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deleted1111261
Jake is fine. We chatted. It’s a perception.
And he’s at least open to the possibility his perception isn’t the reality of it.
And he’s at least open to the possibility his perception isn’t the reality of it.
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deleted1111261
I wish the real Matt Spraker was this funny
surprised the tweet is still up. gives me a tad more respect for lou.
i don't think you want to go down the rabbit hole of looking up COIs and trials/devices.
see SpaceOAR thread and also every immunotherapy trial ever.
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He's also at Cleveland Clinic, which from the outside seems to have among the most pro-resident department in the public sphere. His exposure the woes in the field is going to be limited.
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deleted1111261
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Potters just putting that foot in deeper. Probably the most tone deaf chair the country, since Marcus Randall and the cancel culture op-ed
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Todays Nobel prize in physics. Does a photon have a polarization before it is measured? Does any particle/set of entangled particles have a property before being measured? Einstein believed that there is such a base reality, a “hidden variable” ie that a photon does have an actual polarization or entangled electrons do have an actual direction of spin before being measured. Bell proved that hidden variables can’t exist and the prize went to experimentalists who confirmed bells thereom.
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PhineasGageRadOnc
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Wow medgator, I followed that thread. Here are the gems.
Louis Potters thinking his reply with fellow dingus James Urbanic is private 🤣. Lamenting how the "twitter gen" (apparently including many people outside of radiation oncology and multiple more senior radiation oncologists) backed up Amar Kishan.
Then Potters gets owned by MROGA.
Louis Potters thinking his reply with fellow dingus James Urbanic is private 🤣. Lamenting how the "twitter gen" (apparently including many people outside of radiation oncology and multiple more senior radiation oncologists) backed up Amar Kishan.
Then Potters gets owned by MROGA.
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Potters is a real piece of work and a symptom of a bigger problem. The vast majority of Anderson grads a year ago didn't go into academics and it's a pervasive problem with the field thanks to folks like Potters who eat their young. Why would anyone sign up for that?
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I have a lot of respect for James urbanic. Amars trial was designed/gamed to be positive. I don’t think Amar was particularly influenced by financial incentives but rather the careerist incentive to publish a positive trial. Lou is greedy and thinks everything is about money.
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Question: What if 9 weeks of traditionally fractionated, fiducial/CBCT guided therapy reduced the Grade 2 or greater acute urinary toxicity below 22%? Maybe we should do that as SOC?
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I don't know urbanic but on twitter he has some very reasonable takes, even on proton stuff.
I'm glad this mri trial was done, but there is no escaping the margin issue. As far as I'm aware we have minimal (?no?) clinical efficacy outcomes data that looks at margins. Lots of physics/dosimetry papers...but no strong clinical data. As prostate MRI (diagnostic MRI) gets better and better, i'd be more and more comfortable with minimizing margins...if a bunch of core biopsies are negative in a huge chunk of the prostate and a well done MRI has a nice clean peripheral zone then you feel really good about it. I'm not advocating for partial gland radiation, i'm just saying....
I loathe non-inferiority trials, but somehow they get done and often change practice....anyone wanna bet on a linac with CBCT zero margin trial versus an MRI linac zero margin trial you find non-inferiority for side effects or efficacy?
This trial was essentially clinically worthless due to the margin issue. I don't have a problem with someone pointing that out. Was the author "being played" by the machine companies and PE so they would get the results they want? Certainly is an interesting take and it may have some merit, but it could have been more delicately placed in the narrative without such a direct attack on the author. His private message actually displaces some blame away from the author and (perhaps rightly) places it on his senior advisors.
I've been saying to my wife and other non radoncs that this whole Twitter vs SDN saga has been a great allegory for information battles taking place all over the internet, and the fact that we now have a Boomer doc (I checked, and Gen X starts at 1965, so he Booms) accidentally publishing what was intended to be a private message for all to read, and in said message he calls Millennials the Twitter Gen?
*Chef's kiss*
I've been saying to my wife and other non radoncs that this whole Twitter vs SDN saga has been a great allegory for information battles taking place all over the internet, and the fact that we now have a Boomer doc (I checked, and Gen X starts at 1965, so he Booms) accidentally publishing what was intended to be a private message for all to read, and in said message he calls Millennials the Twitter Gen?
