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Gfunk6 said:
The end game will be as follows:

1. Private practice RO (already at death's door) will shutter completely within the next couple of years. Hospitals in rural and semi-rural areas with disproportionately high percentage of Medicare and Medicaid patients will go under as well.

2. Private practices will likely be bought out by academic health systems/big hospital consortiums and all physicians will be employed. These institutions are still getting crap rates from Medicare and Medicaid patients but they are offset by (a) truly exorbitant rates paid by private insurers, (b) government programs that are used to manipulate costs [e.g. 403b], (c) wealthy cash patients who will pay out of pocket (e.g. protons for right sided breast cancer), and (d) wealthy mega-donors who want their name on something.

3. Eventually even the large hospitals will begin to suffer from the never ending cuts to Medicare and Medicaid. They will be getting less revenue in the face of inflation and increased costs. They can't stop taking these patients as that would be a death knell for them. Instead they will start paying physicians less and less and pass the blame to the government. There is nowhere else for physicians to go (doubly so for Rad Onc) and if you try to resist they will replace you with one of 50 new grads who would kill their firstborn for your spot.
Click to expand...

Wait is this a description of the past 5 years or a description of the next five years? LOL sad...
 
Gfunk6 said:
The end game will be as follows:

1. Private practice RO (already at death's door) will shutter completely within the next couple of years. Hospitals in rural and semi-rural areas with disproportionately high percentage of Medicare and Medicaid patients will go under as well.

2. Private practices will likely be bought out by academic health systems/big hospital consortiums and all physicians will be employed. These institutions are still getting crap rates from Medicare and Medicaid patients but they are offset by (a) truly exorbitant rates paid by private insurers, (b) government programs that are used to manipulate costs [e.g. 403b], (c) wealthy cash patients who will pay out of pocket (e.g. protons for right sided breast cancer), and (d) wealthy mega-donors who want their name on something.

3. Eventually even the large hospitals will begin to suffer from the never ending cuts to Medicare and Medicaid. They will be getting less revenue in the face of inflation and increased costs. They can't stop taking these patients as that would be a death knell for them. Instead they will start paying physicians less and less and pass the blame to the government. There is nowhere else for physicians to go (doubly so for Rad Onc) and if you try to resist they will replace you with one of 50 new grads who would kill their firstborn for your spot.

There are two ways out of the death spiral above and both require actions by the federal government:

a. The Feds realize that private practice physicians provide comparable care to hospitals and at a fraction of the cost. They decide to pay them fairly to provide these services for their beneficiaries.

b. Medicare for all - private insurance is eliminated

Unlike gun violence or airline safety, there will not be a single, spectacular healthcare adverse event that shocks the nation that will prompt legislative action. It will be death by a thousand cuts. Any legislator who proposes a solution (and all who support it) will effectively be falling on their swords because the consequence of such a major shift in policy will rock the core of the US.

My advice is to start saving your money and diversify your skill set. Better to jump off a sinking ship rather than to go down with it.
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Neither solution will exit the death spiral. Sooner or later spending other people's money is unsustainable. Eventually the only real solution is for government to exit completely and return to private pay with catastrophic self insurance based on religious/community networks. Imagine all that admin, regulatory, and coding fat just cut out! But must recognize it never will happen.

Political pressure will force a hybrid model and government finances will circle the drain more rapidly.

Still good advice. Rocky roads ahead no matter what.
 
Gfunk6 said:
1. Private practice RO (already at death's door) will shutter completely within the next couple of years. Hospitals in rural and semi-rural areas with disproportionately high percentage of Medicare and Medicaid patients will go under as well.

2. Private practices will likely be bought out by academic health systems/big hospital consortiums and all physicians will be employed. These institutions are still getting crap rates from Medicare and Medicaid patients but they are offset by (a) truly exorbitant rates paid by private insurers, (b) government programs that are used to manipulate costs [e.g. 403b], (c) wealthy cash patients who will pay out of pocket (e.g. protons for right sided breast cancer), and (d) wealthy mega-donors who want their name on something.

3. Eventually even the large hospitals will begin to suffer from the never ending cuts to Medicare and Medicaid.
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I am in 100% agreement up to the start of Point #3.

What started the death of private practice? Increased complexity of the system with things like documentation (costs time), increased overhead like EMRs (costs money), and decreased reimbursement. The logical "invisible hand" market response was for small entities (private practices) to sell out or band together, creating larger entities, to scale solutions and wield more power to slow reimbursement loss (can't stop CMS, but you can negotiate better private payor contracts as @Gfunk6 points out).

