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radoncftw said:
I don't understand how any Rad Onc (or Med Onc) can laud the omission trials. I have been out in practice for only a few mo and every single one of my breast patients who has started ET hates it. Some have already switched to a different type of ET because they can't tolerate the first agent they are receiving. I know that our treatments can cause toxicity, sometime bad toxicity, but frankly I am sick of Med Oncs minimizing the extent to which systemic therapy can cause bad toxicity too. Any thought of RT omission really hinges on patient getting long term ET. What is going to be easier for the patient? 5 Fx over 1 wk with minimal toxicity or 5-10 years of agony. Here's another thought: Imaging giving men 5-10 yr of ADT. Yikes.
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I honestly think some of the PIs of these studies haven't seen actual patients, or aren't very busy, clinically
 
RickyScott said:
You aren’t going to find the answer in science/dafa. It is abt self promotion and the psychology of virtue signalling. In corey”s wet dreams, the women of Cleveland demand him not chirag, because he is an honest arbiter of xrt necessity:
Same sht at Cornell where some tool is pushing prostate sbrt in 2 fractions with mri linac to compete with the better center next door. (Despite the fact that 2 fractions of hdr failed miserably) the mf even claimed it was cost effective despite when Cornell’s price is probably 100k
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For those interested in virtual signaling…

Couldn’t one design a trial/analysis showing choosing RT over HT for breast cancer as a means of reducing costs?

Who says you can’t have your cake and eat it too?
 
Lamount said:
For those interested in virtual signaling…

Couldn’t one design a trial/analysis showing choosing RT over HT for breast cancer as a means of reducing costs?

Who says you can’t have your cake and eat it too?
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I guess you would have to find someone to pay for it vs some diagnostic company.
 
radoncftw said:
I don't understand how any Rad Onc (or Med Onc) can laud the omission trials. I have been out in practice for only a few mo and every single one of my breast patients who has started ET hates it. Some have already switched to a different type of ET because they can't tolerate the first agent they are receiving. I know that our treatments can cause toxicity, sometime bad toxicity, but frankly I am sick of Med Oncs minimizing the extent to which systemic therapy can cause bad toxicity too. Any thought of RT omission really hinges on patient getting long term ET. What is going to be easier for the patient? 5 Fx over 1 wk with minimal toxicity or 5-10 years of agony. Here's another thought: Imaging giving men 5-10 yr of ADT. Yikes.
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Hahahaha.

This mirrors my experience exactly.

Meanwhile, even when I use the glacial-pace 15 fraction whole breast regimen...I've had zero quitters.
 
Lamount said:
For those interested in virtual signaling…

Couldn’t one design a trial/analysis showing choosing RT over HT for breast cancer as a means of reducing costs?

Who says you can’t have your cake and eat it too?
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5 years of hormone therapy is going to be cheaper than even 5 fractions of RT… cheaper by a HUGE amount at some centers

9B9303B0-C2D6-4B20-9A51-056984D5DA97.png
 
theradiator said:
RealSimulD: was only getting started. He meant to include additional diagnostic mammograms, one or more MRIs, multiple biopsies of additional calcifications or nodularities, oncoplastic reconstruction, reduction mammoplasties, intraoperative ultrasound, Margin probe, additional CDK4/6 inhibitors, TDM-1 and/or immunotherapy, EKGs (Memorial Sloan Kettering only), genetic testing even if performed only a few years prior, Oncotype, Breast Cancer Index test, etc, etc and so forth. Somehow only RT - the only intervention with level 1 evidence improving overall survival - gets eliminated.

Our breast cancer leaders are really grossly incompetent. As opposed to the 3 A's, how about the 4 D's dereliction of duty directly leading to damage to our field.
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elementaryschooleconomics said:
Hahahaha.

This mirrors my experience exactly.

Meanwhile, even when I use the glacial-pace 15 fraction whole breast regimen...I've had zero quitters.
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I have become more and more convinced that academic breast rad oncs don't follow their patients long term. Or if they do they don't talk about AI's at follow up visits.

I've spent more time on follow ups managing AI issues than radiation issues for early stage breast cancer. Patient's HATE IT. I have family members effected by it and it has killed QoL.

