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OTN said:
If the upcoming external beam boost trial can replicate the endocavitary brachytherapy boost data, then I would argue organ preservation with chemoRT will become the SOC in rectal ca.
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It certainly will in our area..... I spend quite a bit of time convincing patients that they should get surgery as "standard of care."

Many who need APR and have cCR are just saying no.
 
NotMattSpraker said:
What do you think would have happened if ASTRO went in and offered to include proton therapy? I'm just curious. The fact is, it's very expensive for medicare among Rad Onc costs.

I've spent a lot of time talking to ASTRO reps about their APM proposal and what they were unhappy about. It never really matched what doctors were unhappy about, see Join Luh's editorial for an example. No one ever brought up protons. 🤷‍♂️
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The grift is alive... in the drive to 2025...

www.linkedin.com

Penn Radiation Oncology team representing strong at #NAPT2023 The National Association for Proton Therapy. | Fern Nibauer-Cohen

Penn Radiation Oncology team representing strong at #NAPT2023 The National Association for Proton Therapy. Having a great conference in Salt Lake City!
www.linkedin.com www.linkedin.com
 
Gfunk6 said:
This really hits the nail on the head. Rad Onc as a field is such a minimal contribution to CMS overall cancer spend. Once CMS gets the authorization to negotiate drug prices (2025, I believe?), then the real cost savings can begin.
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Hospital Prices are a bigger contribution to out of control health care costs than drug prices.
 
medgator said:
Not a lot of cancer Care happening in hospitals but you are right. The whole point of OCM/eom etc is to keep med onc patients out of those high-cost money sinks, to be sure
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In our system, I believe the satellites still bill hospital rates for radiation, radiology etc? I know pps exempt systems use the pps exemption at satellites up to 25-50 miles? I thought mskcc charges same in Brooklyn as at main campus for an infusion of keytuda
 
RickyScott said:
In our system, I believe the satellites still bill hospital rates for radiation, radiology etc? I know pps exempt systems use the pps exemption at satellites up to 25-50 miles? I thought mskcc charges same in Brooklyn as at main campus for an infusion of keytuda
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Such a ridiculous situation.
 
I feel like GBM is Radiation Oncology's white whale.

GBM? Better dose escalate.

GBM? Better combine with [insert drug here].

GBM? Better dose escalate with [insert drug here].

GBM? Better do some giant margins.

GBM? Whoa, better dial back those margins.

GBM? Better omit radiation.

GBM? Better hypofrac.

GBM? Better dial back those margins and hypofrac.

2023:
GBM? Better dial back those margins and hypofrac...BUT WITH THE MRI.

Since we're doing this, can I be the first to suggest "no sham arm"? I'm playing bingo.
 
Palex80 said:


MR-Linac for GBM treatment. Choosing wisely!
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100 Gy to GBMs didn’t improve survival. Using an MRI linac on a fixed target so that you can achieve a 1 mm margin reduction probably ain’t doing squat.
 


charlie chaplin GIF by Maudit
 


Trend for better PFS if you treat the macroscopic oligometastasis on top of systemic treatment.
Oh No Wow GIF by The Great British Bake Off
 
Palex80 said:


charlie chaplin GIF by Maudit
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This is the area I struggle most with, in terms of predicting the future. Although it's not like any of us can be great at forecasting the future in the first place.

But: if I were given complete control to build a department from absolute scratch, I could definitely deploy tools and platforms and regulations/policies in such a way that I could be the solo doc staffing a very busy practice that spans multiple sites, operating 5 days a week.

The issue is...that world doesn't exist. Right now, for example, I'm several months into trying to "fix" a department that was ignored for years and years. I have almost cheerleader-level support from admin - not quite "blank check" but...close.

Even with this setup, where many key admin/executives are backing me to a weird degree, and I have the knowledge and ability to drag this department into the modern era - the systems and inertia AROUND this department mean this will likely take me several years.

I'm very "techno optimist" for AI in RadOnc, but I recognize I might be wrong. My optimism comes from me being in places where I'm the only one that really understands it, and can use it to make myself more efficient.

One day I'll encounter an executive who understands what is possible on a high level.

Perhaps I'll feel differently after that happens.
 
Palex80 said:


charlie chaplin GIF by Maudit
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Contouring is mostly from where we get our self worth right now. But that is so easily malleable. It’s like becoming a paraplegic. One day you realize “I don’t get my self worth from walking” and you have a mindset change and get your self worth from some other new psychological well. I predict it will be as something as hokey as “Rad oncs are the only physicians trained to monitor the AI contours.”
 
elementaryschooleconomics said:
This is the area I struggle most with, in terms of predicting the future. Although it's not like any of us can be great at forecasting the future in the first place.

But: if I were given complete control to build a department from absolute scratch, I could definitely deploy tools and platforms and regulations/policies in such a way that I could be the solo doc staffing a very busy practice that spans multiple sites, operating 5 days a week.

