Cooperberg and his paper

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drowsy12

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@Dr_coops is one of the worst in the med sphere IMO
 
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Chartreuse Wombat said:
Ironic that Ron was the senior author for an early study showing excess toxicity with PBT

pubmed.ncbi.nlm.nih.gov

Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer - PubMed

Among patients with nonmetastatic prostate cancer, the use of IMRT compared with conformal radiation therapy was associated with less gastrointestinal morbidity and fewer hip fractures but more erectile dysfunction; IMRT compared with proton therapy was associated with less gastrointestinal...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
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Its amazing what happens when you become chair and you have to feed the proton beast. All of a sudden protons are a great treatment!
 
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Haha, here I thought I was just dropping a contraversial paper link. Didn't know about the distaste for DrCoops here. May I ask why, other then perhaps having a pro-surgery view (when the reverse would be applauded here?)

Back to the paper: I get and understand unmeasured confounding variables and bias. Prostatectomy protects against MIs and all that. On the other hand, to say I will only ever accept randomized data is a bit Nihlistic. In 10 years, if SBRT for RCC has taken off with retrospective trials showing much better outcomes then surgery, you would poopoo a surgeon who would never change their practice until a big RCT that will never accrue comes out. Take this paper; prospectively collected, highly granular database, far exceeding crappy SEER, NCDB, etc. Well thought out and applied statistical analysis with testing of rubustness of conclusions. Is it subject to unmeasured counfounders? Of course! Does that mean the data is worthless? I certainly would say not.

Side note, but I highly suspect if we had a widely measured objective physical performance metric, it would eliminate a lot of the issue of unmeasured confounding. Since really what we are "eyeballing" is apparent physical fitness. Something like VO2 max, mile walking speed, etc. "Get up and go" time does this in a way (and is a great measure of frailty,) but is a pain to measure and applies only at the frail end of the spectrum.
 
DoctwoB said:
Haha, here I thought I was just dropping a contraversial paper link. Didn't know about the distaste for DrCoops here. May I ask why, other then perhaps having a pro-surgery view (when the reverse would be applauded here?)
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No, he's not just "pro-surgery". He's anti-radiation.

Which, by itself is obviously not a crime, but there's a clear difference between the two. Personally, I am pro-radiation. I am also pro-surgery. I am biased towards radiation in high- and very high-risk disease, but have never had a prostate patient come into my clinic without making sure they've at least considered surgery (and if they don't want to see a Urologist despite my offer of referral, they will need to listen to me still discuss the surgical option).

Moreso - he has a known history of unprofessional behavior both on and off social media.

I obviously can't consume all of MedTwitter, and the internet can be a hot mess at the best of times. But he stands out as uniquely and aggressively anti-radiation, and seems to form his opinions by having no understanding of science or medicine. It would be less glaring if he seemed like he could critically assess papers but...well, maybe one day?
 
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Oh my God this garbage paper couldn't have illustrated my point better:

1697773426537.png


I assume people can understand my concerns with what I highlighted, and I won't waste my time explaining it.

Except Cooperberg. I know he can't understand it but someone with more patience than me needs to teach him.
 
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elementaryschooleconomics said:
Oh my God this garbage paper couldn't have illustrated my point better:

View attachment 378014

I assume people can understand my concerns with what I highlighted, and I won't waste my time explaining it.

Except Cooperberg. I know he can't understand it but someone with more patience than me needs to teach him.
Click to expand...

TBF the things you highlighted are all things that can be accounted for in statistical analysis. It's the things you can't account for like "3 comorbidities" and "3 comorbidities" being very different things that is the problem.
 
DoctwoB said:
Haha, here I thought I was just dropping a contraversial paper link. Didn't know about the distaste for DrCoops here. May I ask why, other then perhaps having a pro-surgery view (when the reverse would be applauded here?)

Back to the paper: I get and understand unmeasured confounding variables and bias. Prostatectomy protects against MIs and all that. On the other hand, to say I will only ever accept randomized data is a bit Nihlistic. In 10 years, if SBRT for RCC has taken off with retrospective trials showing much better outcomes then surgery, you would poopoo a surgeon who would never change their practice until a big RCT that will never accrue comes out. Take this paper; prospectively collected, highly granular database, far exceeding crappy SEER, NCDB, etc. Well thought out and applied statistical analysis with testing of rubustness of conclusions. Is it subject to unmeasured counfounders? Of course! Does that mean the data is worthless? I certainly would say not.

