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TheWallnerus said:
I bet we all use IMRT 100 percent of the time, what is the level one evidence that it is superior to non IMRT methods.
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TheWallnerus said:
I love to poke fun as much as the next guy, especially to deflate hypocrisy or pomposity. But my dad used to start meetings sometimes with “one of these days we all need to get together and be honest.” Whenever we use IMRT (a “device” I’d argue, as would CPT 77338) for prostate cancer, and I bet we all use IMRT 100 percent of the time, what is the level one evidence that it is superior to non IMRT methods.
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Fair but look at the financial delta between IMRT and 3d. Protons vs IMRT far greater with no evidence to support superiority
 
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Dan is probably charging most insurances 5-10x cms rates and has satellites throughout the metro. He is playing the same game. Its ok to charge prices 10x that of a small community hospital for same services, but somehow problematic to hype a shiny new robot.
 
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RickyScott said:
Dan is probably charging most insurances 5-10x cms rates and has satellites throughout the metro. He is playing the same game. Its ok to charge prices 10x that of a small community hospital for same services, but somehow problematic to hype a shiny new robot.
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‘dan’ as if he has anything to do with that let’s be real
 
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drowsy12 said:
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Med school boom? I'm not sure what that was, or when. It looks like we graduate <30,000 MDs and DOs yearly in the US. I'm all for emphasizing that medicine is not what you think or hope it might be but having 2+ times as many applicants as spots only seems like those dreams that were unrealistic in the first place might be over. Maybe my math is wrong/I'm missing something.
 
Ray D. Ayshun said:
Med school boom? I'm not sure what that was, or when. It looks like we graduate <30,000 MDs and DOs yearly in the US. I'm all for emphasizing that medicine is not what you think or hope it might be but having 2+ times as many applicants as spots only seems like those dreams that were unrealistic in the first place might be over. Maybe my math is wrong/I'm missing something.
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Half of applicants are getting in. I thought it used to be 1/4th?
 
According to a quick search there are about 30,000 UD MD/DO medical school positions offered per year and 43,000 residency positions in the match. Seems like we still need a lot more US Med school positions to open up.
 
fiji128 said:
According to a quick search there are about 30,000 UD MD/DO medical school positions offered per year and 43,000 residency positions in the match. Seems like we still need a lot more US Med school positions to open up.
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Should be 42,900 residency positions if our residency programs could get it together!
 
RickyScott said:
Dan is probably charging most insurances 5-10x cms rates and has satellites throughout the metro. He is playing the same game. Its ok to charge prices 10x that of a small community hospital for same services, but somehow problematic to hype a shiny new robot.
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drowsy12 said:
‘dan’ as if he has anything to do with that let’s be real
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Agree with drowsy. Seriously, this is a moving of the goal posts from some of you guys. Why you so obsessed w/ Dan Spratt?

Yes academics and hospital systems get to charge more. This was happening before Spratt became chair and is completely unrelated to him existing.

It started with 'doesn't Spratt push protons'?

The answer was 'no, he's actually pretty conservative in regards to benefits and criticizes protons especially for prostate more than the average Rad Onc who is in a position of power. He criticizes them DESPITE having access to a proton machine at his facility, which is a significant rarity (generally those who are pro protons for prostate work for a proton center, generally those who are against protons for prostate work at a center that does NOT have protons)'

Then, there was a search about a portion of a UH website that is about proton cancer mentions the world prostate, and thus immediately the worst is assumed. Here is the FULL EXCERPT, bold my emphasis:

"Protons are most successful in treating solid tumors with well-defined borders that have not spread to other areas of the body. As such, proton therapy is most often used for tumors of the brain, head, neck, lungs and spine, although it can also treat eye melanoma, pituitary gland tumors, prostate cancer and a number of other contained cancers. Proton therapy can be combined with other forms of radiation and chemotherapy and can even be used as a follow-up treatment to surgery to help eradicate cancer from the surrounding tissues."

