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Speaking of omission of RT in early stage breast cancer...

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If the recurrence rate in the affected (not-irradiated) breast is 2.3%, while the rate of contralateral breast cancer is 1.9%, should we not be irradiating either both breasts or no breast at all?
 
Women ≥ 55 years with grade 1-2 T1N0 luminal A BC following BCS treated with endocrine therapy alone had very low rates of LR at 5 years and are candidates for omission of RT.

Yay moving targets! Was age 70. Now 55? Anyone willing to give'r a go with a 40 yo? (Not me).
 
OTN said:
Multiple payers in the marketplace is precisely what is protecting the pay of everyone in the healthcare industry, as providers have somewhere else to turn for reimbursement as the government continues to ratchet down pay.

M4A is specifically designed to create a legal monopsony in order to decrease reimbursement far below what a market would provide. It is very radical, as it bans private practices from offering services in the private market outside M4A, which other countries have not done. COL increases? No chance in the least.
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Doesn't matter if the whole system is deregulated/corrupt and the evicore, AIMs and Optums of the world dictate care.

Medicare will actually pay for me IGRT or oligomet SBRT when I think it is medically appropriate.

A Cigna patient will get 2D/isodose complex with weekly port imaging instead, in this case Cigna/wellcare/United etc has usurped the role of big bad socialist medical conglomerate paying me peanuts to deliver care that was standard decades ago
 
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sirspamalot said:
Women ≥ 55 years with grade 1-2 T1N0 luminal A BC following BCS treated with endocrine therapy alone had very low rates of LR at 5 years and are candidates for omission of RT.

Yay moving targets! Was age 70. Now 55? Anyone willing to give'r a go with a 40 yo? (Not me).
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We had this trial open at the same time we had an APBI trial open. A lot of overlap with eligibility, had to send pts for central Ki-67 review, threshhold was low to exclude pts from Lumina. Especially from what we know now on how well APBI is tolerated, the APBI was still an easier sell imo
 
OTN said:
Multiple payers in the marketplace is precisely what is protecting the pay of everyone in the healthcare industry, as providers have somewhere else to turn for reimbursement as the government continues to ratchet down pay.
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Multiple payors in the marketplace does wonders for MSKCC. It does little for me. I'm at close to 80% Medicare already with most others Medicaid and private payors who are not exactly paying bank to my small community hospital.

Despite this, cancer care would still be a money maker for hospitals at 100% Medicare. Much of what hospitals do is not lucrative. The 340B program is big money for those that qualify.

We rail against MSKCC because they are flush (someone even negotiated better Medicare rates for them through PPS exemption decades ago), deal with rich patients and are clearly very bottom-line oriented, while producing DEI oriented academics who can't address that they epitomize the problem.

PCPs can decide to go "concierge" and make their patients bank accounts a significant part of the payor mix. (They end up seeing less patients and are not really helping the community as a whole (although they will try to convince you that they are).

I also get the multiple payor argument for ortho. Plastics can and will just charge fee for service if they are in it for the money. This is what dentists do.

But cancer docs? Our value is just a function of our scarcity. I'm sure PENN is raking. I think their docs are underpaid.

sirspamalot said:
I'd be okay with M4A if it has a clause that builds in automatic COL increases for physicians and eliminated 98% of UM except for the worst offenders.
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I'd take it in an instant.
 
theradiator said:
Imagine a world where the following 'riveting' oral presentations are included in the Diversity Inclusion and Equity section at ASTRO

Risk of motor vehicle accidents and exacerbation of global warming from driving to Manhattan for protons

Worsening air pollution and asthma rates from automobile exhaust from stage 0 to 1 breast cancer patients driving to a neighborhood with a high population of historically disadvantaged minorities.

Wasting public and private funds on protons for early stage breast cancer are linked to increased societal risk of food insecurity, education disparities, child poverty and decreased economic growth
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You know I genuinely love these new efforts that consider sustainability in medicine. I love the effort on its face and also seeing young ROs working on things they are passionate about.

However, I have yet to see a single person talking about patients driving past multiple linacs on their way to the ivory tower center and Im not holding my breath.
 
NotMattSpraker said:
You know I genuinely love these new efforts that consider sustainability in medicine. I love the effort on its face and also seeing young ROs working on things they are passionate about.

