What’s your least favorite shady practice?

[evilbooyaa]

Advertisement - Members don't see this ad

Yep. Remember how Urorads were evil for "magically" deciding IMRT was a good thing for localized PC once they owned the machines and the data showed it? You can bet everything you own many of that "old school" patterns of doing as much as possible will just as "magically" go away when reimbursement is not tied to effort.

I don't. I'm too new to remember any discontent with prostate IMRT. Prostate IMRT has been standard of care (AFAIK, my initial experience didn't have me seeing prostate cancers) since I was interested in this field as a medical student.

 

[ramsesthenice]

Agree with the rest of your post, but in regards to bolded, really? You're still doing 4-field box for Cervix pelvis? What about for the lymph nodes (assuming they have positive lymph nodes if you're treating PA)? Still doing just 45/25 to the lymph nodes?

All Gyn gets IMRT from me in this era. SIB LNs if present.

" For patients with intact cervical tumors and uterine involvement " This is a pretty specific subset of patients. For some of these patients by the time you contour the entire uterus on full and empty bladder scans you spare literally nothing with IMRT in the pelvis and I go with 4 field in those cases because it is less to set up error. Again, its just the pelvis. The PA is VMAT matched inferior to the pelvic field with a half-beam block. Dosing is the same. 45/25 to entire CTV and I boost the nodes to whatever I can based on bowel (54-60). SIB when using IMRT.

 

[ramsesthenice]

I don't. I'm too new to remember any discontent with prostate IMRT. Prostate IMRT has been standard of care (AFAIK, my initial experience didn't have me seeing prostate cancers) since I was interested in this field as a medical student.

Oh no, I was referencing something different. I was referencing the papers ASTRO loved that showed there were urology practices who referred < 5% of patients for radiation therapy for localized PC who bought a machine and the next year treated >80% with IMRT in their office.

 

[medgator]

Oh no, I was referencing something different. I was referencing the papers ASTRO loved that showed there were urology practices who referred < 5% of patients for radiation therapy for localized PC who bought a machine and the next year treated >80% with IMRT in their office.

Better than cryo or HIFU, which many were doing instead to keep the revenue in house in situations where RP was not an option.

Urorads was often done as a partnership with private rad onc, unlike the cookbook technicians that seem to populate mdacc/mskcc etc academic satellites these days. The private guys had much more autonomy/collaboration from what i saw of those setups

The ASTRO vendetta against urorads was part of what drove a wedge between academic and private practice rad oncs since the turn of the century

 

[evilbooyaa]

" For patients with intact cervical tumors and uterine involvement " This is a pretty specific subset of patients. For some of these patients by the time you contour the entire uterus on full and empty bladder scans you spare literally nothing with IMRT in the pelvis and I go with 4 field in those cases because it is less to set up error. Again, its just the pelvis. The PA is VMAT matched inferior to the pelvic field with a half-beam block. Dosing is the same. 45/25 to entire CTV and I boost the nodes to whatever I can based on bowel (54-60). SIB when using IMRT.

I contour entirety of uterus as CTV in EBRT regardless of whether they have uterine involvement or not, so I'm not sure how uterine involvement changes management. Doesn't change staging.

Lots of bowel superior to the superior edge of uterus, coplanar with external, internal, and common iliac lymph nodes in most cases.

I've placed the blue line at top of L5 as per your post. That seems like a lot more bowel (bag contoured as light green) than 'literally nothing' that can be spared. This is a mostly midline sagittal view, a little offset to show the fundus of the uterus (which curved to patient's right).

Granted, the bowel that is coplanar with uterus is surrounded by LN ptvs, so from say S3 down, I agree, not a lot of sparing as the bowel there is surrounded by PTV on other planes. This patient had a + LN that is not in plane on current image.

How often do you have to give your cervix patients anti-diarrheals? For me it's very very rarely. Daily CBCT for IGRT.

Granted, I have one attending who does IMRT for every case and another who does 4-field box for node negative patients, but they'll both do full IMRT with SIB for anybody LN positive, with or without PA coverage.


I also don't like sequential boosts for LNs, but that's just a my preference thing and I see it in the community all the time, so as long as you're taking to a higher dose, do your thing.

 

[mheat3]

For central/large tumors, I do 4.5-5 Gy x 15 with dose painting to spare airways, esophagus etc ... 5 Gy x 15 is equivalent to 12.5 Gy x 4 for tumor

Agree, I'll do 70-75 Gy in 15 fractions with dose painting around airways, etc. Seen excellent results with no side effect issues thus far *fingers crossed*

 

[ramsesthenice]

The ASTRO vendetta against urorads was part of what drove a wedge between academic and private practice rad oncs since the turn of the century

I don't want to derail this thread into an antiASTRO party but the urorads vendetta was not a good look for us. This is case in point. For years we complained that urologists ignored good data and surgerized everyone with giving them the option of radiation. Once they finally start doing radiation, we vehemently objected to it for political and financial reasons. I remember getting chastised during journal club when I dared admit that while these papers may show questionable motivations behind practice patterns, if patients are getting appropriate treatment I don't think its inherently a bad thing.

