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Lamount said:
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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Ron will be coming after you… doesn’t matter if you’re over or under billing or billing just right!
 
RadOncDoc21 said:
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
Click to expand...

Its become totally clear this is their new legislative strategy.

We all agree IMRT implementation should have been more evidence based. Unless you'd rather make that past mistake the new standard so you can sell protons.

I wonder what [redacted] thinks about the fact that women still cant get IMRT for their breast cancers despite decent evidence that it reduces toxicity.

Shameful.
 
NotMattSpraker said:
Its become totally clear this is their new legislative strategy.

We all agree IMRT implementation should have been more evidence based. Unless you'd rather make that past mistake the new standard so you can sell protons.

I wonder what [redacted] thinks about the fact that women still cant get IMRT for their breast cancers despite decent evidence that it reduces toxicity.

Shameful.
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Not sure how this ruling is sustainable. It could be applied to any new, high cost intervention that has no significant proof of superiority over a cheaper historical standard unless the evidence for the standard is remarkably robust (not always the case).

Could be catastrophic for insurance.
 
communitydoc13 said:
Not sure how this ruling is sustainable. It could be applied to any new, high cost intervention that has no significant proof of superiority over a cheaper historical standard unless the evidence for the standard is remarkably robust (not always the case).

Could be catastrophic for insurance.
Click to expand...

Devices dont have to be better than SOC, they just have to effective and safe. The argument is that proton therapy is standard, not experimental.

IL passed the same law: Illinois expands cancer care: Groundbreaking Proton Beam therapy now more accessible

CO put one up and it failed. I joined the state medical society and am trying to learn more about this push.

Perhaps we move on from their legislative efforts since I think they will win class action law suits now and eventually this will be put up in every state.

In my opinion, they are also the main source of people thinking radiation is harmful. We should probably be working on their media approach and push back.

What's almost as bad as brain cancer? Photon radiotherapy apparently. What’s (Almost) as Bad as Brain Cancer?

This is just so messed up.

1706211338685.png



1706211436110.png
 
NotMattSpraker said:
Devices dont have to be better than SOC, they just have to effective and safe.
Click to expand...
So I'm guessing this ruling would not be broadly applicable?

I don't believe insurances pay directly for devices regardless. They do pay for procedures associated with devices and sometimes those devices have new codes associated with them (a significant barrier there).
 
I think they have to cover a device if it’s a one time use thing such as some IR stuff, no?
 
communitydoc13 said:
So I'm guessing this ruling would not be broadly applicable?

I don't believe insurances pay directly for devices regardless. They do pay for procedures associated with devices and sometimes those devices have new codes associated with them (a significant barrier there).
Click to expand...

I do not know what will happen but think we will see a lot more of this as well as class action lawsuits.

I don't think its super crazy if you are a True Believer. Insurance is actually a really big burden and it has been shown that the denials are messing up interpretation of trials. I can totally see how they think they are working with good intentions.

It's just depressing to me that this is where we are at, seemingly giving up on generating evidence and just trying to legislate proton use. The spirit of that law suggests that they will be arguing for continued proton use for prostate cancer even if Partiqol is negative. 1 in 4 proton cases in the US are prostate cancer.

Plus there are prominent doctors out there telling everyone that photon radiation is harming people in some settings based only on their beliefs.

I do think there are reasonable proton users out there trying to generate evidence, and some are very prominent. The ASTRO president is a good example. I guess they just dont care enough to push back against the non-sense and put us on a path to sanity.

Just depressing all around 🙁
 
NotMattSpraker said:
I do not know what will happen but think we will see a lot more of this as well as class action lawsuits.

I don't think its super crazy if you are a True Believer. Insurance is actually a really big burden and it has been shown that the denials are messing up interpretation of trials. I can totally see how they think they are working with good intentions.

It's just depressing to me that this is where we are at, seemingly giving up on generating evidence and just trying to legislate proton use. The spirit of that law suggests that they will be arguing for continued proton use for prostate cancer even if Partiqol is negative. 1 in 4 proton cases in the US are prostate cancer.

Plus there are prominent doctors out there telling everyone that photon radiation is harming people in some settings based only on their beliefs.

I do think there are reasonable proton users out there trying to generate evidence, and some are very prominent. The ASTRO president is a good example. I guess they just dont care enough to push back against the non-sense and put us on a path to sanity.

