Expansion

[deleted1111261]

That is fair!

Man I'd love to have a bug in the faculty lounges at a place like that.
Just laughing at us all, making jokes about our livelihood.

---

Members don't see this ad.

 

[thecarbonionangle]

its amazing when what you have long suspected is said behind closed doors is said out in the open, basically i got mine who cares, nothing to see here! Applicants should take heed of this keen insight by the Harvard faculty. The future is more than bleak. The laughing at the country club and faculty lounges where the eliges hang out will continue, drawing out the cacophony of souls falling to the depth of the hellpit. Applicants it is your move!

 

[sirspamalot]

F you got mine is prevalent amongst ASTRO leadership, Academic Chairs, and corrupt bankrupt large private practice leadership. Why, that venn diagram even overlaps a bit don't it.

SK has been lost off radar, repeat, lost off radar

 

[thecarbonionangle]

F you got mine is prevalent amongst ASTRO leadership, Academic Chairs, and corrupt bankrupt large private practice leadership. Why, that venn diagram even overlaps a bit don't it.

SK has been lost off radar, repeat, lost off radar

Ah yes. The old white guy flicking you off at some type of bead mardi gras or carnival party. Le bon temps for me but not for thee! I’ll have a sazerac to that. Perfect GIF for our field.

 

[NotMattSpraker]

Ah yes. The old white guy flicking you off at some type of bead mardi gras or carnival party. Le bon temps for me but not for thee! I’ll have a sazerac to that. Perfect GIF for our field.

I feel bullied by our leadership.

 

[communitydoc13]

The math is so simple and the truth so self evident. Shrink training dramatically or grow the field.

Nobody is looking to grow the field from what I can tell...to re-examine our role in oncology in a way that looks for paths to do more than XRT.

Has any prominent academic radonc looked to do this, or made this their platform, or even published a paper advocating for this?

Why not?

If ASTRO were to put together a 6 week virtual symposium on "Expanding the role of radiation oncologist to primary oncologist in low risk, ER+ breast cancer patients", complete with review of literature, recommendations for holistic management of the patient and descriptions of pertinent laboratory medicine, I would sign up. I'd pay the effing course fee and maybe even rejoin the society.

It would just help our overburdened medonc clinics at this point. It would be a first step. It would make it easier for me to justify another hire in the future.

Why aren't we doing this?

 

[sirspamalot]

But Zietman said at that conference years ago that we'd become Integrative Oncologists!

Expand the field you say? Why sir, we already have, one (dozen) resident(s) at a time!

 

[A_DeMichele]

Dr. Recht is a teaching attending? Shame on him. Although Harvard folks would argue that their program should be the last one to close. Maybe

 

[deleted1111261]

Unsubstantiated rumor: they have been on probation for years and yet acgme let’s them go … bc Harvard

 

[RadRadRad]

It’s very interesting to watch all the press about evil radiation
I’ve had numerous patients die from cancer treatment over the years. The majority from surgery and chemo. Granted second malignancies and increased risk of cardiac disease may be harder to appreciate but they also happen years down the road. Ive seen 1-2 carotid blowout and otherwise can’t recall radiation related death acutely . I’ve seen leukemia death from chemo induced cancer, 2-3 bone marrow failures from temodar leading to death or impending death. Personally seen 3-5 patients die from TPF. A couple from mmc.

 

[RadOncDoc21]

It’s very interesting to watch all the press about evil radiation
I’ve had numerous patients die from cancer treatment over the years. The majority from surgery and chemo. Granted second malignancies and increased risk of cardiac disease may be harder to appreciate but they also happen years down the road. Ive seen 1-2 carotid blowout and otherwise can’t recall radiation related death acutely . I’ve seen leukemia death from chemo induced cancer, 2-3 bone marrow failures from temodar leading to death or impending death. Personally seen 3-5 patients die from TPF. A couple from mmc.

Rad oncs are literally to be blamed directly.

 

[communitydoc13]

It’s very interesting to watch all the press about evil radiation
I’ve had numerous patients die from cancer treatment over the years. The majority from surgery and chemo. Granted second malignancies and increased risk of cardiac disease may be harder to appreciate but they also happen years down the road. Ive seen 1-2 carotid blowout and otherwise can’t recall radiation related death acutely . I’ve seen leukemia death from chemo induced cancer, 2-3 bone marrow failures from temodar leading to death or impending death. Personally seen 3-5 patients die from TPF. A couple from mmc.