 

[evilbooyaa]

Agree, I'll do 70-75 Gy in 15 fractions with dose painting around airways, etc. Seen excellent results with no side effect issues thus far *fingers crossed*

What you putting as dose constranits to Prox. Bronchial Tree in 15fx?

 

[Mandelin Rain]

I don't want to derail this thread into an antiASTRO party but the urorads vendetta was not a good look for us. This is case in point. For years we complained that urologists ignored good data and surgerized everyone with giving them the option of radiation. Once they finally start doing radiation, we vehemently objected to it for political and financial reasons. I remember getting chastised during journal club when I dared admit that while these papers may show questionable motivations behind practice patterns, if patients are getting appropriate treatment I don't think its inherently a bad thing.

Yes, it was a very ill conceived fight to pick.

 

[RickyScott]

What you putting as dose constranits to Prox. Bronchial Tree in 15fx?

I don't think that makes it any better. First, even with 3D you can easily treat healthy patients concurrently. You jut put your field boarder at the top of L5 and half-beam block to match. For patients with intact cervical tumors and uterine involvement I still usually treat the pelvis 3D and the PA nodes with VMAT using a half-beam block. I'll grant you for frail patients there was an argument to be made but.... this is their universal practice and not dependent on patient factors (the patient in the particular case I am discussing was only 44). Third, there is an expectation that you adapt with changing practices over time. Not saying you have to alter what you are doing as soon as new studies come out. But is highly questionable to on the one hand decide that you believe that IMRT reduces toxicity but then reject the notion that it sufficiently reduces toxicity to treat PA and pelvic fields concurrently in the face of a mountain of data and SOC guidelines. They are all in on radiating 3+ extracranial oligomets with SBRT. I guarantee you that is not something they picked up in residency 15-20 years ago.

Since you brought up historical practice patterns, it is worth mentioning that we use to do a lot more PA radiation than we do now. In most of the classic studies it was recommended for patients with common iliac involvement. Most open protocols and people I know are only using the classic chimney approach for frank PA involvement.

One of my favorite papers. 3D large margins

Phase I study of accelerated conformal radiotherapy for stage I non-small-cell lung cancer in patients with pulmonary dysfunction: CALGB 39904 - PubMed

Accelerated conformal radiotherapy was well tolerated in a high-risk population with clinical stage I NSCLC. Outcomes are comparable to prospective reports of alternative therapies, including stereotactic body radiation therapy and limited resection, with less apparent severe toxicity. Further...

pubmed.ncbi.nlm.nih.gov

 

[mheat3]

What you putting as dose constranits to Prox. Bronchial Tree in 15fx?

Good question and would love to hear other's 15 fraction constraints but basically extrapolating BED from the MDACC 10 fraction experience as well as the Canadian Phase II trial that did 60/15 for stage II/III tumors. For tumors with direct overlap of airways I try to keep 0.035 cc max at 63 Gy (105% of 60). For oligomet type cases I am more conservative and typically use 60 Gy voxel max

 

[ramsesthenice]

I contour entirety of uterus as CTV in EBRT regardless of whether they have uterine involvement or not, so I'm not sure how uterine involvement changes management. Doesn't change staging.

Lots of bowel superior to the superior edge of uterus, coplanar with external, internal, and common iliac lymph nodes in most cases.

View attachment 299759


I've placed the blue line at top of L5 as per your post. That seems like a lot more bowel (bag contoured as light green) than 'literally nothing' that can be spared. This is a mostly midline sagittal view, a little offset to show the fundus of the uterus (which curved to patient's right).

Granted, the bowel that is coplanar with uterus is surrounded by LN ptvs, so from say S3 down, I agree, not a lot of sparing as the bowel there is surrounded by PTV on other planes. This patient had a + LN that is not in plane on current image.

How often do you have to give your cervix patients anti-diarrheals? For me it's very very rarely. Daily CBCT for IGRT.

Granted, I have one attending who does IMRT for every case and another who does 4-field box for node negative patients, but they'll both do full IMRT with SIB for anybody LN positive, with or without PA coverage.


I also don't like sequential boosts for LNs, but that's just a my preference thing and I see it in the community all the time, so as long as you're taking to a higher dose, do your thing.

