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Chartreuse Wombat

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From the agenda of an upcoming Varian Particle Users meeting

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We will train you alright.
Members don't see this ad.
 
From personal experience, PT at HUP is a reasonable program.
 
Members don't see this ad :)
Guys, you're channeling your second-hand experience with second-generation "for-profit" proton centers. HUP PT is mandated to treat at least a fixed proportion of pediatric patients and they actually know how to do it. If I were to learn how to treat protons, I'd call them.
 
I'm not saying all proton centers are the devil. But the ones that are looking to do it for marketing rather than true need are. I'm not aware of Penn's practices, but I'm sure they're fine.

But then there's this: Proton Therapy | Penn Medicine

From that website: "
Proton therapy is external beam radiotherapy that works by aiming energized particles – in this case, protons – onto the target tumor. Because of the accuracy of the beam, proton therapy delivers a higher dose of treatment directly to the tumor, while sparing healthy tissue, which can lead to benefits such as:

  • Improved outcomes, and fewer side effects
  • The ability to treat cancerous tumors close to critical organs
  • A greater quality of life during treatment
  • The ability to offer new treatment options for patients whose cancer has recurred
Proton therapy is used to treat a variety of tumors, and at Penn, we are constantly working to expand the list of conditions treated with protons. Download the Penn Medicine Proton Therapy Guide to learn more about the cancers we treat."

Bolded #1 - Citation needed.
Bolded #2 - Well yeah: I'm sure we really need studies like this for those poor patients on which photons is just peasant-quality.
APBI Proton Feasibility and Phase II Study - Full Text View - ClinicalTrials.gov - Early stage breast
Mild Hypofractionation With Proton Therapy or Intensity Modulated Radiation Therapy (IMRT) for Intermediate-Risk Prostate Cancer - Full Text View - ClinicalTrials.gov - Protons for prostate
Proton Therapy for High Risk Prostate Cancer - Full Text View - ClinicalTrials.gov - Protons for prostate pt 2
Proton Radiotherapy for Extremity Soft Tissue Sarcoma - Full Text View - ClinicalTrials.gov - Extremity Sarcoma

However, I'll give them some credit, that some of their stuff is actually going to be useful for clinical practice:
Proton Radiation for Chordomas and Chondrosarcomas - Full Text View - ClinicalTrials.gov
Proton Radiotherapy for Recurrent Tumors - Full Text View - ClinicalTrials.gov
 
I am continually amazed at what radiation oncology advertising can get away with versus that of drug advertising. The old cyberknife ads on the radio for prostate cancer about ten to fifteen years ago in NY were ridiculous.

Now the proton advertising I see is crazy too. Promises of less side effects and improved outcomes in the face of a no phase III data for prostate and a negative phase III lung study.

Partial breast protons is such a load of crap IMO. You can get very good brachy, 3D or IMRT plans (esp with DIBH) and I can't even imagine the number needed to treat with protons to prevent an event (hundreds I'd imagine?). Heck, we've got a very simple way to give DIBH UK import low "partial breast" mini tangents that seems to work well...yet we've got the ivory tower here doing phase II trials that will do nothing but increase usage of off study partial breast protons for APBI at for profit centers for what clinical benefit?
 
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seper said:
Guys, you're channeling your second-hand experience with second-generation "for-profit" proton centers. HUP PT is mandated to treat at least a fixed proportion of pediatric patients and they actually know how to do it. If I were to learn how to treat protons, I'd call them.
Click to expand...
OK care to state publicly what that fixed portion is? A charitable way to view this money-making enterprise is that the men with prostate cancer (most of whom need no treatment) are allowing the children to be treated; fair enough. The advertising is completely over the top.
 
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In general, I think one of the issues is that we know protons are unequivocally better for a handful of indications. Significantly better. The challenge is that the number of patients with those indications is not enough to recoup the cost of the machine. So, I don't think it is necessarily wrong to explore in clinical trials whether there might be additional indications for which there is a significant toxicity advantage in using protons versus conventional.

I think as cancer therapies get better and better, we are going to find ourselves in an increasing number of re-treatment scenarios, and we will find more and more situations where protons are advantageous.

I've seen many H&N patients with late local recurrences or new H&N primaries in or near field of previous treatment which would have had definite advantages being treated with protons.

