Which oncology specialty will make the biggest advances in the coming decades?

[elementaryschooleconomics]

TTF?
You are comparing Flash radiotherapy with TTF?

Did you know they were invented 30 meters away btw?

It's sad to see how depressing the mood became. I have some impressions it could change soon, at least for our patients...

I am 100% comparing it to TTF - how could you not? I am actually pro-TTF so I don't mean it in a derogatory sense, just more in a "cautiously optimistic" sense, emphasis on caution.

I don't see this as depressing - I see this as measured. I have been involved with bench-based research for almost two decades now, and have become excited over countless advances - especially my own. I remain excited, but am unsure about how many of them will ever find use in my lifetime. The patients are who I am most worried about when these things get too much hype. Maybe a third of my GBM patients ask me about the re-engineered polio virus from Duke because they saw it on 60 Minutes, 5 years ago. I had countless people text or email me a year or two ago when that weird "new cure for cancer" story from Israel exploded on Facebook. A patient last week asked me if I could apply an AI algorithm to her post-treatment PET scan to tell if the radiation worked. When people's lives depend on us, it hurts to stomp their spirit because they don't have the education or training to differentiate data from hype.

Not messin' around Jim, we like FLASH here. I think it's going to work. But as I understand it today, its approach will actually lessen the "intellectual rigor" and effort of RT. No (or little) inverse optimization, OARs, etc. And it'll make treatment courses smaller, thus there'll be workforce ramifications. (Always are.) Machine prices may go up, but will CMS pay more for FLASH which they will see as shortened RT courses with less side effects and less physician effort being expended? If FLASH is kind of like a standard dosing recipe, what does that mean for rad onc residencies? So you gotta look at it both ways. GREAT, possibly, for patients; but perhaps/probably bad for a way oversupplied workforce. A fons et origo for improvement or worsening; TBD. The good 'ol 2-sided p-value at work.

Totally agree...a Stranger Things reference? It must be the weekend here on SDN.

---

Members don't see this ad.

 

[deleted1083739]

Not messin' around Jim, we like FLASH here. I think it's going to work. But as I understand it today, its approach will actually lessen the "intellectual rigor" and effort of RT. No (or little) inverse optimization, OARs, etc. And it'll make treatment courses smaller, thus there'll be workforce ramifications. (Always are.) Machine prices may go up, but will CMS pay more for FLASH which they will see as shortened RT courses with less side effects and less physician effort being expended? If FLASH is kind of like a standard dosing recipe, what does that mean for rad onc residencies? So you gotta look at it both ways. GREAT, possibly, for patients; but perhaps/probably bad for a way oversupplied workforce. A fons et origo for improvement or worsening; TBD. The good 'ol 2-sided p-value at work.

I'm not dumb, I know the current state of the field.

I just find sad for MDs not to separate their legitimate worries for their personal finances and potential once in a lifetime serendipity.
Plus I don't know where people here have their numbers, but TTF and Hyperthermia absolutely don't show the same promise as FLASH for the simple reason toxicity limited FLASH doses have not been reached in any study yet...

Damn the FLASH topic is depressing with everybody openly criticizing the specialty. What's wrong with you guys?
What made you chose radonc in the first place? I you don't find that anymore, I advise you to change fields as quickly as you can...

 

[elementaryschooleconomics]

I'm not dumb, I know the current state of the field.

I just find sad for MDs not to separate their legitimate worries for their personal finances and potential once in a lifetime serendipity.
Plus I don't know where people here have their numbers, but TTF and Hyperthermia absolutely don't show the same promise as FLASH for the simple reason toxicity limited FLASH doses have not been reached in any study yet...

Correct me if I'm wrong, but hasn't only a single human been treated with FLASH?

Serendipitous promise is exactly how I would describe FLASH in 2020.

 

[deleted1083739]

Correct me if I'm wrong, but hasn't only a single human been treated with FLASH?

Serendipitous promise is exactly how I would describe FLASH in 2020.

Yep, a cutaneous lymphoma patient with e- and some palliative bones are underway in the beautiful city of Cincinnati with protons if I'm not mistaken...

 

[deleted1083739]

I am 100% comparing it to TTF - how could you not? I am actually pro-TTF so I don't mean it in a derogatory sense, just more in a "cautiously optimistic" sense, emphasis on caution.

