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No reason to panic.

If this lady was eligible for LUMINA, contralateral breast primary is almost as likely as ipsilateral breast recurrence wirhout radiation.



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Palex80 said:
View attachment 378982


No reason to panic.

If this lady was eligible for LUMINA, contralateral breast primary is almost as likely as ipsilateral breast recurrence wirhout radiation.



View attachment 378983
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Yet another reason to hypofx.

Edit: I suppose I can't say that without a trial. But extrapolating, I'm pretty sure that treating the uninvolved breast with hypofx RT is less toxic that standard frac WBRT (wrong breast RT).
 
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sirspamalot said:
#fractionshaming is alive and well innit
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An interesting comp on the GU side: transperineal biopsy.

For a while now, there has been a push by academic centers to transition to TP vs TRUS biopsy, to the point of many in academics grandstanding and saying anything else is not standard of care. People build their career/rep on being the "transperineal guy"

TP biopsy has multiple downsides. Requires a new learning curve. Usually done under MAC vs local for TRUS (though TP can be done under local, often later in learning curve). More painful if under local, though again somewhat operator dependent. Often needs new, expensive equipment, and often uses expensive disposables that are not reimbursed.

The theoretical benefit is to reduce the infection rate and "antibiotic stewardship" since in theory TP can be done without abx. The antibiotic stewardship argument is such a joke. Firstly In practice most still use antibiotics for TP. Secondly we're talking about a single dose at time of biopsy, in a world where I prescribe maybe 10 treatment courses for UTIs a day. Cutting the single cipro dose might reduce my antibiotic prescribing burden by 1%. Less if you count patients on antibiotic ppx.

As for the infectious argument . . .

 
DoctwoB said:
An interesting comp on the GU side: transperineal biopsy.

For a while now, there has been a push by academic centers to transition to TP vs TRUS biopsy, to the point of many in academics grandstanding and saying anything else is not standard of care. People build their career/rep on being the "transperineal guy"

TP biopsy has multiple downsides. Requires a new learning curve. Usually done under MAC vs local for TRUS (though TP can be done under local, often later in learning curve). More painful if under local, though again somewhat operator dependent. Often needs new, expensive equipment, and often uses expensive disposables that are not reimbursed.

The theoretical benefit is to reduce the infection rate and "antibiotic stewardship" since in theory TP can be done without abx. The antibiotic stewardship argument is such a joke. Firstly In practice most still use antibiotics for TP. Secondly we're talking about a single dose at time of biopsy, in a world where I prescribe maybe 10 treatment courses for UTIs a day. Cutting the single cipro dose might reduce my antibiotic prescribing burden by 1%. Less if you count patients on antibiotic ppx.

As for the infectious argument . . .

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Interesting tidbit. Had heard similar things around the same time the Boston scientific reps were pushing spaceoar hard in the beginning, i remember one of the British editorials mentioned TRexit, i still do my fiducials TR, and generally it's so much quicker and really probably only get one infection every few years with abx prophylaxis.

“TREXIT 2020â€: why the time to abandon transrectal prostate biopsy starts now - Prostate Cancer and Prostatic Diseases

www.nature.com www.nature.com
 
DoctwoB said:
An interesting comp on the GU side: transperineal biopsy.

For a while now, there has been a push by academic centers to transition to TP vs TRUS biopsy, to the point of many in academics grandstanding and saying anything else is not standard of care. People build their career/rep on being the "transperineal guy"

TP biopsy has multiple downsides. Requires a new learning curve. Usually done under MAC vs local for TRUS (though TP can be done under local, often later in learning curve). More painful if under local, though again somewhat operator dependent. Often needs new, expensive equipment, and often uses expensive disposables that are not reimbursed.

The theoretical benefit is to reduce the infection rate and "antibiotic stewardship" since in theory TP can be done without abx. The antibiotic stewardship argument is such a joke. Firstly In practice most still use antibiotics for TP. Secondly we're talking about a single dose at time of biopsy, in a world where I prescribe maybe 10 treatment courses for UTIs a day. Cutting the single cipro dose might reduce my antibiotic prescribing burden by 1%. Less if you count patients on antibiotic ppx.

As for the infectious argument . . .

Click to expand...

My take for what it's worth (nothing, since I'm just bloviating on a message board) is that I like someone in the GU team to have the transperineal skill set in their tool kit... especially for the anterior lesions seen on MRI. But I'm not sure it has to be routine practice. Just nice to have someone that can do it if we think it's helpful.