So, scale that process up. "Large hospital systems" can still get larger. What if every single hospital in Florida joined the "Sunshine State Healthcare Borg"? Or several states in the Pacific Northwest became "Bezos and Buddies Health Solutions".

Eventually, you get so big that you can stop CMS cuts. If there are ultimately like, 10 main "health systems" in the country, then you basically have Medicine OPEC. Reimbursement per RVU becomes set like the price of oil per barrel.

That assumes everything remains equal.

While I definitely think we're nowhere near the nadir of "physician death spiral", things can and will "get worse", however you want to define that. But, it can't get so bad that it drives doctors away to a significant degree. Why? Because the system needs a "fall guy". The way laws in this country are currently written, doctors carry all liability. It's the perfect solution for a business, err I mean hospital.

No matter what, people are always going to get sick, forever.
People are always going to want to get better.
Your business model, the product you are selling, is health.
Functionally, your market is captive. You can charge what you want.
If something goes wrong, who gets sued? The doctor.
It is really, really hard for someone to sue a hospital for so much they shut down.
It's much easier to sue a doctor for so much you ruin their career/life etc.

The only things I see fundamentally stopping this trajectory would be:
1) Some sort of cost or problem so complex that becoming an ultra-organization still can't solve it
2) Liability is shifted onto someone or something else
3) The student loan debt incurred to become a trained and licensed physician permanently disappears

As long as the liability rests with the doctor, and as long as our training pathway takes at least a decade and incurs hundreds of thousands of dollars of debt, the invisible hand of the market will shape the system down the path it has been on already for decades.

Because really, the channel of least resistance is definitely to form "super orgs" to shape CMS policy, only because that requires no fundamental changes to the current system, only scaling of past trends.
 
one thing tho - aren't docs employed by large health care systems protected legally by their big corp suits?

i thought that was one of the perks - some peace of mind there if you get sued?
 
elementaryschooleconomics said:
I am in 100% agreement up to the start of Point #3.

What started the death of private practice? Increased complexity of the system with things like documentation (costs time), increased overhead like EMRs (costs money), and decreased reimbursement. The logical "invisible hand" market response was for small entities (private practices) to sell out or band together, creating larger entities, to scale solutions and wield more power to slow reimbursement loss (can't stop CMS, but you can negotiate better private payor contracts as @Gfunk6 points out).

So, scale that process up. "Large hospital systems" can still get larger. What if every single hospital in Florida joined the "Sunshine State Healthcare Borg"? Or several states in the Pacific Northwest became "Bezos and Buddies Health Solutions".

Eventually, you get so big that you can stop CMS cuts. If there are ultimately like, 10 main "health systems" in the country, then you basically have Medicine OPEC. Reimbursement per RVU becomes set like the price of oil per barrel.

That assumes everything remains equal.

While I definitely think we're nowhere near the nadir of "physician death spiral", things can and will "get worse", however you want to define that. But, it can't get so bad that it drives doctors away to a significant degree. Why? Because the system needs a "fall guy". The way laws in this country are currently written, doctors carry all liability. It's the perfect solution for a business, err I mean hospital.

No matter what, people are always going to get sick, forever.
People are always going to want to get better.
Your business model, the product you are selling, is health.
Functionally, your market is captive. You can charge what you want.
If something goes wrong, who gets sued? The doctor.
It is really, really hard for someone to sue a hospital for so much they shut down.
It's much easier to sue a doctor for so much you ruin their career/life etc.

The only things I see fundamentally stopping this trajectory would be:
1) Some sort of cost or problem so complex that becoming an ultra-organization still can't solve it
2) Liability is shifted onto someone or something else
3) The student loan debt incurred to become a trained and licensed physician permanently disappears

As long as the liability rests with the doctor, and as long as our training pathway takes at least a decade and incurs hundreds of thousands of dollars of debt, the invisible hand of the market will shape the system down the path it has been on already for decades.

Because really, the channel of least resistance is definitely to form "super orgs" to shape CMS policy, only because that requires no fundamental changes to the current system, only scaling of past trends.
Click to expand...
Interesting points, I have to ponder a bit before I respond
 
dieABRdie said:
So what exactly does this guy provide? Is it a billing company.... but innovative? It wasn't real clear by looking at the website.
Click to expand...
I *think*they do consulting and investing in the radiation/oncology space.

