Rad Onc Twitter

[alwaysbeIMRTing]

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ASTRO tried to sell the PP docs on ROCR by throwing them a bone with "site neutral" payments, which is something linac owners have been bitching about for decades.
If you buy this, you're a sucker.

ROCR is an enormous threat to RVU-based and independent community (especially rural) docs billing pro fees.
And honestly I don't see how the machine owners are going to take it on the chin with technical payments in return for site neutral payments. Bad deal.

ASTRO and the Jeff M crowd overplayed their hand by trying to cram in supervision mandates. No. Give it up on the linac babysitting nonsense already. Just stop. You don't give a damn about the rad oncs taking care of people in flyover land and you've made that overwhelming clear.

 

[Gfunk6]

I have had docs from big private groups tell me ROCR was the way to go.
Does anyone have good information on what groups would actually benefit versus who wouldn't? Are smaller docs getting screwed by it?

Despite all the hate on ROCR, I know that *I* would personally benefit from it. I hypofractioante like crazy, especially for prostate. I think I would benefit greatly from a case rate on that. We also hypofractioante regularly on breast.

It's not all positive, we would take a hit on SBRT for bone mets and SRS for brain mets but what is the alternative? Endless cuts of Medicare + endless CoL increases to staff + increasing costs of hardware + lack of ownership in lieu of subscription modes = eventual insolvency and employment at your local academic center satellite.

 

[thesauce]

Despite all the hate on ROCR, I know that *I* would personally benefit from it. I hypofractioante like crazy, especially for prostate. I think I would benefit greatly from a case rate on that. We also hypofractioante regularly on breast.

It's not all positive, we would take a hit on SBRT for bone mets and SRS for brain mets but what is the alternative? Endless cuts of Medicare + endless CoL increases to staff + increasing costs of hardware + lack of ownership in lieu of subscription modes = eventual insolvency and employment at your local academic center satellite.

It’s a cat and mouse game. A new technology will come out and that will be reimbursed like crazy and everybody will jump on it and then it will go down and then a few years later it’ll happen again. It’s been happening forever and in every specialty.

ROCR might’ve been good EVENTUALLY simply because it built in regular increases. However, once the cost got high enough, they would just dissolve it or freeze payments.

Anyway, it’s toast now so onto the next thing.

 

[RickyScott]

I have had docs from big private groups tell me ROCR was the way to go.
Does anyone have good information on what groups would actually benefit versus who wouldn't? Are smaller docs getting screwed by it?

Employed radoncs, which is the vast majority, will not benefit from ROCR. Maybe with Rocr, my rvus would only be 5000 higher than neurosurgery, urology, ortho?

 

[grenz]

Employed radoncs, which is the vast majority, will not benefit from ROCR. Maybe with Rocr, my rvus would only be 5000 higher than neurosurgery, urology, ortho?

That’s the spirit, stick it to the independent groups who are struggling to stay independent.

 

[RickyScott]

That’s the spirit, stick it to the independent groups who are struggling to stay independent.

I truly believe most radoncs would be worse off under rocr.

 

[CurbYourExpectations]

I truly believe most radoncs would be worse off under rocr.

Can you go in to detail on this one?

Has anyone done any extensive data analysis on what percentage of practices or even what practices/docs would benefit from this? @TheWallnerus

 

[alwaysbeIMRTing]

Can you go in to detail on this one?

Has anyone done any extensive data analysis on what percentage of practices or even what practices/docs would benefit from this? @TheWallnerus

Hospitals incentivize RVU production.
With ROCR you would have competing incentives. 8 Gy x1 AP-PA is going to make your life easier even though a longer and more complex palliative regimen will sometimes be better for the patient. Because of the nature of how patients come to us, we can't really make more patients appear through networking and marketing. So hospitals will quickly realize they are better off flat salarying rad oncs at whatever level they need to maintain their prior margins in the department, which is going to be a lot less than the base+RVU bonus most doctors currently have that allows busy doctors to do well financially. In the current system, many hospitals are fine with rad oncs blowing out the MGMA median because they are producing so many RVUs. Hospitals are not going to be happy when those RVUs drop precipitously with ROCR and will suddenly start screaming bloody murder about Stark law and fair market value if you try to guarantee a salary anywhere near your prior total comp under the RVU bonus model.

