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I’ve never treated more than 10-15, but I only have a linac.

HOWEVER- I do see the argument for SRS to many lesions in a palliative patient with limited survival, even if it’s not going to be neurocognitive. 1-5 visits (for most patients it will be one visit) is easier than 10, and causes less fatigue than WBRT, regardless.
 
medgator said:
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Does ASTRO understand they're not the CIA?

They're out here with secret meetings, people investigated by the FBI, deleting presentations with data they don't like and inventing weak excuses about it...

ASTRO.

Buddy.

Stop.

You're not that important.

These antics are only for successful organizations. You guys lost $717k on $20.9 million operating income in 2022.

Potters, by himself, can cover your losses with just half his salary.

Please wait till you're in the big leagues before pulling cloak and dagger crap.
 
ASTRO in world politics, one-side view of the 75-year-old Mideast conflict...

 
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Radonc90 said:
ASTRO in world politics, one-side view of the 75-year-old Mideast conflict...

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I was glad they made a statement if only because they have been so vocal about every other issue of the day, The silence was deafening.

I would much rather they make a public statement saying that from now on they will refrain from social and global commentary and focus on our profession only. Then kept their damn mouths shut
 
their statement was pretty odd considering it came on Friday, a week later, when the attack in Gaza is well underway, the WHO has spoken out, as well as multiple humanitarian organizations, yet they make no mention of Palestine or Gaza and all the innocent people including patients and health care workers dying there.
 
elementaryschooleconomics said:
Does ASTRO understand they're not the CIA?

They're out here with secret meetings, people investigated by the FBI, deleting presentations with data they don't like and inventing weak excuses about it...

ASTRO.

Buddy.

Stop.

You're not that important.

These antics are only for successful organizations. You guys lost $717k on $20.9 million operating income in 2022.

Potters, by himself, can cover your losses with just half his salary.

Please wait till you're in the big leagues before pulling cloak and dagger crap.
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Who exactly is Beckta referring to again? Is it Wallner or someone else or? Just tryna keep track o' the scumbags..
 
drowsy12 said:
their statement was pretty odd considering it came on Friday, a week later, when the attack in Gaza is well underway, the WHO has spoken out, as well as multiple humanitarian organizations, yet they make no mention of Palestine or Gaza and all the innocent people including patients and health care workers dying there.
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It looked worse to me because it was Friday at 4:30PM (the old corporate trick of do something late on Friday so people have the weekend to "cool off" - this uh, usually works better in person...).

But...it's a JPG. That text is not searchable/indexable. It's a way to make a statement without making a statement...
 
Last thing this place needs is to debate this, so as a nod to the moderators, we should stop the discussion here.

Point re: ASTRO’s surprising one sided comment (in comparison to many other organizations) stands

One could either 1) give them credit for taking a firm stand (or wonder who is on the communications committee) or 2) be surprised
 
drowsy12 said:
Last thing this place needs is to debate this, so as a nod to the moderators, we should stop the discussion here.

Point re: ASTRO’s surprising one sided comment (in comparison to many other organizations) stands

One could either 1) give them credit for taking a firm stand (or wonder who is on the communications committee) or 2) be surprised
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I deleted my posts. I think the meta-discussion is worthwhile about Astro’s statement
 
RealSimulD said:
I did a sim-free bone met yesterday. We did it vmat for an inpatient. Beautiful!
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Not sure if or how this might apply to you, but we considered sim free treatment planning. However, Varian stated something along the lines that Eclipse is not certified for planning using diagnostic imaging. Therefore, we currently have abandoned that strategy due to liability concerns. It was a brief discussion so I am not familiar with the details and honestly don't have a good grasp of the issue. The moral of the story is that it was determined to be too risky for us.
 
