Rad Onc Twitter

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jondunn said:
Well the dose utilized is not a GBM Dose, and I haven’t seen many of these but the dose is typically 54 gy, so I would let it get that and minimize hot spots as much as possible, ultimately allowing a max of 55-56
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Boomer does not allow 55-56 Gy to optic nerve.
 
I mean in terms of OS it’s decently likely that the VALOR trial will show equivalence. Worse local control yes.
seper said:
Radiation is as good as lung surgery? Such a hopeless stand to die for
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Ray D. Ayshun said:
For small peripheral t1s maybe. Segmentectomy had better os, presumably bc more lung removed is worse. Segmentectomy had lr on par with sbrt, and sbrt is even less surgery. The thoracic surgeon on Twitter suggested surgery is superior given the ability to stage better, which is why I wonder how many of these patients (tiny peripheral tumors), properly staged, had n+ disease. Typically, if the pets negative in this population, it's an extremely high npv, ~95%, generally obviating the need for bronch. Is it hard to think that even better imaging, if that's even necessary, could obviate the need for surgery in this population?
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Important point about the Japanese Lobectomy vs. Segmentectomy trial: staging was CT-based not PET-CT-based.
 
Palex80 said:
Important point about the Japanese Lobectomy vs. Segmentectomy trial: staging was CT-based not PET-CT-based.
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Guess I wouldn't expect that to lead to a difference in surgical outcomes. Otoh, this seems like the ideal population for sbrt to be the first line treatment. I always discuss surgery as soc, but this population probably will never see thoracic surgery in my zip code, and I don't feel guilty.
 
Ray D. Ayshun said:
For small peripheral t1s maybe. Segmentectomy had better os, presumably bc more lung removed is worse. Segmentectomy had lr on par with sbrt, and sbrt is even less surgery. The thoracic surgeon on Twitter suggested surgery is superior given the ability to stage better, which is why I wonder how many of these patients (tiny peripheral tumors), properly staged, had n+ disease. Typically, if the pets negative in this population, it's an extremely high npv, ~95%, generally obviating the need for bronch. Is it hard to think that even better imaging, if that's even necessary, could obviate the need for surgery in this population?
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6% node positive, ~3% pN1 and ~3% pN2, fairly equal in both arms (pN1/pN2 rates of 2.9/2.7 in Lobectomy, 3.1/3.1 in Segmentectomy arms respectively)
 
madchemist89 said:
If Valor shows sbrt equivalent, it will be a big win for rad onc.
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Isn’t valor designed as a superiority trial (hypothesis is SBRT is superior to surgery)? If equivalent numerically, high profile journal might force them to conclude that surgery remains SOC. Hasn’t stopped NEJM to let med oncs publish chemo acceptably inferior, but we know they hate radiation.
 
madchemist89 said:
If Valor shows sbrt equivalent, it will be a big win for rad onc.
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Win-ish…
SBRT utilization has gone up a lot last 10y and grown as high as 30% in Stage I; rad onc has been winning handily in treating historically untreated patients (older, poor PS, etc), and screening seems to be working in rad onc’s instead of surgery’s favor. Stage I numbers are going up, but Stage III has gone down almost just as much. RT utilization in Stage III is historically in the 75-80% range; we definitely had won there. There is a significant difference in “radiotherapy work,” and reimbursement, between Stage III and I. Even if SBRT utilization in Stage I could get to 90%, the Heyday of Lung (pts under beam, reimbursement, number of rad oncs needed) is in rad onc’s past. Who will REALLY win are lung RT patients because they as a group will be (and already are) doing much better medically/QOL than patients of the past.
 