For true equipoise, the same doc should be giving both systemic and XRT. If we gave both, we would be more discretionary regarding XRT than we are presently (the exception being getting single fraction treatments in to high risk metastatic sites earlier and more appropriately than with the present system).

I also believe we would be more discretionary regarding systemic therapy.

Much of the decline of XRT is natural and a result of better systemic therapy. Some of it is ideological.

 

[RickyScott]

Dr. Recht is a teaching attending? Shame on him. Although Harvard folks would argue that their program should be the last one to close. Maybe

He used to be one of the major thought leaders in breast, the kind of academic who could pontificate for ages on wether or not to give a breast boost with photons vs electrons and what the Talmud has to say on the matter. Probably been at Harvard for over 40 years Anyway, for all we know, he could be one of the posters on this site. Don’t think his views abt future of xrt are any different than mine.

 

[deleted1111261]

Kinsley gaffe - Wiktionary, the free dictionary

en.m.wiktionary.org

 

[A_DeMichele]

He used to be one of the major thought leaders in breast, the kind of academic who could pontificate for ages on wether or not to give a breast boost with photons vs electrons and what the Talmud has to say on the matter. Probably been at Harvard for over 40 years Anyway, for all we know, he could be one of the posters on this site. Don’t think his views abt future of xrt are any different than mine.

it used to be so good to be a breast guru... 50.4 / 28 fx WBRT + 12.6 Gy /7 boost. nothing could touch this

 

[RickyScott]

it used to be so good to be a breast guru... 50.4 / 28 fx WBRT + 12.6 Gy /7 boost. nothing could touch this

45 +16! I think Recht or some else at Harvard showed this had better cosmesis

 

[theradiator]

There is actually a RCT confirming this never discussed because it does not fit the dominant narrative of hypofractionation for all

 

[RickyScott]

There is actually a RCT confirming this never discussed because it does not fit the dominant narrative of hypofractionation for all

Thats why I mentioned it.actually learned abt in one of those monthly acr commentaries by recht.

 

[SneakyBooger]

45 +16! I think Recht or some else at Harvard showed this had better cosmesis

100%

 

[SneakyBooger]

There is actually a RCT confirming this never discussed because it does not fit the dominant narrative of hypofractionation for all

Another 100%.

Hypofrac is all they have to offer.

 

[madchemist89]

FLAME is the same. Doesn't fit the narrative.

 

[winstonfoot5]

I've sent Dr. Recht an email.

update on this?

 

[deleted1111261]

He had a very thoughtful reply. He felt that the quote was not reflective of how he felt and was offhand. He was kind in discussing community docs.

I can't get into someone's head about how they really feel, but I've said things before that I felt were jokey or trying to make a point that I regretted.

He asked the reporter to take the quote out. I don't agree with the reporter doing this, but I 100% understand his rationale for doing so.

Even though the quote annoyed me, I give the grace of a mistake. That's all I can really do. He didn't defend it in any way. He didn't push back on my annoyance. I can't say anything bad about how the interaction went.

Seems like a decent guy and Harvard friends mostly gave an eyeroll and said "Oh, that's just Abram". I think my online persona shows I'm pretty gentle with those that engage this way.

EDIT: in his email he called them "offensive sentences". Not "sentences that offended some" or anything wishy washy.

 

[OTN]

"Whenever you speak the truth, someone will be offended"
- Laurence Overmire, Report from X-Star 10

 

[NotMattSpraker]

He had a very thoughtful reply. He felt that the quote was not reflective of how he felt and was offhand. He was kind in discussing community docs.

I can't get into someone's head about how they really feel, but I've said things before that I felt were jokey or trying to make a point that I regretted.

He asked the reporter to take the quote out. I don't agree with the reporter doing this, but I 100% understand his rationale for doing so.

Even though the quote annoyed me, I give the grace of a mistake. That's all I can really do. He didn't defend it in any way. He didn't push back on my annoyance. I can't say anything bad about how the interaction went.

Seems like a decent guy and Harvard friends mostly gave an eyeroll and said "Oh, that's just Abram". I think my online persona shows I'm pretty gentle with those that engage this way.

EDIT: in his email he called them "offensive sentences". Not "sentences that offended some" or anything wishy washy.

Yea, in my opinion the problem with this is the same as so many in this field. Problems like oversupply are not unexplainable things that happen to us like natural disasters. They are the result of conflicts of interest that are going unopposed because they aren't recognized as "bad" or at all, or people don't feel comfortable speaking up.