I agree with you that i too am seeing the urology grandstanding/zealotry on this...I see some strong opinions online from certain uro and rad onc people about this issue.
 
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TheWallnerus said:
I hope rad onc residents get many, many questions about nivo, pembro, atezo, durva, and cemiplimab on their in-service and board exams. It is incredibly important for the rad onc to be as equally or more knowledgeable than the med onc re: the immunotherapies. (We evidently know so much… we never use them.)
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So much for being the “true oncologists”
 
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Palex80 said:
View attachment 379183


RadOncs still on the outlook for miracles a.k.a. "abscopal effect"
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It's real, as is the importance of timing of RT relative to IO, as is loads of preclinical data, including remarkable mouse model data demonstrating abscopal effect as a function of fraction size and other nuances.

But in people, it's a very, very high variance problem. This means it is going to be difficult to figure out exactly how to do it right, and when you do, it is going to be difficult to prove efficacy over a cohort of random patients.

However, the whole SBRT with IO in a personalized medicine context will certainly provide the substrate for many academic careers over the next 20 years.

I think we win in the clinical trial setting when we focus on more prosaic outcomes, like extending the time of efficacy of a given systemic therapy by treating oligoprogressive disease, or treating high risk metastases upfront, as symptomatic progression of disease is closely related tolerance of further therapy and therefor survival.

Our story is pretty peripheral to the bigger story, which is that medonc is rapidly figuring out better ways to give IO to more and more people.
 
communitydoc13 said:
It's real, as is the importance of timing of RT relative to IO, as is loads of preclinical data, including remarkable mouse model data demonstrating abscopal effect as a function of fraction size and other nuances.

But in people, it's a very, very high variance problem. This means it is going to be difficult to figure out exactly how to do it right, and when you do, it is going to be difficult to prove efficacy over a cohort of random patients.

However, the whole SBRT with IO in a personalized medicine context will certainly provide the substrate for many academic careers over the next 20 years.

I think we win in the clinical trial setting when we focus on more prosaic outcomes, like extending the time of efficacy of a given systemic therapy by treating oligoprogressive disease, or treating high risk metastases upfront, as symptomatic progression of disease is closely related tolerance of further therapy and therefor survival.

Our story is pretty peripheral to the bigger story, which is that medonc is rapidly figuring out better ways to give IO to more and more people.
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I can only answer with an (old) meme.

Abscopal.png
 
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grenz said:

Gotta say I agree. The reporter engages with Vinay’s reply, but you can see how some reporters aren’t actually interested in the truth, just their pre-conceived story.
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I'm all for aggressive local therapy when indicated, including for SCLC, but double long transplant seems crazy to me as well, especially off-protocol.

Wild that we're not routinely pushing for thoracic radiation for ES-SCLC in ICI era but folks are contemplating double lung transplant for presumably ES-SCLC. Probably a lot more to the story...
 
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evilbooyaa said:
I'm all for aggressive local therapy when indicated, including for SCLC, but double long transplant seems crazy to me as well, especially off-protocol.
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It seems unethical to the donor. Presumably there are recipients that we know with certainty will benefit from the transplant.
 
Brings up a good point - we think of organs suitable for transplant as being this highly scarce resource, but is that the case in setting of lung transplant in the contemporary era? I truly don't know.
 
Mandelin Rain said:
Double lung transplant for SCLC?

What The Wtf GIF by Justin


That's something an academic center says when they REALLY want to steal a private pay patient from a community center. Complete and utter bull ****.
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So much in life and medicine is just a few bad actors ruining it for everyone.

I get so pissed about prior auth but when you see this stuff and you see what they try to treat at some of the proton centers you understand. It makes you feel dirty to get sympathetic with the insurance company....but come on.
 
BobbyHeenan said:
So much in life and medicine is just a few bad actors ruining it for everyone.

I get so pissed about prior auth but when you see this stuff and you see what they try to treat at some of the proton centers you understand. It makes you feel dirty to get sympathetic with the insurance company....but come on.
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Well and then I'm seeing other physicians wade into the pile on and I'm like dude....my friend, you are not an oncologist. Sure insurance companies are corrupt AF but that still doesn't make a double lung transplant make sense?
 
RO28 said:
Well and then I'm seeing other physicians wade into the pile on and I'm like dude....my friend, you are not an oncologist. Sure insurance companies are corrupt AF but that still doesn't make a double lung transplant make sense?
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It typically is a correct heuristic to come at it that the insurance company is automatically wrong...but in this case....
 
