Rad Onc Twitter

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sueyom said:
thank you for that link, that is a truly interesting story and the joy division connection is wild
you do realize that if you've locked down an idea inside a private forum (or even put it on a public forum) and discussed it using anonymous names, it's pretty hard to attribute? it's kind of like you put an idea on a piece of paper and stuck it inside a balloon or multiple balloons with no signed note - can't exactly call foul if someone becomes interested and tries to move it forward, right?
i don't personally think anything I say or do on social media remains in my control, had to accept that as the precondition of the Internet
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"i don't personally think anything I say or do on social media remains in my control, had to accept that as the precondition of the Internet"

Um...you could just stop using the platform...don't you have agency in this regard?
 
TheWallnerus said:
Jocelyn Bell should give an ASTRO key note!

(*Was referring to the guy on twitter who came up w/ idea on Tendulkar thread, not in the pvt forum here... but both are the same heh)
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well, I am not actually in any kind of decision making capacity at ASTRO (there is a very tall wall separating RJ from ASTRO) but I think JB would be awesome as a keynote and I will actually pass it along although it may very well be ignored - my understanding is that they may need a new keynote speaker, ahem ...
regarding the Rahul etc thread, agree it bubbled up there not from him but others - but to finish the thought, unfortunately it's not just the idea right? it's the execution, and this is also true in research - i do hope someone executes this idea in a way that is believable and concrete enough to publish, because I think it says a lot about patient empowerment and justice in healthcare -- but it may just never happen because no one can put the effort into actually converting this to reality, or people may just do it on their own as an uncategorizable individual swipe/protest at the system which is ok too
patients hang out on Twitter sometimes and I wonder if some of them may have seen this - again some positives there from social media in informing them what goes on behind the curtain
 
Chartreuse Wombat said:
"i don't personally think anything I say or do on social media remains in my control, had to accept that as the precondition of the Internet"

Um...you could just stop using the platform...don't you have agency in this regard?
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well gosh these SDN discussions do develop more and more but i guess that's what makes them real discussions, which is good
I wasn't on social media a lot before but I think it's not possible to avoid it in this day and age
the RJ needs to get younger/hipper/more interactive with its membership as does NRG, which is why both institutions now have social media committees
again, Twitter is very good at rapid dissemination of information and I think this is healthy, instead of just sequestering the new info to the people who have the resources to get access
that's why I do all this - despite frequently (at least twice weekly) thinking I'd just like to delete everything and go back to my closed door existence
yes I have agency as we all do, just reiterating the point that "information wants to be free" (although it's not actually "free" in the monetary sense when you look at the means of production but that's another story entirely), so let's say "ideas want to be free" instead?
i'm going to have to do work now but I have learned a lot from this, and i actually did forward the idea about the speaker btw so let's see!
 
I for one am very glad you've decided to come here join the discussion. As you're seeing, I think the long-form nature of SDN allows for thoughtful back-and-forth that can produce much more involved discussion and outcomes than are available on Twitter.

I totally agree that Twitter can be really good for disseminating information, but the character limit means it's tough to dive deep. I would encourage you as well to think about developing a message board for radiation oncologists which is not character-limited and also not censored as the ASTRO board has been. Information does indeed want to be free, which is why this board continues to have outsized influence in the field. The ASTRO Old Guard clearly does not share your democratic view of information. Easier for them, sure, as you're finding out, but as you've also noted, not the way of the future. The field could really use a leader like yourself to break down the barriers of communication, so we can all start to have the valuable (and detailed) conversations we need to have to move forward.
 
OTN said:
I for one am very glad you've decided to come here join the discussion. As you're seeing, I think the long-form nature of SDN allows for thoughtful back-and-forth that can produce much more involved discussion and outcomes than are available on Twitter.