Side note, but I highly suspect if we had a widely measured objective physical performance metric, it would eliminate a lot of the issue of unmeasured confounding. Since really what we are "eyeballing" is apparent physical fitness. Something like VO2 max, mile walking speed, etc. "Get up and go" time does this in a way (and is a great measure of frailty,) but is a pain to measure and applies only at the frail end of the spectrum.
Click to expand...
Fwiw, I'm in my 40s and would get surgery from now until about 2040 if I needed treatment and there was hope of maintaining erectile function. I'd say the same to my patients. Otoh, we do have a rct addressing this comparison. Both surgery and radiation, and staging, have improved since it's inception. Even so, I'm not sure the point of continuing to reask this question beyond accruing pubs, publicity and academic advancement. Everyone knows the referral stream in this disease is initiated by the urologists and however much some of us would like to convince ourselves we can account for all the confounders retrospectively, it simply can't be done. The best way is an rct, and unlike rcc, it's been done.
 
Bladder is where we really need the RCT
 
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We have prospective data showing 100% local control with SBRT for renal cancer, @DoctwoB. I don’t think it will move the needle at all with urologists. And they are the gatekeepers.
 
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DoctwoB said:
TBF the things you highlighted are all things that can be accounted for in statistical analysis. It's the things you can't account for like "3 comorbidities" and "3 comorbidities" being very different things that is the problem.
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Just a disclaimer with my response:
you're the opposite of Cooperberg and you can never leave here. I bring this up because on SDN and message boards in general, if a "back and forth" goes more than 3 posts it triggers a flame war. It's a law of nature which is...weird.

But anyway -

While you're right in the structure of the greater argument of the paper, that is asking AN AWFUL LOT of the mathematics of statistics.

Looking at the data in the table, you can reframe this as:

"Every single measurement that has a known impact on outcomes is different between surgery and radiation, but don't worry, we were able to use complicated math to correct for each confounding variable, the relationship between those confounding variables, and the confounding that comes from the correction math itself."

This paper and those like it is a magic trick.

It's like...you have to ride in a plane. There are two planes. I present you with a table of 10 important factors for plane safety, and the endpoint is likelihood of a horrific crash.

You notice that virtually all of my input variables are worse for Plane B than Plane A, yet I am telling you Plane A is definitely better because I corrected all those variables on the back end with math and you should definitely believe me.

Would you believe me?
 
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And just to further clarify my plans crash metaphor -

I'm not saying Plane A or Plane B is better. I'm saying that what I've done with the data has made the conclusions worthless, and you are unable to tell.

You're right that it's nihilistic to ignore database papers completely. I absolutely don't. I do ignore papers from Cooperberg though.
 
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Can’t believe I’m defending him but

Cooperberg was pretty pragmatic at least on Twitter about this

Outright said this paper does not show RP is better

So hey. We still have a seat at the table.
 
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TheWallnerus said:
Can’t believe I’m defending him but

Cooperberg was pretty pragmatic at least on Twitter about this

Outright said this paper does not show RP is better

So hey. We still have a seat at the table.
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It's the pub that matters, not the sentiment. Why do this paper in the first place? Why not make a chair or a knife or something?
 
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Ray D. Ayshun said:
It's the pub that matters, not the sentiment. Why do this paper in the first place? Why not make a chair or a knife or something?
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Literal LOL

But, agree! Chair or knife much better use of time.
 
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TheWallnerus said:
Can’t believe I’m defending him but

Cooperberg was pretty pragmatic at least on Twitter about this

Outright said this paper does not show RP is better

So hey. We still have a seat at the table.
Click to expand...
In this one instance, THUS FAR, I would agree with you. In this vacuum, in this moment.

Let's see if it lasts.
 
Wasnt this dude accused on twitter of bullying a minority in our field?
 
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thecarbonionangle said:
Wasnt this dude accused on twitter of bullying a minority in our field?
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Yup.

And the person who experienced the bullying is someone who I've never seen/heard accuse someone of that before, and hasn't accused someone of that since.

So...the pretest probability of the bullying being real is very high.

Maybe we need to hire a statistician to control for confounders, though.
 