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BobbyHeenan said:
It typically is a correct heuristic to come at it that the insurance company is automatically wrong...but in this case....
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I know...its making me gag a little bit...
 
RO28 said:
Well and then I'm seeing other physicians wade into the pile on and I'm like dude....my friend, you are not an oncologist. Sure insurance companies are corrupt AF but that still doesn't make a double lung transplant make sense?
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I just checked out the thread. Apparently, there was an error in an early post and the patient in question has multifocal adenocarcinoma and not small cell lung cancer.

Now, this is a case that may not be amenable to evidence based medicine. 40 something, several years into a metastatic diagnosis and presumably with disease limited to the thorax.

Occasionally, heroic measures are within reason (and will never ever be evidence based).

In terms of how an algorithm for assignment of donor lungs values a case like this? This is highest order medical ethics stuff. I just don't know how well bilateral lung transplant works for anything (although I have seen success in late stage pulmonary fibrosis).
 
communitydoc13 said:
I just checked out the thread. Apparently, there was an error in an early post and the patient in question has multifocal adenocarcinoma and not small cell lung cancer.

Now, this is a case that may not be amenable to evidence based medicine. 40 something, several years into a metastatic diagnosis and presumably with disease limited to the thorax.

Occasionally, heroic measures are within reason (and will never ever be evidence based).

In terms of how an algorithm for assignment of donor lungs values a case like this? This is highest order medical ethics stuff. I just don't know how well bilateral lung transplant works for anything (although I have seen success in late stage pulmonary fibrosis).
Click to expand...

Ok, that's a bit more reasonable than small cell....but still would deny off protocol as an insurer.

I don't know much (?or anything?) about availability of lungs. I never see much luck with our HCC patients getting a liver, so that's my starting point.
 
communitydoc13 said:
I just checked out the thread. Apparently, there was an error in an early post and the patient in question has multifocal adenocarcinoma and not small cell lung cancer.

Now, this is a case that may not be amenable to evidence based medicine. 40 something, several years into a metastatic diagnosis and presumably with disease limited to the thorax.

Occasionally, heroic measures are within reason (and will never ever be evidence based).

In terms of how an algorithm for assignment of donor lungs values a case like this? This is highest order medical ethics stuff. I just don't know how well bilateral lung transplant works for anything (although I have seen success in late stage pulmonary fibrosis).
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Interesting, that does change things a little, especially if EGFR mutant.

But still...it would be investigational, and I dunno, maybe not for the insurance company to pay for? Especially given all the potential complications associated with a double lung transplant in an unproven setting? Super challenging ethical quandry.
 
RO28 said:
maybe not for the insurance company to pay for?
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The payor issue is really interesting from a moral standpoint here. I think we are all jaded by the proton fiasco and the false narrative that denying protons is denying a patient's survival (probably essentially never the case).

There is also nothing (and I mean nothing) preventing an institution as wealthy as Vandy or Northwestern from doing this type of stuff for free when deemed appropriate, and I would view all of these cases as essentially experimental.

I personally think that Vandy should be paying for the procedure.
 
communitydoc13 said:
The payor issue is really interesting from a moral standpoint here. I think we are all jaded by the proton fiasco and the false narrative that denying protons is denying a patient's survival (probably essentially never the case).

There is also nothing (and I mean nothing) preventing an institution as wealthy as Vandy or Northwestern from doing this type of stuff for free when deemed appropriate, and I would view all of these cases as essentially experimental.

I personally think that Vandy should be paying for the procedure.
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yeah I agree with this.

Label it investigational compassionate use, and foot the bill. Vandy has the money and you know they can write something like this off.
 
I wouldn't put this past their lung transplant team as I've already had absurd experiences with them specifically. This sounds like a bad idea. I'm simultaneously hopeful that if they do it it is successful and if it isn't they're crucified.
 
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RO28 said:
Interesting, that does change things a little, especially if EGFR mutant.

But still...it would be investigational, and I dunno, maybe not for the insurance company to pay for? Especially given all the potential complications associated with a double lung transplant in an unproven setting? Super challenging ethical quandry.
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I agree.
I do not see how this would work, if this is not EGFR mutated NSCLC.
Additionally, IO is likely gone as an option (or super risky) after the transplant.
 