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TheWallnerus said:
Win-ish…
SBRT utilization has gone up a lot last 10y and grown as high as 30% in Stage I; rad onc has been winning handily in treating historically untreated patients (older, poor PS, etc), and screening seems to be working in rad onc’s instead of surgery’s favor. Stage I numbers are going up, but Stage III has gone down almost just as much. RT utilization in Stage III is historically in the 75-80% range; we definitely had won there. There is a significant difference in “radiotherapy work,” and reimbursement, between Stage III and I. Even if SBRT utilization in Stage I could get to 90%, the Heyday of Lung (pts under beam, reimbursement, number of rad oncs needed) are in rad onc’s past. Who will REALLY win are lung RT patients because they as a group will be (and already are) doing much better medically/QOL than patients of the past.
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I feel like i see a more IIIs as well thanks to CT screening... Who knows
 
Ray D. Ayshun said:
For small peripheral t1s maybe. Segmentectomy had better os, presumably bc more lung removed is worse. Segmentectomy had lr on par with sbrt, and sbrt is even less surgery. The thoracic surgeon on Twitter suggested surgery is superior given the ability to stage better, which is why I wonder how many of these patients (tiny peripheral tumors), properly staged, had n+ disease. Typically, if the pets negative in this population, it's an extremely high npv, ~95%, generally obviating the need for bronch. Is it hard to think that even better imaging, if that's even necessary, could obviate the need for surgery in this population?
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I would guess NPV for nodes of a negative PET is <80%
 
medgator said:
I feel like i see a more IIIs as well thanks to CT screening... Who knows
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Stage III in terms of its incidence within the lung arena, and also just in terms of raw numbers, falling nationwide. Stage I is now the predominant stage in the better educated, higher socioeconomic ZIPs eg.
 
Ray D. Ayshun said:
Guess I wouldn't expect that to lead to a difference in surgical outcomes. Otoh, this seems like the ideal population for sbrt to be the first line treatment. I always discuss surgery as soc, but this population probably will never see thoracic surgery in my zip code, and I don't feel guilty.
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Actually this may even make the survival benefit seem smaller.
Patients with Stage IIIA or IIA/B were still in the trial and had a higher risk to die from cancer, thus any excessive mortality due to the lobectomy (as the authors hypothesize) may become less of an issue if patients die from cancer.
You cannot die from the long-term toxicity of non-parenchyma-sparing surgery if you die from lung cancer.

CaesarRO said:
6% node positive, ~3% pN1 and ~3% pN2, fairly equal in both arms (pN1/pN2 rates of 2.9/2.7 in Lobectomy, 3.1/3.1 in Segmentectomy arms respectively)
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And these numbers would have been lower, had these patients been staged with PET-CT.
 
jondunn said:
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Umm.

D96C766B-405B-4318-8F16-9CE0500DEDED.png
 
jondunn said:
so this guy works for United Health Care, because they own the NY Proton center?

so they must not have issues with getting coverage. they will proton your lymphoma boom boom.
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Gotta spare the bone marrow in those stage IV NHLs... Oh wait...
 
Now that terms have been finalized for Elon Musk to buy-out Twitter - it will be very interesting to see what, if any, changes are on the horizon. It sounds like he is going to try and purge bots and have less restricted speech.
 
medgator said:
Do you have an agenda against this guy or something? consistently picking on him dude, seems like more than just a policy difference.
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I don’t like their shameless use of proton.

They make Steve Frank look like Ralph when it comes to proton

Sorry if that offends Simul.

NYPC is not your friend.

Point taken, I in no way mean to pick on this guy at all, it’s his institution
 
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jondunn said:
I don’t like their shameless use of proton.

They make Steve Frank look like Ralph when it comes to proton

Sorry if that offends Simul.
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Fair enough, and not asking in an antagonistic way, but how do you think a place that is called the New York Proton Center is going to act?

Yes, he is a friend, and yes he is very pro- protons, but has it ever been under the pretenses of the other large institutions who claim that they are doing research and counting registry trials as such? I’d rather it be open and honest, than pretending to be scientific about it.

On the other hand you have Dr Lee at Sloan saying they are going to use protons in spite of negative trials. So, idk. You can pick on SH if you want, but he’s not even close to the root, and it seems (though I’ll give you the benefit of the doubt) particularly mean spirited to pick on someone who is a few years out of training just doing his job vs all the chairman out there.
 