Do we need four gantry centers capable of treating 1000 people per year outside megalopolises? No, probably not, but I think we do need a better geographic distribution of proton centers.
 
emt409 said:
In general, I think one of the issues is that we know protons are unequivocally better for a handful of indications. Significantly better. The challenge is that the number of patients with those indications is not enough to recoup the cost of the machine. So, I don't think it is necessarily wrong to explore in clinical trials whether there might be additional indications for which there is a significant toxicity advantage in using protons versus conventional.

Do we need four gantry centers capable of treating 1000 people per year outside megalopolises? No, probably not, but I think we do need a better geographic distribution of proton centers.
Click to expand...

What's wrong with the current distribution until we get pricing in the ballpark of $5-10 million for a single gantry machine?

We already have more proton centers than is probably ethically needed to treat the number of patients who would actually benefit from protons
 
emt409 said:
I've seen many H&N patients with late local recurrences or new H&N primaries in or near field of previous treatment which would have had definite advantages being treated with protons.
Click to expand...
There's an idea. The proton centers will start advertising for the multiply recurrent cases and forget about the prostate cases. That's the ticket!
 
Members don't see this ad :)
medgator said:
What's wrong with the current distribution until we get pricing in the ballpark of $5-10 million for a single gantry machine?

We already have more proton centers than is probably ethically needed to treat the number of patients who would actually benefit from protons
Click to expand...

Patients often cannot travel the distances required to get to a proton facility, and stay there for several weeks of treatment.
 
emt409 said:
Dude, go have a beer or something. Your hostility and inability to engage in reasonable discourse is harshing everyone's mellow.
Click to expand...
No need to get defensive. If you regard that obvious sarcasm as hostility then you have lived a charmed life. Reasonable discourse? Happy to have a reasonable conversation but the proton people are the ones making the claims. In my book if you make a claim of superiority the burden is on you to prove it. Show me level I evidence supporting the advertising claims of the protonists listed above. This thread started by highlighting a panel that is to focus on training people to support the growth of proton therapy. It strikes me that we have enough growth already.
We are falling prey to the idea that more dose and better dose delivery will improve survival and using prostate cancer as the example; that is not a reasonable argument.
 
Show me the level 1 evidence that MOC/ABR Unwanted Assault Program improves patient outcomes. If you want to claim that the existence of this organization and it’s burdensome oversight improves patient care, the burden is on you to prove it.

It strikes me that we have enough oversight already.

We are falling prey to the idea that more testing will improve patient care and quality, when perhaps the burden should fall upon academic physicians to actually teach residents to be excellent physicians rather than to be their personal attendants.

More invasive and expensive testing to improve physician quality; that is not a reasonable argument.

Chartreuse Wombat said:
No need to get defensive. If you regard that obvious sarcasm as hostility then you have lived a charmed life. Reasonable discourse? Happy to have a reasonable conversation but the proton people are the ones making the claims. In my book if you make a claim of superiority the burden is on you to prove it. Show me level I evidence supporting the advertising claims of the protonists listed above. This thread started by highlighting a panel that is to focus on training people to support the growth of proton therapy. It strikes me that we have enough growth already.
We are falling prey to the idea that more dose and better dose delivery will improve survival and using prostate cancer as the example; that is not a reasonable argument.
Click to expand...
 
MDACCRules said:
Show me the level 1 evidence that MOC/ABR Unwanted Assault Program improves patient outcomes. If you want to claim that the existence of this organization and it’s burdensome oversight improves patient care, the burden is on you to prove it.

It strikes me that we have enough oversight already.

We are falling prey to the idea that more testing will improve patient care and quality, when perhaps the burden should fall upon academic physicians to actually teach residents to be excellent physicians rather than to be their personal attendants.

More invasive and expensive testing to improve physician quality; that is not a reasonable argument.
Click to expand...
Touche. Point given. Not sure if there are rules about cross posting threads.

There is some evidence that board certification is associated with improved outcomes. The Boards throw the references around but I don't think the evidence is good and certainly not dispositive. If you want to spend the time you can look at the papers from the ABR lately.

I am a pragmatist. If you want to take down the ABR and all of the other boards, have at it. I doubt it is possible and I don't care to spend time trying to get rid of it. I try to work within to improve the product. I stand by the statement that changing the requirements for Part IV (no need for QI project, etc) is a good thing.

I also worry about what would replace the ABR. Arbitrary dictates of politicians are likely to worse than those created by medical professionals. Of course I don't know.

I do think that the attempt to conflate the two subjects, however, is a mistake. If you follow that path then why should we require people to graduate from residencies; where is the evidence that 4 years is enough? What about 3 years? I think it is probably wise to require that doctors "prove" that they know what they are doing, especially those who completed training in the years before 3D.
 
