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RealSimulD said:
Mudit's point is fair. Why should a practicing clinician in the community worry about their fractionation scheme and it's effects on the specialty? The residency programs expanded - does that mean I should stay with maximal fractionation so I can hire a partner down the road and absorb the oversupply?

I don't see that as smug. It's reality.
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I mean it goes WAY beyond residency expansion. Those kids who keep matching are already ****ed.
 
RealSimulD said:
Mudit's point is fair. Why should a practicing clinician in the community worry about their fractionation scheme and it's effects on the specialty? The residency programs expanded - does that mean I should stay with maximal fractionation so I can hire a partner down the road and absorb the oversupply?

I don't see that as smug. It's reality.
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They should worry because the entire field revolves around fxs and indications. If you lose large amounts of either, eventually this comes back to you in the form of lower compensation and less job opportunities.

Also don’t be surprised if your colleagues see it as an opportunity to say “well it’s only 5 treatments what are you really accomplishing” and then they stop sending.

It’s smug because it fails to acknowledge the reality. Talking about what’s best for the patient is just a red herring.
 
RadsWFA1900 said:
They should worry because the entire field revolves around fxs and indications. If you lose large amounts of either, eventually this comes back to you in the form of lower compensation and less job opportunities.

Also don’t be surprised if your colleagues see it as an opportunity to say “well it’s only 5 treatments what are you really accomplishing” and then they stop sending.

It’s smug because it fails to acknowledge the reality. Talking about what’s best for the patient is just a red herring.
Click to expand...

Just to be clear, you feel that my treatment recommendations for my patients have to take into account what is going on out in the world? I think that is extremely heavy-handed and paternalistic. Physician autonomy is paramount (think about how upset people are about working for MDACC Networks!). But, instead of MDACC dictating care, it is the general community (that is rightfully upset about oversupply) that should decide what independent providers should prescribe?

If I am misunderstanding, would be open to hearing what you actually mean.
 
jondunn said:
to play devil's advocate - TheWallnernus has nicely shown we have way too many empty linacs. Makes the argument for centralization of some type, though I hope that happens after I retire, if it was to ever happen.
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To play angels advocate, some centers have 50 patients on every Linac with some patients waiting weeks to months to start treatment while the center a block away has 5. I’m also sure the Q/A isn’t top notch either.
 
RealSimulD said:
Just to be clear, you feel that my treatment recommendations for my patients have to take into account what is going on out in the world? I think that is extremely heavy-handed and paternalistic. Physician autonomy is paramount (think about how upset people are about working for MDACC Networks!). But, instead of MDACC dictating care, it is the general community (that is rightfully upset about oversupply) that should decide what independent providers should prescribe?

If I am misunderstanding, would be open to hearing what you actually mean.
Click to expand...

I don’t care about your personal treatment recommendations. The fact that you see it as a personal attack is also disturbing or that this is somehow about you. The fact of the matter is these decisions have consequences that go beyond whatever patient is in front of you.

And to be clear, physician autonomy is mostly an illusion and it is especially not the case regarding what we do.
 
RealSimulD said:
Just to be clear, you feel that my treatment recommendations for my patients have to take into account what is going on out in the world? I think that is extremely heavy-handed and paternalistic. Physician autonomy is paramount (think about how upset people are about working for MDACC Networks!). But, instead of MDACC dictating care, it is the general community (that is rightfully upset about oversupply) that should decide what independent providers should prescribe?

If I am misunderstanding, would be open to hearing what you actually mean.
Click to expand...
I don't think that either. It's really difficult to make these decisions when access to care and livelihood of many stakeholders are at risk. No individual patient should bear the brunt of that. Of course, the insurers eventually will give you no choice.

The solution is to stop purposely minimizing our role for no benefit other than cost/convenience/CV item.
 
udrag14 said:
I think the bottom line is the more fractions gets paid more is broken. RO APM could have helped if they actually didn't globally cut costs.

We should just get 1 flat fee for treatment. Then everyone can decide what is best for their patient.
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Obvious and noble suggestion. So it'll never happen.
 
udrag14 said:
I think the bottom line is the more fractions gets paid more is broken. RO APM could have helped if they actually didn't globally cut costs.

