Rad Onc Twitter

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What's tougher on a patient? Having to travel 1 hour (or more) each way for 5 treatments or 10 minutes each way for 16 treatments?

These are not easy questions to answer for these isoeffective treatments, but if the smaller centers can't keep the lights on, they become very relevant.
 
RealSimulD said:
“Trending” isn’t good stats. It’s a 2.7% difference and it’s not SS. I don’t think anyone but those holding on to long course is looking at that number. Respectfully…

If we see something non-significant supporting what we already believe, then we evaluate it in a way that supports what we believe. If something goes against what we believe, we muster all of our critical / analytical skills to say why that data is wrong.

Facts -

Two short course vs LCRT trials show no efficacy difference

Acute toxicity is lower with short course
One study shows worse outcomes with distal disease (other study did not show this, nor did RAPIDO)

RAPIDO has excellent outcomes with the intervention arm and is equivalent or better in almost all outcomes

If you’ve never done one or the other before and are starting anew as a RadOnc, I think most people would probably do SCRT. But, I may be wrong.

Say if SCRT was better and we knew with 100% certainty. It still sucks taking 20-23 fractions off. If we get paid substantially different for the treatment, of course our analysis is going to be somewhat flawed. Our getting a massive haircut to do new things is going to throw a wrench into things. I hate that we have to even think that way.

In this case, I think at the very least, we can say it’s 50/50, but practice pattern don’t support that. I think 90+ % people do LCRT.

If everyone at every center rapidly changed to short course everything, it would be an absolute nightmare. So, people have to hold the line.
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you mean the australian trial, which also showed a trend toward a 3% difference in LR (neither powered to detect this size difference)? There have been no short course vs long course definitive comparisons. This trend of which I speak is in the context of a lower dose of RT in the long course arm than anyone gives inthe real-world when NOM is the intent. I'm not sure how it's reasonable to extrapolate from trials investigating neoadjuvant treatment and single arm trials that focus on those who got a cCR in the first place (the sometimes it works arm) to make decisions about the most efficacious approach to treating gross disease definitively from the outset. I trained at a place that use short-course pre-op and long course definitively, so I'm cool with both.
 
Ray D. Ayshun said:
you mean the australian trial, which also showed a trend toward a 3% difference in LR (neither powered to detect this size difference)? There have been no short course vs long course definitive comparisons. This trend of which I speak is in the context of a lower dose of RT in the long course arm than anyone gives inthe real-world when NOM is the intent. I'm not sure how it's reasonable to extrapolate from trials investigating neoadjuvant treatment and single arm trials that focus on those who got a cCR in the first place (the sometimes it works arm) to make decisions about the most efficacious approach to treating gross disease definitively from the outset. I trained at a place that use short-course pre-op and long course definitively, so I'm cool with both.
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Got it! Makes sense.

Just like the more socialist places are biased against longer courses, I think we do have some bias against shorter. Again - hard to be objective when literally we get punished for doing short courses. System is set up in such a way that it’s hard to make progress. At the same time, running short vs long studies seems like a really dumb study most of the time… but once the data is out, what do you do?
 
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Palex80 said:
I see the reactions, but I have not cured a pancreatic cancer patient yet in my career without surgery using SBRT or chemorads or whatever.
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I've had a few make it out a few years with chemo rads, never to 5 though. Not sure how long they would have made it with just chemo alone....
 
RealSimulD said:
However, they don’t speak to the patient like that. There is no “choosing wisely” to hold off on the T
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One of the ways that radonc is trained better. Presenting cost/benefit in somewhat quantitative terms and encouraging mutual decision making. This is particularly important with the type of patients that you see in the community (which are not always very representative of US clinical trial patients). Radiation oncologists routinely do this. For some reason, medical oncologists do not.
Mandelin Rain said:
What's tougher on a patient? Having to travel 1 hour (or more) each way for 5 treatments or 10 minutes each way for 16 treatments?
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Existential threats all around. The last consideration that any of the initiatives in oncology have had is the health of the community radiation oncology work force. Again, I'm OK with academic radonc taking the talent from the last 15 years and finding a way to shrink the field and the time commitment of clinical radonc care over the next 25 years to the point where it fits into the pocket of medical oncology.

