Busier than ever...

[Pointless]

I know this thread won't mesh well with the whole "the sky is falling" vibe that prevails here, but is anyone else busier than ever in their practice? Set to finish our busiest volume year ever with a mix of all sorts, including a distressing trend of younger (e.g. <45) patients. Anyone seeing similar?

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[Palex80]

Same here.

However: we treat a lot of palliative cases, way more than before.
The classic neoadjuvant / primary / adjuvant indications are declining.

 

[RickyScott]

I am also very busy, but that just does not change my long term outlook. Job opportunities and salaries are still far worse than 10 years ago. 15 years ago if MSKCC or Harvard had offered me a satellite job, I would have laughed at them.

 

[Pointless]

Right, I'm not making any forward-looking statements. Just observing that I am objectively busier than ever and wondering if this is anomalous or others are experiencing the same.

 

[fiji128]

I’m busy but I’m in an isolated community practice in an area where several health systems catchment areas overlap. I attribute it to the three A’s so out of system docs feel comfortable sending more patients my way when patients don’t want to travel to the main campuses for xrt. Overall I’d estimate my health system is probably about flat in number of consults/fractions over the past 5 years.

 

[Palex80]

One more thing: We are now treating a lot of really old people.

 

[Mandelin Rain]

One more thing: We are now treating a lot of really old people.

Yeah. First wave of boomers hitting 80.

 

[communitydoc13]

One more thing: We are now treating a lot of really old people.

The absolute reason for this. Baby boomers are now 63-77 years old.

Also, Gen X (~43-62 yo) is small.

My practice is busier than 10 years ago by demographics alone. If practice patterns were as they were in 2010, we would have twice the number on beam as at that time. Instead, it is probably about 20% more.

 

[taserlaser]

Not to unintentionally dox myself, but British Columbia is quite busy with sending patients to the US for treatment, Saskatchewan is sending their patients to Alberta for mammograms, and CARO shows 3 new postings for Alberta yesterday, with their 90th percentile wait times past 16 weeks. It is buuuuusssssyy

Oh yeah and 8 weeks to see a lung MO locally. **** is bad

 

[elementaryschooleconomics]

I'm very busy. Volume is up compared to ~2019 at least 20% across the network. And that's specifically the metric that matters - new starts.

My opinion on the job market remains unchanged, these are two separate things now.

The technology exists to enable us to handle even more volume with even less RadOncs. We just need to have the infrastructure and protocols catch up.

However, doesn't make it any less painful in the short term.

Nor does it fix...all of the problems, everywhere else in medicine.

Ugh.

 

[RickyScott]

I am busy but can see any consult same day and still take on many more consults. I can easily increase throughput with more hypofract, especially 8 gy x 1. I average around 8 consults a week. 15 per week is very doable but much more work than i would like (and wouldn’t change my salary). I would still bite that bullet before hiring another attending.

Try a get a primary care apt in some cities! Every specialty is getting busier, us less so than the others.

 

[ramsesthenice]

Weather vs climate. Models of the future are pretty consistent.

 

[fiji128]

I am busy but can see any consult same day and still take on many more consults. I can easily increase throughput with more hypofract, especially 8 gy x 1. I average around 8 consults a week. 15 per week is very doable but much more work than i would like (and wouldn’t change my salary). I would still bite that bullet before hiring another attending.

Try a get a primary care apt in some cities! Every specialty is getting busier, us less so than the others.

This is basically me. At my current salary I’m definitely not trying to do 15 consults a week but I could if sufficiently motivated to do so.

 

[deleted1111261]

Busiest we’ve been in 4 years

 

[temujim]

Up around 10-15% compared to basket of last 3 years. Mix of more consults and changes in practice patterns.

 

[deleted1111261]

Just got off a P2P. Same thing - sooo busy. Offered an interview to me, lol. On that note, anyone interested in Stafford, VA, community practice, about 35-45 min from Alexandria, VA? Doc made it clear that they were turning down the 17 page CV types, ha! Just want someone normal.

 

[xrt123]

I am in rural practice and numbers are lower now than 6 years ago. Never came back up after Covid and hypofractionation

 

[drowsy12]

I am in rural practice and numbers are lower now than 6 years ago. Never came back up after Covid and hypofractionation

Curious if you have been treating more mets? I agree with Palex above - seeing less of the classic neoadjuvant, adjuvant etc, but more metastases. I haven't even delved into benign stuff yet but that would be the other place you could think about.