We should just get 1 flat fee for treatment. Then everyone can decide what is best for their patient.
Click to expand...

It might have divorced us from it but honestly the castle is coming down regardless and I think the payers know it too.
 
RadsWFA1900 said:
I don’t care about your personal treatment recommendations. The fact that you see it as a personal attack is also disturbing or that this is somehow about you. The fact of the matter is these decisions have consequences that go beyond whatever patient is in front of you.

And to be clear, physician autonomy is mostly an illusion and it is especially not the case regarding what we do.
Click to expand...

I am not taking as a personal attack. It's not about me. I meant in general - sorry if taken that way.

When these academic satellites take over a once busy practice, put two staff in there (where one would have been fine), this is essentially) propping up the market. And, if @OTN or @medgator hired a partner when the next person retires even though they don't need to, that's propping up the market. The residencies screwed up - not us. We just clean up the mess. I think not doing shorter courses is fine, as long as within a standard of care. But, if the short course is within standard of care, then that's okay, too, right? I mean - we do what we feel is best. If we are prescribing longer even though in her hearts we feel shorter is better to support the market, I don't think that feels great, either.
 
I think the moral of the story is that nobody is arguing against hypofx if that is what is best for the patient with evidence to support it.

I think the issue I have is the haves and the have nots controlling the system and crying “it’s all about patient care and access to care” when there is push back regarding the true underlying intent.

At the end of the day, it’s all about the money…period!
 
OTN said:
I love UK/Canadian style hypofractionation and have been very happy with cosmetic outcomes in the long-run. The data from 5 fraction whole breast is pretty clear to me that it sacrifices cosmesis.
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I think you’ve always practiced in the best interest of patient - Mudit feels that way, I feel that way, all of us do.

Going from 33 to 16 in breast was an absolute devastation for that site, but we did it. Yes, there are pockets that don’t. But, people by and large doing it. This is in general a very cost conscious and cost effective specialty. There are individual bozos, but the vast majority do great work.
 
What ever happened to the RAGE Group that sued the NHS decades ago when they developed brachial plexopathy after hypo fractionated XRT.

Oh, that's right, the UK govt determined that the govt mandated hypofractionation had nothing to do with it. I guess people just pop up with brachial plexopathy out of the blue in the UK.

Isn't that like having the govt determine whether your claim against the govt (NHS) is valid?

Hmmmmm...
 
I don't think there is anything wrong with prescribing 5 Fx or other hypofractionated courses that have proven track record.
I think the IRE should directed towards the ivory towers who will continue to keep dropping to drop fractions for now clear apparent reason.

Look around now - plenty of places are trying 1 Fx for breast or 3 Fx for breast. And..well 0 Fx for breast.
 
SneakyBooger said:
What ever happened to the RAGE Group that sued the NHS decades ago when they developed brachial plexopathy after hypo fractionated XRT.

Oh, that's right, the UK govt determined that the govt mandated hypofractionation had nothing to do with it. I guess people just pop up with brachial plexopathy out of the blue in the UK.

Isn't that like having the govt determine whether your claim against the govt (NHS) is valid?

Hmmmmm...
Click to expand...


Was this for hypofrac tangents?
 
radoncftw said:
I don't think there is anything wrong with prescribing 5 Fx or other hypofractionated courses that have proven track record.
I think the IRE should directed towards the ivory towers who will continue to keep dropping to drop fractions for now clear apparent reason.

Look around now - plenty of places are trying 1 Fx for breast or 3 Fx for breast. And..well 0 Fx for breast.
Click to expand...
Mayo does 3 fx with protons for breast
 
elementaryschooleconomics said:
View attachment 353405

Thanks, eviCore!
Click to expand...
Fixed it for you

1650041321747.png
 
jondunn said:
to play devil's advocate - TheWallnernus has nicely shown we have way too many empty linacs. Makes the argument for centralization of some type, though I hope that happens after I retire, if it was to ever happen.
Click to expand...
The question is… should we just write off rural patients having something reasonably close?
 
Mandelin Rain said:
They stand to benefit from all the rural minnesota clinics shutting down if volumes plummet.
Click to expand...

