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The first study that pops up on Google: Radiotherapy for osteoarthritis-an analysis of 295 joints treated with a linear accelerator - PubMed

Oh my, I believe the table indicates over 9000 pts treated with orthovoltage.

The Conclusion:

"Conclusion: Radiotherapy of osteoarthritis with a linear accelerator is an effective treatment which is very well tolerated. All analyzed subgroups show a good response to radiotherapy for at least 24 months. Orthovoltage therapy seems to be superior to treatment with a linear accelerator in a case-related analysis of the published samples. Further investigations should be performed for a definitive answer to this question."

And a table therein:
1697652929664.jpeg
 
Gfunk6 said:
Evil Core will never be happy with how much money you save them. Even if you offer to hold an Iridium source over the patient’s bone met for 15 min - they will find a way to deny or obstruct you.
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If I worked for Evil Core it would be my moral prerogative to insist that all arthritis patients be treated with orthovoltage.

I view it as fraud if one treats with an unnecessarily expensive megavoltage linear accelerator.

My horse is growing even taller as I type!
 
BobbyHeenan said:
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.
Click to expand...

I guess the way I see most billing codes is that you are getting an average of what your time is worth. Some patients are going to be easier, some are going to be more difficult.
Difficult could be due to side effects of treatment, anxiety, need to ask a million questions, etc. I have plenty of patients with no problems take up lots of time each week.
I think if you are seeing the patients, you should bill the charge and assume things average out across the board.
Would a surgeon come out of a really easy case and say “well, maybe I won’t bill that one”
Of course not. And I don’t mean to imply that an otv is akin to surgery. But there are lots of minor surgeries that can be finished in 10-15 min.
 
SneakyBooger said:
The first study that pops up on Google: Radiotherapy for osteoarthritis-an analysis of 295 joints treated with a linear accelerator - PubMed
Click to expand...
BTW, you have to feel for those neglected Northern Europeans. They were scorned by the rest of world regarding very low dose radiotherapy for arthritis. Yet they never gave in and kept on publishing their results, decade after decade. They never gave up. Thank you to all of those who persevered.

After all, arthritis may be all we have to treat in the coming decades...
 
sirspamalot said:
You meant protons. PRO? TONS !

-FFS Exempt Proton Feasting Scumbags
Click to expand...

As much as I love your wordplay here (and also F ASTRO!), the professional fees are the same for protons as they are for photons.

Being a doc using protons is a pain. Patients often want it for no reason. Constant insurance battles. All for the same wRVUs. Hoo-ray.

The rumor I heard from one proton center is that the docs were so sick of it that their volume dropped, and the rumor is the chair threatened to fire someone unless the volume picked back up again...
 
SneakyBooger said:
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...
Click to expand...

To be clear Im cool with your approach! No gauntlet. I also bill 2D, just to clarify.
 
Neuronix said:
As much as I love your wordplay here (and also F ASTRO!), the professional fees are the same for protons as they are for photons.

Being a doc using protons is a pain. Patients often want it for no reason. Constant insurance battles. All for the same wRVUs. Hoo-ray.

The rumor I heard from one proton center is that the docs were so sick of it that their volume dropped, and the rumor is the chair threatened to fire someone unless the volume picked back up again...
Click to expand...

Yes but... and this isn't meant to be personal but... you work for the man, you are the man. To take this to 11, palestinians who say "I'm not Hamas" but send in their dues for membership cards are in fact... supporting Hamas. "But I don't really like Hamas today" isn't good enough.

Yes, I understand wRVU's aren't so different, but the technical income is 3-4x and the owners are printing cash, destroying freestanding practices, and the technology is used wildly inappropriately. Oh, and they want to be exempt from the ROCR (Radically Obliterating Community Radoncs) madness. Sounds like some have begun the rebellion already, but that is hard to do when your paycheck depends on it..




rob reiner lol GIF by Maudit
 
Sorry Episode 2 GIF by Friends


I mean, that sucks. But, there are jobs out there. I am getting pinged for jobs from all over, just not places I want to go. I could ask for 3k+ a day and nobody will blink.
 
Neuronix said:
As much as I love your wordplay here (and also F ASTRO!), the professional fees are the same for protons as they are for photons.