Evil, I love a couple things you said and they support what I said above. I was trained to always treat intact cervix with 3D because there were not clear guidelines on what CTV and PTV margins should be (especially with regards to uterus). I was also taught that IMRT usually "wouldn't spare anything". Fast forward and I am all growed up and can make my own logical conclusions and decided a few things:

1) there now are clear guidelines on how to do IMRT for intact cervix patients and it is an accepted SOC so I do it
2) in many cases (like the one above), there will be significant sparing of bowel and if there is, I will use IMRT all the way. A single VMAT plan is faster and requires no matching so it is generally preferable for everyone involved

There are some patients with big, mobile uteri where you spare much less by the time you make an ITV and in those cases (we are talking a handful a year) I will use 3D for the pelvis. As for why uterine invasion matters to me, its because it affects my PTV volume. If they don't have gross uterine invasion I will use tighter PTV margins around the fundus because I am less worried about being a little cold there from time to time if set up is not perfect. If they have uterine invasion I am more generous with my margins on the uterus and sparing becomes less likely. Again, I am not dogmatic here. If they have uterine invasion but a small(ish) uterus and I can spare a lot with generous margins I will still use IMRT.

 

[Lamount]

What you putting as dose constranits to Prox. Bronchial Tree in 15fx?

Depending on the case, I will let it go as high as 67.5 Gy, keeping D2cc <57 Gy. There is a well done paper from the Netherlands showing minimal grade 3 clinical toxicity with max dose to bronchi < EQD2 of 100 Gy (a/b=3)... in 15 fractions, this comes out to 67.5, which is also BED 100. The supplement of that paper also shows that you can probably get away with D2cc <63 Gy, but I don't want want to push my luck.

 

[Music Man Stan]

I’m surprised there are so many people who don’t like traditional frac for prostate. Most randomized studies comparing hypo to standard frac that I’ve glanced at have higher acute toxicity for the hypo arm, no better control rates for the hypo arm, and some even had higher long term toxicity. I’m guessing a lot of the people who read this forum have never been inside a urorads practice but the one that I visited was exceptionally pleasant, had valet parking, a great lounge with a huge TV, espresso, and games, and was a well oiled machine that could treat 5 patients an hour. Those retired patients definitely didn’t mind coming 45 times to hang out with other guys.

I sadly am not part of a urorads practice but I wish I was. they did excellent work, and literally everybody involved was happy. It was the great example of having your cake and eating it too.

 

[FrostyHammer]

Treat enough, for long enough and odds are you'll see something "rare" happen.

But that's OK! No one is perfect. Statistics say that 1 in 5 locally advanced NSCLC cases with V20 of 20-25ish will have RP. Doesn't stop us, does it? Sometimes you gotta do what you gotta do. Can't run scared forever because of the inevitable one bad experience.

 

[FrostyHammer]

1) in theory you are correct about recurrences, but I have seen cases where a toxicity is exploited politically within a department and a lot of Monday morning qb goes on and someone’s life made difficult. It is lot easier to have this bravado when you haven’t had to deal with this.

Personally never had a major toxicity with sbrt (except for one death on pt with pneumonitis while on immuno) for lung and I had one of first cone beams on East Coast and have have been doing this a long to time.btw At time,chair of mdacc, lung specialist, was denigrating stereo.

“Specialist in lung sbrt” - reminds me of one time prominent academic who was a specialist in breast DCIS. If have doubt, give 100 bed with something like 17/70- Don’t be wedded to stereo-it’s just a name.

Politics suck, not going to sugar coat that. But specialists are real. However I do not define a specialist as an academic lung doc, but rather anyone in academics or PP who does these frequently (The definition of "frequently" of course is up to the eye of the beholder). For instance, Someone who doesn't simply blindly use a dose constraint they happened to look up, but actually thinks and uses their experience to change or modify its implementation.

 

[FrostyHammer]

I’m surprised there are so many people who don’t like traditional frac for prostate. Most randomized studies comparing hypo to standard frac that I’ve glanced at have higher acute toxicity for the hypo arm, no better control rates for the hypo arm, and some even had higher long term toxicity. I’m guessing a lot of the people who read this forum have never been inside a urorads practice but the one that I visited was exceptionally pleasant, had valet parking, a great lounge with a huge TV, espresso, and games, and was a well oiled machine that could treat 5 patients an hour. Those retired patients definitely didn’t mind coming 45 times to hang out with other guys.

I sadly am not part of a urorads practice but I wish I was. they did excellent work, and literally everybody involved was happy. It was the great example of having your cake and eating it too.

1. Slightly higher Acute toxicities are acceptable for saving the patient weeks of RT
2. We wouldn't expect hypofractionation to have better control rates, and indeed they are the same
3. Some have shown higher late toxicity but many more have shown no differences. Likely relates to the margins used and the degree/quality of igrt.

