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.



I find PSMA-therapy great. It‘s a wonderful addition to prostate cancer therapies, but how do you all feel about:

A) It being referred to as „PSMA-targeted radiotherapy“
and
B) It being discussed by 2 med. oncs

?
 
I don't have a problem with "PSMA-targeted radiotherapy" - it's what's being done after all.

It being discussed by two medoncs is, of course, ridiculous.
 
Anybody planning on doing this? What resources are needed to implement? Probably will bill poorly..?
 
There is no evidence that it is better than xofigo and the administration is more nursing and physics intensive. At least how it was done on trial. There is also higher exposure to staff given the higher energy photons.
 
madchemist89 said:
There is no evidence that it is better than xofigo and the administration is more nursing and physics intensive. At least how it was done on trial. There is also higher exposure to staff given the higher energy photons.
Click to expand...
beta emitor right? I read an article
Talking about how next step is to look at PSMA alpha emitors
 
maxxor said:
Nuc Rad: The professional side is meh. The money is in the technical side and especially if you can get 340b pricing.

The CPT is 79101. It’s like 0.7 rvu.
Click to expand...
Yeah so i guess it will only be profitable for set ups where people get technical. In academics, someone will have to do it, probably the new excited deer in headlights new grad. Great task for them!
 
There's a trial running in Australia testing it in the primary, localized setting...
 
Luteitium goes through several possible modes of decay if I recall correctly. I believe it can emit photons as well.
 
Palex80 said:
There's a trial running in Australia testing it in the primary, localized setting...
Click to expand...
Obviously I hope it works really well for patients' sake, but this would just decimate both urology and rad onc.
 
Palex80 said:
There's a trial running in Australia testing it in the primary, localized setting...
Click to expand...
I'm surprised that trial got through ethics committees. I wouldn't be interested in trying it.
 



ralph of all times to tiptoe...we WANT to hear the criticism of ASTRO, ACR etc, don't be afraid!
 
  • Like
Reactions: OTN
Palex80 said:
There's a trial running in Australia testing it in the primary, localized setting...
Click to expand...
Any idea the name of the trial?

I did some googling but did not come up with it. If there's the potential for it to be an upfront treatment it might be prudent for us to start a program sooner rather than later.
 
dieABRdie said:
Any idea the name of the trial?

I did some googling but did not come up with it. If there's the potential for it to be an upfront treatment it might be prudent for us to start a program sooner rather than later.
Click to expand...
PRINCE - Link
 
Gfunk6 said:
PRINCE - Link
Click to expand...
I did find this... but when Palex80 said "localized" I was thinking there is a trial for non-metastatic patients. That would potentially be a death knell for many groups, ours including.
 
dieABRdie said:
I did find this... but when Palex80 said "localized" I was thinking there is a trial for non-metastatic patients. That would potentially be a death knell for many groups, ours including.
Click to expand...
"LuTectomy study (NCT04430192) looking at 177Lu-PSMA-617 in patients with high-risk localized prostate cancer as presurgical treatment, a proof-of-concept phase 1/2 trial investigating whether patients can receive high doses of radiation to the prostate before surgery"


If pCRs, you better believe the surgery will then be omitted.
 
Mandelin Rain said:
"LuTectomy study (NCT04430192) looking at 177Lu-PSMA-617 in patients with high-risk localized prostate cancer as presurgical treatment, a proof-of-concept phase 1/2 trial investigating whether patients can receive high doses of radiation to the prostate before surgery"


If pCRs, you better believe the surgery will then be omitted.
Click to expand...
That is it. Thank you.
 
