RO may have a role in this COVID crisis, but we need a clinical trial.....

[cancer_doc]

I can't let go of the potential harm to the staff. Can anyone think of another example (other than war) where other people are put at risk for the benefit of a clinical investigators career?

Back in the early days of HIV / AIDS research, when there were absolutely no known cure, but known risk of blood transmission, who was drawing the blood of the HIV-infected research subjects? The PI? Heck no, it was "other people" . Responsibility lies in developing proper safety protocol, proper training of safety protocol, and staff compliance of the safety protocol. Same thing then, and same thing now....

---

Members don't see this ad.

 

[thecarbonionangle]

Here is the original tweet:
View attachment 305168

And the nail in the coffin:
View attachment 305169

Incredibly irresponsible to say the least. I mean... broadcasting a single arm 5 patient study that “promises to improve patient outcome” and “will be a game changer” then comparing it to “light therapy” and tagging Trump?

Apart from the reckless delivery on twitter, I have issues with doing a 5 patient whole lung RT study during this pandemic.

What could possible be learned? All patients die? Related to treatment? I dunno. All live? Might be intervention, or not... it’s apparently a phase I/II so there’s some kind of efficacy endpoint?

All the while putting staff at risk and cancer patients too if there’s contamination of the vault. Not worth the risk given nothing can be learned in my opinion.

Perhaps there is a role for RT based on the historical data, but come on need a better study than this that justifies the risk.


Sent from my iPhone using SDN

tagging Trump and basically implying
“Many people are saying it!” Was the best part of it for me. It was definitely a joke. I’d have a beer with Mo.

 

[RadOncDoc21]

Here is the original tweet:
View attachment 305168

And the nail in the coffin:
View attachment 305169

Incredibly irresponsible to say the least. I mean... broadcasting a single arm 5 patient study that “promises to improve patient outcome” and “will be a game changer” then comparing it to “light therapy” and tagging Trump?

Apart from the reckless delivery on twitter, I have issues with doing a 5 patient whole lung RT study during this pandemic.

What could possible be learned? All patients die? Related to treatment? I dunno. All live? Might be intervention, or not... it’s apparently a phase I/II so there’s some kind of efficacy endpoint?

All the while putting staff at risk and cancer patients too if there’s contamination of the vault. Not worth the risk given nothing can be learned in my opinion.

Perhaps there is a role for RT based on the historical data, but come on need a better study than this that justifies the risk.


Sent from my iPhone using SDN

 

[medgator]

tagging Trump and basically implying
“Many people are saying it!” Was the best part of it for me. It was definitely a joke. I’d have a beer with Mo.

You sure he was being sarcastic?

 

[PhotonBomb]

You sure he was being sarcastic?

Yeah definitely wasn’t

 

[scarbrtj]

A few (Ralph-ish types) were remarking on the folly of using very old, early 20th century data re: XRT + pneumonia. Just read this evening:

"Before this [SARS 2003 and COVID-19] outbreak, quarantine and isolation were not often evoked for infectious-disease outbreaks," Khan told me--at least not in the recent past. During the medieval plagues in Europe, infected unfortunates were often sent outside the city walls to die... in late 19th century America, during smallpox outbreaks, victims showing pox could be confined in quarantine camps surrounded by high fences of barbed wire or in nightmarish "pest houses." "That was a concept that had sort of gone out of vogue," Khan told me dryly. He and Chew and colleagues revived it in a more humane version.

- "The Warnings: Why we should have known to prepare for COVID-19," The New Yorker, 5/11/2020. (Khan was formerly of the CDC, and Chew the Chief Minister of Public Health in Singapore)

So via quarantining (which seems to be the most effective intervention now?) some were relying not on 100-year old data but 700-year old data!

 

[evilbooyaa]

A few (Ralph-ish types) were remarking on the folly of using very old, early 20th century data re: XRT + pneumonia. Just read this evening:

"Before this [SARS 2003 and COVID-19] outbreak, quarantine and isolation were not often evoked for infectious-disease outbreaks," Khan told me--at least not in the recent past. During the medieval plagues in Europe, infected unfortunates were often sent outside the city walls to die... in late 19th century America, during smallpox outbreaks, victims showing pox could be confined in quarantine camps surrounded by high fences of barbed wire or in nightmarish "pest houses." "That was a concept that had sort of gone out of vogue," Khan told me dryly. He and Chew and colleagues revived it in a more humane version.

