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medgator said:
it wouldn't fly for payment imo, so not sure why it would fly for anything else.... Again, kinda being conservative here considering the notoriety our specialty has had the last couple of decades.
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The standard for payment is very different than for a civil or criminal penalty. Ie for criminal sanction- beyond reasonable doubt. Clearly if it is permitted in a good portion of the country, nobody can argue you broke federal law beyond reasonable doubt. Whether you lcd chooses to pay you or not is a different matter. In either case, cms has extended the covid supervision exemption in undeniably clear language, so it is hard to see them arguing otherwise.
This again goes back to the entrapment conspiracy: although cms explicitly states you don’t have to be present in the outpatient setting, it’s just a ruse says Ron. You just can take anything that cms says literally. Can’t trust a thing that they codify. You need Ron’s services to guide you and stay out of jail. Still when all is said and done, the clear trend in supervision is not a friend of the job market.
 
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This is a pretty darn big deal in my opinion. This LCD is for IMRT for multiple states, and this seems to be independent of COVID exemptions. Like, if COVID virtual supervision went away this would be the standard for this MAC (?). Is this 2 day a week in person deal gonna be the "compromise" CMS sort of alluded to in it's most recent comments on supervision?

  • The qualified radiation oncology physician, if not physically present in the radiation treatment center, must be immediately available by telephone or other electronic means of communication and must be able to receive and remotely review guidance images allowing the qualified physician to provide advice and/or treatment modification before treatment is provided in situations requiring radiation oncology physician contact.
  • The qualified radiation oncology physician must review and approve guidance images that were produced prior to each daily treatment within 24 hours or prior to the next treatment delivery.
  • The qualified radiation oncology physician must personally evaluate each patient undergoing radiation treatment on a weekly basis, and provide direct supervision of radiation treatment delivery of all patients being treated at least twice during each calendar week of therapy.
 
I didnt catch the date on this, but I have a hard time believing a MAC would make a profound change to an LCD like this witbout some inside knowledge about where cms plans to go with supervision guidelines nationally.
 
Reaganite said:
I didnt catch the date on this, but I have a hard time believing a MAC would make a profound change to an LCD like this witbout some inside knowledge about where cms plans to go with supervision guidelines nationally.
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Cant wait for Ron to step in and claim doc has to be there for a cone beam - even though the LcD is explicitly assuming you are not when it mentions the 24 hour turnn around in context of 2 day a week presence- or that doc must live at the center so that teleheallth has the same billing address as where treatment is Delivered.
 
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Reaganite said:
This is a pretty darn big deal in my opinion. This LCD is for IMRT for multiple states, and this seems to be independent of COVID exemptions. Like, if COVID virtual supervision went away this would be the standard for this MAC (?). Is this 2 day a week in person deal gonna be the "compromise" CMS sort of alluded to in it's most recent comments on supervision?

  • The qualified radiation oncology physician, if not physically present in the radiation treatment center, must be immediately available by telephone or other electronic means of communication and must be able to receive and remotely review guidance images allowing the qualified physician to provide advice and/or treatment modification before treatment is provided in situations requiring radiation oncology physician contact.
  • The qualified radiation oncology physician must review and approve guidance images that were produced prior to each daily treatment within 24 hours or prior to the next treatment delivery.
  • The qualified radiation oncology physician must personally evaluate each patient undergoing radiation treatment on a weekly basis, and provide direct supervision of radiation treatment delivery of all patients being treated at least twice during each calendar week of therapy.
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Theoretically those 2 days could be "virtual" direct supervision.... Right??

Running a zoom practice in perpetuity???
 
Reaganite said:
This is a pretty darn big deal in my opinion. This LCD is for IMRT for multiple states, and this seems to be independent of COVID exemptions. Like, if COVID virtual supervision went away this would be the standard for this MAC (?). Is this 2 day a week in person deal gonna be the "compromise" CMS sort of alluded to in it's most recent comments on supervision?

  • The qualified radiation oncology physician, if not physically present in the radiation treatment center, must be immediately available by telephone or other electronic means of communication and must be able to receive and remotely review guidance images allowing the qualified physician to provide advice and/or treatment modification before treatment is provided in situations requiring radiation oncology physician contact.
  • The qualified radiation oncology physician must review and approve guidance images that were produced prior to each daily treatment within 24 hours or prior to the next treatment delivery.
  • The qualified radiation oncology physician must personally evaluate each patient undergoing radiation treatment on a weekly basis, and provide direct supervision of radiation treatment delivery of all patients being treated at least twice during each calendar week of therapy.
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In fact, this is quite a bit more restrictive than the covid exemption which is still in place for the rest of the country. They are being more stringent an uptight than lets say, Florida where currently, you may only have to be present one day a week?
 