I totally agree that Twitter can be really good for disseminating information, but the character limit means it's tough to dive deep. I would encourage you as well to think about developing a message board for radiation oncologists which is not character-limited and also not censored as the ASTRO board has been. Information does indeed want to be free, which is why this board continues to have outsized influence in the field. The ASTRO Old Guard clearly does not share your democratic view of information. Easier for them, sure, as you're finding out, but as you've also noted, not the way of the future. The field could really use a leader like yourself to break down the barriers of communication, so we can all start to have the valuable (and detailed) conversations we need to have to move forward.
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How does one make this happen?
 
TheWallnerus said:
Jocelyn Bell should give an ASTRO key note!

(*Was referring to the guy on twitter who came up w/ idea on Tendulkar thread, not in the pvt forum here... but both are the same heh)
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ok just looping back here, they have already replaced the keynote, but there was genuine interest in this person - I will also think about this person for the future maybe other venues because her story is really interesting, maybe something at the RJ about supporting female trainees, i dunno - anyway thank you for bringing this story/person to attention
also in response to the person who asked me to set up a "message board" to address communication with ASTRO - i am sorry to say that seems very much beyond my (just north of luddite) abilities, but how about this, why don't we/you set up a topic here called "Messages to ASTRO" or "ASTRO please respond" or something like that? if there's something that needs to be conveyed you could link out to whatever discussion is taking place
I actually think it could be super popular and maybe I don't understand all the issues in play, but I think at least some of the more Internet-savvy ASTRO leadership would look at it and would even welcome it - just a thought
 
sueyom said:
ok just looping back here, they have already replaced the keynote, but there was genuine interest in this person - I will also think about this person for the future maybe other venues because her story is really interesting, maybe something at the RJ about supporting female trainees, i dunno - anyway thank you for bringing this story/person to attention
also in response to the person who asked me to set up a "message board" to address communication with ASTRO - i am sorry to say that seems very much beyond my (just north of luddite) abilities, but how about this, why don't we/you set up a topic here called "Messages to ASTRO" or "ASTRO please respond" or something like that? if there's something that needs to be conveyed you could link out to whatever discussion is taking place
I actually think it could be super popular and maybe I don't understand all the issues in play, but I think at least some of the more Internet-savvy ASTRO leadership would look at it and would even welcome it - just a thought
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While I'm not completely against idea, I'm not sure how to implement it. We can try and see about doing something like this if folks from ASTRO are 1) reading SDN and 2) actually care about our ideas.

Wasn't too long ago that we were being told we weren't actually radiation oncologists, but rather just troll bots, by prominent leaders of ASTRO.
 
evilbooyaa said:
While I'm not completely against idea, I'm not sure how to implement it. We can try and see about doing something like this if folks from ASTRO are 1) reading SDN and 2) actually care about our ideas.

Wasn't too long ago that we were being told we weren't actually radiation oncologists, but rather just troll bots, by prominent leaders of ASTRO.
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I agree. As we enter the next interview season, for both residency applicants and job applicants, with all of the editorials, papers, and social media postings, I have not seen any real changes (or even a movement to change), including those at my current institution. I'll tell you, despite a lot of us recommending downsizing the residency, the higher ups have their head in the sand, completely oblivious to the outside world.

I don't think another forum (in addition to the numerous forums that currently exist) to discuss the issues in our field would help out at all. And that is the problem.
 
RealSimulD said:
You don’t follow me
😡
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Touche. I check on you and lemmi from time to time, but would have to sign up to follow anyone. Respect. I had been wondering why nothing new from him. Now I know. Him, Bob Odenkirk, David Cross, and attending a Southern Baptist Academy are the four things most responsible for my personality. Sad day.
 
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SubserviantToABR said:
I agree. As we enter the next interview season, for both residency applicants and job applicants, with all of the editorials, papers, and social media postings, I have not seen any real changes (or even a movement to change), including those at my current institution. I'll tell you, despite a lot of us recommending downsizing the residency, the higher ups have their head in the sand, completely oblivious to the outside world.

