Rad Onc Twitter

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radoncopotamus said:
It is standard for a (junior) rad onc to be in clinic at least 4 days a week. Every other academic surgeon or med onc is 3 days tops (usually less). We do not value oursleves enough.
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May want to check out what academic medoncs are paid. There's a thread on SDN. Those really serious research medoncs, who are at the mothership and are in clinic 2.5 days/week while doing hardcore research are probably not making much.

Truth is, I don't know, but it does seem to me (from what I've heard) that there is a big disparity in pay in medonc for PP vs community academic medonc vs mothership (true academic) medonc, with significant reductions in pay as you decrease clinical responsibility and increase time for research/teaching.

In radonc, this is less clear to me. Not clear to me that the satellite doc with no chance at meaningful academic advancement is making much more than their mothership colleagues. I actually think they should.

Am I wrong?
 
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sueyom said:
you are a sharp walrus - and you and elementaryschoolE win the funny comments prize
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winstonfoot5 said:
I, for one, would like to see a double blinded peer-reviewed Wallnerus and ElementarySchoolEconomics Red Journal column authored anonymously under their nom de plume
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I think a SDN/IJROBP cross over episode would certainly get excellent ratings and lots of twitter discussion.
 
I agree with Sue Yom here. Red journal should be about science, not opinion.

My opinion (that I don't publish in Red Journal) is that there is already too much non-science stuff in the red journal. The bar for publishing perspectives and survey stuff is very low, while the bar for science is very high. I don't think that's good for our field.

Though I think a perspective paper from a few of the contributors here is well enough researched to potentially make a paper about the decline or stagnation of rad onc demand with projections of dramatic oversupply at the current rate of resident production. I'm surprised that this hasn't been sent already.
 
evilbooyaa said:
I think a SDN/IJROBP cross over episode would certainly get excellent ratings and lots of twitter discussion.
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A "debate edition" set like the "Gray Zone" with a hot-button topic presented and 2-4 responses written by an equal number of pen named/real named authors?

Sign me up.
 
Papers are reviewed anonymously. The authors’ identities shouldn’t be playing a huge role in the decision to publish. I don’t see any reason this should be discouraged. Anonymous authors won’t get credit for their work, but that is their choice.
 
Lamount said:
Papers are reviewed anonymously. The authors’ identities shouldn’t be playing a huge role in the decision to publish. I don’t see any reason this should be discouraged. Anonymous authors won’t get credit for their work, but that is their choice.
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None of us get credit here individually, i still feel it is important to post however to counter the narrative and gaslighting that comes from the other side
 
Lamount said:
Papers are reviewed anonymously. The authors’ identities shouldn’t be playing a huge role in the decision to publish. I don’t see any reason this should be discouraged. Anonymous authors won’t get credit for their work, but that is their choice.
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Author identity shouldn't play a huge role in decision to publish (although the reality is that not everything in RJ is double blinded), but revealing author identity can play a role in influencing content (as evidenced by this forum ad nauseum)
 
RickyScott said:
Anything interesting?
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Not really, the same as what we have heard thrown back and forth over the internets. However Byron May of Mayo clinic threw out a last minute question to the MS4 involved asking if she knew about the RO-APM and how that would impact practice/volume going forward and I was really hoping it would get answered but it did not (or I missed it when I had a follow-up).
 
RO28 said:
Not really, the same as what we have heard thrown back and forth over the internets. However Byron May of Mayo clinic threw out a last minute question to the MS4 involved asking if she knew about the RO-APM and how that would impact practice/volume going forward and I was really hoping it would get answered but it did not (or I missed it when I had a follow-up).
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Sounds exactly like the type of question that would be avoided
 
I listened so you don't have to (although I think it'll be on the ACR website, and I applaud them for hosting and asking tough questions because ASTRO sure as heck would not do this...)

