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elementaryschooleconomics said:
Hmmmm. It's been a few years now since I played around with all this. What's your preferred beam arrangement?

I think the last non-VMAT version I tried was similar to this:


I'd have to see if I still have it somewhere, but I once went through and measured the time from CBCT acquisition to delivery of last MU and 3D was consistently longer...

Though that could have been the therapists I was working with at the time.
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Are we talking fixed beam 3D, or DCA? DCA is way fewer MUs than VMAT and slightly faster in our experience. We do 1 half arc sweep that is comprised of a few partial arc beams. They mode up pretty quickly and are at worst no slower than 2 VMAT arcs.
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grenz said:
Are we talking fixed beam 3D, or DCA? DCA is way fewer MUs than VMAT and slightly faster in our experience. We do 1 half arc sweep that is comprised of a few partial arc beams. They mode up pretty quickly and are at worst no slower than 2 VMAT arcs.
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I’ll add that I really like DCA for targets that move a lot. Has to be the right shape though.
 
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Man I love SDN, where else can you find a simultaneous discussion about PACs, policy, and SBRT treatment times based on technique...

All in a silly Twitter thread?

Never forget everyone, we're anonymous misanthropes and no one can be sure we're even doctors, let alone Radiation Oncologists!

(VMAT FFF SBRT for the win)
 
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elementaryschooleconomics said:
Never forget everyone, we're anonymous misanthropes and no one can be sure we're even doctors, let alone Radiation Oncologists!
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Be careful. I had another account on here in the past and somehow got doxxed at work. Literally no idea how.
Here I am, back for more punishment. A degenerate addict.
 
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MidwestRadOnc said:
Be careful. I had another account on here in the past and somehow got doxxed at work. Literally no idea how.
Here I am, back for more punishment. A degenerate addict.
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I have a lot of comments about this that I'll just...mostly keep to myself...

Internet shenanigans need to stay internet shenanigans.

If anyone feels inclined to take an SDN argument into real life, especially contacting employers - that is literally the saddest, weakest thing you could possibly do.

The best thing about the internet is YOU CAN WALK AWAY. In an argument? Close your browser. Put notifications for that conversation on mute. Never think about it again.

It's literally impossible for me to consider ever respecting someone again once they pull the "find you in real life" move. It tells me everything I need to know about who they are as a person.
 
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thesauce said:
I personally do think that surgery is better than SBRT.

What I don’t understand are the other ablation techniques like RFA etc. Who would be appropriate for that?
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Those who can't get surgery OR SBRT. But IRs don't masturbate over data and trials the way ROs do and thus they've started doing it nationwide. Also see the nonsense about RFA or even Y-90 or TACE in HCC over SBRT. Jeff Ryckman with a lot of good tweetorials about the lack of beneficial randomized data with IR techniques vs some form of EBRT (SBRT, proton RT, etc.) which has positive randomized data.
medgator said:
Best thing is to follow your patients, gets hard with the clinic flow, I've basically tried to alternate with pulm or med onc to space it out, I usually let them go 3-5 years out though. Definitely have gotten some add-on cases through the years, certain pts seem to win that unlucky lottery more than once
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Great space for a RO NP dependent on your volume - CT chest a few days prior to NP visit, NP sees patient, reads report (reviewing imaging personally can be problematic), lets doc know PRN, otherwise continues the q3-6 month CT surveillance (based on time from previous RT).

RadRadRad said:
I actually prefer old school sbrt for lung. You can find data that Imrt /vmat are just as good but there is conflicting data that the increased inhomogeneity with 3D Sbrt is superior in terms of tumor control. From my standpoint if I can make a good portion of the tumor get 110 percent (or more ) of dose without exceeding any normal tissue tolerance, I think that is preferable. Kind of like why brachy may be beneficial in other disease sites.
I’ll use vmat if close to plexus or some critical central structure but only if needed
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Links?

elementaryschooleconomics said:
I agree with you from a step-by-step, logical standpoint.

However, having experimented with this myself: how long are your 3D SBRT patients on the table, compared to VMAT?

You might be using different techniques than what I've tried, but 3D SBRT is a significantly slower treatment, which is very difficult for elderly patients to tolerate. You can have the perfect plan in the computer, but if your patient wiggles from discomfort during their 20 minute treatment sessions, it doesn't really matter.

Currently, I use VMAT with a planned hotspot of ~135%-145% to get both "3D-esque" inhomogeneity and fast treatment times.

