Wanted: a large underutilized vault to convert to proton therapy

[IonsAreOurFuture]

I figure somebody in the era of hypofractionation has a vault sitting empty or treating <1/2 time.

If Flint, MI can convert a big room into a 2 room proton vault, why not me?

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[Fpg1245]

I figure somebody in the era of hypofractionation has a vault sitting empty or treating <1/2 time.

If Flint, MI can convert a big room into a 2 room proton vault, why not me?

We don’t hypo and yet we still have a spare vault

 

[deleted1111261]

Upright ! Anyone have any pictures of how this looks?

 

[Palex80]

We don’t hypo and yet we still have a spare vault

Go BID!

Prostate 80 x 1 Gy BID. Probably better Grade 2 urinary toxicity than in the MIRAGE trial.
(s***storm inbound)

 

[sirspamalot]

Upright ! Anyone have any pictures of how this looks?

 

[Fpg1245]

Upright?

 

[TheWallnerus]

 

[OTN]

I figure somebody in the era of hypofractionation has a vault sitting empty or treating <1/2 time.

If Flint, MI can convert a big room into a 2 room proton vault, why not me?

Sure, come on into our city, grab one of our vaults, and poach our patients by lying about supposed benefits to an unproven treatment which current data shows is both more expensive and more toxic.

 

[sirspamalot]

Sure, come on into our city, grab one of our vaults, and poach our patients by lying about supposed benefits to an unproven treatment which current data shows is both more expensive and more toxic.

This is the way.

 

[radoncftw]

Sure, come on into our city, grab one of our vaults, and poach our patients by lying about supposed benefits to an unproven treatment which current data shows is both more expensive and more toxic.

but they crossed out cancer!

 

[Fpg1245]

but they crossed out cancer!

There was a hospital owned cancer center affiliated with MDA that ended up closing. That crossed out cancer took on a whole new meaning.

 

[IonsAreOurFuture]

Sure, come on into our city, grab one of our vaults, and poach our patients by lying about supposed benefits to an unproven treatment which current data shows is both more expensive and more toxic.

Were you referring to this current data from Baumann, et al, in 2020 JAMA Oncology, which shows that proton therapy is associated with a lower rate of grade 2 and grade 3 toxicity, and lower 90-day hospitalization rates among patients receiving concurrent chemo-RT?

Despite the proton patients being on average 5 years older (66 vs 61 yrs) and having worse baseline comorbidity scores, proton patients were significantly less likely to end up with an unplanned hospitalization, which is a grade 3 toxicity by definition - and also quite expensive.

 

[BobbyHeenan]

Were you referring to this current data from Baumann, et al, in 2020 JAMA Oncology, which shows that proton therapy is associated with a lower rate of grade 2 and grade 3 toxicity, and lower 90-day hospitalization rates among patients receiving concurrent chemo-RT?

Despite the proton patients being on average 5 years older (66 vs 61 yrs) and having worse baseline comorbidity scores, proton patients were significantly less likely to end up with an unplanned hospitalization, which is a grade 3 toxicity by definition - and also quite expensive.

There is no variable that can account for the ability to get off plane with your family to seek destination proton care and/or have cadillac insurance or a bank account that covers protons. That protoplasm hits different.

This study may be correct but I'm awaiting the randomized data.

I have personal first hand experience - the waiting room clientele between the photon clinic and the proton clinic look A LOT different.

 

[TheWallnerus]

There is no variable that can account for the ability to get off plane with your family to seek destination proton care and/or have cadillac insurance or a bank account that covers protons. That protoplasm hits different.

This study may be correct but I'm awaiting the randomized data.

I have personal first hand experience - the waiting room clientele between the photon clinic and the proton clinic look A LOT different.

One of the main drawbacks of any “randomized” proton trial will always be: the institutions will afaik only be randomizing insured patients. And we know insuredness correlates with health outcomes. Confounding.

 

[Chartreuse Wombat]

The one thing we know about PBT is that patients that receive it are NOT REPRESENTATIVE.