 

[Palex80]

I’m surprised there are so many people who don’t like traditional frac for prostate. Most randomized studies comparing hypo to standard frac that I’ve glanced at have higher acute toxicity for the hypo arm, no better control rates for the hypo arm, and some even had higher long term toxicity. I’m guessing a lot of the people who read this forum have never been inside a urorads practice but the one that I visited was exceptionally pleasant, had valet parking, a great lounge with a huge TV, espresso, and games, and was a well oiled machine that could treat 5 patients an hour. Those retired patients definitely didn’t mind coming 45 times to hang out with other guys.

I sadly am not part of a urorads practice but I wish I was. they did excellent work, and literally everybody involved was happy. It was the great example of having your cake and eating it too.

The same argument can be made for breast cancer treatment. Why hypofractionate?
You could decorate your waiting room, serve the ladies coffee and whatever else...

The point is simple: Beyond making money, we should be striving to making medical care cost effective too.

You argument on hypofractionated treatment resulting in more acute toxicity is only partially correct. Acute toxicity happens earlier with hypofractionation, but the AUC in terms of toxicity is the same with hypofractionation or normofractionation more or less. Needless to say, the trials testing hypofractionation versus normofractionation did not use the fancy tools we use nowadays in our patients (daily CBCT, fiducials, spacer), thus any differences between both fractionation regimes are probably a lot harder to pick up now that previously.

 

[medgator]

The same argument can be made for breast cancer treatment. Why hypofractionate?

Toxicity is better with hypofrac in breast. Far different scenario

Acute and Short-term Toxic Effects of Fractionated Breast Irradiation

In this randomized clinical trial, hypofractionated whole-breast irradiation (WBI) appeared to yield lower rates of acute toxic effects than conventionally fractionated WBI as well as less fatigue and less trouble meeting family needs 6 months after radiation therapy.

jamanetwork.com

Breast hypofx is a win win all around. I think that's why there has been much more embrace of it in breast by national groups and guidelines vs prostate where things aren't nearly as much of a slam dunk

 

[xrthopeful]

Personally I think prostate hypofrac should be considered by SOC in most situations (and it will be the only thing people do when APM hits) but yes breast is definitely more of an all around slam dunk with zero anyone can say (but people still find ways! Mostly
Older practitioners in my experience)

 

[medgator]

Personally I think prostate hypofrac should be considered by SOC in most situations (and it will be the only thing people do when APM hits) but yes breast is definitely more of an all around slam dunk with zero anyone can say (but people still find ways! Mostly
Older practitioners in my experience)

https://ascopubs.org/doi/full/10.1200/JCO.18.00317

Still don't combine it with Adria, personally

 

[Palex80]

Toxicity is better with hypofrac in breast. Far different scenario

Indeed, that's a fair argument. But it's not THAT much better.

I do not believe that hypofractionated treatment in breast cancer leading to less side effects than normofractionated treatment was the "driver" that led to hypofractionation being widely implemented. It was the simple understanding that we have enough data, a sufficient follow up and a more convenient treatment for the patients.
In my humble opinion, in 5 years from now with longer follow up of all the hypofractionation trials in prostate cancer, people will look back and ask why we did not adop hypofractionation earlier on. But that's only my opinion.

We have dropped normonfractionation for more than a year now and are doing 60/3 for all (without lymphatics).

Acute and Short-term Toxic Effects of Fractionated Breast Irradiation

In this randomized clinical trial, hypofractionated whole-breast irradiation (WBI) appeared to yield lower rates of acute toxic effects than conventionally fractionated WBI as well as less fatigue and less trouble meeting family needs 6 months after radiation therapy.

jamanetwork.com

Breast hypofx is a win win all around. I think that's why there has been much more embrace of it in breast by national groups and guidelines vs prostate where things aren't nearly as much of a slam dunk

There is a major flaw in the interpretation of this trial. Look at the assessment timepoints. They looked at toxicity with weekly assessments during treatment and then at 6 months. That's it.

1. If you ask 6 times (normofractionation) if someone has toxicity you will probably find more toxicity than if you ask 4 times (hypofractionation) in terms of "maximum reported toxicity". The more weeks you are "allowed" to ask the more likely is that you will get the "wrong" answer.
2. We all have seen that the normofractionated patients do tend to develop some toxicity at week 5-6, while the hypofractionated patients are already at home by then. That's why some of us (I hope many), like to see these patients a few weeks after RT completion, since we know that's the timepoint they likely will develop toxicity. I made the same experience too, when we started hypofractionating: I tended to see patients 4-6 after completion of treatment up until then and suddenly I was facing hypofractionated patients that told me how bad the skin was a couple of weeks ago (around 2 weeks after completion of treatment) and how it was getting better now. I now tend to see all hypofractionated patients around 2 weeks after treatment completion to pick up exactly this early toxicity.
If you merely ask at 6 months, none of the hypofractionated patients ever had the chance to tell you how they felt directly after completion of treatment and in the few weeks after.