Just depressing all around 🙁
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Can I say rad oncs suck as advocates for each other? We will continue to argue about the dumbest, minute things but can’t come together to create a baseline level of dignity and trust in our field. Despite all of us having to pass 4 board exams (most in any field) and 4 yrs of ONCOLOGY training (more then any other field).

Today, it’s all about who has the “highest quality” of care based on whatever flavor smoke is coming from our own ass rather it be who has the “most modern technology” to whoever can draw a better circle with 2mm margin only to be shamed by someone else who uses 1mm margin and one less fraction. We can quote trials to the infinite decimal point because we can, but we can’t focus on anything that actually matters!

Ok, I’ve completed my rant for the day.
 
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"
As for my sister’s team, they believe in proton therapy for glioblastoma patients so much, that for the GBM patients enrolled in their dose escalation study, these docs could not, ethically, include a control group that received only IMRT. This is because, we learn, of “equipoise.”

Equipoise is, according to a 1987 copy of the New England Journal of Medicine that I do not have lying around, “a state of genuine uncertainty on the part of the clinical investigator regarding the comparative therapeutic merits of each arm in a trial. Should the investigator discover that one treatment is of superior therapeutic merit, he or she is ethically obliged to offer that treatment.”

To me, this means: Since Penn’s cancer docs are confident PBT is better than IMRT for GBM, they are morally obligated to give PBT over IMRT people with GBM — and PDQ.
"

LOL wtf. Protons for a 50 year old with GBM. The only ethical way.
They "ethically" took her own self-pay money after 20 fractions into her treatment to switch to protons. Worried about secondary cancers from GBM treatment with photons. Can't make this stuff up.
 
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MidwestRadOnc said:
Since Penn’s cancer docs are confident PBT is better than IMRT for GBM
Click to expand...
Penn's strategic plan is massive Proton expansion (new center in South Jersey, busy center in Lancaster PA, renovating their downtown proton facility).

I am confident that a significant portion of Penn's docs are not confident regarding the differential value of protons in most cases.
 
communitydoc13 said:
Penn's strategic plan is massive Proton expansion (new center in South Jersey, busy center in Lancaster PA, renovating their downtown proton facility).

I am confident that a significant portion of Penn's docs are not confident regarding the differential value of protons in most cases.
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This is why my username is what it is.
 
that statement about lack of equipoise is straight nuts, I would hope even the Penn docs know that.

I would clarify that I don't think it's just Penn's plan, I am increasingly convinced that it is part of RAD ONC's general strategic plan to incorporate more and more proton. Will the NAPT SAVE the field?

it is simply not going away at all. the legislative and guidelines push is clear. soon even ESE and medgator will be hawking this stuff. may take a decade or two. but we will get there.
 
communitydoc13 said:
Penn's strategic plan is massive Proton expansion (new center in South Jersey, busy center in Lancaster PA, renovating their downtown proton facility).

I am confident that a significant portion of Penn's docs are not confident regarding the differential value of protons in most cases.
Click to expand...
Yes, some of them are very straightforward in person.
 
The first-best option to thwart fast-growing GBM cells is ... DEATH. When the patient is dead, they stop growing.
 
RadOncDoc21 said:
Can I say rad oncs suck as advocates for each other? We will continue to argue about the dumbest, minute things but can’t come together to create a baseline level of dignity and trust in our field. Despite all of us having to pass 4 board exams (most in any field) and 4 yrs of ONCOLOGY training (more then any other field).

Today, it’s all about who has the “highest quality” of care based on whatever flavor smoke is coming from our own ass rather it be who has the “most modern technology” to whoever can draw a better circle with 2mm margin only to be shamed by someone else who uses 1mm margin and one less fraction. We can quote trials to the infinite decimal point because we can, but we can’t focus on anything that actually matters!

Ok, I’ve completed my rant for the day.
Click to expand...

A simple proposal, I think it would make a big difference fixing this problem:
1. All society board of directors cannot hold ANY other leadership role, including and especially a leadership role in a working clinic. The number of clinical vice chairs and practice presidents that are making impactful decisions across our field is insane. There are many proton and non-proton examples of baffling permitted COI.

As an aside, what is it with this field where some people need to simultaneously hold multiple leadership positions beyond retirement age. Hobbies are sweet.

2. All society policy statements name the authors. There is no reason at all for this to be anonymous and physicians should stand behind their words if they are directing payer policy. If you cant handle criticism for your political decisions, dont wade in to politics.

3. Clinical leadership roles are listed as COI on all policy related publications.

Such small changes, find me a person not named Dave that would be against them.
 
communitydoc13 said:
Penn's strategic plan is massive Proton expansion (new center in South Jersey, busy center in Lancaster PA, renovating their downtown proton facility).