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The pathologically depraved love love love to bully residents (or other vulnerable groups). Then, one day, they grow into attendings and even stick around on staff. Interesting how that dynamic doesn't work so well after that...

I truly, truly despise bullying. Can't help but step in when I see it.. and why I train hard to be sure to back up my words should it be necessary.
 
A few points I found worth discussion (hoping for honest discussion, not trying to just fan flames)

If we assume that improved PC mortality is due to unmeasured confounders, how do we explain that the mortality difference was only present in higher risk disease and increased proportionally with risk. Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.

To address the point of "we do have randomized data." Well we do. In the PROTECT trial. Where everyone and their father had low risk disease, and everything you or I do had no survival benefit compared to active monitoring (said tongue in cheek, with all the usual caveats). To act as if PROTECT gives us meaningful data in the treatment of higher risk disease is to really extrapolate from tiny samples, and if anything there was some signal towards surgery (for cancer mets, xrt for hrqol). Maybe we will someday get results from the SWOG trial in oligometastatic disease as well, though that is clearly a different paradigm.

Alleged personal issues aside, I do agree with the conclusions that this doesn't prove surgery is a superior option in high risk disease or anything like that, but does suggest it is a good option in the correct patient. There is a vocal minority that believe surgery should not be used in high risk disease, and this argues against that. Of course, proper counselling is needed that surgery is likely to be part of a multimodal treatment approach involving a reasonable to high liklihood of xrt. Conversely, my experience is that patients with high risk disease undergoing xrt do better with combined modality therapy with brachy/xrt/adt.
 
DoctwoB said:
A few points I found worth discussion (hoping for honest discussion, not trying to just fan flames)

If we assume that improved PC mortality is due to unmeasured confounders, how do we explain that the mortality difference was only present in higher risk disease and increased proportionally with risk. Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.

To address the point of "we do have randomized data." Well we do. In the PROTECT trial. Where everyone and their father had low risk disease, and everything you or I do had no survival benefit compared to active monitoring (said tongue in cheek, with all the usual caveats). To act as if PROTECT gives us meaningful data in the treatment of higher risk disease is to really extrapolate from tiny samples, and if anything there was some signal towards surgery (for cancer mets, xrt for hrqol). Maybe we will someday get results from the SWOG trial in oligometastatic disease as well, though that is clearly a different paradigm.

Alleged personal issues aside, I do agree with the conclusions that this doesn't prove surgery is a superior option in high risk disease or anything like that, but does suggest it is a good option in the correct patient. There is a vocal minority that believe surgery should not be used in high risk disease, and this argues against that. Of course, proper counselling is needed that surgery is likely to be part of a multimodal treatment approach involving a reasonable to high liklihood of xrt. Conversely, my experience is that patients with high risk disease undergoing xrt do better with combined modality therapy with brachy/xrt/adt.
Click to expand...
In the 15 year results I didn't see a signal for much of anything. A paper was published re the population, noting a third had int or high risk disease. The only signal I noted was less clinical progression at 10 years in those who got rt when the PSA was >10.
 
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DoctwoB said:
A few points I found worth discussion (hoping for honest discussion, not trying to just fan flames)

If we assume that improved PC mortality is due to unmeasured confounders, how do we explain that the mortality difference was only present in higher risk disease and increased proportionally with risk. Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.

To address the point of "we do have randomized data." Well we do. In the PROTECT trial. Where everyone and their father had low risk disease, and everything you or I do had no survival benefit compared to active monitoring (said tongue in cheek, with all the usual caveats). To act as if PROTECT gives us meaningful data in the treatment of higher risk disease is to really extrapolate from tiny samples, and if anything there was some signal towards surgery (for cancer mets, xrt for hrqol). Maybe we will someday get results from the SWOG trial in oligometastatic disease as well, though that is clearly a different paradigm.

Alleged personal issues aside, I do agree with the conclusions that this doesn't prove surgery is a superior option in high risk disease or anything like that, but does suggest it is a good option in the correct patient. There is a vocal minority that believe surgery should not be used in high risk disease, and this argues against that. Of course, proper counselling is needed that surgery is likely to be part of a multimodal treatment approach involving a reasonable to high liklihood of xrt. Conversely, my experience is that patients with high risk disease undergoing xrt do better with combined modality therapy with brachy/xrt/adt.
Click to expand...
Dude, if I could clone you 100x I would.