  • Moderator did a good job, but said a lot of topics would be answered "offline" -- not sure how that will work
  • Alan Hartford (Dartmouth) kicked it off by essentially saying, "the weather sure is nice, why are you all worried about the climate?" After all, a survey said there are lots of jobs from the people in charge of residency programs. Not a strong start.
  • Brian Kavanagh (Colorado) spoke about program length and being part of the generation where there was an excess of trainees before RO went from 3 to 4 years. I missed part of his talk...
  • Neha Vapiwala (Penn) spoke about the role of the ACGME Residency Review Committee and belabored the point that RCC is not in charge of program number or size, only approving any and all programs that meet criteria. However, RO is down to 91 programs from 96 (!) or something similar...
  • Dr. Vapiwala said ASTRO is soliciting bids for an external company to do a workforce survey (hmm, where have I heard that idea before?) and that SDN Hero Chirag Shah (see: Bloodbath in Red Journal) is co-chair of the workforce committee
  • Question about whether use of SOAP was appropriate. Dr. Vapiwala said a one-size-fits-all approach does not make sense, but that PDs/chairs should be good stewards of the field (ha!).
  • Dr. Hartford then said his program opened 5 or 6 years ago and they have had to SOAP at least once and yet, they make great radiation oncologists
  • One question was whether it was appropriate programs continue to expand despite decreased applicant numbers; no one would come out and say outright that it was wrong (which tells you everything you need to know)
  • There were a number of polls asking about audience opinions (Should conscious efforts be made to increase future applicant numbers?)
  • Everyone agreed there needs to be more women-and-minorities
  • Multiple poll questions about SOAP, expansion, decreasing applicant numbers, etc, generally had people voting in such a way that interests on this board were well represented (just not by the speakers)
  • Nearly everyone mentioned mentorship and outreach to improve applicant numbers
  • Dr. Hartford really knocked it out of the park when he compared online discussions (i.e. SDN) to "Russian collusion" and that outreach, including outreach to MS1s and undergrads at Dartmouth, might help turn things around
  • A medical student applying to the field gave her thoughts about the application process

Overall, it was nearly all "the same old tune" except (1) learning the tidbit about the workforce committee and (2) realizing faculty at Dartmouth aren't above using a webinar to try to appeal to potential applicants.
 
GapCalc said:
I listened so you don't have to (although I think it'll be on the ACR website, and I applaud them for hosting and asking tough questions because ASTRO sure as heck would not do this...)

  • Moderator did a good job, but said a lot of topics would be answered "offline" -- not sure how that will work
  • Alan Hartford (Dartmouth) kicked it off by essentially saying, "the weather sure is nice, why are you all worried about the climate?" After all, a survey said there are lots of jobs from the people in charge of residency programs. Not a strong start.
  • Brian Kavanagh (Colorado) spoke about program length and being part of the generation where there was an excess of trainees before RO went from 3 to 4 years. I missed part of his talk...
  • Neha Vapiwala (Penn) spoke about the role of the ACGME Residency Review Committee and belabored the point that RCC is not in charge of program number or size, only approving any and all programs that meet criteria. However, RO is down to 91 programs from 96 (!) or something similar...
  • Dr. Vapiwala said ASTRO is soliciting bids for an external company to do a workforce survey (hmm, where have I heard that idea before?) and that SDN Hero Chirag Shah (see: Bloodbath in Red Journal) is co-chair of the workforce committee
  • Question about whether use of SOAP was appropriate. Dr. Vapiwala said a one-size-fits-all approach does not make sense, but that PDs/chairs should be good stewards of the field (ha!).
  • Dr. Hartford then said his program opened 5 or 6 years ago and they have had to SOAP at least once and yet, they make great radiation oncologists
  • One question was whether it was appropriate programs continue to expand despite decreased applicant numbers; no one would come out and say outright that it was wrong (which tells you everything you need to know)
  • There were a number of polls asking about audience opinions (Should conscious efforts be made to increase future applicant numbers?)
  • Everyone agreed there needs to be more women-and-minorities
  • Multiple poll questions about SOAP, expansion, decreasing applicant numbers, etc, generally had people voting in such a way that interests on this board were well represented (just not by the speakers)
  • Nearly everyone mentioned mentorship and outreach to improve applicant numbers
  • Dr. Hartford really knocked it out of the park when he compared online discussions (i.e. SDN) to "Russian collusion" and that outreach, including outreach to MS1s and undergrads at Dartmouth, might help turn things around
  • A medical student applying to the field gave her thoughts about the application process

Overall, it was nearly all "the same old tune" except (1) learning the tidbit about the workforce committee and (2) realizing faculty at Dartmouth aren't above using a webinar to try to appeal to potential applicants.
Click to expand...
Cliff notes: field is ****ed for the foreseeable future (could substitute what Hartford is saying for what Potters is saying or KO is saying). If i were an ms3/4, i wouldn't touch the specialty of radiation oncology with a ten foot pole
 
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GapCalc said:
  • Alan Hartford (Dartmouth) kicked it off by essentially saying, "the weather sure is nice, why are you all worried about the climate?" After all, a survey said there are lots of jobs from the people in charge of residency programs. Not a strong start.
  • Dr. Hartford then said his program opened 5 or 6 years ago and they have had to SOAP at least once and yet, they make great radiation oncologists
  • Dr. Hartford really knocked it out of the park when he compared online discussions (i.e. SDN) to "Russian collusion" and that outreach, including outreach to MS1s and undergrads at Dartmouth, might help turn things around
Click to expand...
*sigh*

Not to throw stones at Dartmouth, an oft-punched bag here on SDN, but really?