Im sure Recht is a good person, a caring doctor, and has made important contributions to the field. Right now, we have plenty of all of that and a conspicuous lack of anyone doing the hard thing... speaking out against conflicts driving oversupply, about pharma spin of radiation omission studies, about proton spin. A radiation oncologist could make any of these statements in that same article and it would add significantly to it.

You can do this same thought experiment with Speers. Precision medicine is good and he may greatly impact oncology in a positive way for patients with his research. But what we really need right now is for someone to run Europa, not develop an expensive test to make us feel comfortable "sparing" 5 fractions of APBI to give AI instead. All of twitter does seem to agree on that.

The former is very hard to do, uncomfortable, maybe career ending in the US. The latter could potentially be a lottery ticket for him in personal payments and stock. It is not mean to critique this reality and this aspect of his work. It is not mean to point out "Of course, the guy developing this test that helps reduce radiation use is going to laud reducing radiation".

Recht made a joke, it was removed because its a bad look for him, and that was the end of it. ASTRO will keep lying about numbers, med oncs will keep spinning "radiation bad, more drugs good", rad oncs will "innovate" along the easy paths available, and we will keep being mad.

I totally agree with all your comments about jokes not landing. I do not blame Recht, think hes a bad person, or a bad radiation oncologist. But in this instance he was a weak leader when we need strong leaders.

I am still waiting, seemingly always waiting, for more Chirags.

 

[OTN]

He had a very thoughtful reply. He felt that the quote was not reflective of how he felt and was offhand. He was kind in discussing community docs.

I can't get into someone's head about how they really feel, but I've said things before that I felt were jokey or trying to make a point that I regretted.

He asked the reporter to take the quote out. I don't agree with the reporter doing this, but I 100% understand his rationale for doing so.

Even though the quote annoyed me, I give the grace of a mistake. That's all I can really do. He didn't defend it in any way. He didn't push back on my annoyance. I can't say anything bad about how the interaction went.

Seems like a decent guy and Harvard friends mostly gave an eyeroll and said "Oh, that's just Abram". I think my online persona shows I'm pretty gentle with those that engage this way.

EDIT: in his email he called them "offensive sentences". Not "sentences that offended some" or anything wishy washy.

SUPER weak sauce the reporter removed it. Remember when we used to have "journalism"?

 

[temujim]

SUPER weak sauce the reporter removed it. Remember when we used to have "journalism"?

On the occasions I have interacted with journalists, they get half of it wrong, misquotes abound, and sometimes it all spins out of control no matter your best efforts.

To chop up Ben Rhodes' quote: "The average reporter we talk to is 27 years old, and... They literally know nothing."

 

[deleted1111261]

SUPER weak sauce the reporter removed it. Remember when we used to have "journalism"?

Yeah

What I meant was I understand why he asked to have it removed.

I don’t get why the journalist agreed

 

[thecarbonionangle]

It may have been that he mispoke. Maybe he said what he truly thinks and it is a “bad look” and he took it back. Overall i feel like the “leadeship” in this field is a lot like the “watchu doing? Nothing just hanging around” meme. Nothing to see here of course.

 

[TheWallnerus]

45 +16! I think Recht or some else at Harvard showed this had better cosmesis

I wonder if Jay Harris ever did anything besides 45+16 before he retired

 

[thecarbonionangle]

We can be the crazy plane lady yelling that “that mfer is not real” regarding our doom or we can do something about it. You folks know where the “leaders” are

 

[Mandelin Rain]

We can be the crazy plane lady yelling that “that mfer is not real” regarding our doom or we can do something about it. You folks know where the “leaders” are

Their "kids are already through college."

Seriously, any med student considering this field in 2023 better be amenable to retraining in 2033 (or sooner).

 

[thecarbonionangle]

Their "kids are already through college."

Seriously, any med student considering this field in 2023 better be amenable to retraining in 2033 (or sooner).

Right now many of the SOAP hellpits are having departmental efforts to prevent being on SOAP again. Same as every year the solution is interview more people, interview those you have previously not interviewed, lower standards, etc. of course contracting is never a thought. The loser soapers are the real RIGGERS preventing market correction.

 

[RickyScott]

Right now many of the SOAP hellpits are having departmental efforts to prevent being on SOAP again. Same as every year the solution is interview more people, interview those you have previously not interviewed, lower standards, etc. of course contracting is never a thought. The loser soapers are the real RIGGERS preventing market correction.

these places really will have to recruit internationally. It would not surprise me at all if Dan Golden is on a Caribbean med school tour or organizing a meet and greet with medics from the disbanded Russian Wagner group.

