Rad Onc Twitter

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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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It goes without saying that you have to understand the toxicities of the treatments you’re giving.

Let’s not kid ourselves: immunotherapy is relatively new - many and perhaps most MOs didn’t learn it in training and learn it out in the real world. We need to do the same.
 
thesauce said:
It goes without saying that you have to understand the toxicities of the treatments you’re giving.

Let’s not kid ourselves: immunotherapy is relatively new - many and perhaps most MOs didn’t learn it in training and learn it out in the real world. We need to do the same.
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skin toxicity-> d/c therapy and give steroids
colitis-> d/c therapy and give steroids
hepatitis -> d/c therapy and give steroids
endocrinopathy- d/c therapy, give steroids, refer to endocrinologist
pneumonitis-> c'mon, we do this all the time. The med onc half the time cant figure out if it was from radiation or IO. O2 and steroids maybe a Z- pak.

I think we covered 90% of the potential issues.
 
TheWallnerus said:
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!
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I’ve been in this position about half a dozen times myself. I don’t know, can’t hyperventilate over everything. It’s not like I’m scrubbing in and doing a surgery as the primary doc.

I’m not a fan of it but on the other hand I’m not going to be the guy that says shut chemo down for everyone that day either.
 
fiji128 said:
I’ve been in this position about half a dozen times myself. I don’t know, can’t hyperventilate over everything. It’s not like I’m scrubbing in and doing a surgery as the primary doc.

I’m not a fan of it but on the other hand I’m not going to be the guy that says shut chemo down for everyone that day either.
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I could try to be the guy that says “shut down the chemo!” And then I would be the guy who would get a chuckle from everyone and a pat on the head.
 
Ray D. Ayshun said:
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 doesn't they're crucified.
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You, as a RO, have had specific, multiple negative experiences with a transplant team? Can't say I've routinely interacted with any transplant team as a RO....

RO28 said:
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.
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Counter point to all those who think the institution should foot the bill:
This isn't a one-time surgery that the institution can just foot the bill for and all can move on with their lives. Once the transplants go in, it's life
long immunosuppression.
If you don't make insurance agree that the transplant is worth covering, does anyone doubt that an insurance company would then refuse to pay for all the lifelong immunosuppression/follow-up necessary to minimize chances of rejection of the lungs?
 
xrt123 said:
skin toxicity-> d/c therapy and give steroids
colitis-> d/c therapy and give steroids
hepatitis -> d/c therapy and give steroids
endocrinopathy- d/c therapy, give steroids, refer to endocrinologist
pneumonitis-> c'mon, we do this all the time. The med onc half the time cant figure out if it was from radiation or IO. O2 and steroids maybe a Z- pak.

I think we covered 90% of the potential issues.
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the other 10% include immune myocarditis and bowel gangrene among other things. US RadOnc training is not equipped to train to administer IO
 
I am not saying that we are equipped to administer IO - but med onc is similarly not equipped to handle immune myocarditis and bowel gangrene ... or optic neuritis, nephritis ... You have to be aware of risks, know how to preliminarily work-up symptoms from possible toxicities and then refer to someone who can handle it if you can't. We do this for many radiation toxicities (eg. mandible osteoradionecrosis, esophageal stricture, chronic rectal bleeding)
 
A_DeMichele said:
the other 10% include immune myocarditis and bowel gangrene among other things. US RadOnc training is not equipped to train to administer IO
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Oh puhleeze. You think medonc is managing these things?

Radiation can cause a fistula. Are we also not equipped to give radiation?
 
thesauce said:
Oh puhleeze. You think medonc is managing these things?

Radiation can cause a fistula. Are we also not equipped to give radiation?
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there is an old thread on why should we not give weekly cisplatin... boring to read these arguments again.
anyway, chance of us starting to give IO in US is zero.
we could not even get our hands on radio-labeled antiboides
 
I used to be a regular giver of amifostine. I alone accounted for 1% of the entire planet’s usage at one point in time. The constant and unceasing departmental headaches and blowbacks I got from doing it were a sight to behold. The first rad oncs to give IO routinely need to have the book of Job open in their office for inspirational reading.
 
