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RickyScott said:
Because surgeons like to cut, especially in large systems. Nowhere in oncology, is the role of surgery more dubious than bladder cancer, yet it is still the treatment of choice, despite grotesque consequences.
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Unlike gu, CT surgeons aren't making the diagnosis typically... Usually pulmonary
 
TheWallnerus said:
Three factors at work that have rad onc implications.

First, the immunotherapy. More willingness to do chemo/IO then surgery; and RT is pretty much out in postop Stage III.

Second, smoking is declining; less lung cancer.

Third, screening; rapidly declining incidence of Stage III. This means a significantly declining number of lung cancer patients under beam.

The triple hit hypothesis.
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First point… We can rehash PORT, but truth is, that was never a huge percentage of lung volume anyway.

Second point… sadly, I suspect smoking is on the rise

Third point, stage I is all upside for rad onc. Who’s gonna want a surgery if SBRT + IO gets the job done WITHOUT getting cut open? At my large academic center, my groups volume is going up and T surg is going down.

Edit. Smoking is on the rise, since Covid
 
Smoking related lung cancer typically occurr in the mid to late 60s. The decrease of smoking in 1970s and 80s Is being seen in present data.
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CurbYourExpectations said:
Wonder how it is affected by people that are now vaping and smoking more marijuana.

Vaping statistics 2022​

1 in 20 Americans vape, according to vaping statistics, and youth e-cigarette use has increased by 1,800%
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Would assume vaping and smoking have very strong overlap, but have no idea.
 
Lamount said:
First point… We can rehash PORT, but truth is, that was never a huge percentage of lung volume anyway.

Second point… sadly, I suspect smoking is on the rise

Third point, stage I is all upside for rad onc. Who’s gonna want a surgery if SBRT + IO gets the job done WITHOUT getting cut open? At my large academic center, my groups volume is going up and T surg is going down.

Edit. Smoking is on the rise, since Covid
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I've always said i think some of those on this board have low balled how much early stage lung SBRT we do and how much that indication has grown over the last 5-7 years with the advent of LDCT screening
 
I worry about how many IIIA lungs will be called "resectable" up front and get months of immunotherapy only for progression or some other problem to arise and surgery isn't possible, thus potentially missing curative window and/or complicating radiation.
Even if CT surgery isn't trying to steal all of those patients, the medoncs will gladly start them on IO first and send them to CT surgery cutting us out of the loop entirely. I don't see many "resectable" patients but this situation worries me more than rectal cancer.

Also from a selfish logistics standpoint, it's already annoying enough seeing all the preop breast patients regardless of whether they get radiation or not and keeping track of them for months while they get chemo, let's throw lungs on that list too.
 
Lamount said:
First point… We can rehash PORT, but truth is, that was never a huge percentage of lung volume anyway.

Second point… sadly, I suspect smoking is on the rise

Third point, stage I is all upside for rad onc. Who’s gonna want a surgery if SBRT + IO gets the job done WITHOUT getting cut open? At my large academic center, my groups volume is going up and T surg is going down.

Edit. Smoking is on the rise, since Covid
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One of the problems of being a one trick pony, is the fact that you actually only have one trick. Everyone gets unlimited shots on goal until you are knocked out.(or tied, in which case you still loose) There are other ways of treating stage I nsclc and I will be shocked if nav bronchial microwave ablation is not eating into our stage I cases by the end of the decade. As a bonus, the thoracic surgeons and interventional pulmonologists will get paid.
www.fda.gov

Study Design Considerations for Transbronchoscopic Thermal Ablation

Virtual Public Workshop – Study Design Considerations for Transbronchoscopic Thermal Ablation Devices for the Treatment of Oligometastases to the Lung
www.fda.gov www.fda.gov
www.medicaldesignandoutsourcing.com

Medtronic releases Navablate study results for bronchoscopic microwave ablation

Medtronic said it will keep researching the safety and efficacy of the Emprint ablation catheter kit under an upcoming FDA investigational device exemption study.
www.medicaldesignandoutsourcing.com www.medicaldesignandoutsourcing.com
 
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RickyScott said:
One of the problems of being a one trick pony, is the fact that you actually only have one trick. Everyone gets unlimited shots on goal until you are knocked out.(or tied, in which case you still loose) There are other ways of treating stage I nsclc and I will be shocked if nav bronchial microwave ablation is not eating into our stage I cases by the end of the decade. As a bonus, the thoracic surgeons and interventional pulmonologists will get paid.
www.fda.gov

Study Design Considerations for Transbronchoscopic Thermal Ablation

Virtual Public Workshop – Study Design Considerations for Transbronchoscopic Thermal Ablation Devices for the Treatment of Oligometastases to the Lung
www.fda.gov www.fda.gov
www.medicaldesignandoutsourcing.com

Medtronic releases Navablate study results for bronchoscopic microwave ablation

Medtronic said it will keep researching the safety and efficacy of the Emprint ablation catheter kit under an upcoming FDA investigational device exemption study.
www.medicaldesignandoutsourcing.com www.medicaldesignandoutsourcing.com
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…again, how many lung tumors do you think are accessible by nav bronch that don’t have a vessel nearby that would function as a heat sink? Not to mention the fact that LC is not so hot with ablation.