The dream of the academics is to overtrain residents and flat salary them all just slightly above PCP pay and chain them to the machine at rural satellites and waste their time with quality meetings and pseudo-academic bs in their massive amount of clinical downtime. And this is obviously who ASTRO is advocating for. It's harder to recruit people to sign up for this when the independent hospital down the street is paying per RVU and the number of RVUs you earn is directly correlated to how much work you do (what an awful inequitable system -- everyone should earn the same, except the chair of course).

 

[grenz]

Can you go in to detail on this one?

Has anyone done any extensive data analysis on what percentage of practices or even what practices/docs would benefit from this? @TheWallnerus

Practices that hypofrac a reasonable % of patients would do fine compared to status quo

Hospitals incentivize RVU production.
With ROCR you would have competing incentives. 8 Gy x1 AP-PA is going to make your life easier even though a longer and more complex palliative regimen will sometimes be better for the patient. Because of the nature of how patients come to us, we can't really make more patients appear through networking and marketing. So hospitals will quickly realize they are better off flat salarying rad oncs at whatever level they need to maintain their prior margins in the department, which is going to be a lot less than the base+RVU bonus most doctors currently have that allows busy doctors to do well financially. In the current system, many hospitals are fine with rad oncs blowing out the MGMA median because they are producing so many RVUs. Hospitals are not going to be happy when those RVUs drop precipitously with ROCR and will suddenly start screaming bloody murder about Stark law and fair market value if you try to guarantee a salary anywhere near your prior total comp under the RVU bonus model.

The dream of the academics is to overtrain residents and flat salary them all just slightly above PCP pay and chain them to the machine at rural satellites and waste their time with quality meetings and pseudo-academic bs in their massive amount of clinical downtime. And this is obviously who ASTRO is advocating for. It's harder to recruit people to sign up for this when the independent hospital down the street is paying per RVU and the number of RVUs you earn is directly correlated to how much work you do (what an awful inequitable system -- everyone should earn the same, except the chair of course).

the AHA didn’t oppose ROCR, so they clearly thought it was preferable to the writing on the wall with hypofractionstion and constant Medicare cuts. The modeling showed there would be a modest cut but with reimbursement pegged to inflation, which is a better deal than anyone else in medicine has.

 

[alwaysbeIMRTing]

Practices that hypofrac a reasonable % of patients would do fine compared to status quo

the AHA didn’t oppose ROCR, so they clearly thought it was preferable to the writing on the wall with hypofractionstion and constant Medicare cuts. The modeling showed there would be a modest cut but with reimbursement pegged to inflation, which is a better deal than anyone else in medicine has.

Why would they oppose it? I just illustrated how it would allow them to pay employed doctors less. Physician salary expense is the number one thing administrators care about.

We already have fractionation and modality gatekeepers. Is that not enough? How many people these days are successfully still giving 30 fractions of IMRT for bone mets? Or even conventional fractionation for whole breast? Or is this just still about trying to kill urorads treating 44 fraction prostate? I don't understand how anybody can make a good faith argument that a 30 fraction course of treatment should cost the same as a 15 fraction course of treatment. Should a single mastectomy cost the same as a double mastectomy then? Should we just get rid of the -50 modifier to "stabilize payments" (somehow?) and make sure nobody is cutting off an extra breast just for extra $$$? This strips the physician of the autonomy to choose a longer regimen if felt to be appropriate without a conflict of interest. If we have to have someone mandate how we deliver care, then what are we even doing? Tesla should have programmable robots that can perform that function in a few years. Or the APRT can just follow a cookbook algorithm that says 3 Gy x 20 and approve the AI-generated circle around the prostate the way med onc NPs prescribe chemo now.

Why does rad onc think they are uniquely situated for abuse of the FFS system as compared to other specialties? We strip ourselves of the autonomy to choose without penalty, meanwhile IR continues to go wild ablating anything and everything in sight, derm perform thousands of unnecessary MOHS procedures on demented nursing home patients, psych runs fake "ADHD" adderall clinics for a generation of smartphone-brain damaged adults, spinal fusions are always chosen over conservative management, MRI and CT literally every complaint, bronch everybody (highest paid doc in my last hospital was pulm pulling in over 2M a year from this), coronary stents over medical therapy, straight to c-section, colonoscopies every 2 years because i say so, PCPs going on fishing expeditions ordering everything under the sun to complicate the problem list on annual physicals and generate complex follow-ups, etc.

