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Well I think the difference is we are tied to the machine. Med onc is about constantly looking for new drugs. When rad onc explores new machines that is faced with criticism as well, but there’s only so much we can do.

Surgeons similarly can try fancy new ways to do their knife or look at outcomes with the knife, but it’s still a knife


We can never be more exploratory than Med onc
 
DebtRising said:
But then they dunk on us “oh those sdn ppl hate hypofx, look at those greedy pigs” while those same senior ppl sit at the tail end of careers and wealth never available to us, nor something they even fought to help preserve. It’s great strategy for them, they won.
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Dont let me get started: Many of them are charging 5-10 x cms prices. Hypofractionated 3D treatment at MDACC or MSKCC will almost certainly cost more than conventional freestanding IMRT.
 
RickyScott said:
Dont let me get started: Many of them are charging 5-10 x cms prices. Hypofractionated 3D treatment at MDACC or MSKCC will almost certainly cost more than conventional freestanding IMRT.
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Walk in to any academic department. NONE of them are using hypofx to the maximum extent allowable by data. Eg, none are doing near 100% 5 fx for low risk BCS or 5 fx rectal. Or all prostate SBRT. Or single fraction oligomet SBRT. “Oh the SDN people hate hypofx.” The academics say they love hypofx but continue secret sordid affairs with a conventional mistress on the side.
 
TheWallnerus said:
Walk in to any academic department. NONE of them are using hypofx to the maximum extent allowable by data. Eg, none are doing near 100% 5 fx for low risk BCS or 5 fx rectal. Or all prostate SBRT. Or single fraction oligomet SBRT. “Oh the SDN people hate hypofx.” The academics say they love hypofx but continue secret sordid affairs with a conventional mistress on the side.
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I don’t think lack of hundred percent adoption, some of which would be impossible with any of the examples you listed, really is indicative of much. That’s an impossibly high threshold to set, if that is your expectation. I use a lot of hypofrac In my community practice but it’s far from hundred percent.
 
TheWallnerus said:
Walk in to any academic department. NONE of them are using hypofx to the maximum extent allowable by data. Eg, none are doing near 100% 5 fx for low risk BCS or 5 fx rectal. Or all prostate SBRT. Or single fraction oligomet SBRT. “Oh the SDN people hate hypofx.” The academics say they love hypofx but continue secret sordid affairs with a conventional mistress on the side.
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In my neck of the woods, nci center with very well known prostate thought leader gives very little hypofract. Recently had another pt fly to nyc for mri guided prostate sbrt. Hypofract is for distant catechment .
 
MegaVoltagePhoton said:
He's after breast again
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Im a big Spratt fan but I can’t fully get on board here. I see what he’s saying but it’s not a perfect juxtaposition.

Breast radiation isn’t just local control. It’s organ preservation.

Sure - you can technically salvage many DCiS recurrences with repeat breast conserving surgery but a HUGE % of women with relapse will just be DONE with it all (mammograms/scan anxiety) and then choose an approach of mastectomy which IMO is even more life altering than breast radiation…especially when you factor in the reconstruction, etc which is fraught with its own risks.
 
jondunn said:
I don’t think lack of hundred percent adoption, some of which would be impossible with any of the examples you listed, really is indicative of much. That’s an impossibly high threshold to set, if that is your expectation.
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In the UK, ~65% of all breast cancer patients now get 5 fraction tx, and ~99% receive 15 fractions or less. The threshold is evolving/the threshold is here.

SGQ5H0i.png


 
RickyScott said:
In my neck of the woods, nci center with very well known prostate thought leader gives very little hypofract. Recently had another pt fly to nyc for mri guided prostate sbrt. Hypofract is for distant catechment .
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True story. Degree of reputation in treating prostate cancer is directly proportional to prescribed fractions.
 
MegaVoltagePhoton said:
He's after breast again
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lolllllll.

why does it have it out for breast rad oncs hahahaaah. the UH/Case breast rad oncs must be annoyed with their new boss. If he gets his wish he won't need as many residents, so hopefully he does not scramble this year.
 