I'm always looking for ways to do it better, though.
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Shouldn't be longer... it's less MUs since you're not modulating. Are you using 6MV beams for 3D vs 6MV-FFF for VMAT? The increase in dose rate possible w/ FFF may make up for the increased MUs. 6MV-FFF w/ DCA would hypothetically be fastest, no? This assumes same number of arcs across both plans.

communitydoc13 said:
The difference in time between dynamic conformal arcs and a VMAT plan is going to be very small. Monitor units will be less for the DCA plan but if the arc arrangement is more complicated, this can add a little time.

DCA can still be inverse planned and with dynamic MLCs. You are just not modulating across the target. In principle, this takes away some dosimetric uncertainty.

I have to admit, the modulation of stereotactic, small field VMAT plans enters into the realm of absurdity. There is no longer any intuition and I am sure there are compounding risks of dose uncertainty...however, it works.

You can get any hotspot you want with VMAT by applying proper planning objectives. The hotter plans are not limited to DCA.

What has bothered me is how we should prescribe these heavily modulated plans, because you don't need to have a very hot center and the prescription paradigm is really a volumetric one (e.g. 95% PTV gets 100% prescription dose as opposed to prescribing to the 60-80% IDL). Should we mimic old 3D plans and try to make the center very hot. Should we try to cover the ITV at 125% the periphery of the PTV (as some have suggested)...this makes for much hotter plan.

Lots of variability in terms of how to prescribe and define objectives for these sorts of plans.
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Even w/ VMAT, allowing a hotter center will allow for sharper fall off outside the PTV and minimize the intermediate dose bath surrounding the PTV. Relevant in a lung SBRT case for say lung, chest wall, and midline structure DVH metrics allowing treatment of larger lesions, or receiving multiple rounds of treatment without negatively affecting a parallel organ like the lungs.
 
Wow.



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BREAKING NEWS​

ASTRO leadership has been reported missing. Per text messages from friends and family, they embarked on a teambuilding exercise to "find hearts and brains from a wizard in a castle". Police have released this image from social media:

1705799707207.png


In a press release, police have also confirmed that this teambuilding exercise was the result of a recommendation from a $500,000 McKinsey consultant, paid for with member dues.

We'll bring you more information on this developing story tonight at 11.
 
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In case anyone has ever wondered, when I point the finger at "the establishment" for causing the mess we're currently in, Ron is a key figure of "the establishment".

Not only does he run the largest agency/company which produces RadOnc-focused coding and billing content, he has co-authored or influenced both the ASTRO and ACRO coding/billing manuals for many, many years.

He has also served as an "expert" witness in at least one qui tam case, probably several.

The guy who is on X posting weird, angry content because...lifting weights...fills him with rage, he's also amplifying this obscure NP-lobby propaganda without any critical thought.

Just extrapolate all this backwards 20 years and everything makes sense.
 
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thesauce said:
Even the Astro leaders are no longer saying there is a shortage
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it's got to be at least 6-7 years since that was seriously put forth as an opinion, if not longer. Ron D is a grifter.

Ben Smith published his initial paper in 2010: https://ascopubs.org/doi/full/10.1200/JCO.2010.31.2520

'Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.'

By 2016, he had altered his opinion: Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025 - PubMed

Conclusion: The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.


Ron D is a grifter.
 
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drowsy12 said:
it's got to be at least 6-7 years since that was seriously put forth as an opinion, if not longer. Ron D is a grifter.

Ben Smith published his initial paper in 2010: https://ascopubs.org/doi/full/10.1200/JCO.2010.31.2520

'Demand for radiation therapy is expected to grow 10 times faster than supply between 2010 and 2020. Research is needed to explore strategies to enhance capacity to deliver quality radiation therapy despite increased patient loads.'

By 2016, he had altered his opinion: Supply and Demand for Radiation Oncology in the United States: Updated Projections for 2015 to 2025 - PubMed

Conclusion: The supply of radiation oncologists is expected to grow more quickly than the demand for radiation therapy from 2015 to 2025. Further research is needed to determine whether this is an appropriate correction or will result in excess capacity.


Ron D is a grifter.
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Kendi is a grifter.

This guy appears to be a run of the mill flaming douche bag.

He wants to employ you and strip mine your practice. Future PE vulture written all over him.
 
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MidwestRadOnc said:
Kendi is a grifter.

This guy appears to be a run of the mill flaming douche bag.

He wants to employ you and strip mine your practice. Future PE vulture written all over him.
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Oh he's a grifter too. He will happily sell you all kinds of overly onerous and strict CMS compliance advice and scare your hospital admin
 
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We’ve all come across these characters. He likely wanted to be a doctor but either was too lazy or couldn’t cut it. He goes into admin and makes it his lifelong mission to disrupt the system but not in anyway beneficial to doctors because he’s “smarter.”