You're asking reasonable questions. I honestly don't know how to explain the specific point you're raising about mortality difference. Is it real? I absolutely think it's possible. Which is why I tend to ignore papers like this. I don't care that it's not prospective or randomized. I care that people are putting so much faith in an imperfect source (all databases) and then assuming they can math their way to the truth.

By building a spider web of complicated statistics and "finding" these potentially concerning conclusions, which may or may not be real - there is now a new, very high opportunity cost for biomedical science as we must all debate and/or study this until it's supported or refuted...which might never happen. This would then lead me down the path of too many things are being published because of misaligned incentives, but I'll save that tangent for later.

Surgery is absolutely a good choice in the correct patient. I know for a fact I am more pro-surgery than some Urologists in my area. It drives my patients nuts because, as we all know, some people just want to be told what to do. They hate when I say "there's no wrong choice". And then they say "yeah but what would YOU do if you were me?" and so on.

I'll stop dunking on Coops and stick with the paper. It's a good illustration of my concerns:

1697836232538.png


This database began when Bill Clinton was President. Not only that, it was "pre-Lewinsky" Clinton.

Time-based confounders are a fan favorite, so I'll stop there.

Next, we have self-reported variables and comorbidities were assessed using the "Charlson comorbidity index". As with time, patient self-reporting is a fan favorite and beat to death. But I don't even know what this Charlson thing is. I do know, with absolute certainty, it's not perfect, whatever it is. And I know it has its own confounders internally, and then introducing it in this database causes confounders and...blah blah.

Then we hit the stomping ground of treatment decisions were left up to individual practices across the country. I've trained/practiced medicine in 5 states over the years. Nothing is done the same anywhere, and all it takes is one doc leaving or one doc joining and it's not even consistent internally. This is also a dead horse.

But, at least I can be somewhat novel with this next item:

For many years I moonlighted with a hospice organization. I have signed dozens to hundreds of death certificates. I literally don't know, I never kept track.

For those that haven't done it, death certificates are annoying. They say in black and white "YOU CANNOT JUST WRITE HEART STOPPED, IDIOT".

1697837564071.png


So here's what I would usually do:

First, I was caring for them as a hospice patient. Which means I don't need to go down an insane "chart biopsy" rabbit hole to give them appropriate care. If they have chest pain, I'm not booting up a 10-item differential and calling Montana to get records because the patient lived there for a year in 2002.

So I would always write, as the final terminal event, "cardiopulmonary arrest" because...well that's literally how you die.

But obviously that's against the rules. I can't just write that and call it a day. I need to write out the "chain of events".

Sometimes these patients would be 92 and have a chart longer than Homer's Odyssey. So I would find the admitting H&P or the last comprehensive note before they entered hospice and find what the most likely/most recent terminal illness was, like "pancreas cancer". So that's what I would write, then I would sign it, then I would go on with my day.

Now, I'm a cancer doctor. I have a comprehensive understanding of the natural history of many malignancies. If I saw someone was diagnosed with pancreatic cancer, I know how aggressive that is, and I know it probably is the true reason.

But...prostate cancer? "Most men die with prostate cancer, not of prostate cancer". There's a lot of men on hospice, or just at the end of life in general, with prostate cancer.

Unless it was metastatic prostate cancer, I would almost never write "prostate cancer" in the chain of events. I know how indolent it is. Usually, the H&P note would be something like "past medical history notable for prostate cancer, 1 month ago experienced ground level fall with hip fracture, BIBA and was evaluated by Ortho in ED, determined not to be a surgical candidate, admitted for pain management where he developed aspiration pneumonia and AMS..."

Reading that, I would write "traumatic fracture, pneumonia, cardiopulmonary arrest". I wouldn't write prostate cancer because it has nothing to do with the death.

But...the people most commonly signing death certificates are not Radiation Oncologists. They're often not cancer doctors at all. They're usually in the realm of general internal medicine.

Give a hospitalist that same H&P, and their death certificate would probably read "prostate cancer, pneumonia, cardiopulmonary arrest".

So my closest guess as to what's happening with this CAPSURE study? It's that. It's how the database was designed to record PCSM, and who was filling out the death certificates.

Which is, of course, something we can't "prove".

My point being:

Surgery and radiation are both good options for prostate cancer.
 
