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Wait, Simul @RealSimulD is participating in the forum.
The Graypiece is here...I don't see any problems with this blog...

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Maybe Mudit @radonc17 can tell us more...
When the smoke is cleared, the truth will come out.

PS: This pandemic drives people insane, what is going on @ Rush, Portland, Dallas etc. etc...
 
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Lots of transitions this year. Oklahoma picked up a really sought after chair, who had been offered multiple other spots. Many open places, though. Would be nice if we had some fresh blood, interesting backgrounds, diversity of thought / worldview. I always wonder why academic leadership = papers/grants. Guys like Stu Burri at SERO, my old partner Matt Snyder, the fella at ROC in Chicago area - people like this could inject a new mindset and innovation in these stagnant departments. I think the last time a place did that was UCLA with Dr Steinberg. I disagree with that guy and their crew on a lot of things, but he’s transformed the place. When I interviewed for residency, it was a dismal program with few faculty and not much going on. Anyway, would be nice to have some fresh faces (and people that actually know basic economics and what terms like “cancel culture” mean).
 
UCLA needed the patients volume.
It takes 2 to tango.
Money speaks.
 
Radonc90 said:
Wait, Simul @RealSimulD is participating in the forum.
The Graypiece is here...I don't see any problems with this blog...

---


---

Maybe Mudit @radonc17 can tell us more...
When the smoke is cleared, the truth will come out.

PS: This pandemic drives people insane, what is going on @ Rush, Portland, Dallas etc. etc...
Click to expand...

Mention it to point out he may not be a line-toer and think-aliker. Which means he painted a target on his back possibly.
 
RealSimulD said:


Lots of transitions this year. Oklahoma picked up a really sought after chair, who had been offered multiple other spots. Many open places, though. Would be nice if we had some fresh blood, interesting backgrounds, diversity of thought / worldview. I always wonder why academic leadership = papers/grants. Guys like Stu Burri at SERO, my old partner Matt Snyder, the fella at ROC in Chicago area - people like this could inject a new mindset and innovation in these stagnant departments. I think the last time a place did that was UCLA with Dr Steinberg. I disagree with that guy and their crew on a lot of things, but he’s transformed the place. When I interviewed for residency, it was a dismal program with few faculty and not much going on. Anyway, would be nice to have some fresh faces (and people that actually know basic economics and what terms like “cancel culture” mean).
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Was glad to hear the news about Dr. Jaboin at Oklahoma - an incredibly wise move on their part. By far one of the most intelligent, friendly and down-to-earth people I have met over the years in our field.
 
Palex80 said:
I have some proton experience myself and have seen these issues too around the Bragg peak (and immediately beyond it).
However, I still think the jury is out on what the clinical benefit for protons is when it comes to lowering the V20 for lungs or mean heart dose for instance.
Do we have good data pointing to better clinical endpoints when using protons for common indications were lung V20 and mean heart dose are an issue? I do not believe that a technique should be considered s.o.c. simply because the DVH looks better, you need clinical endpoints to be enhanced in order to make that claim. Even in mengioma or retroperitoneal sarcoma, I yet have to see data for better QoL, neurocognitive function, bowel issues with protons instead of photons. And B8 HCC is not quite a "generalizable" indication, not to mention that HCC is probably the most contested field when it comes to local therapies (RFA, MWA, TACE, IRE, SIRT ... and SBRT), what one does there is often not backed up by great evidence but rather who sits at the tumor board or refers the patient.
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It's hard to test things like V20/MLD and heart dose etc... with protons vs. photons.

Lets use lung as an example...

There are two clinical scenarios to consider when protons could be better.

1) When photons yield a plan that is unsafe/untreatable, but protons yield a treatable plan. This would likely be the most common indication.
2) When photons and protons both yield treatable plans, but protons have significantly better V20/MLD etc... (the photon plan barely meets constraints).

Scenario 1) doesn't lend itself to a randomized trial.

Scenario 2) could be tested, so long as you weed out patients who have V20/MLD and heart doses that are already quite low with photons. Maybe IIIC NSCLC?