 

[communitydoc13]

Hospitals incentivize RVU production.

RVUs are fairly (very) arbitrary. What hospitals are trying to incentivize is revenue, revenue and RVUs being different things (although many admins don't get this). Hospitals are concerned about having unproductive docs, but this is rarely a problem in oncology. They often use RVU bonus structure to encourage productivity, it doesn't always work.

I have discouraged heavy RVU bonus laden contracts in my hospital, because I felt that it engendered "RVU chasing". My worst medonc was making 130% my best doc and providing worse care, while not starting substantially more patients on treatment (where the real money is). He was doing lots of duplicate work, seeing patients too frequently, negatively impacting clinic efficiency and not utilizing APPs appropriately...it was a problem.

I do not have an RVU based contract and there are lots of benefits. We exchange patients while on treatment and no-one is counting OTVs or imaging review. We emphasize getting patients in for consult quickly and fractionate without regard to RVUs. I do a fair bit of telephone care with elderly patients with whom I am just discussing serial imaging studies or labs. It makes us all very flexible with our schedules. We periodically make sure that consults are roughly equitable. Some docs (me) see more follow-ups per clinical preference.

Case based would substantially reduce admin work in my clinic and probably improve our overall revenue over time (this is all contingent on what's going to happen in the future).

No doubt that some docs in a sweet spot with their RVU based contract...and yes, ROCR would hurt those folks. Your point is reasonable IMO given the type of contract you have.

 

[alwaysbeIMRTing]

I agree that RVU-based compensation algorithms do not work well when there is more than one doctor. Ideally, the RVUs should be pooled and divided equally and the doctors have the choice to cover for each other on vacation or to choose to give up RVUs to hire locums. This ideally would self-select for doctors who have similar attitudes to workload and time off. Eat-what-you kill works well when you are alone and not competing with your partner(s) within the same organization.

I can see where case rates aren't going to a big deal for multi-doc employed clinics where everyone is already splitting everything equally. Or even benefit very busy private practices that hypofractionate everything not because they believe it is the ethically correct thing to do, but because they need to to make their schedules work (it's nice to be able to virtue signal fractionation choices to the sleepy rural clinic trying to keep the lights on when you are seeing 20 consults a week -- I have seen this trick before).

However, in areas where it is hard to recruit rad oncs (underserved areas), these are usually small, solo-doc clinics. Case rates would exacerbate the problems hospitals already have staffing these with competent doctors.

 

[Palex80]

 

[drowsy12]

the fact that this guy posits that they could be better for an AP/PA square with 0.5 Gy a fraction just automatically discounts any thing else he could ever say about protons. total joke.

 

[Gfunk6]

Per ASTRO, the old paradigm of evidence-based medicine has been abandoned with protons. Not because it is outmoded, but because it is irrelevant. We have dosimetry that proves protons are better for everything. We live in a post-evidence era folks - welcome to the new age.

 

[RickyScott]

the fact that this guy posits that they could be better for an AP/PA square with 0.5 Gy a fraction just automatically discounts any thing else he could ever say about protons. total joke.

the whole point here is that very low doses are beneficial, so protons w/less scatter may be worse

 

[emt409]

the whole point here is that very low doses are beneficial, so protons w/less scatter may be worse

I wouldn't say this is accurate- the therapeutic effect is based on treatment effect to the joint capsule and its contents, not bathing everything in the vicinity. Obv doesn't mean protons are needed though.

 

[thesauce]

the fact that this guy posits that they could be better for an AP/PA square with 0.5 Gy a fraction just automatically discounts any thing else he could ever say about protons. total joke.

Or anything else. This man has very poor judgement.

 

[RickyScott]

I wouldn't say this is accurate- the therapeutic effect is based on treatment effect to the joint capsule and its contents, not bathing everything in the vicinity. Obv doesn't mean protons are needed though.