Like if you’re looking to expand, buy equipment, start a proton center, buy a practice, etc.
 
jondunn said:
one thing tho - aren't docs employed by large health care systems protected legally by their big corp suits?

i thought that was one of the perks - some peace of mind there if you get sued?
Click to expand...
I'm sure that's what they tell everyone, but similar to the adage "HR is there to protect the company, not you"...

When stuff hits the fan, there's never a question who they'll try to sacrifice first.
 
I think they protect you until they can’t.

Those following the case in Pittsburgh can see it play out. Golden boy until he wasn’t.
 
Gfunk6 said:
Interesting points, I have to ponder a bit before I respond
Click to expand...
Obviously I could be totally wrong. I just feel like life makes a lot of sense if you assume:

1) No one is the villain of their own story (there are relatively few people out there acting with ill intent)
2) People respond to incentives (usually money, but also reputation)
3) Once they get to a certain size/complexity, organizations are often driven by bigger (market) forces
4) If you have enough money and/or connections, laws and regulations don't affect you the same
5) Things usually follow the path of least resistance (which usually means sticking in existing systems)
6) #1 doesn't contradict #4, because of #3 (it makes since for an organization to sacrifice an individual person)

I'm sure there are about 700 other things someone who really studies economics could tell you, I'm just a medical doctor.
 
elementaryschooleconomics said:
Obviously I could be totally wrong. I just feel like life makes a lot of sense if you assume:

1) No one is the villain of their own story (there are relatively few people out there acting with ill intent)
2) People respond to incentives (usually money, but also reputation)
3) Once they get to a certain size/complexity, organizations are often driven by bigger (market) forces
4) If you have enough money and/or connections, laws and regulations don't affect you the same
5) Things usually follow the path of least resistance (which usually means sticking in existing systems)
6) #1 doesn't contradict #4, because of #3 (it makes since for an organization to sacrifice an individual person)

I'm sure there are about 700 other things someone who really studies economics could tell you, I'm just a medical doctor.
Click to expand...
Even senator palpatine had good intentions…I think…
 
Palex80 said:


See? It worked! People think it‘s the protons that led to the benefit not the RT volume…
Click to expand...

But the RT volume is a property of protons unless you mean the high dose volumes vs VMAT are similar and lower doses don’t matter?
 
medgator said:
You can't do the same volume with vmat?
Click to expand...
Depends what you mean, if you mean the higher dose IDL yeah will be similar, but not the middle/lower doses. Lots of dosimetry papers with VMAT/tomo vs 3d vs protons one can look at.
 
The trial showed that:
treating with CSI using protons
was better than
treating the affected areas of the CNS (IFRT) using photons.

How does one interpret these data?

1. Protons are better than photons.
2. Treating with CSI is better than IFRT.
3. Treating with CSI using protons is better than treating with IFRT using photons.
 
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pubmed.ncbi.nlm.nih.gov

Volumetric Modulated Arc Therapy (VMAT) Craniospinal Irradiation (CSI) for Children and Adults: A Practical Guide for Implementation - PubMed

VMAT CSI has potentially significant dosimetric and acute toxicity advantages compared to 3-dimensional conformal. However, proper procedures need to be in place throughout the process in order to be able to realize these potential advantages. We herein describe our detailed standard operating...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Nice how to for those of us who haven’t done it yet
 
Here is pencil beam CSI 30 Gy / 10 fractions with 5 mm robustness. I'm thinking two things.
1. If we go down to 3 mm robustness is that sufficient? The marrow would be more spared this way.
2. What isodose spares marrow? The 1500 cGy line is less than midway through the T and L-spines. The 300 cGy line goes through ~80-90% of the bone.

1657635282174.png
 
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jondunn said:
Click to expand...

Non-proton user here. It is self-evident that craniospinal is an ideal use of proton beam therapy particularly in children.

VMAT CSI is a very practical option because is having an incurable patient travel to a distant proton center seems inappropriate and unnecessary. In this study, the median survival was 10 months and these were highly selected MSK clinical trial patients so worse expected survival in real world. I postulate that VMAT CSI is non-inferior to proton CSI in this very specific context. Given the time and money required to transport these terminally ill patients to a proton center, the burden of proof should be on the proton center rather than VMAT CSI.
 
theradiator said:
Non-proton user here. It is self-evident that craniospinal is an ideal use of proton beam therapy particularly in children.