It's just tricky to find a patient population where there is both equipoise and the likelihood of a dosimetric benefit.
 
Lamount said:
It's hard to test things like V20/MLD and heart dose etc... with protons vs. photons.

Lets use lung as an example...

There are two clinical scenarios to consider when protons could be better.

1) When photons yield a plan that is unsafe/untreatable, but protons yield a treatable plan. This would likely be the most common indication.
2) When photons and protons both yield treatable plans, but protons have significantly better V20/MLD etc... (the photon plan barely meets constraints).

Scenario 1) doesn't lend itself to a randomized trial.

Scenario 2) could be tested, so long as you weed out patients who have V20/MLD and heart doses that are already quite low with photons. Maybe IIIC NSCLC?

It's just tricky to find a patient population where there is both equipoise and the likelihood of a dosimetric benefit.
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In either scenario you have not created justification for the number of proton centers that have and are being built
 
medgator said:
In either scenario you have not created justification for the number of proton centers that have and are being built
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I agree... maybe when/if the overhead for protons become cheaper and the reimbursement were closer it IMRT, it would be reasonable for them to be more widespread.
 
To be honest I could probably believe that protons might be better in some head and neck cancers but these big sites (Anderson and Sloan) could have easily proven that by now. They instead prefer for rich patients to fly to them for protons
 
MegaVoltagePhoton said:
To be honest I could probably believe that protons might be better in some head and neck cancers but these big sites (Anderson and Sloan) could have easily proven that by now. They instead prefer for rich patients to fly to them for protons
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It's not so easy...

Patients come to a proton center... expecting to get protons. There aren't many who would be happy with a coin flip, unless they hadn't heard of protons before the consult. If the trial had outside funding, perhaps patients who wanted protons but were denied by insurance would consider enrolling.
 
Lamount said:
It's not so easy...

Patients come to a proton center... expecting to get protons. There aren't many who would be happy with a coin flip, unless they hadn't heard of protons before the consult. If the trial had outside funding, perhaps patients who wanted protons but were denied by insurance would consider enrolling.
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Plenty of people live in Houston and New York. People come because it’s offered off trial
 
TheWallnerus said:
Sometimes we have to do the hard things in medicine. Like randomize patients.
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Easy for you to say. Who will pay for the randomized trial? As long as nobody forces us to do the randomized trial, and funding for such randomized trials is virtually non-existent, we continue with this status quo. I know it sounds crazy, but it's reality.
 
Neuronix said:
Easy for you to say. Who will pay for the randomized trial? As long as nobody forces us to do the randomized trial, and funding for such randomized trials is virtually non-existent, we continue with this status quo. I know it sounds crazy, but it's reality.
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Don't worry ya'll. I'm sure intersectional feminism will be able cure our proton ills:

 
Neuronix said:
Easy for you to say. Who will pay for the randomized trial? As long as nobody forces us to do the randomized trial, and funding for such randomized trials is virtually non-existent, we continue with this status quo. I know it sounds crazy, but it's reality.
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Proton company could have paid for it. If it wins, then even bigger success because it becomes the clear standard of care and everyone needs to buy one to be competitive.

The fact that an RCT was never run or has not been run yet tells all you need to know about the confidence in the machine.

Or I'm sure NIH would fund a multi-center proton trial. Or PCORI. Or any cost-conscious agency.
 
MegaVoltagePhoton said:
Proton company could have paid for it. If it wins, then even bigger success because it becomes the clear standard of care and everyone needs to buy one to be competitive.

The fact that an RCT was never run or has not been run yet tells all you need to know about the confidence in the machine.

Or I'm sure NIH would fund a multi-center proton trial. Or PCORI. Or any cost-conscious agency.
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Why would they pay for it? Big potential risk. Protons are still spreading all over the place anyway.

NIH/PCORI very hard to get funding unless you are powering an overall survival endpoint. Also very hard to find a mechanism that will give you the funds to run a conclusive trial, because they are very expensive. Where's the overall survival benefit for proton radiation? I'm impressed that RADCOMP was able to pull this off and get funded.

