Rad Onc Twitter

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medgator said:
Another JD rando tweet post without commentary. Great.

Probably would have been more appropriate in the other thread asking about treating oral cavity
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I find those poll answer choices interesting.

If we want to treat contralateral neck, we either have to go to Level 2 or 4? I'm a RadOnc, don't box me in!!! What about Level 3? What about choosing between 4a and 4b?

COME ON.
 
RealSimulD said:
He’s tweaking. He’s TWEAKING
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We could just keep spiraling down the rabbit hole -

What immobilization are you using? How many points of contact is the mask? What algorithm is your TPS running? Is there dental work? When was your CBCT last calibrated on the linac? How long is the interval from CBCT to the last MU being delivered each day? Are your therapists the type to call the MD to the machine if there are minor/major shifts or do they let you discover it later on? Should we account for swallowing? Tubarial glands? Mean esophagus dose vs delineating subdivisions and looking at falloff?

But really -

Should we just go back to plain films and forget all this malarkey?

ViewRay's deep pockets say NEVER.
 
Reaganite said:
Evicore and uhc policy for sarcoma both give relatively clear instructions on how to get imrt approved. If you quote their own words and meet their criteria they are usually forced to approve. Both policies for sarcoma state imrt will be approved if a clinically meaningful reduction in normal tissue sparing can be achieved with imrt as demonstrated on a plan comparison. Clinically meaningful usually means only the imrt plan can meet some quantec constraint. Occasionally they will also allow rtog constraints. This is all spelled out in detail in their imrt policies which are freely available to all providers. Lets be honest: not every extremity sarcoma needs imrt. There are well lateralized sarcomas of the extremities where simple fields offer great bone and skin strip sparing. Would be interested in seeing spraker's case.
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Maybe because he was giving 5 fractions, he somehow couldn’t show he was exceeding one of their conventional constraints?
 
Sorry, @sueyom, you lobbed this softball up, I had to do it:

1645364830002.png
 
StIGMA said:
Photograph: a picture made using a camera
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totally, I thought about that later although in the end everything on the cover is a photograph, they all come in as photographs of an artwork
this is an acid etching by a retired radiation oncologist in South Africa of Boulders Beach
curious what people think of our covers - I did get a comment or two that "this is not an art journal" but really, there's only so much electron microscopy and BioRender figures people can see in their lives before they get the idea
btw ESE I think you missed the initial caption, agree it was asking for it
😉

Screen Shot 2022-02-20 at 12.33.25 PM.png
 
sueyom said:
totally, I thought about that later although in the end everything on the cover is a photograph, they all come in as photographs of an artwork
this is an acid etching by a retired radiation oncologist in South Africa of Boulders Beach
curious what people think of our covers - I did get a comment or two that "this is not an art journal" but really, there's only so much electron microscopy and BioRender figures people can see in their lives before they get the idea
btw ESE I think you missed the initial caption, agree it was asking for it
😉

View attachment 350579
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It’s a pretty picture, and timeless for those who will look back in 20+ years at the journal. Im all in for real art!

Was teasing of course, applying reviewer 2 mentality to a journal tweet 🥸
 
sueyom said:
totally, I thought about that later although in the end everything on the cover is a photograph, they all come in as photographs of an artwork
this is an acid etching by a retired radiation oncologist in South Africa of Boulders Beach
curious what people think of our covers - I did get a comment or two that "this is not an art journal" but really, there's only so much electron microscopy and BioRender figures people can see in their lives before they get the idea
btw ESE I think you missed the initial caption, agree it was asking for it
😉

View attachment 350579
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Oh man, I totally missed that - and it makes it about 100% funnier.

This new era of the Red Journal is a highlight of 2022.
 
Stig - good to know, we went all in on the art covers esp during pandemic when people are really tired and you're right it may be that much of what we contributed 20 years from now is art LOL, taking the long view of what truly lasts in oncology (very little)
ESE - should start a radonc penguin club, I can't remember honestly who said or emailed something to me about climate change and the penguins LOL but I guess there are connections
 
sueyom said:
Stig - good to know, we went all in on the art covers esp during pandemic when people are really tired and you're right it may be that much of what we contributed 20 years from now is art LOL, taking the long view of what truly lasts in oncology (very little)
ESE - should start a radonc penguin club, I can't remember honestly who said or emailed something to me about climate change and the penguins LOL but I guess there are connections
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This is my opportunity to finally ask a question that's been on my mind for years:

What is the conversation behind-the-scenes about the amount of real estate each image gets on the cover?

The penguin one is a great example of using available space:

1645393709875.png


However, they often look like this:

1645393795878.png


I don't have an easy way to search, but I know that there have been even smaller pictures/photographs used in the past.