 

[thecarbonionangle]

these places really will have to recruit internationally. It would not surprise me at all if Dan Golden is on a Caribbean med school tour or organizing a meet and greet with medics from the disbanded Russian Wagner group.

He is now in a different institution i saw on Twitter. But yes many of the hellpits have opened up things to the point of taking anybody with a pulse. There is no way to block SOAP which means the field is doomed.

 

[fiji128]

He is now in a different institution i saw on Twitter. But yes many of the hellpits have opened up things to the point of taking anybody with a pulse. There is no way to block SOAP which means the field is doomed.

It has been completely obvious that things would play out this way for about 5 years now. There is zero evidence that spots not filled in the first round of the match will then simply go unfilled for the following 5 years. Programs have all lowered their standards considerably and for the lowest tier programs the only barrier to entry is the need to complete a US intern year and be able to get a resident medical license. Same basic thing is happening with the ER programs.

 

[thecarbonionangle]

It has been completely obvious that things would play out this way for about 5 years now. There is zero evidence that spots not filled in the first round of the match will then simply go unfilled for the following 5 years. Programs have all lowered their standards considerably and for the lowest tier programs the only barrier to entry is the need to complete a US intern year and be able to get a resident medical license. Same basic thing is happening with the ER programs.

I knew in medical school that ER was doomed because they had multiple PAs/NPs which had done a “fellowship” essentially acting as attendings

 

[dieABRdie]

I think it’s time to turn the ship around… my proposal is to lean into it by showing the world how important radiation is by allowing local recurrences to rise and we go full in on salvage radiation therapy.

We’ve lost being able to come in the front door with upfront definitive radiation in almost all disease sites. Let the “cool kids” mess up and we wait to be the “hero.”

5 fraction APBI a la Livi; Florence trial.

Main argument against whole breast RT is toxicity..... or travel / many weeks of treatment.

If those are a non-issue.... then why would you with-hold the local control benefit?

Establish the pattern now.

 

[medgator]

5 fraction APBI a la Livi; Florence trial.

Main argument against whole breast RT is toxicity..... or travel / many weeks of treatment.

If those are a non-issue.... then why would you with-hold the local control benefit?

Establish the pattern now.

Most pts I've encountered seem to have a much smaller issue with 1-3 weeks of RT vs several years of AI therapy.

Bingo

 

[JustAdocInBox]

I see everyone commenting on radiation instead of endocrine therapy and I know we’re all eagerly waiting on Europa, but is there any data to support omission of endocrine therapy? I am aware of the poor compliance with endocrine therapy

 

[evilbooyaa]

I see everyone commenting on radiation instead of endocrine therapy and I know we’re all eagerly waiting on Europa, but is there any data to support omission of endocrine therapy? I am aware of the poor compliance with endocrine therapy

Below is from NSABP B21. Tam alone loses to XRT alone, and both lose to RT + Tam.

No big evaluation since. But if Tam alone is analogous to AI alone, then RT alone should be more efficacious.

 

[deleted1111261]

Below is from NSABP B21. Tam alone loses to XRT alone, and both lose to RT + Tam.

No big evaluation since. But if Tam alone is analogous to AI alone, then RT alone should be more efficacious.

View attachment 375789

Yeah this is the real deal here. Important chart. We already know it works better.

Problem is some statistical shenanigans will be engaged to say they are the same.

 

[temujim]

I knew in medical school that ER was doomed because they had multiple PAs/NPs which had done a “fellowship” essentially acting as attendings

Have seen some hospital systems advertise that their ERs only staffed by MDs. Probably can do this with the explosion of ER spots and (what seems like the) collapse of the specialty with overtraining.

 

[Fpg1245]

Below is from NSABP B21. Tam alone loses to XRT alone, and both lose to RT + Tam.

No big evaluation since. But if Tam alone is analogous to AI alone, then RT alone should be more efficacious.

View attachment 375789

But but but…luminal A. We finally found a subgroup!

 

[deleted1111261]

Okay so

1) I don’t love studies like this but …
2) It’s Canadian. They need throughput and are hyper focused on cost

We can think bigger and better and we don’t.

If Whelan’s institution and nation need this, I don’t fault them.

RT in ‘Merica is cheap (compared to pills, chemo, IO), effective and safe. We don’t think big. We don’t build.

It’s our academic centers.

