WaPo takes on RadOnc

[Chartreuse Wombat]

https://www.washingtonpost.com/outlook/2018/10/04/industry-has-too-much-influence-medicine-its-time-end-that/?utm_term=.06b7527c1b5b

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[RO2019]

This thread of tweets says it all :

 

[Neuronix]

There is no substance to this article. The author discusses questionable marketing from the 1930s, 1950s, and 1970s. The only part relevant to the modern era is:

Twenty-first-century developments in “radio surgery” and proton beam therapy bring the history of industry’s role in using and diffusing high-cost technologies of uncertain efficacy up to date. Proton oncologists have been famously resistant to comparative randomized controlled trials to assess outcomes of their work, and proton center websites make unsupported claims of effectiveness. Accuray, launched by a Stanford neurosurgeon to manufacture his CyberKnife innovation, has been accused of deceptive advertising.

That's all you got? It's just not a well researched article to support its headline.

 

[thecarbonionangle]

Although the article has a lot of fake news, it does get right a few things. I actually learned Trump had an uncle who sounded very much like him in the rad onc business. Who knew!!! Our field was corrupt from the start and continues to be corrupt. We have a guy heavily involved in one of the most corrupt organizations in oncology in charge of our boards at ABR. The field is filled with corrupt individuals. The proton pushers at "big name" institutions who have buried data showing protons are inferior or equivalent (personally know of it). Let's not be surprised when we are portrayed as out of touch corrupt Trumps, perhaps we deserve some of it.

 

[BobbyHeenan]

Just like in most things in medicine, it's a few bad actors ruining it for everyone. The proton advertising is over the top IMO, supported by the paper cited above. I routinely have patients demanding second opinions for things like right sided breast or even whole brain because they saw the proton advertising on TV or internet.

 

[medgator]

Just like in most things in medicine, it's a few bad actors ruining it for everyone. The proton advertising is over the top IMO, supported by the paper cited above. I routinely have patients demanding second opinions for things like right sided breast or even whole brain because they saw the proton advertising on TV or internet.

Like getting CK 10-15 years ago. Billboards and tv ads everywhere in certain markets

 

[RickyScott]

While the author gets a lot wrong, her basic point is that there"something rotten in the state of denmark," and this couldnt be more true. Most leading departments in this field have now structurally and financially centered themselves around proton centers (w/expanding residencies), which need prostate pts, and we all know proton/prostate is bs and potentially harmful, and will become an easy target and poster child for health economists. I dont know of anything analagous in medicine where the core is so rotten. And yes, I also know of leading academic departments suppressing data that show that prostate have inferior rectal toxicities.

 

[scarbrtj]

She must've watched 'Bleeding Edge' (trailer features blink-and-you'll-miss-it linac).

 

[Brim]

She must've watched 'Bleeding Edge' (trailer features blink-and-you'll-miss-it linac).

The best part of clicking on that YouTube link is that it led me to here:

 

[Ray D. Ayshun]

Is she suggesting that cobalt is naturopathic?

 

[mavrik13]

As could be expected in an article like this, it makes a bold statement (which is ultimately true) using some over-dramatization that will irk people the wrong way. Comparing cobalt to MV photons is like apples to oranges - yes cobalt will work the same but we don't need an RCT when there is a minimal cost difference and there is a significant throughput benefit. The article does not talk about the benefits of radiation over time and makes it seem like we're working in the stone age.

However, the overall point - that industry and the financial incentive to treat has too much pull in radiation oncology is true. As a field, our ability to treat has long outpaced our evidence of whether or not we should treat. There are several examples where "doing more" is not necessarily better in medicine (a great read is Ending Medical Reversal).

With the exception of pediatric, skull base or reirradiation near a critical OAR, I believe we should not be using protons off-study (preferably a randomized study at that). Protons should not -ever- be used in prostate cancer (and it is ridiculous the NCCN tip-toes around this basically saying there is 'no harm' so go ahead and use protons). The explosion of proton facilities around the world is unfounded. Financial toxicity is real and we should be incentivized to produce 'good' results not only for the patient but society as a whole. For example, I would go a step further that we should not be treating 5+ brain mets with stereo (until we have evidence), nor should we still be treating low/intermediate risk prostates with 40+ fractions or treating standard breast tangents with 25 fractions when 16 will do.

 

[evilbooyaa]

As could be expected in an article like this, it makes a bold statement (which is ultimately true) using some over-dramatization that will irk people the wrong way. Comparing cobalt to MV photons is like apples to oranges - yes cobalt will work the same but we don't need an RCT when there is a minimal cost difference and there is a significant throughput benefit. The article does not talk about the benefits of radiation over time and makes it seem like we're working in the stone age.

However, the overall point - that industry and the financial incentive to treat has too much pull in radiation oncology is true. As a field, our ability to treat has long outpaced our evidence of whether or not we should treat. There are several examples where "doing more" is not necessarily better in medicine (a great read is Ending Medical Reversal).

With the exception of pediatric, skull base or reirradiation near a critical OAR, I believe we should not be using protons off-study (preferably a randomized study at that). Protons should not -ever- be used in prostate cancer (and it is ridiculous the NCCN tip-toes around this basically saying there is 'no harm' so go ahead and use protons). The explosion of proton facilities around the world is unfounded. Financial toxicity is real and we should be incentivized to produce 'good' results not only for the patient but society as a whole. For example, I would go a step further that we should not be treating 5+ brain mets with stereo (until we have evidence), nor should we still be treating low/intermediate risk prostates with 40+ fractions or treating standard breast tangents with 25 fractions when 16 will do.

I do agree that industry has a big hand in rad onc care - however, they have a similar hand in med onc care. The parallel to the med-onc at MSKCC is not a reasonable one IMO.

I'd argue against both of those bolded points. Not that following those principles is wrong for an individual radiation oncologist, but to say that nobody should be doing the bolded is extreme, IMO.

There's already data that says volume of intracranial disease is more important than number of discrete lesions, and published retrospective series on patients with 5-10 brain mets. There's also Japanese prospective (not randomized data) saying 5-10 is no different than 2-4: Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. - PubMed - NCBI

We've discussed prostate hypofrac extensively here, but the potential for increased toxicity is a discussion point. I'm curious how strongly worded the ASTRO prostate radiation guidelines will be worded whenever they come out.

Breast hypofrac doesn't really have any arguments against it, and especially given the most recent WBI guidelines (saying it's a full go in every tangents only scenario discussed), I agree with you on that point.