Winter Is Coming

[medgator]

I mean, couldn't we offer hypofractionatedRT only, as in no surgery as valid option? I have never had a woman choose ET or RT in the setting.

Don't see why not and there are some forthcoming trials looking at this iirc

---

Members don't see this ad.

 

[flannery o'connor]

Don't see why not and there are some forthcoming trials looking at this iirc

How would you see the results of this going down in the mdt?

 

[TheWallnerus]

I offer it quite a bit. If a woman is concerned about being compliant with 5 years of an AI, i tell them a short course of RT becomes even more important to consider

I mean, couldn't we offer hypofractionatedRT only, as in no surgery as valid option? I have never had a woman choose ET or RT in the setting.

Gator what Flannery is saying is The Life You Save May Be Your Own… and calling for eliminating both surgery and anti-estrogen therapy completely. A kind of “virtual lumpectomy.” Now, if we call it virtual lumpectomy, Susan Komen and the Culture of Oncology will have us drawn and quartered. So we need to think this through very carefully. Maybe call it The Stinky Radiotherapy Cheese Option (But Some Women Might Like the Taste). Going to need trick plays a-plenty to kick both surgery and the med oncs out of the early stage breast cancer bed.

 

[flannery o'connor]

My man. Wallernus with the goods. A good man is not that hard to find, after all.

 

[RadOncDoc21]

A med onc could just throw in the words “garble garble spit…hookie pookie… immunotherapy” and boom there goes a trial!

 

[flannery o'connor]

A med onc could just throw in the words “garble garble spit…hookie pookie… immunotherapy” and boom there goes a trial!

NEED THOSE REFERALS. CANNOT UPSET ANYONE. CHEMO DOCTORS AND SURGEONS DO AS THEY PLEASE.

 

[medgator]

How would you see the results of this going down in the mdt?

Good reason to be tight with your surgeons with or without mdt.

I get a handful of referrals a year from gen Surg where the patient has already made up her mind never to take endocrine therapy

 

[flannery o'connor]

Good reason to be tight with your surgeons with or without mdt.

I get a handful of referrals a year from gen Surg where the patient has already made up her mind never to take endocrine therapy

I see them when they get referred to us and the chemo doctors with the option to take 1 or the other or both...none have ever chosen ET.

 

[theradiator]

NEED THOSE REFERALS. CANNOT UPSET ANYONE. CHEMO DOCTORS AND SURGEONS DO AS THEY PLEASE.

Actually breast cancers are diagnosed by radiologists and the vast majority of mammograms are ordered by primary care and obstetrics and gynecology. Chemo doctors, surgeons, plastic surgeons and radiation oncologists are technically all in the same boat in terms of needing referrals from other specialists.

We are vulnerable because breast radiation is positioned last after surgery and chemotherapy with no meaningful role in the neoadjuvant or definitive settings. Thus all referrals are filtered through breast surgery or medical oncology.

 

[medgator]

Actually breast cancers are diagnosed by radiologists and the vast majority of mammograms are ordered by primary care and obstetrics and gynecology. Chemo doctors, surgeons, plastic surgeons and radiation oncologists are technically all in the same boat in terms of needing referrals from other specialists.

We are vulnerable because breast radiation is positioned last after surgery and chemotherapy with no meaningful role in the neoadjuvant or definitive settings. Thus all referrals are filtered through breast surgery or medical oncology.

Importance of cross referrals to other specialties out in the real world when possible.... Where do you send h&n, anal etc pts when they need concurrent? Where do you send your h&n pts when they need a peg and possibly a port?

 

[wandering star]

I dunno; did oncotype have prospective data when it entered routine practice?

Imagine this will be ordered by med oncs and surgeons who will then not send the low risk patients.

Not to say any of the above is right, but probably how it will go down.

As I understand it, Oncotype was first published back in 2004 and then was available as a commercial product, where anyone could use it but its predictive value was not known. The TAILORx trial, arguing that it can guide chemo, was a prospective randomized trial on 10,000 patients. In this context (giant sample size, commercial product, prospective setting) the risk of false discovery is pretty low.