We actually don’t know the answer to that question. Any life anywhere in the universe evolved in the presence of ionizing radiation and as far as I know all cells have dna damage repair pathways that need to be engaged. Mice raised in low radiation conditions get more cancer and may have shorter lifespans. Humans in high background environments also have less cancer. Some small amount of radiation vs none is optimal.

 

[emt409]

We actually don’t know the answer to that question. Any life anywhere in the universe evolved in the presence of ionizing radiation and as far as I know all cells have dna damage repair pathways that need to be engaged. Mice raised in low radiation conditions get more cancer and may have shorter lifespans. Humans in high background environments also have less cancer. Some small amount of radiation vs none is optimal.

Yea, we do. Just because you don’t doesn’t mean we don’t.

But if you wanna be the guy arguing that full skin dose is somehow treating the inflammation in the joint capsule then please be my guest.

 

[TheWallnerus]

Yea, we do. Just because you don’t doesn’t mean we don’t.

But if you wanna be the guy arguing that full skin dose is somehow treating the inflammation in the joint capsule then please be my guest.

I don’t think Ricky was saying that.

If you’re treating midfoot arthritis very often people can seem to have symptoms of plantar fasciitis and or peroneal tendonitis.

Or with trochanteric bursitis there seems to be hip arthritis too, sometimes.

If you’re treating hand arthritis which joint capsule (singular) are you treating there? (Trick question as the hand has 27 joints I think.) Same question for foot arthritis.

Seegenschmidt has data that wider fields produce better results.

There can be a sympathetic pulmonary effusion from nearby inflmmation. I am suspicious that joint inflammation causes surrounding inflammation (especially of tendinous things) and that arthritis is not (always) PURELY a problem of the joint. Case in point: you can still have “knee arthritis” after a knee replacement. And I have seen knee replacement patients get significant relief from LDRT.

In short, stereotactic thinking is about as far away from LDRT thinking as I can imagine.

EDIT: ... and btw 18MV photon beam will give less dose at skin surface and ~1mm deep to that surface versus a clinical energy proton beam

 

[alwaysbeIMRTing]

Hmmm... a bizarrely antagonistic and overly confident (but incorrect) post at midnight on a Saturday?

Giving the benefit of the doubt about what spurred that...

The benefit of LDRT for OA is not limited to the joint capsule. Data indicate that anti-inflammatory effects extend to periarticular soft tissues, including synovium and adjacent structures/soft tissue and hence generous open fields should be used around the joint. This also explains why those of us who have treated SI joints and the spine have seen benefits in these locations as well even though data is admittedly lacking.

Hopefully we can all agree at least that there is not even a theoretical benefit for protons in this setting and actually theoretically a detriment given uncertainties about increased RBE at the bragg peak potentially making the "low dose" radiation no longer low dose (which is why it works). Again, giving the benefit of the doubt where Maryland really doesn't deserve it, the now scrubbed X post was probably written by someone in marketing tasked with advertising for both protons and OA who decided to kill two birds with one stone not understanding that this is clinically insane and somebody on staff caught it and corrected the mistake. If anybody can confirm that Maryland has actually treated OA with protons, I will gladly retract my benefit of the doubt assumption.

Edit: Maryland is actually advertising protons for OA treatment. Disregard the above. Subluxation/life-force chiropractors are blushing.

 

[evilbooyaa]

I wouldn't say this is accurate- the therapeutic effect is based on treatment effect to the joint capsule and its contents, not bathing everything in the vicinity. Obv doesn't mean protons are needed though.

I don't know that anyone is supremely confident as to the MoA of how LDRT helps OA pain. I don't know that Seegenschmidt himself would have this level of confidence into what is happening in LDRT....

I don’t think Ricky was saying that.

If you’re treating midfoot arthritis very often people can seem to have symptoms of plantar fasciitis and or peroneal tendonitis.

Or with trochanteric bursitis there seems to be hip arthritis too, sometimes.

If you’re treating hand arthritis which joint capsule (singular) are you treating there? (Trick question as the hand has 27 joints I think.) Same question for foot arthritis.

Seegenschmidt has data that wider fields produce better results.