VMAT CSI is a very practical option because is having an incurable patient travel to a distant proton center seems inappropriate and unnecessary. In this study, the median survival was 10 months and these were highly selected MSK clinical trial patients so worse expected survival in real world. I postulate that VMAT CSI is non-inferior to proton CSI in this very specific context. Given the time and money required to transport these terminally ill patients to a proton center, the burden of proof should be on the proton center rather than VMAT CSI.
Click to expand...
Agreed. Perhaps we should do a better job of teaching trial design and interpretation during residency. Presuming the ultimate motivation is truth inasmuch as that's a sensical term in the first place.
 
Neuronix said:
2. What isodose spares marrow? The 1500 cGy line is less than midway through the T and L-spines. The 300 cGy line goes through ~80-90% of the bone.
Click to expand...
That is an excellent question, one I do not think we have a definitive answer for.
Given the radiobiology of how you would be treating that marrow --> with small doses per day, what is trigger point that would result into cytopenia?

If you look at the 3 Gy isodose lines of breast cancer patients treated with full-rotational VMAT for breast/chest wall + extensive RNI, you will see that comparable doses may encompass large parts of the bone marrow in these patients.
Many of them have had long courses of chemotherapy before radiotherapy, yet I have not seen cytopenias developing during RT in occasional CBCs. Any other observations?
 
metallica81788 said:
Cool I'll be sure to send the few LM patients I get for protons so they can spend the last few weeks of their life traveling and spending all their remaining money

👍
Click to expand...
Sounds like less bad snake oil than intrathecal chemo.... Both still snake oil at the end of the day in these patients though
 
The plan I showed is for a young woman with CNS only metastatic disease and good performance status except for some neuro deficits. So... CSI is snake oil? I should just let her die then?

Tell that to the similar young woman in the same situation I treated two years ago who has been stable ever since. She's not the only patient I've treated of course, and I've had a range of survivals, months, years...

Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.

Some SDN posters cry about the death of the field in every thread, then whenever an interesting technique or technology comes out they just attack it... That is a self-fulfilling prophecy.
 
Neuronix said:
Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.
Click to expand...
(Almost) noone is excited to give craniospinal RT!

I still have my notes from the earliest years of my training when we planned CSI with a simulator only.
Including those lovely cosine calculations we had to do, trying to find out how to match the fields, how much to rotate the couch in the brain-cervical spine junction and what skin gaps to use... Sets of colourful markers to draw on the films and the patient different setups. Those were the days! 🙂
 
Neuronix said:
The plan I showed is for a young woman with CNS only metastatic disease and good performance status except for some neuro deficits. So... CSI is snake oil? I should just let her die then?

Tell that to the similar young woman in the same situation I treated two years ago who has been stable ever since. She's not the only patient I've treated of course, and I've had a range of survivals, months, years...

Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.

Some SDN posters cry about the death of the field in every thread, then whenever an interesting technique or technology comes out they just attack it... That is a self-fulfilling prophecy.
Click to expand...
You’re not wrong and proton CSI is pretty cool.

What I’m arguing on Twitter is we are seeing a pattern of new technology being compared but also changing the volume treated.

Is this the only way to show new tech is better? No more apples to apples comparisons? Idea of leveraging tech makes sense, but this study could have used vmat csi. And it would have been more robust.
 
Neuronix said:
The plan I showed is for a young woman with CNS only metastatic disease and good performance status except for some neuro deficits. So... CSI is snake oil? I should just let her die then?

Tell that to the similar young woman in the same situation I treated two years ago who has been stable ever since. She's not the only patient I've treated of course, and I've had a range of survivals, months, years...

Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.

Some SDN posters cry about the death of the field in every thread, then whenever an interesting technique or technology comes out they just attack it... That is a self-fulfilling prophecy.
Click to expand...

Well said.

Some people don’t want to offer CSI but also don’t want YOU to do it

The concern about ‘people in their dying days’ is silly as that’s obviously not someone who would be selected for continued aggressive therapy (they wouldn’t get intensive chemo either, by a good doc at least)

This is very different than the MRI Linac trial. That’s a solution in search of a problem, though I don’t think the investigators are bad people or anything like that.

This is a radiation intervention that improves OS! In a tough population. Regardless of the modality used, it shows that CSI isn’t futile, like many tend to believe.