 

[evilbooyaa]

Institution is busier, yes. More folks living longer, more re-treatments is part of it. More systemic therapy for those > age 80 from MO as well.
Part of it if you're at a smaller facility is longer, better relationships from you being in practice longer with your referrings?

 

[xrt123]

Curious if you have been treating more mets? I agree with Palex above - seeing less of the classic neoadjuvant, adjuvant etc, but more metastases. I haven't even delved into benign stuff yet but that would be the other place you could think about.

Our numbers are we are done 22% over last 4 years compared to the prior 4 years. There is probably nothing we can attribute this to specifically.

We are probably treating far less breast. A few more mets. A few more node positive or oligometastatic prostate. We have held onto rectal with OPRA. We do not treat any resectable lung anymore but were not treating that many 4 years ago. Also we are rarely treating stage 3 endometrial which we previously saw lots of these patients.

Most things come down to which referring docs are in the area and how they control the patients. Our health systems have had multiple operating room issues since Covid that have decreased the number of cancer surgeries and some of these patients may leak out into other health systems for that reason. We work with our nuc med department to deliver all radiopharmaceuticals. We treat large numbers with Pluvicto/Lutathera/Xofigo compared to average radonc but surprisingly these have not translated into much EBRT palliation on beam.

I have thought about trying to get more benign disease to maintain volume but we need a validated or positive phase 3 trial in my opinion. Anecdotal evidence is all I see.

 

[TheWallnerus]

Our numbers are we are done 22% over last 4 years compared to the prior 4 years

In other words, 2020-23 is 22% less patients than 2016-19?

 

[Palex80]

Also we are rarely treating stage 3 endometrial which we previously saw lots of these patients.

Indeed, this indication has also dramatically shrunk in our practice. Not sure why. Far less patients present with advanced disease and we still recommend RT, when they are presented at the tumor board (it's not chemotherapy taking them away).

 

[grenz]

Indeed, this indication has also dramatically shrunk in our practice. Not sure why. Far less patients present with advanced disease and we still recommend RT, when they are presented at the tumor board (it's not chemotherapy taking them away).

You recommend based on what? So many different takes in the trials

 

[Palex80]

You recommend based on what? So many different takes in the trials

Well, if you have a look at the two prominent and influential trials of the past years (PORTEC-3 and GOG-258 ), both of them did not really compare radiotherapy to chemotherapy. They tested combination therapy. None of these trials generated evidence saying that we should abandon EBRT.

And then there's GOG-249 (which did not address stage III, but high-risk stage I&II).
This trial has often be neglected in my opinion, but clearly underlines the value of EBRT for high-risk endometrial cancer.

 

[grenz]

Well, if you have a look at the two prominent and influential trials of the past years (PORTEC-3 and GOG-258 ), both of them did not really compare radiotherapy to chemotherapy. They tested combination therapy. None of these trials generated evidence saying that we should abandon EBRT.

And then there's GOG-249 (which did not address stage III, but high-risk stage I&II).
This trial has often be neglected in my opinion, but clearly underlines the value of EBRT for high-risk endometrial cancer.

A lot of people use GOG 258 to argue against RT.

 

[Palex80]

A lot of people use GOG 258 to argue against RT.

Which is wrong.

 

[grenz]

Which is wrong.

bc of the pelvic recurrences?

 

[xrt123]

In other words, 2020-23 is 22% less patients than 2016-19?

yes

 

[xrt123]

Which is wrong.

I would love to hear the argument for continuing XRT in stage III endometrial. GOG 258 trial showed no OS benefit, minimal LRC benefit and increased side effects. Because of this I am not recommending XRT for these patients.

 

[ramsesthenice]

I would love to hear the argument for continuing XRT in stage III endometrial. GOG 258 trial showed no OS benefit, minimal LRC benefit and increased side effects. Because of this I am not recommending XRT for these patients.

Well, lets take a deeper dive into 258. Nodal failures after chemotherapy are rarely salvageable so in theory, a significant improvement in regional control with RT should translate to better survival. I would personally not call a 50% reduction in regional failures minimal. So the question becomes why then did a reduction in regional failures not translate to better survival? Because it was offset by increased distant failures. Why in the world would adding radiation to chemo increase the distant failure rate? Could it have something to do with the fact that the RT group got 2 cycles less carboplatin? Or delaying chemo to start with RT might compromise distant control?