Dr Hartford: please provide your operational definition of a "great Radiation Oncologist". Your program has, at most, produced no more than one or two attending Radiation Oncologists.

Those attendings have, at most, been practicing for one or two years.

I assume I'm being generous with these estimates.

I think it's reasonable to say that there is simply no way we can know, for certain, that ANYONE is a "great" doctor in ANY specialty after only 1-2 years in independent practice. Being a "great" undergrad does not always translate into being a "great" medical student, being a "great" medical student does not always translate into being a "great" resident, and being a "great" resident does not always translate into being a "great" attending. Additionally, your definition of "great" might not be the same as my definition of "great".

This really gives off some used-car-salesman vibes. Dear people in this specialty with some grey hair and memories of "how it used to be": it's OK to acknowledge the situation on the ground. The practice of Radiation Oncology is different than the economics of Radiation Oncology. You can love the medicine and recognize the systemic issues. Saying "hey, maybe we're training too many folks" is NOT the same as saying "wow I hate Radiation Oncology".

The quicker everyone realizes this false dichotomy, the quicker we can get on the road to recovery.
 
5ukv81.jpg
 
GapCalc said:
I listened so you don't have to (although I think it'll be on the ACR website, and I applaud them for hosting and asking tough questions because ASTRO sure as heck would not do this...)

  • Moderator did a good job, but said a lot of topics would be answered "offline" -- not sure how that will work
  • Alan Hartford (Dartmouth) kicked it off by essentially saying, "the weather sure is nice, why are you all worried about the climate?" After all, a survey said there are lots of jobs from the people in charge of residency programs. Not a strong start.
  • Brian Kavanagh (Colorado) spoke about program length and being part of the generation where there was an excess of trainees before RO went from 3 to 4 years. I missed part of his talk...
  • Neha Vapiwala (Penn) spoke about the role of the ACGME Residency Review Committee and belabored the point that RCC is not in charge of program number or size, only approving any and all programs that meet criteria. However, RO is down to 91 programs from 96 (!) or something similar...
  • Dr. Vapiwala said ASTRO is soliciting bids for an external company to do a workforce survey (hmm, where have I heard that idea before?) and that SDN Hero Chirag Shah (see: Bloodbath in Red Journal) is co-chair of the workforce committee
  • Question about whether use of SOAP was appropriate. Dr. Vapiwala said a one-size-fits-all approach does not make sense, but that PDs/chairs should be good stewards of the field (ha!).
  • Dr. Hartford then said his program opened 5 or 6 years ago and they have had to SOAP at least once and yet, they make great radiation oncologists
  • One question was whether it was appropriate programs continue to expand despite decreased applicant numbers; no one would come out and say outright that it was wrong (which tells you everything you need to know)
  • There were a number of polls asking about audience opinions (Should conscious efforts be made to increase future applicant numbers?)
  • Everyone agreed there needs to be more women-and-minorities
  • Multiple poll questions about SOAP, expansion, decreasing applicant numbers, etc, generally had people voting in such a way that interests on this board were well represented (just not by the speakers)
  • Nearly everyone mentioned mentorship and outreach to improve applicant numbers
  • Dr. Hartford really knocked it out of the park when he compared online discussions (i.e. SDN) to "Russian collusion" and that outreach, including outreach to MS1s and undergrads at Dartmouth, might help turn things around
  • A medical student applying to the field gave her thoughts about the application process

Overall, it was nearly all "the same old tune" except (1) learning the tidbit about the workforce committee and (2) realizing faculty at Dartmouth aren't above using a webinar to try to appeal to potential applicants.
Click to expand...
 
1637208141373.png


It seems weird that pharma lobbyists spend almost as much greasing the wheels as the dollar amount CMS is trying to cut from RadOnc.

