Rad Onc Twitter

[TheWallnerus]

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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.

Seems like the takeaway on twitter by rad oncs regarding this trial is “we are going to need more data before this changes practice.”

 

[Palex80]

PMRT still relevant for Luminal A patients with cN1/ypN0 disease?


View attachment 404620

How about less axillary dissection?

 

[theradiator]

we can't really go back but the 'original sin' was our breast cancer 'leaders' blithely accepting the premise of neoadjuvant chemotherapy for breast cancer in the first place despite the absence of an overall survival advantage whereas post-mastectomy RT improves OS. huge win for the medical oncologists and drug companies and devastating loss for breast radiation oncology

it would be analogous to GI radiation oncologists declaring victory in the TOPGEAR based on improved pathologic complete response without improved overall survival but of course stuff like that never happens for our side.

 

[Ray D. Ayshun]

we can't really go back but the 'original sin' was our breast cancer 'leaders' blithely accepting the premise of neoadjuvant chemotherapy for breast cancer in the first place despite the absence of an overall survival advantage whereas post-mastectomy RT improves OS. huge win for the medical oncologists and drug companies and devastating loss for breast radiation oncology

it would be analogous to GI radiation oncologists declaring victory in the TOPGEAR based on improved pathologic complete response without improved overall survival but of course stuff like that never happens for our side.

If there were fewer of us, this would be nbd. Literally nobody likes breast.

 

[A_DeMichele]

is there a subset of B51 patients that we should still treat? Like, postemastectomy ER+ ? Granted, pCR to chemo in ER+ is rare

 

[TheWallnerus]

is there a subset of B51 patients that we should still treat? Like, postemastectomy ER+ ? Granted, pCR to chemo in ER+ is rare

Prior to ~2015, rad oncs didn't give PMRT to cN1/pN1; the (maybe "a" rule) "rule" was 4 or more nodes positive equals PMRT. And when rad oncs did do PMRT, most often times it was just chest wall and s'clav (no intentional IMN or axilla RT).

 

[Ray D. Ayshun]

Prior to ~2015, rad oncs didn't give PMRT to cN1/pN1; the (maybe "a" rule) "rule" was 4 or more nodes positive equals PMRT. And when rad oncs did do PMRT, most often times it was just chest wall and s'clav (no intentional IMN or axilla RT).

Prior to 2015 pN1 meant 1 or 2 of 10-15 nodes. For me, it frequently means 1 or 2 of 1 or 2.

 

[Ray D. Ayshun]

Also, does anyone think NSABP b51 will lead to more breast conservation?

 

[TheWallnerus]

Prior to 2015 pN1 meant 1 or 2 of 10-15 nodes. For me, it frequently means 1 or 2 of 1 or 2.

This is a very quaint worry imho. But I think you perhaps had a famous name old school breast mentor 😉

 

[metallica81788]

If your surgeons just hacked away up front on everyone like mine do, thus vastly reducing the amount of people getting NAC - this wouldn't change your numbers.

😎

 

[communitydoc13]

but of course stuff like that never happens for our side

The neoadjuvant deal is pretty good for high risk breast patients IMO. It allows for a tailored post-op systemic plan and now allows for de-escalation of RT and surgery. Response is remarkably predictive of outcomes.

For patients who are definitely candidates for chemo, neoadjuvant usually makes sense. This is not unique to bCa.

Now if the issue is including neoadjuvant chemo in patient's who would have equivalent survival outcomes without any chemo in their treatment regimen (e.g. head and neck cancers) this is another issue altogether.

Also, does anyone think NSABP b51 will lead to more breast conservation?

I don't think so.

Prior to NSABP b51, you could counsel a patient that you would recommend post-op XRT in node positive patients regardless of pathologic response or type of surgery.

Now, a nodal pCr with mastectomy means no adjuvant XRT at all. This makes mastectomy a more favorable option for some patients.

 

[Fpg1245]

The neoadjuvant deal is pretty good for high risk breast patients IMO. It allows for a tailored post-op systemic plan and now allows for de-escalation of RT and surgery. Response is remarkably predictive of outcomes.

For patients who are definitely candidates for chemo, neoadjuvant usually makes sense. This is not unique to bCa.

Now if the issue is including neoadjuvant chemo in patient's who would have equivalent survival outcomes without any chemo in their treatment regimen (e.g. head and neck cancers) this is another issue altogether.


I don't think so.

Prior to NSABP b51, you could counsel a patient that you would recommend post-op XRT in node positive patients regardless of pathologic response or type of surgery.

