Rad Onc Twitter

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jondunn said:
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Interesting

If the patient is pre-menopausal and N+, don't get the Oncotype, just give the chemo. Always had a sneaking suspicion that this "old way" which got moderately replaced once Oncotype arrived was the good way.

Have no idea re: RT patterns (who got it, did they get ENI, etc) in RxPONDER but these are very good DFSs. I re-looked at EORTC and MA20:

aU8t6e3.png

Breast patients are doing better over time. DFSs getting better. Still a role for ENI for every pN1? I am skeptical.
 
temujim said:
Not a single word about radiation in that paper. Like it did not exist. As if receipt (or not) could in no way impact the primary endpoint (invasive disease free survival).
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Indeed, it appears that the protocol did not specify anything about radiotherapy, apart from...

Radiation is recommended per institutional and National Comprehensive Cancer Network
(NCCN) guidelines (National Comprehensive Cancer Network - Home) and may be given after chemotherapy and
during endocrine therapy. Partial breast irradiation following ASTRO guidelines is allowed
(for a copy of the consensus statement, contact [email protected]).

The so called "Radiation Therapy Form" was collected by the sites, but nothing specific on it is mentioned.
 
I took a look at Rxponder’s supplementary data, and in table S10 its ‘Dermatitis radiation’ is listed as a side effect of <= G2 for each participant on each arm basically. If I am interpreting this correctly, implied is every single patient enrolled received radiation, but would have been nice to have explicit confirmation of this, as well as further detail of type, field size, etc. Alas. Breast is the worst.
 
TheWallnerus said:
Facemash? TheFacebook?

XhiWx1I.png
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Saw Dr. Spratts tweets. I agree with the basics that focal therapy is experimental and should not be routinely used. I don’t offer it personally, and don’t care if docs that abuse it are named and shamed.

What did rub me the wrong way is the whole “X should not be done off trial”. It smacks of elitism and academic center bias. If I have the right patient with low volume GG2 disease who doesn’t want radical therapy and believes (not unreasonably based on current data) that focal therapy will reduce the likelihood of him progressing to radical therapy in the future and doesn’t want to be bothered enrolling in a trial and traveling, who the hell are you to tell me it can’t/won’t/shouldn’t be done in the community.
 
DoctwoB said:
Saw Dr. Spratts tweets. I agree with the basics that focal therapy is experimental and should not be routinely used. I don’t offer it personally, and don’t care if docs that abuse it are named and shamed.

What did rub me the wrong way is the whole “X should not be done off trial”. It smacks of elitism and academic center bias. If I have the right patient with low volume GG2 disease who doesn’t want radical therapy and believes (not unreasonably based on current data) that focal therapy will reduce the likelihood of him progressing to radical therapy in the future and doesn’t want to be bothered enrolling in a trial and traveling, who the hell are you to tell me it can’t/won’t/shouldn’t be done in the community.
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Amen
 
Hmmm. Trials exist for a reason. And involve IRBs, primary and secondary endpoints, prospective data collection. Some sort of rigor.

Sorry. I’m in the community and have no problem saying that.

next you’re going to say protons should be widely used and promoted!
 
jondunn said:
Hmmm. Trials exist for a reason. And involve IRBs, primary and secondary endpoints, prospective data collection. Some sort of rigor.

Sorry. I’m in the community and have no problem saying that.

next you’re going to say protons should be widely used and promoted!
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Urologists aren't exactly known for their evidence based approach to prostate cancer treatment over the years. Overuse of ADT in the 90s when it was profitable, flying people for HIFU out of the country for cash when it wasn't FDA approved, upfront cryo etc

That being said, once again Spratt comes across as looking like a complete tool
 
medgator said:
Urologists aren't exactly known for their evidence based approach to prostate cancer treatment over the years. Overuse of ADT in the 90s when it was profitable, flying people for HIFU out of the country for cash when it wasn't FDA approved, upfront cryo etc

That being said, once again Spratt comes across as looking like a complete tool
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I agree with spratt coming across as a total tool
 
DoctwoB said:
Saw Dr. Spratts tweets. I agree with the basics that focal therapy is experimental and should not be routinely used. I don’t offer it personally, and don’t care if docs that abuse it are named and shamed.