TheWallnerus said:
I used to be a regular giver of amifostine. I alone accounted for 1% of the entire planet’s usage at one point in time. The constant and unceasing departmental headaches and blowbacks I got from doing it were a sight to behold. The first rad oncs to give IO routinely need to have the book of Job open in their office for inspirational reading.
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Even if someone was able to do it, we’ll find a way to make it difficult.
 
Why do we think we could be giving IO?

Like just logistically? The med onc just abdicates that portion of infusional, systemic therapy to us? After giving the same patient multiple rounds of chemotherapy?

It’s not that I think we couldn’t figure out the drugs, dosages, and toxicity management in relatively short order. Literally every med onc who has been working >15-20 years just learned it on the job as drugs were developed and indications grew. It wasn’t part of their residency curriculum either, because it didn’t exist.

It’s just that it doesn’t make any sense to have us do it when the pathway to patients being referred for and administration of IO already exists. And honestly, makes much more sense.

This would be akin to the Endocrinology board deciding that they should be the ones to read ECHOs on hypothyroid patients or administer dialysis on diabetics with renal failure, or some other such thing.

Just pissing in the wind.
 
TheWallnerus said:
I used to be a regular giver of amifostine. I alone accounted for 1% of the entire planet’s usage at one point in time. The constant and unceasing departmental headaches and blowbacks I got from doing it were a sight to behold. The first rad oncs to give IO routinely need to have the book of Job open in their office for inspirational reading.
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Awful drug
 
medgator said:
Awful drug
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Eh, nah.

The basic science mechanism can be easily understood; should be a good radiation protectant.

In vitro and in vivo data showed it was preferentially taken up by cancer cells.

Clinical data showed improvements in acute and late toxicities in many disease sites.

It was easier to administer as SQ versus IV and had less side effects that way. Like any drug, it didn’t have zero side effects. If the side effects were bothersome, one just d/c’d the Ethyol.

What was most awful about it? You got reimbursed about 1% less than the cost of the drug.
 
TheWallnerus said:
Eh, nah.

The basic science mechanism can be easily understood; should be a good radiation protectant.

In vitro and in vivo data showed it was preferentially taken up by cancer cells.

Clinical data showed improvements in acute and late toxicities in many disease sites.

It was easier to administer as SQ versus IV and had less side effects that way. Like any drug, it didn’t have zero side effects. If the side effects were bothersome, one just d/c’d the Ethyol.

What was most awful about it? You got reimbursed about 1% less than the cost of the drug.
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Lot of hypotension and passed out pts. Became irrelevant in the IMRT era
 
medgator said:
Lot of hypotension and passed out pts. Became irrelevant in the IMRT era
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Again, eh. I never had a passed out patient. That was way more of an IV problem than SQ. Even with IMRT, the PTVs can be very big on some lung and esophageal patients with borderline or non-met OAR constraints. Likewise for parotids in HNSCC. IMRT diversified the physics-based normal tissue protecting portfolio, granted. Amifostine was and still is the sui generis stock in the biochemical portfolio.
 
TheWallnerus said:
Again, eh. I never had a passed out patient. That was way more of an IV problem than SQ. Even with IMRT, the PTVs can be very big on some lung and esophageal patients with borderline or non-met OAR constraints. Likewise for parotids in HNSCC. IMRT diversified the physics-based normal tissue protecting portfolio, granted. Amifostine was and still is the sui generis stock in the biochemical portfolio.
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At one time I had seen some reports of possible po or pr amofistine for thoracic or pelvic radiation (I think Ben Josef at UM was publishing about it) but that seemed to go away. I always felt like an amifostin/carafate slurry a few minutes before radiation would be interesting to test for esophagitis.
 
1701458681516.png


Of course „rectum not in field at all“, because…

1701458795840.png


🙈🙈🙈
 
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BobbyHeenan said:
At one time I had seen some reports of possible po or pr amofistine for thoracic or pelvic radiation (I think Ben Josef at UM was publishing about it) but that seemed to go away. I always felt like an amifostin/carafate slurry a few minutes before radiation would be interesting to test for esophagitis.
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Yes, kind of almost like ethyol enema pre rectal RT. That sort of thing. That data looked good, to me.
 