I don't see this as depressing - I see this as measured. I have been involved with bench-based research for almost two decades now, and have become excited over countless advances - especially my own. I remain excited, but am unsure about how many of them will ever find use in my lifetime. The patients are who I am most worried about when these things get too much hype. Maybe a third of my GBM patients ask me about the re-engineered polio virus from Duke because they saw it on 60 Minutes, 5 years ago. I had countless people text or email me a year or two ago when that weird "new cure for cancer" story from Israel exploded on Facebook. A patient last week asked me if I could apply an AI algorithm to her post-treatment PET scan to tell if the radiation worked. When people's lives depend on us, it hurts to stomp their spirit because they don't have the education or training to differentiate data from hype.



Totally agree...a Stranger Things reference? It must be the weekend here on SDN.

Maybe because TTF and Stupp regimen for the matter just have a palliative intend...

 

[drewdog1973]

I'm not dumb, I know the current state of the field.

I just find sad for MDs not to separate their legitimate worries for their personal finances and potential once in a lifetime serendipity.
Plus I don't know where people here have their numbers, but TTF and Hyperthermia absolutely don't show the same promise as FLASH for the simple reason toxicity limited FLASH doses have not been reached in any study yet...

Damn the FLASH topic is depressing with everybody openly criticizing the specialty. What's wrong with you guys?
What made you chose radonc in the first place? I you don't find that anymore, I advise you to change fields as quickly as you can...

Please explain how we can change fields as quickly as we can, because I’d be happy to become a Med Onc, it’s just I can’t stop working for 5 years to re train.

we chose it because it was a great field.

was.
was
was.

 

[RickyScott]

You are comparing Flash radiotherapy with TTF?
This is hopeless.

Did you know they were both invented 100 feet away btw?

It's sad to see how depressing the mood became. I sincerely hope it could change soon, at least for our patients...

Let’s say each fraction of radiation delivered 30% more cell kill. (At best 2 log kills over typical fractionated course) That would be great for patients, but not sure that would be great for the job market as pointed out by scarbtj. Let’s take prostate and breast, do you think a more locally effective xrt would significantly increase utilization?

Only way this field gets fixed is by training radoncs to deliver some types of systemic therapy.

 

[elementaryschooleconomics]

Damn the FLASH topic is depressing with everybody openly criticizing the specialty. What's wrong with you guys?
What made you chose radonc in the first place? I you don't find that anymore, I advise you to change fields as quickly as you can...

Wait, what?

1) Your account says "MD/PhD Student" - is that accurate? I guess I can understand that statement coming from a student, but it's very difficult to just "change fields" after 5 years of residency training (after 4+ years of medical school) - we'd have to go back and do, at minimum, another 3 years of training to practice in a different specialty. I don't have that kind of gas in the tank - I'd probably go into industry to be honest.

2) A common misconception is that the complaining on SDN is because we hate RadOnc. On the contrary, all of the criticizing of the specialty comes around the meta-reality of how RadOnc is (or is not) managed in America (regarding supply and demand and about 4,000 other points). I've actually come to believe that most of the regular posters on this board love Radiation Oncology more than a lot of people I know in real life.

If you don't feel passionately about something, why spend so much time writing about it? @scarbrtj alone has written a library's worth of hyperlink-laden diatribes that make it clear he is extraordinarily passionate about the field and desperately doesn't want it to die.

 

[deleted1083739]

Let’s say each fraction of radiation delivered 30% more cell kill. (At best 2 log kills over typical fractionated course) That would be great for patients, but not sure that would be great for the job market as pointed out by scarbtj. Let’s take prostate and breast, do you think a more locally effective xrt would significantly increase utilization?

Only way this field gets fixed is by training radoncs to deliver some types of systemic therapy.

I told you before this "30% more cell kill" is wrong.

Early models show at least 30% MORE PHYSICAL single fraction dose to isotoxicity. And these are models, no published study has ever compared isotoxic regimen at clinically relevant dose.