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Nancy ‘we will use proton even if the trials are negative’ Lee practically lives there, so I don’t think that is true.

But whatever. Proton is another argument that will never
Die.
 
And it’s rich to see medgator aka the guy who attacks Med students on Twitter, clutch his pearls about an anti-proton post. What’s next, defending hallahan?

Lmao.
 
Gfunk6 said:
Now that terms have been finalized for Elon Musk to buy-out Twitter - it will be very interesting to see what, if any, changes are on the horizon. It sounds like he is going to try and purge bots and have less restricted speech.
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Healthy cancel culture already getting started as a welcome mat I'm guessing

www.cnet.com

Twitter Bans Climate Change Denial Ads

Twitter announces that it will prohibit advertisements that contradict the scientific consensus on climate change.
www.cnet.com www.cnet.com
 
I still don't follow the logic for what people think Hallahan is saying. The implication is that he thinks faculty salaries are too high so he is going to open more residency spots to drive down academic salaries? Which would take minimum 5+ years and actually didn't even work?

The most likely interpretation is that he incorrectly thought there was a true shortage of rad oncs in 2013 (with chairs having their head in the sand etc) and that they are well justified to increase their residency slots. To prove his point further that they are justified in increasing residency slots, he says the salaries are going up so there must be a true shortage. He was trying to say then about rad onc what people are saying about psych now - salaries going up because there is an increased need and shortage of mental health practitioners. Nobody is saying psych should be paid less when they talk about increasing mental health workforce. Now he was obviously completely wrong, but saying he wanted to increase residency slots to pay people less is a stretch

Hanlon's razor: Never attribute to malice that which is adequately explained by stupidity
 
radiation said:
I still don't follow the logic for what people think Hallahan is saying. The implication is that he thinks faculty salaries are too high so he is going to open more residency spots to drive down academic salaries? Which would take minimum 5+ years and actually didn't even work?
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It's pretty clear what he said. Moreover he cited zero data if that's what he was truly thinking.

No need to go all KO on us.
 
radiation said:
I still don't follow the logic for what people think Hallahan is saying. The implication is that he thinks faculty salaries are too high so he is going to open more residency spots to drive down academic salaries? Which would take minimum 5+ years and actually didn't even work?

The most likely interpretation is that he incorrectly thought there was a true shortage of rad oncs in 2013 (with chairs having their head in the sand etc) and that they are well justified to increase their residency slots. To prove his point further that they are justified in increasing residency slots, he says the salaries are going up so there must be a true shortage. He was trying to say then about rad onc what people are saying about psych now - salaries going up because there is an increased need and shortage of mental health practitioners. Nobody is saying psych should be paid less when they talk about increasing mental health workforce. Now he was obviously completely wrong, but saying he wanted to increase residency slots to pay people less is a stretch

Hanlon's razor: Never attribute to malice that which is adequately explained by stupidity
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When I was interviewing for residency with Dennis, he said “We do not make private practice rad oncs here. We expect everyone to go into academics.” His ulterior motives are pretty transparent imho. Of course at that time time he was blabbering on about he had a patent on a molecule that did this and a patent on a molecule that did that. All of it seemed to really pan out! JK. If you can’t make money off molecules that revolutionize RT, you can make money by underpaying your physicians.
 
elementaryschooleconomics said:
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Several things to unpack here, but two immediately leap to mind:

1) I'm not sure what the abbreviation "HD" stands for. Does he mean HDR brachy? Am I just being dense? Regardless, while it's good (perhaps necessary) to be exposed to the uncommon cases and procedure-based treatments, I think we're past the point where we can stop pretending like doing a couple T&O (+/- interstitial) cases over the entire course of residency makes it OK for you to go out into the world and do it independently. For the uncommon-to-rare/high risk treatments requiring a level of procedural skill (so, most brachy that isn't skin or cylinder), we should be moving towards ACGME-accredited fellowships with separate board certification. Pediatrics should go that way as well. However, I have read papers in the Red Journal from literally 40 years ago calling for the exact same thing, and clearly nothing happened...so I guess we can continue pretending. Because "doing" 8 instead of 6 cervix cases over 4 years was definitely the missing link.