However, I have yet to see a single person talking about patients driving past multiple linacs on their way to the ivory tower center and Im not holding my breath.
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It’s literally (well, almost; ok, not really) whistling past the graveyard
 
NotMattSpraker said:
You know I genuinely love these new efforts that consider sustainability in medicine. I love the effort on its face and also seeing young ROs working on things they are passionate about.

However, I have yet to see a single person talking about patients driving past multiple linacs on their way to the ivory tower center and Im not holding my breath.
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That is because those of us in the drive by centers have ZERO interest in publishing this research. Though maybe we should....

I don't like ideas that propose more work for myself.
 
"Why aren't you coming for treatment here?"
-Academic center 2.5 hours away from your rural location questions patient

And when that fails..

The second I caught a whiff of someone's NP at a bigger center ****-talking us.. I was on the phone with their radonc. Cut that crap out, quit scaring patients. You need a pancreatectomy? Go to a big bad center. A bag of chemo or routine radonc? No.. no you do not need to spend 50$ each way driving your truck for routine care.

Most of my referrals are from docs outside my hospital. Compete, or wither.
 
NotMattSpraker said:
You know I genuinely love these new efforts that consider sustainability in medicine. I love the effort on its face and also seeing young ROs working on things they are passionate about.

However, I have yet to see a single person talking about patients driving past multiple linacs on their way to the ivory tower center and Im not holding my breath.
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You have to go back in time to when UroRads was considered the evil empire to come across this research.
 
sirspamalot said:
"Why aren't you coming for treatment here?"
-Academic center 2.5 hours away from your rural location questions patient

And when that fails..

The second I caught a whiff of someone's NP at a bigger center ****-talking us.. I was on the phone with their radonc. Cut that crap out, quit scaring patients. You need a pancreatectomy? Go to a big bad center. A bag of chemo or routine radonc? No.. no you do not need to spend 50$ each way driving your truck for routine care.

Most of my referrals are from docs outside my hospital. Compete, or wither.
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yeah where i trained many attendings would tell patients to drive hours (or stay at the local hope lodge) for RT.
I took the liberty to tell patients the truth once i signed my PGY5 contract. they deserve to know it. i was also irked because i knew that i'd be at a community center not too far away.
 
sirspamalot said:
"Why aren't you coming for treatment here?"
-Academic center 2.5 hours away from your rural location questions patient

And when that fails..

The second I caught a whiff of someone's NP at a bigger center ****-talking us.. I was on the phone with their radonc. Cut that crap out, quit scaring patients. You need a pancreatectomy? Go to a big bad center. A bag of chemo or routine radonc? No.. no you do not need to spend 50$ each way driving your truck for routine care.

Most of my referrals are from docs outside my hospital. Compete, or wither.
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Loving your posts. I'm just like you...anybody who tries to steal a patient or talk **** gets the "meet me in the parking lot" call...unless it's an orthopod. Those I google first.
 
Reaganite said:
Loving your posts. I'm just like you...anybody who tries to steal a patient or talk **** gets the "meet me in the parking lot" call...unless it's an orthopod. Those I google first.
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Lol. Learn to box, you won't give a flying f about them either. They need their hands more than you do lol...
 
sirspamalot said:
Lol. Learn to box, you won't give a flying f about them either. They need their hands more than you do lol...
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Just for any prospective applicants out there. The person on the board who has made this market work best for them may be both a boxer and private pilot.

So...if you are capable of landing your own plane at small airports and scrapping in parking lots with the local ortho docs/football coaches. This gigs for you!

I once lost a slap fight with a neurologist after getting no actionable recommendations for my patient. My options are limited.
 
“I once lost a slap fight with a neurologist after getting no actionable recommendations for my patient. My options are limited.”

… is one of the greatest no context lines I’ve seen.
 
fiji128 said:
Same could be said about a GI doc as well. As a MD, you will probably only be aware if another specialty doc is operating in the bottom 5 or 10% of what would be expected.
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If you sit in credentialing committee or similar you'll figure it out. Poor dictation quality and habits are often the first and most obvious flag.
 
Ray D. Ayshun said:
I'm not sure how I would see an endeavor such as this resulting in anything positive. This has the makings of another big vs small radonc battle. How would this be done?
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That’s possible.