28Gy single fraction vs 21 is not "30% more cell kill" (and you can't extrapolate that to standard fractionation, early hypofrac seems to show the effect qualitatively holds, but again they tested smaller they undershoot isotoxic doses)

And I'm not in the US, it seems clear to me the job market is in a bad shape and that the specialty will survive in very large centers only whether this works or not.
As an intern I semi-joked that I should be the only one still exploring hyperfractionation for common indications as a hedge.
I wonder what pushed people in such a tiny field, it was my 3rd choice and only went in once I was guaranteed I would do fine even if everything went bust...
Only country I know of where rad onc have the power to force med onc to let them touch their money is France for historical reasons.
In the US they will let you do that as much as cardiologists will let you put stents and ophthalmologists do cataract surgery.
And you know well it's not like its a question of training

 

[RickyScott]

On further reflection, maybe flash is less likely to cause lymphopenia, but still don’t see how a modest improvement in radiation cytotoxicity or se profile would impact job market.

 

[RickyScott]

I told you before this "30% more cell kill" is wrong.

Early models show at least 30% MORE PHYSICAL single fraction dose to isotoxicity. And these are models, no published study has ever compared isotoxic regimen at clinically relevant dose.

28Gy single fraction vs 21 is not "30% more cell kill" (and no, it doesn't mean 2.6Gy standard fractions either because nobody knows the maths for FLASH iso toxicity at standard fractionation)

And I'm not in the US, it seems clear to me that the specialty is dead and will survive in academic centers only whether this works or not.
I wonder what pushed people in such a tiny field, it was my 3rd choice and only went in once I was guaranteed I would do fine even if everything went bust...
Only country I know of where rad onc have the power to force med onc to let them touch their money is France for historical reasons.
In the US they will let do that as much as cardiologists will let you put stents and ophthalmologists do cataract surgery.

2 log kills (100x) is a safe and generous
estimate.

 

[deleted1083739]

Wait, what?

1) Your account says "MD/PhD Student" - is that accurate? I guess I can understand that statement coming from a student, but it's very difficult to just "change fields" after 5 years of residency training (after 4+ years of medical school) - we'd have to go back and do, at minimum, another 3 years of training to practice in a different specialty. I don't have that kind of gas in the tank - I'd probably go into industry to be honest.

2) A common misconception is that the complaining on SDN is because we hate RadOnc. On the contrary, all of the criticizing of the specialty comes around the meta-reality of how RadOnc is (or is not) managed in America (regarding supply and demand and about 4,000 other points). I've actually come to believe that most of the regular posters on this board love Radiation Oncology more than a lot of people I know in real life.

If you don't feel passionately about something, why spend so much time writing about it? @scarbrtj alone has written a library's worth of hyperlink-laden diatribes that make it clear he is extraordinarily passionate about the field and desperately doesn't want it to die.

I'm an attending in a far away land.

My point was, didn't you all know rad onc was the most specialized field in all modern medicine. (IMO only deeper pit is surg onc's)
The current state of affairs was a very expected risk for decades.
Being an organ or "theme" specialist is a muuuuch safer route.

What made you take that risk anyway? My bets are hedged, but I never would have gone in rad onc in the US.

 

[deleted1083739]

2 log kills (100x) is a safe and generous
estimate.

Talking about log kills is a pseudo simplification, it is heavily non linearly depending on models themselves depending of non linear assumptions.
Only measurable parameter is the one log kills is supposed to predict (TCP models are mostly used as interpolation functions between known TC points, I would be very careful using them outside that context)

And we don't even know 40 years after what the alpha/beta is at the doses FLASH are currently tested. (key to extrapolate overdose effect >15Gy)

What we see now is NO toxicity in tissues and animals at doses that should have killed them.
If we only have hyperthermia without hyperthermia it is a revolution.
It will mean, maybe apart GBM, infield recurrence in GTV will become rare.

But for now we have no clue if current models hold either for fractionation, field size, ceramide/vascular dose thresholds, immuno magic, radiosensitizers etc etc

 

[deleted1083739]

On further reflection, maybe flash is less likely to cause lymphopenia, but still don’t see how a modest improvement in radiation cytotoxicity or se profile would impact job market.

Well, I don't think cytotoxicity is the dose limiting tox nowadays. (as is hippocampal stem cells depletion in neurooncology to come back to the papers I must confess)

30% more physical dose at current radiosurgery dose means >90% cure for anything you can already treat at >15Gy single fraction.
And that is the only thing the data shows us at this day.

But assuming LQ hold (absolutely no clue about that), the benefit should be substantially larger with fractionation.