- "The Warnings: Why we should have known to prepare for COVID-19," The New Yorker, 5/11/2020. (Khan was formerly of the CDC, and Chew the Chief Minister of Public Health in Singapore)

So via quarantining (which seems to be the most effective intervention now?) some were relying not on 100-year old data but 700-year old data!

Quarantining (but really what we are doing now is aggressive social distancing, NOT the quarantining done in the past [except in Wuhan]) was well established as a good option based on retrospective analysis of the 1918 spanish flu:

How two US cities responded to the 1918 flu pandemic very differently — and what we can learn from those mistakes

In 1918, Philadelphia did not act fast enough against the flu pandemic whereas St. Louis took swift action and saw a much lower death rate.

www.businessinsider.com

 

[Palex80]

I believe one major issue with the US may be the fact that citizens are able to travel between States. I read in the NY-Times that governors and federal government cannot prevent this from happening since it is a constitutional right.
In Europe all states have closed their borders, practically containing the infected within each country. The smaller the country the easier it is to track down all infected persons to the last, quarantine them and end the pandemic (at least as long as the borders remain closed).

Island states with adequate measures and no access other by plane are in a sweet spot here. Have a look at the official statistics from New Zealand for instance...

The big issue right now is what happens when we start opening borders again, with summer coming and all... Although the fact that many people will choose not to travel far, we are going to lose the ability to follow the infection tracts once people start crossing borders on business trips or holidays.
It's a mess...

 

[RadOncMegatron]

In theory, it's immunomodulatory. And if you look into the ex-vivo research, you will see that the dose ranges are variable. Which means that if you go substantially over 1 Gy (but still in "safe regions") you may have a counter-effect. So, 2-4 Gy seem to be immunosuppressive, but doses up to 1 Gy seem not to.
ALL EX-VIVO, all in theory...


The point is, that perhaps 1 Gy of WLI may be good for pneumonia. That's at least what was studied back in the 30s and based on that, people are speculating it may work on COVID too. That's the theory. And to prove that, you need an experiment.


Valid arguments. It's a risk/benefit calculation.


I posted here a couple of weeks ago that one of our patients got COVID in the middle of his head&neck treatment. We kept on treating him, daily, with full PPE and all. The whole show. For ONE patient. Yes, one cancer patient and one important part of his treatment (adjuvant RT for pN+ SCC of H&N), but we decided to subject personell to all those risks to help this one patient. With a fractionated treatment and something like 20+ fractions to go... On a daily basis.
Unfortunately we had to stop treatment a few days afterwards, since his COVID-condition deteriorated and haven't been able to restart (unclear if we ever will).

The trial is Emory is looking at 5 patients, which will get 1 (?) fraction. That's 5 "encounters" with a COVID patient (or perhaps 10, since they will have to sim them too). But still, the whole exposure risk from that one trial is less than the exposure risk we had with one patient. And believe me, we were certainly not the first ones and will certainly not be the last ones in that situation.

Great response. Appreciate the post.

 

[thecarbonionangle]

I believe one major issue with the US may be the fact that citizens are able to travel between States. I read in the NY-Times that governors and federal government cannot prevent this from happening since it is a constitutional right.
In Europe all states have closed their borders, practically containing the infected within each country. The smaller the country the easier it is to track down all infected persons to the last, quarantine them and end the pandemic (at least as long as the borders remain closed).

Island states with adequate measures and no access other by plane are in a sweet spot here. Have a look at the official statistics from New Zealand for instance...

The big issue right now is what happens when we start opening borders again, with summer coming and all... Although the fact that many people will choose not to travel far, we are going to lose the ability to follow the infection tracts once people start crossing borders on business trips or holidays.
It's a mess...

USA people are also very fat, unhealthy diabetic CHFer messes. This is America.

