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medgator said:
Supervision train left the station... CMS actually started up the locomotive at the beginning of 2020 pre pandemic iirc @TheWallnerus
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Yeah, I'm a bit confused if the concern is that we were improperly tying our high compensation to linac babysitting where we would literally do nothing or to the amount of time it takes to plan and supervise a treatment course. I'd argue the former is far more damning. If you can manage 25 patients in 3 days a week, that doesn't mean we are secretly 0.6 FTE doctors getting paid 1.0 FTE rates. It's just the value of our labor. Very admin-ish way to be concerned about it -- if you're not on site 40 hours a week, you're not working as hard/much as you should. Go pull some patients out of thin air or else type 3 page long A&Ps and contour the lungs slice by slice to justify your worth? Maybe have a bunch of meetings. Don't punish somebody for being efficient.
 
Moonbeams said:
Yeah, I'm a bit confused if the concern is that we were improperly tying our high compensation to linac babysitting where we would literally do nothing or to the amount of time it takes to plan and supervise a treatment course. I'd argue the former is far more damning. If you can manage 25 patients in 3 days a week, that doesn't mean we are secretly 0.6 FTE doctors getting paid 1.0 FTE rates. It's just the value of our labor. Very admin-ish way to be concerned about it -- if you're not on site 40 hours a week, you're not working as hard/much as you should. Go pull some patients out of thin air or else type 3 page long A&Ps and contour the lungs slice by slice to justify your worth? Maybe have a bunch of meetings. Don't punish somebody for being efficient.
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The problem is the academic overlords like Potters, Steinberg, Hallahan etc have used supervision regs as a way to justify overtraining and residency expansion. Forgetting of course that pre IGRT, direct was never the law of the land

So it's a big house of cards waiting to fall
 
medgator said:
The problem is the academic overlords like Potters, Steinberg, Hallahan etc have used supervision regs as a way to justify overtraining and residency expansion.

So it's a big house of cards waiting to fall
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Their argument was we have to train a bunch of linac babysitters? Recruit the best and brightest med students by putting them through a grueling board certification process with the promise of a low paid satellite job where they have nothing to do and are not allowed to leave? What a joke.
 
Moonbeams said:
Their argument was we have to train a bunch of linac babysitters? Recruit the best and brightest med students by putting them through a grueling board certification process with the promise of a low paid satellite job where they have nothing to do and are not allowed to leave? What a joke.
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When you're cutting fractions left and right, what else do you have left?
 
OTN said:
I am once again reiterating to any CMMS employees browsing this thread that these are outlier cases and not indicative of the time, energy, and effort it takes to provide the excellent radiotherapeutic cancer care patients deserve to receive.
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I agree, as shown in Figure 1 many members of the ASTRO membership actively participate in a broad variety of clinical activities that would require a large number of hours of onsite management.

US Radiation Oncologists (Re)Defined: An American Society for Radiation Oncology Scope of Practice Study - PMC

To assess US radiation oncologists’ views on practice scope and the ideal role of the radiation oncologist (RO), the American Society for Radiation Oncology (ASTRO) conducted a scope of practice survey. In spring 2019, ASTRO distributed an online ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
Fpg1245 said:
This entire thing is quickly becoming fraudulent.
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For-fifteen-thousand-years-fraud-and-short-sighted-thinking-have-never-ever-worked.-Not-once.-Eventually-you-get-caught-things-go-south.jpg
 
West Virginia has an especially atrocious economy, public health situation, and payor mix that impacts physicians. Really needs its own classification. Beautiful state, though.
 
Mandelin Rain said:
This ought to clear it up
View attachment 359633
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I don’t love this map.

East Tennessee remained staunchly pro Union in the Civil War and attempted to secede from the rest of TN (middle and west TN). This is why there are three stars on its state flag to this day (East, Middle, West TN) signifying its divisions during the Civil War. So not easily confirmed as Confederate. Certainly not as Confederate as, say, Georgia.

wtl7fis.png


Second, Kentucky and MO are in the SEC… no school in Virginia is…

I could go on 🙂
 
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TheWallnerus said:
I don’t love this map.