This guy isn’t telling us the whole story. “Oh yeah it hurt us but look at me I’m all about the patient” but what actually happened? Did you fire therapists? Get bought out by the hospital? Or how about this How much money did you personally lose as a result of this change? Did you fire any attendings? Did you even have a choice in the matter or was the insurer just like well 15 is enough so there?
 
RealSimulD said:
Mayo does 3 fx with protons for breast
Click to expand...
Three weeks of 15 minute treatment on way home from work.

Vs.

Leave your home and job for 1 week.
Travel to Rochester, MN.
Get a hotel for this week.
Consult, sim, and receive three fractions of proton radiation at Mayo during that week.
Travel home.
Esophagitis manifests, ribs break.

Cost to patient? Higher
Cost to health care system? Higher.
Convenience? Worse.
Toxicity? Likely worse.
Oncologic outcomes? Non-inferior, probably.

Shorter does not equate to cost savings or convenience or better in all cases.

This is the goal. This is the grift. There is no moral high ground to stand on.
 
Mandelin Rain said:
Three weeks of 15 minute treatment on way home from work.

Vs.

Leave your home and job for 1 week.
Travel to Rochester, MN.
Get a hotel for this week.
Consult, sim, and receive three fractions of proton radiation at Mayo during that week.
Travel home.
Esophagitis manifests, ribs break.

Cost to patient? Higher
Cost to health care system? Higher.
Convenience? Worse.
Toxicity? Likely worse.
Oncologic outcomes? Non-inferior, probably.

This is the goal. This is the grift. There is no moral high ground to stand on.
Click to expand...

If anything it gives MOs in those rural communities more incentive to omit RT and just use an AI.
 
elementaryschooleconomics said:
View attachment 353405

Thanks, eviCore!
Click to expand...
It's an OK point Evicore is making but it loses a little nuance. Like in prostate especially.

If you read the first sentence of the Danish HYPO trial that came out in JCO in 2020 for hypofx in DCIS, you almost do a double-take...

"Given the poor results using hypofractionated radiotherapy for early breast cancer, a dose of 50 Gy in 25 fractions (fr) has been the standard regimen used by the Danish Breast Cancer Group (DBCG) since 1982."

They go on to explain that the late effects of 36 Gy in 12 fx for breast cancer in the 1970s was HUGE. Since 36/12 on paper using LQ has pretty much the same late effects as 40/15, clearly we just simply do a much better job of simulating and tracking doses (and higher energy beams too I bet) nowadays than we did in the 1970s. Although in START 39/13 was associated with a little bit higher brachial plexus side effect rate versus the other regimens IIRC.
 
I’ve always said that using Mayo AZ as an example is not going to win over most people, except those that are hardened in stance. They teach well. They have good tech including protons. People pass their boards. Residents are very happy there. They are getting jobs.

I already know what @medgator will say: “but they have no reason to exist”. Maybe? Phoenix is a top 5 metro area - they shouldn’t have a program at all? If you’re going to compare the two AZ programs… well, I’ll leave that to others.

Mayo AZ is not the problem. If every program was like them - providing good training, limiting their numbers, making sure grads get good jobs, etc - then we wouldn’t be in this situation. They can train more but choose not to. That’s what a lot of other places should have done. A huge part of growth is expansion of programs vs new programs.

Keole’s one of the good guys. He’s not signaling. He’s stating facts. Niska who wrote that paper is a friend and Mayo AZ well aware of problems in our field. Mayo AZ is not Mayo MN. This isn’t like MDACC network sites - they have more independence.

But if ya wanna continue dogging Mayo AZ, go for it. There are probably 20 programs with a longer history that should be eliminated before them. History alone is not a reason to exist. Just like being new isn’t reason enough to shutdown. UTSW way newer than half the ****ty NY programs and so many other terrible programs, but they do good work and train good residents and do good research. But because they are new, they shouldn’t exist, but Loyola, Allegheny, Case, Wayne state, Minnesota, etc all should? This isn’t a winning argument. Quality is what we should look at, not longevity. It’s almost harder to get rid of a bad residency than a Boomer radonc!
 
RealSimulD said:
I’ve always said that using Mayo AZ as an example is not going to win over most people, except those that are hardened in stance. They teach well. They have good tech including protons. People pass their boards. Residents are very happy there. They are getting jobs.