Mandelin Rain said:
"LuTectomy study (NCT04430192) looking at 177Lu-PSMA-617 in patients with high-risk localized prostate cancer as presurgical treatment, a proof-of-concept phase 1/2 trial investigating whether patients can receive high doses of radiation to the prostate before surgery"


If pCRs, you better believe the surgery will then be omitted.
Click to expand...
Are we actually going to inject a radionuclide with dose factors for kidneys and parotid glands roughly equivalent to tumor and deposit like 110 Gy? This seems impossible to me. But would love to learn how its not impossible.
 
communitydoc13 said:
Are we actually going to inject a radionuclide with dose factors for kidneys and parotid glands roughly equivalent to tumor and deposit like 110 Gy? This seems impossible to me. But would love to learn how its not impossible.
Click to expand...
Yes. Doesn't seem likely. Not sure why else they'd be doing it for "presurgical "treatment"" however.


This open label, phase I/II non-randomised clinical trial will evaluate the dosimetry, efficacy and toxicity of Lu-PSMA in men with high PSMA-expressing high-risk localized or locoregional advanced prostate cancer (HRCaP) undergoing radical prostatectomy (RP) and pelvic lymph node dissection (PLND). Patients will receive one or two cycles of 177Lu-PSMA followed by surgery. The primary objective is to determine the radiation absorbed dose in the prostate and involved lymph nodes. Secondary objectives include evaluating imaging response to therapy using PSMA-PET, biochemical response, pathological response, adverse effects of Lu-PSMA and surgical safety, and health-related Quality of Life (QoL).
 
madchemist89 said:
There is no evidence that it is better than xofigo and the administration is more nursing and physics intensive. At least how it was done on trial. There is also higher exposure to staff given the higher energy photons.
Click to expand...

Where is the evidence it is no better? Xofigo basically does nothing. Lu-PSMA has Vision trial which shows greater benefit in heavily pretreated benefit and has multiple trials on going. Even if RVU value is low seems like this should be radiation oncology. Small single node of recurrence? --> SBRT and then follow. More diffuse disease then proper workup of PET FDG and PET PSMA then consideration of Lu-PSMA once trials pan out. PSMA is going to change the staging completely and best to have urology and medonc keep us in the loop on everything because we are a vital part of the treatment team.

How many more node positive patients will we see now that PSMA will be done everywhere? 20-30% more maybe? Guess what now we cut back on unneeded prostatectomy and do XRT because the data suggests that what is best for patients with N+. It would be unethical to even run a node positive trial right now without having XRT as part of SOC.
 
Mandelin Rain said:
Yes. Doesn't seem likely. Not sure why else they'd be doing it for "presurgical "treatment"" however.


This open label, phase I/II non-randomised clinical trial will evaluate the dosimetry, efficacy and toxicity of Lu-PSMA in men with high PSMA-expressing high-risk localized or locoregional advanced prostate cancer (HRCaP) undergoing radical prostatectomy (RP) and pelvic lymph node dissection (PLND). Patients will receive one or two cycles of 177Lu-PSMA followed by surgery. The primary objective is to determine the radiation absorbed dose in the prostate and involved lymph nodes. Secondary objectives include evaluating imaging response to therapy using PSMA-PET, biochemical response, pathological response, adverse effects of Lu-PSMA and surgical safety, and health-related Quality of Life (QoL).
Click to expand...
Actually, not opposed to the trial. Seems like only rational circumstance where they can go and fetch treated prostate and LN for correlating in-vivo dosimetry with pathologic findings. I don't think they're expecting pCrs in prostates. Will certainly treat micrometastatic disease.
 
communitydoc13 said:
Are we actually going to inject a radionuclide with dose factors for kidneys and parotid glands roughly equivalent to tumor and deposit like 110 Gy? This seems impossible to me. But would love to learn how its not impossible.
Click to expand...
Doesn't Lutathera have pretreatment infusions of amino acids precisely for that reason?
 
pubmed.ncbi.nlm.nih.gov

Radiation Dosimetry in 177Lu-PSMA-617 Therapy Using a Single Posttreatment SPECT/CT Scan: A Novel Methodology to Generate Time- and Tissue-Specific Dose Factors - PubMed

Calculation of radiation dosimetry in targeted nuclear medicine therapies is traditionally resource-intensive, requiring multiple posttherapy SPECT acquisitions. An alternative approach is to take advantage of existing pharmacokinetic data from these smaller cohorts to enable dose computation...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Doing cool stuff in OZ.
 
xrt123 said:
Even if RVU value is low seems like this should be radiation oncology...because we are a vital part of the treatment team.
Click to expand...