If.....they don't accept a single resident ever again. (There is no need to, these are docs that are actually between 30 and 50 years old today!)
 
RAPIDO was an unbalanced trial with much less systemic therapy given in the SOC arm, yet LC still "favored" long course. I'll see what I want to see 😉

1634320661826.png
 
radmonckey said:
RAPIDO was an unbalanced trial with much less systemic therapy given in the SOC arm, yet LC still "favored" long course. I'll see what I want to see 😉

View attachment 344624
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That was always my thing with this trial. RAPIDO was a trial of early chemo vs +/- post-op chemo (>50% didn't get multiagent chemo). I'm not sure why broad conclusions on the radiation schema were inferred.
 
In my experience, gabapentin takes so long to actually work (because you need to increase the dose slowly) that by the time it works, therapy is already over. 🤔
 
Based on where that breast surgeon works- is she talking about TOPA?
 
jondunn said:
Based on where that breast surgeon works- is she talking about TOPA?
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Or these guys

Now Offering Telehealth Appointments | Greater Houston Radiation Oncology: Radiation Oncologists: North Houston, South Houston & Huntsville, TX

Now offering virtual visits - Book online today! Trusted Radiation Oncologists serving North Houston, South Houston & Huntsville, TX. Visit our website to book an appointment online: Greater Houston Radiation Oncology
www.ghro.com www.ghro.com

TBH though neither has posted jobs in a few years. They don't sound like the typical churn and burn type places based on that
 
jondunn said:
Based on where that breast surgeon works- is she talking about TOPA?
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She's probably talking about TOPA in Austin. Looks like she's at Austin Cancer Centers. For what it is worth, I had a friend fly down there to interview years ago and was told that they paid straight salary, with no bonus structure. I can't remember the exact number, but I don't recall it being a lot (maybe 280K?). I remember them saying that they had plenty of people knocking on their doors since it was Austin, but judging from their website, they look like they have not hired a new-ish grad in years.
 
RickyScott said:
I start it on first day of treatment 300 x 3 by the third day, and then if no side effects 600 x 3 by week 2
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what is your taper up schedule? I find it challenging when it is too complicated. do you just go from 300 x 3 up to 600 x3?
 
RickyScott said:
I start it on first day of treatment 300 x 3 by the third day, and then if no side effects 600 x 3 by week 2
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I generally increase it only after 2-3 weeks, but still I find that even if you reach the desired dose it still takes some time for the actual effect of the treatment to kick in.
 
jondunn said:
what is your taper up schedule? I find it challenging when it is too complicated. do you just go from 300 x 3 up to 600 x3?
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Palex80 said:
I generally increase it only after 2-3 weeks, but still I find that even if you reach the desired dose it still takes some time for the actual effect of the treatment to kick in.
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Penn has some papers on this. 300 x 1 first day, 300 x 2 second , 300 x 3 third. If not having any issues after a week, taper up to 600 x 3 over days. Almost all issues I see with neurontin are when starting medication- sleepiness dizziness. If only issue is sleepiness, then 300s during day and 600 at night. In UPenn experience, they were giving 1800-3000/day
 
have you guys ever been on linkedin? all of our compatriots in non-medicine fields - their entire job title and page is full of buzzword titles. I have no problem if docs want to participate too.

same as when I call myself the medical director of my two person site

medical director one of the most meaningless titles in rad onc, but we all use it
 
What do you disagree with? Finding the steady state is the key, we all agree on that
 
certainly no monopoly on cringe-inducing actions these days
 
The gaslighting on twitter over how it's wonderful that RO is now a less competitive specialty is really something. It's like when a CEO gets fired from a job and in news interviews he's like "It's actually great that they fired me... I now have time to do all the important things in life and hang out with my family."
 