There can be a sympathetic pulmonary effusion from nearby inflmmation. I am suspicious that joint inflammation causes surrounding inflammation (especially of tendinous things) and that arthritis is not (always) PURELY a problem of the joint. Case in point: you can still have “knee arthritis” after a knee replacement. And I have seen knee replacement patients get significant relief from LDRT.

In short, stereotactic thinking is about as far away from LDRT thinking as I can imagine.

EDIT: ... and btw 18MV photon beam will give less dose at skin surface and ~1mm deep to that surface versus a clinical energy proton beam

You've given LDRT for someone s/p TKR? That really throws a wrench in the 'I am confident as to what in the hell is going on in there' explanation of LDRT....

 

[CurbYourExpectations]

Has anyone started up a blinded randomized sham trial in the US yet?

If not, it has to be coming right?

Just checked, looks like Mayo clinic is doing it for knee. 128 patients planned. It looks like they are allowing retreatment for non-responders after initial treatment depending on the randomization. I'd argue knee has the best data behind it so far. Will be interested to see if people stop treating if it's negative. Interested to see if it's the LDRT or the laying underneath a LINAC that cures OA.
Any bets?

 

[maxxor]

I don't know that anyone is supremely confident as to the MoA of how LDRT helps OA pain. I don't know that Seegenschmidt himself would have this level of confidence into what is happening in LDRT....



You've given LDRT for someone s/p TKR? That really throws a wrench in the 'I am confident as to what in the hell is going on in there' explanation of LDRT....

Maybe it's treating the nerves in the same way genicular RFA is a thing for post-arthroplasty persistent pain...

The thing with LDRT is you are kinda blasting everything. There's no targeting of the pain generator.

It's not elegant, but at the same time, it appears it doesn't matter that it's a figurative bludgeon.

 

[madchemist89]

Maybe it's treating the nerves in the same way genicular RFA is a thing for post-arthroplasty persistent pain...

The thing with LDRT is you are kinda blasting everything. There's no targeting of the pain generator.

It's not elegant, but at the same time, it appears it doesn't matter that it's a figurative bludgeon.

It is like bludgeoning the joint with a feather.

 

[alwaysbeIMRTing]

Bludgeon the joint with huge margins or contour the joint capsule with high resolution volumes, add a 1mm PTV margin, and prescribe to 70% isodose line with a stereotactic plan constraining tendons, subQ fat, and superficial veins? Make sure beam entrance avoids tattoo ink in the field. Factor in equivalent dose from cone beam ct required for stereo margins.

OA is complicated. Look forward to OA fellowships with boozy mad-men style lunches to aid in tedious afternoon joint contouring.

 

[drowsy12]

 

[emt409]

I don’t think Ricky was saying that.

If you’re treating midfoot arthritis very often people can seem to have symptoms of plantar fasciitis and or peroneal tendonitis.

Or with trochanteric bursitis there seems to be hip arthritis too, sometimes.

If you’re treating hand arthritis which joint capsule (singular) are you treating there? (Trick question as the hand has 27 joints I think.) Same question for foot arthritis.

Seegenschmidt has data that wider fields produce better results.

There can be a sympathetic pulmonary effusion from nearby inflmmation. I am suspicious that joint inflammation causes surrounding inflammation (especially of tendinous things) and that arthritis is not (always) PURELY a problem of the joint. Case in point: you can still have “knee arthritis” after a knee replacement. And I have seen knee replacement patients get significant relief from LDRT.

In short, stereotactic thinking is about as far away from LDRT thinking as I can imagine.

EDIT: ... and btw 18MV photon beam will give less dose at skin surface and ~1mm deep to that surface versus a clinical energy proton beam

Is stereotactic what anyone is suggesting for this treatment?

 

[emt409]

I don't know that anyone is supremely confident as to the MoA of how LDRT helps OA pain. I don't know that Seegenschmidt himself would have this level of confidence into what is happening in LDRT....



You've given LDRT for someone s/p TKR? That really throws a wrench in the 'I am confident as to what in the hell is going on in there' explanation of LDRT....

Actually yes, I have some one THR on beam now.

Why are ppl pretending the MOA is some magical mystery?

It’s just an anti-inflammatory bath.