Now, a nodal pCr with mastectomy means no adjuvant XRT at all. This makes mastectomy a more favorable option for some patients.

Or move the xrt to preop? I’ve heard MDACC has starting doing this but idk for how long?

 

[Ray D. Ayshun]

The neoadjuvant deal is pretty good for high risk breast patients IMO. It allows for a tailored post-op systemic plan and now allows for de-escalation of RT and surgery. Response is remarkably predictive of outcomes.

For patients who are definitely candidates for chemo, neoadjuvant usually makes sense. This is not unique to bCa.

Now if the issue is including neoadjuvant chemo in patient's who would have equivalent survival outcomes without any chemo in their treatment regimen (e.g. head and neck cancers) this is another issue altogether.


I don't think so.

Prior to NSABP b51, you could counsel a patient that you would recommend post-op XRT in node positive patients regardless of pathologic response or type of surgery.

Now, a nodal pCr with mastectomy means no adjuvant XRT at all. This makes mastectomy a more favorable option for some patients.

Yes, but nodal pCR with lumpectomy means BCT. It looks like around 78% of women on this trial got RT of some sort. Perhaps this is also evidence that we can spare women the toxicity of mastectomy in cN1 ypN0 disease.

 

[communitydoc13]

Perhaps this is also evidence that we can spare women the toxicity of mastectomy in cN1 ypN0 disease.

I think that has been widely assumed for a long time?

I don't believe we've ever had evidence that mastectomy confers a meaningful survival benefit over lumpectomy with XRT even in node positive disease?

 

[drowsy12]

 

[OTN]

"This revolutionary treatment will enhance our ability to treat aggressive cancers"

[citation needed]

 

[temujim]

Mayo taking an enormous financial risk. They will have to navigate regulatory approval for the center, cms/private insurance models for reimbursement, etc. And after all that fixed physical plant and personnel cost, will be clinical around the time at least one phase 3 trial comparing carbon vs proton or photon may report out. Good luck to them.

 

[thesauce]

Mayo taking an enormous financial risk. They will have to navigate regulatory approval for the center, cms/private insurance models for reimbursement, etc. And after all that fixed physical plant and personnel cost, will be clinical around the time at least one phase 3 trial comparing carbon vs proton or photon may report out. Good luck to them.

There is no risk. Patients will think this is better “just because” it’s at Mayo and they will exploit that. They’ll pay out of pocket for it for low-risk prostate.

 

[temujim]

There is no risk. Patients will think this is better “just because” it’s at Mayo and they will exploit that. They’ll pay out of pocket for it for low-risk prostate.

Suckers born every minute. But treated a billionaire a few years ago with photons after his private insurance declined to cover protons.

 

[drowsy12]

 

[NotMattSpraker]

This quote surprised me. This is common in primary care in my market and a large urology practice here (+urorads) closed, which caused some stress for patients in diagnosis/treatment planning. My personal experience is seeing a lot more consolidation and change of ownership than linacs going away, but I dont know a lot about the AZ market.

“I have been treating patients for over two decades, and I have seen patients left bewildered and searching for a new provider because their practice closed due to ever-declining payments,” said Aaron Ambrad, MD, a practicing radiation oncologist at Ironwood Cancer & Research Centers in Scottsdale, AZ, and COA board member. “The ROCR program is a chance to reverse this trend. If we want patients to receive the best treatment possible, we need to take the commonsense step of supporting local, independent community oncology practices.”

 

[RickyScott]

This quote surprised me. This is common in primary care in my market and a large urology practice here (+urorads) closed, which caused some stress for patients in diagnosis/treatment planning. My personal experience is seeing a lot more consolidation and change of ownership than linacs going away, but I dont know a lot about the AZ market.

“I have been treating patients for over two decades, and I have seen patients left bewildered and searching for a new provider because their practice closed due to ever-declining payments,” said Aaron Ambrad, MD, a practicing radiation oncologist at Ironwood Cancer & Research Centers in Scottsdale, AZ, and COA board member. “The ROCR program is a chance to reverse this trend. If we want patients to receive the best treatment possible, we need to take the commonsense step of supporting local, independent community oncology practices.”

Somewhat familiar with Phoenix, and this is bs.

 

[BobbyHeenan]

Is this like when the financial toxicity guru works at the most expensive cancer center(s) in the world?

 

[metallica81788]

As a small community oncologist, ROCR's requirement for accreditation is a direct threat to smaller community programs even if (big if) all the rest of it is net neutral/positive

 

[BobbyHeenan]

As a small community oncologist, ROCR's requirement for accreditation is a direct threat to smaller community programs even if (big if) all the rest of it is net neutral/positive

….not to mention CMS and APEX have different “rules” for supervision.

