Rad Onc Twitter

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Ray D. Ayshun said:
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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As a diagnostic wielder of radiation, this is what I read as well.

Maybe it’s not a ligand at all. Maybe radiation is immune suppressive and the down regulation of the immune system allows suppressed Mets to thrive?

Hence let’s give immune therapy and RT at the same time!
 
CurbYourExpectations said:
With the prefaces of me not being an expert or very smart, my initial thought was that SBRT decreases "metastasis", but increases tumor growth in poly metastatic cancer patients. So I thought about it differently, but need to read it cuz I could be completely off, busy clinic days. What is weird is that we don't see any significant increase in mets in SBRT cases in the primary tumor (of micrometastatic disease, so logically, this is not clinically relevant and won't pan out). But I am hopeful whatever the nonsensical ranting that is happening on twitter does pan out and somehow this shows ablating cancers in polymetastatic diseases with a molecular inhibitor is somehow beneficial in non treated sites. The paper being negative regarding radonc is, I guess I would say uncalled for (but how many times do I say stuff I shouldn't? Daily? You guys have witnessed it, I hide behind an anonymous account and admit i'm an idiot 99% of the time), but if the actual stuff becomes relevant and we start seeing decreases in metastatic growth, that is a boon for RadOnc. Ralph isn't dumb, he's very intelligent imo (who cares about my opinion?), he knows that being flamboyant gets people talking about his pubs. Tbh idk, smart people... what should I think
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I'm not sbrting 1 of 10 visible Mets. It's 1 of 1. This paper means zero to me as far as I can tell. it's still interesting, but clinically irrelevant.
 
drowsy12 said:
it’s not anti radiation at all
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Sure, you're right, technically. But it's very easy to take this and run with it. That rectal trial last year wasn't anti radiation, but the newspaper articles made it such. I would argue that the fact this is in Nature Nature is a little anti radiation though. It seems like a slow month in natural science if this is sneaking in.
 


Glad he’s walking back his knee jerk hyperbole from before.

Also this surgeon is right. It also makes rad oncs look silly.

 
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drowsy12 said:


Glad he’s walking back his knee jerk hyperbole from before.

Also this surgeon is right. It also makes rad oncs look silly.

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"Radiation" is such a vague term for a Nature paper title. Is it dsbs, is it free radical damage to proteins, immune inhibition? It's some sort of localized thing that happens that manifests systemically. If they sbrt'd a normal tissue, would the same thing happen? I presume this was a control (can't read the paper).

Re cetuximab, a quote from RW suggests it's efficacy in this context.

“Interestingly, the combination of radiation and amphiregulin blockade decreased both tumor size and the number of metastatic sites,” Weichselbaum said.

In any case, this is interesting, irrelevant, and treatable. But ultimately NBD so long as it's not editorialized to inanity. Twitter makes anyone who participates look silly.
 
drowsy12 said:
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Chirag Shah was right (how many times can we say this)....

We have a distribution problem, not a lack of residents. Churning out more residents just puts more rad oncs in the cities. "Solving" the rural rad onc issue is not accomplished by more residents.

First step to regaining trust in ASTRO/Red Journal....I want to see a "where are we now?" update to that red journal back-and-forth.
 
BobbyHeenan said:
Chirag Shah was right (how many times can we say this)....

We have a distribution problem, not a lack of residents. Churning out more residents just puts more rad oncs in the cities. "Solving" the rural rad onc issue is not accomplished by more residents.

First step to regaining trust in ASTRO/Red Journal....I want to see a "where are we now?" update to that red journal back-and-forth.
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There’s a relatively easy fix for it. Increase the pay, give tax break and loan forgiveness.
 
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NotMattSpraker said:
Eliminate? Or acquire and make it a network satellite covered part time by a physician?

Anecdote, but I'm seeing more of the latter.
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sorry, yeah, that's true. Some of them are finding out those places are tough to staff at academic sat pay.

Edit: I'm one of those red dots fwiw
 
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Another red dot checking in. Perhaps one of the loneliest ones on the map. I lasted < 2 years. The place is now staffing with non-BC locums and they will never be able to hire a new grad again.