RealSimulD said:
Was reading this and realized that this field (and much of medicine) suffers from this problem: “once and for-all-ism”

People eventually decide they are done thinking about a problem and won’t let future facts or data change their mind. Like anyone who still thinks the specialty is safe. Or that 60 Gy is all it takes to treat stage 3 lung (yah, I went there). More people should think rationally and with Bayesian mindset ..

marginalrevolution.com

The intellectual mistake of once-and-for-allism - Marginal REVOLUTION

One of the most common intellectual mistakes! Do note however that it is an efficient mistake for many people to commit, and that is part of why it is so common. “Once-and-for-allism” occurs when people decide that they wish to stop worrying about an issue at the margin. They might either...
marginalrevolution.com marginalrevolution.com
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With latest PACIFIC data showing survival to 48 months and improving outcomes, we are going to start seeing more recurrences and dealing with more re-irradiation. 1308 only goes to 70gy. Isotoxic dose escalation is not dead, it might be the future. Maybe it is already here!
 
RickyScott said:
In fact, this is quite a bit more restrictive than the covid exemption which is still in place for the rest of the country. They are being more stringent an uptight than lets say, Florida where currently, you may only have to be present one day a week?
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The federal COVID exemption states virtual supervision is allowed and does not specify the number of days a physician must personally be present like in this LCD. So I agree--this LCD is actually more stringent, although again, the Federal rules trump the LCD. I thought this was a recent revision to an LCD intended to be their standard once the federal COVID exemption ended and was perhaps reflective of inside knowledge of recent CMS discussions. It appears this revision came in 1/2021, however. I'm curious as to why that MAC was willing to add these specifics way back in 1/2021 even as CMS still seemed to be "open to suggestions" at the end of 2021.
 
Excuse my ignorance here, but is this supervision for IMRT from the LCD applicable to both hospital based and freestanding centers?
 
jondunn said:
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I don't really see how this would work?
The issue with protons and LET is NOT that the RBE of protons may be universally higher than what we think (which is what is being suggested in this thread). The issue is that RBE may be higher at the end of the Bragg Peak (and possibly directly after the end of the Bragg Peak). This is why the ribs are breaking and not the skin is showing necrosis (which may be target in PMRT) with protons.
How can one test that in a trial ethically?
If you decided to challenge this thesis, you would have to underdose one group of patients, giving them a lower dose at the hope of showing that this would demonstrate lower rates of rib fractures (which is a no-brainer obviously). At the same time you would be putting these patients at risk of recurrence, since you underdosed them in the anterior parts of the Bragg Peak.
 
Palex80 said:
I don't really see how this would work?
The issue with protons and LET is NOT that the RBE of protons may be universally higher than what we think (which is what is being suggested in this thread). The issue is that RBE may be higher at the end of the Bragg Peak (and possibly directly after the end of the Bragg Peak). This is why the ribs are breaking and not the skin is showing necrosis (which may be target in PMRT) with protons.
How can one test that in a trial ethically?
If you decided to challenge this thesis, you would have to underdose one group of patients, giving them a lower dose at the hope of showing that this would demonstrate lower rates of rib fractures (which is a no-brainer obviously). At the same time you would be putting these patients at risk of recurrence, since you underdosed them in the anterior parts of the Bragg Peak.
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I mean… there are certainly ways to plan cases in a more “LET conscious” manner… e.g. MFO where the chest wall component is covered more so with tangential beams, and having the en face beam focus more on the superficial parts of the target. This would avoid having the ribs being heavily treated at the end-of-range. Not to say I have actually done this… just musing.

ADDENDUM. This approach could be compared to an approach which has more en face beam coverage … and both plans could have same physical dose coverage, with the only difference being the LET distribution.
 