It’s hard to beat SBRT for efficacy and how drama-free it is
 
medgator said:
I've always said i think some of those on this board have low balled how much early stage lung SBRT we do and how much that indication has grown over the last 5-7 years with the advent of LDCT screening
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Subjectively speaking, Stage I SABR has exploded. Stage IIi chemoRT has imploded. Stage III patients reimburse higher than stage I and utilize about 6 times as much linac time. The explosion and implosion are about equal in patient number intensity though. So rad onc is getting reimbursed less for lung cancer care, and the whole of rad oncs are working quite a bit less on treating lung cancer (the oversupply and dilution of labor force makes up a lot of this too).
 
Lamount said:
…again, how many lung tumors do you think are accessible by nav bronch that don’t have a vessel nearby that would function as a heat sink? Not to mention the fact that LC is not so hot with ablation.

It’s hard to beat SBRT for efficacy and how drama-free it is
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I am playing devils advocate, but I would say over half my primary stage I sbrt pts are apical or peripheral, often ggo s w/small solid component that are amenable. I have seen how this plays out in the liver, where xrt is also drama and pain free. (And probably more effective). Also let’s not rule out future tech, like a purple pulsating lasers w/photactivating pigment.

I used to treat a lot of these without path, but even in pts with the worst pfts, our Ct surgeons now get to almost everything with a nav bronch and usually drop a fiducial (which I don’t ask for). If you can get a Catheter there, possibilities are endless of for what you can do to the lesion- cold, heat, pdt, destructive us
 
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Lamount said:
…again, how many lung tumors do you think are accessible by nav bronch that don’t have a vessel nearby that would function as a heat sink? Not to mention the fact that LC is not so hot with ablation.

It’s hard to beat SBRT for efficacy and how drama-free it is
Click to expand...

Look at what they did to liver tumors…somehow the drama free Sbrt became the treatment of last choice even in the most chip shot of cases. We stopped going to liver tumor board because it was a waste of time.
 
RadsWFA1900 said:
Look at what they did to liver tumors…somehow the drama free Sbrt became the treatment of last choice even in the most chip shot of cases. We stopped going to liver tumor board because it was a waste of time.
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Really sad

I see rad oncs on twitter explaining why CONKO was not really a negative trial

In politics they say “if you’re explaining you’re losing”
 
RickyScott said:
Ok, but within 10-15 yrs, radiation will disappear from rectal cancer. Presently, we don’t have any good evidence that neoadjuvant chemorads has any benefit over folfox alone. It’s hanging on by a thread (w a less than 5% absolute benefit in local control), that the next active systemic agent will cut.
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I’ve seen this posted multiple times. I’m not doubting you, but are there any studies that have looked at pCr/LC with FOLFOX alone or compared chemo vs chemoRT?
 
Lamount said:
…again, how many lung tumors do you think are accessible by nav bronch that don’t have a vessel nearby that would function as a heat sink? Not to mention the fact that LC is not so hot with ablation.

It’s hard to beat SBRT for efficacy and how drama-free it is
Click to expand...
I think an APM can really help our field defend against these IR interventions for ablative treatment (bone Mets, NSCLC). Single fraction palliative RT and sbrt have pretty good data and diminish the value proposition of IR ablation. Just need to incentivize it
 
RadsWFA1900 said:
Look at what they did to liver tumors…somehow the drama free Sbrt became the treatment of last choice even in the most chip shot of cases. We stopped going to liver tumor board because it was a waste of time.
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Liver is weird. From what I can tell, IR runs the show there. For lung, SBRT has always been a close second to surgery for ES-NSCLC in the few institutions I have worked at… and the leading modality for mets.

If a trial like VALOR confirms resection is better, the status quo would remain… but if there is even a whiff of equivalency, referrals will go up.

Like I said, all upside for SBRT in lung
 
Lamount said:
Liver is weird. From what I can tell, IR runs the show there. For lung, SBRT has always been a close second to surgery for ES-NSCLC in the few institutions I have worked at… and the leading modality for mets.

If a trial like VALOR confirms resection is better, the status quo would remain… but if there is even a whiff of equivalency, referrals will go up.