2) As always...you don't get to throw your opinion out into the universe on a public platform and request discourse only from certain individuals. That's not how any of this works. Because, to flesh out Ken's last Tweet:

"Here I am as faculty at a well-known institution with opinions on the classic/traditional side of academic RadOnc, on a platform (Twitter) with a razor-thin edge for any sort of debate devolving into chaos, and I am only going to engage with people who are not anonymous, knowing full well that dissenting opinions from traditional RadOnc on Twitter (or elsewhere) carries high personal/career risk for the person(s) dissenting, as this is a very small field where everyone knows everyone and it's very easy to blacklist people from seeking employment in an entire geographic region".

I don't think many of us are willing to openly debate the Elder RadOnc Faction and risk White Knighting/Radical Candor/"plz don't cancel me miscreants" editorials/etc.

Elder RadOncs are going to do what they want on whatever timeline they want until they retire at age 82, and the rest of us are just left here to languish and hope medical students seek gainful employment elsewhere.
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HD is likely Hodgkin's Disease. Spoken like a true boomer. Not HL, but Hodgkin's DISEASE.

And Elder RadOncs are going to do whatever they want on whatever timeline they want until they retire at age 82, but more likely a fraction of them DIE AT THEIR DESKS. Bogardus (RIP) was just the first of note to go that way.
grenz said:
Then it would appear you two are spurned lovers of JD. He/she is clearly renting space in your head
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Not to be pedantic (well actually I guess I am) the phrase is "living rent-free in your head"
 
evilbooyaa said:
HD is likely Hodgkin's Disease. Spoken like a true boomer. Not HL, but Hodgkin's DISEASE.

And Elder RadOncs are going to do whatever they want on whatever timeline they want until they retire at age 82, but more likely a fraction of them DIE AT THEIR DESKS. Bogardus (RIP) was just the first of note to go that way.

Not to be pedantic (well actually I guess I am) the phrase is "living rent-free in your head"
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Senior academic RadOnc faculty appears to be the greatest job on the planet.

I'm sort of surprised to hear that about residents and Hodgkin's at Mayo. Yeah, the MedOncs seem to keep them as much as they can, and the majority of my lymphoma cases as a resident were DLBCL, but I still caught a stray Hodgkin's case here and there. I actually see more of them in community practice than I thought. I wonder if it's an academic thing? I bet my community MedOncs are more eager to use ISRT per NCCN than skip radiation altogether.
 
I don’t think I saw more than 1 HD in training, but I see more lymphoma in the community than I ever did in academic center for residency
 
evilbooyaa said:
HD is likely Hodgkin's Disease. Spoken like a true boomer. Not HL, but Hodgkin's DISEASE.

And Elder RadOncs are going to do whatever they want on whatever timeline they want until they retire at age 82, but more likely a fraction of them DIE AT THEIR DESKS. Bogardus (RIP) was just the first of note to go that way.

Not to be pedantic (well actually I guess I am) the phrase is "living rent-free in your head"
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Who says he’s paying for it?
 
95% of the lymphomas I see out in the world are follicular types; very few DLBCL and even fewer Hodgkin's

Pretty sure my medoncs are holding some out on me without my knowledge
 
jondunn said:
I don’t think I saw more than 1 HD in training, but I see more lymphoma in the community than I ever did in academic center for residency
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I think we had about one true stage I-II Hodgkin case come through our department per year and cases were always given to senior resident to log. Haven't seen one since except for heavily pretreated palliative stuff maybe. About as rare as those stage II pure seminomas.
 
Gah lymphoma drives me nuts. I get it, MedOnc, you only remember IFRT. I swear we do it better now. Stop blasting everyone with anthracyclines without thinking about our fancy, cutting-edge technology.

You know, everything that isn't a couple cerrobend blocks in between a patient and a wide-open linac. We can do a couple other things these days. We have computers!
 
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