You guys got what you wanted

[RickyScott]

Talk about falling up.

We refused to put pts on her anal trial because volumes were idiotic.

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[drewdog1973]

We refused to put pts on her anal trial because volumes were idiotic.

insanity

Who in their right mind treats that way?

 

[medgator]

can you clarify why columbia is terrible? also why kachinic is bad?

Multiple chairs in the last decade. Not really known for good education, also home to an exploitative unaccredited fellowship. They love cheap resident and fellow labor

 

[StIGMA]

Multiple chairs in the last decade. Not really known for good education, also home to an exploitative unaccredited fellowship. They love cheap resident and fellow labor

Just 2 right? They didn't have a chair for >half the decade & took awhile to recruit one. Department is small and I don't see how it could support 8 residents (not to mention an occasional fellow)

 

[scarbrtj]

We refused to put pts on her anal trial because volumes were idiotic.

can you refresh our memories

 

[thecarbonionangle]

0529 can be summarized by a simple rule: “you wouldn’t want to miss”

 

[medgator]

can you refresh our memories

Who treats elective volumes at 1.5/day?

 

[OTN]

We refused to put pts on her anal trial because volumes were idiotic.

I was in a conversation about the creation of that trial. Apparently the doses and volumes were created "by committee", with some of the committee members insisting on large, old-school volumes that made it into the final cut. Not everyone agreed with them, but it was the only way to get consensus among the panel.

 

[RickyScott]

can you refresh our memories

huge margins so that not much of difference between imrt and 2d

 

[elementaryschooleconomics]

I was in a conversation about the creation of that trial. Apparently the doses and volumes were created "by committee", with some of the committee members insisting on large, old-school volumes that made it into the final cut. Not everyone agreed with them, but it was the only way to get consensus among the panel.

As someone who started residency long after IMRT was "the norm", this trial (and anal cancer in general) was really how I came to understand and appreciate what people are comfortable with (margins) and how what decade (and where) they trained influenced that comfort.

So, I at least appreciate 0529 as "how I learned to contextualize studies and techniques"?

But...I don't think that was the intent...

 

[drewdog1973]

RTOG investigators have a hard time with converting 2D to 3D techniques. The first time was a GBM trial from the 90s. 2D was 2-3cm to block edge. These clowns did 2-3cm CTV + a PTV margin. Anyone who trained in the past understands that you still have to add a block margin. We were talking 3-4cm to block edge. “Conformal”. This occurs on the rectal and anal studies, too, and your “conformal” boost is way bigger than a Minsky 2cm to block edge boost.

 

[thecarbonionangle]

As an aside LK ended up “senior author” on NRG CC001. This time they did not recommend contouring the whole ventricle because “you would not want to miss”, so they learned something.

 

[evilbooyaa]

Just 2 right? They didn't have a chair for >half the decade & took awhile to recruit one. Department is small and I don't see how it could support 8 residents (not to mention an occasional fellow)

Seems like there are at least 11 attendings, although I'm not sure how many of those are main campus vs satellites.

Regardless, in the current climate, to EXPAND a residency program, while incredibly short-sighted and selfish, is definitely real ballsy.

 

[scarbrtj]

Seems like there are at least 11 attendings, although I'm not sure how many of those are main campus vs satellites.

Regardless, in the current climate, to EXPAND a residency program, while incredibly short-sighted and selfish, is definitely real ballsy.

Since (despite what some people say or think) there is no neural tissue residing in the balls—and thus balls are incapable of independent, intelligent thought— yes, it's ballsy.

 

[fiji128]

In regards to Columbia Rad Onc, I think the recent chairs were something like this:

Clifford Cao 2008 to 2015? had to resign due to some conflict of interest scandal in Taiwan.
Silvia Formenti 2015 to ? Chair of joint Cornell/Columbia program?
Lawrence Schwartz 2018? Interim chair (but is the chair of radiology)
Lisa Kachnic 2019 to present.

 

[thecarbonionangle]

In regards to Columbia Rad Onc, I think the recent chairs were something like this:

Clifford Cao 2008 to 2015? had to resign due to some conflict of interest scandal in Taiwan.
Silvia Formenti 2015 to ? Chair of joint Cornell/Columbia program?
Lawrence Schwartz 2018? Interim chair (but is the chair of radiology)
Lisa Kachnic 2019 to present.