I really wish there was an interest in knowing if we are doing quality work.

The immediate response from everyone is - “we can’t”. And that bums me out. Spent our entire schooling and training getting evaluated. And then we get out - then nothing.
 
RealSimulD said:
That’s possible.

I really wish there was an interest in knowing if we are doing quality work.

The immediate response from everyone is - “we can’t”. And that bums me out. Spent our entire schooling and training getting evaluated. And then we get out - then nothing.
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I would argue it’s incredibly challenging to go to a bad quality radonc if they trained in the last 10-15 years, unless they are simply lazy or negligent. That is in part due to the high barrier for entry into the field. Another reason why programs should not be okay with matching any warm body into the field…
 
goodkerma said:
I would argue it’s incredibly challenging to go to a bad quality radonc if they trained in the last 10-15 years, unless they are simply lazy or negligent.
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More common is the early career rad onc who can't manage more than 10-15 on treat because they are not comfortable making treatment planning decisions, spend forever on back and forth with dosi/physics and indecisiveness over minutiae, overthink everything, etc. Versus Dr. Boomer on the other end managing 50 at a time spending a couple of minutes on contours, rubber stamping everything, and either undertreating to avoid having to manage toxicity on treatment or inappropriately hypofractionating to also not have to deal with them on treat and let someone else deal with the late fallout.
 
RealSimulD said:
That’s possible.

I really wish there was an interest in knowing if we are doing quality work.

The immediate response from everyone is - “we can’t”. And that bums me out. Spent our entire schooling and training getting evaluated. And then we get out - then nothing.
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There's just so many non textbook situations I'm put in where I'd hate to be evaluated without making a case. In a lot of cases we're in the position of having to clean up messes, particularly us rural radoncs. I just hesitate to think about how these situations can be evaluated objectively.
 
Ray D. Ayshun said:
There's just so many non textbook situations I'm put in where I'd hate to be evaluated without making a case. In a lot of cases we're in the position of having to clean up messes, particularly us rural radoncs. I just hesitate to think about how these situations can be evaluated objectively.
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It’s impossible in our specialty because we already have presumed biases. We can’t even agree on the value of using bolus for chest wall or when to use 3 vs 5 fractions for SBRT, let alone actually come up with a “correct” way to treat patients especially in regard to a disease that doesn’t like to obey the “rules” despite “perfect” planning.
 
RadOncDoc21 said:
It’s impossible in our specialty because we already have presumed biases. We can’t even agree on the value of using bolus for chest wall or when to use 3 vs 5 fractions for SBRT, let alone actually come up with a “correct” way to treat patients especially in regard to a disease that doesn’t like to obey the “rules” despite “perfect” planning.
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Given that UPenn thinks we need a "national palliative care network" to teach us lowly community radoncs to do even palliative RT, I will never participate in any sort of quality initiative put forth by academia. We do our own assessments in our practice, which is fine by me.
 
RadOncDoc21 said:
It’s impossible in our specialty because we already have presumed biases. We can’t even agree on the value of using bolus for chest wall or when to use 3 vs 5 fractions for SBRT, let alone actually come up with a “correct” way to treat patients especially in regard to a disease that doesn’t like to obey the “rules” despite “perfect” planning.
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Its like pornography "I know it when I see it"
 
OTN said:
Given that UPenn thinks we need a "national palliative care network" to teach us lowly community radoncs to do even palliative RT, I will never participate in any sort of quality initiative put forth by academia. We do our own assessments in our practice, which is fine by me.
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I don’t think most practices do internal assessments. This alone puts your group in great standing.
 
Sometimes its not even "wrong" it just.... sloppy. Careless. Or not explainable. Will it pass? Yeah, I guess. It'll do. Not pretty, but photons don't win beauty contests.

My CTV's are subject to being seen on a large display with a jury pool (theoretically). My notes will be read by those seeking to cause harm.

I've seen some of the worst possible (I mean, horrifyingly bad) notes and ... nothing. Nothing comes of it. Bizarre fractionation schemes. Nothing. Spacer gel for eevvvveerrrrryyyooooonnneeeeeee - not a pip.