Indians out here be doing VMAT breast palliation studies (good) and we count the number of people with certain demographic features (bad)

 

[JustAdocInBox]

Okay so

1) I don’t love studies like this but …
2) It’s Canadian. They need throughput and are hyper focused on cost

We can think bigger and better and we don’t.

If Whelan’s institution and nation need this, I don’t fault them.

RT in ‘Merica is cheap (compared to pills, chemo, IO), effective and safe. We don’t think big. We don’t build.

It’s our academic centers.

Indians out here be doing VMAT breast palliation studies (good) and we count the number of people with certain demographic features (bad)

We do have several oligomet SBRT trials in the pipeline, but honestly doing SBRT to 5 oligomets and getting reimbursed for a single SBRT course is demoralizing. Hypofrac breast with boost has better professional reimbursement.

 

[TheWallnerus]

Most pts I've encountered seem to have a much smaller issue with 1-3 weeks of RT vs several years of AI therapy.

Bingo

But but but…luminal A. We finally found a subgroup!

Okay so

1) I don’t love studies like this but …
2) It’s Canadian. They need throughput and are hyper focused on cost

We can think bigger and better and we don’t.

If Whelan’s institution and nation need this, I don’t fault them.

RT in ‘Merica is cheap (compared to pills, chemo, IO), effective and safe. We don’t think big. We don’t build.

It’s our academic centers.

Indians out here be doing VMAT breast palliation studies (good) and we count the number of people with certain demographic features (bad)

If America had been, for a good while prior to now, rigorously prescribing 5 fraction RT in an evidence based fashion for the proper patients… which should arguably be 26/5 partial breast (even instead of 30/5 because probably less risk for side effects with 26)… I doubt the paper in NEJM today about omitting RT for luminal A would be appealing for publishing or interesting to read. It would be unTITillating.

But we f****** couldn’t do 5 fraction for the number one RT indication in America because it would have unemployed too many academics and literally shut some academic programs down not to mention community programs. Over supply is like ionizing X-ray induced cell death, killing us directly and indirectly.

 

[temujim]

If America had been, for a good while prior to now, rigorously prescribing 5 fraction RT in an evidence based fashion for the proper patients… which should arguably be 26/5 partial breast (even instead of 30/5 because probably less risk for side effects with 26)… I doubt the paper in NEJM today about omitting RT for luminal A would be appealing for publishing or interesting to read. It would be unTITillating.

But we f****** couldn’t do 5 fraction for the number one RT indication in America because it would have unemployed too many academics and literally shut some academic programs down not to mention community programs. Over supply is like ionizing X-ray induced cell death, killing us directly and indirectly.

Can recall the breast rad oncs at an old job whine about going from 25-30 fractions to 15-20 fractions (only 5 year data!) and how their rvu target should be lower (and everyone else's higher by consequence) while at the same time demanding 100% resident coverage and APPs to help them out. Leaders in the field -- writ broadly now.

 

[communitydoc13]

But but but…luminal A. We finally found a subgroup!

50-60% of all breast cancers. Big ass subgroup.

Local recurrences will go up after 5 years (they happen forever in ER+ breast cancer) and I'm guessing in a 55 y/o their lifetime risk of local recurrence without XRT might reach 10%?

It doesn't matter. Armies of navigators and survivorship plans and PCPs will catch the recurrences early. You'll treat then, maybe 5% of the subgroup that you were treating before.

Combine this with the little bump we are experiencing of 75 year olds getting diagnosed with favorable intermediate risk prostate cancer by MRI fusion biopsy (and Uro sometimes ordering Decipher on these guys). This population will go away too.

Now look at your census without stage I, 55+ luminal A patients and 70+intermediate risk prostate cancer patients.

Yeah. We could cut working numbers in half.

 

[TheWallnerus]

50-60% of all breast cancers. Big ass subgroup.

Local recurrences will go up after 5 years (they happen forever in ER+ breast cancer) and I'm guessing in a 55 y/o their lifetime risk of local recurrence without XRT might reach 10%?

It doesn't matter. Armies of navigators and survivorship plans and PCPs will catch the recurrences early. You'll treat then, maybe 5% of the subgroup that you were treating before.

Combine this with the little bump we are experiencing of 75 year olds getting diagnosed with favorable intermediate risk prostate cancer by MRI fusion biopsy (and Uro sometimes ordering Decipher on these guys). This population will go away too.

Now look at your census without stage I, 55+ luminal A patients and 70+intermediate risk prostate cancer patients.

Yeah. We could cut working numbers in half.

You could cut 'em half without all that.

With all that, you could cut by 75%!