For POLAR, it looks much smaller, retrospective, and the whole point was to find a group for which you can omit radiotherapy. These kinds of studies are prone to overfitting and false discovery, and the line between well run methodology and poorly run methodology is hard to identify. They say in the methods that "the score was locked prior to validation." For Oncotype this was airtight: the product was already on shelves for a decade, of course the gene score was locked. For POLAR, what if they found a bug in the code? Of course they would go back and change the data processing then ... how many iterations did they make? In the best case scenario, Team A makes the POLAR score, has no access to the validation data, and hands over the algorithm to Team B who tests it on validation data. This is much better than what many academic groups do, but then if you have 20 such groups in the world working on 20 different datasets, 1 of them will find p < 0.05. Because these datasets are small, it's hard to estimate publication bias (as opposed to Oncotype where even a failed trial would have been known because of its size). Or, because of the vagaries of machine learning, it might work well at the host institution but fail to generalize to another location.

 

[RickyScott]

nuclear fusion and quantum computing may be possible in the next 20 years, but better predictions of who needs radiation for early stage breast cancer is an insurmountable and so much more complex problem?

 

[OTN]

nuclear fusion and quantum computing may be possible in the next 20 years, but predicting who needs radiation for breast cancer is an insurmountable and so much more complex problem?

It's easier to build something from the ground up than fix a biological system we're not close to fully understanding which has gone awry.

 

[RickyScott]

It's easier to build something from the ground up than fix a biological system we're not close to fully understanding which has gone awry.

This is not a hard biological problem. Apparently better ki 67 testing can almost get you there. So many avenues to a solution including improvements in Ct dna, ngs etc. we are not talking abt curing cancer or coming up with a better drug.

.Lastly, what’s the big deal if you omit xrt in early stage? It has 0 impact on survival and second surgery is not very invasive and can even be done under local.

Hormones improve survival by 1% in early breast and decrease risk of contra lateral cancer. Radiation has 0 impact on survival or the contralateral breast.

“

 

[TheWallnerus]

For POLAR, it looks much smaller, retrospective, and the whole point was to find a group for which you can omit radiotherapy. These kinds of studies are prone to overfitting and false discovery

Essentially: the KM curves for POLAR-low and POLAR-high could just as easily be replicated by designing a score that looked at, for example, the day of week a patient is born coupled with their Zodiac sign. And that is a possibility. I just don't think, in this instance, the possibility is large.

A test like POLAR, or POLAR itself, *will* be used in Oncology and applied to radiotherapy decisions in the next decade. The paradigm that will change is this: radiation oncologists will come to believe that there are post-lumpectomy patients who are not helped with radiotherapy. The thing is we have HUGE amounts of data already telling us this... at best, for low risk older women, we needlessly irradiate about 9 out of 10 women (number needed to needlessly irradiate is NNT minus one). Someone, somewhere, will be able to predict who most or all of those nine women are; we just don't have that predictive ability today so we irradiate 10 out of 10 post-lumpectomy women in general. Medicine will eventually look back on this approach as anachronistic.

 

[theradiator]

nuclear fusion and quantum computing may be possible in the next 20 years, but predicting who needs radiation for breast cancer is an insurmountable and so much more complex problem?

Actually the problem is prioritization and who the burden of proof is on to justify treatment. Why is radiotherapy always targeted for omission?

https://ascopubs.org/doi/full/10.1200/JCO.22.02171

For breast - other salient questions relative to 'appropriate utilization' could be:

subgroups not requiring endocrine therapy
subgroups not requiring surgery for certain breast atypias
subgroups not requiring breast MRI and extensive and often duplicative imaging such as repeat mammograms, ultrasound, second look imaging, preRT mammogram
plastic surgery and oncoplastic tissue transfer of uncertain oncologic or even cosmetic benefit
rationale for much of neoadjuvant chemotherapy until an overall survival advantage is proven
contralateral mastectomy without survival benefit

I could go on for days. Pretty sure much of this activity is simply accepted as 'standard' local practice. All of these activities generate clinical activity. This logic appears to apply to all specialties except for radiation oncology.

 

[RickyScott]

Actually the problem is prioritization and who the burden of proof is on to justify treatment. Why is radiotherapy always targeted for omission?

https://ascopubs.org/doi/full/10.1200/JCO.22.02171

For breast - other salient questions relative to 'appropriate utilization' could be:

subgroups not requiring endocrine therapy
subgroups not requiring surgery for certain breast atypias
subgroups not requiring breast MRI and extensive and often duplicative imaging such as repeat mammograms, ultrasound, second look imaging, preRT mammogram
plastic surgery and oncoplastic tissue transfer of uncertain oncologic or even cosmetic benefit
rationale for much of neoadjuvant chemotherapy until an overall survival advantage is proven
contralateral mastectomy without survival benefit

I could go on for days. Pretty sure much of this activity is simply accepted as 'standard' local practice. All of these activities generate clinical activity. This logic appears to apply to all specialties except for radiation oncology.