It is just really hard to understand why we as an oncology community have not tried to figure out who can omit that damn pill.
 
BobbyHeenan said:
I have become more and more convinced that academic breast rad oncs don't follow their patients long term. Or if they do they don't talk about AI's at follow up visits.

I've spent more time on follow ups managing AI issues than radiation issues for early stage breast cancer. Patient's HATE IT. I have family members effected by it and it has killed QoL.

It is just really hard to understand why we as an oncology community have not tried to figure out who can omit that damn pill.
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Similar to radiation data, we know that hormonal therapy improves overall survival in meta-analyses. Medical oncology leadership doesn't waste time criticizing that conclusion even though the underlying studies are ancient, mostly detected on clinical exam and few of the patients were over 70 years of age. In contrast to our academics, breast medical oncologists are too busy taking pharma money with both hands to 'waste' their time on omission studies and are instead focused on expanding indications on patent protected medications. In the absence of evidence to the contrary, is just accepted as gospel that hormonal therapy improves overall survival when there logically must be a subgroup where it does not.

There was a recent review showed that less than 60% of older breast conservation patients received RT while a higher percentage received hormonal therapy.

pubmed.ncbi.nlm.nih.gov

Breast conservation among older patients with early-stage breast cancer: Locoregional recurrence following adjuvant radiation or hormonal therapy - PubMed

LRR risk following BCS is low among women aged ≥65 years with T1N0, ER+/HER2- breast cancer. Adjuvant RT and HT monotherapy each similarly reduce this risk; the combination yields a marginal improvement. Further study is needed to elucidate whether appropriate patients may feasibly receive...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
We can complain about anti-E therapy, because we don't dabble in it... but it has probably saved more lives than radiation has. I'm moderately confident that's so; the med oncs are supremely confident that is so. One of the main complaints I hear from patients is weight gain. Had one patient tell me "I had a lot of hobbies before I got breast cancer, now my main hobby is gaining weight." We will never get news articles about the debilitating side effects of 5-fraction breast RT, but keep in mind this is a disease where fear rules (even rules the rad oncs!) as much as or more than logic does.
 
TheWallnerus said:
We can complain about anti-E therapy, because we don't dabble in it... but it has probably saved more lives than radiation has. I'm moderately confident that's so; the med oncs are supremely confident that is so. One of the main complaints I hear from patients is weight gain. Had one patient tell me "I had a lot of hobbies before I got breast cancer, now my main hobby is gaining weight." We will never get news articles about the debilitating side effects of 5-fraction breast RT, but keep in mind this is a disease where fear rules (even rules the rad oncs!) as much as or more than logic does.
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Anything node + or young i'm really pushing that AI.

But over 70 and at 4 weeks post AI they're already miserable.....that patient doesn't need to suffer. She very well may also not need radiation...but even if this type of patient is a small % of all breast cancers, the absolute number is ENORMOUS. We have done them a disservice to not try to figure out who really needs that pill. All the focus has been on eliminating the radiation and there are a zillion explanations why (ranging from used to be 7 weeks treatment, to career aspirations of rad oncs)...but it's frustrating to see EUROPA docs asking what I perceive (bias and all) as the right questions while the US docs are asking the wrong one.

The new calculus as of 2022 is that we have a 5 treatment regimen for radiation and an even better understanding of biology (oncotypes, etc)...so efforts need to be re focused.
 
BobbyHeenan said:
Anything node + or young i'm really pushing that AI.

But over 70 and at 4 weeks post AI they're already miserable.....that patient doesn't need to suffer. She very well may also not need radiation...but even if this type of patient is a small % of all breast cancers, the absolute number is ENORMOUS. We have done them a disservice to not try to figure out who really needs that pill. All the focus has been on eliminating the radiation and there are a zillion explanations why (ranging from used to be 7 weeks treatment, to career aspirations of rad oncs)...but it's frustrating to see EUROPA docs asking what I perceive (bias and all) as the right questions while the US docs are asking the wrong one.