The question now is figuring out what to do with it.

Me? I’m both gonna consider sending to a local nearby easy to send proton center but I’m also going to get my team on board with seeing if we can do VMAT CSI, as if we find it feasible to plan and deliver, we will.
 
Neuronix said:
The plan I showed is for a young woman with CNS only metastatic disease and good performance status except for some neuro deficits. So... CSI is snake oil? I should just let her die then?

Tell that to the similar young woman in the same situation I treated two years ago who has been stable ever since. She's not the only patient I've treated of course, and I've had a range of survivals, months, years...

Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.

Some SDN posters cry about the death of the field in every thread, then whenever an interesting technique or technology comes out they just attack it... That is a self-fulfilling prophecy.
Click to expand...
Go quickly can you sim and treat here?
 
RickyScott said:
Go quickly can you sim and treat here?
Click to expand...
It's not been my experience that these patients are in any kind of shape to travel for protons, can barely get a week or two of palliative xrt locally before the inevitable hospice consult....

Maybe it's just been the patients I've seen. Have heard neuro oncs talk about giving them IT chemo though at other centers
 
medgator said:
It's not been my experience that these patients are in any kind of shape to travel for protons, can barely get a week or two of palliative xrt locally before the inevitable hospice consult....

Maybe it's just been the patients I've seen. Have heard neuro oncs talk about giving them IT chemo though at other centers
Click to expand...
A lot has to do with type of leptomengeal- diffuse dural thickening in new diagnosed horMone sensitive breast cancer vs extensive tumor cells in the fluid.
 
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RealSimulD said:
What I’m arguing on Twitter is we are seeing a pattern of new technology being compared but also changing the volume treated.

Is this the only way to show new tech is better? No more apples to apples comparisons?
Click to expand...
Have a look at this example of a trial from Germany.

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov

This is a "Preference-based Comparative Study" of photons vs. protons for prostate cancer.
Same dose for both groups, same target delineation.

Primary endpoint is toxicity, hypothesis is that protons will produce a meaningful difference.

That's how we should be putting technology to test.

The Dutch are also quite active in this field.


​

 
Palex80 said:
Have a look at this example of a trial from Germany.

ClinicalTrials.gov

clinicaltrials.gov clinicaltrials.gov

This is a "Preference-based Comparative Study" of photons vs. protons for prostate cancer.
Same dose for both groups, same target delineation.

Primary endpoint is toxicity, hypothesis is that protons will produce a meaningful difference.

That's how we should be putting technology to test.

The Dutch are also quite active in this field.


​

Click to expand...
Maybe but the third arm is concerning

1657718975006.png

Comparing toxicity with photons allowing pelvic treatment doesn't sound like "same volume"

Notice that <200 patients. The US proton enthusiasts could have done this trial in one year if they had equipoise but those machines cost money
 
Chartreuse Wombat said:
Maybe but the third arm is concerning

View attachment 357152
Comparing toxicity with photons allowing pelvic treatment doesn't sound like "same volume"

Notice that <200 patients. The US proton enthusiasts could have done this trial in one year if they had equipoise but those machines cost money
Click to expand...
I think they had to put that arm in to allow for patients who would require WPRT. But your point is certainly valid!
 
Neuronix said:
Most private rad oncs I know are not excited to give craniospinal RT, even with photons. It's not something they do probably ever, and it's complicated.
Click to expand...

I do it, and I'm basically the only one here. The alternative is intrathecal chemo, which is arguably worse.

What dose did this study go to? I have a lady with LMD I'm treating right now (no disease elsewhere, excellent PS, non-symptomatic). I do VMAT, and yes my staff hate me for it. Counts are low but she was getting Ibrance initially (now held). I also have to do about 7-8 mm PTV margins on the spine. I've tried 6mm in the past, but setup was extremely challenging to not have the sac creep out of the PTV somewhere and had to re-plan.