To be clear, I am very pro radiation, but just can’t imagine it being delivered adjuvantly for early breast in 20 years. Our pathologists are convinced that better ki67 testing can identify the Gleason 6s of breast cancer and whelan also said something to this effect. Ultimately, we can’t control the outcome here unlike with resident numbers.

In terms of radiation replacing surgey. Never going to happen because surgery here is so minimally invasive. We can’t even replace cystectomies despite much better evidence of equivalence.

 

[TheWallnerus]

Actually the problem is prioritization and who the burden of proof is on to justify treatment. Why is radiotherapy always targeted for omission?

https://ascopubs.org/doi/full/10.1200/JCO.22.02171

For breast - other salient questions relative to 'appropriate utilization' could be:

subgroups not requiring endocrine therapy
subgroups not requiring surgery for certain breast atypias
subgroups not requiring breast MRI and extensive and often duplicative imaging such as repeat mammograms, ultrasound, second look imaging, preRT mammogram
plastic surgery and oncoplastic tissue transfer of uncertain oncologic or even cosmetic benefit
rationale for much of neoadjuvant chemotherapy until an overall survival advantage is proven
contralateral mastectomy without survival benefit

I could go on for days. Pretty sure much of this activity is simply accepted as 'standard' local practice. All of these activities generate clinical activity. This logic appears to apply to all specialties except for radiation oncology.

These are great points, but I can't further expend any energy going forward in life thinking about them. The Culture of Oncology has moved on and even trying to have this discussion with someone outside rad onc must be like those first few moments when God changed the language of everyone working on the Tower of Babel. Or like that episode of Twilight Zone, "Wordplay."

 

[TheWallnerus]

To be clear, I am very pro radiation, but just can’t imagine it being delivered adjuvantly for early breast in 20 years. Our pathologists are convinced that better ki67 can identify the Gleason 6s of breast cancer and whelan also said something to this effect. Ultimately, we can’t control the outcome here unlike with resident numbers.

In terms of radiation replacing surgey. Never going to happen because surgery here is so minimally invasive. We can’t even replace cystectomies despite much better evidence of equivalence.

If I were to write a history of radiation oncology, I would have to include the heady times of the 70s and 80s when mastectomy began being knocked off its perch of supremacy in breast cancer. And lumpectomy and radiation were accepted as mastectomy's equal. It cannot be overstated enough that this was a HUGE paradigm shift. It soon became apparent in the mid 90s (1993... the Annus Mirabilis of Radiation Oncology if there ever was one), especially as women began flocking to mammography, that there were not going to be enough radiation oncologists in America. I vividly remember a segment on Good Morning America, circa 1995, where a very comely physician was being interviewed by Joan Lunden. I was considering rad onc, wasn't really sure, and the lady MD states something to the effect: "Now, based on these NEJM reports, thousands of more women a year are going to need radiation." This was an incredible statement, and she seemed surprised even making it (wish I could find the video!). Radiation oncology was monumentally changing/evolving, becoming ever more popular; I would write in my history of radiation oncology tome: post-lumpectomy radiation therapy all by itself gave rad onc an established and well earned position within the Culture of Oncology. (NB: NEJM helped get it there.)

But it might have been, as I mentioned, a position which... as the history continues being written... continued into anachronism.

EDIT: Oh. One other thing. Veronesi writing in NEJM in 1993: "However, there was a substantial effect of age: patients more than 55 years old who did not receive radiotherapy had a low rate of local recurrence (3.8 percent). The four-year overall survival was similar in the two treatment groups."

 

[RickyScott]

Part of the culture of radonc in the 90s included a respected and accomplished leadership. Today, the field is dominated by sh-t birds. Name a leader from 90s like Carlos Perez or jay Harris and everyone knew what they had done for the field. Not at all true today- ie the chair of mdacc.

 

[Mandelin Rain]

Actually the problem is prioritization and who the burden of proof is on to justify treatment. Why is radiotherapy always targeted for omission?

To be fair, this isn't the case.

I'm old enough to remember when just about every breast cancer >1 cm or node positive got chemo. OncotypeDx came a LONG time ago.

I'm not old enough to remember Halsteds and full dissections on every breast cancer, however. That was even longer ago.

 

[RadOncDoc21]

To be fair, this isn't the case.