What about people grandfathered in? We don’t seem to want to know if they were competent? Isn’t that wise? Why don’t the people that are in charge care about that?

Chartreuse Wombat said:
Touche. Point given. Not sure if there are rules about cross posting threads.

There is some evidence that board certification is associated with improved outcomes. The Boards throw the references around but I don't think the evidence is good and certainly not dispositive. If you want to spend the time you can look at the papers from the ABR lately.

I am a pragmatist. If you want to take down the ABR and all of the other boards, have at it. I doubt it is possible and I don't care to spend time trying to get rid of it. I try to work within to improve the product. I stand by the statement that changing the requirements for Part IV (no need for QI project, etc) is a good thing.

I also worry about what would replace the ABR. Arbitrary dictates of politicians are likely to worse than those created by medical professionals. Of course I don't know.

I do think that the attempt to conflate the two subjects, however, is a mistake. If you follow that path then why should we require people to graduate from residencies; where is the evidence that 4 years is enough? What about 3 years? I think it is probably wise to require that doctors "prove" that they know what they are doing, especially those who completed training in the years before 3D.
Click to expand...
 
Chartreuse Wombat said:
; where is the evidence that 4 years is enough? What about 3 years? I think it is probably wise to require that doctors "prove" that they know what they are doing, especially those who completed training in the years before 3D.
Click to expand...

Wasn't the extra year added around the time the job market woes came about in the early 90s?
 
I'm not in charge to be sure but I do care about that. The legal reality is that the grandfathered people were given a time unlimited certificate and there was no legal means to force them to enroll in MOC. I voluntarily entered MOC (one of the few grandfathered who did); most of my colleagues thought it was a bad idea. Again I wanted to be able to experience it and (when it was clear that the first iteration was onerous) tried to shape the process from within. To repeat I have no leadership position but I have volunteered to improve the system and will continue to do so. In fact I will be working with many others to develop the Part III (Cognitive Test) piece. No more tests every ten years. Instead periodic quick assessments. Should be rolled out in 2019 or 2020.
Info at link
ABR
 
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Chartreuse Wombat said:
I'm not in charge to be sure but I do care about that. The legal reality is that the grandfathered people were given a time unlimited certificate and there was no legal means to force them to enroll in MOC. I voluntarily entered MOC (one of the few grandfathered who did); most of my colleagues thought it was a bad idea. Again I wanted to be able to experience it and (when it was clear that the first iteration was onerous) tried to shape the process from within. To repeat I have no leadership position but I have volunteered to improve the system and will continue to do so. In fact I will be working with many others to develop the Part III (Cognitive Test) piece. No more tests every ten years. Instead periodic quick assessments. Should be rolled out in 2019 or 2020.
Info at link
ABR
Click to expand...

What legal reality? If the voters vote for everyone to be able to pass to gain certification then that’s the law of the land?
 
MDACCRules said:
What legal reality? If the voters vote for everyone to be able to pass to gain certification then that’s the law of the land?
Click to expand...
I am not a lawyer; are you? You are the one that wants to tear the whole thing down.
 
Guys. I get MDACCRules post in response to Chartreuse's, as did Chartreuse. Please take further discussion of ABR back to the ABR thread. Let's not have every thread end up in a mangled mess of stuff for which we can't keep our focus longer than a 7-year old ADHD'er who just sold off his last bit of Adderall.
 
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I know for a fact MULTIPLE institutions have buried/killed/pidgeholed data comparing their protons vs IMRT data for MULTIPLE sites showing WORST outcomes for protons. None of these places are "reasonable".
 
BobbyHeenan said:
I am continually amazed at what radiation oncology advertising can get away with versus that of drug advertising. The old cyberknife ads on the radio for prostate cancer about ten to fifteen years ago in NY were ridiculous.

Now the proton advertising I see is crazy too. Promises of less side effects and improved outcomes in the face of a no phase III data for prostate and a negative phase III lung study.

Partial breast protons is such a load of crap IMO. You can get very good brachy, 3D or IMRT plans (esp with DIBH) and I can't even imagine the number needed to treat with protons to prevent an event (hundreds I'd imagine?). Heck, we've got a very simple way to give DIBH UK import low "partial breast" mini tangents that seems to work well...yet we've got the ivory tower here doing phase II trials that will do nothing but increase usage of off study partial breast protons for APBI at for profit centers for what clinical benefit?
Click to expand...

