Rad Onc Twitter

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metallica81788 said:
I think the days of hungry new grads going to upper Midwest for amazing salaries are done. The salaries are not amazing anymore and even the new grads don't want to tolerate living in those places for a few years. Maybe in the near future when they're having trouble getting A job but the money won't be there.
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I'm not sure any of these places ever paid the 800-900 they need to properly recruit. Instead they had independent rad oncs who billed on their owned (the other way that would be attractive), then they retired and they replaced with permalocums. Sooooooo many permalocums in rural midwest. Sucks for the patients. You have a field of new grads who matched during peak rad onc (ie, the elite crowd that would never be interested in rural) and hospitals that are only willing to pay 10-15% higher than major midwest metros without giving lifestyle concessions. Recipe for permalocums or perm hires that need visas (not many in rad onc unlike other fields).
 
jondunn said:
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I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
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I agree! But, yes you are preaching to the choir… I’ll see you again on Sunday!
 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
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It's going to be absolute no-brainer argument if I can consult the breast patient at 9 am, sim at 10, and complete the entire course of post-lumpectomy EBRT by noon.
 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
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YES!
Especially those I see after 5 fraction Livi.
We spend our time talking about AI side effects, not breast issues. Chasing hot flashes with SSRI's/gabapentin, adding more meds (Prolia) to strengthen bone, my joints hurt, etc.
It makes me think any rad onc running these omission trials does not have a busy breast clinic or does not see patients in follow up after a year on their AI. Seems impossible that would be the case but who knows?!?
 
Our posts are indexed by Google, so if we repeat ourselves enough, if a patient were to search for something like "omission of radiation breast cancer", then perhaps they will find 8,000 posts on SDN saying things like:

Modern radiation therapy for breast cancer is significantly easier, effective, and cost-effective than it was even 10 years ago, and significantly reduces the risk of local recurrence, and if you're of an age and health status where "omitting" something is being discussed, perhaps doing the treatment that's completed in a week with a benefit of a lifetime is much better than a daily pill for FIVE YEARS?

Talk to your doctor today!
 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
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It just comes down to who will see the patient first. This is one of many reasons that it is important that we play much more of an upfront role
 
BobbyHeenan said:
YES!
Especially those I see after 5 fraction Livi.
We spend our time talking about AI side effects, not breast issues. Chasing hot flashes with SSRI's/gabapentin, adding more meds (Prolia) to strengthen bone, my joints hurt, etc.
It makes me think any rad onc running these omission trials does not have a busy breast clinic or does not see patients in follow up after a year on their AI. Seems impossible that would be the case but who knows?!?
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I strongly suspect this is the case, spending as much time as I did in academia vs now in general practice.

I treat...a lot of breast. I spend more time counseling patients about endocrine therapy than radiotherapy. I can't tell you how many times patients express joyful surprise at how "easy" and "boring" radiation was.

Conversely, I personally know and worked closely with some of the people who are in charge of breast cancer recommendations/guidelines. I know with concrete, absolute certainty that breast cancer patients are discharged to MedOnc for long term follow-up by a lot (majority?) of the people calling the shots.
 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
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I think there would be close to 💯 % agreement among radoncs. To me, the real issue is the outrageous residency expansion in light of these entirely predictable developments in the face of multiple warnings on social media and in the red journal by the likes of shah and zeitman. Scarop still feels that sdn is a hotbed of unjustified concerns.
 
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"Yet with so much global brain power devoted to waging war on this scourge, there are signs that we are tantalisingly close to a cure for cancer — or some forms of it, at least."



 
elementaryschooleconomics said:
I know I'm preaching to the choir on this forum, but at least this way it will show up in a Google search:

For those of us who treat breast with any regularity, we can tell you that in 2022 (and beyond), radiation is an absolute breeze compared to FIVE YEARS of endocrine therapy. It's not even in the same universe.

If society is going to push for omission of one of the three components of breast-conserving therapy, it's a medicine you need to take for FIVE YEARS, not the treatment which, at worst, takes 3 weeks (15 treatments), can can often be done quicker (5 treatments).