I'm old enough to remember when just about every breast cancer >1 cm or node positive got chemo. OncotypeDx came a LONG time ago.

I'm not old enough to remember Halsteds and full dissections on every breast cancer however.

True but come on, it’s chemo… a little bit of radiation never hurt anyone. I am 100% certain of this claim.

 

[sirspamalot]

Is it possible to laugh and cry at the same time? Cause this thread is doing it for me bigly. Welcome to 2023 and the ride into oblivion has begun. Good luck to all players.

 

[sirspamalot]

Part of the culture of radonc in the 90s included a respected and accomplished leadership. Today, the field is dominated by sh-t birds. Name a leader from 90s like Carlos Perez or jay Harris and everyone knew what they had done for the field. Not at all true today- ie the chair of mdacc.

CP was el jefe. He was famously known for two things academically speaking: being a retrospective publishing machine using 1970's computer technology (which was radical for its time and wildly successful) and... running one of the most malignant radiation oncology training programs known to man reaching its apex in the late 90's along with a cast of bizarre staff.

He was an impeccable physician, but a poor steward of human beings, and held onto his chairmanship (and his, at the time, plush salary) for far far too long. He stymied the career development of several prominent young radoncs by failing to lead (all whom left) and failed miserably in a succession plan. Fear, intimidation, and allowing senior staff to harass junior staff is not a good strategy. And yet, the institution survives, as it always does.

Let us not reminisce too much for the old days.

 

[NotMattSpraker]

Essentially: the KM curves for POLAR-low and POLAR-high could just as easily be replicated by designing a score that looked at, for example, the day of week a patient is born coupled with their Zodiac sign. And that is a possibility. I just don't think, in this instance, the possibility is large.

A test like POLAR, or POLAR itself, *will* be used in Oncology and applied to radiotherapy decisions in the next decade. The paradigm that will change is this: radiation oncologists will come to believe that there are post-lumpectomy patients who are not helped with radiotherapy. The thing is we have HUGE amounts of data already telling us this... at best, for low risk older women, we needlessly irradiate about 9 out of 10 women (number needed to needlessly irradiate is NNT minus one). Someone, somewhere, will be able to predict who most or all of those nine women are; we just don't have that predictive ability today so we irradiate 10 out of 10 post-lumpectomy women in general. Medicine will eventually look back on this approach as anachronistic.

Great posts! I love this Culture of Oncology discussion. That said, I hate NNT. It's an arm chair oncologist's measure, not a clinician's measure. I tell patients about this all the time and say what you say... 9/10 people don't need radiation, we just don't know who the 1 person is. Not very useful for people that need to make decisions about real patients.

I've always found it interesting how risk assessment seems different for breast versus other cancers. In my experience, it's not a place where oncologists or patients like to ride a 10% risk.

As I understand it, Oncotype was first published back in 2004 and then was available as a commercial product, where anyone could use it but its predictive value was not known. The TAILORx trial, arguing that it can guide chemo, was a prospective randomized trial on 10,000 patients. In this context (giant sample size, commercial product, prospective setting) the risk of false discovery is pretty low.

For POLAR, it looks much smaller, retrospective, and the whole point was to find a group for which you can omit radiotherapy. These kinds of studies are prone to overfitting and false discovery, and the line between well run methodology and poorly run methodology is hard to identify. They say in the methods that "the score was locked prior to validation." For Oncotype this was airtight: the product was already on shelves for a decade, of course the gene score was locked. For POLAR, what if they found a bug in the code? Of course they would go back and change the data processing then ... how many iterations did they make? In the best case scenario, Team A makes the POLAR score, has no access to the validation data, and hands over the algorithm to Team B who tests it on validation data. This is much better than what many academic groups do, but then if you have 20 such groups in the world working on 20 different datasets, 1 of them will find p < 0.05. Because these datasets are small, it's hard to estimate publication bias (as opposed to Oncotype where even a failed trial would have been known because of its size). Or, because of the vagaries of machine learning, it might work well at the host institution but fail to generalize to another location.

This is exactly the kind of methodology where I don't believe it for a second unless it's validated prospectively. A LOT of these models never succeed in the clinic for all the reasons you state.

Im a believer in the concept, but don't think it is doomsday.