Im with Palex on this one. I think the data shows that both modalities do what they are expected to do. Our practice has always been to do 6 cycles of doublet chemo with at least 3 before starting radiation. GOG258 does nothing to convince me that we should stop.

I will be the first to acknowledge that the endometrial data is a mess. PORTEC-3 is honestly not all that helpful as it is reasonable to question if RT alone was the right control arm in that population to begin with. As for 258, I've never understood the concept of having RT "replace" a couple of cycles of systemic therapy in presumed systemic diseases and personally would have given both arms the same chemotherapy and not given concurrent cis with RT as the data supporting that is thin at best. GOG249 and post-hoc from PORTEC3 agree that adding chemo to RT probably doesn't help high risk early stage patients except for maybe serous cancers.

 

[fiji128]

These numbers are not too different from what adjuvant RT does for breast.

I would love to hear the argument for continuing XRT in stage III endometrial. GOG 258 trial showed no OS benefit, minimal LRC benefit and increased side effects. Because of this I am not recommending XRT for these patients.

Of the 813 patients enrolled, 736 were eligible and were included in the analysis of relapse-free survival; of those patients, 707 received the randomly assigned intervention (346 received chemoradiotherapy and 361 received chemotherapy only). The median follow-up period was 47 months. At 60 months, the Kaplan–Meier estimate of the percentage of patients alive and relapse-free was 59% (95% confidence interval [CI], 53 to 65) in the chemoradiotherapy group and 58% (95% CI, 53 to 64) in the chemotherapy-only group (hazard ratio, 0.90; 90% CI, 0.74 to 1.10). Chemoradiotherapy was associated with a lower 5-year incidence of vaginal recurrence (2% vs. 7%; hazard ratio, 0.36; 95% CI, 0.16 to 0.82) and pelvic and paraaortic lymph-node recurrence (11% vs. 20%; hazard ratio, 0.43; 95% CI, 0.28 to 0.66) than chemotherapy alone, but distant recurrence was more common in association with chemoradiotherapy (27% vs. 21%; hazard ratio, 1.36; 95% CI, 1.00 to 1.86). Grade 3, 4, or 5 adverse events were reported in 202 patients (58%) in the chemoradiotherapy group and 227 patients (63%) in the chemotherapy-only group.

 

[evilbooyaa]

Which is wrong.

I hear you, and as a Rad Onc, I agree. But, the reality is different.

Stage III endometrial cancer in the US is frequently a chemo primary disease. I've pushed to at least let vaginal brachy remain in the mix but my Gyn/Oncs are NOT enthusiastic for sequential chemo then radiation the way ASTRO considers an acceptable option (which is all just based on 'expert opinion')

I personally think the best thing for these patients is full dose chemo, re-staging, then followed by whole pelvic RT but I don't have any prospective evidene to support this regimen and thus can't convince the GynOncs. Would be an easy NRG trial - CarboTaxol +/- sequential whole pelvis RT. I'm sure people have recommended it in NRG and been shut down by strong opinionated GynOncs (in the US). Similar to RTOG 0848 for pancreas but we see how long that's taking to result out....

And now with RUBY and GY018 adding open questions about adding in immunotherapy in stage III patients... it's an absolute ****show.

Can't do 9708 regimen anymore as distant mets will (almost) always be lethal while regional mets can likely be salvaged some percentage of the time.

 

[TheWallnerus]

I hear you, and as a Rad Onc, I agree. But, the reality is different.

Stage III endometrial cancer in the US is frequently a chemo primary disease. I've pushed to at least let vaginal brachy remain in the mix but my Gyn/Oncs are NOT enthusiastic for sequential chemo then radiation the way ASTRO considers an acceptable option (which is all just based on 'expert opinion')

I personally think the best thing for these patients is full dose chemo, re-staging, then followed by whole pelvic RT but I don't have any prospective evidene to support this regimen and thus can't convince the GynOncs. Would be an easy NRG trial - CarboTaxol +/- sequential whole pelvis RT. I'm sure people have recommended it in NRG and been shut down by strong opinionated GynOncs (in the US). Similar to RTOG 0848 for pancreas but we see how long that's taking to result out....