I am confident that a significant portion of Penn's docs are not confident regarding the differential value of protons in most cases.
Click to expand...
Upton Sinclair comes to mind...you know the quote

It is difficult to get a man to understand something when his salary depends upon his not understanding it.
 
Palex80 said:
View attachment 381639


Another quality meme provided by my colleague:

View attachment 381640
Click to expand...
It's almost like...

Maybe, just maybe, we shouldn't accept trials designed and statistically powered simply to show non-inferiority. Maybe the Ivory Tower RadOncs in America, so inept at politics and the business of Medicine, believed they could endure the few years in the spotlight 15 years ago only by spending every waking moment trying to figure out how to erase the specialty from existence until it basically collapsed.

And then, only after med students have figured out this isn't the career they want to bet their lives on, only after our reimbursement got cut and bundled while specialties with actual lobbyists drank our milkshakes...

That we discover, completely unsurprisingly, that perhaps we were too hasty in adopting shorter regimens for a bread-and-butter radiotherapy indication.

Because the ultimate embarrassment, after everything that happened since 2008, would be to discover that conventional radiation for prostate has been superior all this time.
 
elementaryschooleconomics said:
It's almost like...

Maybe, just maybe, we shouldn't accept trials designed and statistically powered simply to show non-inferiority. Maybe the Ivory Tower RadOncs in America, so inept at politics and the business of Medicine, believed they could endure the few years in the spotlight 15 years ago only by spending every waking moment trying to figure out how to erase the specialty from existence until it basically collapsed.

And then, only after med students have figured out this isn't the career they want to bet their lives on, only after our reimbursement got cut and bundled while specialties with actual lobbyists drank our milkshakes...

That we discover, completely unsurprisingly, that perhaps we were too hasty in adopting shorter regimens for a bread-and-butter radiotherapy indication.

Because the ultimate embarrassment, after everything that happened since 2008, would be to discover that conventional radiation for prostate has been superior all this time.
Click to expand...

Hahaha

I haven’t read the paper if it’s out. Did they report causes of death?

Prostate cancer trials are famous for participants dying from other cancers.
 
Did prostate become the new breast? Is prostate the worst now??
 
elementaryschooleconomics said:
Maybe, just maybe, we shouldn't accept trials designed and statistically powered simply to show non-inferiority.
Click to expand...
Agree wholeheartedly. Non-inferiority trials are usually infuriating and need to both have an excellent rationale and a good way of assessing the impact on other rare outcomes (toxicity), particularly when there is a clear mechanism for increased late toxicity in the setting of XRT.

Equipoise...that peculiar word that is almost ironically employed in the defense of protons above yet is employed in basically the opposite way to encourage hypofractionation or even XRT omission trials. Maybe equipoise is too vague and too nuanced a concept for docs to employ meaningfully at all.

elementaryschooleconomics said:
could endure the few years in the spotlight 15 years ago only by spending every waking moment trying to figure out how to erase the specialty from existence until it basically collapsed
Click to expand...

There is no easier way to make a mark as a clinical academic radonc than to be the PI on non-inferiority or omission trials (not to say getting any trial off the ground is easy, kudos to all those who work harder than me). The power of careerism in those heady days undoubtedly has contributed to our relative marginalization as a field today...but even worse I suspect, in moving the standard of care at times in the wrong direction.

elementaryschooleconomics said:
Because the ultimate embarrassment, after everything that happened since 2008, would be to discover that conventional radiation for prostate has been superior all this time.
Click to expand...
To this day, I just don't know. I was a relatively late adopter of moderate hypofractionation in prostate (44--->28 fractions for most patients with occasional SBRT). The overwhelming rationale for the change was vague cultural pressure, rooted in regional competitor's practices, a sense that I was being a steward of resources (virtue signaling to myself) and patient expectations. To this day, I believe there is a slight increase in toxicity even with moderate fractionation. Cancer control outcomes are good enough that I will have no intuition about relative cancer control outcomes. I would never indict a practice for using 40-44 fractions (unless it was protons).

But...studying survival outcomes in pCA is just so tough, the cancer specific endpoint rare enough and OS overwhelmingly mitigated by other factors (the best data for OS benefit of XRT in pCA is 55Gy in the setting of limited metastatic disease) that any given trial only means so much. Is it not crazy to have variance of 10% in OS for two 250 person groups of 70 year old men at 10 years based on randomness alone (this likelihood is seriously increased in the setting of the temporal nature of clinical trials, where the number evaluable at late time points is much smaller that the number enrolled).