Anyway, it's easy for people to say "let's run a randomized trial", but the political will/funding is not there. I have looked into this myself. I know SDN likes to hate on academics, and there's plenty there to hate, but there are good people in academics who would like to study these things. It's not as easy as it sounds. If you want to write your own grant and trial, by all means... If you say "well I'm not in academics", please don't act like there's some cabal of lazy or stupid people in academics who haven't been thinking or trying to do real studies for years.

What we really need is for an NIH special interest RFA that's specifically designed for phase IIR/phase III trials to compare radiation treatment modalities (clinical trial required). These trials require many millions (phase 2 ~4 million, phase 3 10+ million) each, and I suspect the political will is not there.
 
RadOncMegatron said:
Don't worry ya'll. I'm sure intersectional feminism will be able cure our proton ills:
Click to expand...
"Here at Generation X-RT, we take an intersectional feminism approach towards synergistic scaling of key, actionable goals which facilitate the development of best practices from industry KOLs in novel spaces".

 
Neuronix said:
Why would they pay for it? Big potential risk. Protons are still spreading all over the place anyway.

NIH/PCORI very hard to get funding unless you are powering an overall survival endpoint. Also very hard to find a mechanism that will give you the funds to run a conclusive trial, because they are very expensive. Where's the overall survival benefit for proton radiation? I'm impressed that RADCOMP was able to pull this off and get funded.

Anyway, it's easy for people to say "let's run a randomized trial", but the political will/funding is not there. I have looked into this myself. I know SDN likes to hate on academics, and there's plenty there to hate, but there are good people in academics who would like to study these things. It's not as easy as it sounds. If you want to write your own grant and trial, by all means... If you say "well I'm not in academics", please don't act like there's some cabal of lazy or stupid people in academics who haven't been thinking or trying to do real studies for years.

What we really need is for an NIH special interest RFA that's specifically designed for phase IIR/phase III trials to compare radiation treatment modalities (clinical trial required). These trials require many millions (phase 2 ~4 million, phase 3 10+ million) each, and I suspect the political will is not there.
Click to expand...
There are funded RCTs but accrual is slow

ClinicalTrials.gov

www.clinicaltrials.gov www.clinicaltrials.gov

400 patients QOL endpoint protons vs photons

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov

Nonrandomized comparison of protons vs photons and randomization of conventional versus moderate hypo
 
Neuronix said:
Why would they pay for it? Big potential risk. Protons are still spreading all over the place anyway.

NIH/PCORI very hard to get funding unless you are powering an overall survival endpoint. Also very hard to find a mechanism that will give you the funds to run a conclusive trial, because they are very expensive. Where's the overall survival benefit for proton radiation? I'm impressed that RADCOMP was able to pull this off and get funded.

Anyway, it's easy for people to say "let's run a randomized trial", but the political will/funding is not there. I have looked into this myself. I know SDN likes to hate on academics, and there's plenty there to hate, but there are good people in academics who would like to study these things. It's not as easy as it sounds. If you want to write your own grant and trial, by all means... If you say "well I'm not in academics", please don't act like there's some cabal of lazy or stupid people in academics who haven't been thinking or trying to do real studies for years.

What we really need is for an NIH special interest RFA that's specifically designed for phase IIR/phase III trials to compare radiation treatment modalities (clinical trial required). These trials require many millions (phase 2 ~4 million, phase 3 10+ million) each, and I suspect the political will is not there.
Click to expand...
I'm sorry, I like you a lot but I don't buy this. If protons were worth their salt, they would have a BIG quality of life effect. A big effect does not require a large trial. We are not talking a budget of millions here. A small, $300,000 grant could easily cover a RCT. Again, big effect -- small single center RCT. Youre telling me Sloan, Anderson, and MGH couldn't do this? In the past 50 years?
 
Yeah that's the other problem. Patients don't want to be randomized.

Most of my patients are convinced that protons are better. It's more expensive, it's newer, there's lots of advertising around it, only some centers have it (especially the big name places), so it must be better. We have protons where I work, and if I tell many of my patients that I won't use protons in their case they will go elsewhere and get their protons.