What is going on with Michigan chair search? I am hearing many many interested, many trying to jump ship from nearby rafts!
 
thecarbonionangle said:
What is going on with Michigan chair search? I am hearing many many interested, many trying to jump ship from nearby rafts!
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Feels like there were so many chair jobs open this cycle? OHSU recently lost their chair to Dartmouth, moffitt and Michigan seem to have been looking forever
 
dieABRdie said:
Just to add my personal 2 cents; when our next senior partner retires I'm certain that we will not replace that person. Furthermore, I do not see there being enough growth in volume to counteract the continued move to hypofractionation as well as the loss of compensation from declining reimbursement. I really hate to say this but I would not be surprised if we do not increase the total number of partners for my entire career. I think about it every day and feel awful for others who are going to suffer.
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As I've said many times before, my practice will not hire to replace retiring docs for another 15+ years, most likely.

I don't feel bad, however, for a couple reasons. One, I'm not in charge of hiring residents/expanding programs/trying to get med students in the field. Not my circus, not my monkeys. Second, "Bloodbath in the Red Journal" was 8 years ago: Bloodbath in Red Journal

Current residents have had ample opportunity to learn the truth about the job market in this field, most notably by this very board trying to counteract the academic propaganda which has tried to hide it. I hope for their sake they're able to find meaningful careers, but I don't feel personally responsible to make sure it happens.
 

“Even in fabled Atlantis, the night that the ocean engulfed it,The drowning still cried out for their slaves. “

Yea folks we have many questions. Many questions, indeed! the field is sinking. The Chairs are ignoring truth in their fake Dubai-esque parody of reality. As the final parts of the atlantis sink, the chairs are still thirsty for warm bodies. Medical students please don’t leave! Who will do my work? Who will write my stupid retrospective reviews? Who will wipe my chin when i drool? Who will boost my ego after i look in the mirror in the morning?

Many questions into the sinking, a silent harmonious answer to our fabled end as the haggard daylight steers toward a deep monotone.

RIP
 
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jondunn said:
good short course data from WashU

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Is it really good data, though? A 90-person, single-arm, single-institution trial? Is that even remotely good enough to move the field? Sure, it's hypothesis-generating, but I would say that's about it.
 
OTN said:
Is it really good data, though? A 90-person, single-arm, single-institution trial? Is that even remotely good enough to move the field? Sure, it's hypothesis-generating, but I would say that's about it.
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Rapido study had many patients that didn’t undergo surgery for whatever reason, and their outcome mirrors other non-operative management studies. There is a study running at WashU I think for non-operative with short course as the RT component.

25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.

We tend to do SCRT for most rectal cases, with caveat being for those who “need heroic downstaging” being considered for long course. And we do for non-operative, but the data doesn’t isn’t better one way than the other. People tend to mood affiliate and lean towards long or short depending on their priors.

Which, at the end of the day, is completely fine! Both lead to great outcomes. Modern treatment of rectal cancer is fantastic and continues to improve.
 
RealSimulD said:
25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.
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For me, in my community, it's more about managing expectations of the referring docs. I'm currently trying to get everyone who has been practicing for 20 years on the TNT train, I shudder to think about trying to convince them that 25/5 is OK.

On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it. Obviously this is just local politics for me, and my experience might not be generalizable to the rest of you.
 
RealSimulD said:
Rapido study had many patients that didn’t undergo surgery for whatever reason, and their outcome mirrors other non-operative management studies. There is a study running at WashU I think for non-operative with short course as the RT component.

25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.

We tend to do SCRT for most rectal cases, with caveat being for those who “need heroic downstaging” being considered for long course. And we do for non-operative, but the data doesn’t isn’t better one way than the other. People tend to mood affiliate and lean towards long or short depending on their priors.

Which, at the end of the day, is completely fine! Both lead to great outcomes. Modern treatment of rectal cancer is fantastic and continues to improve.
Click to expand...
For radiation, GI is the new lymphoma/seminoma
 
elementaryschooleconomics said:
For me, in my community, it's more about managing expectations of the referring docs. I'm currently trying to get everyone who has been practicing for 20 years on the TNT train, I shudder to think about trying to convince them that 25/5 is OK.