I don't think another forum (in addition to the numerous forums that currently exist) to discuss the issues in our field would help out at all. And that is the problem.
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Bingo. The vvpn discussion had actually had one of the PDs (RT) mention that. There isn't a shared set of facts between the older and newer attendings in rad Onc, esp when it comes to things like the job market and demand for our specialty in light of fractionation and reimbursement changes
 
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ROforbetterorworse said:
Is it just me or is it kinda sad watching these Twitter heads using SDN talking points and then being idolized while simultaneously SDN stays pooped on
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We discussed it in that other thread. Better late than never I suppose.

SDN RO will always be the boogeyman to those who don't care or have the time to try to understand.
 
OTN said:
I don't mind it. If they're all the #ROCKSTARS then we get to be punk rock. Dibs on Gang of Four.
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We are the Scandinavian melodic death metal of the RadOnc world. Incredibly talented with mastery of our craft, open to experimentation, yet will always be rejected by some and can be off-putting to others without open minds.
 
ROforbetterorworse said:
Is it just me or is it kinda sad watching these Twitter heads using SDN talking points and then being idolized while simultaneously SDN stays pooped on
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We're all (mostly) anonymous; I assume most of us care more about the message/ideas than gaining notoriety, which is vastly different than what the Twitterati/KOL folks appear interested in.

Curse my name, make a voodoo doll, accuse me of magical thinking...as long as we're talking about meta-RadOnc issues and oversupply, I'm happy.
 
elementaryschooleconomics said:
We're all (mostly) anonymous; I assume most of us care more about the message/ideas than gaining notoriety, which is vastly different than what the Twitterati/KOL folks appear interested in.

Curse my name, make a voodoo doll, accuse me of magical thinking...as long as we're talking about meta-RadOnc issues and oversupply, I'm happy.
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Agreed I’m happy with overall message.

Just surprised at level of sycophant behavior after a common idea on SDN becomes attached to a “famous rad onc” 😆
 
ROforbetterorworse said:
Is it just me or is it kinda sad watching these Twitter heads using SDN talking points and then being idolized while simultaneously SDN stays pooped on
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RealSimulD said:
So funny. I have chatted with @sueyom about this… it’s an interesting phenomenon, that’s for sure.
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ROforbetterorworse said:
Agreed I’m happy with overall message.

Just surprised at level of sycophant behavior after a common idea on SDN becomes attached to a “famous rad onc” 😆
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I just got off the phone with a pretty well known academic NY rad onc. I have talked to him many times through the years. There's been... some changes... in his viewpoints. I was gobsmacked. In brief:

1) ASTRO leadership has been horrible in protecting the specialty
2) People were worried about IMRT in PP and now academics are realizing bad karma is blowing back on them
3) He has instructed his dept to do 25+5 on all breasts, no hypofx
4) They have a policy of single fraction for bone mets followed by SBRT ~4-8 weeks later to evade Evicore denial and incr reimbursement
5) Even MSKCC is complaining about decr reimbursements
6) Some of their academic satellites will be under APM and it's going to necessitate system wide adjustments in everyone's salary
7) He thinks APM will mean far more hypofractionating in their system
8) Before IMRT, Rad onc used to be in the basement 30 years ago with everyone making $100,000/year, maybe we go back to that?
9) Med oncs have the power now
10) Have you ever seen a med onc run a trial for the non-inferiority of 1 cycle of cis versus 3 cycles? No
11) Everyone needs to start talking about cutting residency slots if APM does actually happen, maybe cutting academic positions after that

So, pretty much, SDN is mainstream now.
 
TheWallnerus said:
I just got off the phone with a pretty well known academic NY rad onc. I have talked to him many times through the years. There's been... some changes... in his viewpoints. I was gobsmacked. In brief:

1) ASTRO leadership has been horrible in protecting the specialty
2) People were worried about IMRT in PP and now academics are realizing bad karma is blowing back on them
3) He has instructed his dept to do 25+5 on all breasts, no hypofx
4) They have a policy of single fraction for bone mets followed by SBRT ~4-8 weeks later to evade Evicore denial and incr reimbursement
5) Even MSKCC is complaining about decr reimbursements
6) Some of their academic satellites will be under APM and it's going to necessitate system wide adjustments in everyone's salary
7) He thinks APM will mean far more hypofractionating in their system
8) Before IMRT, Rad onc used to be in the basement 30 years ago with everyone making $100,000/year, maybe we go back to that?
9) Med oncs have the power now
10) Have you ever seen a med onc run a trial for the non-inferiority of 1 cycle of cis versus 3 cycles? No
11) Everyone needs to start talking about cutting residency slots if APM does actually happen, maybe cutting academic positions after that

So, pretty much, SDN is mainstream now.
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Well good, maybe some folks are realizing perhaps we should be directing our energies towards improving and/or expanding the indications for XRT, not continually pushing for omission.

Come on, academia. I know it's a lot easier to get the "less radiation" trials and protocols approved, but you're skinning us alive.
 
elementaryschooleconomics said:
Come on, academia.
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What trials? There's the oligometastatic thing, which is very important but we get people putting out 70 pt trials with poor power or design and that's pretty much it for oncology.

Some effort at definitive XRT for breast? Do you think this is going anywhere?

For oncology, to me it's clear, expand our scope beyond XRT.

Or....expand our scope beyond oncology. Arthritis, PNA, cardiac arrythmias?

Just not enough good stuff to study. Not a synthetic field.

edit: There's plenty good stuff to study and the academics are already doing it: cost analysis, non-inferiority, personalized indications research, disparities research. But none of this will increase indications.
 
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communitydoc13 said:
What trials? There's the oligometastatic thing, which is very important but we get people putting out 70 pt trials with poor power or design and that's pretty much it for oncology.

Some effort at definitive XRT for breast? Do you think this is going anywhere?

For oncology, to me it's clear, expand our scope beyond XRT.

Or....expand our scope beyond oncology. Arthritis, PNA, cardiac arrythmias?

Just not enough good stuff to study. Not a synthetic field.

edit: There's plenty good stuff to study and the academics are already doing it: cost analysis, non-inferiority, personalized indications research, disparities research. But none of this will increase indications.
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I'm all for oligomet treatment, but sabr comet came off as a positive trial on recent board exam.
 
communitydoc13 said:
What trials? There's the oligometastatic thing, which is very important but we get people putting out 70 pt trials with poor power or design and that's pretty much it for oncology.

Some effort at definitive XRT for breast? Do you think this is going anywhere?

For oncology, to me it's clear, expand our scope beyond XRT.

Or....expand our scope beyond oncology. Arthritis, PNA, cardiac arrythmias?

Just not enough good stuff to study. Not a synthetic field.

edit: There's plenty good stuff to study and the academics are already doing it: cost analysis, non-inferiority, personalized indications research, disparities research. But none of this will increase indications.
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A lot of our efforts on trials has gone into studying fractionation and doses, what we have not studied that well are volumes.

Look for instance at prostate cancer. There are probably something like 50 completed randomized trials on fractionation and dose (mainly hypofractionation and dose escalation), but how many trials have been run on elective lymph node RT? 3. Why is that?

How many randomized trials of fractionation and drug-combinations for head & neck cancer can you name? I bet a few dozen. How many randomized trials exist on volumes? I cannot recall even one.
 
Palex80 said:
A lot of our efforts on trials has gone into studying fractionation and doses, what we have not studied that well are volumes.

Look for instance at prostate cancer. There are probably something like 50 completed randomized trials on fractionation and dose (mainly hypofractionation and dose escalation), but how many trials have been run on elective lymph node RT? 3. Why is that?

How many randomized trials of fractionation and drug-combinations for head & neck cancer can you name? I bet a few dozen. How many randomized trials exist on volumes? I cannot recall even one.
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Couldn't agree more. Look at the consensus contouring guidelines on... well, just about anything, and the reason is apparent. Everyone contours things differently... and no one wants to be told how to do it.
 
Lamount said:
Couldn't agree more. Look at the consensus contouring guidelines on... well, just about anything, and the reason is apparent. Everyone contours things differently... and no one wants to be told how to do it.
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Precisely. That is the main reason.