 

[RadOncMegatron]

Here it is the counter reply :

Lack of supporting data make the risks of a clinical trial of radiation therapy as a treatment for COVID-19 pneumonia unacceptable

www.sciencedirect.com

 

[scarbrtj]

Here it is the counter reply :

Lack of supporting data make the risks of a clinical trial of radiation therapy as a treatment for COVID-19 pneumonia unacceptable

www.sciencedirect.com

Thought it was a hackneyed, tired mayonnaise response. Summary:
1) There are many reports from the 1940's from hundreds of patients showing a benefit to XRT in pneumonia. These results are "anecdotal" and have many flaws.
2) There is data from about 16 mice and 12 cats in the 1940's that XRT didn't help mouse or cat pneumonia. We like these studies much more, and it pretty much shows that XRT won't work in humans.
3) You need B cells and T cells to fight COVID (ed note: you need B cells to fight COVID acutely?) and low dose radiation makes them low (ed note: talk about lack of supporting data!) and that might kill you.
4) Low dose radiation will increase cancer rates and give you heart attacks. We don't cite any hard data for this but direct you to BEIR etc. Oh and also NASA worries about radiation on space missions. Oh and also we give low dose radiation outside the target area constantly across millions of patients over time but radiation oncologists don't even track that. (ed note: talk about lack of supporting data!)
5) If you get around COVID-19 patients they might infect you.
6) We have spoken.

 

[scarbrtj]

 

[scarbrtj]

Doctor with Staten Island ties thinks radiation treatment could cure COVID-19 related pneumonia

Dr. James S. Welsh will be taking part in a clinical study determining if that form of therapy can work

www.silive.com

 

[RadOncDoc21]

Doctor with Staten Island ties thinks radiation treatment could cure COVID-19 related pneumonia

Dr. James S. Welsh will be taking part in a clinical study determining if that form of therapy can work

www.silive.com

I need his marketing crew.

 

[thecarbonionangle]

is Mo Khan the man in the arena? Some are saying it. I see a man trying to make something happen! And I really like this sort of man.


"It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat." T.R

 

[deleted774703]

Preprint is up...

Low-Dose Whole-Lung Radiation for COVID-19 Pneumonia: Planned Day-7 Interim Analysis of an Ongoing Clinical Trial

Background Individuals with advanced age and comorbidities face higher risk of death from COVID-19, especially once ventilator-dependent. Respiratory decline in COVID-19 is mediated by a pneumonic aberrant immune cytokine storm. Low-dose radiation was used to treat pneumonia in the...

www.medrxiv.org

 

[cancer_doc]

Preprint is up...

Low-Dose Whole-Lung Radiation for COVID-19 Pneumonia: Planned Day-7 Interim Analysis of an Ongoing Clinical Trial

Background Individuals with advanced age and comorbidities face higher risk of death from COVID-19, especially once ventilator-dependent. Respiratory decline in COVID-19 is mediated by a pneumonic aberrant immune cytokine storm. Low-dose radiation was used to treat pneumonia in the...

www.medrxiv.org

Curious why 4 of the 9 screened patients did not get treated. Technical / safety issues??
[update - it was reported in their manuscript: 1 died prior to enrollment, 1 did not meet severity criteria, 2 were intubated before LD-RT could be given]

 

[medgator]

Curious why 4 of the 9 screened patients did not get treated. Technical / safety issues??
[update - it was reported in their manuscript: 1 died prior to enrollment, 1 did not meet severity criteria, 2 were intubated before LD-RT could be given]

We treated tubed patients in residency.... Maybe not on pressors though

 

[cancer_doc]

Preprint is up...

Low-Dose Whole-Lung Radiation for COVID-19 Pneumonia: Planned Day-7 Interim Analysis of an Ongoing Clinical Trial

Background Individuals with advanced age and comorbidities face higher risk of death from COVID-19, especially once ventilator-dependent. Respiratory decline in COVID-19 is mediated by a pneumonic aberrant immune cytokine storm. Low-dose radiation was used to treat pneumonia in the...

www.medrxiv.org

I find these early results optimistically promising......

and microwaving some popcorn in anticipation of what ralph weichselbaum will heat up on his twitter account......