 

[scarbrtj]

Talking about log kills is a pseudo simplification, it is heavily non linearly depending on models themselves depending of non linear assumptions.
Only measurable parameter is the one log kills is supposed to predict (TCP models are mostly used as interpolation functions between known TC points, I would be very careful using them outside that context)

And we don't even know 40 years after what the alpha/beta is at the doses FLASH are currently tested. (key to extrapolate overdose effect >15Gy)

 

[StIGMA]

What we see now is NO toxicity in tissues and animals at doses that should have killed them.

Dude, you are either being intentionally misleading or uninformed.

Here's just one (of many papers) showing FLASH toxicitiy-

The Advantage of FLASH Radiotherapy Confirmed in Mini-pig and Cat-cancer Patients - PubMed "Using, respectively, depilation and fibronecrosis as acute and late endpoints, a protective effect of FLASH-RT was observed (≥20% dose-equivalent difference vs. Conv-RT). Three cats experienced no acute toxicity, whereas 3 exhibited moderate/mild transient mucositis, and all cats had depilation."

So half the animals in this highly cited paper had "toxicity in tissues." ... Using an optimized dose regimen to maximize the effect of the results. Most human FLASH experiments / treatments will not be single beam/single fraction which will also decrease the potential therapeutic benefit.

I agree with you that 30% improvement would be very significant clinically for same reasons you describe.

 

[evilbooyaa]

I mean Flash is cool, but how about we prove it outside of in-vitro and mouse models before we claim it to be the great savior? I'm optimistic, but not a zealot - show me the data

 

[Ray D. Ayshun]

Its no wonder convicted sex offenders will comprise a substantial proportion of incoming residents with all this talk about the future of radonc being built on flashing patients.

 

[scarbrtj]

Speaking of advances.
A great recap re MRgRT

Is the MR-linac the future of adaptive radiotherapy? – Physics World

A debate at the ESTRO 2020 congress questioned whether there is a future for adaptive radiotherapy without an MR-linac

physicsworld.com

 

[RadOncDoc21]

Oncology Programs: Take Action Now to Avoid a Massive Increase in Physician Expense in 2021

Explore the anticipated impact of the proposed CMS changes to the MPFS for CY 2021 to avoid possible financial losses for your organization.

www.ecgmc.com

looks like med onc still wins but definitely a big blow to oncology overall. No way organizations are going to pay over FMV!

 

[drewdog1973]

Explain in simple terms?

 

[RadOncDoc21]

Explain in simple terms?

I’ll try but I’m a simple man myself. Basically the wRVU model has changed significantly in a way where now less wRVU means more compensation. This is good and bad as places will start dropping docs due to having to pay them more for less work. Might be good for whoever is left but that means less help and more work overall. That’s my 2 cents, but again I could be wrong.

 

[drewdog1973]

Hmm. Unless I’m misunderstanding ...

Another way of saying less RVU means more compensation is saying the $/RVU has gone up. This happens from time to time. That’s not a bad thing, generally. If I got more per RVU, I would not be unhappy. If I got less per RVU, I would be unhappy.

If the $/RVU went down, would we celebrate?

 

[RadOncDoc21]

I’m a pessimist by nature. When was the last time you’ve seen salaries go up and work go down for docs?

 

[drewdog1973]

Late 1990s Rad Onc?

Not buying it (unless I’m missing something). If the opposite happened, we wouldn’t celebrate “less money for more work” as a good thing...

 

[RadOncDoc21]

Late 1990s Rad Onc?

Not buying it (unless I’m missing something). If the opposite happened, we wouldn’t celebrate “less money for more work” as a good thing...

No we definitely wouldn’t celebrate that.

I hope you’re right, I just see (again pessimist side) a rationale to cut jobs, overwork the ones that are left then cut compensation because this thing is always changing (usually for the bad).

 

[summarizer]

Nuclear medicine. Theranostics ftw

 

[TheWallnerus]

Progress/advances in rad onc = (-1)^0.5 ?

1999:
MSKCC publishes an article about IMRT for whole breast RT; finds that "[t]he use of intensity modulation with tangential fields can significantly reduce the dose received by coronary arteries, normal lung, contralateral breast, and surrounding soft tissues... improvements in dose homogeneity throughout the breast can also be achieved, particularly in the inferior and superior regions."

2013:
ASTRO proclaims that breast IMRT studies were not IMRT studies. And even if they were: don't use IMRT for whole breast RT.