The Mirage trial showed the rates of bowel toxicity at three months was the same between the CT-guided arm (4mm margins*) and MRI-guided arm (2mm margins). Those rates were not 0% in either arm.

*I use 3mm margins for my CT-guided SBRT
 
Can literally see the PTV not being in the rectum for even CT based prostate SBRT that has a spacer.
And MIRAGE didn't show any benefits in terms of GI toxicity with MR-Linac. WTF we talking about here?? Man, Percy is leaning real hard into the wonders of MR-Linac not dissimilar to many a proton enthusiast....
 
"PPL reports consulting fees from ... Viewray"
"PPL reports personal fees from Viewray ..."

hmmmm
 
I think this is a weird Twitter flex, but there were GI toxicity benefits...0% grade 2 GI, and half as much decline on bowel PROs. So not true to say no GI benefit on MIRAGE.

But yeah not sure I would tweet patient images like this and this is a pretty shameless plug
 
Mandelin Rain said:
Why do we think we could be giving IO?

Like just logistically? The med onc just abdicates that portion of infusional, systemic therapy to us? After giving the same patient multiple rounds of chemotherapy?

It’s not that I think we couldn’t figure out the drugs, dosages, and toxicity management in relatively short order. Literally every med onc who has been working >15-20 years just learned it on the job as drugs were developed and indications grew. It wasn’t part of their residency curriculum either, because it didn’t exist.

It’s just that it doesn’t make any sense to have us do it when the pathway to patients being referred for and administration of IO already exists. And honestly, makes much more sense.

This would be akin to the Endocrinology board deciding that they should be the ones to read ECHOs on hypothyroid patients or administer dialysis on diabetics with renal failure, or some other such thing.

Just pissing in the wind.
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Thanks Mandelin Rain, I completely agree with you. As nice as it would be to add IO to our skillset and income streams, there are some major obstacles to entry into another discipline. Not impossible, but not trivial, and not as easy as it seems.

A Canadian colleague told me a few years back that there is an oncology fellowship program (almost wrote pogrom!) up there that would train a surgical oncologist or rad onc MD to do medical oncology in just one year. I don't know if it still exists, but it would be one year shorter than the usual 2 year medical oncology fellowships in the US. Heme-onc fellowship is 3 years, but I don't think most people are that into heme unless they want to do transplant, CAR-T etc.

I once considered med onc as a career pivot, earlier in the IO era when the abscopal effect seemed like a real thing and truly synergistic combo, but I eventually decided on a proton fellowship instead, when the opportunity presented itself. At least for me, I think it was the right choice, career-wise. Trying to keep up with new drug approvals, even in a single subspecialty like lung, is not simple. Remember that it's not just IO that they are prescribing, but also chemo-IO, and therefore all the toxicities that will entail. So, rather than broaden, sub-specialized.

It seems like it would have been a simple thing to do, to narrow my focus, but it was still extremely difficult and the most humbling thing I've ever done, to go back to being the low man on the totem pole and taking a major pay cut after doing pretty well before then. It was also very hard on my family, in ways and to a degree that I didn't expect; a difficult experience for all of us.

Practice-wise, it turns out that it didn't narrow my focus at all, but opened a whole new horizon to explore. In addition to the X-ray and brachy skills that I still love and use every day, I've added peds, clinical trials, particle research, and many more fun things that I didn't even think about before.

I've doubled down on our field. I don't think we will go away as long as we keep innovating, and fast. At the same time, I can see the current attraction of medical oncology. For those who seriously believe that rad onc is doomed, maybe a med onc fellowship IS the way to go
 
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Gfunk6 said:
I thought the whole point of MRI-guided prostate radiotherapy was that you didn't need a rectal spacer???
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Wow.

Wow.

Wow.

Percy, buddy, stop.

You can't be over at a PPS-exempt institution tagging the President in a plea to have the federal government bail out the bankrupt company who built your $10 million dollar MR-linac THAT YOU ARE USING WITH THE GREATEST GRIFT IN MODERN RADIOTHERAPY.