 

[evilbooyaa]

Preprint is up...

Low-Dose Whole-Lung Radiation for COVID-19 Pneumonia: Planned Day-7 Interim Analysis of an Ongoing Clinical Trial

Background Individuals with advanced age and comorbidities face higher risk of death from COVID-19, especially once ventilator-dependent. Respiratory decline in COVID-19 is mediated by a pneumonic aberrant immune cytokine storm. Low-dose radiation was used to treat pneumonia in the...

www.medrxiv.org

Author to patient ratio of > 2 for a 'clinical trial'. Impressive.

IJROBP here we come!!

They excluded those who received COVID-directed drug therapy along with LD-RT. Can't get remdesevir if you want to get LD-RT. Can't be intubated.

But I guess not all of them immediately died so let's move it on to more patients? It's funny how in a few weeks COVID-19 is no longer the main thing on most people's radar.

 

[scarbrtj]

Either those docs from the 1930's and 1940's were all liars or XRT does pretty good for pneumonia.

 

[scarbrtj]

I find these early results optimistically promising......

and microwaving some popcorn in anticipation of what ralph weichselbaum will heat up on his twitter account......

it won't be a spoiler alert to say: Ralph will hate it. And Ralphsplain to us the coincidence of rapid clinical improvement in the face of the patients' preceding clinical declines. Plus or minus, lament how the patients irradiated now must face a lifetime of risk and "rad worry" dying at age 80 100 vs the comfort of dying unirradiated earlier in life.

 

[Chartreuse Wombat]

Preprint is up...

Low-Dose Whole-Lung Radiation for COVID-19 Pneumonia: Planned Day-7 Interim Analysis of an Ongoing Clinical Trial

Background Individuals with advanced age and comorbidities face higher risk of death from COVID-19, especially once ventilator-dependent. Respiratory decline in COVID-19 is mediated by a pneumonic aberrant immune cytokine storm. Low-dose radiation was used to treat pneumonia in the...

www.medrxiv.org

I have to say COVID-19 has made peer review look very bad. I trust that this is never published in a reputable journal

Why?

There is no pre-specified hypothesis/sample size statement. Why did they decide to report when they did? No comparator group
Sample size is a joke. No specifics on which inflammatory biomarkers were measured.
Endpoint is a joke. Some of these patients were demented. More co-authors than patients.

Alternative conclusion. **** happens; sometime people get better despite what we do.

Embarassing

 

[scarbrtj]

I have to say COVID-19 has made peer review look very bad. I trust that this is never published in a reputable journal

Why?

There is no pre-specified hypothesis/sample size statement. Why did they decide to report when they did? No comparator group
Sample size is a joke. No specifics on which inflammatory biomarkers were measured.
Endpoint is a joke. Some of these patients were demented. More co-authors than patients.

Alternative conclusion. **** happens; sometime people get better despite what we do.

Embarassing

Uh oh some people now in stage 2 fight mode

 

[Chartreuse Wombat]

Uh oh some people now in stage 2 fight mode

Is this a rebuttal? Invoking Elizabeth Holmes?
Or are you just that clever...comparing the esteemed Emory investigators to the fraud that is Ms Holmes?
It's hard to know.

 

[Ray D. Ayshun]

Now I feel like all those daily bedside x-rays I ordered during intern year to check tube placement may have been helpful.

 

[CaesarRO]

I have to say COVID-19 has made peer review look very bad. I trust that this is never published in a reputable journal

Why?

There is no pre-specified hypothesis/sample size statement. Why did they decide to report when they did? No comparator group
Sample size is a joke. No specifics on which inflammatory biomarkers were measured.
Endpoint is a joke. Some of these patients were demented. More co-authors than patients.

Alternative conclusion. **** happens; sometime people get better despite what we do.

Embarassing

I thought I read this was a planned interim analysis, but now I can't find it.

If this is the whole study, that's disappointing. If this is the first step in something bigger, I'm a little more optimistic.

Does anybody know?