 

[Ray D. Ayshun]

Is this like when the financial toxicity guru works at the most expensive cancer center(s) in the world?

Shocking? I think I said this somewhere in the "Do not reply!" thread like 3 years ago. I bet that thread, as much as it's maligned, is a good roadmap to DJT's reascension.

 

[alwaysbeIMRTing]

Shocking? I think I said this somewhere in the "Do not reply!" thread like 3 years ago. I bet that thread, as much as it's maligned, is a good roadmap to DJT's reascension.

Luxury belief - Wikipedia

en.wikipedia.org

These are the same people who proudly proclaimed that citizens who had a different opinion, regardless of how educated it was or where it was coming from, about the pandemic than them deserved to die on the street and should not be allowed in the hospital. Physicians literally said that openly, and some still cling to it.

 

[alwaysbeIMRTing]

Community Oncology Alliance Endorses Radiation Oncology Case Rate Program

What is the Community Oncology Alliance? I am a community oncologist and whoever these clowns are don't speak for me.

ROCR is a lifeline to our field and especially to our colleagues in community practice who own equipment and operate small businesses

BULLS(HT. This hare-brained case-rate payment scheme and direct supervision mandate are a direct threat to independent community practices. It is also a threat to patients as doctors will be incentivized to use simpler treatments and churn-and-burn patients on and off treatment as quickly as possible.

 

[communitydoc13]

Is this like when the financial toxicity guru works at the most expensive cancer center(s) in the world?

This is hardly shocking, and it is also a bit specious.

There are certainly "Luxury beliefs" among the very elite academically...there are also some sincere people who happen to be very smart. While there is plenty rotten in places like the IVY league, none of those rotten things are actually being addressed presently IMO...and yes, elite institutions should be making more exceptionally good "ordinary people" as opposed to folks who work in private equity or elite consultancy.

I also agree that no sincere "financial toxicity" expert should be collecting a paycheck from MSKCC (or at least a very good one). But, as we all know, many academic docs are paying a serious financial "opportunity cost" to remain in academics. They are actually "mission oriented" people....you know, like many people in the federal government.

Regarding the tweet, as long as I can remember (greater than 20 years that I've been paying attention to this stuff), med schools have been partitioned into "research" and "primary care" institutions. The research institutions are of course the "big guns" with the academic cache and the highest aggregate rankings. They overwhelmingly make academic physicians, specialists and researchers. These folks just do not practice in poor areas or medical deserts. Nor would you in general want them to...It's not particularly high value. The tweet is referencing the obvious while calling it shocking.

DJTs re-ascension has made the "dare you to reply" thread moot. Enjoy what you have wrought.

Maybe I should start posting there about geo-politics, the dismantling of vaccines, the history of the Ames test as it relates to MAHA or being 6'3" and 220 lbs with 7% body fat at age 79?

 

[Palex80]

 

[alwaysbeIMRTing]

It looks like the Community Oncology Alliance is an advocacy organization for independent medical oncology practices.

So ASTRO, who is supposed to represent us, is trying to cram this down our throats and using the opinion a bunch of private practice med oncs (those of whom who own machines and possibly employ rad oncs who would be obviously interested in stabilizing technical payments without a care at all about supervision issues or how this affects RVU-based doctors on the professional fee side)?

This is a joke.

 

[yesmaster]

Community Oncology Alliance Endorses Radiation Oncology Case Rate Program

What is the Community Oncology Alliance? I am a community oncologist and whoever these clowns are don't speak for me.

ROCR is a lifeline to our field and especially to our colleagues in community practice who own equipment and operate small businesses

BULLS(HT. This hare-brained case-rate payment scheme and direct supervision mandate are a direct threat to independent community practices. It is also a threat to patients as doctors will be incentivized to use simpler treatments and churn-and-burn patients on and off treatment as quickly as possible.

Tell your congressman!

 

[communitydoc13]

View attachment 405228

This is a problem. Baby boomers are here with CA. Weird things like Gentle Cure are recruiting RTTs to do very little. Recruitment and retention of RTTs is a challenge.

 

[Ray D. Ayshun]

This is hardly shocking, and it is also a bit specious.

There are certainly "Luxury beliefs" among the very elite academically...there are also some sincere people who happen to be very smart. While there is plenty rotten in places like the IVY league, none of those rotten things are actually being addressed presently IMO...and yes, elite institutions should be making more exceptionally good "ordinary people" as opposed to folks who work in private equity or elite consultancy.