The issue is...that world doesn't exist. Right now, for example, I'm several months into trying to "fix" a department that was ignored for years and years. I have almost cheerleader-level support from admin - not quite "blank check" but...close.

Even with this setup, where many key admin/executives are backing me to a weird degree, and I have the knowledge and ability to drag this department into the modern era - the systems and inertia AROUND this department mean this will likely take me several years.

I'm very "techno optimist" for AI in RadOnc, but I recognize I might be wrong. My optimism comes from me being in places where I'm the only one that really understands it, and can use it to make myself more efficient.

One day I'll encounter an executive who understands what is possible on a high level.

Perhaps I'll feel differently after that happens.
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Over time I have realized one of the key ulterior (unspoken) motives of admin is never to let MD pay float too high. It would be far too cognitively dissonant to admin to have an MD being super efficient and covering 5 sites… it would send off too many “We need to give this guy a huge raise” vibes. So it’s much more pleasing to admin (and probably a chairman) to have the doctor relatively underutilized so they can have logical ground to stand on to keep MD pay low. In other words, the ultra efficient one-doctor-for-many-sites thing may never happen in the US, even though technology is increasingly making it highly logical and safe.
 
TheWallnerus said:
Contouring is mostly from where we get our self worth right now. But that is so easily malleable. It’s like becoming a paraplegic. One day you realize “I don’t get my self worth from walking” and you have a mindset change and get your self worth from some other new psychological well. I predict it will be as something as hokey as “Rad oncs are the only physicians trained to monitor the AI contours.”
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Rad onc is born to lose

It’s more likely they efficiency gains will continue to make the remainder of the RO physician workforce redundant. You’ll still be employed but the issue is that admin still keep a large underemployed underpaid workforce that can easily step in when needed.
 
Palex80 said:

Hypofractionation for nodes too! Nice!
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OTN said:
I've been doing UK/Canadian hypofx for nodes for years now, it works just fine
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In the UK prior to COVID, no breast ENI patient got more than 15 fractions. After COVID, about 35% of all breast ENI patients get 5 fractions. The FAST Forward nodal sub study results should be out any day now.

Right now in the US most insurers let early stage breast patients get up to 21 fractions and ENI patients get up to 33 fractions. I predict this is headed to 15 fractions for both in near future.
 
Palex80 said:


A 129-patient randomized trial was supposed to demonstrate that it‘s safe to give tamoxifen parallel to RT.
Meryl Streep Doubt GIF

I still do it, but the trial is clearly underpowered.
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Like what was the absolute best case scenario of this study?

A tiny (2-3%) statistically significant reduction in clinically insignificant radiographic changes?

This is where we are?
 
RealSimulD said:
Okay so it’s not a “game change” study but it’s a good question! It comes to a lot - how to sequence. I’d rather have a study that’s practical like that. Now we know - it doesn’t matter.
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All these physiologic justifications I’ve heard iver the years for doing all the things we do. it doesn’t surprise me that a lot of it has no real basis
 
Fpg1245 said:
How dare you even suggest this.
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It is a mathematical and clinical certainty that 50.4/28 whole breast will produce more breast fibrosis than 26/5 partial breast, and a mathematical certainty that 50.4/28 whole breast will produce more breast fibrosis than 26/5 whole breast. Adding a breast boost to the 50.4/28 will take those certainties to something past totality.
 
Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT
 
thecarbonionangle said:
Coming soon by all insurances and they wouldnt be “wrong”:

Standard non IBC RNI without a needed boost: we will only cover 15

Standard non IBC which requires a standard boost: we will only cover 16

APBI candidate: we will cover 5

Non RNI, not APBI: we will cover 5 WBRT
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Community hospitals not yet acquired will basically hand over their RO Dept to remote mega hospital criminal academic RO cogs at that point who will be signing off on NP/AI generated notes while the attending frantically writes his next manuscript on RTT midlevels and the prognostic factors of head and neck outcomes on stool samples.

I really hate that this is what I wasted my time fighting to get into.
 
Fpg1245 said:
Community hospitals not yet acquired will basically hand over their RO Dept to remote mega hospital criminal academic RO cogs at that point who will be signing off on NP/AI generated notes while the attending frantically writes his next manuscript on RTT midlevels and the prognostic factors of head and neck outcomes on stool samples.

I really hate that this is what I wasted my time fighting to get into.
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This has been in works for a while. “ Academics” are also working hard to eliminate radiation from HER2/TNBC. Once the five fx RNI data is out, it will all go to 5 fx except for IBC/+margins/gross disease which must all be treated with protons. Thats what i hear!
 
thecarbonionangle said:
This has been in works for a while. “ Academics” are also working hard to eliminate radiation from HER2/TNBC. Once the five fx RNI data is out, it will all go to 5 fx except for IBC/+margins/gross disease which must all be treated with protons. Thats what i hear!
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Their treatment recommendations are garbage. They’ll still be charging these people 150K per treatment and paying the attendings dog****.
 
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