And will there be a control arm of any kind? Efficacy is not meaningful at all without a proper comparator

Sent from my SM-G986U1 using Tapatalk

 

[scarbrtj]

I thought I read this was a planned interim analysis, but now I can't find it.

If this is the whole study, that's disapproving. If this is the first step in something bigger, I'm a little more optimistic.

Does anybody know?

And will there be a control arm of any kind? Efficacy is not meaningful at all without a proper comparator

Sent from my SM-G986U1 using Tapatalk

There is an alternative view. I'm not a pulmonologist nor do I want to play one on TV. An MD in the last century... no doubt in between some rounds of relaxing bloodletting and trephination... said this:

“A patient with a high fever, severe dyspnea, and cyanosis is irradiated. A few hours later, often within a period of six hours, he states that he can breathe more easily, and he takes some nourishment. After twelve to twenty-four hours the fever abates, in most cases by crisis, breathing is no longer painful, and dyspnea decreases or disappears entirely. In most of the cases reacting favorably a normal condition is re-established in twenty-four to forty-eight hours. In some cases the fever does not resolve by crisis but falls in two long steps; in some there is a gradual decline to normal. In all these cases the decline of temperature, disappearance of dyspnea, general improvement, and indeed the whole course of the disease appear to have been definitely hastened by irradiation. And as this observation was made consistently, it would seem to be an established fact."

If ~80% of (really old, really sick!) patients on vent are getting un-vented in 36-48h, when do we say we don't need a comparator?

Is this a rebuttal? Invoking Elizabeth Holmes?
Or are you just that clever...comparing the esteemed Emory investigators to the fraud that is Ms Holmes?
It's hard to know.

Sometimes a bad messenger can deliver a good message. There is a real chance we may give up on XRT for COVID due to lack of positive outcomes, logistics, the virus fading into the wastebin of history, etc. Almost a zero percent chance of this having a Holmesian level crash and burn though. Unless someone gets Bezwodian with their data!

 

[Chartreuse Wombat]

There is an alternative view. I'm not a pulmonologist nor do I want to play one on TV. An MD in the last century... no doubt in between some rounds of relaxing bloodletting and trephination... said this:

“A patient with a high fever, severe dyspnea, and cyanosis is irradiated. A few hours later, often within a period of six hours, he states that he can breathe more easily, and he takes some nourishment. After twelve to twenty-four hours the fever abates, in most cases by crisis, breathing is no longer painful, and dyspnea decreases or disappears entirely. In most of the cases reacting favorably a normal condition is re-established in twenty-four to forty-eight hours. In some cases the fever does not resolve by crisis but falls in two long steps; in some there is a gradual decline to normal. In all these cases the decline of temperature, disappearance of dyspnea, general improvement, and indeed the whole course of the disease appear to have been definitely hastened by irradiation. And as this observation was made consistently, it would seem to be an established fact."

If ~80% of (really old, really sick!) patients on vent are getting un-vented in 36-48h, when do we say we don't need a comparator?


Sometimes a bad messenger can deliver a good message. There is a real chance we may give up on XRT for COVID due to lack of positive outcomes, logistics, the virus fading into the wastebin of history, etc. Almost a zero percent chance of this having a Holmesian level crash and burn though. Unless someone gets Bezwodian with their data!

Anecdotal descriptions from a century ago before penicillin may be of interest to some but hardly germane to 21st century medicine.

None of these patients were on ventilators. Read the paper.

"Eligible patients were hospitalized, had radiographic pneumonic infiltrates, required supplemental oxygen, and were clinically deteriorating."

Clinical deterioration is not defined. When the treaters are allowed to determine whether the treatment worked (without providing specific criteria) i am very skeptical.

This is not a guaranteed terminal illness even in older people.

BTW already some examples of scientific misconduct with COVID although not (yet) as bad as the South African fraudster.

https://www.nejm.org/doi/full/10.1056/NEJMe2020822?query=featured_home

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31290-3/fulltext

 

[scarbrtj]

Anecdotal descriptions from a century ago before penicillin may be of interest to some but hardly germane to 21st century medicine.

None of these patients were on ventilators. Read the paper.