Obviously, there's a need to maintain aspect ratio to prevent distortion of the image. But why couldn't the picture from the September 2019 issue have been expanded like the penguin one?

Is there a reason it can't take up the whole cover, like Nature does? Is it to preserve the fact that it's called the "Red Journal"?

From a design standpoint, the covers where the image is very small and its mostly empty space puzzle me.
 
the first cover is the redesign which I put into place starting Jan 2022 - in the redesign the font is different and the cover is a banner and there is no text other than the required logos on the front - that's what I meant when i said we went "all in" on the art
it didn't seem to me that we needed the rest of it and frankly to me it looked antiquated, not to mention we are moving to a digital era where articles are archived and accessed independently and as Stig said, the primary contribution of this cover will be its place in the art gallery
 
sueyom said:
the first cover is the redesign which I put into place starting Jan 2022 - in the redesign the font is different and the cover is a banner and there is no text other than the required logos on the front - that's what I meant when i said we went "all in" on the art
it didn't seem to me that we needed the rest of it and frankly to me it looked antiquated, not to mention we are moving to a digital era where articles are archived and accessed independently and as Stig said, the primary contribution of this cover will be its place in the art gallery
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This is awesome. I didn't think that in the modern era of 50,000 journals and everything-digital that I would ever get a chance to notice design changes in a medical journal.

Is this what it was like to be a doctor in the 1950s? Can we get ash trays back in the physician's lounge?

(Kidding, of course - there is no lounge, that's where they put admin offices for the Assistant Directors of Sub-Service Line Integration and Compliance)
 
jondunn said:
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I'll summon @RealSimulD because he asked the question which prompted Spraker/Campbell's response, but I'll just speak for myself and my environment:

For us, the rate limiting step is rarely how much we know/how good we are, it's the rest of the team and the equipment we have available. The division isn't strictly academic vs community, because I know small "academic" departments with limited staff/machines and large community practices with all the bells/whistles.

There are techniques and treatments I would love to do, and know that it is within "my" ability. However, there are elements downstream (and upstream) of me that make those techniques not feasible (or unsafe). Over the years, I have been very surprised at where things can go wrong - scenarios and situations I would have never considered until they happened. Some are improbable accidents that are unlikely to happen again, but some are symptoms of more global issues.

Obviously, many specialties face similar challenges. However, RadOnc ranks WAY up there in terms of having a lot of cooks in the kitchen to take a single patient from consult to ringing the bell, and it's pretty easy to forget that when you spend a lot of time erasing and re-drawing little pixels every day, thinking it matters.
 
I’m not going to minimize challenging cases and to consult the university when necessary, but most of us literally have sarcoma rotations, have it on our written exam and it’s a section on the oral exam. There are more STS cases diagnosed than anal cancer cases.

If there is a concern that we cannot handle it, why would certification hinge on passing that subsite? In addition, there are an incredible amount of resources on it - emailing your attendings, ChartRounds, TheMedNet, DM’ing Matt or calling him.

There is an arrogance in academic RadOnc that is bordering on ridiculous. An attending once told me that “head and neck cancer shouldn’t be treated in the community”

You get a sarcoma case, review NCCN, email a friend, and have someone check your volumes. Like any other case… that’s just my opinion, though. I’m a simple community doc in rural MI!
 
RealSimulD said:
I’m not going to minimize challenging cases and to consult the university when necessary, but most of us literally have sarcoma rotations, have it on our written exam and it’s a section on the oral exam. There are more STS cases diagnosed than anal cancer cases.

If there is a concern that we cannot handle it, why would certification hinge on passing that subsite? In addition, there are an incredible amount of resources on it - emailing your attendings, ChartRounds, TheMedNet, DM’ing Matt or calling him.

There is an arrogance in academic RadOnc that is bordering on ridiculous. An attending once told me that “head and neck cancer shouldn’t be treated in the community”

You get a sarcoma case, review NCCN, email a friend, and have someone check your volumes. Like any other case… that’s just my opinion, though. I’m a simple community doc in rural MI!
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Agree. With Sarcoma, I don’t think rad onc is the specialty that drives the need for high volume centers, it’s the surgeon… and then academic surgeons are gonna want the rad onc they work with handling their cases. I think we can all agree that these patients shouldn’t be touched by a community surgeon who sees two of these in a career
 
RealSimulD said:
I’m not going to minimize challenging cases and to consult the university when necessary, but most of us literally have sarcoma rotations, have it on our written exam and it’s a section on the oral exam. There are more STS cases diagnosed than anal cancer cases.