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The bias against surgery for high risk disease has been overplayed imho

But at the end of the day the whole discussion amongst us rad oncs is pretty funny because if I see a high risk intact prostate case it’s because a urologist sent me the patient (and I will treat them fast enough to make heads spin)

And when I don’t see such a patient, it’s Tuesday
 
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SPCG is actively enrolling an RT vs surgery RCT in high risk disease. I’ll just ignore until that publishes or is terminated
 
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sirspamalot said:
Yes it was super kind of him to show up, tell us he's listening (but is too busy to be here often) and then after the hard questions flowed..

POOF

He be gone.
Click to expand...

I genuinely thought he would do good things.

Quickly learning very few people in this field will do the right thing if it’s hard, uncomfortable, or unpopular.

Then if you do that, people become hostile. It’s very unfortunate.

I love the day to day of rad onc more than ever, but finding it ever harder to recommend medical students go to in to this field because of the people and leadership.
 
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Yes, I have that exact scenario now: "Can you assist this med student interested in radoc with some guidance"

My guidance:



Run Away Nuclear Bomb GIF by Identity
 
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NotMattSpraker said:
I genuinely thought he would do good things.

Quickly learning very few people in this field will do the right thing if it’s hard, uncomfortable, or unpopular.

Then if you do that, people become hostile. It’s very unfortunate.

I love the day to day of rad onc more than ever, but finding it ever harder to recommend medical students go to in to this field because of the people and leadership.
Click to expand...

Its preposterous that someone who claims to be a leader of our field come on here and behave the way he did. He exhibited no class, no backbone and no transparency while throwing shade at a vocal invested group of peers.

You wanted the leadership job - then show some g-damn leadership skillz. It was a sales job folks, I'm sorry to say.

FASTRO? No..
 
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sirspamalot said:
Yes, I have that exact scenario now: "Can you assist this med student interested in radoc with some guidance"

My guidance:



Run Away Nuclear Bomb GIF by Identity
Click to expand...

Haha I am offered a chance to mentor a medical student, I still try to be a little more nuanced than that. I know a lot of very happy Rad Oncs that just work the job and avoid the rest of the field.

I've learned this year through a job change and attempts to engage some field leaders that being vindictive, fake, and/or toxically positive just bothers me a lot to the point where I can't be around it. It ablates my happiness. I know some happy Rad Oncs that acknowledge its a problem in this field, but just live among it, laugh it off, and it doesn't bother them. Everyone is different.

The only goal should be to help the student find happiness as a physician. The best thing to do is be fully honest about the pros and cons of Rad Onc, all fields have cons. Help them figure out how that complicated matrix will result in ideal happiness given their priorities and personality.

I always make sure they understand how timing and luck play a big role in "job outcomes and career success" in a very small field like Rad Onc, especially in academics.

I agree that the unclear workforce future, efforts to quash discussion, geographic restriction, and toxic leadership makes a lot of people nervous even if they know the day to day job is great. I explain to them that ASTRO is not Rad Onc; again, I know lots of happy non-members. But if you look at the workforce data that ends at 2030 and the behavior of people like Michalski running Wash U and Sameer pretending to "engage the field", it's a little naive to be super optimistic about the QoL of a new grad in 2030.

If we discuss all that and they still want to go in, it's a great time to be an applicant, so we discuss strategy. Etc.

It is amazing how disrespectful people act in advising trainees either by making it about them and their personal baggage, being overly positive/gaslighting, or overly negative. Or just calling them stupid (Wallner, mimosis guy), bold strategy Cotton.

A lot of academic faculty do this, which is kind of sad since they are the "front line" for medical students. Don't be that!
 
‘It is amazing how disrespectful people act in advising trainees either by making it about them and their personal baggage, being overly positive/gaslighting, or overly negative’


Yes yes yes. And that also goes for the anon prolific Twitter accounts (also prolific SDN posters) who have been known to reply to and engage with medical students in negative fashion on Twitter.
 
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drowsy12 said:
Yes yes yes. And that also goes for the anon prolific Twitter accounts (also prolific SDN posters) who have been known to reply to and engage with medical students in negative fashion on Twitter.
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A big problem is the level of contextual nuance in the phrase "negative engagement".