Like I said, all upside for SBRT in lung
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If we had anything remotely similar with liver, I might consider going back to the tumor board.
 
RadsWFA1900 said:
Look at what they did to liver tumors…somehow the drama free Sbrt became the treatment of last choice even in the most chip shot of cases. We stopped going to liver tumor board because it was a waste of time.
Click to expand...

Yes. IR takes most of the easier liver mets cases in my neck of the woods.

The existential threat to early stage inoperable lung cancer is the robotic bronch with on board CBCT. That thing in well trained hands is crazy good at getting needles in crazy places. Remember it would be a pulmonologist treating the patient, not IR in that situation if they can get an ablative instrument in that bronch. Then you're dealing with something that looks much closer to urology (diagnose and treat in one shop) than IR.
 
BobbyHeenan said:
Yes. IR takes most of the easier liver mets cases in my neck of the woods.

The existential threat to early stage inoperable lung cancer is the robotic bronch with on board CBCT. That thing in well trained hands is crazy good at getting needles in crazy places. Remember it would be a pulmonologist treating the patient, not IR in that situation if they can get an ablative instrument in that bronch. Then you're dealing with something that looks much closer to urology (diagnose and treat in one shop) than IR.
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The pulmonologists in our neck of the woods got very excited about being able to "diagnose and treat" lung cancer all at once. When I pointed out that the rates of control with their modality were inferior to ours, I was dismissed because I was a radonc.

Fortunately, the medoncs were not dismissive of the idea and have pushed back effectively. IMO bronchoscopic ablation has such a high rate of recurrence (20-40%), I would treat with SBRT after the procedure to give a better chance to actually cure the patient.
 
OTN said:
The pulmonologists in our neck of the woods got very excited about being able to "diagnose and treat" lung cancer all at once. When I pointed out that the rates of control with their modality were inferior to ours, I was dismissed because I was a radonc.

Fortunately, the medoncs were not dismissive of the idea and have pushed back effectively. IMO bronchoscopic ablation has such a high rate of recurrence (20-40%), I would treat with SBRT after the procedure to give a better chance to actually cure the patient.
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But but IR may be able to cure them and spare them bad radiation!

I love how it’s become now not what treatment is effective but having patients pass through multiple specialties to try their hand at curing them even if it’s more invasive and less efficacious first.
 
CurbYourExpectations said:
How long does it take to conclude a workforce analysis?

And are you guys betting the over or under of 140 a year?
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If ASTROs known agenda is any indication, the conclusions and course of action have already been written. The most you’ll get out of them is “yes but it’s not that bad and we can’t do anything about it anyway…”

You also have to consider that they’re assumptions will probably be faulty and won’t account for losing or becoming more of a footnote in major disease sites in the near future.
 
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TheWallnerus said:
Many prominent thoracic oncologists cite this (20-40%) as the SBRT recurrence rate too though. Not saying I agree, just saying: this is the battleground.

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They're including regional and distant recurrence.

My answer to that is to enroll our patients on the RCT investigating the addition of immunotherapy to SBRT for Stage I
 
RadOncDoc21 said:
I swear you were an administrator in a former life!
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Medicine taught me pattern recognition, and I just choose to apply that to everything else in life.

I can diagnose an RN who turned into a middle manager in a 150 bed hospital in less than 45 seconds!
 
elementaryschooleconomics said:
Pink horizontal line is my addition, actual headline: MSKCC receives significantly more reimbursement per procedure than other NYC hospitals.
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Great work. The authors may also be making the assumption that the "charge" on the charge master list or wherever they are getting it represents what someone without insurance will pay.

This is almost certainly false, with the charge representing roughly the highest amount that they might collect from a favorable payor. Typically, those without insurance pay less for services than those with Medicare and often somewhat comparable to Medicaid. Those without insurance and a new cancer diagnosis will often go through an expedited process to get disability based on diagnosis and then establish some sort of coverage based on this status.

They should take a sample of uninsured patients (let MSKCC find some in their system) and find out where these folks are getting care and how much they are paying.

The authors know full well that the lowest charge for Pembro from any center far exceeds affordability for anyone without insurance other than the filthy rich.
 
communitydoc13 said:
Great work. The authors may also be making the assumption that the "charge" on the charge master list or wherever they are getting it represents what someone without insurance will pay.

This is almost certainly false, with the charge representing roughly the highest amount that they might collect from a favorable payor. Typically, those without insurance pay less for services than those with Medicare and often somewhat comparable to Medicaid. Those without insurance and a new cancer diagnosis will often go through an expedited process to get disability based on diagnosis and then establish some sort of coverage based on this status.

They should take a sample of uninsured patients (let MSKCC find some in their system) and find out where these folks are getting care and how much they are paying.