Palex80 said:
I don't really see how this would work?
The issue with protons and LET is NOT that the RBE of protons may be universally higher than what we think (which is what is being suggested in this thread). The issue is that RBE may be higher at the end of the Bragg Peak (and possibly directly after the end of the Bragg Peak). This is why the ribs are breaking and not the skin is showing necrosis (which may be target in PMRT) with protons.
How can one test that in a trial ethically?
If you decided to challenge this thesis, you would have to underdose one group of patients, giving them a lower dose at the hope of showing that this would demonstrate lower rates of rib fractures (which is a no-brainer obviously). At the same time you would be putting these patients at risk of recurrence, since you underdosed them in the anterior parts of the Bragg Peak.
Click to expand...

These issues should have been figured out before the first patient was treated with protons.
 
Palex80 said:
I don't really see how this would work?
The issue with protons and LET is NOT that the RBE of protons may be universally higher than what we think (which is what is being suggested in this thread). The issue is that RBE may be higher at the end of the Bragg Peak (and possibly directly after the end of the Bragg Peak). This is why the ribs are breaking and not the skin is showing necrosis (which may be target in PMRT) with protons.
How can one test that in a trial ethically?
If you decided to challenge this thesis, you would have to underdose one group of patients, giving them a lower dose at the hope of showing that this would demonstrate lower rates of rib fractures (which is a no-brainer obviously). At the same time you would be putting these patients at risk of recurrence, since you underdosed them in the anterior parts of the Bragg Peak.
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It may turn out that firing charged (or uncharged) massive particles (weighing 2000 times as much as an electron) at near-light-speed velocities into eukaryotic cells, literally transmuting the atomic elements in those cells into other atomic elements, may have different biological effects than shining high energy chargeless/massless particles into those cells where the interactions are essentially purely electronic and ionizing. Sketching a Bragg peak on a piece of paper and saying "Look how pretty this is" didn't guarantee that protons were better, yet here we are with a substantial number of our rad onc colleagues believing that protons are always either better—or at least fungible—with photons in every clinical situation. The physics at the quantum level (the only level that counts) is wholly different for protons versus photons, and we understand this not so great in my opinion for photons and even more poorly for protons. And yet "cobalt gray equivalents" still persist to give proton prescribers comfort. We are comparing bullets and light rays and saying they do the same thing... and thus the underlying mechanisms of either one are meaningless because the ends justify the means.
 
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Lamount said:
I mean… there are certainly ways to plan cases in a more “LET conscious” manner… e.g. MFO where the chest wall component is covered more so with tangential beams, and having the en face beam focus more on the superficial parts of the target. This would avoid having the ribs being heavily treated at the end-of-range. Not to say I have actually done this… just musing.

ADDENDUM. This approach could be compared to an approach which has more en face beam coverage … and both plans could have same physical dose coverage, with the only difference being the LET distribution.
Click to expand...
That is certainly one way to do it. So it would then be more of a randomized planning / beam-arrangement study, actually.
 
Lamount said:
This approach could be compared to an approach which has more en face beam coverage … and both plans could have same physical dose coverage, with the only difference being the LET distribution.
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This is coming from someone who is clearly smart and very facile with protons.

Let's think about how different this type of thinking is to IMRT planning.

Here, @Lamount is suggesting varying beam arrangements to accommodate for dosimetric uncertainties.

With IMRT, there is very little dosimetric uncertainty (although not none, we are talking low single digits percentage wise) and calculated dose is so well characterized that it can be used as an input to iteratively find solutions for dynamic beam modulation.

IMPT is not IMRT and one of the greatest misnomers in our field.

Some have suggested Intensity Modulated electron treatment. I would be hesitant, as again, I don't believe that the dose is nearly as well characterized even for the lightest directly ionizing particle that we use as it is for photons. When I look at an electron plan in my treatment software, it is much more of a general thing. I'm sure many of you have looked at 60 Gy en-face with 6x and a 1 cm bolus on your treatment software and been like, "How does this treat anything?"
 
I didn't read the article, but any time I ask my proton colleagues about this breast stuff the answer is always "these problems were with less robust planning and pre IMPT....."

Anecdotally the plastic surgeons tell me there is a clear difference in tissue effects s/p proton vs. photons. One in particular in town refuses to do reconstruction if patient getting protons.
 
BobbyHeenan said:
I didn't read the article, but any time I ask my proton colleagues about this breast stuff the answer is always "these problems were with less robust planning and pre IMPT....."
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If I were a rad onc who 15 years ago got cancer and decided to go for protons, this sort of talk... "We figured out we were making mistakes in the dose calcs back then"... would be depressing-to-scary. I would be presently pretty pissed that my colleagues had given me some non-robustly planned radiation. I guess we should be confident that it's all robust and properly figured out now.
 