 

[theradiator]

Actually the problem is prioritization and who the burden of proof is on to justify treatment. Why is radiotherapy always targeted for omission?

https://ascopubs.org/doi/full/10.1200/JCO.22.02171

For breast - other salient questions relative to 'appropriate utilization' could be:

subgroups not requiring endocrine therapy
subgroups not requiring surgery for certain breast atypias
subgroups not requiring breast MRI and extensive and often duplicative imaging such as repeat mammograms, ultrasound, second look imaging, preRT mammogram
plastic surgery and oncoplastic tissue transfer of uncertain oncologic or even cosmetic benefit
rationale for much of neoadjuvant chemotherapy until an overall survival advantage is proven
contralateral mastectomy without survival benefit

I could go on for days. Pretty sure much of this activity is simply accepted as 'standard' local practice. All of these activities generate clinical activity. This logic appears to apply to all specialties except for radiation oncology.

Am I unique that I spend more time interacting with other specialties (aka 'real' physicians) and observing their behavior as opposed to other radiation oncologists?

My point is this - our specialty in contradistinction to our peer specialties has chosen a distinct strategy for our most common indication, adjuvant treatment after breast conserving surgery. We have essentially engaged in a form of virtue signaling that radiation would only be recommend if it clearly improves an important endpoint, preferably overall survival. In that context, our field has already self reduced our footprint for post-lumpectomy breast from 33 fractions to 5 fractions. Irradiated volume has also been reduced to address any concerns of toxicity. Is this not a form of self-censoring? We already played that card but yet it still does not immunize us from further loss of relevance in the future from interventions such as POLAR.

Perhaps a poor analogy, nations have a choice in how to engage with other nations, including larger neighbors. It is interesting to compare the approach of Finland to Estonia, Latvia and Poland during World War II. If radiation oncology were a nation, we are not the Fighting Finns but I wish we had more of that fighting spirit.

 

[Mandelin Rain]

We have essentially engaged in a form of virtue signaling that radiation would only be recommend if it clearly improves an important endpoint, preferably overall survival.

I'd like to think that all docs engage with medicine in this way.

Because we have better premeds to reduce the toxicity of chemo, I don't see med onc prescribing in spite of low-risk genomic profiles.

If an intervention has no clinical value, you shouldn't be doing it regardless of how convenient/reduced toxic it is. We can debate what constitutes "clinical value" but you'd be hard pressed to demonstrate it if prospective POLAR data replicates the curves seen above. We don't have to like it. It's just what is going to happen (or not, in which case we'll continue current standard).

I don't understand lamenting progress that actually benefits patients. Direct ire at protons that are out there breaking ribs, causing esophagitis (somehow), and bankrupting our specialty.

 

[RadOncDoc21]

I'd like to think that all docs engage with medicine in this way.

Because we have better premeds to reduce the toxicity of chemo, I don't see med onc prescribing in spite of low-risk genomic profiles.

If an intervention has no clinical value, you shouldn't be doing it regardless of how convenient/reduced toxic it is. We can debate what constitutes "clinical value" but you'd be hard pressed to demonstrate it if prospective POLAR data replicates the curves seen above. We don't have to like it. It's just what is going to happen (or not, in which case we'll continue current standard).

I don't understand lamenting progress that actually benefits patients. Direct ire at protons that are out there breaking ribs, causing esophagitis (somehow), and bankrupting our specialty.

 

[dieABRdie]

To be clear, I am very pro radiation, but just can’t imagine it being delivered adjuvantly for early breast in 20 years.

Got to get that Florence APBI protocol up and running in your region. Every prospective, randomized trial still shows a local control benefit to RT. If you can get that benefit without toxicity.... it doesn't make sense to avoid it. Our surgeons have been thrilled and are asking about this rather than "choosing wisely" from now on.

Whole breast for HR+, early stage will be dead though.

 

[TheWallnerus]

We could try farting in their general direction?

 

[DoctwoB]

View attachment 364212
View attachment 364213


These are the kind of trials we need i guess

Pretty sure there is a similar trial ongoing for cT0 patients after neoadjuvant chemotherapy for bladder cancer, though I could be wrong

Edit: Here it is, https://ascopubs.org/doi/abs/10.1200/JCO.2021.39.6_suppl.397.

They risk stratify based on mutation testing, though in future would expect ctDNA t o be the standard.

 

[Doctorer]

Perhaps a poor analogy, nations have a choice in how to engage with other nations, including larger neighbors. It is interesting to compare the approach of Finland to Estonia, Latvia and Poland during World War II. If radiation oncology were a nation, we are not the Fighting Finns but I wish we had more of that fighting spirit.

