker/farmer/construction worker who comes down with small cell lung cancer and looks you in the eye and says. "I've had a good run." Totally different skill set needed to connect with, earn trust and maximize outcomes in these patients. Also, they are not wrong.
 
ROforbetterorworse said:
Willful ignorance

it’s hard to publicly disparage your employer….

though I personally recommend keeping quiet rather than looking foolish
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I Don’t expect her to speak out (I certainly wouldn’t- especially with state of job market) but she probably should take a pass on this one.
 
RadOncDoc21 said:
You know what her answer will be. Shots have been fired especially when it comes down to money.
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As someone who takes a lot of Medicaid and Medicare HMO, i don't have a lot of sympathy, esp when a patient finds out the local nci-designated, often PPS exempt, center isn't in their network for a second opinion for a reasonably complicated case
 
Ray D. Ayshun said:
So reverting to gender-centered tu quoque attacks is a fine line?
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I think the Twitter attack on Dr. Fumiko Chino was over the line. I agree with her when she points out that she hasn’t been there for very long. The first step to create change at these large academic institutions is to deliberately, with data, point out a problem. She did that masterfully with parking. I’m sure she understands that the next step is action, and I look forward to what she can accomplish moving forward.

I also agree that the gendered attack was unfortunate and will unnecessarily alienate some who might otherwise be on her side.
 
OTN said:
I think the Twitter attack on Dr. Fumiko Chino was over the line. I agree with her when she points out that she hasn’t been there for very long. The first step to create change at these large academic institutions is to deliberately, with data, point out a problem. She did that masterfully with parking. I’m sure she understands that the next step is action, and I look forward to what she can accomplish moving forward.

I also agree that the gendered attack was unfortunate and will unnecessarily alienate some who might otherwise be on her side.
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Twitter and the like does lead otherwise smart people to make statements they regret. Playing the victim card as a high earner (dare I say 1%er) at a prestigious institution doesn't play well. I hope that she will succeed but I suspect the forces are too great to bring price transparency to the most ivory of all towers.
 
OTN said:
I think the Twitter attack on Dr. Fumiko Chino was over the line. I agree with her when she points out that she hasn’t been there for very long. The first step to create change at these large academic institutions is to deliberately, with data, point out a problem. She did that masterfully with parking. I’m sure she understands that the next step is action, and I look forward to what she can accomplish moving forward.

I also agree that the gendered attack was unfortunate and will unnecessarily alienate some who might otherwise be on her side.
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Didn't see the gendered attack?
 
I think Fumiko and some other commenters are misunderstanding their role. She is being played, as are most of us. MSKCC is able to use her to continue to justify their high prices because they have hired people who on paper are working to improve the issue. Really standard stuff, similar to large companies advocating for diversity on paper but none of the leadership changes... but it's just so very important to them, they even have a whole department dedicated to it!

1625198317481.png
 
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OTN said:
I think the Twitter attack on Dr. Fumiko Chino was over the line. I agree with her when she points out that she hasn’t been there for very long. The first step to create change at these large academic institutions is to deliberately, with data, point out a problem. She did that masterfully with parking. I’m sure she understands that the next step is action, and I look forward to what she can accomplish moving forward.

I also agree that the gendered attack was unfortunate and will unnecessarily alienate some who might otherwise be on her side.
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This is a fair point. She is doing great work, but the gendered attack on her pay should also be directed at MSKCC as well. I mean if they are price gouging why shouldn’t Dr. Chino make more money? But to cite that sorry worthless article looks bad.

From the beginning, we all knew (including herself) that her research would have to attack MSKCC for her to have any validity and that day seems to be coming sooner rather than later. It’s a hard road that she has chosen, we all just wanted her to walk it. We all clearly see it will likely cost her job and are waiting to see what happens. It’s really unfortunate that she quotes that highly confounded article saying academic centers have higher OS, not sure what she is thinking, as most people in PP have her back.
 
Chartreuse Wombat said:
Mmm we d Twitter and the like does lead otherwise smart people to make statements they regret. Playing the victim card as a high earner (dare I say 1%er) at a prestigious institution doesn't play well. I hope that she will succeed but I suspect the forces are too great to bring price transparency to the most ivory of all towers.
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She probably does feel poor. If she earns 300k and pays 50+% in state, city and federal taxes followed by 5k a month in rent, she is quickly down to around 80k. (If she ever has a kid, nanny to allow long work hours could take out at least 40-60k) And, Hopefully she doesn’t have student debt,
 
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