I also agree that no sincere "financial toxicity" expert should be collecting a paycheck from MSKCC (or at least a very good one). But, as we all know, many academic docs are paying a serious financial "opportunity cost" to remain in academics. They are actually "mission oriented" people....you know, like many people in the federal government.

Regarding the tweet, as long as I can remember (greater than 20 years that I've been paying attention to this stuff), med schools have been partitioned into "research" and "primary care" institutions. The research institutions are of course the "big guns" with the academic cache and the highest aggregate rankings. They overwhelmingly make academic physicians, specialists and researchers. These folks just do not practice in poor areas or medical deserts. Nor would you in general want them to...It's not particularly high value. The tweet is referencing the obvious while calling it shocking.

DJTs re-ascension has made the "dare you to reply" thread moot. Enjoy what you have wrought.

Maybe I should start posting there about geo-politics, the dismantling of vaccines, the history of the Ames test as it relates to MAHA or being 6'3" and 220 lbs with 7% body fat at age 79?

Was referring to my belief that the dare you to reply thread is a, however imperfect, map of our specialty becoming fixated with identity. I'm not sure how many DJT supporters were even contributing. The title of the thread could be changed to "this won't end well." Our specialty's journey was in-line with that of much of academics, and what we have now feels like a natural consequence.

 

[alwaysbeIMRTing]

Quick, can someone tell me what the ROCR case rate payment for LDRT for osteoarthritis is? 🤣🤣🤣

I have it on pretty good authority our academic masters really really hate community practices using linacs for this and billing for it.

So elite.

 

[drowsy12]

Quick, can someone tell me what the ROCR case rate payment for LDRT for osteoarthritis is? 🤣🤣🤣

I have it on pretty good authority our academic masters really really hate community practices using linacs for this and billing for it.

So elite.

there's a strange phenomenon some of you have with characterizing hundreds or thousands of people as having the same opinion.

I know for a fact that some of the academic places in my region are fans of RT for OA.

the same is true of community rad onc not having the same opinion on ROCR

 

[alwaysbeIMRTing]

there's a strange phenomenon some of you have with characterizing hundreds thousands of people as having the same opinion.

I know for a fact that some of the academic places in my region are fans of RT for OA.

the same is true of community rad onc not having the same opinion on ROCR

I'm not the one claiming to speak for everyone. ASTRO is doing that.
I am aware there are a handful of academic centers advertising this. But I promise you there has been very aggressive (to the point of bizarre hostility) pushback from some academic rad oncs on this. I also know this for a fact.

I do think it's a good question. How is ROCR handling payments for the use of RT in situations that don't fall in their pre-defined case buckets? The aforementioned would love to see LDRT no longer paid for.

 

[OTN]

I'm not the one claiming to speak for everyone. ASTRO is doing that.
I am aware there are a handful of academic centers advertising this. But I promise you there has been very aggressive (to the point of bizarre hostility) pushback from some academic rad oncs on this. I also know this for a fact.

I do think it's a good question. How is ROCR handling payments for the use of RT in situations that don't fall in their pre-defined case buckets? The aforementioned would love to see LDRT no longer paid for.

What do they have against LDRT for arthritis?

 

[drowsy12]

I'm not the one claiming to speak for everyone. ASTRO is doing that.

they did an entire issue in benign indications of their newsletter and specifically highlighted practical things like billing codes, technique etc.

strange take to suggest that ASTRO is anti LDRT?

 

[alwaysbeIMRTing]

they did an entire issue in benign indications of their newsletter and specifically highlighted practical things like billing codes, technique etc.

strange take to suggest that ASTRO is anti LDRT?

While ASTRO preferentially represents the interests of academic centers in my opinion, they are not the same thing, which you know, and you know that I did not mean to say that the official policy stance of ASTRO is the opposition of the use of LDRT for OA by stating that some academics are critical of its use.

If you're an apologist for ASTRO and academic centers, that's fine. But that's two strawmen posts in a row. I mean, dishonest debate is beloved by ASTRO and academic centers, so I'm not surprised.

 

[drowsy12]

While ASTRO preferentially represents the interests of academic centers in my opinion, they are not the same thing, which you know, and you know that I did not mean to say that the official policy stance of ASTRO is the opposition of the use of LDRT for OA by stating that some academics are critical of its use.