Those taiwanese mafia scandals will get you.

 

[drewdog1973]

Seems like there are at least 11 attendings, although I'm not sure how many of those are main campus vs satellites.

Regardless, in the current climate, to EXPAND a residency program, while incredibly short-sighted and selfish, is definitely real ballsy.

Has there been actual confirmation of this?

 

[RickyScott]

Those taiwanese mafia scandals will get you.

Rumor was that he was just horrible and rarely present.

 

[thecarbonionangle]

Rumor was that he was just horrible and rarely present.

He did have that cliff chao book which allowed many old timers to learn IMRT

 

[bergonieandtribondeau]

Seems like there are at least 11 attendings, although I'm not sure how many of those are main campus vs satellites.

Regardless, in the current climate, to EXPAND a residency program, while incredibly short-sighted and selfish, is definitely real ballsy.

To the uninitiated, "residency expansion" makes it sound like things are going well. This, of course, is how it can be spun - as if residency expansion and departmental expansion are one and the same, and that the expansion is simply filling a pre-existing need, for everyones benefit.

"Business is booming! Our department is doing so well and has been so prosperous over the past few years, we need more people to join our ranks to help serve our patients. Because our training is so good, we have been given the green light to grace more residents with our top-notch educational and clinical experience."

 

[dieABRdie]

Can someone simplify this discussion? Oversaturation? Too many residents?

Simplify? Yes

Don't do it. Hands down better control of the specialty in Med Physics. Covid will hurt for a bit but that hurts everyone in healthcare. Physicists are the least harmed by fractionation or reimbursement changes. And there is much less incentive to increase residencies in their case because they cost money.

But then again..... that means that physicist residents save money? (foreshadowing......)

 

[medgator]

Simplify? Yes

Don't do it. Hands down better control of the specialty in Med Physics. Covid will hurt for a bit but that hurts everyone in healthcare. Physicists are the least harmed by fractionation or reimbursement changes. And there is much less incentive to increase residencies in their case because they cost money.

But then again..... that means that physicist residents save money? (foreshadowing......)

Physics job market is very good right now, esp with experience and BC, even in places where the rad onc job market is terrible

 

[elementaryschooleconomics]

Physics job market is very good right now, esp with experience and BC, even in places where the rad onc job market is terrible

Some would say more physics jobs are posted to the ASTRO job board than physician jobs!

Me. I would say that.

 

[dieABRdie]

Physics job market is very good right now, esp with experience and BC, even in places where the rad onc job market is terrible

I believe the physicist at my last rural gig did 15 minutes of "actual work" per week.

 

[metallica81788]

There will always be a market for good physicists

 

[w00tz]

There will always be a market for good physicists

On the other hand, the market for therapists looks even bleaker than rad onc physicians. The therapy programs are pumping those guys out like crazy and fractionation will affect them the most.

 

[RadOncDoc21]

On the other hand, the market for therapists looks even bleaker than rad onc physicians. The therapy programs are pumping those guys out like crazy and fractionation will affect them the most.

I still rather have extra therapists around then a RN. I think a resident would be the gold standard.

To be honest I work in a hospital that has residents rotate in our dept... never ever let your attending have you believe a resident isn’t useful to them. I can get more out of a pgy-1 psych resident then I can my nurse who has been working here for over 20 years!

 

[RadOncMegatron]

I still rather have extra therapists around then a RN. I think a resident would be the gold standard.

To be honest I work in a hospital that has residents rotate in our dept... never ever let your attending have you believe a resident isn’t useful to them. I can get more out of a pgy-1 psych resident then I can my nurse who has been working here for over 20 years!

Yo that sucks. My nurses, honestly, are better than a PGY-2 or 3 resident.

 

[medgator]

Yo that sucks. My nurses, honestly, are better than a PGY-2 or 3 resident.

Yup...in the same way an ICU nurse is better than an intern on the unit. People get better with years and years of experience

 

[BobbyHeenan]

As someone who started residency long after IMRT was "the norm", this trial (and anal cancer in general) was really how I came to understand and appreciate what people are comfortable with (margins) and how what decade (and where) they trained influenced that comfort.

So, I at least appreciate 0529 as "how I learned to contextualize studies and techniques"?

But...I don't think that was the intent...