So yes, proton therapy CAN be used to treat prostate cancer. Sure, it doesn't say whether it should or it shouldn't, but proton therapy can clearly be used to treat prostate cancer (even though IMO it shouldn't because there's no benefit to an individual patient and harm on a global scale).

I'm not saying Dan Spratt is amazing either, but, when it comes to prostate cancer, he is, IMO, at least consistent. He argues against non evidence based things and claims, regardless of who is making money off of it.
 
evilbooyaa said:
Agree with drowsy. Seriously, this is a moving of the goal posts from some of you guys. Why you so obsessed w/ Dan Spratt?

Yes academics and hospital systems get to charge more. This was happening before Spratt became chair and is completely unrelated to him existing.

It started with 'doesn't Spratt push protons'?

The answer was 'no, he's actually pretty conservative in regards to benefits and criticizes protons especially for prostate more than the average Rad Onc who is in a position of power. He criticizes them DESPITE having access to a proton machine at his facility, which is a significant rarity (generally those who are pro protons for prostate work for a proton center, generally those who are against protons for prostate work at a center that does NOT have protons)'

Then, there was a search about a portion of a UH website that is about proton cancer mentions the world prostate, and thus immediately the worst is assumed. Here is the FULL EXCERPT, bold my emphasis:

"Protons are most successful in treating solid tumors with well-defined borders that have not spread to other areas of the body. As such, proton therapy is most often used for tumors of the brain, head, neck, lungs and spine, although it can also treat eye melanoma, pituitary gland tumors, prostate cancer and a number of other contained cancers. Proton therapy can be combined with other forms of radiation and chemotherapy and can even be used as a follow-up treatment to surgery to help eradicate cancer from the surrounding tissues."

So yes, proton therapy CAN be used to treat prostate cancer. Sure, it doesn't say whether it should or it shouldn't, but proton therapy can clearly be used to treat prostate cancer (even though IMO it shouldn't because there's no benefit to an individual patient and harm on a global scale).

I'm not saying Dan Spratt is amazing either, but, when it comes to prostate cancer, he is, IMO, at least consistent. He argues against non evidence based things and claims, regardless of who is making money off of it.
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Agree. Typical behavior from the condiments lobby
 
Palex80 said:
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I would say, he likes protons.
But not for prostate.
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Uro weighing in. I see Dans point on the quality of evidence for focal therapy.

To play devils advocate, however, go through the thought experiment of how you could design a trial for a new focal device for Gleason 3+4 prostate cancer.

What is your outcome? Sham therapy will have equal 10 year OS to radiation or RALP. PSA dynamics is a mess and not comparable to post surgery or radiation. Surveillance biopsy result is also not a comparable finding compared to either surgery or EBRT, and i don't know if we have any data on rates of viable cancer on biopsy post radiation (whether clinically significant or not), though at least you can compare to surveillance. Progression to salvage therapy is also a comparison with little meaning as the definition of who needs salvage varies by primary treatment.

MFS is probably the only hard disease endpoint that has any chance of being different, but any reasonable therapy would be heavily favored to show non-inferiority without a truly massive sample.

Finally there is the practical aspect of no novel device company can really survive while awaiting 10 year trial data.

So with all that in mind, prospective registry data is a reasonable, as are trials with fuzzy outcomes such as progression to radical therapy.

That said, the WATER 4 trial is accruing for Aquablation for prostate cancer, randomized vs. Ralp using MFS as an outcome in patients who had already decided to undergo active radical therapy. I'm hesitant since already we can likely say it will show non inferiority; which may be due to true non inferiority or the long time course of prostate cancer.
 
DoctwoB said:
Ditto for XRT. All about your patient population.
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Love rad onc and rad oncs, but there's a seductive blind spot for patients' radiation toxicities and regrets therefrom; takes a good decade or more in rad onc practice to start to understand this. In our defense, the chronologies of radiation toxicities are just so remarkably different than the chronologies of surgical or drug toxicities.
 