In fact by some criteria PBT is racist

Association of Race With Receipt of Proton Beam Therapy for Patients With Newly Diagnosed Cancer in the US, 2004-2018 - PubMed

In this cross-sectional study, Black patients were less likely to receive PBT than their White counterparts, and disparities were greatest for cancers for which PBT was the recommended radiation therapy modality. These findings suggest that efforts other than increasing the number of facilities...

pubmed.ncbi.nlm.nih.gov

 

[OTN]

Were you referring to this current data from Baumann, et al, in 2020 JAMA Oncology, which shows that proton therapy is associated with a lower rate of grade 2 and grade 3 toxicity, and lower 90-day hospitalization rates among patients receiving concurrent chemo-RT?

Despite the proton patients being on average 5 years older (66 vs 61 yrs) and having worse baseline comorbidity scores, proton patients were significantly less likely to end up with an unplanned hospitalization, which is a grade 3 toxicity by definition - and also quite expensive.

Yep, I'm referring to the fact that the only data you could come up with is garbage

 

[NotMattSpraker]

Were you referring to this current data from Baumann, et al, in 2020 JAMA Oncology, which shows that proton therapy is associated with a lower rate of grade 2 and grade 3 toxicity, and lower 90-day hospitalization rates among patients receiving concurrent chemo-RT?

Despite the proton patients being on average 5 years older (66 vs 61 yrs) and having worse baseline comorbidity scores, proton patients were significantly less likely to end up with an unplanned hospitalization, which is a grade 3 toxicity by definition - and also quite expensive.

On oral boards, they should ask people "do you believe this study?" and if they say yes, they should fail.

I'm still a believer in protons for some patients, but this study is ridiculous.

You might also go re-assess the baseline characteristics table and re-evaluate your last statement there.

 

[sirspamalot]

proton sales rep has entered the chat

 

[radoncftw]

There is major cognitive dissonance amongst academicians.
In residency, everyone made a big deal about ph3 randomized data. "We won't do prostate SBRT or hypofrac breast until we have long-term ph3 data...hmm UK fast forward only has 5 yr data, we need 10 yr data"
With protons...I guess that all just goes out the window?
Upton sinclair quote would be applicable.

 

[Fpg1245]

There is major cognitive dissonance amongst academicians.
In residency, everyone made a big deal about ph3 randomized data. "We won't do prostate SBRT or hypofrac breast until we have long-term ph3 data...hmm UK fast forward only has 5 yr data, we need 10 yr data"
With protons...I guess that all just goes out the window?
Upton sinclair quote would be applicable.

This is part of the reason why I don’t feel the need to follow how they practice and why I will always hate pathways.

 

[Gfunk6]

It is a recurring and inescapable theme in Rad Onc that our field is driven by marketing of new technology. Nobody really believes in protons, MRI-guidance, CK, Reflexion, or whatever until they buy one. Then it's the bee's knees and doing any other form of radiation is basically malpractice.

I do it, you do it, everyone does it.

 

[OTN]

It is a recurring and inescapable theme in Rad Onc that our field is driven by marketing of new technology. Nobody really believes in protons, MRI-guidance, CK, Reflexion, or whatever until they buy one. Then it's the bee's knees and doing any other form of radiation is basically malpractice.

I do it, you do it, everyone does it.

It is a recurrent and inescapable theme in academic Rad Onc that our field is driven by marketing of new technology. The rest of us who actually have to pay for the machines without massively inflated payments have to do it old-school: waiting for data to actually see if the new technology benefits (or, in the case of protons) harms patients.

For example, Reflexion has tried very, very hard to get us to purchase one of their machines for a long time. Until someone tells me how it's any different than PET/CT fusion to a standard CT sim, no chance we're buying it. For MgRT, until someone generates good data, no chance we're spending $8 million for a machine with no proven benefit.

 

[NotMattSpraker]

For example, Reflexion has tried very, very hard to get us to purchase one of their machines for a long time. Until someone tells me how it's any different than PET/CT fusion to a standard CT sim, no chance we're buying it.

I see so many ads for this machine, what is the point? They do a really bad job of explaining why I should care about it.