I treat the vast majority of my anal patients with dose painting a la 0529. However, I don't see how anyone enrolled on that trial and followed the exact contouring instructions and was still able to meet most of those constraints. Taking the WHOLE NODAL LEVEL of an involved node to 50.4 Gy yet somehow getting minimal bowel < 45 Gy is nearly impossible, especially in a post-hysterectomy female.

I like the dose painting and dosing (though somtimes if a huge tumor I'll give an extra 3.6 Gy to 57.6ish after 54) on the trial though. Good to hear I"m not the only one out in rad onc world that doesn't follow the contouring on the trial to a T.

 

[drewdog1973]

The reason it was possible is that the coverage goals are way lower than what we tolerate for curative cases. Goes down to 80% being acceptable. So they made massive volumes and you barely cover them.

 

[RadOncDoc21]

Sounds like a good trial for protons!

 

[BobbyHeenan]

Sounds like a good trial for protons!

I think UCincy is enrolling.

In my experience with some patients treated with protons (not by me, but by colleagues), the perineal skin reaction is even worse. It's true of breast cancer so it seems it would be true of anal as well. I bet the bowel toxicity might be better though (depending on your volumes).

 

[thecarbonionangle]

Sounds like a good trial for protons!

Anal proton plans can look very nice

 

[evilbooyaa]

I think UCincy is enrolling.

In my experience with some patients treated with protons (not by me, but by colleagues), the perineal skin reaction is even worse. It's true of breast cancer so it seems it would be true of anal as well. I bet the bowel toxicity might be better though (depending on your volumes).

For a modality that seems to struggle with keeping skin doses low (see increased skin reaction in breast cancer) and struggles with interfaces between soft tissue and rib (more rib fractures in breast cancer) treating anal cancer with protons seems.... counter intuitive. Of course I think treating breast cancer, especially early stage, with protons seems counter intuitive in the face of data but god knows it's being done somewhere on a clinical registry.

But yeah, 0529 volumes are huge and non-sensical. I personally like to treat by 9811 volumes with consideration of sequential boost rather than 1.5Gy daily for elective volumes (which haven't been verified by a PhIII trial), but just use IMRT to minimize bowel/bladder dose.

 

[RadOncDoc21]

Anal proton plans can look very nice

For some reason. I would have figured you would be more into this modality:

Mayo Clinic, Hitachi to build first, next generation, carbon ion therapy treatment facility in North America - Mayo Clinic News Network

ROCHESTER, Minn. and TOKYO, Japan — Mayo Clinic and Hitachi, Ltd. have reached an agreement in principle to build a carbon ion treatment facility as part of Mayo Clinic's recently announced integrated oncology facility which will be constructed at Mayo Clinic's campus in Jacksonville, Florida...

newsnetwork.mayoclinic.org

Agree with what everyone is doing, no reason to stick with such ridiculous fractionations when you can extrapolate doses from other disease sites.

 

[seper]

Criticizing 0529 design and methods... What year is this again

 

[thecarbonionangle]

For some reason. I would have figured you would be more into this modality:

Mayo Clinic, Hitachi to build first, next generation, carbon ion therapy treatment facility in North America - Mayo Clinic News Network

ROCHESTER, Minn. and TOKYO, Japan — Mayo Clinic and Hitachi, Ltd. have reached an agreement in principle to build a carbon ion treatment facility as part of Mayo Clinic's recently announced integrated oncology facility which will be constructed at Mayo Clinic's campus in Jacksonville, Florida...

newsnetwork.mayoclinic.org

Agree with what everyone is doing, no reason to stick with such ridiculous fractionations when you can extrapolate doses from other disease sites.

You would want the proton or carbon plan if you had anal cancer. You know you would.

 

[RadOncDoc21]

Criticizing 0529 design and methods... What year is this again

Last I checked it’s pretty much all we got that’s “new” in regards to radiation and anal cancer. That should also be a sign of where we are today.

 

[RadOncDoc21]

You would want the proton or carbon plan if you had anal cancer. You know you would.

All I know is that I definitely don’t want a “boost” in my anus.

 

[drewdog1973]

All I know is that I definitely don’t want a “boost” in my anus.

Lol.

spot on with last two posts, kind sir/madam

 

[thecarbonionangle]

All I know is that I definitely don’t want a “boost” in my anus.

You know what you like!

 

[taserlaser]

All I know is that I definitely don’t want a “boost” in my anus.