Another one is visibility of our field.

It's easier to publish in the JCO a trial on combinations of RT with cytotoxic drugs. These are things med oncs understand and like to read.
Even with "dose" it's easy for them to understand that less fractions = more convenience for the patient and less dose = less side effects.

But try to explain a med onc how we delineate a target volume... It's striking to hear how little other professionals understand how we treat and how we can spare tissue and how we decide what to include and what not to include in a target volume.
 
Palex80 said:
But try to explain a med onc how we delineate a target volume... It's striking to hear how little other professionals understand how we treat and how we can spare tissue and how we decide what to include and what not to include in a target volume.
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True. Whenever a med onc/ENT/surg onc fellow rotate through clinics its a huge disservice that they just follow us around in clinic. They are going to see these patients anyway. I would always pull them aside and tell them they need to spend the day designing and contouring a plan. Whenever they did inevitably they would comment, "I had no idea this is how it was done..."
 
dieABRdie said:
True. Whenever a med onc/ENT/surg onc fellow rotate through clinics its a huge disservice that they just follow us around in clinic. They are going to see these patients anyway. I would always pull them aside and tell them they need to spend the day designing and contouring a plan. Whenever they did inevitably they would comment, "I had no idea this is how it was done..."
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The EPs I work with know exponentially more about radiation planning than any of my onc colleagues.
 
Palex80 said:
A lot of our efforts on trials has gone into studying fractionation and doses, what we have not studied that well are volumes.

Look for instance at prostate cancer. There are probably something like 50 completed randomized trials on fractionation and dose (mainly hypofractionation and dose escalation), but how many trials have been run on elective lymph node RT? 3. Why is that?

How many randomized trials of fractionation and drug-combinations for head & neck cancer can you name? I bet a few dozen. How many randomized trials exist on volumes? I cannot recall even one.
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There’s no industry money behind studying volumes. Or radiation really.

the pharma money behind drug trials is at an almost infinite scale relative to radiation. Reality of how much money pharma makes. Med oncs will be able to run trial after trial based on company funding and then if one is positive, the reward is so great the game continues. Look at the recent data of immuno post cystectomy - a great positive trial negated a completely negative trial in that space. Now the next step is to combine the immuno therapies - maybe 2 are better, right? Or combine it with a single agent chemo. Or maybe a targeted agent. On and on, pharma profits and potential profits power the science.

Doesn’t mean pharma is sinister mind you, but no one is making money off if we perfect head and neck or prostate volumes and improve patient survival. But if we add immunotherapy to head and neck radiation? Some one makes a lot of money off that.
 
DebtRising said:
There’s no industry money behind studying volumes. Or radiation really.
...
Doesn’t mean pharma is sinister mind you, but no one is making money off if we perfect head and neck or prostate volumes and improve patient survival. But if we add immunotherapy to head and neck radiation? Some one makes a lot of money off that.
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I basically agree with what you said, however:
1. There's also no money behing alot of fractionation trials we have carried out in the past in head&neck, lung, prostate.
One exception here would probably be CHHIPP for prostate, since the UK decided to fund this trial by doing the math. They calculated that if they can establish 60/3 as s.o.c., they can refer from buying dozens of new linacs in the coming years, since it would free up capacity. But no pharma industry ever sponsored fractionation trials or combined modality treatment with established drugs (like cisplatin for H&N cancer).
2. You are not going to increase survival by changing volumes, I agree to that. It's going to take thousands and thousands of patients to see differences there. But you will certainly spare patients from toxicity and side effects.


Here's an interesting example on how missing evidence is leading to potential overtreatment.

cT2b cN1 (?) SCC of the cervix
The CT showed one potentially suspicious lymph node in the pelvis. Not really enlarged and the PET-CT showed no avid nodes.
The gynecologists opted for primary RCT but wanted to rule out the suspicious node, so they performed a laparoscopic lymphadenectomy. More than 30 nodes removed, all negative.