Who doesn't love a good Ben Smith APBI proton plan
 
emt409 said:
Patients often cannot travel the distances required to get to a proton facility, and stay there for several weeks of treatment.
Click to expand...
I get it, but until costs become more reasonable, that is probably exactly what needs to happen.

Or we will continue to see the shenanigans we have read about in this thread and the hypocrisy of some of those in academics who call out the bad actors in PP for overuse of imrt/prolonged fractionation, while blessing overpaid and overused proton therapy (which is no more effective for things like prostate, lung, breast etc, and costs the system significantly more per pt than 40/20 imrt to a bone met).
 
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emt409 said:
In general, I think one of the issues is that we know protons are unequivocally better for a handful of indications. Significantly better. The challenge is that the number of patients with those indications is not enough to recoup the cost of the machine. So, I don't think it is necessarily wrong to explore in clinical trials whether there might be additional indications for which there is a significant toxicity advantage in using protons versus conventional.

....
Click to expand...

I largely agree with you here. My frustration is with off study treatment of R sided breast cancer, GBM, partial breast, anal cancer, and lung cancer. It is very labor and cost intensive to put everything on a trial - I get that - but it's also very costly to the system to just try to treat everything with protons because of a slight nominal DVH improvement.

Prostate is a whole other matter. I really hope we get phase III toxicity data. We don't need to wait on efficacy IMO because it'll be similar I bet. I'd imagine with the ascende-RT brachy boost data the prostate patient numbers may slightly decline (surely you can't get proton for 5 weeks then brachy boost right? who knows?), so that may pinch budgets even tighter.

But if the standard is "significant toxicity advantage" then I think we can put breast APBI off that list for running a trial.

I think comprehensive nodal treatment of L sided breast/chest wall/nodes is very reasonable on study (or even off study I don't get too worked up about) and the PCORI trial is looking at that in a pragmatic randomized fashion (though I believe they do allow R sided on there too).

There's probably a good head and neck trial out there too - I just don't know if one off the top of my head.
 
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Do we really think protons is going to provide better toxicity numbers than IMRT already can for prostate?

Based off how much proton is being marketed (and how busy places are) if these proton centers were actually showing CLINICAL improvements in acute toxicity (it literally takes like 3 months tops per patient), that it wouldn't be plastered all over every JCO and IJROBP in the world?

Of course, I pubmed and find this at the top of the list (in JCO no less): Comparative Toxicities and Cost of Intensity-Modulated Radiotherapy, Proton Radiation, and Stereotactic Body Radiotherapy Among Younger Men With Pr... - PubMed - NCBI
Improved bladder, but worse rectal toxicity with protons. Double the cost of IMRT. Toxicity evaluation is kind of sketchy and likely not the cleanest eval, but it's something.
 
these others have been mentioned here too ...

Sheets NC et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA. 2012 Apr 18;307(15):1611-20.

Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. - PubMed - NCBI

This paper has been discussed plenty. The editorials on this paper discuss some major limitations of this study - but still not a strong argument for protons.

2 others are ...

Yu et al. Proton Versus Intensity-Modulated Radiotherapy for Prostate Cancer: Patterns of Care and Early Toxicity. J Natl Cancer Inst. 2013 Jan 2;105(1):25-32

Proton versus intensity-modulated radiotherapy for prostate cancer: patterns of care and early toxicity. - PubMed - NCBI


Fang P et al. A case-matched study of toxicity outcomes after proton therapy and intensity-modulated radiation therapy for prostate cancer. Cancer. 2015 Apr 1;121(7):1118-27.

A case-matched study of toxicity outcomes after proton therapy and intensity-modulated radiation therapy for prostate cancer. - PubMed - NCBI
 
With those studies as above, I don't get then why insurance would pay so much for a treatment with no defined improvement in side effects/efficacy? I understand paying for it if they're on a phase III trial, but off study treatment I just don't get it with all the cost cutting going on.

Maybe it's because the patients get put on "registry trials" - which IMHO for prostate add little if any to any scientific body of evidence at this point.
 
I don’t work at Upenn, but I think 30% of gantry time is pediatric. Those who do, please corect me. It is due to CHOP HemOnc having a stake.
 
BobbyHeenan said:
With those studies as above, I don't get then why insurance would pay so much for a treatment with no defined improvement in side effects/efficacy? I understand paying for it if they're on a phase III trial, but off study treatment I just don't get it with all the cost cutting going on.