Ray D. Ayshun said:
simultaneously hopeful that if they do it it is successful and if it doesn't they're crucified
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My hope would be that cases like this are brought before internal medical ethics boards (they all should be).

Extraordinary resources, extraordinary risk, extraordinary real cost and uncertain outcomes.

This does not mean that doing stuff like this is always wrong, but rather that the case should be presented for review before an ethics committee prior to being performed (or frankly even presented as an option to the patient).

The payor can stay the hell out of this. That is a false narrative here. I would never expect my insurance to pay for an artificial heart (in 1982). The institution can forgive the cost.
 
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communitydoc13 said:
This does not mean that doing stuff like this is always wrong, but rather that the case should be presented for review before an ethics committee prior to being performed (or frankly even presented as an option to the patient).
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The most frustrating part by far. Docs do crazy stuff, blame insurance for not paying. Insurance cheaps out on routine stuff, and cites crazy docs as a need for prior auth as a "quality intervention". Patients have false hope and misplaced rage, the lay public becomes further misinformed about the realities of cancer care.

Everyone that isn't doing the care or experiencing the disease is making money though, right? All good.

Round and round we go.
 
grenz said:
Who?
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In my clinic it’s a med onc and me. Whenever he is on vacay or out for day, I am supervising all fhe chemo and IO, and for all intents and purposes and in CMS’s eyes I am giving all that. (I.e I’m the supervising MD and all the chemo etc billing goes under my NPI.) There are some years where billing-wise I give more chemo than radiation!
 
Just food for thought:

If a patient has a complication and dies, and you get added to the lawsuit, and they discover that you were "covering" for billing purposes, and they use that during the lawsuit... a jury could be convinced to award damages.

Now for the fun fun part: Will your medmal insurer protect you while you were performing duties outside the scope of your practice?

Looney Tunes Nothing To See Here GIF


I flatly refused to do this, because I'm not sure what the outcome would be but.. I definitely do not want to...

200.gif
 
sirspamalot said:
Just food for thought:

If a patient has a complication and dies, and you get added to the lawsuit, and they discover that you were "covering" for billing purposes, and they use that during the lawsuit... a jury could be convinced to award damages.

Now for the fun fun part: Will your medmal insurer protect you while you were performing duties outside the scope of your practice?

Looney Tunes Nothing To See Here GIF


I flatly refused to do this, because I'm not sure what the outcome would be but.. I definitely do not want to...

200.gif
Click to expand...
I like having a job more than I like crusades against billing/coding/supervision issues. I have to take vacations too, and the med onc “gives” (supervises) the radiation when I’m out. Arrangements like this are more common than we think. Before NPs could supervise chemo, many med oncs used to hire retired family practice guys to cover.
 
sirspamalot said:
Just food for thought:

If a patient has a complication and dies, and you get added to the lawsuit, and they discover that you were "covering" for billing purposes, and they use that during the lawsuit... a jury could be convinced to award damages.

Now for the fun fun part: Will your medmal insurer protect you while you were performing duties outside the scope of your practice?

Looney Tunes Nothing To See Here GIF


I flatly refused to do this, because I'm not sure what the outcome would be but.. I definitely do not want to...

200.gif
Click to expand...

The chances of being sued for giving immunotherapy to the appropriate patient is about as unlikely as it gets. More of us need to step up and do it before our specialty becomes extinct.
 
thesauce said:
The chances of being sued for giving immunotherapy to the appropriate patient is about as unlikely as it gets. More of us need to step up and do it before our specialty becomes extinct.
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I wonder if malpractice allegations for catastrophic IO complications are actually pretty common.

Patients get super-sick quickly and die

Should be easy to look up
 
thesauce said:
The chances of being sued for giving immunotherapy to the appropriate patient is about as unlikely as it gets. More of us need to step up and do it before our specialty becomes extinct.
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Need to be on top of those complications real quick. Do you feel game for that while administering RT? Pt education regarding diarrhea, checking labs etc.

It can be devastating but that doesn't absolve you of responsibility to make sure things are addressed in a timely manner.
 
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medgator said:
Need to be on top of those complications real quick. Do you feel game for that while administering RT? Pt education regarding diarrhea, checking labs etc.

It can be devastating but that doesn't absolve you of responsibility to make sure things are addressed in a timely manner.
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This. You won’t be sued for a complication on the consent form, but where the lawyers nail doctors is on failure to diagnose and/or manage a complication in a timely/correct manner.
 
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