*Chef's kiss*
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deleted1111261
I don’t think anyone was hiding the margin issue. I’ve said my piece on it, but they aren’t wrong by saying that the “standard” margin (which is an academic standard, not reflecting reality of practice) is 4-5mm and theirs’ was 2mm.
I simply don’t care about the COI. Life is a f*ckin COI. You can have zero COIs and be unethical AF. You can have Tom Boike levels (my friend, who collects them like stamps) of COI and practice in a way that I’d send loved ones to.
I simply don’t care about the COI. Life is a f*ckin COI. You can have zero COIs and be unethical AF. You can have Tom Boike levels (my friend, who collects them like stamps) of COI and practice in a way that I’d send loved ones to.
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I don't think it's worthless if your contention is that you can ONLY shrink margins on the basis of superior MR imaging.
Is that true? I don't know. Has it been well evaluated with non-MR guided RT? I don't think so. There is considerable variation between centers on that.
EDIT: Simul beat me.
Is that true? I don't know. Has it been well evaluated with non-MR guided RT? I don't think so. There is considerable variation between centers on that.
EDIT: Simul beat me.
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I wish I had COI!
I agree at a personal level it does not matter, but it matters big time when assessing clinical trials, outcomes, patterns of care, how we bill, all of that.
It is extremely hard to reliably assess toxicity IMO, even in a well designed clinical trial. Just look at the UK breast trials. I think they did the absolute best that they could and they can't reproduce their own toxicity data. So, in the setting of COI, of wanting a particular outcome, these trials that demonstrate some improvement in toxicity must be looked at very skeptically.
I don't know either. MRI does not have the best spatial fidelity. It distorts dimensions but provides much better contrast for soft tissue. Kishan himself states outcomes better in non-adaptive planned patients. Why doesn't an MRI fusion for treatment planning alone do all the things that an MRI at the treatment machine does for margin reduction?
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I guess the theory is real time cine tracking is reducing random error in case of flatus or poop descent.
Real time MRI gives flatus afflatus. And I have waited my whole life to use that phrase.
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can be done without MRI however
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I expect the main issue to be motion management, if you are not using some other technique on a "normal" Linac to control for intrafraction motion of the prostate.
We had an interesting discussion when the first results came up, and (without wanting to brag or anything), here was my comment on the trial:
Rad Onc Twitter
If you read the entire thread or the abstract, you will see that the PTV-margins were not the same. 4mm for the CT-guided SBRT and 2mm for the MRI-guided SBRT. So, basically this is not a pure trial of CT- vs. MRI-guidance, but rather margins AND CT- vs. MRI-guidance. This is sketchy. Not...
forums.studentdoctor.net
What a term... 😍
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Yeah, you nailed it back then. Great critique. Wonder if Potters read it.I expect the main issue to be motion management, if you are not using some other technique on a "normal" Linac to control for intrafraction motion of the prostate.
We had an interesting discussion when the first results came up, and (without wanting to brag or anything), here was my comment on the trial:
Rad Onc Twitter
If you read the entire thread or the abstract, you will see that the PTV-margins were not the same. 4mm for the CT-guided SBRT and 2mm for the MRI-guided SBRT. So, basically this is not a pure trial of CT- vs. MRI-guidance, but rather margins AND CT- vs. MRI-guidance. This is sketchy. Not...
What a term... 😍
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deleted1116990
Ah rad onc twitter. The irony of someone with a 1.8M salary aggressively calling out somebody on a personal basis for taking industry money. What conflict of interest does a 1.8M salary come with? How may patients per day to you have to see to justify that on a pro revenue basis? 30 consults a week and 70 OTVs? Must be a busy man.
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It’s probably 2 million now and I would argue you can’t carry this kind of salary and not have a residency program in New Yorks largest hospital system.Ah rad onc twitter. The irony of someone with a 1.8M salary aggressively calling out somebody for taking industry money. What conflict of interest does a 1.8M salary come with? How may patients per day to you have to see to justify that on a pro revenue basis? 30 consults a week and 70 OTVs? Must be a busy man.
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I am patiently waiting for the Tom's and Amar's out there to replace the absolute dumpster fire of Potters and peers. Worst of the worst in Rad Onc.
Same with Ralph and friends
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Hallahan, Randall, even Steinberg. All of them
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Would add kachnic, dicker, the wash u chair as well that awful Canadian lady.