I doubt 10 Gy really changes OS by 10% and the trial does not help regarding the 80/40 vs 70/28 (maybe with an SIB) decision. But clearly, nobody should be shaming anyone for doing 40-45 fractions with long term ADT for high risk prostate cancer.
 
TheWallnerus said:
I always do 45

life of brian monthy python GIF
Click to expand...
I also do, but some payors have a hard limit of 40 fractions even when treating nodes. Funny enough I've never seen them mandate 200 over 180/fraction in any other site, except prostate which has the lowest alpha/beta.

Speaking of nodes, this trial treated nodes in 23 fractions. Not sure it will do much with Evicore as they only let you use conventional if you are treating nodes, and this is also a 40 fraction trial, not 45.
 
communitydoc13 said:
Agree wholeheartedly. Non-inferiority trials are usually infuriating and need to both have an excellent rationale and a good way of assessing the impact on other rare outcomes (toxicity), particularly when there is a clear mechanism for increased late toxicity in the setting of XRT.

Equipoise...that peculiar word that is almost ironically employed in the defense of protons above yet is employed in basically the opposite way to encourage hypofractionation or even XRT omission trials. Maybe equipoise is too vague and too nuanced a concept for docs to employ meaningfully at all.



There is no easier way to make a mark as a clinical academic radonc than to be the PI on non-inferiority or omission trials (not to say getting any trial off the ground is easy, kudos to all those who work harder than me). The power of careerism in those heady days undoubtedly has contributed to our relative marginalization as a field today...but even worse I suspect, in moving the standard of care at times in the wrong direction.


To this day, I just don't know. I was a relatively late adopter of moderate hypofractionation in prostate (44--->28 fractions for most patients with occasional SBRT). The overwhelming rationale for the change was vague cultural pressure, rooted in regional competitor's practices, a sense that I was being a steward of resources (virtue signaling to myself) and patient expectations. To this day, I believe there is a slight increase in toxicity even with moderate fractionation. Cancer control outcomes are good enough that I will have no intuition about relative cancer control outcomes. I would never indict a practice for using 40-44 fractions (unless it was protons).

But...studying survival outcomes in pCA is just so tough, the cancer specific endpoint rare enough and OS overwhelmingly mitigated by other factors (the best data for OS benefit of XRT in pCA is 55Gy in the setting of limited metastatic disease) that any given trial only means so much. Is it not crazy to have variance of 10% in OS for two 250 person groups of 70 year old men at 10 years based on randomness alone (this likelihood is seriously increased in the setting of the temporal nature of clinical trials, where the number evaluable at late time points is much smaller that the number enrolled).

I doubt 10 Gy really changes OS by 10% and the trial does not help regarding the 80/40 vs 70/28 (maybe with an SIB) decision. But clearly, nobody should be shaming anyone for doing 40-45 fractions with long term ADT for high risk prostate cancer.
Click to expand...
Nice post but I would emphasize the best evidence for RT improving survival by overcoming resistance to androgen blockage alone in high risk non-metastatic prostate cancer is quite compelling indeed. Established conventionally fractionated radiation as the standard of care and great to see the new standard raised to 80 Gy. This is signal (helping patients) while endless non-inferiority trials = shiny objects/plenary presentation/career advancement etc.

pubmed.ncbi.nlm.nih.gov

Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial - PubMed

In patients with locally advanced or high-risk local prostate cancer, addition of local radiotherapy to endocrine treatment halved the 10-year prostate-cancer-specific mortality, and substantially decreased overall mortality with fully acceptable risk of side-effects compared with endocrine...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
theradiator said:
Nice post but I would emphasize the best evidence for RT improving survival by overcoming resistance to androgen blockage alone in high risk non-metastatic prostate cancer is quite compelling indeed. Established conventionally fractionated radiation as the standard of care and great to see the new standard raised to 80 Gy. This is signal (helping patients) while endless non-inferiority trials = shiny objects/plenary presentation/career advancement etc.

pubmed.ncbi.nlm.nih.gov

Endocrine treatment, with or without radiotherapy, in locally advanced prostate cancer (SPCG-7/SFUO-3): an open randomised phase III trial - PubMed

In patients with locally advanced or high-risk local prostate cancer, addition of local radiotherapy to endocrine treatment halved the 10-year prostate-cancer-specific mortality, and substantially decreased overall mortality with fully acceptable risk of side-effects compared with endocrine...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
Click to expand...
Old school high risk patients. Wonder what their PSMA pet scans would look like.