The more severe the OA, the quicker pain recurs.

Gr 2’s may not ever need a retreatment. Gr 4’s recur in a month or 2.

Maybe weekly or biweekly maintenance is the answer.

I don’t know the optimal regimen yet, but the rad bio is certainly not complicated.

 

[CurbYourExpectations]

Why are ppl pretending the MOA is some magical mystery?

It’s just an anti-inflammatory bath.

The more severe the OA, the quicker pain recurs.

Smart money is on it's a placebo. Okay i said it, you forced it out of me.

If your answer to inflammation is irradiating someone weekly or biweekly, that's straight up insanity and wrong. Either it has a long term benefit from radiation, or radiation isn't needed. MAYBE if you're doing the very very low dose, not 3Gy a treatment course stuff. Do people believe this? Radiation can't even beat nothing, ibuprofen will make a fool out of it.

Things LDRT have beaten in any kind or comparison trial let alone randomized blinded trials or sham trials:

edit- Actually IIRC there was a single plantar fasciitis trial. Someone correct me if wrong.

 

[goodluck1234]

Has anyone started up a blinded randomized sham trial in the US yet?

If not, it has to be coming right?

Just checked, looks like Mayo clinic is doing it for knee. 128 patients planned. It looks like they are allowing retreatment for non-responders after initial treatment depending on the randomization. I'd argue knee has the best data behind it so far. Will be interested to see if people stop treating if it's negative. Interested to see if it's the LDRT or the laying underneath a LINAC that cures OA.
Any bets?

agree, at least one blinded sham randomized trial showing a benefit would be great

 

[TheWallnerus]

Is stereotactic what anyone is suggesting for this treatment?

You, or some anyone iirc, suggested the joint capsule is the target. Correct me if I’m wrong. I pictured treating rhizarthrosis where the joint capsule is sub-cc in size. If that’s the target, certainly sounds “stereotactic curious” at least.

 

[RickyScott]

Smart money is on it's a placebo. Okay i said it, you forced it out of me.

If your answer to inflammation is irradiating someone weekly or biweekly, that's straight up insanity and wrong. Either it has a long term benefit from radiation, or radiation isn't needed. MAYBE if you're doing the very very low dose, not 3Gy a treatment course stuff. Do people believe this? Radiation can't even beat nothing, ibuprofen will make a fool out of it.

Things LDRT have beaten in any kind or comparison trial let alone randomized blinded trials or sham trials:

I have seen xrt rapidly work for hypertrophic pulmonary osteoathropathy where the hands were so swollen, pt could not button shirt.

 

[emt409]

Smart money is on it's a placebo. Okay i said it, you forced it out of me.

If your answer to inflammation is irradiating someone weekly or biweekly, that's straight up insanity and wrong. Either it has a long term benefit from radiation, or radiation isn't needed. MAYBE if you're doing the very very low dose, not 3Gy a treatment course stuff. Do people believe this? Radiation can't even beat nothing, ibuprofen will make a fool out of it.

Things LDRT have beaten in any kind or comparison trial let alone randomized blinded trials or sham trials:

The only people on this side of the fence are the ones who have never treated it.

The severe OA people get more pain relief than the people we palliatively irradiate for tumors.

 

[emt409]

You, or some anyone iirc, suggested the joint capsule is the target. Correct me if I’m wrong. I pictured treating rhizarthrosis where the joint capsule is sub-cc in size. If that’s the target, certainly sounds “stereotactic curious” at least.

Haha- agree if you only have pathology in the TMC joint, that's a smaller target than many of our stereotactics, but having a small CTV, and treating it stereotactically are two different things.

I guess my point in the original response was, just because you don't need protons or stereotactic targeting at this dose level, doesn't mean the dose spill everywhere outside the joint is contributing to the therapeutic efficacy.

 

[CurbYourExpectations]

The only people on this side of the fence are the ones who have never treated it.

The severe OA people get more pain relief than the people we palliatively irradiate for tumors.

And those that have ran a randomized trial on it.

I just want to see one randomized trial show benefit if tens of thousands are going to start getting irradiated in the US. We are never this blind to data in this field, other than this.