"Eligible patients were hospitalized, had radiographic pneumonic infiltrates, required supplemental oxygen, and were clinically deteriorating."

Clinical deterioration is not defined. When the treaters are allowed to determine whether the treatment worked (without providing specific criteria) i am very skeptical.

This is not a guaranteed terminal illness even in older people.

BTW already some examples of scientific misconduct with COVID although not (yet) as bad as the South African fraudster.

https://www.nejm.org/doi/full/10.1056/NEJMe2020822?query=featured_home

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31290-3/fulltext

People do seem to get pretty mad about this XRT for COVID thing. It's like Uncle Buck's hat or something. The Lancet thing was crazy!

Nowadays, almost no woman (none?) gets IV alcohol for pre-term labor. (Debate the sadness of that for a moment.) But it was an established treatment, and it worked. People got worried it may harm the fetus, etc. So it fell out of favor. But any OB could use it today and wouldn't need a trial for it. It seems to have value, has historical precedent, etc. Same thing about aspirin for headache, acupuncture for XRT xerostomia, or a whole host of other medical interventions. We don't have to know how much or how little every medical intervention works in comparison to placebos or other treatments... "There is no need for new studies to evaluate the use of ethanol for preventing preterm birth." It would be nice to know, but we could have easily said this--"don't need a randomized trial"--about XRT for pneumonia. And we can't naysay the clinical outcomes just 'cause they're old IMHO.

It's good we're doing the "trials." I now give more than even money XRT will have a beneficial effect. Willing to take bets. Y'all ever consider the ramifications of getting an indication for XRT for all pneumonias????

 

[deleted774703]

People do seem to get pretty mad about this XRT for COVID thing. It's like Uncle Buck's hat or something. The Lancet thing was crazy!

It's good we're doing the "trials." I now give more than even money XRT will have a beneficial effect. Willing to take bets. Y'all ever consider the ramifications of getting an indication for XRT for all pneumonias????

Yeah, the ramifications would be pharma would end us

We already on the last leg as a field as it so stands lol

Agree with you on why so mad for XRT in COVID? I've brought up my concerns over logistics, but they pulled it off so hats off to Emory/Khan.

It's not like Remdesivir or HCQ encouraging at the moment

Plus we already know whole lung RT is generally safe for Ewing's Sarcoma pts

Granted, for a younger patient with COVID who survives 50 years what will happen is not 100% certain. Though even with young breast cancer pts, we quote <1% for 2nd malignancy right?

 

[scarbrtj]

Plus we already know whole lung RT is generally safe for Ewing's Sarcoma pts

And so much more dose. I remember Rusty Marcus saying 1) they seldom used lung blocks for 2Gy times 6fx for TBI at UF (in kids), and 2) he never saw any pneumonitis or adverse lung issues long-term. And think how many thousands and thousands of lungs/parts of lungs we are directly/scatteredly irradiating needlessly per year for breast cancer e.g. Don't see much clutching the pearls, writing editorials, 'bout that.

 

[cancer_doc]

I have to say COVID-19 has made peer review look very bad. I trust that this is never published in a reputable journal

Why?

There is no pre-specified hypothesis/sample size statement. Why did they decide to report when they did? No comparator group
Sample size is a joke. No specifics on which inflammatory biomarkers were measured.
Endpoint is a joke. Some of these patients were demented. More co-authors than patients.

Alternative conclusion. **** happens; sometime people get better despite what we do.

Embarassing

I find it amusing that some people are trying to score points and make a broad judgement on this therapeutic concept based on early results of 5 patients. The ink to the first sentence of this novel isn't even dry, yet some have neared the completion of this book review with the satisfaction of making sure their witty jabs are expended. Let this story unfold - with more data- there are at least 7 studies around the world enrolling patients on trial, and then make your view heard at that time. But quite frankly, your view (or should I say bias) is already heard.

 

[Palex80]

Two comments:

1. Although it‘s just 5 patients, we can probably say that safety looks good. Those, who put up safety as a major issue, should probably be a bit more quiet now.

