Rad Onc Twitter

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We’ve all come across these characters. He likely wanted to be a doctor but either was too lazy or couldn’t cut it. He goes into admin and makes it his lifelong mission to disrupt the system but not in anyway beneficial to doctors because he’s “smarter.”

He made it in life, CEO, rubs elbows with the big wigs and gets to have followers and best of all he gets to challenge the doctors because he has “power.”
 
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RadOncDoc21 said:
We’ve all come across these characters. He likely wanted to be a doctor but either was too lazy or couldn’t cut it. He goes into admin and makes it his lifelong mission to disrupt the system but not in anyway beneficial to doctors because he’s “smarter.”

He made it in life, CEO, rubs elbows with the big wigs and gets to have followers and best of all he gets to challenge the doctors because he has “power.”
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I would go a step further:

For all my stone casting at the field, very, VERY seldom do I think the people are "bad". Even many of the extremely uh...annoying people are either misled by those who came before or formed strong opinions without actually looking into "controversial" RadOnc things (which aren't really all that controversial in the bigger picture).

I do think the vast majority are doing what they think is "good".

Ron, however, is a different breed. Ignoring stories I've heard (if you get the chance, go ask a coding/billing person in your department at least 40ish years old about him), and relying exclusively on what I've seen for years, his entire business plan appears to be "drive up fear and complexity of medical billing so you think you're going to jail unless you listen to what he and his company tell you".

Seriously, if you listen to his crap you'd think we're out here killing people with IGRT or something.

It's a marketing tactic, and it's done tremendous damage to a generation of the field, physician or otherwise.
 
TexasMed22 said:
I mean, isn't this correct? Med oncs work more hours per week than rad oncs, earn ~50k less per MGMA, have (some) overnight call, and round on (some) weekends. Plus their pay is very vulnerable to changes in drug reimbursement (they start making 250k a year real quick if chemo billing changes and they lose the 6% cut on chemo infusions).
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The truth is very much in the middle. Market forces are important, but so are reimbursement levels for services provided.
 
OTN said:
The truth is very much in the middle. Market forces are important, but so are reimbursement levels for services provided.
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They are 6-18 month waits for a pcp in some locales and yet they’ll still lag behind their specialist counterparts.
 
Mandelin Rain said:
Harvard falsifies cancer research. Cool, cool, cool.
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So...Dana Farber is one of the "big, fancy hospitals" that my patients will get second opinions at, or come to me having already been there.

I have, on many occasions, steered those patients to Sloan instead.

I know, I know - normally it's the academic medical center stealing from the community, right?

But man...talk about leveraging institutional prestige. I'm not sure what goes on in Boston, but if we find out 70% of their research papers contain some element of fraud, I'd have zero trouble believing it.

I know I like to dunk on Sloan for the PPS-exempt/financial toxicity stuff, but in terms of actual medicine, I'd go there personally.

(to be clear, my opinion is about the non-RadOncs at DFCI/Mass Gen - I'm particularly fond of the Boston Pediatric RadOnc crew)
 
thesauce said:
Holy f—-

Why the hell put these patients at so much risk?? Just split it up - no one cares if they have to come in a few more times to avoid a major complication. This has gotten so out of hand.
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This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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Did you even read the trial inclusion criteria? How many of those lesions were in mobile, weight-bearing bones?

Easy to shoot from the hip if you have the blanket of sovereign immunity in academic practice
 
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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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I think there is a big difference in risk between one and 3 fractions when it comes to fractures. Most bones can take 1000 x 3 with mimal risk of fracture. Not sure why most pts couldn’t come for 2 more days. A fracture would be a lot more inconvenient and disruptive to chemo. I once necrosed an acetabulum and felt horrible. Also had some miserable pts after late insufficiency fractures from pelvic xrt.
 
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24 Gy x 1 is completely reasonable to some bony sites.

If a patient refuses anything other than a single treatment for an oligiomet in the clivus, well I guess I just have to give 24 Gy x 1 then.

The patient has metastatic disease. If there truly is some extenuating circumstance keeping them from coming back 2 more times under any circumstance (which sounds dubious this is not a fixable problem), then just give 10-12 Gy or something and retreat later if needed. Holy crap.
 
emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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You would be well served by examining your practice pattern in the context of this paper rather than the one you linked: https://www.practicalradonc.org/article/S1879-8500(20)30056-4/fulltext

For a femur metastasis, single fraction is stated to be “Not recommended” by 7/9 international sbrt experts (with 1 of the remaining 2 stating “No opinion”) and only 1 stated that single fraction is their preferred scheme.