 

[Palex80]

If you’re treating hand arthritis which joint capsule (singular) are you treating there?

I have no idea, here's my field arrangement.

Future generation of radiation oncologists will thank me for producing another case of myeloma.

 

[CurbYourExpectations]

Have you considered laying them under a linac for a few minutes without turning it on?

 

[TheWallnerus]

Things LDRT have beaten in any kind or comparison trial let alone randomized blinded trials or sham trials:

LDRT has beaten cortisone injection for plantar fasciitis

If you look in the packet I attached here a while back there is a positive randomized sham controlled trial for knee arthritis now

 

[RickyScott]

Haha- agree if you only have pathology in the TMC joint, that's a smaller target than many of our stereotactics, but having a small CTV, and treating it stereotactically are two different things.

I guess my point in the original response was, just because you don't need protons or stereotactic targeting at this dose level, doesn't mean the dose spill everywhere outside the joint is contributing to the therapeutic efficacy.

There are nerves and vessels in the tiasues surrounding the joint capsule. Xrt causes effects adhesion mechanisms/icam docking of leukocyes in vessels and may have anti inflam in nerves. Even the joint capsule is not easy to define. I don’t think the target is very discrete.

 

[CurbYourExpectations]

LDRT has beaten cortisone injection for plantar fasciitis

If you look in the packet I attached here a while back there is a positive randomized sham controlled trial for knee arthritis now

Yeah, I editted earlier about the plantar trial, briefly forgot about that one.

Hopefully it works out in the long run. Would you quit treating if the Mayo trial comes up negative?

 

[emt409]

And those that have ran a randomized trial on it.

I just want to see one randomized trial show benefit if tens of thousands are going to start getting irradiated in the US. We are never this blind to data in this field, other than this.

There is a large Russian randomized trial. The 10 year MRI follow up are being presented at Astro is my understanding.

The trial is referenced in many of the reviews. As are what seem to me very valid appropriate critiques of the two negative studies.

 

[CurbYourExpectations]

There is a large Russian randomized trial. The 10 year MRI follow up are being presented at Astro is my understanding.

The trial is referenced in many of the reviews. As are what seem to me very valid appropriate critiques of the two negative studies.

It looks like that trial's results were not significant, but may have some radiographic benefit? Sorry if I'm misreading this.
Agree that some of the trials seemed weak.

 

[Ray D. Ayshun]

I recently fired a patient I treated 9 months ago for knee OA. She kept saying the pain was improved and she was able to be more active, so I told I couldn't see he any more because I was tired of the lies.

 

[TheWallnerus]

I recently fired a patient I treated 9 months ago for knee OA. She kept saying the pain was improved and she was able to be more active, so I told I couldn't see he any more because I was tired of the lies.

“Everybody lies.”

- House, M.D.

 

[thesauce]

And those that have ran a randomized trial on it.

I just want to see one randomized trial show benefit if tens of thousands are going to start getting irradiated in the US. We are never this blind to data in this field, other than this.

lol you’ve heard of protons, right?

 

[thesauce]

Yeah, I editted earlier about the plantar trial, briefly forgot about that one.

Hopefully it works out in the long run. Would you quit treating if the Mayo trial comes up negative?

We have 72 months of followup on pf with durable pain relief. Have you really even tried to look through the literature?

 

[thesauce]

It looks like that trial's results were not significant, but may have some radiographic benefit? Sorry if I'm misreading this.
Agree that some of the trials seemed weak.

The Russian trial showed reduction in progressing to disability

 

[TheWallnerus]

Haha- agree if you only have pathology in the TMC joint, that's a smaller target than many of our stereotactics, but having a small CTV, and treating it stereotactically are two different things.

I guess my point in the original response was, just because you don't need protons or stereotactic targeting at this dose level, doesn't mean the dose spill everywhere outside the joint is contributing to the therapeutic efficacy.

OTOH, as Herman Suit used to say, “There is no clinical indication for even one picogray outside the target volume.” And if one followed the logic that the dose spill outside the joint capsule contributes zero clinical efficacy, protons (which is the most precise radiation currently available, or photon stereotactic precision and accuracy) would actually make imminently more clinical sense than the wide field (aka imprecise) approaches everyone currently uses.