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deleted1111261
they won’t go. They will retire, but will mostly be replaced by similar people, don’t you think?
The careerist/credentialist academic types drink the Kool Aid hard.
The careerist/credentialist academic types drink the Kool Aid hard.
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deleted1111261
I don’t know that it was gamed?
That was the intention - to use MRI to decrease PTV margins.
I’m not enjoying Urbanic’s descent into questioning the ethics.
If you don’t believe shrinking from 4mm to 2mm is going to change things, then you’re a nihilist.
(Not you - just people that don’t believe this).
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Do you think if I just started shrinking my PTV expansions from 5 mm to 2 mm I'd notice a statistically significant recurrence risk? I could easily design a trial that would show none, or that would show one. The latter would require like a zillion patients. I'm probably arguing a different point here, and certainly being hyperbolic. My belief is that if I shrank PTV margins today and used daily CBCTs, I'd see less toxicity and no obvious change in BCR over the course of my career.
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deleted1111261
100% agree
Amar’s point has been “publish it!”
I’m not an academic. I don’t care about that.
Todd S does all kinds of interesting stuff and some of it I adopt because it’s logical, not because it’s in a journal somewhere.
That’s how a lot of us are.
But for the “radonc-y” types, they need a study.
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I am sure a trial with 0 mm on prostate but 3 mm on mri defined lesion would be equivalent to anything else.
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Agree. Many of us were trained to emphasize Dmin within our target volume and to be concerned about the possibility of a marginal miss. What this means and the significance of cold spots in the SBRT era is completely unknown....but it is probably not very significant when considering the dose fall off for modern plans as well as the doses prescribed. Most of us could likely arbitrarily shrink our margins for SBRT prostate with no appreciable negative clinical consequences.
I do believe that criticism is warranted to the extent that the trial is used to emphasize the value of a particular technology.
Of course, doing a trial at all is hard work and should be lauded.
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Just a drop of Tc-99 PR.
There's some interesting data out there which suggests heterogeneity in SBRT plans for oligomets - even significant cold spots- doesn't seem to influence control the way we would think.
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I think the more important aspect of his point is that there is very little data supporting those small margins. In addition (because of or regardless of data), a lot of people aren't comfortable doing those margins with CT-based imaging. You might be, but if the people recruiting and enrolling to that trial are not comfortable then the trial is DOA. Features of the environment (who is recruiting/enrolling, competing trials, funding, politics, etc.) have a huge impact on design in real life.
If you personally are comfortable, great. At this point, you can do a very easy QI study that is likely IRB exempt. There are many possible designs that would add knowledge, so you can even do it without an MR Linac. There seems to be a lot of people that are "sure" about the results of this hypothetical trial but no one is designing and running it as far as I can tell.
Don't get me wrong, these are definitely valid critiques and great adult discussion as opposed to Boomer/Lou tantrums. The critiques just seem blind to the realities of practical trial design, especially for a single-institution IIT that is internally funded.
As an aside from all of this, I keep thinking about how the Calypso folks must be kicking themselves haha.
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deleted1111261
Great post
The other thing is - nobody does “practical” studies with margins and with volumes, different dose schemes (not just escalation and de-escalation, but SIBs vs SEQ or other variations). They are relatively easy - don’t require much resources. So, places like Tata Memorial can do them, but for some reason the only way we can do it is make it an MRL study and then this cluster happens.
If community doctors wanted to band together and do practical studies, I would be on board with it. Interesting, practical questions that help us figure out how to do our jobs better. But, most of the studies out there aren’t great. B51 is a good one - didn’t have to be NRG and could have been maybe done quickly/efficiently in the real world.
I get it - maybe you all treat with 2mm - but no prospective data on it, and you’d fail on boards saying it (not saying that’s the final arbiter). But, now if you say it, there is data.
Sadly "not much resources" runs up against institutional and government mandated regs at least in the US. Co-operative group trials pay $2000-3000 per accrual. If any place could break even on that, you would think more would participate. Clinical research is a money pit. Even these practical trials of which you speak cost that kind of money or more per accrual.
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Totally. Even me just thinking about skin, a lot of the superficial radiotherapy guidelines suggest using energies for which the base of tumor is covered by D1/2. What other tumor site do we consider covering part of the tumo by half the dose acceptable (Apart from gamma knife)? We really don’t know everything we think we know about this, imo.