SneakyBooger said:
Not sure if or how this might apply to you, but we considered sim free treatment planning. However, Varian stated something along the lines that Eclipse is not certified for planning using diagnostic imaging. Therefore, we currently have abandoned that strategy due to liability concerns. It was a brief discussion so I am not familiar with the details and honestly don't have a good grasp of the issue. The moral of the story is that it was determined to be too risky for us.
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That’s interesting …

It doesn’t sound like they gave details, but we use a diagnostic CT every time - since we have to use radiology (don’t have our own sim).

I’m curious what they mean by this.

The situations id consider use it for right now are emergent / palliative, limited life expectancy inpatients.
 
SneakyBooger said:
Not sure if or how this might apply to you, but we considered sim free treatment planning. However, Varian stated something along the lines that Eclipse is not certified for planning using diagnostic imaging. Therefore, we currently have abandoned that strategy due to liability concerns. It was a brief discussion so I am not familiar with the details and honestly don't have a good grasp of the issue. The moral of the story is that it was determined to be too risky for us.
Click to expand...
That doesn't...make...what?

For that statement to be true, that means that Varian has somehow "certified" or whatever word you want to use on every single make and model of CT scanner used as a "CT simulator", but NOT any make or model of CT scanner that is used as a diagnostic scanner.

This implies, or course, a standardization in CT scanner choices, meaning that every department is using only CT scanners "meant" for treatment planning, which is obviously not the case.

There could be something specific to you and your equipment? But there's too much variation in CT scanner equipment for that statement to make sense.

Obviously I 100% believe that's what you were either told or recall, but there's probably some detail or confounder at play specific to your practice.
 
elementaryschooleconomics said:
That doesn't...make...what?

For that statement to be true, that means that Varian has somehow "certified" or whatever word you want to use on every single make and model of CT scanner used as a "CT simulator", but NOT any make or model of CT scanner that is used as a diagnostic scanner.

This implies, or course, a standardization in CT scanner choices, meaning that every department is using only CT scanners "meant" for treatment planning, which is obviously not the case.

There could be something specific to you and your equipment? But there's too much variation in CT scanner equipment for that statement to make sense.

Obviously I 100% believe that's what you were either told or recall, but there's probably some detail or confounder at play specific to your practice.
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Am I the only one worried about errors from sim free VMAT / IMRT? Are we really saving that much time by not contouring? Not sure it’s worth the potential miss.
 
SneakyBooger said:
Not sure if or how this might apply to you, but we considered sim free treatment planning. However, Varian stated something along the lines that Eclipse is not certified for planning using diagnostic imaging. Therefore, we currently have abandoned that strategy due to liability concerns. It was a brief discussion so I am not familiar with the details and honestly don't have a good grasp of the issue. The moral of the story is that it was determined to be too risky for us.
Click to expand...
Varian says that… but you have to nod politely and then use your noggin. First of all, it’s just a palliative case. Second of all, you could just have Eclipse set the density of everything within the (diagnostic scan) body to water… then it’s certified! If you are prescribing 8 Gy in 1 fx AP/PA and Eclipse calcs ~400 MUs for each beam based on a diagnostic scan sim, we all good.
 
RadOncMegatron said:
Am I the only one worried about errors from sim free VMAT / IMRT? Are we really saving that much time by not contouring? Not sure it’s worth the potential miss.
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At this point in time, I wouldn't consider sim free for VMAT for this reason.

I currently use sim free techniques for palliative/urgent treatment though.

(disclaimer being VMAT means definitive case to me, I don't really use VMAT for palliative right now)
 
You know what we call a sim free treatment?

Setting someone up on a cobalt 4MV treatment and crudely setting the box leaves over a bone or chest.