Latvia and Poland were stuck in the tough, difficult to defend space between the Germans/Russians, while Finland had a much more defensible position, and was separated by the Baltic from Germany.

Nice analogy: are the medoncs the Germans or Russians?

 

[RickyScott]

Latvia and Poland were stuck in the tough, difficult to defend space between the Germans/Russians, while Finland had a much more defensible position, and was separated by the Baltic from Germany.

Nice analogy: are the medoncs the Germans or Russians?

Fins had great leadership. Russians lost 4-500k in the winter war despite Finland receiving almost no arms from the west. Hitler thought he could easily take Russia based on their performance against the fins. Leadership counts and so does strategic depth. Radonc has 0 going for it.

 

[medgator]

We could try farting in their general direction?

Honestly in the community, i feel like biggest catfish are the IR guys who literally get referrals for biopsies and feel the need to "consult" the patient and push RFA for early stage lung without sending the patient back to the referring or getting us/CT surgery/pulm involved.

Can't imagine it's any different with bone biopsies. The problem is, that **** eventually gets out in the community, esp when patients are coming in with recurrences/malignant effusions or empyemas to the hospital and those same pulmonologists/CT guys are getting consulted to manage the IR ****ups/recurrences when they inevitably happen.

 

[RickyScott]

Honestly in the community, i feel like biggest catfish are the IR guys who literally get referrals for biopsies and feel the need to "consult" the patient and push RFA for early stage lung with sending back to the referring or getting us/CT surgery/pulm involved.

Can't imagine it's any different with bone biopsies. The problem is, that **** eventually gets out in the community, esp when patients are coming in with recurrences/malignant effusions or empyemas to the hospital and those same pulmonologists are getting consulted

In my hospital, they are consulted by house to ablate Mets all the time.

 

[TheWallnerus]

In my hospital, they are consulted by house to ablate Mets all the time.

 

[medgator]

In my hospital, they are consulted by house to ablate Mets all the time.

That's fine... Inpatient radiation is a pain in the ass out in the real world anyways.

Most oncology isn't happening inpatient.... Let them catfish those cases before the inevitable hospice consult

 

[TheWallnerus]

That's fine... Inpatient radiation is a pain in the ass out in the real world anyways.

Most oncology isn't happening inpatient.... Let them catfish those cases before the inevitable hospice consult

I remember doing a lot more inpatient radiation in residency and early in career. Has that fallen off or am I romanticizing the past.

 

[madchemist89]

I'm doing very little inpatient in the community. In residency, we did lots of inpatient. Multiple consults per day. I even asked the program director if we could have an inpatient service since there were so many, but he just chuckled.

 

[flannery o'connor]

Actually breast cancers are diagnosed by radiologists and the vast majority of mammograms are ordered by primary care and obstetrics and gynecology. Chemo doctors, surgeons, plastic surgeons and radiation oncologists are technically all in the same boat in terms of needing referrals from other specialists.

We are vulnerable because breast radiation is positioned last after surgery and chemotherapy with no meaningful role in the neoadjuvant or definitive settings. Thus all referrals are filtered through breast surgery or medical oncology.

lol why Mastodon?

 

[flannery o'connor]

Actually breast cancers are diagnosed by radiologists and the vast majority of mammograms are ordered by primary care and obstetrics and gynecology. Chemo doctors, surgeons, plastic surgeons and radiation oncologists are technically all in the same boat in terms of needing referrals from other specialists.

We are vulnerable because breast radiation is positioned last after surgery and chemotherapy with no meaningful role in the neoadjuvant or definitive settings. Thus all referrals are filtered through breast surgery or medical oncology.

Thats not really true. Also, in early stage, chemo/systemic improves cure by at most 1-3%. RT reduces ipsilateral recurrence by at least 50%. Sequencing is not always rational.

Neoadjuvant radiotherapy of early-stage breast cancer and long-term disease-free survival

Compared with surgery alone, postoperative adjuvant radiotherapy (RT) improves relapse-free survival of patients with early-stage breast cancer. We evaluated the long-term overall and disease-free survival rates of neoadjuvant (presurgical) versus adjuvant ...

www.ncbi.nlm.nih.gov

 

[NotMattSpraker]

Honestly in the community, i feel like biggest catfish are the IR guys who literally get referrals for biopsies and feel the need to "consult" the patient and push RFA for early stage lung with sending back to the referring or getting us/CT surgery/pulm involved.