East Tennessee remained staunchly pro Union in the Civil War and attempted to secede from the rest of TN (middle and west TN). This is why there are three stars on its state flag to this day (East, Middle, West TN) signifying its divisions during the Civil War. So not easily confirmed as Confederate. Certainly not as Confederate as, say, Georgia.

wtl7fis.png


Second, Kentucky and MO are in the SEC… no school in Virginia is…

I could go on 🙂
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keeping up appearances 90s GIF
 
TheWallnerus said:
I don’t love this map.

East Tennessee remained staunchly pro Union in the Civil War and attempted to secede from the rest of TN (middle and west TN). This is why there are three stars on its state flag to this day (East, Middle, West TN) signifying its divisions during the Civil War. So not easily confirmed as Confederate. Certainly not as Confederate as, say, Georgia.

wtl7fis.png


Second, Kentucky and MO are in the SEC… no school in Virginia is…

I could go on 🙂
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No NC schools either. Bunch of basketball fans. Yuck.
 


Thoughts on potential bias of this trial with Boston Scientific sponsorship? Primary endpoint: G2+ GI toxicity. No doubt what will be found.

PACE-B no spacers and:

 
As has been pointed out here before, the placement of a SpaceOAR device itself should constitute at least Grade 1 toxicity. I'm not holding my breath to see 100% G1 rates in the SpaceOAR arm, though. Something tells me Boston Scientific would disagree with our assessment there.
 
Within the last year they sent out a letter addressing several vascular embolism complications from injecting into a vessel.

I wasn't really excited about it in the first place.... but offered it regardless. Since then, pretty much all of us have stopped.
 
OTN said:
As has been pointed out here before, the placement of a SpaceOAR device itself should constitute at least Grade 1 toxicity. I'm not holding my breath to see 100% G1 rates in the SpaceOAR arm, though. Something tells me Boston Scientific would disagree with our assessment there.
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Occasional and minimal pain, G1 rectal toxicity
Intermittent and tolerable pain, G2 rectal toxicity
U/S up the ass and 1 gauge needle through your taint, G?
 
Mandelin Rain said:
Like SBRT vs Lobectomy.

Faint erythema = G1 toxicity
Thoracotomy wound = All part of the plan
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This is why the chest wall / rib fracture complication rate for SBRT makes me chuckle.
100% rib fracture rate with surgery and 100% chance of thoracotomy site pain. I've never met anyone that said it doesn't hurt.
And we worried about 30% chance of discomfort? So overly conservative.
 
RealSimulD said:
This is why the chest wall / rib fracture complication rate for SBRT makes me chuckle.
100% rib fracture rate with surgery and 100% chance of thoracotomy site pain. I've never met anyone that said it doesn't hurt.
And we worried about 30% chance of discomfort? So overly conservative.
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But but VATS lobectomy. Whose doing thoros anymore?
 
Guys. The point was meant to be illustrative. Everyone is so literal these days.
 
Is it just me or is it a… cultural phenomenon?… that the more negative radiation trials we get, the more we have academic radiation oncologists statsplaining the shortcomings of studies (almost Talmudically). As opposed to simply saying, like we do for the positive studies, it’s a new standard of care.

 
TheWallnerus said:
Is it just me or is it a… cultural phenomenon?… that the more negative radiation trials we get, the more we have academic radiation oncologists statsplaining the shortcomings of studies (almost Talmudically). As opposed to simply saying, like we do for the positive studies, it’s a new standard of care.

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I gave them the benefit of the doubt after espac 1 (when I was in medschool) but that was a very long time ago. After failing for 30 years, maybe the base reality is that radiation does not help or any even hurts here? My best guess is that some sort of immunosuppression from the xrt leads to poorer outcomes.
 