If there is a concern that we cannot handle it, why would certification hinge on passing that subsite? In addition, there are an incredible amount of resources on it - emailing your attendings, ChartRounds, TheMedNet, DM’ing Matt or calling him.

There is an arrogance in academic RadOnc that is bordering on ridiculous. An attending once told me that “head and neck cancer shouldn’t be treated in the community”

You get a sarcoma case, review NCCN, email a friend, and have someone check your volumes. Like any other case… that’s just my opinion, though. I’m a simple community doc in rural MI!
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I really don’t think sarcomas are very hard from a radonc standpoint.
 
Lamount said:
Agree. With Sarcoma, I don’t think rad onc is the specialty that drives the need for high volume centers, it’s the surgeon… and then academic surgeons are gonna want the rad onc they work with handling their cases. I think we can all agree that these patients shouldn’t be touched by a community surgeon who sees two of these in a career
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I saw this post today from a senior resident. From the sounds of it, not all university departments are created equal, and it’s a disservice to a sarcoma patient being treated there to not have a balanced discussion between pre- versus post-op RT.

 
JS1987 said:
I am worried. I do prostate SBRT without intrafraction monitoring and 3-4 mm margins. 10-20% of the time these patients need to temporarily use Flomax. Should I refer these patients to UCLA?
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SBRT is inferior to conventional fractionation. You should only offer 9 weeks of treatment so you can help that 20 percent.
 
elementaryschooleconomics said:
Ah, this is a perfect example of what I was talking about (ability and environment).

Objectively, I agree with you here. This approaches a "perfect" setup. Then I think about doing it for my GI cases...

...and remember the therapists who staff my department, and the workflow in general.

1) You have your patients do an enema before EVERY treatment? Are you doing short-course or is that 28-30 enemas? Obviously, if they only do it for sim, your Dosi may look perfect but it's not "real".

2) Most importantly, I worry about my therapists and setting up with a cylinder every day, let alone cylinder AND prone. I see that not going...well.

If I were in a big academic department with several linacs and therapists/staff with the "time" to do something like this I'd try, but in my two linac, 50 patient hospital, and therapists who just want to move the meat and go home...nah.
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100% behind you but one could argue that the academic place is able to provide better care due to the rapid pace of the community doc. They can provide more “individualized patient care.”

In my opinion, I believe we find the smallest minutiae to focus in on but I guess we all have to prove our worth, especially in a poor job market.
 
RealSimulD said:
I’m not going to minimize challenging cases and to consult the university when necessary, but most of us literally have sarcoma rotations, have it on our written exam and it’s a section on the oral exam. There are more STS cases diagnosed than anal cancer cases.

If there is a concern that we cannot handle it, why would certification hinge on passing that subsite? In addition, there are an incredible amount of resources on it - emailing your attendings, ChartRounds, TheMedNet, DM’ing Matt or calling him.

There is an arrogance in academic RadOnc that is bordering on ridiculous. An attending once told me that “head and neck cancer shouldn’t be treated in the community”

You get a sarcoma case, review NCCN, email a friend, and have someone check your volumes. Like any other case… that’s just my opinion, though. I’m a simple community doc in rural MI!
Click to expand...

I would just LOVE for an academic attending tell me to my face I shouldn't be treating head and neck cancer. Not holding my breath.
 
RadOncDoc21 said:
100% behind you but one could argue that the academic place is able to provide better care due to the rapid pace of the community doc. They can provide more “individualized patient care.”

In my opinion, I believe we find the smallest minutiae to focus in on but I guess we all have to prove our worth, especially in a poor job market.
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Totally agree - if the patient happens to be able to access such an academic environment.

At my residency institution, there were mostly two types of faculty: the clinical workhorses who "specialized" in a disease site but actually saw a little bit of everything, and the scientists who also "specialized" but were better with a pipette than a linac.

Gun to my head, even I can only guess as to where someone should go for the "best" care. I think about this a lot, if I or my family got sick. I've seen behind a lot of curtains, and I'm fairly uncertain what I would do.
 
elementaryschooleconomics said:
Totally agree - if the patient happens to be able to access such an academic environment.

At my residency institution, there were mostly two types of faculty: the clinical workhorses who "specialized" in a disease site but actually saw a little bit of everything, and the scientists who also "specialized" but were better with a pipette than a linac.