All of those red dots should be making minimum 1M with 4 day week and 8 weeks PTO. And they better be nice to you. Really nice.
Unfortunately many want to bait-and-switch a new grad and chain them to the machine in BFE at MGMA median. When you complain that they lied, they show you the door, smear your name to future employers, and hire eager-to-please locums. Seen it happen to probably half a dozen peers at this point.

There can be some great rural solo employed gigs. In fact, I think this is the best job in the field. The happiest rad oncs I know are those in good solo gigs where they have total freedom. But you have to be very, very careful in vetting these. A new grad just doesn't have the experience to do this. Which is why the stats are showing over half leave in a few years.
 
These Astro and IJROBP arguments are stupid. As said above, you have to make the job attractive enough for someone to take when there is a serious location handicap. But the underlying thinking is someone should magically want to fill these spots basically on the same terms as any other place with maybe a modest bump in pay.
 
drowsy12 said:
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StIGMA said:
More practicing doctors means more options for care, no? even though it may be at fewer physical locations
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The doctors aren't responsible for the price of radiation therapy. The locations are. Global charge of radiation charged by the center, not the doctor at hospital based places

Less freestanding, more hospital and academic consolidation means fewer choices and higher prices

More docs simply serves to drive down salaries and make the job market less competitive for graduating residents.

Think back to the bloodbath thread and why Dennis Hallahan at Wash U told everyone in the IJROBP why he was expanding positions at his residency program
 
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evilbooyaa said:
Is it misinfo though? Patients have less options as to where to get radiation now than they did previously, due to consolidation. Is anyone arguing aginst that?
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I jumped the gun on the joke and also you are right it doesnt really make sense for this paper. I misunderstood the argument of the author.

StIGMA said:
More practicing doctors means more options for care, no? even though it may be at fewer physical locations
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Todd Scarbrough had some nice tweets about this back in 2022. It appears there are more physical locations, not less.

1748025698577.png
 
NotMattSpraker said:
I jumped the gun on the joke and also you are right it doesnt really make sense for this paper. I misunderstood the argument of the author.



Todd Scarbrough had some nice tweets about this back in 2022. It appears there are more physical locations, not less.

View attachment 404038
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Indeed data seems to support that there are more RT facilities now than in the past

We also gotta keep in mind that ~1% or less of the US population lives >50 miles from an RT center.

I just don't think the data shows "fewer options" for care. I mean, an RT center is an RT center is an RT center (for the most part if we can ignore protons, BgRT, MRgRT, etc.). There are more products, and more sales people, but probably less brands (if that makes sense).
 
TheWallnerus said:
Indeed data seems to support that there are more RT facilities now than in the past

We also gotta keep in mind that ~1% or less of the US population lives >50 miles from an RT center.

I just don't think the data shows "fewer options" for care. I mean, an RT center is an RT center is an RT center (for the most part if we can ignore protons, BgRT, MRgRT, etc.). There are more products, and more sales people, but probably less brands (if that makes sense).
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I think less 'brands' means fewer 'options' - most multi-site practices, whether they be academic or not are not going to really encourage second opinions within the system in terms of alternative approaches to X/Y/Z... More brick and mortar doesn't really matter.
 
evilbooyaa said:
I think less 'brands' means fewer 'options' - most multi-site practices, whether they be academic or not are not going to really encourage second opinions within the system in terms of alternative approaches to X/Y/Z... More brick and mortar doesn't really matter.
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drowsy12 said:
yeah. is it really 'more options' if there are more Upenn network sites that are all spokes of the same wheel and charge the same prices in your sleepy suburban PA locale?

I agree Upenn would say there are more options, but I'm not sure I would agree.
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Which gives more options: you can only buy a Ford, or you can buy either Tesla or a Rivian.

It's very debatable.

And let's be real. Rad onc patients are not very shop-around-y/looking for second opinion type patients.

"Options"... again, it's very subjective. A patient presents with unfavorable intermediate risk prostate cancer. The NCCN lists 16 EBRT fraction options, 6 boost options (seeds, SBRT), SpaceOAR and proton options, also need to consider hormones (yes/no, and oral or standard?). That’s about 16x2x6x2x2x4=3072 different treatment iterations for this one presentation. Now add in "you can come here, or you can go to the academic center across town, or the major academic center in the next state over"... ~10,000 options for one disease(?!). In a few years people will just ask the AI, maybe.
 