Being a doc using protons is a pain. Patients often want it for no reason. Constant insurance battles. All for the same wRVUs. Hoo-ray.

The rumor I heard from one proton center is that the docs were so sick of it that their volume dropped, and the rumor is the chair threatened to fire someone unless the volume picked back up again...
Click to expand...

This is how I felt, and I felt lucky that I wasn't part of one of those scummy proton centers when I had it. Trust me, I love to trash my former employer given that leadership is actually evil... like in the biblical sense... but they deserve praise for being good stewards of proton therapy.

When I used it, I felt it had real benefit or it was on trial. But you better believe that admins came around trolling for patients whenever the center got slow. It just wasn't threatening or anything. I have also heard of multiple centers where the admins are not nice to their doctors about it.

But not everyone is that way. Some radiation oncologists have zero equipoise when it comes to proton therapy. They genuinely believe it is better in any setting where you can show a dosimetry benefit and trials do not matter. Believe enough to write it down in journals and insult your colleagues that don't agree. We are literally in a place where Penn... PENN!... is telling people not to treat breast with protons haha. And yet it remains one of the top indications for most centers.

Has anyone actually read ASTROs proton payment policy update? It is shockingly bad. Virtually no one cares, not even a little. IJROBP continues to publish garbage proton hyping studies.

The game is over on equipoise and integrity, best thing one can do is protect one's own patients from harm and try to stop the grifters from burning down the entire house of Rad Onc.
 
NotMattSpraker said:
This is how I felt, and I felt lucky that I wasn't part of one of those scummy proton centers when I had it. Trust me, I love to trash my former employer given that leadership is actually evil... like in the biblical sense... but they deserve praise for being good stewards of proton therapy.

When I used it, I felt it had real benefit or it was on trial. But you better believe that admins came around trolling for patients whenever the center got slow. It just wasn't threatening or anything. I have also heard of multiple centers where the admins are not nice to their doctors about it.

But not everyone is that way. Some radiation oncologists have zero equipoise when it comes to proton therapy. They genuinely believe it is better in any setting where you can show a dosimetry benefit and trials do not matter. Believe enough to write it down in journals and insult your colleagues that don't agree. We are literally in a place where Penn... PENN!... is telling people not to treat breast with protons haha. And yet it remains one of the top indications for most centers.

Has anyone actually read ASTROs proton payment policy update? It is shockingly bad. Virtually no one cares, not even a little. IJROBP continues to publish garbage proton hyping studies.

The game is over on equipoise and integrity, best thing one can do is protect one's own patients from harm and try to stop the grifters from burning down the entire house of Rad Onc.
Click to expand...
I'm afraid we have long passed that point.

Burning House Burn GIF by Halloween
 
NotMattSpraker said:
This is how I felt, and I felt lucky that I wasn't part of one of those scummy proton centers when I had it. Trust me, I love to trash my former employer given that leadership is actually evil... like in the biblical sense... but they deserve praise for being good stewards of proton therapy.

When I used it, I felt it had real benefit or it was on trial. But you better believe that admins came around trolling for patients whenever the center got slow. It just wasn't threatening or anything. I have also heard of multiple centers where the admins are not nice to their doctors about it.

But not everyone is that way. Some radiation oncologists have zero equipoise when it comes to proton therapy. They genuinely believe it is better in any setting where you can show a dosimetry benefit and trials do not matter. Believe enough to write it down in journals and insult your colleagues that don't agree. We are literally in a place where Penn... PENN!... is telling people not to treat breast with protons haha. And yet it remains one of the top indications for most centers.

Has anyone actually read ASTROs proton payment policy update? It is shockingly bad. Virtually no one cares, not even a little. IJROBP continues to publish garbage proton hyping studies.

The game is over on equipoise and integrity, best thing one can do is protect one's own patients from harm and try to stop the grifters from burning down the entire house of Rad Onc.
Click to expand...

I read it in its entirety.

I don't feel it is hyperbole to summarize it as: Every definitive/curative intent case is appropriate for protons on a registry.
 
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 don't think you can claim you're on a high horse in regards to not billing an OTV and then calling the treatment 3D. Complex is basically a step below what they call 3D-CRT (where you have to document doses to I believe at least 2 OARs).