He made it in life, CEO, rubs elbows with the big wigs and gets to have followers and best of all he gets to challenge the doctors because he has “power.”
 
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RadOncDoc21 said:
We’ve all come across these characters. He likely wanted to be a doctor but either was too lazy or couldn’t cut it. He goes into admin and makes it his lifelong mission to disrupt the system but not in anyway beneficial to doctors because he’s “smarter.”

He made it in life, CEO, rubs elbows with the big wigs and gets to have followers and best of all he gets to challenge the doctors because he has “power.”
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I would go a step further:

For all my stone casting at the field, very, VERY seldom do I think the people are "bad". Even many of the extremely uh...annoying people are either misled by those who came before or formed strong opinions without actually looking into "controversial" RadOnc things (which aren't really all that controversial in the bigger picture).

I do think the vast majority are doing what they think is "good".

Ron, however, is a different breed. Ignoring stories I've heard (if you get the chance, go ask a coding/billing person in your department at least 40ish years old about him), and relying exclusively on what I've seen for years, his entire business plan appears to be "drive up fear and complexity of medical billing so you think you're going to jail unless you listen to what he and his company tell you".

Seriously, if you listen to his crap you'd think we're out here killing people with IGRT or something.

It's a marketing tactic, and it's done tremendous damage to a generation of the field, physician or otherwise.
 
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TexasMed22 said:
I mean, isn't this correct? Med oncs work more hours per week than rad oncs, earn ~50k less per MGMA, have (some) overnight call, and round on (some) weekends. Plus their pay is very vulnerable to changes in drug reimbursement (they start making 250k a year real quick if chemo billing changes and they lose the 6% cut on chemo infusions).
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The truth is very much in the middle. Market forces are important, but so are reimbursement levels for services provided.
 
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OTN said:
The truth is very much in the middle. Market forces are important, but so are reimbursement levels for services provided.
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They are 6-18 month waits for a pcp in some locales and yet they’ll still lag behind their specialist counterparts.
 
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Mandelin Rain said:
Harvard falsifies cancer research. Cool, cool, cool.
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So...Dana Farber is one of the "big, fancy hospitals" that my patients will get second opinions at, or come to me having already been there.

I have, on many occasions, steered those patients to Sloan instead.

I know, I know - normally it's the academic medical center stealing from the community, right?

But man...talk about leveraging institutional prestige. I'm not sure what goes on in Boston, but if we find out 70% of their research papers contain some element of fraud, I'd have zero trouble believing it.

I know I like to dunk on Sloan for the PPS-exempt/financial toxicity stuff, but in terms of actual medicine, I'd go there personally.

(to be clear, my opinion is about the non-RadOncs at DFCI/Mass Gen - I'm particularly fond of the Boston Pediatric RadOnc crew)
 
thesauce said:
Holy f—-

Why the hell put these patients at so much risk?? Just split it up - no one cares if they have to come in a few more times to avoid a major complication. This has gotten so out of hand.
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This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

1706064512841.png
 
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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

View attachment 381497
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Did you even read the trial inclusion criteria? How many of those lesions were in mobile, weight-bearing bones?

Easy to shoot from the hip if you have the blanket of sovereign immunity in academic practice
 
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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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I think there is a big difference in risk between one and 3 fractions when it comes to fractures. Most bones can take 1000 x 3 with mimal risk of fracture. Not sure why most pts couldn’t come for 2 more days. A fracture would be a lot more inconvenient and disruptive to chemo. I once necrosed an acetabulum and felt horrible. Also had some miserable pts after late insufficiency fractures from pelvic xrt.
 
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It’s crazy how far we’ve come. A couple of years ago, patients didn’t even balk at having to come in for 8-9 weeks of treatment. Today, 3 treatments is impossible!
 
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hqdefault.jpg


24 Gy x 1 is completely reasonable to some bony sites.

If a patient refuses anything other than a single treatment for an oligiomet in the clivus, well I guess I just have to give 24 Gy x 1 then.

The patient has metastatic disease. If there truly is some extenuating circumstance keeping them from coming back 2 more times under any circumstance (which sounds dubious this is not a fixable problem), then just give 10-12 Gy or something and retreat later if needed. Holy crap.
 
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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

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You would be well served by examining your practice pattern in the context of this paper rather than the one you linked: https://www.practicalradonc.org/article/S1879-8500(20)30056-4/fulltext

For a femur metastasis, single fraction is stated to be “Not recommended” by 7/9 international sbrt experts (with 1 of the remaining 2 stating “No opinion”) and only 1 stated that single fraction is their preferred scheme.