TheWallnerus said:
If I were a rad onc who 15 years ago got cancer and decided to go for protons, this sort of talk... "We figured out we were making mistakes in the dose calcs back then"... would be depressing-to-scary. I would be presently pretty pissed that my colleagues had given me some non-robustly planned radiation. I guess we should be confident that it's all robust and properly figured out now.
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That's the thing with insurers too.

Insurance exec: You told us protons would be better so we let you treat off protocol. But now that study X is showing not better, why should we trust you now that you say "this time it's different?"

====

I'm a rad onc so of course I think the DVH matters. I send patients for protons at least once a month I'd guess. But if the calculation (or the biologic impact/metrics) used to get that DVH is off then.....
 
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BobbyHeenan said:
That's the thing with insurers too.

Insurance exec: You told us protons would be better so we let you treat off protocol. But now that study X is showing not better, why should we trust you now that you say "this time it's different?"

====

I'm a rad onc so of course I think the DVH matters. I send patients for protons at least once a month I'd guess. But if the calculation (or the biologic impact/metrics) used to get that DVH is off then.....
Click to expand...
The inventor of the DVH cautioned not to get overly reliant on the DVH being the sole arbiter of good plan vs bad plan. I was saying the other day with protons it seems like the DVH can look better but the patient can look worse!
 
Lamount said:
I mean… there are certainly ways to plan cases in a more “LET conscious” manner… e.g. MFO where the chest wall component is covered more so with tangential beams, and having the en face beam focus more on the superficial parts of the target. This would avoid having the ribs being heavily treated at the end-of-range. Not to say I have actually done this… just musing.

ADDENDUM. This approach could be compared to an approach which has more en face beam coverage … and both plans could have same physical dose coverage, with the only difference being the LET distribution.
Click to expand...

Yes. People are already trying to move this "LET conscious planning" to the clinic. As with any model, I just wanted people to test this prospectively as opposed to claim it will fix the problems seen in the clinic.

Given the retrospective/limited prospective data out there today, putting people on such a study (even if single arm) is better than treating breast or prostate off trial on protons. IMO of course.
 
BobbyHeenan said:
I didn't read the article, but any time I ask my proton colleagues about this breast stuff the answer is always "these problems were with less robust planning and pre IMPT....."

Anecdotally the plastic surgeons tell me there is a clear difference in tissue effects s/p proton vs. photons. One in particular in town refuses to do reconstruction if patient getting protons.
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robustness takes care of everything, especially when it cant be modeled. I would love to have robust software to predict stocks
 
BobbyHeenan said:
Anecdotally the plastic surgeons tell me there is a clear difference in tissue effects s/p proton vs. photons. One in particular in town refuses to do reconstruction if patient getting protons.
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Hardest salvage prostatectomy too per the high volume GU in our region... Puts cryo, hifu, IMRT etc to shame
 
medgator said:
Hardest salvage prostatectomy too per the high volume GU in our region... Puts cryo, hifu, IMRT etc to shame
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I remember a twitter urology thread with people commenting about post proton prostatectomy being much different from protons.
 
BobbyHeenan said:
That's the thing with insurers too.

Insurance exec: You told us protons would be better so we let you treat off protocol. But now that study X is showing not better, why should we trust you now that you say "this time it's different?"

====

I'm a rad onc so of course I think the DVH matters. I send patients for protons at least once a month I'd guess. But if the calculation (or the biologic impact/metrics) used to get that DVH is off then.....
Click to expand...

Wow once a month? That’s a lot

What’s the common indication for you to send?
 
jondunn said:
Wow once a month? That’s a lot

What’s the common indication for you to send?
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Once a month is probably slight exaggeration. Definitely once every two months though. I shouldn't have phrased it as "send them for protons" either, it's really send to be evaluated for it...many times it's patient essentially asking for referral.

Most common is peds I think, but others may be re-irradiation, thymoma near heart, lymphoma, certain cholangiocarcinoma/HCC cases, a rare challenging anatomy left sided comprehensive breast cases (hopefully not getting reconstruction!!!), some (not all) head/neck, mesothelioma.

I sit on big network wide tumor board(s), so sometimes it's not a clinic patient per se, just a case...and I go to 4-5 tumor boards a week... so that's a lot of cases I'm "seeing."