DoctwoB said:
Ditto for XRT. All about your patient population.
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Agreed. I'm sure definitive RT folks requiring ongoing cystos for ongoing hemorrhagic cystitis probably aren't happy with their choice to do RT.

All prostate cancer pts should see a surgeon and a Rad Onc prior to making a decision on their local therapy. AS should be discussed as appropriate.

All other non proven therapies should not be offered in the absence of a clinical trial, and not just a registry.
 
Well well well folks. Looks like the failure rates on boards back up to six percent. Man is it any surprise why any of this is happening? PDs and APDs lowered standards to match any warm body with a pulse. I reckon the mayo PD essentially echoing Trump that the first class of the decreased standards was “the best ever” (the very best people!). is this only the beginning of what is to come. Is ABR going to “cook the books” to pass all the warm bodies? Discuss.
 
thecarbonionangle said:
Well well well folks. Looks like the failure rates on boards back up to six percent. Man is it any surprise why any of this is happening? PDs and APDs lowered standards to match any warm body with a pulse. I reckon the mayo PD essentially echoing Trump that the first class of the decreased standards was “the best ever” (the very best people!). is this only the beginning of what is to come. Is ABR going to “cook the books” to pass all the warm bodies? Discuss.
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I expect there will be more transparency and communication from the new leadership of ABR compared to 2018. Based on X, it sounds like there were scoring changes that may have had an impact.

Its funny how people are working soooo hard out the gate to fight the idea that maybe increased SOAPs, the majority of which were not originally interested in RO, may do a bit worse on the inherently subjectively scored oral boards. What an evil hypothesis. Discourse in this field is so healthy 🙂

Obviously much more information is needed to really know what happened.
 
thecarbonionangle said:
Well well well folks. Looks like the failure rates on boards back up to six percent. Man is it any surprise why any of this is happening? PDs and APDs lowered standards to match any warm body with a pulse. I reckon the mayo PD essentially echoing Trump that the first class of the decreased standards was “the best ever” (the very best people!). is this only the beginning of what is to come. Is ABR going to “cook the books” to pass all the warm bodies? Discuss.
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I blame AI.

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StealthTech said:
Is there a recent paper this is referencing?
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As i understand it the proposed mechanism is AREG is increased, which is an EGFR ligand. I'm partly joking about it being this simple, but whatever is causing this, if true, isn't magic.

Edit: I searched for the nature pub. could only read the abstract, though, as i chose money over academia...
 
CurbYourExpectations said:
The patient portion is so small you could probably have polled on mcdonalds dinery in the last 7 days before treatment and found a significant finding.

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the ish is weak (but not deniable, yet)
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this a real deal Nature pub, not Nature Clinical Radiation Oncology. Perhaps biases got it there, as it seems like a red journal article, but simply being a Nature pub makes it "strong" in some sense.
 
Ray D. Ayshun said:
this a real deal Nature pub, not Nature Clinical Radiation Oncology. Perhaps biases got it there, as it seems like a red journal article, but simply being a Nature pub makes it "strong" in some sense.
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Sure, strong is a strong word though, I mean the science and data is good, but low numbers is like a big shrug. Is it reproducible? Does it make any clinical significance? Why is this in nature, but actually practice changing pro RadOnc stuff is relegated to lesser journals? Because it's radiation? Lame.
 
CurbYourExpectations said:
Sure, strong is a strong word though, I mean the science and data is good, but low numbers is like a big shrug. Is it reproducible? Does it make any clinical significance? Why is this in nature, but actually practice changing pro RadOnc stuff is relegated to lesser journals? Because it's radiation? Lame.
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because it's anti-radiation. ibram x kendi was a middle author.
 
My understanding of rt in the oligometastatic setting is to theoretically kill all of the remaining cancer. The proposition here is not that it makes new Mets. It's that it releases a growth ligand that could make subclinical disease become clinical. This would happen anyway if there is subclinical disease, rt or no. Hence, what does this have to do with anything? Sbrt for oligomets doesn't work if there's subclinical disease elsewhere, not because it induces new Mets out of the ether.
 
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