Man, I'd want to open a residency program too, if it meant I could pay a doctor $60k a year to write my notes and compile all this new CDE the government demands on all my patients!
 
GapCalc said:
I listened so you don't have to (although I think it'll be on the ACR website, and I applaud them for hosting and asking tough questions because ASTRO sure as heck would not do this...)
Click to expand...

This is why nothing will ever change. Bottom line is keep the resident pipeline wide open if that benefits you or your position. Remember we are graduating 190 rad oncs a year with the best guest of about 90 retirements a year. These people are fine with rad onc having the worst job market in medicine.
 
Lamount said:
I am only in clinic three days… does that count?
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Do you find that the other two days are mostly catch up or do you find time to do actualy focus on academic stuff those days?
 
Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.
 
TheWallnerus said:
Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.
Click to expand...

Always got pushback for BID from Ins and also the staff. So Im still doing 60/30 for SCLC and telling residents what to say to the friendly oral examiner for an exam that shouldn't even exist.
 
RadsWFA1900 said:
Always got pushback for BID from Ins and also the staff. So Im still doing 60/30 for SCLC and telling residents what to say to the friendly oral examiner for an exam that shouldn't even exist.
Click to expand...
It's unrealistic to do bid in situations, esp low volume clinics where you are trying to give 4-6 hours between fractions, not to mention it pretty much makes it impossible for the patient to continue to work through tx
 
TheWallnerus said:
Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.
Click to expand...
I would consider in highly selected patients with favorable distribution of dz. That’s a pretty toxic tx if a lot of the esophagus overlaps with PTV (acute > chronic)
 
Lamount said:
I would consider in highly selected patients with favorable distribution of dz. That’s a pretty toxic tx if a lot of the esophagus overlaps with PTV (acute > chronic)
Click to expand...
At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.
 
RickyScott said:
At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.
Click to expand...
Thank god ENI was not a thing in my time, and I can just focus on the uptake on the PET scan.
 
medgator said:
It's unrealistic to do bid in situations, esp low volume clinics where you are trying to give 4-6 hours between fractions, not to mention it pretty much makes it impossible for the patient to continue to work through tx
Click to expand...
When it comes to BID I am in low volume centers and just have to “suck it up” schedule wise when they appear. I have done a lot of BID and almost never have logistic problems per se. I agree it is impossible to work during BID. But being able to continue work during chemo radiation for locally advanced lung cancer is not safe bet even for once a day RT. I have FOMOS (fear of missing overall survival) when people or insurance companies attack BID. The worst financial toxicity and the most effective way to miss work is death. (Yes that’s hyperbolic.)
 
RickyScott said:
At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.
Click to expand...

Subtle brag that all of your stage III lungs don't have fat level 7 nodes
 
RickyScott said:
At least w/45 bid most the toxicity is in the last week/after xrt. In the years since abandoning elective nodal radiation, don’t see nearly as much esophageal toxicity.
Click to expand...
On paper we all know 45/30 has a bit less acute radiobiological punch than 45/25 (the study that said 45/30 had worse esophageal toxicity) so it truly is a chronological area under the curve phenomenon. That said, in the Intergroup study, CT based planning happened for exactly zero patients. An esophageal DVH would have been a Martian to those investigators. I don’t even think the word “DVH” had been invented when the study started accruing. Now we are giving 60/15 to large volumes in the chest. That’s certainly got more acute RBE (on the esophagus) than 45/30.

pubmed.ncbi.nlm.nih.gov

Accelerated Hypofractionated Image-Guided vs Conventional Radiotherapy for Patients With Stage II/III Non-Small Cell Lung Cancer and Poor Performance Status: A Randomized Clinical Trial - PubMed

ClinicalTrials.gov Identifier: NCT01459497.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **
 
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TheWallnerus said:
Insurance aside, I don’t understand reticence on 60/40. The best by test regimen before that was 45/30. 60/40 beat it. Nothing else really ever did. People who don’t like BID are like the people who say “I hate that band” when you know darn well they never truly listened to any of their stuff.
Click to expand...
In other words, BID is the nickelback of bands. Sadly my patients never agree to it
 
BID is great/fine, that's not the issue, though I agree that most patients will choose another option.

the issue is 30 fraction BID vs 40 BID. I feel like this gentleman academic from Vanderbilt is the first person I've seen say that they want to offer it. When this first came out, on twitter, mednet, etc, most lung disease site academics said that they were not going to offer it, given the murkiness of the data. In this case it's not just Evicore, but the general tenor of the field. Med Onc has intense regulatory processes (for better or worse). Our version of this is a general consensus opinion from academics, lol.
 