This is a well established fact in all accelerated treatments. It's the core principle behind the efficacy of 45/1.5 bid for SCLC. You finish up therapy in 3 weeks and the "toxicity truck" hits you then. It's why in CONVERT less patients dropped 45/1.5 than 66/2. If you are still under therapy when toxicity hits you, you can drop treatment. If treatment is already done, there's not much you can do. 🙂

 

[scarbrtj]

Watched 'Cosmos' (the third one) on Nat Geo the other night and part of the episode was on Paul Broca, he of Broca's area. Broca was a bit of a radical and contrarian; went on to form a society of free thinkers e.g. However, he was also a sexist and racist and believed men superior to women and whites to be the superior race. At the time and place (mid-1800's France) these were non-controversial thoughts. But as Neil deGrasse Tyson asked: what will people in the future think of us destined to live in the past, after we're all gone? It's likely there are things we think and do now that will appear "shady" as time goes by. This has occurred innumerably throughout human history.

I have seen whole brain IMRT evolve from shady to non-shady. I have seen IGRT for all curative patients evolve from shady to non-shady. I have seen IMRT as a blanket solution in certain disease sites evolve from shady to non-shady. We can even have randomized trials proving the superiority of one treatment over another but still have some not believe the outcomes and call those that do "shameful" e.g. (not judging you bro). Shadiness is subjective. Giving chemotherapy without an MD present: not shady. Ever. Giving XRT without an MD present? Used to be pretty shady... but before that, never shady. Still shady? Well it literally depends on where you are now thus giving shadiness a temporal as well as spatial element. Is shadiness billing for something that one shouldn't? If so, according to the U.S. government, 1379 out of 1454 rad onc departments in the U.S. are shady. Thus chances are the government has assessed probably every single one of us posting here currently practices in a shady department, doing shady things, daily and constantly. The government may think that about us, but I have a hunch we don't feel that about ourselves. Who's right? Who's wrong?

Is shadiness doing something that's not medically necessary on all patients? I have foreseen that one day payors will make us assert medical necessity on weekly treatment visits e.g. Perhaps 50 years from now seeing every single patient every single week, regardless their medical state or complaints, will seem shady. Thus we all might be future rad oncs' Brocas. To paraphrase the Apostle Paul, "For all have sinned and come short of the glory of non-shadiness." At least a little bit and especially in the eyes of man. I have no idea what God thinks.

 

[mheat3]

Toxicity is better with hypofrac in breast. Far different scenario

Acute and Short-term Toxic Effects of Fractionated Breast Irradiation

In this randomized clinical trial, hypofractionated whole-breast irradiation (WBI) appeared to yield lower rates of acute toxic effects than conventionally fractionated WBI as well as less fatigue and less trouble meeting family needs 6 months after radiation therapy.

jamanetwork.com

Breast hypofx is a win win all around. I think that's why there has been much more embrace of it in breast by national groups and guidelines vs prostate where things aren't nearly as much of a slam dunk

Generally agree, I hypofractionate all breast only patients (in some adopting a 5 fraction regimen) but am more cautious with prostate. I will hypofractionate men with favorable anatomy (no bowel falling into region) and those who when I ask express travel/cost/etc as a concern, as long as they understand the increased risk of short term side effects. Men with bowel in field, needing node RT, previous cryo/HIFU/whatever the heck, I will recommend standard fractionation.

 

[BobbyHeenan]

- Protons for prostate off of a randomized trial. We don't need any more registry data.
- Protons for (especially right sided) breast off randomized trial; I think regional left sided nodal irradiation with IM's with protons probably won't move the needle, but I'm not willing to call it "shady."
- Protons for anal cancer off trial
- Protons for stage I lung cancer (ie use protons instead of SBRT).

I see all of the above used on medicare patients regularly.

I'm willing to call standard frac whole breast used routinely as "shady" at this point.

 

[ramsesthenice]

Watched 'Cosmos' (the third one) on Nat Geo the other night and part of the episode was on Paul Broca, he of Broca's area. Broca was a bit of a radical and contrarian; went on to form a society of free thinkers e.g. However, he was also a sexist and racist and believed men superior to women and whites to be the superior race. At the time and place (mid-1800's France) these were non-controversial thoughts. But as Neil deGrasse Tyson asked: what will people in the future think of us destined to live in the past, after we're all gone? It's likely there are things we think and do now that will appear "shady" as time goes by. This has occurred innumerably throughout human history.