What did rub me the wrong way is the whole “X should not be done off trial”. It smacks of elitism and academic center bias. If I have the right patient with low volume GG2 disease who doesn’t want radical therapy and believes (not unreasonably based on current data) that focal therapy will reduce the likelihood of him progressing to radical therapy in the future and doesn’t want to be bothered enrolling in a trial and traveling, who the hell are you to tell me it can’t/won’t/shouldn’t be done in the community.
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I, personally, do not believe that HIFU, Cryo, Thermal ablation, etc. should be offered to ANY patient in place of active surveillance.

AS, RP, or RT. Those a patient's 3 oncologically sound options.

Insurance should not cover HIFU unless on clinical trial.
 
evilbooyaa said:
I, personally, do not believe that HIFU, Cryo, Thermal ablation, etc. should be offered to ANY patient in place of active surveillance.

AS, RP, or RT. Those a patient's 3 oncologically sound options.

Insurance should not cover HIFU unless on clinical trial.
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Totally fine by me. It is not standard of care. No reason insurance should pay for it.

But there is a difference between “not standard of care” and “not evidence based.” There is published prospective evidence for focal therapy in reducing progression to radical therapy on AS. Personally I don’t find it compelling. But it exists. And patients ask for it, just like they ask for proton therapy despite lack of evidence.

I would say it is unethical for MD Anderson to push a run of the mill prostate patient into proton therapy. Is it unethical for MD Anderson to treat a patient who is demanding proton therapy because the patient thinks it’s better? I would say not.
 
evilbooyaa said:
I, personally, do not believe that HIFU, Cryo, Thermal ablation, etc. should be offered to ANY patient in place of active surveillance.

AS, RP, or RT. Those a patient's 3 oncologically sound options.

Insurance should not cover HIFU unless on clinical trial.
Click to expand...
Also your methods are quaint. Vascular targeted photodynamic therapy and irreversible electroporation FTW!
 
DoctwoB said:
Saw Dr. Spratts tweets. I agree with the basics that focal therapy is experimental and should not be routinely used. I don’t offer it personally, and don’t care if docs that abuse it are named and shamed.

What did rub me the wrong way is the whole “X should not be done off trial”. It smacks of elitism and academic center bias. If I have the right patient with low volume GG2 disease who doesn’t want radical therapy and believes (not unreasonably based on current data) that focal therapy will reduce the likelihood of him progressing to radical therapy in the future and doesn’t want to be bothered enrolling in a trial and traveling, who the hell are you to tell me it can’t/won’t/shouldn’t be done in the community.
Click to expand...
That's fine.... It's just not clear to me that the cryo/HIFU guys were being honest with patients when presenting it in the context of other options.

I know for a fact pts were definitely flying out of the country several years ago and paying thousands oop to have hifu done and I've definitely treated a few failures (pales in comparison to the number of cryo failures I've treated, likely owing to the fact there is a smaller group of pts willing to shell out several grand and fly out to get HIFU)
 
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medgator said:
That's fine.... It's just not clear to me that the cryo/HIFU guys were being honest with patients when presenting it in the context of other options.

I know for a fact pts were definitely flying out of the country several years ago and paying thousands oop to have hifu done and I've definitely treated a few failures (pales in comparison to the number of cryo failures I've treated, likely owing to the fact there is a smaller group of pts willing to shell out several grand and fly out to get HIFU)
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I remember those days. I was approached to invest in a medical luxury boat so the uros could Do HIFU and Cryo in international waters with their cash paying patients….I feel like I stepped into the twilight zone
 
RadsWFA1900 said:
I remember those days. I was approached to invest in a medical luxury boat so the uros could Do HIFU and Cryo in international waters with their cash paying patients….I feel like I stepped into the twilight zone
Click to expand...

Reminds me of a call I got from Ben smith once!

He had a new Ponzi scheme cooking he was calling Brocade

Wonder what ever happened with that scam…..
 
medgator said:
That's fine.... It's just not clear to me that the cryo/HIFU guys were being honest with patients when presenting it in the context of other options.

I know for a fact pts were definitely flying out of the country several years ago and paying thousands oop to have hifu done and I've definitely treated a few failures (pales in comparison to the number of cryo failures I've treated, likely owing to the fact there is a smaller group of pts willing to shell out several grand and fly out to get HIFU)
Click to expand...