I apologize in advance for how many times I repeat myself in the coming years.
Click to expand...
I am going to make a counterpoint here.
Although I fully agree that radiation is a lot more comfortable and less toxic than 5 (-10) years of antihormonal treatment, it‘s not so easy to state „If you are going to drop something, drop the antihormonal treatment.“

You need to:
A) Do the trials to prove that.
B) Bear in mind that RT and AHT have different effects. RT merely influences in-breast recurrence risk (and with PBI only in a part of that breast), while AHT also tackles DCIS in the contralateral breast as well as lowers the risk for regional/distant recurrence. Communication of these distinct goals is not that trivial and quantification of the associated benefits with each treatment still not well (because we have not done the proper trials) understood.
Many patients are not concerned about a local recurrence but rather systemic relapse or a second primary. These needs of the patients must be weighted carefully when thinking about how to deescalate treatment.

We still have a lot of work to do!
 
TheWallnerus said:
"Yet with so much global brain power devoted to waging war on this scourge, there are signs that we are tantalisingly close to a cure for cancer — or some forms of it, at least."



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Obviously a cure is hyperbole, but there is a steady march of progress w/each asco and that is certainly an existential threat to our job market. Radiation wont disappear but its footprint will be much smaller by asco 2030. I can see with better chemo/io combos and newer IO agents in the following scenarios. oustide ctla4 and PDL1, not many other immuno targets, but they will come!

chemo/io-> surgery for esophagus
2nd/3rd generation Chemo/io regimens as neoadjuvant treatment of choice in majority of stage III lung.
IO cutting down on brain met pts getting srt.
chemo/IO-if followed by a very good response- leading to a less radical surgery (wedge, in lung) simple hysterectomy in cervix, TURB in bladder.
 
Palex80 said:
I am going to make a counterpoint here.
Although I fully agree that radiation is a lot more comfortable and less toxic than 5 (-10) years of antihormonal treatment, it‘s not so easy to state „If you are going to drop something, drop the antihormonal treatment.“

You need to:
A) Do the trials to prove that.
B) Bear in mind that RT and AHT have different effects. RT merely influences in-breast recurrence risk (and with PBI only in a part of that breast), while AHT also tackles DCIS in the contralateral breast as well as lowers the risk for regional/distant recurrence. Communication of these distinct goals is not that trivial and quantification of the associated benefits with each treatment still not well (because we have not done the proper trials) understood.
Many patients are not concerned about a local recurrence but rather systemic relapse or a second primary. These needs of the patients must be weighted carefully when thinking about how to deescalate treatment.

We still have a lot of work to do!
Click to expand...
In the properly selected population omitting RT hurts in breast recurrences without affecting survival. (PRIME-II etc.) In fact I guess in these types trials of all the outcomes reported it’s always OSs (vs recurrence or mets eg) that have smallest delta between RT and no RT. It thus certainly may be possible that omitting anti-E therapy will see no difference in local controls but worse OS. That would be… infaust.
 
Palex80 said:
I am going to make a counterpoint here.
Although I fully agree that radiation is a lot more comfortable and less toxic than 5 (-10) years of antihormonal treatment, it‘s not so easy to state „If you are going to drop something, drop the antihormonal treatment.“

You need to:
A) Do the trials to prove that.
B) Bear in mind that RT and AHT have different effects. RT merely influences in-breast recurrence risk (and with PBI only in a part of that breast), while AHT also tackles DCIS in the contralateral breast as well as lowers the risk for regional/distant recurrence. Communication of these distinct goals is not that trivial and quantification of the associated benefits with each treatment still not well (because we have not done the proper trials) understood.
Many patients are not concerned about a local recurrence but rather systemic relapse or a second primary. These needs of the patients must be weighted carefully when thinking about how to deescalate treatment.

We still have a lot of work to do!
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Totally agree - which is why I save the hyperbolic statements in this arena for my SDN avatar.

In the "assessing readiness to change", RadOnc is still largely in the midst of a self-defeating culture. I use SDN for trickle-down economics: what is written and read then sits in the mind of the reader, whether they agree or disagree.
 