The new calculus as of 2022 is that we have a 5 treatment regimen for radiation and an even better understanding of biology (oncotypes, etc)...so efforts need to be re focused.
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Important reason to have a good relationship with your surgeons... Have had a few pts directly referred to me for xrt when they clearly weren't going to do any type of endocrine tx
 
medgator said:
Important reason to have a good relationship with your surgeons... Have had a few pts directly referred to me for xrt when they clearly weren't going to do any type of endocrine tx
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Yes.

And good luck getting the 70 year old still on estrogen to not only go off estrogen, but take and tolerate AI . Forget about it.
 
Actual discourse at breast tumor board. Med onc brought up the "cost savings" of using DecisionRT to spare RT. No discussion of other forms of potentially wasteful spending for modalities that have not reduced their footprint from 33 to 5 fractions. No discussion of a test to inform the need for chemoprevention. No discussion of PPS exempt or drug spending. I give up.
 
theradiator said:
Actual discourse at breast tumor board. Med onc brought up the "cost savings" of using DecisionRT to spare RT. No discussion of other forms of potentially wasteful spending for modalities that have not reduced their footprint from 33 to 5 fractions. No discussion of a test to inform the need for chemoprevention. No discussion of PPS exempt or drug spending. I give up.
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The biggest threat to rad onc was never did you babysit the linac during your lunch hour today, who’s doing too much breast IMRT, or even who did or didn’t succumb to UroRads… it was our place at the Oncology Table and how we were perceived sitting there.
 
TheWallnerus said:
The biggest threat to rad onc was never did you babysit the linac during your lunch hour today, who’s doing too much breast IMRT, or even who did or didn’t succumb to UroRads… it was our place at the Oncology Table and how we were perceived sitting there.
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theradiator said:
Med onc brought up the "cost savings" of using DecisionRT to spare RT.
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We're experiencing the inevitable consequences of our own actions.

"Radiation" is confusing to everyone because it's not in the spectrum of human experience. It's simultaneously everywhere in our environment, can affect us directly...and is invisible without technology.

So we take this fundamentally confusing force and then use it in medicine. Compared to the other specialties with a heavy radiation component, we are the most involved/"high-profile" doctors when treatment decisions are without concrete "good" and "bad" options.

We should have been ambassadors. We should have worked to democratize understanding of radiation and radiation therapy.

But what did we do? We aggressively tried to eliminate ourselves. We changed definitions of what "modulated" means, or wrote our own guidelines shaming each other for treatment choices, or published studies trying to reduce radiotherapy...or even better, omit. We focused on hazing trainees and developed a culture where memorizing p-values from old, obscure studies somehow means you're "smart". If you don't know the proteins in the DNA damage response signaling pathways, well, you're not minimally competent!

We objectively look ridiculous. Because saying some proprietary test with a high out-of-pocket cost should be used to avoid a quick, evidenced-based treatment is Willy Wonka-level insane.

And we completely deserve it.
 
I have had the omission discussion with every early stage patient over the age of 70. Sometimes I advise against it but still bring it up anyway. Sometimes I say it's reasonable.

I have never, once, had an invasive patient choose omission. Literally ever. For DCIS a couple of times.

In training, the breast attending would have hour+ long conversations with patients about omission data and show picture after picture of lymphedema and skin toxicity. It was bizarre and ridiculous and I could only imagine what the patient thought.
 
Moonbeams said:
I have had the omission discussion with every early stage patient over the age of 70. Sometimes I advise against it but still bring it up anyway. Sometimes I say it's reasonable.

I have never, once, had an invasive patient choose omission. Literally ever. For DCIS a couple of times.

In training, the breast attending would have hour+ long conversations with patients about omission data and show picture after picture of lymphedema and skin toxicity. It was bizarre and ridiculous and I could only imagine what the patient thought.
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ah yes - the "academic" mentality. less is more. i have never seen people fight harder to not see patients. i remember being a resident seeing inpatient consults and literally having to beg to find someone to "staff".

Things are much different in community practice
 
The other thing about breast academics is besides the constant mental gymnastics to avoid actually treating patients and severely over-complicating the treatments on the occasions that they do treat is that they have no idea how to treat other bread and butter sites. Prostate? Esophagus? Not possible. Can you even look up how to do it if you had to? In many cases no. Really amazing.