Regarding your explanation about time off from work or interdigitating with chemo, I’ve never met a patient who wasn’t willing to come 1 or 2 extra days in order to avoid a higher risk of a long bone fracture. If you look at the orthopedic literature, very few patients ever get back to their original PS after a femur fracture, and the mortality rate due to eventual complications is very high. What is your NNH in order to avoid one missed half-day of work?
 
emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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We know that doses that high in a single fraction puts the patient at a higher risk of path fracture. The twitter comment makes it seem like that is your 'usual' regimen.

Aspiring to do that high of a dose in a single fraction and putting patient at higher risk of path fracture to avoid the benefits of fractionation to even 3Fx is a wrong answer. If patient can't come for 3Fx, would just do 8Gy x 1. Chemotherapy is usually every 2-3 weeks. Not an issue to take a week and do 3Fx of SBRT.

This is arguably MORE important in metastatic patients where you 100% do not want to cause ANY QoL hit, especially not something as potentially devastating to not only a quality of life, but also quantity of life, as a femoral neck fracture. I would encourage you to read up on how lethal femur fractures are for patients based on increasing patients' age and re-consider your practice.

24Gy in 1 fraction to a scapula or even like a humerus (something that is technically weight bearing, but not on a daily basis the way a femur is) is very different than 24Gy in 1 fraction to not only a femur, but a femoral neck metastasis.
 
evilbooyaa said:
We know that doses that high in a single fraction puts the patient at a higher risk of path fracture. The twitter comment makes it seem like that is your 'usual' regimen.

Aspiring to do that high of a dose in a single fraction and putting patient at higher risk of path fracture to avoid the benefits of fractionation to even 3Fx is a wrong answer. If patient can't come for 3Fx, would just do 8Gy x 1. Chemotherapy is usually every 2-3 weeks. Not an issue to take a week and do 3Fx of SBRT.

This is arguably MORE important in metastatic patients where you 100% do not want to cause ANY QoL hit, especially not something as potentially devastating to not only a quality of life, but also quantity of life, as a femoral neck fracture. I would encourage you to read up on how lethal femur fractures are for patients based on increasing patients' age and re-consider your practice.

24Gy in 1 fraction to a scapula or even like a humerus (something that is technically weight bearing, but not on a daily basis the way a femur is) is very different than 24Gy in 1 fraction to not only a femur, but a femoral neck metastasis.
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Maybe he is treating a 4 mm met with a cyberknife with rigid immobilization and 0mm PTV drawn off MRI performed with treatment setup?
Even then...
 
Perfect academic, big-hospital strategy: convince patients to come to your center to get single fraction radiotherapy (what a convenience!) after an 80-mile one way drive despite the fact that they live 5 min from the local community center. Treat the patient and bill insurance $70,000, the patient is delighted that they had no acute side effects! 🙂

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Patient winds up in the local community hospital with a pathologic fracture and/or esophageal perforation and/or bowel perforation and/or brainstem necrosis without records or input from academic center/big-hospital. Patient dies a slow and painful death.

In the meantime, the academic center/big-hospital publishes their "single instution prospective trial" of single fraction SBRT citing 100% local control and 0% late toxicity with median 6 month follow-up.

The world keeps on spinning, ASTRO demands more money for their PAC and DEI initiatives.
 
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If a patient can't travel to the academic center 5 times for treatment, one could always refer to their community linac close to home.

Lose some revenue capture, I know. But often times, that's the right thing to do.

EDIT: Gfunk (just) beat me.
 
Gfunk6 said:
Perfect academic, big-hospital strategy: convince patients to come to your center to get single fraction radiotherapy (what a convenience!) after an 80-mile one way drive despite the fact that they live 5 min from the local community center. Treat the patient and bill insurance $70,000, the patient is delighted that they had no acute side effects! 🙂

View attachment 381526

Patient winds up in the local community hospital with a pathologic fracture and/or esophageal perforation and/or bowel perforation and/or brainstem necrosis without records or input from academic center/big-hospital. Patient dies a slow and painful death.

In the meantime, the academic center/big-hospital publishes their "single instution prospective trial" of single fraction SBRT citing 100% local control and 0% late toxicity with median 6 month follow-up.