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Behind a paywall but this is a really good editorial on this issue. The argument is that we should be able to run clinical quality improvement studies with a lot less regulatory overhead. Obviously NRG-style interventional trials don't fall in to this category, but testing between two slightly different PTV margins is a great example of something that could be done cheaply.
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OK, then do it. Or academics should do it. People are more than willing to throw stones but haven't contributed anything to the literature space in a margin reduction study
If you treat prostate SBRT and do 2mm margins in all directions without a MR-linac, do it, however you want, and publish your outcomes. I am not aware of anyone personally doing that.
The Calypso or other intrafraction monitoring people had DECADES to publish on how their technology would allow safe shrinkage of PTV margins.
I remember a post on SDN a long time ago about someone taking over previous prostate follow-ups treated long ago - they had high rates of rectal toxicity (7-10mm margin posteriorly) or poor rates of control (0mm margin posteriorly) without a good in-between.
LP is remarkably unprofessional in his posts and is mostly getting wrecked on Twitter, which at least is good that folks are coming to Kishan's defense. Of course, I do not expect any professional consequences for him. I'd be ashamed to be affiliated with him or LIJ similar to others at UChicago (RW) or Kentucky (MR). I wouldn't be surprised to see a 'cancel culture: redux' editorial from him a la MR coming up in PRO soon....
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We had a very detailed conversation on this very thread about Mirage when the early results were released. Many here were critical of the study for a number of reasons (including that physician assessed, early grade 2 toxicity was an endpoint). I was critical of it. It is not data that is going to make me lobby for an MRI linac.
The COI is relevant. Sorry. It does not matter if the PI is a nice guy. As a matter of fact, if you know the PI, this is a COI (not financial) in terms of reviewing work. We are all very interested in the COI story regarding SpaceOAR.
Potters calling out on Twitter is symptomatic of the cultural toxicity in our field.
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I agree that this trial does not make a MR-Linac mandatory for all places that treat prostate cancer. I think having a balanced nuanced discussion of the trial is good. I think it is reasonable to have the opinion that this could be done without MR-Linac and interpret the trial that way. I think asking whether a physician reported toxicity where the difference is whether the unblinded physician prescribes Flomax or not is sufficient to justify this expensive technology is a reasonable one. I agree that criticism of the trial is a good thing that should be done and I agree that this trial does not make me run to go justify a MR-linac, because is prescribing Flomax for urinary symptoms better than having a patient with urinary symptoms and not prescribing Flomax? But is it BAD research? Is it research that shouldn't be done? Is it research that is unethical to pursue?
Questioning the ethics of a prominent researcher because he works with industry when you are a chair making a hyperinflated salary in one of New York's wealthier neighborhoods and have created and expanded an unnecessary residency program that leads to their graduates doing fellowships prior to finding gainful employment is a bit of throwing stones from a glass house in terms of what is the more unethical 'COI'.
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That was me... Boomers used big margins and it seemed to be quite a high rate of proctitis a few years out
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Obviously, I can't do it as I'm treating patients. My issue is simply that we can't ask one question, and therefore never answer any. In turn, especially in these situations where it ain't that broke, I just do 28 fx image guided RT with full bladder, empty rectum and get on with life.
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Can you elaborate how you think COI affects this specific study? Importantly, the study was NOT funded by Viewray, it was funded by UCLA. It's the most pure possible way to do an IIT of a medical device that is sold by a company. This is different than SpaceOAR. I'd also argue it is less COI than an investigator who is developing a drug at the university and running a trial with hopes it will spin off to a start up or be sold to pharma, a far more common situation.
He is part of the VR speakers bureau or whatever term they use. But UCLA has been an early adopter and collaborator with VR for a while and this has included other faculty and other diseases.
By the way, I think all the raised methodological critiques are valid, I just dont see how COI is driving those issues.
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I am presently doing 5mm posterior margin and 7mm everything else with spaceOAR, fiducials, and daily CBCT and 6 degree couch. I used to do 6 and 8. I am still thinking this is overkill and may start taking to down to 4 and 6 or even 5 isotropically. Unless the therapists really suck, shouldn't we be able to approach SBRT-level margins (physician at machine verifying with intrafraction monitoring) with all this tech?