2. We can probably understand what that Twitter-hype and „blasphemy“ of the RadOnc resident from Emory was. Treatments were in the end of April. He saw patients doing good and was very euphoric.

Looking forward to more data.

 

[scarbrtj]

Two comments:

1. Although it‘s just 5 patients, we can probably say that safety looks good. Those, who put up safety as a major issue, should probably be a bit more quiet now.

2. We can probably understand what that Twitter-hype and „blasphemy“ of the RadOnc resident from Emory was. Treatments were in the end of April. He saw patients doing good and was very euphoric.

Looking forward to more data.

Point 1:
What in the hell were people on about that low-dose RT to lungs was "unsafe." Yeesh. The NNTs for most of our high dose RTs are in the ~20 range, ie 19/20 RT patients in the clinic are getting unnecessary high dose RT to their various body parts. This is much lower RT dose than that. The safety's gonna look good for years given the main worry was 2nd cancer risk. Oh yeah, some people worried that a hundred or so centigray to the thorax would maybe kill COVID patients (nothin' but love man)
Point 2:
Huh. Prob true, good catch. Although "he" is an attending, not a resident.

Bring on the data.

 

[Neuronix]

I have to say COVID-19 has made peer review look very bad. I trust that this is never published in a reputable journal

If they wanted to publish in the highly reputable "red journal", they should have sent out a survey asking for rad onc's feelings about radiation for covid-19. Once a 5% response rate is achieved, publish away!

 

[Mandelin Rain]

If they wanted to publish in the highly reputable "red journal", they should have sent out a survey asking for rad onc's feelings about radiation for covid-19. Once a 5% response rate is achieved, publish away!

Just got one from NY Proton Center about tele-consults, i.e. tell us how to steal your patients more efficiently. Yeah, umm.... pass.

 

[Mandelin Rain]

I kind of expected these results. Safe. No problems. Of course. Most people got better, relatively quickly, which is more than can be said for a lot of hospitalized and "deteriorating" 90 year old patients. Rock on Khan.

 

[Neuronix]

I've published my own share of pushing the envelope small patient series. So maybe I'm a bit biased here.

These little studies are not all you should publish to make a career, but sometimes you gotta get it out there to silence nay sayers who say it technically can't work or is a bad idea for some "obvious" reason that isn't true.

Then your little series justifies moving forward with larger studies and/or getting funding. You can't have the larger study or the funding without the feasibility data, which has to be published in a peer reviewed journal.

 

[scarbrtj]

I kind of expected these results. Safe. No problems. Of course. Most people got better, relatively quickly, which is more than can be said for a lot of hospitalized and "deteriorating" 90 year old patients. Rock on Khan.

Just grandstanding. But really: try XRT on the lungs in medically deteriorating ~nonagenarians with lung problems and see many getting better rapidly... and rad oncs say "anything could have caused that improvement besides the XRT." Or "I need a comparator to know if XRT is working." Rad oncs would be for Phineas Gage keeping a railroad spike in his skull for fret of removing it wouldn't have any pre-clinical data to back up spike removal, or there are no trials for spike removal to support spike removal, etc. Only in rad onc, folks, as carbonionangle would say.

 

[Neuronix]

Just got one from NY Proton Center about tele-consults, i.e. tell us how to steal your patients more efficiently. Yeah, umm.... pass.

For review? LOL. I've been sent a decent number of papers from several journals that are straight up just advertising attempts in scientific literature.

I reject these articles, but they usually end up getting published in open access somewhere. The standards for peer review in many open access journals are basically zero. Just give us your money, we'll fake peer review, and boom that'll be $3000 please.

This is problematic though, because much like journalism, readers can have a hard time telling the difference between real articles and paid for advertising pieces.

 

[BobbyHeenan]

I've published my own share of pushing the envelope small patient series. So maybe I'm a bit biased here.

These little studies are not all you should publish to make a career, but sometimes you gotta get it out there to silence nay sayers who say it technically can't work or is a bad idea for some "obvious" reason that isn't true.

Then your little series justifies moving forward with larger studies and/or getting funding. You can't have the larger study or the funding without the feasibility data, which has to be published in a peer reviewed journal.