On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it. Obviously this is just local politics for me, and my experience might not be generalizable to the rest of you.
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I led a group meeting of all members that would be treating rectal cancer in the area, which included my private practice RO competitors (who are wonderful - every region needs hospital folks and private folks - it’s better for the community). The data spoke to the group. It was actually really helpful to go through it detail with the multi D team. It made sense for our patients.
 
RealSimulD said:
25/5 is gonna take religious style conversion. I would bet if a person did 5 cases on people they’d do long course typically on, they would see the outcome and likely utilize it more. It’s just too much of a jump for many people.
Click to expand...

elementaryschooleconomics said:
On the RadOnc side, I think those of us who trained in a more modern era can adopt this more easily, but the pre-IMRT RadOncs will fight me on it.
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But goshdangit galdarnit 25/5 is not "new" by a long shot, antedates IMRT, and was one of a vanishing few trials of the 20th century to show a survival advantage from radiotherapy application (and maybe unless I'm forgetting something one of the most significant p-value survival advantages from RT of all time). I like to quote this trial from time to time to hint that US docs don't read, or hate non-US data (they used to hate it very much so), and/or are hypocritical.

AC8TBxK.png
 
RealSimulD said:
I led a group meeting of all members that would be treating rectal cancer in the area, which included my private practice RO competitors (who are wonderful - every region needs hospital folks and private folks - it’s better for the community). The data spoke to the group. It was actually really helpful to go through it detail with the multi D team. It made sense for our patients.
Click to expand...
That's a good idea. I feel like this is a "herding cats" situation for me right now, but I'm probably being unfairly pessimistic about it.
 
TheWallnerus said:
Honestly I am not sure why I've not shoved all in on 5 fraction rectal.

Oh I know why. When I send my patients back to the academic place for surgery the patient gets told I might have given them unsafe radiotherapy.
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It’s really too bad academic centers work this way. I wonder if there would be a way to have an open conversation about this. Or @OTN and MDACC to have it out and listen at how damaging and one-sided the relationship feels. I felt that way with JHH when I worked in DC area, but UMaryland was an excellent partner. Truly collegial. In AZ, there was no academic center. Allegedly, we were “Banner University Medical Center” but not really academic.
 
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I'm a huge fan of 25 / 5; and participated in the RAPIDO trial. Easier on the patient, good results; easier for the patient and the oncologists, and has level 1 evidence from at least TWO prospective, randomized studies that it's either better or not worse (RAPIDO, Polish-2). It does take different communication with the patient due to the proctitis happening after the radiation is complete...

This latest WashU report builds on a long WashU legacy to let people know that there isn't something magical about US rectal cancer patients as opposed to European ones! After doing SCRT -> immediate surgery for several years there, a nice prospective, phase II study with SC-TNT came out (Five fractions of radiation therapy followed by 4 cycles of FOLFOX chemotherapy as preoperative treatment for rectal cancer - PubMed)

I don't think the WashU report on it's own moves the needle; but it continues to investigate the regimen for organ preservation, and has patients with less advanced disease than RAPIDO. It includes the population that may be recommended for NO RADIATION after PROSPECT reports out. And it shows that this population may have good organ preservation with SC-TNT. That's going to keep radiation therapy involved in these 'bi-modality' patients; who may do equally well with RT+chemo; chemo+surgery; or maybe even RT+surgery.

The key trial for the organ preservation, of course, is going on in Europe in Germany. They are randomizing patients between long course chemoradiation + chemo VERSUS short course radiation + chemo; essentially OPRA vs RAPIDO with the endpoint of cCR. Short-course Radiotherapy Versus Chemoradiotherapy, Followed by Consolidation Chemotherapy, and Selective Organ Preservation for MRI-defined Intermediate and High-risk Rectal Cancer Patients - Full Text View - ClinicalTrials.gov.

With regards to changing practices... I brought short course radiation and TNT to our practice a few years ago; with many colleagues who had 20 years plus of experience. It took about 1 year to change the practice; and definitely to have some flexibility when starting out. I should collect our path outcomes both before and after the change; but anecdotally patients are doing quite similarly.