I already know what @medgator will say: “but they have no reason to exist”. Maybe? Phoenix is a top 5 metro area - they shouldn’t have a program at all? If you’re going to compare the two AZ programs… well, I’ll leave that to others.

Mayo AZ is not the problem. If every program was like them - providing good training, limiting their numbers, making sure grads get good jobs, etc - then we wouldn’t be in this situation. They can train more but choose not to. That’s what a lot of other places should have done. A huge part of growth is expansion of programs vs new programs.

Keole’s one of the good guys. He’s not signaling. He’s stating facts. Niska who wrote that paper is a friend and Mayo AZ well aware of problems in our field. Mayo AZ is not Mayo MN. This isn’t like MDACC network sites - they have more independence.

But if ya wanna continue dogging Mayo AZ, go for it. There are probably 20 programs with a longer history that should be eliminated before them. History alone is not a reason to exist. Just like being new isn’t reason enough to shutdown. UTSW way newer than half the ****ty NY programs and so many other terrible programs, but they do good work and train good residents and do good research. But because they are new, they shouldn’t exist, but Loyola, Allegheny, Case, Wayne state, Minnesota, etc all should? This isn’t a winning argument. Quality is what we should look at, not longevity. It’s almost harder to get rid of a bad residency than a Boomer radonc!
Click to expand...
Last i checked, mayo az wasn't the only satellite program they had? Sounds like jax was doing fine with uf alone before Mayo metastasized a program there. Let's not forget that Mayo and CCF both went to 3 a year the last decade as well while all of this was happening.

Having a great program doesn't mean you have a necessary one
 
Last edited:
I've done 26/5 on some older patients (where I didn't think appropriate for APBI for whatever reason). I haven't done a standard frac whole breast in a decade+.

But as mentioned, are we SURE cosmesis for 26/5 is equivalent to 40-42/15-16? 27 Gy in 5 was worse on the trial. Is 1 Gy magically OK?

No way I'm giving 5 fractions at this point to a (especially younger) patient that expresses cosmesis concerns.
 
BobbyHeenan said:
I've done 26/5 on some older patients (where I didn't think appropriate for APBI for whatever reason). I haven't done a standard frac whole breast in a decade+.

But as mentioned, are we SURE cosmesis for 26/5 is equivalent to 40-42/15-16? 27 Gy in 5 was worse on the trial. Is 1 Gy magically OK?

No way I'm giving 5 fractions at this point to a (especially younger) patient that expresses cosmesis concerns.
Click to expand...
Me either! Whole breast gets you 15-20
 
I’m sure Mayo AZ is a perfectly great place to do residency. But just about everyone makes the same argument regarding their program as well, even the so called “hell pit” places. At least the opening of new programs and rampant expansion has mostly stopped. But not sure how anybody really contracts or shuts down moving forward.
 
fiji128 said:
I’m sure Mayo AZ is a perfectly great place to do residency. But just about everyone makes the same argument regarding their program as well, even the so called “hell pit” places. At least the opening of new programs and rampant expansion has mostly stopped. But not sure how anybody really contracts or shuts down moving forward.
Click to expand...

They all have to cut 1 spot. You get to keep your program but you're cutting back.
 
Mandelin Rain said:
Three weeks of 15 minute treatment on way home from work.

Vs.

Leave your home and job for 1 week.
Travel to Rochester, MN.
Get a hotel for this week.
Consult, sim, and receive three fractions of proton radiation at Mayo during that week.
Travel home.
Esophagitis manifests, ribs break.

Cost to patient? Higher
Cost to health care system? Higher.
Convenience? Worse.
Toxicity? Likely worse.
Oncologic outcomes? Non-inferior, probably.

Shorter does not equate to cost savings or convenience or better in all cases.

This is the goal. This is the grift. There is no moral high ground to stand on.
Click to expand...
Patients don't pay for their own care. So they're out of luck. They're gonna go where their insurance co or medicare, etc tell them. Treated an honest to goodness billionaire a few years back. The only reason was the insurance refused to pay for protons.
 
Lock her up… I mean cut them all! Hell, take some jobs away starting with the same jobs we see advertised every single year.. I see you Witchita and Marshfield!
 
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