TheWallnerus said:
Which gives more options: you can only buy a Ford, or you can buy either Tesla or a Rivian.

It's very debatable.

And let's be real. Rad onc patients are not very shop-around-y/looking for second opinion type patients.

"Options"... again, it's very subjective. A patient presents with unfavorable intermediate risk prostate cancer. The NCCN lists 16 EBRT fraction options, 6 boost options (seeds, SBRT), SpaceOAR and proton options, also need to consider hormones (yes/no, and oral or standard?). That’s about 16x2x6x2x2x4=3072 different treatment iterations for this one presentation. Now add in "you can come here, or you can go to the academic center across town, or the major academic center in the next state over"... ~10,000 options for one disease(?!). In a few years people will just ask the AI, maybe.
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You haven't had patients come in with pages of ChatGPT printouts yet telling them exactly what we "should" be doing? It's a ton of fun.
 
TheWallnerus said:
Which gives more options: you can only buy a Ford, or you can buy either Tesla or a Rivian.

It's very debatable.

And let's be real. Rad onc patients are not very shop-around-y/looking for second opinion type patients.

"Options"... again, it's very subjective. A patient presents with unfavorable intermediate risk prostate cancer. The NCCN lists 16 EBRT fraction options, 6 boost options (seeds, SBRT), SpaceOAR and proton options, also need to consider hormones (yes/no, and oral or standard?). That’s about 16x2x6x2x2x4=3072 different treatment iterations for this one presentation. Now add in "you can come here, or you can go to the academic center across town, or the major academic center in the next state over"... ~10,000 options for one disease(?!). In a few years people will just ask the AI, maybe.
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That may be your personal experience but it is not at all uncommon for me to see a second opinion that has already been to or plans to go to MDA, MSKCC, or some other monolith, looking for someone willing to give them what they want. I mean you hear it from anyone who has access to protons - the sheer number of men who come looking for prostate cancer RT w/ protons...

I also see a number of second opinions who get told something by their local rad onc and they are looking if what they were told locally is reasonable or not. Usually it is, sometimes it isn't.
 
RickyScott said:
Probably could get rid of xrt altogether in these pts.
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fiji128 said:
True
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Now here's a really soul-search-y, inflammatory question... on the basis of B51's results, how many women in America have been needlessly irradiated in the last 5 years, how much money was wasted in doing so, and what health detriments were wrought. 'I Am Legend' type stuff! Need Alanis Morissette to write a song about a rad onc recycler, Prius driver, #MeToo'er who's irradiated hundreds of women's upper body ~quadrants needlessly. Oof.

Also, does anyone recall how all our leaders told us in the past that as the chemo/systemic therapy got better, it made radiation therapy more important and needed?
 
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From ChatGPT:

The proportion of breast-cancer patients who are rendered node-negative (ypN0) after neoadjuvant chemotherapy (NAC) has risen steadily for more than two decades. Large registries show roughly a doubling of ypN0 rates since the early-2000s, with steeper gains in HER2-positive and triple-negative disease once modern taxanes, dual-HER2 blockade and platinum‐based regimens became routine.

How we measure it​


  • Incidence would be the number of new ypN0 cases in a population each year.
  • Prevalence would be every living person who is ypN0 after NAC at a single time-point.
  • In practice, published studies track the proportion (rate) of NAC-treated patients who emerge ypN0, which is the most clinically relevant metric and the one summarised below.