And, it's interesting that the two NCCN centers in our area do not use short course radiation routinely! But none have the temerity to point out that the radiation I delivered was 'inappropriate'! Cause, you know, data.
 
I was converted by force to 25/5 by my institution upon arrival; they are very aggressive about it.

Initially I hated it, and the short term proctitis is real - generally worse than I see with long course. Seems like patients either do fantastic or terrible shortly after finishing. However, I strongly dislike treating any GI so it moves these patients along quicker and the (anecdotal) post-surgical outcomes have been fantastic. I also don't see too many rectal cancers so it doesn't make a huge impact on my practice metrics.

Our institutional protocol is 25/5 for all with exception of very low tumors or any consideration for watch/wait style. At least I don't have to worry about any surgeons accusing me of "inappropriate" care.
 
RickyScott said:
seminoma
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To ruminate on RickyScott's point for those reading who aren't in rad onc...

1. 1970's seminoma paper from MDACC:
keC6HJl.png

2. Then we all just sort of decided chest RT for seminoma was a little much.
3. Then the dog leg got eliminated.
4. Then the RT dose got reduced.
5. Then a drug seemed to be better than the RT.
6. Then the options became surveil, risk-adapt w/ chemo, or, according to the NCCN, RT if the patient begs on his hands and knees for it but you have to tell him long-term side effects are greater.

As time went on we did less and less. How'd the B.A.L.L.S. initiative go @Gfunk6?
 
For GI: 1)gastric xrt eliminated. 2) anal cancer will disappear in 2030s w/vaccine 3) pancreas XRT- large studies continue to disappoint. preop Esophageal XRT= FLOT (one drug away from being eliminated) Rectal cancer: In setting of LAR, absolute benefit of XRT is very low and again one drug away from being eliminated and most pts are now candidate for 5 fractions. Sure, xrt for non operative manangement of rectal cancer is promising, and can also be given in 5 fractions, but minority of rectal cases.
 
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We have a surg onc that is really into watch and wait. So I've been very reluctant to use 5 fraction for these.

Maybe I need to revisit this?

I'm very comfortable with 5 fraction for patients surely going to surgery...but for these cases where surgeon is on board (and hoping) not to operate, I've stuck with long course.
 
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BobbyHeenan said:
I'm very comfortable with 5 fraction for patients surely going to surgery...but for these cases where surgeon is on board (and hoping) not to operate, I've stuck with long course.
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Feel exactly the same way. One question I have is TNT with significant nodal disease. I remember Chris Crane on mednet discussing what is actually taken out with TME and noting that pelvic sidewall nodes and higher nodes near iliac bifurcation not typically removed. I like to dose escalate these nodes with standard fractionation close to 60 Gy (or some dose painted equivalent).

Is there an equivalent strategy with 5 fxn treatment?
 
I am very skeptical of 25/5, especially for NOM. Based on what we know/believe about BED and alpha/beta, LC has significantly higher BED than SC. If SC does prove to be equivalent to LC for in NOM for big T3 tumors, I will have an existential crisis and throw my Hall book in a dumpster fire.
 
TheWallnerus said:
As time went on we did less and less. How'd the B.A.L.L.S. initiative go @Gfunk6?
Click to expand...

It's gone great! I have not treated a seminoma in 10 years. I can only assume this means that these insanely complex and high-dose treatments are being performed using IMPT on a registry trial at academic medical centers.
 
communitydoc13 said:
Feel exactly the same way. One question I have is TNT with significant nodal disease. I remember Chris Crane on mednet discussing what is actually taken out with TME and noting that pelvic sidewall nodes and higher nodes near iliac bifurcation not typically removed. I like to dose escalate these nodes with standard fractionation close to 60 Gy (or some dose painted equivalent).

Is there an equivalent strategy with 5 fxn treatment?
Click to expand...
Yes

When and how to use a nodal boost

www.estro.org www.estro.org
 
Gfunk6 said:
It's gone great! I have not treated a seminoma in 10 years. I can only assume this means that these insanely complex and high-dose treatments are being performed using IMPT on a registry trial at academic medical centers.
Click to expand...
Please, don’t be ridiculous, hyperbole like this isn't helpful!