Biology-guided radiotherapy doesnt even mean anything haha.

 

[temujim]

It is a recurrent and inescapable theme in academic Rad Onc that our field is driven by marketing of new technology. The rest of us who actually have to pay for the machines without massively inflated payments have to do it old-school: waiting for data to actually see if the new technology benefits (or, in the case of protons) harms patients.

For example, Reflexion has tried very, very hard to get us to purchase one of their machines for a long time. Until someone tells me how it's any different than PET/CT fusion to a standard CT sim, no chance we're buying it. For MgRT, until someone generates good data, no chance we're spending $8 million for a machine with no proven benefit.

It was different back in the day... pvt practice was the first in for CT sims, IMRT implementation, etc... recall many an academic center swallowing their pride to ask for help from pvt practice physics and docs...

 

[sirspamalot]

And if there's no code to pay for the shiny new overpriced object, only academia (who gets it under the table) will support it (to write papers, to foster careers).

The whole thing is just a sham really, but it sure is fun.

 

[Gfunk6]

I've gotten a Reflexion factory tour (it is local to my practice) and been through multiple presentations. I think the machine is great - a great feat of engineering really. Like others, I question the clinical utility. Will treating x20 mets at the same time really improve outcomes? Isn't the cancer a systemic disease at that point?

I do know that Reflexion is supposedly close to getting unique codes approved by CMS which would massively increase its appeal due to ability to bill way more than regular SBRT.

 

[sirspamalot]

I do know that Reflexion is supposedly close to getting unique codes approved by CMS which would massively increase its appeal due to ability to rapidly recoup costs.

There it is. And when they do, the sales pitch fervor will reach orgasmic levels.

 

[Gfunk6]

There it is. And when they do, the sales pitch fervor will reach orgasmic levels.

Of note Reflexion did get a "unique device" designation with CMS or something like that. MRI-guided linacs tried to get it and failed.

 

[NotMattSpraker]

I've gotten a Reflexion factory tour (it is local to my practice) and been through multiple presentations. I think the machine is great - a great feat of engineering really. Like others, I question the clinical utility. Will treating x20 mets at the same time really improve outcomes? Isn't the cancer a systemic disease at that point?

I do know that Reflexion is supposedly close to getting unique codes approved by CMS which would massively increase its appeal due to ability to bill way more than regular SBRT.

I guess I need to understand how PET helps as an onboard image because getting a diagnostic PET and fusing it is an option for target definition.

Whether you think the MR Linac is clinically exciting or not, its very easy to understand how the technology offers unique onboard imaging that you can't otherwise get.

Whether you think protons are clinically exciting or not, you can look at a dosimetry plan and understand there is a theoretical difference.

PET seems like a bad choice for on board imaging, it is slow and has poor resolution. I still dont get it.

 

[OTN]

I guess I need to understand how PET helps as an onboard image because getting a diagnostic PET and fusing it is an option for target definition.

Whether you think the MR Linac is clinically exciting or not, its very easy to understand how the technology offers unique onboard imaging that you can't otherwise get.

Whether you think protons are clinically exciting or not, you can look at a dosimetry plan and understand there is a theoretical difference.

PET seems like a bad choice for on board imaging, it is slow and has poor resolution. I still dont get it.

I truly don't think there's anything to get. I think it's a tremendous sham, and I am appalled there is going to be a CPT code for it. I have talked with physicists, representatives from the company itself, etc, etc. NO ONE can tell me the advantages it offers over PET/CT fusion to traditional sim, because there aren't any.

 

[temujim]

I've gotten a Reflexion factory tour (it is local to my practice) and been through multiple presentations. I think the machine is great - a great feat of engineering really. Like others, I question the clinical utility. Will treating x20 mets at the same time really improve outcomes? Isn't the cancer a systemic disease at that point?

I do know that Reflexion is supposedly close to getting unique codes approved by CMS which would massively increase its appeal due to ability to bill way more than regular SBRT.

Whether it works or not, applaud Reflexion for trying to expand indications and payments for radiation oncology. They're out there (saying at least) they'll put money behind trials to develop the evidence.