Maybe it's because the patients get put on "registry trials" - which IMHO for prostate add little if any to any scientific body of evidence at this point.
Click to expand...
In some markets (Cali I have heard of for sure), private insurance companies won't pay for protons for prostate CA

Medscape: Medscape Access

Prostate-Cancer Therapy Comes Under Attack

Insurers doing what feds haven’t in refusing to pay for proton beam therapy
 
@radiaterMike You just quoted me a bunch of essentially negative (or even in favor of IMRT) studies from 3ish years ago. I guarantee you Penn is still doing protons for prostate even though their own published data says it doesn't provide benefit. This is the indoctrination those of us without proton centers have to deal with.

I'm saying if there were POSITIVE studies saying proton is better, we'd see them very well publicized and on the front page of every proton institution.
 
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Regardless of the available data and all other things being equal, I would love to see a survey of rad oncs regarding what they would personally choose for themselves for prostate RT - protons or imrt. I know what my answer would be.
 
kristofer said:
Regardless of the available data and all other things being equal, I would love to see a survey of rad oncs regarding what they would personally choose for themselves for prostate RT - protons or imrt. I know what my answer would be.
Click to expand...

Brachytherapy? ;)
 
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kristofer said:
Regardless of the available data and all other things being equal, I would love to see a survey of rad oncs regarding what they would personally choose for themselves for prostate RT - protons or imrt. I know what my answer would be.
Click to expand...
Active surveillance?
 
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HUP has a great faculty, some of the best I know in this field, but once you get Protons, you are joining the medical/industrial complex (ironically, Eli Glatstein, coined this concept for radiation- one of the few things he was right about) Obviously, after that kind of investment, you are going to advertise heavily, and I believe they have plans to open a second proton center in southern NJ. I recently had a patient who traveled 2000 miles from here to Penn to get a meningioma treated with protons. I was mildly irritated that they didnt send her back to be treated close to home, but I am not sure that kind of chivalry exists anymore.
 
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@evilbooyaa -- yes I agree. I just wanted to emphasize that there are several studies (albeit not level 1 evidence) that suggest no benefit to PBT for prostate ca.

On a related note - UMD has contracted with local insurers to bill PBT at the same rate is IMRT. Perhaps if others were doing this, there would be less controversy (and perhaps more willingness to complete more RCTs since both arms would reimburse the same). UMD still has issues with out-of-network patients trying to get PBT for prostate cancer though.
 
kristofer said:
Regardless of the available data and all other things being equal, I would love to see a survey of rad oncs regarding what they would personally choose for themselves for prostate RT - protons or imrt. I know what my answer would be.
Click to expand...

Neuronix said:
Brachytherapy? ;)
Click to expand...

Chartreuse Wombat said:
Active surveillance?
Click to expand...

:laugh:

I've spoken to a high-volume robotic surgeon at a tertiary care center (1000+ RPs he's done) who just does prostate and does a fair amount of salvage in his practice. He says proton salvages are by far the hardest surgeries that he does with the most scar tissue/fibrosis to deal with (worse than imrt, cryo, hifu etc). I know my answer would put protons last for patients, family or myself.
 
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radiaterMike said:
@evilbooyaa -- yes I agree. I just wanted to emphasize that there are several studies (albeit not level 1 evidence) that suggest no benefit to PBT for prostate ca.

On a related note - UMD has contracted with local insurers to bill PBT at the same rate is IMRT. Perhaps if others were doing this, there would be less controversy (and perhaps more willingness to complete more RCTs since both arms would reimburse the same). UMD still has issues with out-of-network patients trying to get PBT for prostate cancer though.
Click to expand...
A lot of centers are doing this including HUP/mayo clinic. The issue is that IMRT rates at these centers are astronomically high! It is bit of a gimmick like a registry trial to see if protons improve the cosmesis when used as a breast boost. (I could swear that was a trial at uf or somewhere else 5 to 10 years ago)
 
thecarbonionangle said:
I know for a fact MULTIPLE institutions have buried/killed/pidgeholed data comparing their protons vs IMRT data for MULTIPLE sites showing WORST outcomes for protons. None of these places are "reasonable".
Click to expand...

Yup. I am also personally aware of some scary data that was buried...
 
Neuronix said:
Brachytherapy? ;)
Click to expand...

For low and lower to moderate intermediate risk, yes totally agree. For high risk, IMPT with spacer all the way. Most importantly keep that knife away from me.
 
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