Anyhoo, just playing devil's advocate here. I've tried to run comparative effectiveness studies myself and been frustrated by the lack of interest from everyone involved in actually running these sorts of trials or comparisons unless forced to or provided with large amounts of funding that nobody wants to provide. That was my point.
 
Neuronix said:
We have protons where I work, and if I tell many of my patients that I won't use protons in their case they will go elsewhere and get their protons.
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Yes, this is the real world and we must live in it. Of course I get it. But "real world" is different in the different worlds of oncology. We are strict when we wanna be, loosey-goosey when we wanna be. Imagine if CAR-T guys had done this with CAR-T. "Look, this patient really wants the CAR-T, let's just treat this one off study."
 
Neuronix said:
Yeah that's the other problem. Patients don't want to be randomized.

Most of my patients are convinced that protons are better. It's more expensive, it's newer, there's lots of advertising around it, only some centers have it (especially the big name places), so it must be better. We have protons where I work, and if I tell many of my patients that I won't use protons in their case they will go elsewhere and get their protons.

Anyhoo, just playing devil's advocate here. I've tried to run comparative effectiveness studies myself and been frustrated by the lack of interest from everyone involved in actually running these sorts of trials or comparisons unless forced to or provided with large amounts of funding that nobody wants to provide. That was my point.
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But that's the issue. Sloan, Anderson, MGH, etc. didnt want to lose rich people that have the option of going elsewhere, and were not apparently willing to randomize run-of-the mill patients. Meaning, the non-wealthy local patients in New York, Houston, Boston.

I mean lets be real. The nutting trial for IMRT in head and neck cancer? What, 94 patients total? You're telling me those three centers couldn't randomize, together, or in isolation, 100 patients? to show protons was better for head neck? This is not a multi million dollar trial...
 
TheWallnerus said:
Yes, this is the real world and we must live in it. Of course I get it. But "real world" is different in the different worlds of oncology. We are strict when we wanna be, loosey-goosey when we wanna be. Imagine if CAR-T guys had done this with CAR-T. "Look, this patient really wants the CAR-T, let's just treat this one off study."
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Drug trials require phase III data for FDA approval.

Radiation devices require class II 510(k) substantial equivalence premarket authorization.

The bar is much, much lower to start using a new radiation device.

This is a political issue.

MegaVoltagePhoton said:
But that's the issue. Sloan, Anderson, MGH, etc. didnt want to lose rich people that have the option of going elsewhere, and were not apparently willing to randomize run-of-the mill patients. Meaning, the non-wealthy local patients in New York, Houston, Boston.

I mean lets be real. The nutting trial for IMRT in head and neck cancer? What, 94 patients total? You're telling me those three centers couldn't randomize, together, or in isolation, 100 patients? to show protons was better for head neck? This is not a multi million dollar trial...
Click to expand...

This is a good question. Maybe someone from one of those places can chime in. I've been rejected for a job from all of those places more than once, so I don't really know what the politics are like there. At my home institution the mentality is "go write us a grant and bring us funding for such a trial and we're happy to open it", which I have been unable to do.
 
Neuronix said:
Drug trials require phase III data for FDA approval.

Radiation devices require class II 510(k) substantial equivalence premarket authorization.

The bar is much, much lower to start using a new radiation device.

This is a political issue.



This is a good question. Maybe someone from one of those places can chime in. I've been rejected for a job from all of those places more than once, so I don't really know what the politics are like there. At my home institution the mentality is "go write us a grant and bring us funding for such a trial and we're happy to open it", which I have been unable to do.
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Well I was rejected from residency at all three and didn’t apply for jobs there. But we don’t need to work there to know the reason. The reason is as you said obvious. We just disagree on how hard it would have been to do it.
essentially they didn’t want to risk losing 50 or so patients (control arm of a head neck photon imrt trial)
 
MegaVoltagePhoton said:
But that's the issue. Sloan, Anderson, MGH, etc. didnt want to lose rich people that have the option of going elsewhere, and were not apparently willing to randomize run-of-the mill patients. Meaning, the non-wealthy local patients in New York, Houston, Boston.
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This. These entities are so damn corporate and the private money coming from rich men with prostate cancer or rich men with wives with breast cancer (wish there was more gender parity here but there just isn't) who think the chair/prostate guy/breast attending actually saved their lives (when they were likely to live anyway) and then give big donations and float whole physician scientist careers with their private money and are politically connected to boot....

anyway,... big radonc
 
MegaVoltagePhoton said:
But that's the issue. Sloan, Anderson, MGH, etc. didnt want to lose rich people that have the option of going elsewhere, and were not apparently willing to randomize run-of-the mill patients. Meaning, the non-wealthy local patients in New York, Houston, Boston.