Key trend data​

CohortYears coveredDefinitionypN0 (earliest)ypN0 (latest)Relative ↑
National Cancer Database (NCDB) 104 161 pts ‡2010 → 2017ypT0/is, ypN0 (total pCR)15.1 % (2010)27.2 % (2017)×1.8 ascopubs.org
German Breast Group registry 44 905 pts2008 → 2017ypT0/is, ypN015.0 % (2008)34.2 % (2017)×2.3 onlinelibrary.wiley.com
Pooled international meta-analysis 25 trials (ALND reference standard)2003 → 2019ypN0 (± ITC/mi)—~45 % overall (sub-analyses show early-era ≈30 %, late-era ≈55 %) pmc.ncbi.nlm.nih.gov
Large modern multi-centre series 7 688 pts converting from cN1 → ycN02015-2022ypN046 % overall; 57 % HER2+, 48 % TNBC, 35 % HR+/HER2- pmc.ncbi.nlm.nih.gov
‡ The NCDB paper reports both total pCR and nodal pCR; the nodal component rose from ≈22 % to ≈34 %, mirroring the total-pCR trend (numbers in manuscript appendix).

Drivers of the upward trend​

EraPractice changeImpact on nodes
Early 2000sAnthracycline + cyclophosphamide (AC) → add taxanesypN0 moves into low-20 % range
~2005-2012Routine NAC for TNBC & HER2+ cT2-3/cN1 disease; trastuzumab addedypN0 mid-20 % to low-30 %
2013-2017Dual HER2 blockade (trastuzumab + pertuzumab); Platinum for TNBC; move toward dose-dense schedulesypN0 ≈35-45 % overall; >60 % in HER2+
2018-2025Immunotherapy (pembrolizumab) for TNBC; more HER2-targeted ADCs in trialsEarly reports pushing ypN0 above 70 % in biomarker-selected subsets

Bottom-line take-aways for clinic or trial design​



  • Expect roughly one in three unselected NAC patients to be ypN0 today; higher in HER2+ / TNBC, lower in ER+/HER2-.
  • Historical controls from the 1990s or early-2000s substantially underestimate current nodal clearance rates.
  • Rising ypN0 rates are the underpinning rationale for trials that de-escalate axillary surgery (e.g., omission of ALND or even SLNB after proven nodal pCR).
 
TheWallnerus said:
Well I think in B51 the mastectomy patients got no RT; no ENI, no PMRT… and if AI eligible, they got that (in lieu of PMRT/ENI), right?
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Right. So the default now is AI instead of PMRT. So next step will be to randomize between AI and PMRT. When PMRT wins out, medoncs will keep giving AI anyway and we’ll be back to square one. Sort of like post-lumpectomy.
 
Idk if I would look too closely at unplanned subgroups. If you did you would see that triple negative patients have worse cancer outcomes with RNI than no RT.
 
drowsy12 said:
Idk if I would look too closely at unplanned subgroups. If you did you would see that triple negative patients have worse cancer outcomes with RNI than no RT.
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Was it unplanned? They randomized by hr and her2 status. I can't imagine proposing a breast cancer trial with no plans to consider analyzing by molecular subgroup. Maybe they state explicitly they have no planned subgroups, but it feels inevitable that would be analyzed.
 
Yeah this is a wonder on luminal A. Worth some thought and discussion anyways.

I'm not sure the mechanism for the TNBC's why they did worse. Presumably with ypN0 if they had ypT0 they wouldn't get adjuvant capecitabine, so it's not like that would have been delayed for a bunch of patients (or could it have been?). TNBCs are potentially immunogenically active and could RT be harmful by sterilizing the nodes of lymphocytes? It may be we get more data as things go along. In the meantime no difference in the curves in aggregate. Maybe Glaucomflecken needs to do a short on this trial akin to his INSEMA one with a poor rad onc wanting to irradiate away haha.
 
taserlaser said:
Yeah this is a wonder on luminal A. Worth some thought and discussion anyways.

I'm not sure the mechanism for the TNBC's why they did worse. Presumably with ypN0 if they had ypT0 they wouldn't get adjuvant capecitabine, so it's not like that would have been delayed for a bunch of patients (or could it have been?). TNBCs are potentially immunogenically active and could RT be harmful by sterilizing the nodes of lymphocytes? It may be we get more data as things go along. In the meantime no difference in the curves in aggregate. Maybe Glaucomflecken needs to do a short on this trial akin to his INSEMA one with a poor rad onc wanting to irradiate away haha.
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Seems like the takeaway on twitter by rad oncs regarding this trial is “we are going to need more data before this changes practice.”
 
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