But a trial I still think about regularly when counseling very locally advanced men to incorporate XRT into their treatment. Very important work.
 
communitydoc13 said:
Old school high risk patients. Wonder what their PSMA pet scans would look like.

But a trial I still think about regularly when counseling very locally advanced men to incorporate XRT into their treatment. Very important work.
Click to expand...
There is also the Canadian trial
pubmed.ncbi.nlm.nih.gov

Combined androgen deprivation therapy and radiation therapy for locally advanced prostate cancer: a randomised, phase 3 trial - PubMed

Canadian Cancer Society Research Institute, US National Cancer Institute, and UK Medical Research Council.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
communitydoc13 said:
Old school high risk patients. Wonder what their PSMA pet scans would look like.

But a trial I still think about regularly when counseling very locally advanced men to incorporate XRT into their treatment. Very important work.
Click to expand...

Oh man do the PSMA on the biology guided RT machine and youre really cookin.

Or doing something. Yes, were doing things.
 
communitydoc13 said:
Agree wholeheartedly. Non-inferiority trials are usually infuriating

There is no easier way to make a mark as a clinical academic radonc than to be the PI on non-inferiority in moving the standard of care at times in the wrong direction.

But...studying survival outcomes in pCA is just so tough,

I doubt 10 Gy really changes OS by 10% and the trial does not help regarding the 80/40 vs 70/28 (maybe with an SIB) decision. But clearly, nobody should be shaming anyone for doing 40-45 fractions with long term ADT for high risk prostate cancer.
Click to expand...
Noninferiority trials show non inferiority 85% of the time - what kind of science is that?

PI's love noninf trials to pad their CV while also leading to biocreep.

Survival outcomes - the French have shown OS analysis can (and should) be done. IMO, surrogates also pad one's CV and lead to biopcreep. Surrogates are not needed in prostate ca trials.

This study had 550 pts with long term followup. Maybe STAMPEDE will be able to produce a similar trial with hypofrac - until then, I wait.

The standard for high risk prostate ca is conventional EBRT to 80 Gy with 3 yrs ADT.
 
MidwestRadOnc said:
I also do, but some payors have a hard limit of 40 fractions even when treating nodes. Funny enough I've never seen them mandate 200 over 180/fraction in any other site, except prostate which has the lowest alpha/beta.

Speaking of nodes, this trial treated nodes in 23 fractions. Not sure it will do much with Evicore as they only let you use conventional if you are treating nodes, and this is also a 40 fraction trial, not 45.
Click to expand...
They "let you" treat with 45. You have to appeal.
 
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thesauce said:
Anyone have the info?

This may (probably will) IMPROVE outcomes rather than just proving non-inferiority
Click to expand...
pubmed.ncbi.nlm.nih.gov

Ultra-high dose (86.4 Gy) IMRT for localized prostate cancer: toxicity and biochemical outcomes - PubMed

This report represents the largest data set of patients treated to ultra-high radiation dose levels of 86.4 Gy using IMRT for localized prostate cancer. Our findings indicate that this treatment is well tolerated and the early excellent biochemical control rates are encouraging.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
drowsy12 said:
know people doing both.
Click to expand...
This is a great example of the disconnect between "the RadOnc conversation" and "the RadOnc reality".

I also know many people doing FLAME-style regimens as well.

But why would they talk about it, or worse: publish? For almost a decade the only real "safe" thing to openly discuss was hypofrac or omission.

It's why I'm so happy for these high risk results. It forces a topic change.
 
Idk I guess I may be missing your circles or social media view but I feel like lots of stuff gets talked about in prostate cancer other than hypofrac or omission. It’s changed quite a bit over the past few years. The sequencing and types of hormonal therapy, the impact of PSMA on staging, volume delineation, and prognosis in the high risk and salvage settings, the treatment of the primary or metastases in the metastatic setting, dominant nodule boosting, POP-ART - all of these to me are interesting and are discussed quite a bit I see in the literature and social media. Prostate RT has gotten a lot more interesting as of late IMO
 
SneakyBooger said:
They "let you" treat with 45. You have to appeal.
Click to expand...

How do you convince them to “let you” do 81 in 45 instead of 80 in 40?

I prefer to do 1.8/fx so I can more gently do an integrated boost. I also prefer to treat nodes to 50.4
 
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