They’re not on a registry.
 
Findings from Rapido study:

Probability at three years of distant metastasis and locoregional failure were, in the experimental and standard arms, 19.8% vs 26.6% (HR 0.69 [0.53 – 0.89]; p = 0.004) and 8.7% vs 6.0% (HR 1.45 [0.93 – 2.25]; p = 0.10), respectively.

Reception of more systemic therapy in the exp arm may have also reduced LRF a little more as well. In any case, possibly a 3% improvement in LRF for an extra 4 weeks of RT.
 
I’m no statistician, but I don’t think that’s how that works… two studies comparing long and short (non TNT) have shown no local control difference. I’m not sure an non-statistically significant absolute difference of 2.7% is the argument to hang your hat on.
 
RealSimulD said:
I’m no statistician, but I don’t think that’s how that works… two studies comparing long and short (non TNT) have shown no local control difference. I’m not sure an non-statistically significant absolute difference of 2.7% is the argument to hang your hat on.
Click to expand...
Like I said, possibly. We are a specialty good at powering trials for one thing to conclude other things. Kinda like powering a trial comparing breast schemes for local control in order to conclude toxicity equivalence.
 
Ray D. Ayshun said:
Findings from Rapido study:

Probability at three years of distant metastasis and locoregional failure were, in the experimental and standard arms, 19.8% vs 26.6% (HR 0.69 [0.53 – 0.89]; p = 0.004) and 8.7% vs 6.0% (HR 1.45 [0.93 – 2.25]; p = 0.10), respectively.

Reception of more systemic therapy in the exp arm may have also reduced LRF a little more as well. In any case, possibly a 3% improvement in LRF for an extra 4 weeks of RT.
Click to expand...
That's the big issue many of us have with that study, not a pure sc vs LC comparison. Hopefully data from those more recently accruing trials will clear things up
 
GI_RadOnc said:
I'm a huge fan of 25 / 5; and participated in the RAPIDO trial. Easier on the patient, good results; easier for the patient and the oncologists, and has level 1 evidence from at least TWO prospective, randomized studies that it's either better or not worse (RAPIDO, Polish-2). It does take different communication with the patient due to the proctitis happening after the radiation is complete...

This latest WashU report builds on a long WashU legacy to let people know that there isn't something magical about US rectal cancer patients as opposed to European ones! After doing SCRT -> immediate surgery for several years there, a nice prospective, phase II study with SC-TNT came out (Five fractions of radiation therapy followed by 4 cycles of FOLFOX chemotherapy as preoperative treatment for rectal cancer - PubMed)

I don't think the WashU report on it's own moves the needle; but it continues to investigate the regimen for organ preservation, and has patients with less advanced disease than RAPIDO. It includes the population that may be recommended for NO RADIATION after PROSPECT reports out. And it shows that this population may have good organ preservation with SC-TNT. That's going to keep radiation therapy involved in these 'bi-modality' patients; who may do equally well with RT+chemo; chemo+surgery; or maybe even RT+surgery.

The key trial for the organ preservation, of course, is going on in Europe in Germany. They are randomizing patients between long course chemoradiation + chemo VERSUS short course radiation + chemo; essentially OPRA vs RAPIDO with the endpoint of cCR. Short-course Radiotherapy Versus Chemoradiotherapy, Followed by Consolidation Chemotherapy, and Selective Organ Preservation for MRI-defined Intermediate and High-risk Rectal Cancer Patients - Full Text View - ClinicalTrials.gov.

With regards to changing practices... I brought short course radiation and TNT to our practice a few years ago; with many colleagues who had 20 years plus of experience. It took about 1 year to change the practice; and definitely to have some flexibility when starting out. I should collect our path outcomes both before and after the change; but anecdotally patients are doing quite similarly.

And, it's interesting that the two NCCN centers in our area do not use short course radiation routinely! But none have the temerity to point out that the radiation I delivered was 'inappropriate'! Cause, you know, data.
Click to expand...
The European trial will, of course, tell us the answer. Do we even bother to try RCTs anymore in the US?
 
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