What, on God's green Earth, are you doing? You're seriously using SpaceOAR/Barrigel WITH the MR-Linac? WHY????

I'm extremely impressed with what the MR-linacs can do. It's why I think the technology should continue to exist (and the choice to use it should be done wisely).

But...literally, the whole point of what the MR-linac can do is to OBVIATE THE NEED FOR THE GEL.

The insertion of the hydrogel is, by far, the biggest side effect of receiving MRI-guided radiotherapy at City of Hope for prostate cancer.

I certainly wouldn't do it, and if a family member told me that was recommended to them, I would advise they seek a second opinion.
 
Mandelin Rain said:
Why do we think we could be giving IO?

Like just logistically? The med onc just abdicates that portion of infusional, systemic therapy to us? After giving the same patient multiple rounds of chemotherapy?

It’s not that I think we couldn’t figure out the drugs, dosages, and toxicity management in relatively short order. Literally every med onc who has been working >15-20 years just learned it on the job as drugs were developed and indications grew. It wasn’t part of their residency curriculum either, because it didn’t exist.

It’s just that it doesn’t make any sense to have us do it when the pathway to patients being referred for and administration of IO already exists. And honestly, makes much more sense.

This would be akin to the Endocrinology board deciding that they should be the ones to read ECHOs on hypothyroid patients or administer dialysis on diabetics with renal failure, or some other such thing.

Just pissing in the wind.
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If you are beholden to medical oncology for your referrals, then yes you probably won’t be able to give much.
 
thesauce said:
If you are beholden to medical oncology for your referrals, then yes you probably won’t be able to give much.
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Like maybe indications will continue to grow….Stage 1 NSCLC. High-risk prostate cancer. Early stage head and neck. Early stage endometrial.


Maybe not. I don’t know.

I do know that everyone who currently qualifies for IO is seeing a med onc regardless of where my/your referral comes from.
 
Mandelin Rain said:
Like maybe indications will continue to grow….Stage 1 NSCLC. High-risk prostate cancer. Early stage head and neck. Early stage endometrial.


Maybe not. I don’t know.

I do know that everyone who currently qualifies for IO is seeing a med onc regardless of where my/your referral comes from.
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This is not true for me
 
thesauce said:
This is not true for me
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Cool. I don’t know who you’re seeing, but cool.

Edit: unless you’re talking metastatic patients, in which case, you don’t want to just give IO, you want to be a med onc.
 
Mandelin Rain said:
Cool. I don’t know who you’re seeing, but cool.

Edit: unless you’re talking metastatic patients, in which case, you don’t want to just give IO, you want to be a med onc.
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I’m not

My hope is that we can all (maybe not all but the majority) agree that giving IO is within our capability and we aren’t going to shame the next radonc who gives it just because one may not be able to with their current setup and referral patterns

This is an important step in the field for RO and we should all embrace it
 
thesauce said:
I’m not

My hope is that we can all (maybe not all but the majority) agree that giving IO is within our capability and we aren’t going to shame the next radonc who gives it just because one may not be able to with their current setup and referral patterns

This is an important step in the field for RO and we should all embrace it
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Never going to happen in the US outside of maybe extremely underserved areas. How many rad onc clinics even have a set up and staff available to start doing routine infusions? I'm not saying its impossible for theoretical stand point but is from a practical standpoint.
 
I’ve asked the question for years around here. It’s just the culture of radiation oncology. We are timid and afraid to upset anyone and we are paralyzed by the need for endless data to make any type of decision. Just look at neurologists..they came up with some bs neuro oncology fellowship to give systemic therapy. Wait maybe an even less qualified group is gyn oncology. What do they know about chemo and they sure didn’t learn about immunotherapy if they trained over 10 years ago, but they all use it now. Or there’s dermatology who just uses radiation and I’ve even seen some Mohs surgeons using erivedge. Oh and then there’s neurosurgeons now with gyroscopic radiosurgery claiming no need for radiation oncologists. I’m sure the list will go on…
 
I'm going to avoid stating my opinion on whether we should/should not give IO, because that part isn't important.