I have seen whole brain IMRT evolve from shady to non-shady. I have seen IGRT for all curative patients evolve from shady to non-shady. I have seen IMRT as a blanket solution in certain disease sites evolve from shady to non-shady. We can even have randomized trials proving the superiority of one treatment over another but still have some not believe the outcomes and call those that do "shameful" e.g. (not judging you bro). Shadiness is subjective. Giving chemotherapy without an MD present: not shady. Ever. Giving XRT without an MD present? Used to be pretty shady... but before that, never shady. Still shady? Well it literally depends on where you are now thus giving shadiness a temporal as well as spatial element. Is shadiness billing for something that one shouldn't? If so, according to the U.S. government, 1379 out of 1454 rad onc departments in the U.S. are shady. Thus chances are the government has assessed probably every single one of us posting here currently practices in a shady department, doing shady things, daily and constantly. The government may think that about us, but I have a hunch we don't feel that about ourselves. Who's right? Who's wrong?

Is shadiness doing something that's not medically necessary on all patients? I have foreseen that one day payors will make us assert medical necessity on weekly treatment visits e.g. Perhaps 50 years from now seeing every single patient every single week, regardless their medical state or complaints, will seem shady. Thus we all might be future rad oncs' Brocas. To paraphrase the Apostle Paul, "For all of have sinned and come short of the glory of non-shadiness." At least a little bit and especially in the eyes of man. I have no idea what God thinks.

This show is based on Carl Sagan's book Cosmos which frankly everyone should read. It was written in 1980 but except for the occasional giveaways (like not knowing what killed the dinosaurs) you would think it might be written in the last 18 months given its hyperrelevance to the consequences of suppressing scientific facts in favor of political or religious ideology. But that is not the purpose of this post...

I actually wanted to give a nod to scar. It is important not to get too carried away with calling things shady. I use IMRT with daily IGRT for most definitive disease sites. Where I trained, this would be blasphemy. I was taught the only reason people do that is to get better reimbursement. You can debate individual disease sites but I think we can all agree that there are significant advantages to these approaches and not everyone uses them because they want to increase their bottom line. Are they so significant they always justify the increased cost to the system? That is debatable. But I think a core question that is overlooked is this: If you got paid the same amount no matter how you treat the patient would it change your practice? If the answer is yes it is time to do some reflecting.

 

[RickyScott]

This show is based on Carl Sagan's book Cosmos which frankly everyone should read. It was written in 1980 but except for the occasional giveaways (like not knowing what killed the dinosaurs) you would think it might be written in the last 18 months given its hyperrelevance to the consequences of suppressing scientific facts in favor of political or religious ideology. But that is not the purpose of this post...

I actually wanted to give a nod to scar. It is important not to get too carried away with calling things shady. I use IMRT with daily IGRT for most definitive disease sites. Where I trained, this would be blasphemy. I was taught the only reason people do that is to get better reimbursement. You can debate individual disease sites but I think we can all agree that there are significant advantages to these approaches and not everyone uses them because they want to increase their bottom line. Are they so significant they always justify the increased cost to the system? That is debatable. But I think a core question that is overlooked is this: If you got paid the same amount no matter how you treat the patient would it change your practice? If the answer is yes it is time to do some reflecting.

When I first started using daily igrt, I caught a number of failure to shift errors. It is really hard to screw up xrt with daily igrt. (assuming you look at it.)

 

[xrthopeful]

Daily IGRT is a good thing. Using KVs still counts as IGRT.

Lot of the stuff that people are talking about as shady has no medical purpose and is done ONLY for billing. There will be no ‘future’ point where we look back to some of this stuff as important. The technology stuff like proton is more like IGRT where it ‘could’ have a point, but the truly shady stuff like three sims and plans for a stage III or billing SBRT courses back to back to back weeks aren’t okay

 

[scarbrtj]

Daily IGRT is a good thing. Using KVs still counts as IGRT.

Lot of the stuff that people are talking about as shady has no medical purpose and is done ONLY for billing. There will be no ‘future’ point where we look back to some of this stuff as important. The technology stuff like proton is more like IGRT where it ‘could’ have a point, but the truly shady stuff like three sims and plans for a stage III or billing SBRT courses back to back to back weeks aren’t okay

well the MR Linac crowd was/is/will be doing LOTS more than three plans for their Stage III lungs. Which I suppose (I'll never be fortunate enough to use such fancy tech) they think is neither fishy nor shady.

 

[deleted1002574]

Daily IGRT is a good thing. Using KVs still counts as IGRT.