EviCore will fight you on the complex vs 3D and not on the OTV. Feel free to light money on fire for no good reason!
 
NotMattSpraker said:
This is how I felt, and I felt lucky that I wasn't part of one of those scummy proton centers when I had it. Trust me, I love to trash my former employer given that leadership is actually evil... like in the biblical sense... but they deserve praise for being good stewards of proton therapy.

When I used it, I felt it had real benefit or it was on trial. But you better believe that admins came around trolling for patients whenever the center got slow. It just wasn't threatening or anything. I have also heard of multiple centers where the admins are not nice to their doctors about it.

But not everyone is that way. Some radiation oncologists have zero equipoise when it comes to proton therapy. They genuinely believe it is better in any setting where you can show a dosimetry benefit and trials do not matter. Believe enough to write it down in journals and insult your colleagues that don't agree. We are literally in a place where Penn... PENN!... is telling people not to treat breast with protons haha. And yet it remains one of the top indications for most centers.

Has anyone actually read ASTROs proton payment policy update? It is shockingly bad. Virtually no one cares, not even a little. IJROBP continues to publish garbage proton hyping studies.

The game is over on equipoise and integrity, best thing one can do is protect one's own patients from harm and try to stop the grifters from burning down the entire house of Rad Onc.
Click to expand...

Nebraska Prostate Cancer Patient Travels to Kansas for Proton Treatment | The University of Kansas Cancer Center

Nebraska man with prostate cancer travels 3 hours to Kansas City for proton therapy treatment. He receives the most advanced treatment without leaving his family behind for the duration. He has few side effects and is back to normal a month after treatment.
www.kucancercenter.org www.kucancercenter.org

Looks like WashU's proton neighbors to the west take a different approach? Interesting take from Dr. Chen...

“Proton therapy has a proven track record for prostate cancer,” says Ronald Chen, MD, MPH, chair of radiation oncology at the University of Kansas Medical Center and associate director for health equity at the cancer center. “It’s been shown to be a very safe and effective treatment. And with our facility here, people from a wide region around Kansas City can get this treatment closer to home than before.”
Click to expand...
 
Wildcat321 said:

Nebraska Prostate Cancer Patient Travels to Kansas for Proton Treatment | The University of Kansas Cancer Center

Nebraska man with prostate cancer travels 3 hours to Kansas City for proton therapy treatment. He receives the most advanced treatment without leaving his family behind for the duration. He has few side effects and is back to normal a month after treatment.
www.kucancercenter.org www.kucancercenter.org

Looks like WashU's proton neighbors to the west take a different approach? Interesting take from Dr. Chen...
Click to expand...
Ironic that Ron was the senior author for an early study showing excess toxicity with PBT

pubmed.ncbi.nlm.nih.gov

Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer - PubMed

Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
Wildcat321 said:

Nebraska Prostate Cancer Patient Travels to Kansas for Proton Treatment | The University of Kansas Cancer Center

Nebraska man with prostate cancer travels 3 hours to Kansas City for proton therapy treatment. He receives the most advanced treatment without leaving his family behind for the duration. He has few side effects and is back to normal a month after treatment.
www.kucancercenter.org www.kucancercenter.org

Looks like WashU's proton neighbors to the west take a different approach? Interesting take from Dr. Chen...
Click to expand...
This story is wild to me:

Protons for run of the mill SALVAGE prostate? That's being touted as better than photons for salvage prostate?

Patient went to MDACC for protons and he was lovingly referred to KU Protons? So proton centers are referring to closer to home, but only for proton centers?

It is a safe and effective treatment, as is photon radiation for this exact clinical scenario

Chartreuse Wombat said:
Ironic that Ron was the senior author for an early study showing excess toxicity with PBT

pubmed.ncbi.nlm.nih.gov

Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer - PubMed

Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...