And no butts about it

 

[heavyluva]

Just 2 right? They didn't have a chair for >half the decade & took awhile to recruit one. Department is small and I don't see how it could support 8 residents (not to mention an occasional fellow)

I heard they were trying to double the number of residents from 6 to 12. Any increase in this climate obviously is absurd and reflects a complete disregard for residents, non-boomer attendings, and the general future of this field. So irresponsible and selfish.

 

[Mandelin Rain]

I heard they were trying to double the number of residents from 6 to 12. Any increase in this climate obviously is absurd and reflects a complete disregard for residents, non-boomer attendings, and the general future of this field. So irresponsible and selfish.

Well, programs with 6 or fewer residents were the problem according to Kachnic when she and the ABR failed half a class. Increasing it to 12 makes her part of the solution, clearly.

 

[DavidP]

1) It's actually more due to the change in standard of care for breast and prostate, the most common cancers treated by Radiation Oncology. Breast used to always be like 25 fractions, prostate like 44. Now breast is ~15 and prostate is ~28 (again, grossly over simplifying). SRS/SBRT plays a part, but you could argue that helps us treat more patients than we were 20 years ago (Stage I lung or oligomets, for example). There are multiple other examples as well (active surveillance for low risk prostate etc).

2) RadOnc or not, I would absolutely not recommend going to medical school - it's not a good investment in yourself. This conversation can go in 1,000 different ways, and I'm sure people will disagree with me about this...but I will be actively discouraging my children from going into medicine.

Are you already a board-certified medical physicist or are you still in training?

Could you extrapolate on why you would discourage anyone from medicine? I'm about to apply to med school next year and thats all I hear.

 

[yesmaster]

Could you extrapolate on why you would discourage anyone from medicine?

FAANG/tech

You could look into medical physics, my extrapolation is that medical physicists will be more valued than radiation oncologists as the microeconomics of the labor market plays out.

 

[DoctwoB]

Could you extrapolate on why you would discourage anyone from medicine? I'm about to apply to med school next year and thats all I hear.

Personally I do not discourage people from medicine, but I do think people need to go into it with open eyes. It is long (7 year minimum to finish residency, 9-10 is more typical), expensive (~350k followed by 3-8 years of below market pay), and difficult (2 years of intense studying followed by years of long hours + studying). After making it to the other side, physicians often still feel overworked and undervalued by a system that is increasingly corporitized, offers diminishing autonomy, and is trying to replace their care with cheaper providers while also increasing demands on them that have little to do with medical care in terms of clerical work.

Now with all that said, I think I have one of the best jobs in the world. I treat patients and help them, I take care of interesting pathophysiology, I am intellectually stimulated by what I do, and I am well (relatively speaking) paid for it. But there are a lot of cons to go along with the pros.

 

[DebtRising]

What DoctorB said with the specific addition that many people/physicians know and agree with those statements, but physician advocacy is too splintered between specialties, lobbying power, and different hospital systems to be a stronger advocate. And most importantly by generation - rad onc is not the only speciality where the previous generation has cashed out or is in process of selling what they have left. It is this generation that still has the power. Honestly even they might not have been strong enough, but sure as heck not enough of them tried. Medicine will be picked apart by MBAs on the insurance, pharma, and hospital admin sides until pan professional morale hits so low (or suicides so high - not a cry for help, physician suicide rate is well above the national average) that something breaks.

It’s awesome to do what I do and help and yes challenge myself. It is soul crushing to realize how much worse (relativism) my specific job is to those who came just 10 years before, how much the system profits off my work while both burdening me with targets and metrics that add and change every year, while still preserving the physician as both the source of responsibility and greed in an environment I can’t even control what tests or treatments I deliver. I write this in between doing work so I am not behind for tomorrow. Living the dream!

 

[KeratinPearls]

Congratulations, only 109 Rad onc MD applicants this year; with total 176 applicants. Soon Rad onc will be an escape for those who didn't match in the SOAP, and a guaranteed visa for FMGs that want to move to the United States.

Grad Type

ERAS 2016

ERAS 2017

ERAS 2018

ERAS 2019

ERAS 2020

ERAS 2021

DO	10	3	9	8	10	16
IMG	44	38	19	30	40	51
MD	215	233	213	183	143	109

Sounds like Pathology!!!!