I am treating to 36 Gy in 20 fractions. I use this paper to justify to insurance: Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis

30 Gy in 10 fractions to the entire CNS seems like it would be pretty toxic, and I haven't found any data to support that.

jondunn said:
I’m also going to get my team on board with seeing if we can do VMAT CSI
Click to expand...
Huh? God, I hate our field so much sometimes. You don't have a meeting to talk about whether or not you can offer CSI. You tell them you are doing it and they will do it. This is basic radiotherapy treatment. If they can't do it, they can find work elsewhere. I get so frustrated with pushback on things like CSI, BID, IV contrast, etc. There should not be a question, and certainly not a meeting about it (speaking from prior experience with a clinic manager that wanted to have a department meeting about everything I wanted to do differently from dear old Dr. Boomer, which was literally everything as he was checked out and made their lives incredibly cushy).
 
medgator said:
It's not been my experience that these patients are in any kind of shape to travel for protons, can barely get a week or two of palliative xrt locally before the inevitable hospice consult....

Maybe it's just been the patients I've seen. Have heard neuro oncs talk about giving them IT chemo though at other centers
Click to expand...

That's my experience as well, hence my skepticism

However, I am big fan of evaluating patients individually - no situation is the same. I'm sure there are some people this can help but they are not the people I am seeing. I'm just poo-pooing it for my practice, not others who have the capabilities.
 
I also want to note that a nearby proton center does not offer CSI treatments. Of course they don't offer one of the very few treatments their modality has a demonstrated advantage for. Easier to treat prostates and have everybody go home at 3PM.
 
Moonbeams said:
I also want to note that a nearby proton center does not offer CSI treatments. Of course they don't offer one of the very few treatments their modality has a demonstrated advantage for. Easier to treat prostates and have everybody go home at 3PM.
Click to expand...
Yes... I've noticed many are selective about which cases they like to take.. re tx/palliative is at the bottom of the totem pole
 
Moonbeams said:
I just really, really. really hate pushback and meetings. Especially meetings.
Click to expand...

All I said was before I submitted contours for the first time and said hey plan tbis VMAT CSI I’m gonna at least talk to my physics team who I have a fantastic relationship with so they can brainstorm and think ahead on how they will handle
 
jondunn said:
All I said was before I submitted contours for the first time and said hey plan tbis VMAT CSI I’m gonna at least talk to my physics team who I have a fantastic relationship with so they can brainstorm and think ahead on how they will handle
Click to expand...
Great!

I misunderstood that you were going to ask permission from your overlords (clinic admin, physics, dosi) to practice medicine.
Practice for a bit in a place that has had permalocums for a while and you will understand where I'm coming from.
 
Moonbeams said:
I do it, and I'm basically the only one here. The alternative is intrathecal chemo, which is arguably worse.

What dose did this study go to? I have a lady with LMD I'm treating right now (no disease elsewhere, excellent PS, non-symptomatic). I do VMAT, and yes my staff hate me for it. Counts are low but she was getting Ibrance initially (now held). I also have to do about 7-8 mm PTV margins on the spine. I've tried 6mm in the past, but setup was extremely challenging to not have the sac creep out of the PTV somewhere and had to re-plan.

I am treating to 36 Gy in 20 fractions. I use this paper to justify to insurance: Outcome and prognostic factors following palliative craniospinal irradiation for leptomeningeal carcinomatosis

30 Gy in 10 fractions to the entire CNS seems like it would be pretty toxic, and I haven't found any data to support that.
Click to expand...

Not wrong to do 36/20. I'm doing 30/10 based on:

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases - PMC

Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. We evaluated the toxicities of proton craniospinal irradiation ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Moderator note: After a report popped up in the moderation queue, I deleted a few posts that were essentially personal attacks, please keep it professional.
 
Neuronix said:
Not wrong to do 36/20. I'm doing 30/10 based on:

Clinical trial of proton craniospinal irradiation for leptomeningeal metastases - PMC

Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. We evaluated the toxicities of proton craniospinal irradiation ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Thanks. Glad to know this is a reasonable option. Would definitely be preferably to get these people done in 2 weeks vs. 4, both for staff/patient convenience, and radiobiology of breast which is what most of these are.

From the standpoint of hematologic toxicity and radiosensitivity of bone marrow, I would also think that limiting fractions would be preferable, but I did not know about how they would otherwise tolerate higher dose per fraction, and of course all peds CSI data is low dose per fraction.
 
jondunn said:
All I said was before I submitted contours for the first time and said hey plan tbis VMAT CSI I’m gonna at least talk to my physics team who I have a fantastic relationship with so they can brainstorm and think ahead on how they will handle
Click to expand...
You should try escalation.
"If you don't come up with a plan for this CSI with VMAT, I am coming tomorrow with a request for a TBI with VMAT".

Diamonds are created under pressure.
😛 😛 😛
 
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