Maybe you guys can merge back with another dying specialty: Nuc Med. At my academic institution, the Nucs are getting a clinical service started in anticipation of PSMA therapies. At least they are creating new treatments 😛
 
maxxor said:
Maybe you guys can merge back with another dying specialty: Nuc Med. At my academic institution, the Nucs are getting a clinical service started in anticipation of PSMA therapies. At least they are creating new treatments 😛
Click to expand...
Look, I’ve always argued we need to be a fellowship after general radiology residency. The speciality is not quite there yet but I suspect it will be before too long.
 
fiji128 said:
Look, I’ve always argued we need to be a fellowship after general radiology residency. The speciality is not quite there yet but I suspect it will be before too long.
Click to expand...


The idea that some of you think it’s important we waste years learning mostly about knee tears, lung blebs, and brain bleeds is so wild to me!

We are cancer doctors.
 
jondunn said:
The idea that some of you think it’s important we waste years learning mostly about knee tears, lung blebs, and brain bleeds is so wild to me!

We are cancer doctors.
Click to expand...
Just to devils advocate: spending years memorizing clinical trial minutia and whether to give chemo that you don’t administer is more relevant?

If you returned to the radiology fold, you could at least have something to do when fractions drop and cancer incidence declines.

It’s a more realistic pivot than infiltrating academic Med onc industrial complex and giving chemo.
 
People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.
 
jondunn said:
People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.
Click to expand...
So is learning about the pathology that can present on their routine restaging exams that you could be interpreting when there’s no new consults or OTVs.

This is the same argument ad absurdum as “why do Med students destined for radonc have to do OBGYN”?

Is an incidental brain bleed not a “toxicity”?
 
maxxor said:
So is learning about the pathology that can present on their routine restaging exams that you could be interpreting when there’s no new consults or OTVs.

This is the same argument ad absurdum as “why do Med students destined for radonc have to do OBGYN”?

Is an incidental brain bleed not a “toxicity”?
Click to expand...


Ok you lost the plot.
 
jondunn said:
People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.
Click to expand...
culturally, radonc goes “overboard” stressing minutiae (ie radiobiology). Oncology was way ahead of other fields in championing EBM over bioplausibiIity (think ortho) but radonc takes it to an unhealthy level. I attribute this to insecurity among many of the “leaders” of the older generation who were probably not the cream of the crop when they fell into the specialty. (And why they had a fetish for md/phds). Talmudic study of the data somehow provides equalizing legitimacy for the one trick pony at tumor boards?

This could actually worsen as we go to 1-5 fractions and adopt an IR like footprint in pt care of gettting -in -and -getting-out, yet continue to view ourselves as equals to surg and medonc because we bring minutiae to the table.
 
Last edited:
RickyScott said:
culturally, radonc goes “overboard” stressing minutiae (ie radiobiology).
Click to expand...
Radiobiology is the biggest dumpster fire of radiation oncology.

Now, don't get me wrong, a lot of the things we do nowadays are based on radiobiology research of the past. However...

Think of all the money and resources that have been invested in radiobiology. Good.
Now name me ONE item that came out of radiobiology research conducted in the past 20 years and that made it into clinical practice. Just one.
 
Last edited:
jondunn said:
People get tested on minutae their entire educational lives. We can argue about standardized testing and the way education works all day; that’s a good conversation and important one. But at the end of the day learning about the trials that affect how we generally treat patients and knowing about systemic therapies that affect our patients is way more relevant than anything else.
Click to expand...
Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”
 
RickyScott said:
culturally, radonc goes “overboard” stressing minutiae (ie radiobiology). Oncology was way ahead of other fields in championing EBM over bioplausibiIity (think ortho) but radonc takes it to an unhealthy level. I attribute this to insecurity among many of the “leaders” of the older generation who were probably not the cream of the crop when they fell into the specialty. (And why they had a fetish for md/phds). Talmudic study of the data somehow provides equalizing legitimacy for the one trick pony at tumor boards?