jondunn said:
What do you disagree with? Finding the steady state is the key, we all agree on that
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KO is just such a "which way is the wind blowing today" type of "leader". He has a long history of this documented on this thread going back for years. Today he wants a reasonable/balanced number of quality candidates. FWIW Mayo hasn't decreased resident numbers at any of its three programs.
 
fiji128 said:
KO is just such a "which way is the wind blowing today" type of "leader". He has a long history of this documented on this thread going back for years. Today he wants a reasonable/balanced number of quality candidates. FWIW Mayo hasn't decreased resident numbers at any of its three programs.
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He's the Brick Tamland "I love lamp" of Radiation Oncology.
 
fiji128 said:
KO is just such a "which way is the wind blowing today" type of "leader". He has a long history of this documented on this thread going back for years. Today he wants a reasonable/balanced number of quality candidates. FWIW Mayo hasn't decreased resident numbers at any of its three programs.
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It makes sense when you consider when he matched....

 
TheWallnerus said:
The gaslighting on twitter over how it's wonderful that RO is now a less competitive specialty is really something. It's like when a CEO gets fired from a job and in news interviews he's like "It's actually great that they fired me... I now have time to do all the important things in life and hang out with my family."
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It's amazing that it is only now that they claim they want compassionate physicians and in the recent past, women and minorities, as if we never needed them before. There are a lot of great, smart, hardworking, compassionate doctors and soon-to-be doctors out there, many of which we work with or we see for our own care.

What I tell a medical student who is looking at our field, who appears to be a solid and good person, is that you can be a good doctor in any specialty because your future patients will need it. It is everything else that affects the specialty that you will have to live with.
 
jondunn said:


Imagine being a practicing rad onc, trying to relitigate events from a decade plus ago. Embarrassing!
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I get what you're saying, and sometimes MROGA and lemmiwinks can go overboard. Their tactics of basically finding every pro-RadOnc thread and hitting it with napalm isn't what I would do, but it has been effective in terms of quieting down the sycophantic rhetoric on Twitter.

However, though applications from medical students have plummeted...what has changed, exactly? Virtually no programs have cut spots. The mismatch between available slots and number of applicants - which should be how the market corrects itself - is being artificially greased by programs taking people from either the SOAP or outside the Match. The core issue of oversupply isn't being addressed, but reimbursement cuts and the decreased utilization of radiation therapy continues on, unhindered.

I remain pessimistic that programs will cut spots in any meaningful way, even with all the turmoil going on in Radiation Oncology right now. But there is some hope for change, as long as the conversation (or flame throwing) continues. If we stopped talking about this, if MROGA and lemmiwinks left Twitter, if SDN shut down - what do you think would happen?

It's pretty obvious. The monetary incentive for academic institutions is to have as many residents as possible. There are FAR more Dennis Hallahans in this specialty than there are Brian Kavanaghs. Chairs will do what they perceive as best for them and their departments, even though it is a detriment to the specialty as a whole. The term "oversupply" would be swept under the rug and there would be absolutely no hope for contraction.
 
The refrain of "just don't soap and it will all work out" is so ludicrously misguided for all the above reasons. Yes apps have plummeted, a symptom of our specialty's increasingly unbearable stench, but when it all shakes out, what has changed in terms of pumping out rad oncs? Nothing
 
at least the US med students are evaluating the future and choosing against rad onc. That is a plus - we are wasting less human capital on this field

The chairs are never going to shrink spots. They care about their budget and retirement accounts more than the next generation of rad oncs. People like Olivier exist to cheer them on and continue the charade for their own benefit until the game stops.

And the game is stopping, please join my “fellowship”.

college.mayo.edu

Advanced Radiation Oncology Fellowship (Minnesota) - Residencies and Fellowships - Mayo Clinic College of Medicine & Science

Mayo Clinic School of Graduate Medical Education offers the Advanced Radiation Oncology Fellowship in Rochester, Minnesota.
college.mayo.edu college.mayo.edu
 
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