Then, you turn the key. Do you remember?


episode 5 shock GIF
 
RealSimulD said:
Palliative
1 cm margin for PTV
CBCT
Match to bone (target)

Clear eyes, full heart can’t miss
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Ok I’m missing something here. So do you have a premade plan, let’s say for a femoral met that would have a volume of 5 CCs then you set the room lasers to the approximate area of the met and then the machine will use that as an iso and deliver a plan. Very confused (surely I can’t be the only one). Or is this just a static arc plan where you have a set field size that you don’t have to modulate. If so what’s the benefit over a simple AP/PA plan you can do a light field “old school” hand calc set up? Sorry just trying to understand this sim free vmat concept as it’s blowing my mind
 
RealSimulD said:
I deleted my posts. I think the meta-discussion is worthwhile about Astro’s statement
Click to expand...
That has always been the problem with scientific organizations getting involved in non-core politics and social issues. ASTRO dove into this deep end and now the entire community will demand statements on every divisive issue. Maybe that's what they want after all -- better that than actually working to make rad onc better. Are you distracted yet?
 
TheWallnerus said:
Varian says that… but you have to nod politely and then use your noggin. First of all, it’s just a palliative case. Second of all, you could just have Eclipse set the density of everything within the (diagnostic scan) body to water… then it’s certified! If you are prescribing 8 Gy in 1 fx AP/PA and Eclipse calcs ~400 MUs for each beam based on a diagnostic scan sim, we all good.
Click to expand...
I think it was something to do with if Varian didn't certify it our liability insurer would not cover in the event of damages.
 
Doctorer said:
You guys are getting sued on palliative cases?
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As an aside, someone else has posted this before.

Nature of Medical Malpractice Claims Against Radiation Oncologists - PMC

We examined characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period. Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

”The largest proportion of closed claims by diagnosis was for neoplasms with unspecified origin, likely representing metastases. This is not surprising in view of estimates that approximately half of all radiotherapy is prescribed with palliative intent29. What was unexpected was that none of these claims were paid.“
 
RadOncMegatron said:
Ok I’m missing something here. So do you have a premade plan, let’s say for a femoral met that would have a volume of 5 CCs then you set the room lasers to the approximate area of the met and then the machine will use that as an iso and deliver a plan. Very confused (surely I can’t be the only one). Or is this just a static arc plan where you have a set field size that you don’t have to modulate. If so what’s the benefit over a simple AP/PA plan you can do a light field “old school” hand calc set up? Sorry just trying to understand this sim free vmat concept as it’s blowing my mind
Click to expand...
Mine too
Zoomer rad oncs don’t know what a 2D plan is 😂😂😂
 
SneakyBooger said:
I think it was something to do with if Varian didn't certify it our liability insurer would not cover in the event of damages.
Click to expand...
Well, as an MD, I “certify” the treatments. Varian doesn’t. But I get it.

(Still, highly unlikely the malpractice carrier or opposing lawyers could even understand that a diagnostic CT was used for a dose calc and have that register in their minds as something the TPS vendor says they’d wash their hands clean of, and thereby allow your malpractice carrier to “drop” you. Liability insurers cover liabilities aka mistakes and use of diagnostic CT would just be a “mistake”… but not a mistake! But now this thread is discoverable. Dammit.)
 
I don't personally use diagnostic scans for VMAT planning but would be open to it. Limited by physics 'comfort'. Usually the institutional need for QA prior to delivery makes using it for emergent/urgent treatment less significant. But for 3D palliation that already has a recent diagnostic CT scan and you're not going to create and patient immoblization, not entirely sure there's a need for routinely CT simming...

And also - political discussion regarding Israel vs Hamas beyond the scope of ASTRO's post has been deleted. Additional political posts AFTER this one in regards to the current conflict WILL be deleted, WITH warnings.
 
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It's just one of those things that seems very unusual that in 2-3 years won't.

Remember now, "we" (not me, but as a field) were legit worried that IMRT was going to give patients cancer.
 
OTN said:
I've always billed "conventional" - there's no need for arthritis treatments to be 3D, so I genuinely consider it to be fraud to bill it
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From the undesirables at Evicore:

"The typical course of radiation uses complex planning and is..."

Is 2D really considered complex? Hmmm...

I don't bill 77427 since these patients don't need weekly management and I consider it fraud to do so.