This could actually worsen as we go to 1-5 fractions and adopt an IR like footprint in pt care of gettting -in -and -getting-out, yet continue to view ourselves as equals to surg and medonc because we bring minutiae to the table.
Click to expand...
I agree with this with every inch of my soul. This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position. It's like that Feynman quote of "if you can't explain something in simple terms, you don't understand it". Just talking fast and throwing out statistic after statistic - of things that are easily looked up on Google - really sets off my BS radar that someone is either trying to sell me something or they are trying to appear much more confident than they really are.

Very relevant is this Tweet from yesterday:

1633697361478.png


And this recent study:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

While generally true in all specialties, I feel a sense of urgency about how we're handling complexity of knowledge in Radiation Oncology. Training programs, on balance, long ago shifted away from emphasizing clinical skills vs valuing memorizing trivia. We desperately need to course correct medical education in RadOnc by getting away from vomiting p values out of 30 year old trials and instead focus on learning how to be excellent doctors in an environment where we can carry literally all the knowledge of the world on a 5 inch device in our pockets.
 
elementaryschooleconomics said:
I agree with this with every inch of my soul. This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position. It's like that Feynman quote of "if you can't explain something in simple terms, you don't understand it". Just talking fast and throwing out statistic after statistic - of things that are easily looked up on Google - really sets off my BS radar that someone is either trying to sell me something or they are trying to appear much more confident than they really are.

Very relevant is this Tweet from yesterday:

View attachment 344378

And this recent study:

Changes in Length and Complexity of Clinical Practice Guidelines in Oncology, 1996-2019

While generally true in all specialties, I feel a sense of urgency about how we're handling complexity of knowledge in Radiation Oncology. Training programs, on balance, long ago shifted away from emphasizing clinical skills vs valuing memorizing trivia. We desperately need to course correct medical education in RadOnc by getting away from vomiting p values out of 30 year old trials and instead focus on learning how to be excellent doctors in an environment where we can carry literally all the knowledge of the world on a 5 inch device in our pockets.
Click to expand...

That’s nice but if your going to educate these clinicians in a better way but can it at least be for something that I can use and preferably bill for?
 
RealSimulD said:
Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”
Click to expand...

I came out of residency with pCR rate of German Rectal Study engrained in my head but did not know how to treat or plan breast cancer

Doubtful I'm alone here
 
elementaryschooleconomics said:
This data worship (which you appropriately label Talmudic study) is a great defense mechanism for those who feel insecure about their position.
Click to expand...
This is understandably how we've always been IMO. It is definitely how I am presently. Once medonc started getting off the ground, I believe that a common "goal" of cancer care from the medical oncology perspective was to eliminate XRT when possible based on the visceral understanding that "radiation is bad for you". This is clearly manifested in the treatment of lymphomas, where present day XRT is fairly benign in older patients but sort of excluded "based on principle". Back when I was in residency, a lymphoma specialist medonc would come down every 1-2 years to give an update on lymphoma treatment. He explicitly told us that he refused to refer most patients to our lymphoma specialist up front because "he would confuse the patient with data".

Agree with the exponential knowledge growth rates....in medical oncology. Check out the Aggrego Oncology newsletter every damn week. I did see a study looking at the robustness of MRI guided alignment as a function of treatment time in a recent update. Meanwhile Keynote 522 just massively reduced the applicability of CREATE-X. We should actually know the later so we can at least be coordinators of care out in the community. We don't need to know the former for the most part.
 
communitydoc13 said:
This is understandably how we've always been IMO. It is definitely how I am presently. Once medonc started getting off the ground, I believe that a common "goal" of cancer care from the medical oncology perspective was to eliminate XRT when possible based on the visceral understanding that "radiation is bad for you". This is clearly manifested in the treatment of lymphomas, where present day XRT is fairly benign in older patients but sort of excluded "based on principle". Back when I was in residency, a lymphoma specialist medonc would come down every 1-2 years to give an update on lymphoma treatment. He explicitly told us that he refused to refer most patients to our lymphoma specialist up front because "he would confuse the patient with data".