And now with RUBY and GY018 adding open questions about adding in immunotherapy in stage III patients... it's an absolute ****show.

Can't do 9708 regimen anymore as distant mets will (almost) always be lethal while regional mets can likely be salvaged some percentage of the time.

All the erudition, high level pontificating, and world class brachy training/experience in the world will never change a referral pattern

 

[drowsy12]

These numbers are not too different from what adjuvant RT does for breast.

with a different side effect profile and length of treatment though, to be fair.

 

[ramsesthenice]

I hear you, and as a Rad Onc, I agree. But, the reality is different.

Stage III endometrial cancer in the US is frequently a chemo primary disease. I've pushed to at least let vaginal brachy remain in the mix but my Gyn/Oncs are NOT enthusiastic for sequential chemo then radiation the way ASTRO considers an acceptable option (which is all just based on 'expert opinion')

I personally think the best thing for these patients is full dose chemo, re-staging, then followed by whole pelvic RT but I don't have any prospective evidene to support this regimen and thus can't convince the GynOncs. Would be an easy NRG trial - CarboTaxol +/- sequential whole pelvis RT. I'm sure people have recommended it in NRG and been shut down by strong opinionated GynOncs (in the US). Similar to RTOG 0848 for pancreas but we see how long that's taking to result out....

And now with RUBY and GY018 adding open questions about adding in immunotherapy in stage III patients... it's an absolute ****show.

Can't do 9708 regimen anymore as distant mets will (almost) always be lethal while regional mets can likely be salvaged some percentage of the time.

Thanks for bringing in the sadness of reality LOL

You are correct. There is a strong contingent of American gyn oncs who happily wright off RT for improving PFS without OS yet all of them will still give adjuvant chemo for all high risk early stage endometrial cancers despite the very difficult time showing any benefit in that setting.

Gyn-Oncs are the gate keepers of all Gyn patients. I have an absolutely amazing group. Very reasonable. We radiate most stage 3 patients based on the agreement that even the negative trials suggest that RT probably does something and even with chemo, they don't do that great. We typically do sandwich based on the canadian phase 2 data. But its not just endometrial. They also typically don't operate on most 1B SCC patients since they are already 1/3rd of the way to needing adjuvant RT. I am very pampered to have such a reasonable group. I am fully aware this is not the norm.

 

[yesmaster]

I’m at about 15-20 under beam with average 6 new consults per week. RVU’s approximately 65th percentile based on mgma 2023.

I sometimes feel like I’m dying of boredom at work and I would love to be twice as busy and get a couple more nickels to put in my piggy bank with the curly tail.

 

[deleted1111261]

I’m at about 15-20 under beam with average 6 new consults per week. RVU’s approximately 65th percentile based on mgma 2023.

I sometimes feel like I’m dying of boredom at work and I would love to be twice as busy and get a couple more nickels to put in my piggy bank with the curly tail.

Add OA?

 

[Doctorer]

Well, lets take a deeper dive into 258. Nodal failures after chemotherapy are rarely salvageable so in theory, a significant improvement in regional control with RT should translate to better survival. I would personally not call a 50% reduction in regional failures minimal. So the question becomes why then did a reduction in regional failures not translate to better survival? Because it was offset by increased distant failures. Why in the world would adding radiation to chemo increase the distant failure rate? Could it have something to do with the fact that the RT group got 2 cycles less carboplatin? Or delaying chemo to start with RT might compromise distant control?

Im with Palex on this one. I think the data shows that both modalities do what they are expected to do. Our practice has always been to do 6 cycles of doublet chemo with at least 3 before starting radiation. GOG258 does nothing to convince me that we should stop.

I will be the first to acknowledge that the endometrial data is a mess. PORTEC-3 is honestly not all that helpful as it is reasonable to question if RT alone was the right control arm in that population to begin with. As for 258, I've never understood the concept of having RT "replace" a couple of cycles of systemic therapy in presumed systemic diseases and personally would have given both arms the same chemotherapy and not given concurrent cis with RT as the data supporting that is thin at best. GOG249 and post-hoc from PORTEC3 agree that adding chemo to RT probably doesn't help high risk early stage patients except for maybe serous cancers.