Lot of the stuff that people are talking about as shady has no medical purpose and is done ONLY for billing. There will be no ‘future’ point where we look back to some of this stuff as important. The technology stuff like proton is more like IGRT where it ‘could’ have a point, but the truly shady stuff like three sims and plans for a stage III or billing SBRT courses back to back to back weeks aren’t okay

I don't think that's accurate about the stage III, especially with different types of IGRT or bio-GRT
EDIT: scarbs beat me to it

 

[radoncgrad2019]

to keep spirits alive for my Covid patients, i have been serving shady fishsticks

(they don't know I'm billing CPT 88327 for it

what they dont know cant hurt them

 

[xrthopeful]

I don't think that's accurate about the stage III, especially with different types of IGRT or bio-GRT
EDIT: scarbs beat me to it

I’m talking about people that are doing it for every stage III Patient without adaption as was discussed by others uptnread

 

[Gfunk6]

to keep spirits alive for my Covid patients, i have been serving shady fishsticks

(they don't know I'm billing CPT 88237 for it

what they dont know cant hurt them

After reading this thread, I've asked that infrared heating lamps be installed in all of our RO treatment changing rooms. Not only will this facilitate patient comfort but will allow me to bill a hyperthermia technical code thereby offsetting other revenue losses.

 

[radoncgrad2019]

After reading this thread, I've asked that infrared heating lamps be installed in all of our RO treatment changing rooms. Not only will this facilitate patient comfort but will allow me to bill a hyperthermia technical code thereby offsetting other revenue losses.

got to this is america

 

[BobbyHeenan]

After reading this thread, I've asked that infrared heating lamps be installed in all of our RO treatment changing rooms. Not only will this facilitate patient comfort but will allow me to bill a hyperthermia technical code thereby offsetting other revenue losses.

Probably can get them real cheap right now from the restaurant closures. Make lemonade out of these COVID lemons!

 

[Mandelin Rain]

For what it’s worth, I’m pretty sure if you treat 2 consecutive 5 fraction sbrt courses consecutively, you can’t Bill sbrt for either of them.

just becomes a 10 fraction course

 

[radoncgrad2019]

For what it’s worth, I’m pretty sure if you treat 2 consecutive 5 fraction sbrt courses consecutively, you can’t Bill sbrt for either of them.

just becomes a 10 fraction course

that's what i thought, but nope, it can be done. and it is done. probably by a few of the people here. you have to be creative with how you space them and when you bill them.

 

[scarbrtj]

I’m talking about people that are doing it for every stage III Patient without adaption as was discussed by others uptnread

About "every" Stage III lung patient I treat has an ongoing visually assessable response to the chemoRT throughout treatment. One doesn't need anything other than standardly available XRT equipment (ie linac w/ CBCT and a CT sim) to do adaptation. You see a ~5 mm unidimensional response in treatment, you adapt. See another 5 mm, adapt. By adapt I mean recontour from scratch on a new CT and replan and clinically utilize the next day, or that day if you have a slow clinic and efficient physicist. But who knows maybe even with 3 mm or 2 mm responses... adapt. All this would be very labor-intensive and probably gilding the lily. Or maybe it's not. "There's no data." There's no clinical data that MRI linac adaptation is good/better either. Big fancy expensive MR linac machine to do lots of replanning: OK. Using "regular" equipment to do essentially the same thing: shady. Someone who was doing very anal retentive regular CT sim replanning and rescanning on all Stage III lungs once a week e.g.: shady or brilliant? IDK. But I bet the outcomes wouldn't be worse.

 

[Mandelin Rain]

that's what i thought, but nope, it can be done. and it is done. probably by a few of the people here. you have to be creative with how you space them and when you bill them.

I’m not as creative as other people then. I’ve done this more than a few times for folks (Usually COPDers or back pain people) who couldn’t lie flat and still for two or three site SBRT.

Ive just given up the sbrt charge altogether. And I’m (pretty) sure that’s the most compliantthing to do.

I’ve never waited like a month or more between spots or something. I’m guessing you’d have to do something like that.

 

[radoncgrad2019]

Ive just given up the sbrt charge altogether. And I’m (pretty) sure that’s the most compliantthing to do.

yes, this is what i do in that scenario too.

 

[evilbooyaa]

Evil, I love a couple things you said and they support what I said above. I was trained to always treat intact cervix with 3D because there were not clear guidelines on what CTV and PTV margins should be (especially with regards to uterus). I was also taught that IMRT usually "wouldn't spare anything". Fast forward and I am all growed up and can make my own logical conclusions and decided a few things:

1) there now are clear guidelines on how to do IMRT for intact cervix patients and it is an accepted SOC so I do it
2) in many cases (like the one above), there will be significant sparing of bowel and if there is, I will use IMRT all the way. A single VMAT plan is faster and requires no matching so it is generally preferable for everyone involved

There are some patients with big, mobile uteri where you spare much less by the time you make an ITV and in those cases (we are talking a handful a year) I will use 3D for the pelvis. As for why uterine invasion matters to me, its because it affects my PTV volume. If they don't have gross uterine invasion I will use tighter PTV margins around the fundus because I am less worried about being a little cold there from time to time if set up is not perfect. If they have uterine invasion I am more generous with my margins on the uterus and sparing becomes less likely. Again, I am not dogmatic here. If they have uterine invasion but a small(ish) uterus and I can spare a lot with generous margins I will still use IMRT.