Agree with the exponential knowledge growth rates....in medical oncology. Check out the Aggrego Oncology newsletter every damn week. I did see a study looking at the robustness of MRI guided alignment as a function of treatment time in a recent update. Meanwhile Keynote 522 just massively reduced the applicability of CREATE-X. We should actually know the later so we can at least be coordinators of care out in the community. We don't need to know the former for the most part.
Click to expand...
When I think about data onanism, it is more about sites like prostate and breast than lymphoma. With breast and prostate radonc it seems like thought leaders create and often cite exponentially accruing retrospective crap. Ontologically, there is just not much depth to prostate and breast radiation vs the systemic treatment of those diseases. Pumping out hundreds of papers as a breast radonc just seems like desperation to stay academically relevant to med/surg onc peers. It almost feels like data is so heavily emphasized because there is just not that much to the delivery and management of these pts.
 
Last edited:
RickyScott said:
When I think about data onanism, it is more about sites like prostate and breast than lymphoma. With breast and prostate radonc it seems like thought leaders create and often cite exponentially accruing retrospective crap. Ontologically, there is just not much depth to prostate and breast radiation vs the systemic treatment of those diseases. Pumping out hundreds of papers as a breast radonc just seems like desperation to stay academically relevant to peers. It almost feels like data is so heavily emphasized because there is just not that much to the delivery and management of those pts.
Click to expand...

That’s what I didn’t understand until it was too late. I used to marvel at their command of the data but when it came to actually caring for patients day to day there was precious little to do. It was only after years of listening to attendings castigate residents for not understanding the data and seeing how RO is done day to day that I began to question how this might not be the best use of our time. If you remove this emphasis, I don’t see how you could train someone to do this is 2 years rather than 4.
 
RealSimulD said:
Learning about studies is important.

Getting tested like this:

“What was the pCR rate in the German Rectal Study?
A 8%
B 9%
C 10%
D 12%”

Is why #radoncrocks

“Jondunn gets a ‘Strawman’ sticker”
Click to expand...


you literally didn't read what I said. Like i said we can argue about how this is tested, but we are in medicine and have been tested about minutae since birth it feels like. do you think radiology doesn't get tested on minutae? JFC.

my point was that if we are going to be in residency training, oncology (and the minutae that clearly comes with it) is better for us to know than radiology (and their minutae)


I urge, actually BEG, you to try to read and understand.


the irony of you invoking strawman and then posting that....
 
and im a huge supporter of Bryan Carmody and his efforts and activism to change the minutae of medical education.

I was very happy to see that Step 1 has been changed to pass/fail, good step. I know many disagree, and there are surely downsides to it too, but I think we should be thinking about how to improve education and assessment of education too rather than sticking with the status quo
 
The important question is: is our children learnin’? The answer in many hellpits is undoubtedly not and people are basically teaching themselves. The amount of terrible places is embarassing for this field. The hellpit story is very similar from many people who trained at these places: little educational value, attendings who have no skin in game in success of residents, absent chairs, clinic all day writing notes as a grunt, tons of scut. It is not surprising how someone can graduate and have no idea how to treat breast when basically their only job was doing scut. A good resident keeps their head down, says yes sir, and writes a good note and contours on time. Who the hell cares if they know what is going on?
But hey at least they know pCR in german was about <10%, or was it? They ain’t even sure about that either!

We need a massive closing of bad programs.
 
Last edited:
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
6K
RickyScott
R
TheWallnerus
Rad Onc is in a dark place
Replies
13
Views
2K
RickyScott
R
D
Future of rad onc job market
2
Replies
58
Views
9K
BobbyHeenan
B
Top