I would hope that we can all universally agree that, oh I dunno, an anonymous X account showing up on virtually every thread with a drive-by "GARBAGE FIRE" post/Tweet is not constructive. Fortunately, that has calmed down somewhat since its peak in 2020 or so, though it unfortunately persists.

But the primary reaction of ASTRO and those in establishment positions of authority perceive ANYTHING voiced about potential issues with the field as "negative" and inappropriate.

Now, by the dictionary definition, criticism is "negative".

But that's a fairly ham-fisted worldview.

Historically, the only "safe" way to express concern over the job market was to invoke the "maldistribution argument". It makes sense, because then it shifts the blame off ASTRO/SCAROP and other responsible parties.

"We were right to expand, it's the students not choosing the rural jobs who are wrong!"

At the now deleted Workforce Panel discussion, a department Chair literally booed a panelist after the panelist disagreed with his statement about needing to expand to balance out maldistribution.

The insane childishness of that is unreal.

There needs to be less of an "I'm being attacked" reaction by ASTRO/establishment physicians when any form of constructive criticism or concern is voiced.

It's why we're in our current predicament - there has been no opportunity for genuine debate.
 
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drowsy12 said:
‘It is amazing how disrespectful people act in advising trainees either by making it about them and their personal baggage, being overly positive/gaslighting, or overly negative’


Yes yes yes. And that also goes for the anon prolific Twitter accounts (also prolific SDN posters) who have been known to reply to and engage with medical students in negative fashion on Twitter.
Click to expand...

Yes. Reply to ASTRO org, Sameer, Michalski, honestly the list is SUPER long.. pick anyone haha.

Do that instead of harassing medical students please.
 
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DoctwoB said:
Is it just due to event rate increasing? That could explain a difference in statistical significance due to sample size but not effect size. Do we magically select only healthy patients for surgery in high risk disease but have less selection bias in low risk disease? That doesn't ring true, if anything it is the opposite.
Click to expand...
We are making this too complicated.

www.ncbi.nlm.nih.gov

Gleason score stratification according to age at diagnosis in 1028 men

Gleason score stratification according to age at diagnosis has been retrospectively evaluated in 1028 men with biopsy-proven prostate cancer (PCa).From January 2006 to December 2014, 2435 Caucasian men aged between 37 and 92 years underwent transperineal ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

An interesting phenomenon with prostate cancer is that older patients are more likely to be diagnosed with higher grade disease (this is opposite to breast cancer).

Age has a pretty big impact on overall survival.

Playing with men's life expectancy calculators at age 62 vs 70 make you realize how different these ages are regarding competitive risk mortality within 15 years.

You can never trust cause specific survival numbers too much.

None of us are doing much good for low risk or favorable intermediate risk patients.
 
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communitydoc13 said:
We are making this too complicated.

www.ncbi.nlm.nih.gov

Gleason score stratification according to age at diagnosis in 1028 men

Gleason score stratification according to age at diagnosis has been retrospectively evaluated in 1028 men with biopsy-proven prostate cancer (PCa).From January 2006 to December 2014, 2435 Caucasian men aged between 37 and 92 years underwent transperineal ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

An interesting phenomenon with prostate cancer is that older patients are more likely to be diagnosed with higher grade disease (this is opposite to breast cancer).

Age has a pretty big impact on overall survival.

Playing with men's life expectancy calculators at age 62 vs 70 make you realize how different these ages are regarding competitive risk mortality within 15 years.

You can never trust cause specific survival numbers too much.

None of us are doing much good for low risk or favorable intermediate risk patients.
Click to expand...
PREACH

I wish we could aim the collective intellectual energy spent arguing about niche prostate cancer items towards the cancers that are, you know, actually killing people with ease and speed.
 
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NotMattSpraker said:
Yes. Reply to ASTRO org, Sameer, Michalski, honestly the list is SUPER long.. pick anyone haha.

Do that instead of harassing medical students please.
Click to expand...
Or attacking newly matched people or current residents. These people are already in our field.
 
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NotMattSpraker said:
.

I always make sure they understand how timing and luck play a big role in "job outcomes and career success" in a very small field like Rad Onc, especially in academics.
Click to expand...
Has been true for the good PP jobs too. A combination of timing when you graduate, connections and whether some negative news came out regarding hypofx, apm, rocr etc that might derail hiring plans for your cycle
 
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