0_2WgjdiJNFmKQsSHb.jpeg
 
radoncftw said:
ah yes - the "academic" mentality. less is more. i have never seen people fight harder to not see patients. i remember being a resident seeing inpatient consults and literally having to beg to find someone to "staff".

Things are much different in community practice
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When I was a resident I had one senior attending who would insist on obtaining all the relevant clinical information to review before a consult. If the patient "probably wouldn't benefit" from radiation then the attending would cancel the consult.

The Chair had told him on multiple occasions to at least bring the patient in so that you can inform him/her and BILL FOR THE CONSULT. However, that attending was tenured and untouchable so he laughed it off.

I had another attending who was a big-time site specialist so, naturally, got a lot of 2nd opinions. However she was very annoyed that the patient wouldn't stay locally for treatment but would go back to the community. She then stopped seeing second opinions because "why put in the effort if the patient is only going to be treated elsewhere?"
 
I think the academic mentality is one of the biggest problems with our field. Most fields are majority private practice. Radonc has been different in this regard and there is definitely a degree of work aversion/laziness/ that permeates academics… especially pre-rvu
 
TheWallnerus said:
DEI research… an ironclad always legit excuse for the new generation not to do real research in clinic or at the bench???

Discuss
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I try not to wade into these things, but one of the mud phuds I know is making great strides to bring diversity to the forefront of theirs and others departments. It’s through a genuine desire of theirs to help with underrespresentation, as they came from a very unlikely and underprivileged background. It’s remarkable that one could accomplish so much, coming from those kind of circumstances. Attention to efforts to raise people up, encourage them for more success, I can’t argue with and I think has a role to play. Sometimes people had a rough go and recognize it’s tough to get to this level of professional success, and want to make it easier for other well deserving folks. Call me naive, but I think that’s an important part of what a society should strive for. A rising tide lift all ships, and all that.
 
taserlaser said:
I try not to wade into these things, but one of the mud phuds I know is making great strides to bring diversity to the forefront of theirs and others departments. It’s through a genuine desire of theirs to help with underrespresentation, as they came from a very unlikely and underprivileged background. It’s remarkable that one could accomplish so much, coming from those kind of circumstances. Attention to efforts to raise people up, encourage them for more success, I can’t argue with and I think has a role to play. Sometimes people had a rough go and recognize it’s tough to get to this level of professional success, and want to make it easier for other well deserving folks. Call me naive, but I think that’s an important part of what a society should strive for. A rising tide lift all ships, and all that.
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The problem is that most DEI research is trash, and before the DEI boom very few people were interested. There simply aren't many URM in rad onc or med onc, unfortunately it is unlikely to change. Would have to target medical students to encourage more URM to enter the field, and we are the most esoteric field with the least representation in medical school curriculum, not to mention anything about the future job market.
 
Radonky said:
The problem is that most DEI research is trash, and before the DEI boom very few people were interested. There simply aren't many URM in rad onc or med onc, unfortunately it is unlikely to change. Would have to target medical students to encourage more URM to enter the field, and we are the most esoteric field with the least representation in medical school curriculum, not to mention anything about the future job market.
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Huge push for dei and getting URMs into the field now given the lack of MS4 interest by academic depts
 
taserlaser said:
I try not to wade into these things, but one of the mud phuds I know is making great strides to bring diversity to the forefront of theirs and others departments. It’s through a genuine desire of theirs to help with underrespresentation, as they came from a very unlikely and underprivileged background. It’s remarkable that one could accomplish so much, coming from those kind of circumstances. Attention to efforts to raise people up, encourage them for more success, I can’t argue with and I think has a role to play. Sometimes people had a rough go and recognize it’s tough to get to this level of professional success, and want to make it easier for other well deserving folks. Call me naive, but I think that’s an important part of what a society should strive for. A rising tide lift all ships, and all that.
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Great! But is all what you said research. Does it follow a scientific method. Are there testable hypotheses. Was MLK Jr a scientist.
 