We just do it for free.
 
SneakyBooger said:
From the undesirables at Evicore:

"The typical course of radiation uses complex planning and is..."

Is 2D really considered complex? Hmmm...

I don't bill 77427 since these patients don't need weekly management and I consider it fraud to do so.

We just do it for free.
Click to expand...

I would not do that unless you're just not seeing the patients. If you devalue yourself (and your time) then others will as well.

77427 isn't just for managing symptoms. It's also for any non IGRT film review, etc. Any medication adjustments, etc.
What if you need to make a decision about a retreatment ?don't some of these arthritis courses have an option to repeat the course a month or so later?

If you're meeting with the patient to see how things are going you should be billing IMO.

Now, if you just treat them and see them back in 3 months but don't actually see them during treatment (which is reasonable for arthritis) then of course you shouldn't bill 77427.
 
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BobbyHeenan said:
I would not do that unless you're just not seeing the patients. If you devalue yourself (and your time) then others will as well.

77427 isn't just for managing symptoms. It's also for any non IGRT film review, etc. Any medication adjustments, etc.
What if you need to make a decision about a retreatment ?don't some of these arthritis courses have an option to re-peat the course a month or so later?

If you're meeting with the patient to see how things are going you should be billing IMO.

Now, if you just treat them and see them back in 3 months but don't actually see them during treatment (which is reasonable for arthritis) then of course you shouldn't bill 77427.
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Since I am currently riding my Moral High Horse, I am having a bit of trouble hearing anyone else as they are so far beneath me.

However, I think I did hear something about the value in seeing an arthritis patient and images?

Do we really need imaging? What is the value of imaging in arthritis? Can a therapist not recognize a hand? Or a knee?

How can I put a value on something that I do not see value in? If I see the patient and believe with all my heart there is no value in it for the patient how can one charge the patient?

Oh my! Please excuse me, I must clutch my pearls as I am going to faint! Someone please bring the vapors.
 
SneakyBooger said:
Do we really need imaging? What is the value of imaging in arthritis? Can a therapist not recognize a hand? Or a knee?
Click to expand...

I don't treat arthritis (yet) but I meant if you are doing any non-IGRT imaging (like weekly imaging on a breast patient). So I didn't know how often these patients are getting imaged, etc.

If it's in the "rules" that you MUST visit with a patient very 5 fractions...and you do actually visit with them. I personally would bill it.

I get what you're saying though. It's crazy to think you get paid the same for that visit and for the visit of the tonsil dude at 60 Gy to his throat in your clinic that needs fluids, narcotics, and a change in his feeding tube regimen....

But unless they give us a new CPT code, i'm billing them both.

Maybe I'm in the minority on this one though.
 
SneakyBooger said:
Since I am currently riding my Moral High Horse, I am having a bit of trouble hearing anyone else as they are so far beneath me.

However, I think I did hear something about the value in seeing an arthritis patient and images?

Do we really need imaging? What is the value of imaging in arthritis? Can a therapist not recognize a hand? Or a knee?

How can I put a value on something that I do not see value in? If I see the patient and believe with all my heart there is no value in it for the patient how can one charge the patient?

Oh my! Please excuse me, I must clutch my pearls as I am going to faint! Someone please bring the vapors.
Click to expand...

CT sim, MVs x1 day, 1 OTV.

All of these things have value in my opinion. You could argue that benign indications demand even more precise dosimetry, not less. I personally like to see the patients I am treating. You could be reasonable and argue against these points too, but why?

Extremities are not easy to set up. We have prospective evidence of this from RTOG 0630. You could treat the wrong side.

There is basically no upside to doing zero IGRT and a lot of potential downside.
 
I will wager that hundreds if not thousands have been treated with radiation for arthritis without imaging and had no proven untoward effect...

BTW, I have not researched this issue so I graciously accept defeat should I be proven wrong.

Shall someone else lay down the gauntlet as I am sitting far too high on my horse to do so...
 
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