RickyScott said:
I gave them the benefit of the doubt after espac 1 (when I was in medschool) but that was a very long time ago. After failing for 30 years, maybe the base reality is that radiation does not help or any even hurts here? My best guess is that some sort of immunosuppression from the xrt leads to poorer outcomes.
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My very close friends wrote a veritable screed against ESPAC at the time. Wonder if they’d vent their spleen so nowadays.

 
I remember when calgb breast came out when I was a rotating student. People were upset!! But now, it’s a standard of care. Takes time to get used to. But we just can’t quit pancreas
 
TheWallnerus said:
Is it just me or is it a… cultural phenomenon?… that the more negative radiation trials we get, the more we have academic radiation oncologists statsplaining the shortcomings of studies (almost Talmudically). As opposed to simply saying, like we do for the positive studies, it’s a new standard of care.
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It's brutal and I'm prone to it. With pancreas we now have decades of negative data. I would say that the expectation going into Alliance A021501 should have been that it was going to be a negative trial. I wouldn't read too much into XRT being detrimental here (might be, who knows, probably is a little, but probably not as much as it seems from this trial), but I think promoting XRT as part of a neoadjuvant borderline strategy is just ridiculous at this point. There has been more data for chemo response than XRT response since forever.

I'm just a community doc, and I care about trial design and stats probably to justify (to myself and tumor boards) retention of XRT in many clinical scenarios. I have no doubt that my community medonc colleagues don't worry much about this at all. Another 4 month progression free survival benefit with addition of IO? Yeah! Curves deviating clearly and reproducibility in multiple trials and always in favor of their new intervention? Must feel nice.
 
communitydoc13 said:
It's brutal and I'm prone to it. With pancreas we now have decades of negative data. I would say that the expectation going into Alliance A021501 should have been that it was going to be a negative trial. I wouldn't read too much into XRT being detrimental here (might be, who knows, probably is a little, but probably not as much as it seems from this trial), but I think promoting XRT as part of a neoadjuvant borderline strategy is just ridiculous at this point. There has been more data for chemo response than XRT response since forever.

I'm just a community doc, and I care about trial design and stats probably to justify (to myself and tumor boards) retention of XRT in many clinical scenarios. I have no doubt that my community medonc colleagues don't worry much about this at all. Another 4 month progression free survival benefit with addition of IO? Yeah! Curves deviating clearly and reproducibility in multiple trials and always in favor of their new intervention? Must feel nice.
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In my community, I encourage multi-agent neoadjuvant chemo in all patients with inoperable pancreatic cancer. After chemo, if surgery remains questionable (which is typically the case), then we can offer XRT (I prefer SBRT > conventional radiation). However, I emphasize to patients that this is really a "Hail Mary" to render them resectable or at least maximize local-regional control.
 
Gfunk6 said:
In my community, I encourage multi-agent neoadjuvant chemo in all patients with inoperable pancreatic cancer. After chemo, if surgery remains questionable (which is typically the case), then we can offer XRT (I prefer SBRT > conventional radiation). However, I emphasize to patients that this is really a "Hail Mary" to render them resectable or at least maximize local-regional control.
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I never do conventional because it simply doesn’t work. Usually go with 75/25
 
Gfunk6 said:
In my community, I encourage multi-agent neoadjuvant chemo in all patients with inoperable pancreatic cancer. After chemo, if surgery remains questionable (which is typically the case), then we can offer XRT (I prefer SBRT > conventional radiation). However, I emphasize to patients that this is really a "Hail Mary" to render them resectable or at least maximize local-regional control.
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RickyScott said:
I never do conventional because it simply doesn’t work. Usually go with 75/25
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So yeah. What usually happens is chemo upfront, patient not going to surgery or maybe never was, and we are asked to irradiate. And does irradiating to 50 or 54 Gy with chemo in this era predispose patients to worse outcomes than a non RT approach. And on the basis of this trial, does any RT, SBRT or otherwise, predispose patients as a group to worse outcomes. Data not anecdotes. Preferably from this century and especially within the last 10 years.
 
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