TheWallnerus said:
Great! But is all what you said research. Does it follow a scientific method. Are there testable hypotheses. Was MLK Jr a scientist.
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Salient point. Even on my post, seems that anything like that gets a label, whether it is research like you say, or advocacy projects, etc. There is a spectrum, and a lot of overlap. More of the projects I’ve seen have included a research component, moreso I think at the level of trying to characterize/describe the problem/issue. As with anything in RO, describing and characterizing a population is much more facile than evaluating an intervention, but I suspect we will arrive at that point soon enough. Have to start somewhere. I just was made aware of another university and RO program which ended up adjusting their rank list to account for DEI issues as part of a pilot stufy. It did require extensive unconscious bias training, ethics, legal review, and using quite detailed and sensitive information from the applicants in the end. I suspect we’ll be getting their results published soon. But research along the lines of hiring/admissions process has been done at the UME level for a while, and PGME level amongst some larger specialties, and I think it’s not unreasonable to think it could come to this small specialty.

Are there testable hypotheses? I think there has to be. Do people follow the rigueur like in basic sciences? Perhaps. But also there is a distribution amongst those that do clinical research as well. How many studies have we read where (and in especially rare disease sites) we see what ends up being ‘we did this, this happened’. There’s probably room for both I imagine.

As for MLK - I’ll leave that for someone else’s thesis. Who know what other hobbies he had in his free time lol
 
RickyScott said:
From twitter posts, seems like there are almost no white males interested in radonc. The DEI crowd should celebrate?
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Ironically, in Canada I think the new chair of the soon to be DEI committee for RO will be a senior mud phud white male. I believe he is very much aware of the irony.
 
taserlaser said:
Salient point. Even on my post, seems that anything like that gets a label, whether it is research like you say, or advocacy projects, etc. There is a spectrum, and a lot of overlap. More of the projects I’ve seen have included a research component, moreso I think at the level of trying to characterize/describe the problem/issue. As with anything in RO, describing and characterizing a population is much more facile than evaluating an intervention, but I suspect we will arrive at that point soon enough. Have to start somewhere. I just was made aware of another university and RO program which ended up adjusting their rank list to account for DEI issues as part of a pilot stufy. It did require extensive unconscious bias training, ethics, legal review, and using quite detailed and sensitive information from the applicants in the end. I suspect we’ll be getting their results published soon. But research along the lines of hiring/admissions process has been done at the UME level for a while, and PGME level amongst some larger specialties, and I think it’s not unreasonable to think it could come to this small specialty.

Are there testable hypotheses? I think there has to be. Do people follow the rigueur like in basic sciences? Perhaps. But also there is a distribution amongst those that do clinical research as well. How many studies have we read where (and in especially rare disease sites) we see what ends up being ‘we did this, this happened’. There’s probably room for both I imagine.

As for MLK - I’ll leave that for someone else’s thesis. Who know what other hobbies he had in his free time lol
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Since the Enlightenment, there has been a focus in science and scientific research on rigorously following the scientific method; if the scientific method isn’t followed, or one is in a field where the scientific method can’t be applied, it’s not science. I guess with DEI research we can throw centuries of scientific progress away and finally make real progress that matters.
 
taserlaser said:
I try not to wade into these things, but one of the mud phuds I know is making great strides to bring diversity to the forefront of theirs and others departments. It’s through a genuine desire of theirs to help with underrespresentation, as they came from a very unlikely and underprivileged background. It’s remarkable that one could accomplish so much, coming from those kind of circumstances. Attention to efforts to raise people up, encourage them for more success, I can’t argue with and I think has a role to play. Sometimes people had a rough go and recognize it’s tough to get to this level of professional success, and want to make it easier for other well deserving folks. Call me naive, but I think that’s an important part of what a society should strive for. A rising tide lift all ships, and all that.
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I think we all agree with you and obviously what you stated is a good thing. I'm not sure anyone disagrees. The disagreement comes with how this is implemented with the current DEI plan. I am sure you are aware that DEI has caused much division and any dissent against comes at the peril of your career and/or reputation. Do you truly believe, the current DEI movement is an inclusive movement that is bringing harmony and is a rising tide? I truly believe it is accomplishing the opposite of those goals.