In addition, patients are very often asking for it. Very strong advertising all over the country/google algorithms. Seeing that more and more in esophagus and I think that's reasonable.
 
NotMattSpraker said:
Yes. People are already trying to move this "LET conscious planning" to the clinic. As with any model, I just wanted people to test this prospectively as opposed to claim it will fix the problems seen in the clinic.

Given the retrospective/limited prospective data out there today, putting people on such a study (even if single arm) is better than treating breast or prostate off trial on protons. IMO of course.
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Would agree with this.

I am a true believer that protons may be better in some circumstances, some of which we likely haven't discovered yet... but they aren't magic, and new techniques should be considered experimental until the data bear them out.
 
Lamount said:
This approach is not all that uncommon at MGH... I've seen it for prostate, sarcoma/chordoma and even a few H&N/brain
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Same in Germany (Heidelberg) for photon/proton and photon/carbon-ion trials.
The issue there is however that any differences between only-photon and photon/proton treatments are going to be even more diffucult to find.
If you deliver 60% of the treatment with photons on both arms using the same technique, you need to show a big difference with protons for the other 40%.
 
Lamount said:
This approach is not all that uncommon at MGH... I've seen it for prostate, sarcoma/chordoma and even a few H&N/brain
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There are places where insurance is the only barrier. I have been told "mixed plans are not allowed" full stop. Even when directly applying prospective data that used mixed plans or trying to design a mixed plan study. 🙁
 
We're getting in the weeds here with these mixed plans.

Could a mixed plan be beneficial in a tough lung case with bilateral and anterior mediastinal adenopathy where dose uncertainties are unlikely to result in toxicity (that vasculature can probably get 90 Gy over 30 fractions no problem)? Sure.

Are we going to meaningfully reduce 2nd malignancies with mixed plans (not that this matters in stage III lung patients)? Probably not.

Is this value based medicine? I'll let the ion jockeys argue this point.
 
Mixed plans sound like a great idea for single vault departments. Mix in a week or 2 of protons and that way everyone can get protons! Will really broaden your appeal and mitigate/hedge the proton toxicity. Even if you don’t get reimbursed for that week of protons, it would be a strong inducement for pts to drive/fly in for 5-7 weeks of imrt at 10x cms rates.
Loma Linda pioneered this approach. 4-5 weeks of 4 field box for prostate at centers in SoCal and then come in for 2 weeks of proton boost?
 
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“Cost effective” comparison of 15 3D vs 3 proton.

?no 5 fraction IMRT? Which has more data than any proton course.

This has got to be a ploy for get your breast cancer treated in Rochester in a week with protons, no?

I just can’t imagine it’s in any way better than Livi 30/5 (or even 26/5) except for maybe some tiny sliver of patients.

 
Can't help but think of this when I see this research

1656545275549.png
 
communitydoc13 said:
We're getting in the weeds here with these mixed plans.

Could a mixed plan be beneficial in a tough lung case with bilateral and anterior mediastinal adenopathy where dose uncertainties are unlikely to result in toxicity (that vasculature can probably get 90 Gy over 30 fractions no problem)? Sure.

Are we going to meaningfully reduce 2nd malignancies with mixed plans (not that this matters in stage III lung patients)? Probably not.

Is this value based medicine? I'll let the ion jockeys argue this point.
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My understanding: Mixed plans are helpful in some situations. The penumbra of protons is bigger than a 6MV beam so if you absolutely want to avoid uncertainties with a certain OAR, you might want to cover/boost that area with photons, while placing your spots away from OAR as an example. Similarly lets say you have a sacral chordoma. Some of the particle therapy series get a bad posterior sacral skin ulcer. You can avoid the more superficial component prioritizing skin dose and cover it with higher energy photons. the combination strategy basically gives you an even better plan complimenting eachother in specific situations
 
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BobbyHeenan said:
“Cost effective” comparison of 15 3D vs 3 proton.

?no 5 fraction IMRT? Which has more data than any proton course.

This has got to be a ploy for get your breast cancer treated in Rochester in a week with protons, no?

I just can’t imagine it’s in any way better than Livi 30/5 (or even 26/5) except for maybe some tiny sliver of patients.

Click to expand...

What im hearing is IMRT LIVI 5 fx is dead. 3 fraction SFO IMPT is now THE SOC! Many are saying it!
 
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