This is my read (and thankfully, our gyn onc tumor boards' read) as well. I will say we have shifted to doing more sequential treatment (ie chemo -> RT) rather than treating with chemoRT a la PORTEC-3.

 

[Palex80]

bc of the pelvic recurrences?

Because of the suboptimal design of the trial.
Insufficient chemotherapy given together with pelvic RT only managed to increase toxicity.
A sequential approach would have been wiser, in retrospect, just like ramsesthenice (and others) proposed.

The way forward is treating endometrial cancer patients based on molecular profiling. The RAINBO trials are testing this.

​

 

[evilbooyaa]

This is my read (and thankfully, our gyn onc tumor boards' read) as well. I will say we have shifted to doing more sequential treatment (ie chemo -> RT) rather than treating with chemoRT a la PORTEC-3.

Data on tolerability of such an approach?

 

[RSAOaky]

Data on tolerability of such an approach?

This has been my approach. I don't have data on tolerability but anecdotally, patients tolerate post-op IMRT exceptionally well with or without chemo (be it neoadjuvant or concurrent). The recent PRO guidelines state that for IB/II/III/IVA, "EBRT with chemotherapy is conditionally recommended" so that's what I do and I've just stopped thinking about it.

 

[evilbooyaa]

This has been my approach. I don't have data on tolerability but anecdotally, patients tolerate post-op IMRT exceptionally well with or without chemo (be it neoadjuvant or concurrent). The recent PRO guidelines state that for IB/II/III/IVA, "EBRT with chemotherapy is conditionally recommended" so that's what I do and I've just stopped thinking about it.

I get it and glad it works for you, individually - but how sad that an entire clinical situation, with guidelines to recommend it (sequential chemo CarboTaxol x 6 followed by whole pelvic RT) are based purely on anecdotes and expert opinion than even a retrospective study evaluating not only outcomes, but clinical toxicities. NCDB doesn't count.

 

[RSAOaky]

I get it and glad it works for you, individually - but how sad that an entire clinical situation, with guidelines to recommend it (sequential chemo CarboTaxol x 6 followed by whole pelvic RT) are based purely on anecdotes and expert opinion than even a retrospective study evaluating not only outcomes, but clinical toxicities. NCDB doesn't count.

I agree, it's sad. Unfortunately the studies that asked the questions never did a good enough job of answering them, so we're left interpreting the results. My take is that we have a treatment that we know is beneficial (locoregional control benefit) that causes acceptable toxicity, with failures being highly morbid to salvage. Unless someone shows me definitive evidence that it is detrimental or that there is no benefit, I do it.

 

[RadOnc2019]

Similar boat. Can anyone invite me to the business discussion group forum here?

 

[JustAdocInBox]

I’m at about 15-20 under beam with average 6 new consults per week. RVU’s approximately 65th percentile based on mgma 2023.

I sometimes feel like I’m dying of boredom at work and I would love to be twice as busy and get a couple more nickels to put in my piggy bank with the curly tail.

Are you on a 4 day work week? Sounds like the perfect set up for one

 

[IonsAreOurFuture]

Busiest we’ve been in 4 years

I concur. I don't know what happened, but it's like some kind of pent up demand has been breached. It's what I had expected to happen in 2022 when the pandemic seemed to be over but never got as busy as this

 

[NotMattSpraker]

I concur. I don't know what happened, but it's like some kind of pent up demand has been breached. It's what I had expected to happen in 2022 when the pandemic seemed to be over but never got as busy as this

Also crazy busy, and end of December Im used to a slow down.

Is anyone slower than usual over months?

It's hard to tell if this is the wave we've all been waiting for or site of service migration or both.

 

[radiaterMike]

December became busy (for me) when high deductible plans came on the scene. People want their doctor appointments (especially if following up on expensive tests - CTs, MRIs) before the insurers hit the reset button.

 

[metallica81788]

Guess I'm the exception here - was very slow during the fall and just recently experiencing more uptick in volume

Overall the volume is similar to years prior

 

[TexasMed22]

This workforce projection from the government projects a shortage of rad oncs in metro areas by 2028. Compare to med onc which actually projects (and currently has) a surplus. This goes against the narrative you see on SDN and reddit, so is this projection incorrect? Or is the narrative wrong?

Here is the source if anyone wants to play around with it

Workforce Projections

data.hrsa.gov