Can't imagine it's any different with bone biopsies. The problem is, that **** eventually gets out in the community, esp when patients are coming in with recurrences/malignant effusions or empyemas to the hospital and those same pulmonologists are getting consulted

This happened to me! He didnt call or anything. We sent the person for a fiducial and then next thing we know they are scheduled for TACE haha.

It has shifted referral patterns a bit. Weird choice honestly to have all that happen to capture a single case.

I remember doing a lot more inpatient radiation in residency and early in career. Has that fallen off or am I romanticizing the past.

Ive noticed in academic hospitals, there are a ton of inpatient consults that arent necessary. Today I love to do a card drop and say hi, but for a very busy rad onc or trainees trying to learn, thats silly.

Rad Onc leadership was always kind of timid pushing back on it. I get it, but kinda weird.

 

[medgator]

This happened to me! He didnt call or anything. We sent the person for a fiducial and then next thing we know they are scheduled for TACE haha.

It has shifted referral patterns a bit. Weird choice honestly to have all that happen to capture a single case.

No reason not to push back. I'm usually sending most lung pts to pulmonary anyways for enb ebus bx.

I guess some IRs do ports and pegs but no reason not to send those to general surgeons who refer breast/skin/gi cases etc to you.

And if someone actually needs a CT guided bx of something, plenty of diagnostic folks can do those too without trying to steal the patient for something shady

 

[elementaryschooleconomics]

This happened to me! He didnt call or anything. We sent the person for a fiducial and then next thing we know they are scheduled for TACE haha.

It has shifted referral patterns a bit. Weird choice honestly to have all that happen to capture a single case.



Ive noticed in academic hospitals, there are a ton of inpatient consults that arent necessary. Today I love to do a card drop and say hi, but for a very busy rad onc or trainees trying to learn, thats silly.

Rad Onc leadership was always kind of timid pushing back on it. I get it, but kinda weird.

I also noticed a HUGE drop in inpatient consults from residency to practice.

A few months ago I mentioned this to a nurse, who gave me a funny look - "What? Our inpatient numbers are more than twice what the were before you got here".

I still definitely got silly consults too, but the nature of "silly" changed as navigating the Healthcare system has gotten worse and worse with staffing shortages etc.

In the final few weeks before leaving my prior gig, I believe I had 3-4 consults which were essentially "SOS" cries from MedOnc, with patients they were trying to transfer out but couldn't get beds.

Anyway - spines? Academic RadOncs? Nah.

 

[medgator]

I remember doing a lot more inpatient radiation in residency and early in career. Has that fallen off or am I romanticizing the past.

I tell referrings that like me to minimize calling me to the hospital unless it's absoutely urgent.... The hospital is a pain about sending the patients over and it's a real cluster**** trying to get paid if it's a Medicare patient because of the DRG/payment bundle. Way better for them to discharge them right over to my office

 

[communitydoc13]

Ive noticed in academic hospitals, there are a ton of inpatient consults that arent necessary.

There's a ton of inpatient consults that aren't necessary period. I believe that the era of intelligent, inpatient generalist care has passed us by.

One thing that I've learned recently, in trying to keep a community onc clinic afloat during a staffing shortage, is that all those things that are valued during full staffing operations go out the window when there aren't enough docs.

When you are fully staffed, the typical culture of specialist docs is to see whatever consult is sent your way as quickly as possible. This is frankly, just good business and ingratiates you to referring docs. It is how I have always practiced. (BTW, I never go to the hospital. The hospital's cancer center is 10 minutes away and if they aren't sending by ambo, we aren't treating. There is no point to consult a patient on a drip. I will see anyone they send over however, at any time of day.)

During staffing shortages, you have to keep people sane. The vast majority of inpatient medonc consultations do not need to be staffed by a physician. They are almost uniformly outpatient workups and management. Medonc also falls prey to reflexive heme consultations in the setting of hospitalists who no longer want to solve problems. No board certified IM doc should need a hemeonc to recommend referral to GI, to transfuse or to manage acute clot.

Of course, all docs should be available by phone to their colleagues at any time, unless they are on vacation IMO. This means that your patient, who is admitted for respiratory failure secondary to COPD and has 2 previously treated early stage non-small cell lung cancers that have been effectively treated with SBRT, is not reflexively put on hospice in the setting of disease progression by the hospitalist when they see the CT chest.

 

[radoncftw]

This happened to me! He didnt call or anything. We sent the person for a fiducial and then next thing we know they are scheduled for TACE haha.