radmonckey said:
So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **
Click to expand...
I seriously doubt that anyone will look into this in the future in a randomized Phase III design. The CALGB trial had to shut down the CCB-arm due to higher toxicity, if I recall correctly, and that CCB-arm would have produced an effect partially similar to what 60/1.5 bid did.
I will be offering 60/1.5 in fit patients, if I can meet constraints.
"Stong metastastic phenotype" is an argument, but we know (even from the Intergroup trial) that local progression is a major issue in these patients.
And I give almost all my LD-SCLC patients PCI. I believe in PCI. 🙂
 
radmonckey said:
So 170 pt phase 2 unreplicated study in disease with strong metastatic phenotype and heavy predilection for high comorbidity population tells us we need to drag these patients in for 40 fractions in 4 weeks? Less chemo given, more dose reductions, more patients > 70, and worse ECOG in 45gy arm. Also better be offering PCI to all (85% received) to appropriately mirror these results. Survival curves started separating from day 1 btw.

Interesting premise but don't buy it yet.

*Edit: Evilcore still shouldn't be able to tell you how to practice **
Click to expand...
Do you drag the patients in for more than 15 or 20 days?
 
Palex80 said:
I seriously doubt that anyone will look into this in the future in a randomized Phase III design. The CALGB trial had to shut down the CCB-arm due to higher toxicity, if I recall correctly, and that CCB-arm would have produced an effect partially similar to what 60/1.5 bid did.
I will be offering 60/1.5 in fit patients, if I can meet constraints.
"Stong metastastic phenotype" is an argument, but we know (even from the Intergroup trial) that local progression is a major issue in these patients.
And I give almost all my LD-SCLC patients PCI. I believe in PCI. 🙂
Click to expand...
was sclc one of the first disease sites where a local radiotherapy in metastatic patients improved survival. ‘‘Twas controversial, hard to believe, etc. In SCLC, rad oncs could hold more sway. The med oncs don’t want us to though, and rad oncs seem to get taught in residency by the rad oncs they look up to that things like BID and PCI are almost being cruel to patients. You must be a mean guy if you want patients to come in twice a day.

pubmed.ncbi.nlm.nih.gov

Use of thoracic radiotherapy for extensive stage small-cell lung cancer: a phase 3 randomised controlled trial - PubMed

Dutch Cancer Society (CKTO), Dutch Lung Cancer Research Group, Cancer Research UK, Manchester Academic Health Science Centre Trials Coordination Unit, and the UK National Cancer Research Network.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
jondunn said:
When this first came out, on twitter, mednet, etc, most lung disease site academics said that they were not going to offer it, given the murkiness of the data
Click to expand...
Will bet a 2019 dollar that those same academics were not offering 45/30 already. In relationship to its primacy and standard of care-ness, it (45/30) is the most underutilized thing of that nature in all of rad onc. If you already kind of staked your rep on being Mr QD (because I’m a good and smart doc) in SCLC, of course this data is “murky.”
 
TheWallnerus said:
Will bet a 2019 dollar that those same academics were not offering 45/30 already. In relationship to its primacy and standard of care-ness, it (45/30) is the most underutilized thing of that nature in all of rad onc. If you already kind of staked your rep on being Mr QD (because I’m a good and smart doc) in SCLC, of course this data is “murky.”
Click to expand...
Prob should up the dose a bit to 70 if you're going to do QD but otherwise, there should be no problem compared to bid and we now have data to support that

 
Palex80 said:
I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.
Click to expand...
That doesn't seem to be the case here.... 70/35 looks perfectly fine as an alternative imo
 
Palex80 said:
I am sorry, but we had "data" before as well.
The CONVERT trial was negative. 66/2 QD was not superior to 45/1.5 BID and frankly, I think it looked a lot like inferiority for the QD-regimen.
Click to expand...

medgator said:
That doesn't seem to be the case here.... 70/35 looks perfectly fine as an alternative imo
Click to expand...
Again on paper alpha beta wise what a huge jump in RBE from 45/30 to 66 or 70 qd. And they yielded bupkis. And then we do one dose escalation trial of bid and it’s positive. It’s almost like the SCLC data is trying to tell us BID works. If you have a plan where cord or lung or heart constraints can’t be met with 70 Gy RX dose, 45 Gy is such a friend.
 
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