But what I will say is that in my current practice, it is not uncommon for patients who are eligible for IO are seeing me first (and usually only me, as I'm the one making the MedOnc referral).

The physical location and layout of my hospital is also one where me prescribing IO would not be a problem for the staff. To be clear, if I were to do such a thing, it would be the "regular" nurses/support staff doing it, just as if MedOnc had prescribed it.

Out of all the problems I see with this becoming a "normalized" thing for us: I'm painfully aware of the politics behind this at bigger institutions...and especially every single institution where you can find a RadOnc residency.

So while I think there's a lot of places in the country where we COULD be managing IO, I don't see a clear way as to how residents could get any experience. Which means you would need to have more of a "cowboy" mentality...which is not what RadOnc is known for.

I could see something like a dedicated, structured training arising, as in a ~3 month certificate program that residents could do during elective time, or those already in practice could complete at their own discretion.

My point is that I don't think it's all that uncommon for IO-eligible patients to only be seeing a RadOnc at some point, and the MedOnc nurses with their infusion chairs can be pretty close to a linac, depending on the hospital.
 
I see plenty of stage III nsclc first and I refer them to med onc. Plenty of sclc first. Plenty of borderline PS bladder patients first without staging and I refer them to med onc to see if chemo eligible for bladder preservation. Plenty of metastatic patients first and I refer them to med onc. Plenty of rectal biopsies without MMR done. Plenty of everything first and direct care.

The point is, all these patients still need to see a med onc, whether I refer them or not.

To my knowledge, there are zero indications (the sauce’s patient population notwithstanding) for IO and XRT that a rad onc could/should be managing without any med onc input. Regardless of what direction the referral flow is going.

If you are the guy who is going to take a stand and tell the med onc, “I’m sending you this patient for only weekly carbo/taxol and then you will be done and I’ll be giving the durva. If not, I’ll never send you another of my patients.” Cool. I probably wouldn’t want to work with you in a multi disciplinary team, but cool. If you’re the guy who want to run NGS and make unilateral chemo eligibility decisions on metastatic patients before starting IO, cool. Hope your med mal is strong because you’re now practicing as a med onc.
 
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If SBRT + IO for early stage lung cancer becomes a thing. The Rad Onc giving IO makes sense.

If XRT + IO for bladder preservation is better than chemorads, it makes sense for the rad onc to give IO.

If IO expands role in non metastatic prostate ca, the rad onc giving IO makes sense. Plenty of us already manage long term ADT.

VC cuff brachy and IO in stage III endometrial cancer.

Altered fraction XRT/IO in head and neck.

I can think of plenty of things that “might” work better than current standard, that could make us a common sense prescriber of IO.

But I just don’t see a current indication that it makes practical sense outside of some pissing match for pissing match sake.
 
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fiji128 said:
Never going to happen in the US outside of maybe extremely underserved areas. How many rad onc clinics even have a set up and staff available to start doing routine infusions? I'm not saying its impossible for theoretical stand point but is from a practical standpoint.
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Using this logic, gynecology oncology shouldn't be giving IO and neuro-oncologists shouldn't be giving Avastin. Further, gastroenterologists shouldn't be treating inflammatory bowel disease and neurologists shouldn't be treating multiple sclerosis.

The problem is clearly our failing academic radiation oncology problems for not creating pathways for our residents to receive appropriate training for modern clinical oncology.
 
theradiator said:
Using this logic, gynecology oncology shouldn't be giving IO and neuro-oncologists shouldn't be giving Avastin. Further, gastroenterologists shouldn't be treating inflammatory bowel disease and neurologists shouldn't be treating multiple sclerosis.

The problem is clearly our failing academic radiation oncology problems for not creating pathways for our residents to receive appropriate training for modern clinical oncology.
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The first chemo was for choriocarcinoma, so it made sense for the GynOncs to give it. As other drugs came to the fore, they just added them to their arsenal. Makes sense historically.

Neuro-oncology didn't ruffle any feathers, because, let's be honest, not very many medoncs want to treat GBM.
 
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