It has shifted referral patterns a bit. Weird choice honestly to have all that happen to capture a single case.



Ive noticed in academic hospitals, there are a ton of inpatient consults that arent necessary. Today I love to do a card drop and say hi, but for a very busy rad onc or trainees trying to learn, thats silly.

Rad Onc leadership was always kind of timid pushing back on it. I get it, but kinda weird.

rad onc leadership who had residents to do all the work. i swear that as a resident i saw, simmed, contoured/planned, and treated patients who the attendings never saw. they did have to sign off on the plan, but that was it. i hated all the inpatient consults we had in residency. pagers were thrown, tears were shed, happy hours were missed sometimes.

now in practice, i occasionally get the silly inpatient consult such as post-op high grade glioma day 1 with prelim path. i go to the room, introduce myself, and do a quick card drop.

i also reward myself by going to the hospital doctors lounge every time i see an inpatient consult. i have cinnamon toast crunch boxes for days.

 

[elementaryschooleconomics]

One thing that I've learned recently, in trying to keep a community onc clinic afloat during a staffing shortage, is that all those things that are valued during full staffing operations go out the window when there aren't enough docs.

During staffing shortages, you have to keep people sane.

SDN is the primary mechanism keeping me sane.

God this is so true, and I'm so glad to hear it outside my own head.

My clinic is doing better than most with staff retention, but that's basically because of the small/rural nature of it, and people don't leave. Even in that setting, though, there's been a ton of turnover.

Right now I feel like most of my day is spent doing anything BUT practicing medicine. Obviously, I think that describes most of our days.

But people "outside" the Healthcare system don't understand what's happening. Maybe it's just where me and my friends work, and that would be great if true. I doubt it though.

It's not even just that it's staffing shortages, it's the loss of institutional knowledge with the the shortages as well. So then when you can actually find people to hire, you end up with new people being "trained" by people barely more senior than they are, still in a short-staffed environment.

A big part of my day, now, is playing mental health therapist to the department. Simultaneously, since I'm the (solo) doc, I am also the primary "villain" if someone doesn't like something I did. This is the natural order of things.

I knew what I was getting into, and I accept my fate...but they don't tell you about this in med school.

 

[TheWallnerus]

SDN is the primary mechanism keeping me sane.

God this is so true, and I'm so glad to hear it outside my own head.

My clinic is doing better than most with staff retention, but that's basically because of the small/rural nature of it, and people don't leave. Even in that setting, though, there's been a ton of turnover.

Right now I feel like most of my day is spent doing anything BUT practicing medicine. Obviously, I think that describes most of our days.

But people "outside" the Healthcare system don't understand what's happening. Maybe it's just where me and my friends work, and that would be great if true. I doubt it though.

It's not even just that it's staffing shortages, it's the loss of institutional knowledge with the the shortages as well. So then when you can actually find people to hire, you end up with new people being "trained" by people barely more senior than they are, still in a short-staffed environment.

A big part of my day, now, is playing mental health therapist to the department. Simultaneously, since I'm the (solo) doc, I am also the primary "villain" if someone doesn't like something I did. This is the natural order of things.

I knew what I was getting into, and I accept my fate...but they don't tell you about this in med school.

Re: they don’t tell you about this in med school (or residency), I wonder if this is more unique of a sentiment in rad onc versus other specialties. My feeling is it might be. This comes from practicing in different “arenas” and seeing similar themes as above arise in very different arenas. And remembering the culture and complaints of my time spent in different specialties, neurosurgery especially. Neurosurgeons don’t brook much nonsense from staff. They really don’t brook staff with which they work villainizing them. The best behaved of those neurosurgery characters can make even the worst behaved rad oncs look like Saint Neri.

We *could* tell residents about the things they don’t tell you about; “end the cycle of abuse.” Maybe write a book. With never ending residency expansion, it might be a decent selling book.

 

[NotMattSpraker]

rad onc leadership who had residents to do all the work. i swear that as a resident i saw, simmed, contoured/planned, and treated patients who the attendings never saw. they did have to sign off on the plan, but that was it. i hated all the inpatient consults we had in residency. pagers were thrown, tears were shed, happy hours were missed sometimes.

I suspect this is quietly becoming a huge problem as academic satellite networks expand. This is not good and seems like it could be just a matter of time until some department has the equivalent bombshell that surgeons have when they run multiple ORs at once with trainees doing basically unsupervised surgery.