I mean lets be real. The nutting trial for IMRT in head and neck cancer? What, 94 patients total? You're telling me those three centers couldn't randomize, together, or in isolation, 100 patients? to show protons was better for head neck? This is not a multi million dollar trial...
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Considering the spending for protons, what I don't understand is why insurance companies allow it. Medicare should say "the only way we will reimburse for protons is if a patient is randomized to it on a clinical trial" and private insurers should follow suit. Patients with money who want protons can pay out of pocket for it. Patients who want it as long as someone else is paying for it, despite no proven benefit, can still potentially get it covered. And most importantly, everyone in the world gets the data we need to determine if it is actually beneficial.
 
How exactly will RO model affect prostate protons?
 
MegaVoltagePhoton said:
But that's the issue. Sloan, Anderson, MGH, etc. didnt want to lose rich people that have the option of going elsewhere, and were not apparently willing to randomize run-of-the mill patients. Meaning, the non-wealthy local patients in New York, Houston, Boston.

I mean lets be real. The nutting trial for IMRT in head and neck cancer? What, 94 patients total? You're telling me those three centers couldn't randomize, together, or in isolation, 100 patients? to show protons was better for head neck? This is not a multi million dollar trial...
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We all know it to be true, but to reiterate pharma trials are trying to make money so they push it. Rad onc trials try adjust dose and looks like dec. fractions is the quickest way for fame, sadly less fortune for all of us.

If I had a proton machine, why would I run a trial for prostate? Heck no, nothing to gain, a little fame and LOTS of fortune lost. The whole industry might go down. It’s only worth it if they try to get a new site so that’s why they are going after breast and tried for lung.
 
RealSimulD said:
As seen on the Bird… interesting for various reasons.

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What matters is who is doing the testing, not the actual tests (utilization). Having a basket of unnecessary tests at some random outpt surgical center is still going to be a lot cheaper than having the appropriate tests at mskcc. In healthcare it’s the prices stupid! not the utilization.
 
Why does MSKCC have so much low value nonsense that people can build academic careers detailing how all this low value nonsense can be ditched? Seems to be an issue across multiple specialties at MSKCC...

Looking for Dr. Chino to write the paper about low value nonsense in Rad Onc at MSKCC, like pre-treatment EKGs or whatever else is being done there.
 
evilbooyaa said:
Why does MSKCC have so much low value nonsense that people can build academic careers detailing how all this low value nonsense can be ditched? Seems to be an issue across multiple specialties at MSKCC...

Looking for Dr. Chino to write the paper about low value nonsense in Rad Onc at MSKCC, like pre-treatment EKGs or whatever else is being done there.
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It is not low value for mskcc. If you can bill 10x cms for ekg…
 
Not saying this is true to him but Twitter can help feed egos. Can it be like that here in some degree, I’m sure but I find it much harder for an alias to have an ego then your own name.
 
medgator said:
Usually David Chang is on point....

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For those who are on twitter and don't care about posting things that are non-controversial (I don't think David Chang's employer cares about his anti-academic bias on twitter), what's the value in posting anonymously?

Better to gain notoriety for your posts. I had no idea who David Chang was before I started reading RO Twitter (had never heard of his book either).

For those who DO work in a position where getting doxxed may lead to damage to one's professional career (either for current comments or those from the archived post history on SDN).... those people are who SDN is for. For little rad onc.
 
fiji128 said:
If you can't understand what numbers like these mean for your potential future in face of massive residency expansion at the same time, then rad onc could be a good fit for you.
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fgog591.png
 
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