I also think it is tremendously ironic having a mud phud white male in charge of DEI... if that dude makes one small misstep he'd better watch out LOL
 
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RadOncMegatron said:
I think we all agree with you and obviously what you stated is a good thing. I'm not sure anyone disagrees. The disagreement comes with how this is implemented with the current DEI plan. I am sure you are aware that DEI has caused much division and any dissent against comes at the peril of your career and/or reputation. Do you truly believe, the current DEI movement is an inclusive movement that is bringing harmony and is a rising tide? I truly believe it is accomplishing the opposite of those goals.

I also think it is tremendously ironic with have a mud phud white male in charge of DEI... if that dude makes one small misstep he'd better watch out LOL
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DEI is fine. DEI is great! We need DEI.

But let’s not call it science. Just because we are in a scientific field doesn’t mean we have to label every single ethos or goal “science” or “research.” These words have deep meanings that are essentially unalterable at this point; quite unlike the words “man” or “she” or “they,” I hope. If DEI research is submitting itself to falsifying its own hypotheses, which is the primary goal of science/the scientific method, then I shall stand corrected. Otherwise it truly is holding itself out as the Latin “Dei.”
 
There is a lot of top DEI... and some that is mediocre as well (which can be said about any field of research).

The problematic part about DEI is... there doesn't appear to be equipoise in terms of what is publishable

Whenever I read a DEI paper, regardless of how valid the questions and how meticulous the statistical analysis, I always find myself asking a simple question "would an identical paper that had the opposite conclusion be published?" Most of the time, the answer is "nope".

We always encounter some degree of publication bias in medicine... particularly with phase I and phase II trials. However, the results of practice changing phase III trials usually find their way into a journal, even when they are negative. DEI research also seeks to change practice, but does so when no dissenting hypotheses can ever be tested.
 
Lamount said:
There is a lot of top DEI... and some that is mediocre as well (which can be said about any field of research).

The problematic part about DEI is... there doesn't appear to be equipoise in terms of what is publishable

Whenever I read a DEI paper, regardless of how valid the questions and how meticulous the statistical analysis, I always find myself asking a simple question "would an identical paper that had the opposite conclusion be published?" Most of the time, the answer is "nope".

We always encounter some degree of publication bias in medicine... particularly with phase I and phase II trials. However, the results of practice changing phase III trials usually find their way into a journal, even when they are negative. DEI research also seeks to change practice, but does so when no dissenting hypotheses can ever be tested.
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Trying to dissent in DEI:

 
TheWallnerus said:
DEI is fine. DEI is great! We need DEI.

But let’s not call it science. Just because we are in a scientific field doesn’t mean we have to label every single ethos or goal “science” or “research.” These words have deep meanings that are essentially unalterable at this point; quite unlike the words “man” or “she” or “they,” I hope. If DEI research is submitting itself to falsifying its own hypotheses, which is the primary goal of science/the scientific method, then I shall stand corrected. Otherwise it truly is holding itself out as the Latin “Dei.”
Click to expand...

It would be really awesome for medicine if people agreed it was advocacy not research, and then medical schools valued advocacy like they value bench or clinical research. We might have more action and less papers. I think that would be great for all.
 
I am so glad I got into pissing matches with universities and large hospital systems during review over take-it-or-leave-it contracts and didn't end up working there. My lawyer basically said this is the most ridiculous nonsense I have ever seen, why would you sign this. Oh well, ma'am, let me tell you about all the perks of working for these mega institutions...
 
Lamount said:
There is a lot of top DEI... and some that is mediocre as well (which can be said about any field of research).

The problematic part about DEI is... there doesn't appear to be equipoise in terms of what is publishable

Whenever I read a DEI paper, regardless of how valid the questions and how meticulous the statistical analysis, I always find myself asking a simple question "would an identical paper that had the opposite conclusion be published?" Most of the time, the answer is "nope".

We always encounter some degree of publication bias in medicine... particularly with phase I and phase II trials. However, the results of practice changing phase III trials usually find their way into a journal, even when they are negative. DEI research also seeks to change practice, but does so when no dissenting hypotheses can ever be tested.
Click to expand...
Was going to write the same thing but you put it much more eleoquently. Propents of dei would contest even the notion of falsification as racism.
 
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