The world keeps on spinning, ASTRO demands more money for their PAC and DEI initiatives.
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This is why I never censored on a Kaplan Meier graph without at least a personal phone call verifying that 6 month (toxicity) followup… being lost to followup can’t be graphed (or calculated). But, if looking at local control, this also would be a censor (and the patient would be local controlled until the heat death of the universe, or longer), so caveat emptor. Yet if plotting LRFS, it would be an event.
 
elementaryschooleconomics said:
Alright let's yank the wheel in a new direction:

If 25Gy in 5 fractions is SBRT, why isn't 20Gy in 5 fractions also SBRT?

Discuss.
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20 Gy in 5 has been over-represented in radiation medicine. Calling it 3DCRT just makes it so all the other fractionations feel things are more equitable.
 
Thought there was something something about good localization... combined with 5Gy+/fx...

Otherwise 20Gy in 5Fx using IMRT would be SBRT. And that'd be... madness. Madness?

Or is SBRT just like that other thing (that we won't post about in the interest of the children) - ya just know it when you see it?
 
radoncftw said:
you bring up a good point. what about keloids? 6Gyx3
or heterotopic ossification? 8Gy x1
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I have billed 8 Gy in one fx, very conformal to a vertebral body, as SBRT before in an area previously receiving 30/10. This was before an era where we felt OK to go a lot higher in the community (maybe people always felt that way but you know… community). Probably happened twice in my life.
 
evilbooyaa said:
Thought there was something something about good localization... combined with 5Gy+/fx...

Otherwise 20Gy in 5Fx using IMRT would be SBRT. And that'd be... madness. Madness?

Or is SBRT just like that other thing (that we won't post about in the interest of the children) - ya just know it when you see it?
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We cant say plagiarism on SDN?
 
RadOncDoc21 said:
Had therapists in the past I swear were undercover whistleblowers just waiting for this to happen!
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Put a few mil on the table and I’ll blow a whistle Lewinsky style.

I’m speaking of Dr. Lewinsky, Monica’s rad onc dad. So this is NOT a risqué joke.
 
NotMattSpraker said:
I wish I could see the persons face as they read the nomination, that would be the best part by far.

Hey look, monster survival benefit with 80 Gy to the prostate. Im not sure if this is in 1 or 5 fractions or what, but thats cool! (/s)

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Uh...

1706206165017.png


Joke's on them, I've considered this standard of care for years, and it's always the recommendation I make to my patients.
 
NotMattSpraker said:
I wish I could see the persons face as they read the nomination, that would be the best part by far.

Hey look, monster survival benefit with 80 Gy to the prostate. Im not sure if this is in 1 or 5 fractions or what, but thats cool! (/s)

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Yes, why can I not find what this actually means from a fractionation pov. I did search to a reasonable degree
 
elementaryschooleconomics said:
Uh...

View attachment 381593

Joke's on them, I've considered this standard of care for years, and it's always the recommendation I make to my patients.
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And this represents one of the key drawbacks of prostate cancer trials. In order for them to be clinically relevant they need > 10 years of follow-up and by the time that happens the bar for "standard of care" has already shifted.
 
Gfunk6 said:
And this represents one of the key drawbacks of prostate cancer trials. In order for them to be clinically relevant they need > 10 years of follow-up and by the time that happens the bar for "standard of care" has already shifted.
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Not for protons!

proton-therapy.org

Virginia Attorney General Issues Opinion that Insurance Coverage for Proton Therapy May Not Be Denied by Applying Higher Standards of Clinical Evidence

Virginia Attorney General Jason S. Miyares in December issued an opinion confirming that insurers in the Commonwealth are prohibited from denying coverage for proton therapy for cancer treatment when
proton-therapy.org proton-therapy.org
 
elementaryschooleconomics said:
Alright let's yank the wheel in a new direction:

If 25Gy in 5 fractions is SBRT, why isn't 20Gy in 5 fractions also SBRT?

Discuss.
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Would argue that "SBRT" is meant to specify the need for a highly precise, highly conformal treatment in 5 or fewer fractions, where not being so careful could cause a lot of toxicity. It is not often that 20/5 need be highly precise/conformal -but if using this for re-RT in the context of a high risk of overdosing a nearby OAR, utilizing precise IGRT/immobilization, I would say that you SHOULD be able to bill 20/5 as SBRT.
 
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