RickyScott said:
Obviously a cure is hyperbole, but there is a steady march of progress w/each asco and that is certainly an existential threat to our job market. Radiation wont disappear but its footprint will be much smaller by asco 2030. I can see with better chemo/io combos and newer IO agents in the following scenarios. oustide ctla4 and PDL1, not many other immuno targets, but they will come!

chemo/io-> surgery for esophagus
2nd/3rd generation Chemo/io regimens as neoadjuvant treatment of choice in majority of stage III lung.
IO cutting down on brain met pts getting srt.
chemo/IO-if followed by a very good response- leading to a less radical surgery (wedge, in lung) simple hysterectomy in cervix, TURB in bladder.
Click to expand...
Unfortunately this is sad, but true. I think we are so dependent on technology that our next real advance will be based on some future technological advance that makes radiation dose-esc quicker, faster, more effective, and safer.

Stereotactic Adaptive Proton Modulated Flash Knife or something like that....
 
Def see those pts eligible for lobectomy w/stage 3b based on mediastinal involvement going to surgey (especially if pdl1+) . As neoadjuvant regimens rapidly evolve, maybe surgeons can get away with wedges?
 
RickyScott said:
our own personal Jesus. What will
Save the specialty?
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Abscopal at first place...

1655054296101.png
 
when the breadlines come, he will be first in line
 
RickyScott said:
our own personal Jesus. What will
Save the specialty?
Click to expand...

If radiation were a drug, and cisplatin were that drug...

Abscopal Inject patient with cisplatin; patient in nearby infusion chair gets tumor response
Adaptive If patient gets tumor response, adjust cisplatin dose
Biomarkers check patient for ERCC1 prior to cisplatin infusion
FLASH cisplatin 300 mg/m2, infuse over 1 second
Grid cisplatin infusion: subclavian, antecubital, and popliteal
Particle radiation liposomal cisplatin
Radiopharmaceuticals radioactive cisplatin: [Pt-185m(NH3)2Cl2]
PULSAR cisplatin 300 mg/m2, q8w
SRS/SBRT intratumoral cisplatin injection (microsurgical approach)
 



curious about this? my community shop exclusively does HA-WBRT for patients who can wait 2-3 days to start. are other PP docs not doing this? it's also better billing....
 
jondunn said:



curious about this? my community shop exclusively does HA-WBRT for patients who can wait 2-3 days to start. are other PP docs not doing this? it's also better billing....
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What @Mandelin Rain said. Great hippocampal sparing comes from SRS/SRT
 
RickyScott said:
Radiopharm won’t support the specialty. Nuc med/radiology controls it in large systems and let’s face it, the sht reimbursement of this loss leader won’t be able to keep radoncs employed
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Enjoy your 79101 with 1.96 wRVU per administration. I'm sure that will make up for all those fractions lost.
 
RickyScott said:
And the lutetium is a real pain btw. Get same rvus for 2-3 cbct
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1 PETCT is worth more for us. Even 1 CT AP is close. The professional reimbursement is simply terrible. It's why a lot of Nuc (Rad|Med) departments are starting to do patient tele consults as a way to at least capture the time used for the radiation safety and treatment consent process. They mostly just bill straight time which often takes up to an hour.

medgator said:
Real time suck, and a financial risk if you're buying the drug and the billers don't know what they are doing
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1 x 200mCi dose of lutathera costs $50,000. Pluvicto is $42,500. Better not have a no-show or a goof in reimbursement. It's not like chemo drugs where you can just give it the next day.
 
jondunn said:



curious about this? my community shop exclusively does HA-WBRT for patients who can wait 2-3 days to start. are other PP docs not doing this? it's also better billing....
Click to expand...

The best hippocampal avoidance is SRS...

I am doing, maybe, gosh it hurts to say it but, like, one palliative whole brain to the 30 Gy range every 2 to 3 months. Or every 4 mos maybe who knows. As I have said before, this used to be bread-'n-buttery for rad onc; you couldn't go in a rad onc center no matter how small that didn't have a whole brain RT patient under treatment. And historically a good 4 out of 5 were NSCLC related. On top of this, the incidence of Stage IV NSCLC is decreasing.
 
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