Oh I agree. There’s a big difference between being willing to offer the rare patient non standard care who asks for it and pushing it on anyone you see, which is wildly unethical. Plenty of shysters out there. Not sure I buy there are more in Uro then other fields absent data. Show me that 10% of urologists regularly use HIFU or cryo and I’d be quite surprised (not that 5% is ok).
 
RadsWFA1900 said:
I remember those days. I was approached to invest in a medical luxury boat so the uros could Do HIFU and Cryo in international waters with their cash paying patients….I feel like I stepped into the twilight zone
Click to expand...

That is terrifying yet awesome. A boat of unapproved medical therapies. PRP, Stem cells, HiFU for all. Throw in a few cameras for a reality show and it sounds like a solid investment.
 
RO28 said:


Memes? Twitter? Or dare you to reply🙃
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Honestly, the only way I can see this changing (people conducting "research" on "hot" topics that serves to build their own name more than anything else) is if we can ever move away from how tightly wound publishing is to advancing careers in medicine.

At the student level, it worsens the gap between the people who have the ability to take years off to conduct unpaid work solely for the purpose of CV padding.

At the residency level, it virtually requires people to take significant effort and attention away from learning clinical medicine (which is what the majority of doctors will end up doing for their career).

At the attending/faculty level, it means recruiting students and residents into this feedback loop to continue and worsen this cycle.

At the societal level, it means that a handful of publishing companies make millions of dollars utilizing the unpaid volunteerism of students/residents/faculty (estimated to be worth $1.5 billion per year in the US alone). It also means a significant amount of "noise" is introduced into the literature which makes it hard to discern what publications actually have a positive impact on the health of our patients.

I know everyone is aware of this. I just don't see how we're getting out of this system we've built. I don't think my generation will do it, I suspect it won't even be current medical students, but perhaps the generation of future physicians currently in undergrad/high school?

Who knows.
 
elementaryschooleconomics said:
Honestly, the only way I can see this changing (people conducting "research" on "hot" topics that serves to build their own name more than anything else) is if we can ever move away from how tightly wound publishing is to advancing careers in medicine.

At the student level, it worsens the gap between the people who have the ability to take years off to conduct unpaid work solely for the purpose of CV padding.

At the residency level, it virtually requires people to take significant effort and attention away from learning clinical medicine (which is what the majority of doctors will end up doing for their career).

At the attending/faculty level, it means recruiting students and residents into this feedback loop to continue and worsen this cycle.

At the societal level, it means that a handful of publishing companies make millions of dollars utilizing the unpaid volunteerism of students/residents/faculty (estimated to be worth $1.5 billion per year in the US alone). It also means a significant amount of "noise" is introduced into the literature which makes it hard to discern what publications actually have a positive impact on the health of our patients.

I know everyone is aware of this. I just don't see how we're getting out of this system we've built. I don't think my generation will do it, I suspect it won't even be current medical students, but perhaps the generation of future physicians currently in undergrad/high school?

Who knows.
Click to expand...

There would need to be a catastrophic event that completely upends the existing system which basically assumes excessive interest of students to become doctors. At some point applicants may just say screw it volunteering to do research this much isn’t worth my time

I wish that was the case when I was applying. The amount of free academic work and community volunteering I did just to check a box I probably would have been better off sleeping or having a social life.

Looking back, none of the research I did amounted to anything and quite honestly after seeing the nonsense that goes on in labs academia seemed like a horrible waste of time.

Over I’d say the 5 years that I volunteered my time, if I was paid a wage I’d probably have 10K.

Looking back on the experiences I’ve had, honestly it made me more cynical person and made me want to avoid these kind of projects in the future. You have to be a real lucky duck for these projects to go anywhere

The sheer amount of fake enthusiasm that went into the whole thing looks exhausting in retrospect.
 
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DoctwoB said:
Totally fine by me. It is not standard of care. No reason insurance should pay for it.

But there is a difference between “not standard of care” and “not evidence based.” There is published prospective evidence for focal therapy in reducing progression to radical therapy on AS. Personally I don’t find it compelling. But it exists. And patients ask for it, just like they ask for proton therapy despite lack of evidence.