There is utility out there for some of us community docs of these small series too - especially for rare situations when struggling with what to do.

One great thing about rad onc is I've emailed the PI's on some of these case studies to get guidance on cases. I have a 100% response rate within 24 hours from experts all across the field on issues ranging from gamma knife to a brainstem AVM, a complicated peds SBRT case, another complicated abdomen SBRT case, pneumonitis risk/management in ILD, breast re-irradiation, etc. With all the faults of ivory tower academics (esp resident #'s), the willingness to help via email (and the rad onc culture that seems to support this), is why I am so thankful for them.

 

[Mandelin Rain]

For review? LOL. I've been sent a decent number of papers from several journals that are straight up just advertising attempts in scientific literature.

I reject these articles, but they usually end up getting published in open access somewhere. The standards for peer review in many open access journals are basically zero. Just give us your money, we'll fake peer review, and boom that'll be $3000 please.

This is problematic though, because much like journalism, readers can have a hard time telling the difference between real articles and paid for advertising pieces.

No, just to fill out. I'm sure there is no intention to publish anything. It's just a way to remind people that there is a proton facility happy to see your patients via teleconference.

 

[Neuronix]

I know a few proton centers that will treat anything with protons.

Patient has a few weeks to live and this is purely palliative? No problem.

Is there a benefit to protons? No way. But, the patient wants protons, protons are "not worse" than photons, and insurance will pay for it, so protons are given.

Anything is good enough justification as long as the center can get paid (20% medicare co-pay, cash pay, or attempt lengthy series of arguments with insurance).

 

[medgator]

I know a few proton centers that will treat anything with protons.

Patient has a few weeks to live and this is purely palliative? No problem.

Is there a benefit to protons? No way. But, the patient wants it and it's certainly not worse and insurance will pay for it, so we're giving protons.

Anything is good enough justification as long as the center can get paid (20% medicare co-pay, cash pay, or attempt lengthy series of arguments with insurance).

Those debt payments won't service themselves!

 

[thecarbonionangle]

No, just to fill out. I'm sure there is no intention to publish anything. It's just a way to remind people that there is a proton facility happy to see your patients via teleconference.

Chuck Simone is coming for your patients brotha!

 

[evilbooyaa]

Anecdotal descriptions from a century ago before penicillin may be of interest to some but hardly germane to 21st century medicine.

None of these patients were on ventilators. Read the paper.

"Eligible patients were hospitalized, had radiographic pneumonic infiltrates, required supplemental oxygen, and were clinically deteriorating."

Clinical deterioration is not defined. When the treaters are allowed to determine whether the treatment worked (without providing specific criteria) i am very skeptical.

This is not a guaranteed terminal illness even in older people.

BTW already some examples of scientific misconduct with COVID although not (yet) as bad as the South African fraudster.

https://www.nejm.org/doi/full/10.1056/NEJMe2020822?query=featured_home

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31290-3/fulltext

I've reflected a little bit more on this study.

While I agree with you on this, this has at least silenced me from saying "this is not even worthy of looking at" as I was previously saying. I would not start using this on every COVID-19 nonagerian that's circling the drain but not intubated, but if academic places want to continue evaluating this, and keep their conclusions in check and don't editorialize the data (which is asking a lot of the authors as well as the twitterati that over-reacts to any study results), then I'm now on board with them.

 

[Chartreuse Wombat]

I've reflected a little bit more on this study.

While I agree with you on this, this has at least silenced me from saying "this is not even worthy of looking at" as I was previously saying. I would not start using this on every COVID-19 nonagerian that's circling the drain but not intubated, but if academic places want to continue evaluating this, and keep their conclusions in check and don't editorialize the data (which is asking a lot of the authors as well as the twitterati that over-reacts to any study results), then I'm now on board with them.

I am not opposed to investigating the effects of LD-RT on COVID19. My point was that the data provided in the manuscript was insufficient to draw any conclusions.

 

[Mandelin Rain]

I drew a conclusion that it didn't kill people instantly and that more people improved, and more quickly than I'd expect given the population. Gotta start somewhere. I'd say those results were as encouraging as one could hope for.