So what now? This lady is getting external beam RT folllowed by brachytherapy + cisplatin based concurrent chemotherapy.
I am going to treat the pelvic lymphatics with an elective 45/1.8, but do I really need to do that?
What is the isolated nodal recurrence rate if I opted not to treat them at all? Or if I opted only to treat a "small pelvis"? Or if I de-escalated the dose to 36/1.8 like we do in anal SCC?

Noone knows...

We do have evidence from the postoperative situation telling us that in pN0 and not high-GOG scores (when you deliver EBRT because of a large primary) you can resort to only a small-pelvis-RT when you administer adjuvant RT but there are not data for patients who have had upfront lymphadenectomy, came back negative and are scheduled to undergo primary RT.
Why? Because we have been busy studying induction chemotherapy priot to concurrent RCT, celecoxib as a radiosensitizer, consolidation chemotherapy...
 
^^ This is an exceedingly rare case @Palex80 ... upfront lymphadenectomy for borderline pelvic LN? If it's enlarged by size (~1cm) and not FDG avid, it's not positive in my book and gets standard RT. Or if it's "free" to boost it in terms of side effect risk, just take it to 55/25.

T2b is going to be chemoRT + brachy anyways regardless if it's N0 or N1. You're going to get a bigger improvement in toxicity going from 3D to small margin (not as per current guidelines) IMRT rather than deciding whether to cover regular pelvis or mini pelvis, or the decision between 36 and 45Gy.
 
medgator said:
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Astro needs to reflect its membership if it wants to have legitimacy. By which I mean the people in leadership need to reflect at least roughly those in private practice vs “academics” and those working in the community. Astro has policies in place that virtually ensure only academics from high end institutions can obtain these positions. This is something unique to rad onc. As I’ve said before on these forums, this is probably at the root of so many problems with this organization. The fact that Ben Smith is a board member is an absolute travesty of Astro’s current group think.
 



i wonder if MROGA and lemmiwinks, both of who post here, one of which is a prolific poster who makes it obvious he is MROGA, ever get tired of posting the same thing over and over and over again to med students. very strange behavior.

like really, grow up a bit.
 
The strange cult like behavior solidly lies within the specialty and the chairs destroying it, while pimping the field to medical students. Kind of creepy. Who is acting dishonestly and without integrity here? A lot of strange behavior has become normative from pushing for diversity and inclusion on a sinking ship to a bizarre fixation on the minutia of trials.
 
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RickyScott said:
The strange cult like behavior solidly lies within the specialty and the chairs destroying it, while pimping the field to medical students. Kind of creepy. Who is acting dishonestly and without integrity here? A lot of strange behavior has become normative from pushing for diversity and inclusion on a sinking ship to a bizarre fixation on the minutia of trials.
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Don't forget the hypocritical financial toxicity virtue signaling. Huge push from some in the PPS-exempt ivory towers
 
medgator said:
Don't forget the hypocritical financial toxicity virtue signaling. Huge push from some in the PPS-exempt ivory towers
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I know there are PPS exempt docs who are "consulting" on the process... but for most at PPS docs, they are very worried. They know that the writing is on the wall regarding physician compensation. PPS docs are freaking out about the future because of APM. They are well aware that if the APM is deemed "successful", it will be a pox on everyone's house... especially since many have RVU-based compensation that tagged to national medians.

Division only hurts our cause...

1632074135887.png
 
Lamount said:
I know there are PPS exempt docs who are "consulting" on the process... but for most at PPS docs, they are very worried. They know that the writing is on the wall regarding physician compensation. PPS docs are freaking out about the future because of APM. They are well aware that if the APM is deemed "successful", it will be a pox on everyone's house... especially since many have RVU-based compensation that tagged to national medians.

Division only hurts our cause...

View attachment 343626
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Who started the fraction and IMRT shaming years ago, again? Where has ASTRO been during shameless proton expansion? Divisions started somewhere and it wasn't the guy out in Timbuktu trying to virtue signal to the academic centers
 
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