 

[OTN]

Whether it works or not, applaud Reflexion for trying to expand indications and payments for radiation oncology. They're out there (saying at least) they'll put money behind trials to develop the evidence.

I'm not going to applaud them until someone can tell me how Reflexion is not a scam. Until then, it is a waste of everyone's time, energy, and effort and reflects poorly on our specialty. The investigation of SBRT for oligometastatic disease is too important of a topic to be abdicated to industry. The recent MR-guided SBRT vs CT-guided SBRT prostate trial demonstrates that investigators will not hesitate to put their thumb on the scales to tip the balance in favor of their particular machine or treatment modality, and I expect nothing less from Reflexion.

 

[BobbyHeenan]

Their reps came and talked to our hospital system too. I had the same thoughts - ?why not just fuse the PET?

I guess if SABR-COMET10 is positive, then I'll pay attention.

I like the hustle, but I just don't get it. IF they get some super reimbursement code it'll be something else.

 

[FindMeOnTheLinks]

Reflexion gave a pitch at my institution but I don’t think anyone bought it, least of all the physicists.

The 3 main angles they’re trying to sell:
1. Real time tracking of the PET tracer for motion management. (Seems like a way worse version of MR linac given poor spatial resolution and specificity of PET)

2. “Biologically guided” RT to adapt dose based on PET response. (Again seems far fetched based on poor resolution and specificity of PET and lack of data for modulation of dose based on PET and how wonky the tracer signal can be depending on a myriad of factors unrelated to cancer).

3. Workflow capability to sim and treat in same session, as many sites as you want. (I’ll believe it when I see it- the PET workflow is really not conducive to how a RadOnc shop runs)

It seems very gimmicky and just a worse version of an MRI linac. Only reason it will be used is because there will be a special CPT code (cha-ching) and junior faculty can design ****ty single arm trials to add to their resume

 

[medgator]

it. For MgRT, until someone generates good data, no chance we're spending $8 million for a machine with no proven benefit.

All that non-profit "profit" and foundation/endowment "charity" $$$ has to go chase something... Protons, MgRT, reflexion etc. The only place it can't go is to helping actual patients get care

 

[seper]

I saw their sales pitch at my university too.
I think that oligometastatic RT concept is out of favor with insurers. Even if the company gets new CPT codes, it will be an uphill battle to get them added to the insurance policies.
Hard pass.

 

[taserlaser]

We are installing MR-Ls. It will take a few years before we can treat anything other than prostate on them. We have a star researcher who has time and energy for upper GI projects, but no therapist or physics resources to help implement. What a waste. When I point this out, all I get from my chair is that this is an investment, and even if low volume, drives donations, publicity, etc. 😑

 

[sirspamalot]

Grifters gonna grift. Its what they do.

 

[evilbooyaa]

Were you referring to this current data from Baumann, et al, in 2020 JAMA Oncology, which shows that proton therapy is associated with a lower rate of grade 2 and grade 3 toxicity, and lower 90-day hospitalization rates among patients receiving concurrent chemo-RT?

Despite the proton patients being on average 5 years older (66 vs 61 yrs) and having worse baseline comorbidity scores, proton patients were significantly less likely to end up with an unplanned hospitalization, which is a grade 3 toxicity by definition - and also quite expensive.

Here is a relevant table. Green are the things you pointed out. I'll ask you to look at the Red and think about whether literally any of those factors could perhaps tip the scales or act as a confounder as to why certain patients were hospitalized and others were not, separate from what modality they were treated with.

You mean the black patient with non-Medicare insurance (delays in potential care) with T4N2 H&N patient at a satellite facility in the definitive setting (to 70Gy) receiving RT (more likely to be photons) is more likely to be admitted than the white medicare definitive lung patient receiving RT for a T3N2 NSCLC, potentially for pre-operative intent?

NO ****ING WAY!