Gun to my head, even I can only guess as to where someone should go for the "best" care. I think about this a lot, if I or my family got sick. I've seen behind a lot of curtains, and I'm fairly uncertain what I would do.
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When doctors in our practice get cancer, we treat them. I strongly, strongly disagree that academic facilities are able to provide better care than our practice.
 
elementaryschooleconomics said:
Gun to my head, even I can only guess as to where someone should go for the "best" care. I think about this a lot, if I or my family got sick. I've seen behind a lot of curtains, and I'm fairly uncertain what I would do.
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this is the million dollar question.

for some disease sites, anyone can take care of it.

if a family member of mine gets a head and neck cancer - you can believe that I am going to care about where they are getting radiation. don't care if it's community or academic, but I want the person to be good.
 
OTN said:
I would just LOVE for an academic attending tell me to my face I shouldn't be treating head and neck cancer. Not holding my breath.
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Ah, the classic accusation from academia. There was one faculty member in particular early in my residency who would just absolutely blast community head and neck treatments. Obviously, there's no scan quite like the retrospectoscope, so this isn't fair but - that faculty member would have been wise to be a little more kind based on who came back for recurrences later on.

I sometimes (ok, a lot) worry that we've gotten "too cute" too fast, and head and neck is the perfect example. In the race for 3mm PTV margins and maximizing the sparing of parotids and constrictors etc - is everyone sure that we're not mesmerized by the THEORETICAL dose cloud we approve in the TPS vs what actually happens? I'm certainly not convinced. Especially not when our MedOnc colleagues have complete control over the chemo portion, and ultimate decide which regimen or when to hold for toxicity (true for academia and community).

OTN said:
When doctors in our practice get cancer, we treat them. I strongly, strongly disagree that academic facilities are able to provide better care than our practice.
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I love this.
 
elementaryschooleconomics said:
In a perfect world, I would welcome this.

I wish we could have the "academic ideal" of large academic systems hiring RadOnc faculty to TRULY focus on one thing. Currently, everyone is distracted by trying to pull in as many RVUs as possible and/or publish as many papers as possible and/or obtain as many grants as possible. The system has completely mutated to respond to incentives.

Allowing - and appropriately rewarding - faculty to be completely focused CLINICALLY on a disease/disease site (without the pressure to be RVU machines), then publishing/disseminating their knowledge when it's appropriate (and not because X amount of papers are needed this year for the tenure packet) for the greater good of the rest of us generalists is what I thought medicine was supposed to be.

This also extends to the rest of the links in our chain - physics, Dosimetry, therapists.

A RadOnc is only as good as the Dosimetrist who plans the case, the physicist who QA's and chart-checks it, and the therapist who sets the patient up each day.
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In my world, the academic center has a couple of surrounding satellites and all they do is advertise their equipment in order to drum up their business. I guess I would do it to if I was them but you’re right, in a perfect world, it shouldn’t have to be this way.
 
In my experience the difference that maybe seen in academics is driven by the skill/specialization of the surgeons. Lets be honest, sarcoma outcomes are driven by the skill of the surgeon, assuming that the rad onc doctor is competent. There are plenty of "academic" rad oncs out there (especially older ones) that I would never send someone to for treatment. But obviously there are some outstanding academic rad oncs as well. Same goes for community rad oncs.
 
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elementaryschooleconomics said:
Totally agree - if the patient happens to be able to access such an academic environment.

At my residency institution, there were mostly two types of faculty: the clinical workhorses who "specialized" in a disease site but actually saw a little bit of everything, and the scientists who also "specialized" but were better with a pipette than a linac.

Gun to my head, even I can only guess as to where someone should go for the "best" care. I think about this a lot, if I or my family got sick. I've seen behind a lot of curtains, and I'm fairly uncertain what I would do.
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Thought about this quite a bit -- how does one measure quality of a radiation oncologist? Certainly it is not board certification or MOC. When I was in a large practice, could get a sense of who was good based on peer review and complaints/lack thereof filtered up from therapists, nurses, dosimetry, and physics.

But at an institution/practice never been to? In general my heuristic would be a practice with site specialization, with a physician 5ish -15ish years out, who has 50%+ clinic time. Ideally would want to see a selection of their cases/plans before making a decision, but good luck with that.
 
OTN said:
I would just LOVE for an academic attending tell me to my face I shouldn't be treating head and neck cancer. Not holding my breath.
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At my program, some of our attendings don't even refer out to the satellite docs for head/neck, GYN, GI stuff.
 
There are absolute hellpit academic places where I would not recommend anybody to touch with a ten foot pole. Likewise, there are terrible community places where people just move the meat, draw big, “you don’t wanna miss”, no 4DCT, no CBCT, no IMRT. I have seen pictures of head neck plans from “academics” who draw huge and overtreat. Many of these people are older and basically just reproduce 3D fields, but some are shockingly young!
Of course this happens in community too. Bottomline, it comes down to your doctor and how much they care.
 
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