A -lot- can go on thats bad in radonc. Anyone really checking those daily films with diligence.. or just hitting "approved" - ? How would you know unless you went back and looked at them?

And yet, very little harm (well, not immediate and obvious anyway) can occur from all of the above. But when it does go wrong. oh boy. Look out.
 
RealSimulD said:
I don’t think most practices do internal assessments. This alone puts your group in great standing.
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Agreed. Tough on single docs in particular, but on the verge of setting up virtual peer review with another doc. Beyond that, I curbside a lot of old friends and trainers. Out of context though, etc, there are probably a lot of cases where I could be questioned etc. For instance, if the wallnerus found out I treat nodes...
 
Ray D. Ayshun said:
Agreed. Tough on single docs in particular, but on the verge of setting up virtual peer review with another doc. Beyond that, I curbside a lot of old friends and trainers. Out of context though, etc, there are probably a lot of cases where I could be questioned etc. For instance, if the wallnerus found out I treat nodes...
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Omg
Delete before ..
 
sirspamalot said:
Sometimes its not even "wrong" it just.... sloppy. Careless. Or not explainable. Will it pass? Yeah, I guess. It'll do. Not pretty, but photons don't win beauty contests.

My CTV's are subject to being seen on a large display with a jury pool (theoretically). My notes will be read by those seeking to cause harm.

I've seen some of the worst possible (I mean, horrifyingly bad) notes and ... nothing. Nothing comes of it. Bizarre fractionation schemes. Nothing. Spacer gel for eevvvveerrrrryyyooooonnneeeeeee - not a pip.

A -lot- can go on thats bad in radonc. Anyone really checking those daily films with diligence.. or just hitting "approved" - ? How would you know unless you went back and looked at them?

And yet, very little harm (well, not immediate and obvious anyway) can occur from all of the above. But when it does go wrong. oh boy. Look out.
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I know of a wrong site treatment swept under the rug. I suspect I'm not the only one. I'm not sure what a rad onc has to do to piss a patient off enough to actually get sued, and I don't really want to find out.

In ortho, you take off somebody's wrong leg, well, your leg's off. In rad onc, palliate the wrong femur, "well sorry the system got things backwards for one treatment, good news it was only one of 10 and we've got it worked out, and there were some small areas of the disease on the left anyway so maybe it will keep those from growing for a while..."
 
Moonbeams said:
I know of a wrong site treatment swept under the rug. I suspect I'm not the only one. I'm not sure what a rad onc has to do to piss a patient off enough to actually get sued, and I don't really want to find out.

In ortho, you take off somebody's wrong leg, well, your leg's off. In rad onc, palliate the wrong femur, "well sorry the system got things backwards for one treatment, good news it was only one of 10 and we've got it worked out, and there were some small areas of the disease on the left anyway so maybe it will keep those from growing for a while..."
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Hence why we don’t get paid the big bucks (anymore)!
 
Lol. The cost of living outran the poor pay, and to supplement.. well there you have it. And while its true that an individuals bonuses are not based on % denials.. its pretty easy to understand subconsciously that % denials is directly tied to profitability which is gonna be tied to.. you guessed it... annual bonuses.
 
Palex80 said:
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A true power flex would be for the attending to have the resident call you and deny your claim. When you question the resident, they say "All key elements of this denial were reviewed by Dr. so-and-so."
 
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Gfunk6 said:
A true power flex would be for the attending to have the resident call you and deny your claim. When you question the resident, they say "All key elements of this denial were reviewed by Dr. so-and-so."
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“It’s important for residents to participate in P2P.”
 
If we want to see P2P ratcheted down, we need to have a CPT payable code for the time spent doing it. At some point, the "true cost" of doing a P2P will present itself and the system will adjust to ensure that P2P are more efficiently focused on those situations where its warranted.

But hey, what do I know... (sips tea)..
 
sirspamalot said:
If we want to see P2P ratcheted down, we need to have a CPT payable code for the time spent doing it. At some point, the "true cost" of doing a P2P will present itself and the system will adjust to ensure that P2P are more efficiently focused on those situations where its warranted.

But hey, what do I know... (sips tea)..
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So you think the insurance company who is questioning our claim would pay out on a bill for our trouble?

I certainly appreciate the sentiment...
 
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