 

[sirspamalot]

 

[IonsAreOurFuture]

We are installing MR-Ls. It will take a few years before we can treat anything other than prostate on them. We have a star researcher who has time and energy for upper GI projects, but no therapist or physics resources to help implement. What a waste. When I point this out, all I get from my chair is that this is an investment, and even if low volume, drives donations, publicity, etc. 😑

There are a couple MR-Ls in my area. It seems like they need a pretty hefty vault retrofit to install one. Any idea from your place how much it costs to put one in?

 

[OTN]

There are a couple MR-Ls in my area. It seems like they need a pretty hefty vault retrofit to install one. Any idea from your place how much it costs to put one in?

$6-8M is what I've heard

 

[FindMeOnTheLinks]

There are a couple MR-Ls in my area. It seems like they need a pretty hefty vault retrofit to install one. Any idea from your place how much it costs to put one in?

Ours was $9M

 

[thesauce]

A lot of my patients have been reading about proton therapy on Wikipedia and come in thinking it's this great thing. I looked at it myself and the page seems very pro-protons, only mentioning the positives and downplaying the negatives.

I have tried twice now to update the page to add in the controversies and the changes keep getting rejected.

Anyone been able to successfully change a Wikipedia page?

 

[sirspamalot]

I'm guessing... because the army of pro-protons editors keep it nice n'clean. Talk page would show the edits and resolves. tl;dr - anyone check?

 

[NotMattSpraker]

A lot of my patients have been reading about proton therapy on Wikipedia and come in thinking it's this great thing. I looked at it myself and the page seems very pro-protons, only mentioning the positives and downplaying the negatives.

I have tried twice now to update the page to add in the controversies and the changes keep getting rejected.

Anyone been able to successfully change a Wikipedia page?

Holy crap, people were complaining about this on the Talk page in 2007!

 

[NotMattSpraker]

I'm guessing... because the army of pro-protons editors keep it nice n'clean. Talk page would show the edits and resolves. tl;dr - anyone check?

This is a fascinating article. A lot of this stuff does not seem like it is written by radiation professionals, they probably would benefit from help. Agree the article is mostly positive with poor citations supporting many statements.

Tonight I learned the distressing wiki-fact that the US has like <5% of the world's population but half the proton centers. 😬

 

[Fpg1245]

This is a fascinating article. A lot of this stuff does not seem like it is written by radiation professionals, they probably would benefit from help. Agree the article is mostly positive with poor citations supporting many statements.

Tonight I learned the distressing wiki-fact that the US has like <5% of the world's population but half the proton centers. 😬

The US also has 25% of the worlds wealth so that might have something to do with it

 

[sirspamalot]

Its money you say.. well, color me shocked.

 

[IonsAreOurFuture]

The US and Sweden were early inventors of proton therapy after WW2, so there is a historical head-start and trained personnel impact as well. I think the first patients were treated in the 1950s.

Very few other governments were in an economic position to make huge investments in basic research after the war.

In addition to proton and deuterium beams, helium ion was also developed in the US from 1970s to 1990s at Lawrence Berkley national lab. Helium ion is basically a beam of alpha particles that you can direct anywhere in the body; you don't need to attach it to a monoclonal antibody that gets stuck in the liver or kidneys. Berkley treated patients on a rotating chair because their accelerators were truly ginormous. Over 2,000 patients were treated with helium ions, and quite a few NEJM articles came out of it, but the cost was simply prohibitive.

Lawrence Berkley Lab, under pioneers like Cornelius Tobias and Eleanor Blakely, also invented carbon ion therapy, which Japan (7 centers) Germany (2 centers), Italy, Austria, and China (2 centers) have subsequently embraced. There are now 13 carbon centers and about 100 proton centers in operation worldwide.

Going back to Sweden, Lars Leksell's early radiosurgery patients were not treated on a Gamma Knife, but actually with a proton beam. His team wrote about its potential in Nature in 1958:

The High-Energy Proton Beam as a Potential Neurosurgical Tool
The High-Energy Proton Beam as a Neurosurgical Tool - Nature

And a proton treatment picture from Uppsala in 1960:

https://www.researchgate.net/publication/272406617_Introduction_to_Radiosurgery/figures?lo=1

Pretty bold and amazing what they did even prior to the invention of the CT and MRI.