OK fair enough. Thanks for the healthy discussion.

I suppose if there is involvement all the way to the fundus I'd be a little bit more concerned, but in all honesty, we sim full and empty bladder to create a generous ITV of both cervix and uterus, and plan and treat on full bladder. Most cervicals seem to have some motion at the uterus but within a 1cm PTV margin.

I just don't find myself using 3D for cervix anymore. How do you determine whether a uterus is big and mobile vs say big and fixed? If it's on full and empty bladder scans, I'd still create an ITV and place an additional 1cm for a PTV margin. I think it'd be interesting to see what percentage of the time a 1cm PTV margin is actually necessary, or can we shrink it to 0.5cm like most disease sites (assuming an ITV is created).

 

[evilbooyaa]

I’m surprised there are so many people who don’t like traditional frac for prostate. Most randomized studies comparing hypo to standard frac that I’ve glanced at have higher acute toxicity for the hypo arm, no better control rates for the hypo arm, and some even had higher long term toxicity. I’m guessing a lot of the people who read this forum have never been inside a urorads practice but the one that I visited was exceptionally pleasant, had valet parking, a great lounge with a huge TV, espresso, and games, and was a well oiled machine that could treat 5 patients an hour. Those retired patients definitely didn’t mind coming 45 times to hang out with other guys.

I sadly am not part of a urorads practice but I wish I was. they did excellent work, and literally everybody involved was happy. It was the great example of having your cake and eating it too.

Agree. Prostate hypofrac is an option but many patients choose conventional to avoid risk of acute toxicity. I discuss both with intact prostate patients.

You argument on hypofractionated treatment resulting in more acute toxicity is only partially correct. Acute toxicity happens earlier with hypofractionation, but the AUC in terms of toxicity is the same with hypofractionation or normofractionation more or less. Needless to say, the trials testing hypofractionation versus normofractionation did not use the fancy tools we use nowadays in our patients (daily CBCT, fiducials, spacer), thus any differences between both fractionation regimes are probably a lot harder to pick up now that previously.

Guidance from the national guidelines has expressly written to counsel patients on an increased risk of acute GI toxicity with hypofrac regimens. It is a higher percentage risk. Not a ton, but non-zero.

Comparing breast hypofrac to prostate hypofrac are not equal comparisons, IMO.

 

[evilbooyaa]

https://ascopubs.org/doi/full/10.1200/JCO.18.00317

Still don't combine it with Adria, personally

What do you mean - like concurrent Adria? Or a history of receiving Adria. If the former, why are you doing concurrent. If the latter, not sure you have a leg to stand on given the most recent WBI consensus guidelines.

 

[medgator]

What do you mean - like concurrent Adria? Or a history of receiving Adria. If the former, why are you doing concurrent. If the latter, not sure you have a leg to stand on given the most recent WBI consensus guidelines.

Latter, the guidelines are still pretty weak in evidence for the chemo issue if you look through them, esp for the anthracyclines, unlike larger breast size etc that turned out to be ok in the recent randomized trial. I know ASTRO pushed hard on it, but i just don't see the supporting data in those patients.

 

[evilbooyaa]

Latter, the guidelines are still pretty weak in evidence for the chemo issue if you look through them, esp for the anthracyclines. I know ASTRO pushed hard on it, but i just don't see the supporting data in those patients

I suppose most early stage LN negative patients with a high oncotype probably aren't getting Adria unless they're TNBC. But what's the rationale?

I mean, I guess whatever, do your thing, but I personally don't see the issue with hypofrac in patients w/ history of Adria.

 

[medgator]

I suppose most early stage LN negative patients with a high oncotype probably aren't getting Adria unless they're TNBC. But what's the rationale?

I mean, I guess whatever, do your thing, but I personally don't see the issue with hypofrac in patients w/ history of Adria.

Recall reaction, mainly.. Adria isn't benign, and I'd rather not risk an adverse reaction out in the community. It's becoming less and less common to see it used these days, but every once in awhile it still happens.

 

[radoncgrad2019]

some people act like the community is a china shop lol

 

[deleted1002574]

Who's the Bull?

 

[RadOncDoc21]

Who's the Bull?

Coronavirus

 

[deleted1002574]

Recall reaction, mainly.. Adria isn't benign, and I'd rather not risk an adverse reaction out in the community. It's becoming less and less common to see it used these days, but every once in awhile it still happens.

How often?