I would say it is unethical for MD Anderson to push a run of the mill prostate patient into proton therapy. Is it unethical for MD Anderson to treat a patient who is demanding proton therapy because the patient thinks it’s better? I would say not.
Click to expand...

I'd be interested in links for the bolded.

In regards to protons for prostate, I mostly agree with you in terms of the cost, but at least I am confident that protons will be equally effective (even if more toxic) to photon RT or RP. With focal therapy we are discussing a therapy that is oncologically inferior to RP or RT.
It would be similarly unethical to do say focal gland brachytherapy off trial in 2021.

Plenty of shysters in all fields. For me, the HIFU/Cryo/focal therapy bandwagon is a relatively small portion. I think what is much more relevant on a day-to-day is the lack of "prostate cancer patient meets with Urologist and Radiation Oncologist" paradigm that should be routine in this country and worldwide, but in reality it's more like 30-50% dependent on where you look.
DoctwoB said:
Also your methods are quaint. Vascular targeted photodynamic therapy and irreversible electroporation FTW!
Click to expand...

Ha, those both fall under the ETC of additional "big words" nonsense that has not been proven to have clinical utility similar to the gold standard.
 
elementaryschooleconomics said:
Honestly, the only way I can see this changing (people conducting "research" on "hot" topics that serves to build their own name more than anything else) is if we can ever move away from how tightly wound publishing is to advancing careers in medicine.

At the student level, it worsens the gap between the people who have the ability to take years off to conduct unpaid work solely for the purpose of CV padding.

At the residency level, it virtually requires people to take significant effort and attention away from learning clinical medicine (which is what the majority of doctors will end up doing for their career).

At the attending/faculty level, it means recruiting students and residents into this feedback loop to continue and worsen this cycle.

At the societal level, it means that a handful of publishing companies make millions of dollars utilizing the unpaid volunteerism of students/residents/faculty (estimated to be worth $1.5 billion per year in the US alone). It also means a significant amount of "noise" is introduced into the literature which makes it hard to discern what publications actually have a positive impact on the health of our patients.

I know everyone is aware of this. I just don't see how we're getting out of this system we've built. I don't think my generation will do it, I suspect it won't even be current medical students, but perhaps the generation of future physicians currently in undergrad/high school?

Who knows.
Click to expand...
yes, 100%, 10/10. We should have a drink together someday. I have so many things to say about all of this. I'm getting to the point where I'm going bald from ripping my hair out (jkjk, just ongoing post-baby hairloss).
 
RO28 said:
yes, 100%, 10/10. We should have a drink together someday. I have so many things to say about all of this. I'm getting to the point where I'm going bald from ripping my hair out (jkjk, just ongoing post-baby hairloss).
Click to expand...

Absolutely. The writing of "academic" articles for the sole purpose of padding the CV is the hidden shame of our field (by that I mean medicine not just rad onc). We know (I am guilty as well) most articles are just for the CV. I was surprised one day when a rad onc friend of mine said, "Hey, I read your article." I was caught off guard and wasn't sure whether to be flattered or be ashamed to know he read my retrospective masterpieces (ie garbage) LOL
 
RadOncMegatron said:
Absolutely. The writing of "academic" articles for the sole purpose of padding the CV is the hidden shame of our field (by that I mean medicine not just rad onc). We know (I am guilty as well) most articles are just for the CV. I was surprised one day when a rad onc friend of mine said, "Hey, I read your article." I was caught off guard and wasn't sure whether to be flattered or be ashamed to know he read my retrospective masterpieces (ie garbage) LOL
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should prob just watermark the last page of my CV with GARBAGE. But yeah, I have the exact same reaction when someone says they read something I wrote. 😆
 
evilbooyaa said:
I'd be interested in links for the bolded.

In regards to protons for prostate, I mostly agree with you in terms of the cost, but at least I am confident that protons will be equally effective (even if more toxic) to photon RT or RP. With focal therapy we are discussing a therapy that is oncologically inferior to RP or RT.
It would be similarly unethical to do say focal gland brachytherapy off trial in 2021.