That was the old GARBAGE proton radiation, obviously what he has now is the better proton radiation!
 
you know you've met on a real protonist when they claim 'well that was before X'

all of the current trials are going to be DERIDED btw in future as they were 'before VMAT proton'
 
Chartreuse Wombat said:
Ironic that Ron was the senior author for an early study showing excess toxicity with PBT

pubmed.ncbi.nlm.nih.gov

Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer - PubMed

Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
something something upton sinclair
 
Fpg1245 said:
I don’t know how breast surgeons are in your neck of the woods but here they seem increasingly nihilistic.
Click to expand...
Mandelin Rain said:
100%. Looking for any reason to not operate.
Click to expand...
Agree, but they aren't going to be joining us in the breadlines. They are just getting really accustomed to minimizing surgery and having less complaints/side effects to deal with.

The will continue to be the face of "breast centers", to do outreach, to do biopsies, to do presentations, to recommend regimens to the medical oncologists.

They are definitely not justifying their community salaries with surgical volume however. (At least oncologic surgery).

An axillary dissection is very rare nowadays and even a SLN bx is getting remarkably less common.
 
sirspamalot said:
Soon everyone will just eat immuni tablets and no more dirty knives or beams or poison chemo.

Yay!
Click to expand...
Better than having to eat nasty organic vegetables and fruits, unprocessed whole grains, and minimizing meat intake.

Plus, the tablets will make someone billions/trillions!
 
communitydoc13 said:
Agree, but they aren't going to be joining us in the breadlines. They are just getting really accustomed to minimizing surgery and having less complaints/side effects to deal with.

The will continue to be the face of "breast centers", to do outreach, to do biopsies, to do presentations, to recommend regimens to the medical oncologists.

They are definitely not justifying their community salaries with surgical volume however. (At least oncologic surgery).

An axillary dissection is very rare nowadays and even a SLN bx is getting remarkably less common.
Click to expand...

I don’t think the community really cares who is the face of the operation. They can barely tell who is a doctor versus an NP. Probably could make a Med onc or rad onc the face and people would be none the wiser. The show goes on.
 
Fpg1245 said:
I don’t think the community really cares who is the face of the operation. They can barely tell who is a doctor versus an NP. Probably could make a Med onc or rad onc the face and people would be none the wiser. The show goes on.
Click to expand...

This hasn't been my experience. Patients have been seeking out fellowship-trained breast surgeons, so the volume I've seen from general surgery has cratered.
 
Depends on your clientele. Agree with OTN. People underestimate
community patients just as much as they do community docs
 
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OTN said:
This hasn't been my experience. Patients have been seeking out fellowship-trained breast surgeons, so the volume I've seen from general surgery has cratered.
Click to expand...

Unless non-op management becomes a reality for the average BC patient.
 
Fpg1245 said:
I don’t think the community really cares who is the face of the operation. They can barely tell who is a doctor versus an NP. Probably could make a Med onc or rad onc the face and people would be none the wiser. The show goes on.
Click to expand...

OTN said:
This hasn't been my experience. Patients have been seeking out fellowship-trained breast surgeons, so the volume I've seen from general surgery has cratered.
Click to expand...
Agree with otn, some of the pts seeking our care also want to see docs not extenders. Have heard of a fellowship -trained breast surgeon using them for consults and having patients move to a different surgeon (general with lots of breast experience) in disgust right after the initial eval

Pts would rather see a general surgeon physician than a breast surgeon's extender
 
Last edited:
Neuronix said:
I can't get our surgeons to do any SRS for functional disorders outside of a small minority of trigeminal neuralgia cases. They want to ablate everything with a needle.
Click to expand...
The key is building referral networks directly from the neurologists (and the NP's in their clinics). There are lots of ppl refractory to propranolol/primidone that have already said no to DBS referral, and are candidates for SRS thalamotomy.

At some point I'll put up a youtube video on how to do the classical VIM targeting and shot shaping. We are moving as a field to using tractography to improve these cases and targeting where the DRTT intersects the VIM, but I'd be wary about using DTI unless you have a well QA'd magnet and someone pretty good with the distortion corrections/tractography seeding.
 
thesauce said:
Lumpectomy + RT + AI has like a 3% recurrence for early stage ER+.

Systemic alone will never touch that.

Granted the medoncs don’t care and will do what’s best for them so you may not be wrong.
Click to expand...

Well I was actually thinking more along the lines of RT and AI as “non-op”. Not holding my breath though
 
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