The authors know full well that the lowest charge for Pembro from any center far exceeds affordability for anyone without insurance other than the filthy rich.
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There are charges.
There is what payors pay.
There is what patients pay.

None of these three things link up in any discernable or logical way. It's a bit of a wonder that healthcare gets delivered at all.
 
communitydoc13 said:
Great work. The authors may also be making the assumption that the "charge" on the charge master list or wherever they are getting it represents what someone without insurance will pay.

This is almost certainly false, with the charge representing roughly the highest amount that they might collect from a favorable payor. Typically, those without insurance pay less for services than those with Medicare and often somewhat comparable to Medicaid. Those without insurance and a new cancer diagnosis will often go through an expedited process to get disability based on diagnosis and then establish some sort of coverage based on this status.

They should take a sample of uninsured patients (let MSKCC find some in their system) and find out where these folks are getting care and how much they are paying.

The authors know full well that the lowest charge for Pembro from any center far exceeds affordability for anyone without insurance other than the filthy rich.
Click to expand...
In the end, I'm very pleased to see this work is being done and presented. I obviously think the notable headlines from the data are different than the author's. My jokes aren't motivated by derision, but rather because I know people don't understand the nuance of charges...while everyone understands hotdogs.

Having these conversations are very important, and @communitydoc13 nailed it with how complicated this is and what is likely actually happening behind the scenes.

Somehow, and I'm not sure how, but somehow I want all this financial stuff to result in the MBAs being booted out of healthcare. I can dream, right?
 
I dont think the highest charge represents what the most favorable payor is willing to pay. I think it is there for when some plans negotiate global 20-30% reimbursement. In terms of the lowest charge, I am not sure hospital are allowed to charge less than medicare.
 
TheWallnerus said:
Pancreatic RT gettin' a bit dragged

r0G9yVz.png
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Are these medoncs or radoncs? If they’re medoncs, then I’d take it with a grain of salt. They have an agenda against RT in pretty much every disease site these days and it’s gotten old.

Radonc does enough to kill their own indications so medoncs jumping in on treatments they know nothing about warrants one of those “🤫 the adults are talking.”

I had a patient present to me the other day with a locally advanced low-grade NHL with essentially no airway and stridor. I started steroids got RT planned for 2 x 2 treatment and the medonc stepped in and cancelled it saying the RT would cause her extreme dysphagia and odynophagia.
 
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thesauce said:
Are these medoncs or radoncs? If they’re medoncs, then I’d take it with a grain of salt. They have an agenda against RT in pretty much every disease site these days and it’s gotten old.
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I am sorry, but as radiation oncologists we have done a terrible job when it comes to clinical research in the field of pancreatic cancer.
Most of the trial we conducted were negative for RT in any setting of the disease and poorly designed.
It's not hard for med oncs to hit on us when it comes to pancreatic cancer.
 
Palex80 said:
I am sorry, but as radiation oncologists we have done a terrible job when it comes to clinical research in the field of pancreatic cancer.
Most of the trial we conducted were negative for RT in any setting of the disease and poorly designed.
It's not hard for med oncs to hit on us when it comes to pancreatic cancer.
Click to expand...
As radiation oncologists we have done a terrible job when it comes to clinical research of anything outside of prostate, some breast, Timmerman's work, and cardio-ablation. Everything else is trash-tier.
 
thesauce said:
Are these medoncs or radoncs? If they’re medoncs, then I’d take it with a grain of salt. They have an agenda against RT in pretty much every disease site these days and it’s gotten old.

Radonc does enough to kill their own indications that medonc jumping in on treatments they know nothing about warrants one of those “🤫 the adults are talking.”

I had a patient present to me the other day with a locally advanced low-grade NHL with essentially no airway and stridor. I started steroids got RT planned for 2 x 2 treatment and the medonc stepped in and cancelled it saying the RT would cause her extreme dysphagia and odynophagia.
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The concluding slide of the talk: "until we have better systemic control of PDAC, RT is unlikely to be enough to drive an OS benefit."


1654612279949.png
 
OTN said:
As radiation oncologists we have done a terrible job when it comes to clinical research of anything outside of prostate, some breast, Timmerman's work, and cardio-ablation. Everything else is trash-tier.
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I wouldn't have put cardio-ablation on the top four.
 
OTN said:
As radiation oncologists we have done a terrible job when it comes to clinical research of anything outside of prostate, some breast, Timmerman's work, and cardio-ablation. Everything else is trash-tier.
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Generally, hard to argue with you. Although now quite in the rearview of the present, her body of work in asking important (seminoma) RT questions I think was pretty stellar:

OUH - Staff

Research pages of Long Term Studies
www.ous-research.no
 
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