Plenty of shysters in all fields. For me, the HIFU/Cryo/focal therapy bandwagon is a relatively small portion. I think what is much more relevant on a day-to-day is the lack of "prostate cancer patient meets with Urologist and Radiation Oncologist" paradigm that should be routine in this country and worldwide, but in reality it's more like 30-50% dependent on where you look.


Ha, those both fall under the ETC of additional "big words" nonsense that has not been proven to have clinical utility similar to the gold standard.
Click to expand...
pubmed.ncbi.nlm.nih.gov

A Multicentre Study of 5-year Outcomes Following Focal Therapy in Treating Clinically Significant Nonmetastatic Prostate Cancer - PubMed

In this multicentre study of 625 patients undergoing focal therapy using high-intensity focused ultrasound (HIFU), failure-free survival, metastasis-free survival, cancer-specific survival, and overall survival were 88%, 98%, 100%, and 99%, respectively. Urinary incontinence (any pad use) was...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

5 year failure free survival for mostly GG2 disease was 88%. They define failure as freedom from radical therapy, ADT, or progression. One could argue that is not bad, as most series of AS in similar patients have a progression to radical treatment rate of ~50%.

Of course in the weeds of the article, you see they ignore PSA kinetics, and local recurrence that was retreated with HIFU was not counted as "failure" which is obviously BS. 40 of the 600 something patients had in field recurrence, and 27 had out of field recurrence. Note the real number is almost certainly higher since they only did for cause biopsies, not surveillance.

Anyways. As I've mentioned, I am unimpressed by the data. But it would not be completely unreasonable for someone who is highly motivated to avoid surgery or xrt to look at it and want that topline result.
 
elementaryschooleconomics said:
At the societal level, it means that a handful of publishing companies make millions of dollars utilizing the unpaid volunteerism of students/residents/faculty (estimated to be worth $1.5 billion per year in the US alone). It also means a significant amount of "noise" is introduced into the literature which makes it hard to discern what publications actually have a positive impact on the health of our patients.
Click to expand...
Do your part to destroy the publishing industry and use sci hub
 
jondunn said:
Guy was cancelled!
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Well, if being cancelled = earning 80-90% of your maximum annual salary for life complete with benefits and perks then sign me up. I also expect to see him pop up soon as a highly-compensated consultant for any number of companies.
 
Gfunk6 said:
Well, if being cancelled = earning 80-90% of your maximum annual salary for life complete with benefits and perks then sign me up. I also expect to see him pop up soon as a highly-compensated consultant for any number of companies.
Click to expand...
Yes please sign me up for this cancelling as well. I would also like a Genesis gig in the south of France. Wally, where u at?
 
jondunn said:
Guy was cancelled!
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What really? Wouldn’t surprise me if he was asked politely to retire.

I remember interviewing with him years ago. Nice guy. Probably best he leave though at least he can look back on a decent career that got him to retirement. Jealous I probably won’t be able to say the same.
 
elementaryschooleconomics said:
Yes please sign me up for this cancelling as well. I would also like a Genesis gig in the south of France. Wally, where u at?
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I don’t mind the word cancel. It’s “sell” which is not such a bad word. And “can” in front of it which is the opposite of can’t. So “can”… “sell.” It’s pretty refreshing compared with the alternatives.

Now if Randall had given all the residents a tie and t shirt that said “Gettin Lucky in Kentucky” I would be here for it.
 
RadsWFA1900 said:
What really? Wouldn’t surprise me if he was asked politely to retire.

I remember interviewing with him years ago. Nice guy. Probably best he leave though at least he can look back on a decent career that got him to retirement. Jealous I probably won’t be able to say the same.
Click to expand...

Kidding.

He wrote an article about getting cancelled
 
elementaryschooleconomics said:
View attachment 346518
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I forsee more of these “retirements”. These hellpit places are getting 60 applications if that. Many of them are facing a terrible match prospect for the forseable future. UK already cut the match to 401ks using the pandemic as an excuse. Why would you want to preside over departments who cannot match and employees have decreasing salaries and benefits. Retirement with a sweet pension new grads no longer have access to and continue grift elsewhere opening up clinics in Scotland all of a sudden sounds great. Sneak out the backdoor with tons of cheese before the ship sinks is what our “leaders” do.
 
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