If you're an apologist for ASTRO and academic centers, that's fine. But that's two strawmen posts in a row. I mean, dishonest debate is beloved by ASTRO and academic centers, so I'm not surprised.

got it - I may have misunderstood what you meant by saying ASTRO. this isn't worth arguing. my point stands that I'm not sure why you are talking about 'your academic masters' being anti LDRT. I don't have a deep obsession with either astro or academics as some on this board do, including you it seems.

as a reminder, this is what you said a mere short while ago: I have it on pretty good authority our academic masters really really hate community practices using linacs for this and billing for it.

Good luck to you!

 

[alwaysbeIMRTing]

I don't have a deep obsession with either astro or academics as some on this board do, including you it seems.

It is true that I have a deep obsession with individuals and nanny organizations actively trying to impede and regulate the way I practice my profession and make my living.

I can only guess why some in the ivory tower (not naming names) feel that it is inappropriate to treat OA, but I have a pretty good idea.

 

[OTN]

It is true that I have a deep obsession with individuals and nanny organizations actively trying to impede and regulate the way I practice my profession and make my living.

I can only guess why some in the ivory tower (not naming names) feel that it is inappropriate to treat OA, but I have a pretty good idea.

 

[NotMattSpraker]

I'm not the one claiming to speak for everyone. ASTRO is doing that.
I am aware there are a handful of academic centers advertising this. But I promise you there has been very aggressive (to the point of bizarre hostility) pushback from some academic rad oncs on this. I also know this for a fact.

I do think it's a good question. How is ROCR handling payments for the use of RT in situations that don't fall in their pre-defined case buckets? The aforementioned would love to see LDRT no longer paid for.

They get billed to usual medicare servicers is my understanding.

 

[drowsy12]

 

[emt409]

I'm not the one claiming to speak for everyone. ASTRO is doing that.
I am aware there are a handful of academic centers advertising this. But I promise you there has been very aggressive (to the point of bizarre hostility) pushback from some academic rad oncs on this. I also know this for a fact.

I do think it's a good question. How is ROCR handling payments for the use of RT in situations that don't fall in their pre-defined case buckets? The aforementioned would love to see LDRT no longer paid for.

This seems jaded and misinformed. Everything not in ROCR stays FFS.

Also, the presidential symposium is dedicated to benign this year, and the longest block is LDRT for MSK.

 

[thesauce]

Community Oncology Alliance Endorses Radiation Oncology Case Rate Program

What is the Community Oncology Alliance? I am a community oncologist and whoever these clowns are don't speak for me.

ROCR is a lifeline to our field and especially to our colleagues in community practice who own equipment and operate small businesses

BULLS(HT. This hare-brained case-rate payment scheme and direct supervision mandate are a direct threat to independent community practices. It is also a threat to patients as doctors will be incentivized to use simpler treatments and churn-and-burn patients on and off treatment as quickly as possible.

Tell your congressman!

Anyone who needs a template letter to combat this, feel free to PM

 

[alwaysbeIMRTing]

This seems jaded and misinformed. Everything not in ROCR stays FFS.

Also, the presidential symposium is dedicated to benign this year, and the longest block is LDRT for MSK.

Simul posted about the hate he got for cheerleading LDRT on his blog. IMO it's coming from the usual suspects, the academic fraction-shaming crowd who have a problem with basically anything being treated in community practices.

How is asking a question about the gaps in diagnoses that don't fall under ROCR "cases" being misinformed? Their typo-filled "FAQ" doesn't address it. Making some uses case-rate and some uses FFS further belies the purported simplicity and cost-savings of this scheme.

The pro-ROCR contingent is pointing fingers and saying that if you oppose this then it's because you want to continue FFS because it's more profitable for your practice. While at the same time they are claiming that this scheme will stabilize payments and result in increased revenue in the future. So if you oppose this, you're doing so out of a corrupted financial self-interest, but also you should support this because it's in your financial best interest. Ridiculous.

 

[TheWallnerus]

The pro-ROCR contingent is pointing fingers and saying that if you oppose this then it's because you want to continue FFS because it's more profitable for your practice. While at the same time they are claiming that this scheme will stabilize payments and result in increased revenue in the future. So if you oppose this, you're doing so out of a corrupted financial self-interest, but also you should support this because it's in your financial best interest. Ridiculous

My dad would call this talking out both sides of your mouth. And ASTRO is great at it.

 

[TheWallnerus]

How does this get thumbs down. IMPORT LOW and Livi are very mature, thousands of patients, etc. There’s as much clinical indication to irradiate elbow as there is uninvolved breast in women who are PBI appropriate (and we know what we’d say about a rad onc who was irradiating elbow for a breast cancer case). PBI pays just as well as whole breast too 😉 maybe even more depending on the insurance guideline.