Regarding your explanation about time off from work or interdigitating with chemo, I’ve never met a patient who wasn’t willing to come 1 or 2 extra days in order to avoid a higher risk of a long bone fracture. If you look at the orthopedic literature, very few patients ever get back to their original PS after a femur fracture, and the mortality rate due to eventual complications is very high. What is your NNH in order to avoid one missed half-day of work?
 
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emt409 said:
This is not an uncommon fractionation, particularly outside of the US. Many here could benefit from traveling and familiarizing themselves with the successes and failures in various international practice patterns. Minimizing time off or interdigitating with chemotherapy is also a major priority for many patients, and I aspire to balance each patient's oncologic needs according to their best interests. Would I do every patient with 3 or 5 fractions if I could? Sure. Is it feasible for every patient, no.

View attachment 381497
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We know that doses that high in a single fraction puts the patient at a higher risk of path fracture. The twitter comment makes it seem like that is your 'usual' regimen.

Aspiring to do that high of a dose in a single fraction and putting patient at higher risk of path fracture to avoid the benefits of fractionation to even 3Fx is a wrong answer. If patient can't come for 3Fx, would just do 8Gy x 1. Chemotherapy is usually every 2-3 weeks. Not an issue to take a week and do 3Fx of SBRT.

This is arguably MORE important in metastatic patients where you 100% do not want to cause ANY QoL hit, especially not something as potentially devastating to not only a quality of life, but also quantity of life, as a femoral neck fracture. I would encourage you to read up on how lethal femur fractures are for patients based on increasing patients' age and re-consider your practice.

24Gy in 1 fraction to a scapula or even like a humerus (something that is technically weight bearing, but not on a daily basis the way a femur is) is very different than 24Gy in 1 fraction to not only a femur, but a femoral neck metastasis.
 
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evilbooyaa said:
We know that doses that high in a single fraction puts the patient at a higher risk of path fracture. The twitter comment makes it seem like that is your 'usual' regimen.

Aspiring to do that high of a dose in a single fraction and putting patient at higher risk of path fracture to avoid the benefits of fractionation to even 3Fx is a wrong answer. If patient can't come for 3Fx, would just do 8Gy x 1. Chemotherapy is usually every 2-3 weeks. Not an issue to take a week and do 3Fx of SBRT.

This is arguably MORE important in metastatic patients where you 100% do not want to cause ANY QoL hit, especially not something as potentially devastating to not only a quality of life, but also quantity of life, as a femoral neck fracture. I would encourage you to read up on how lethal femur fractures are for patients based on increasing patients' age and re-consider your practice.

24Gy in 1 fraction to a scapula or even like a humerus (something that is technically weight bearing, but not on a daily basis the way a femur is) is very different than 24Gy in 1 fraction to not only a femur, but a femoral neck metastasis.
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Maybe he is treating a 4 mm met with a cyberknife with rigid immobilization and 0mm PTV drawn off MRI performed with treatment setup?
Even then...
 
Perfect academic, big-hospital strategy: convince patients to come to your center to get single fraction radiotherapy (what a convenience!) after an 80-mile one way drive despite the fact that they live 5 min from the local community center. Treat the patient and bill insurance $70,000, the patient is delighted that they had no acute side effects! :)

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Patient winds up in the local community hospital with a pathologic fracture and/or esophageal perforation and/or bowel perforation and/or brainstem necrosis without records or input from academic center/big-hospital. Patient dies a slow and painful death.

In the meantime, the academic center/big-hospital publishes their "single instution prospective trial" of single fraction SBRT citing 100% local control and 0% late toxicity with median 6 month follow-up.

The world keeps on spinning, ASTRO demands more money for their PAC and DEI initiatives.
 
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If a patient can't travel to the academic center 5 times for treatment, one could always refer to their community linac close to home.

Lose some revenue capture, I know. But often times, that's the right thing to do.

EDIT: Gfunk (just) beat me.
 
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Gfunk6 said:
Perfect academic, big-hospital strategy: convince patients to come to your center to get single fraction radiotherapy (what a convenience!) after an 80-mile one way drive despite the fact that they live 5 min from the local community center. Treat the patient and bill insurance $70,000, the patient is delighted that they had no acute side effects! :)

View attachment 381526

Patient winds up in the local community hospital with a pathologic fracture and/or esophageal perforation and/or bowel perforation and/or brainstem necrosis without records or input from academic center/big-hospital. Patient dies a slow and painful death.

In the meantime, the academic center/big-hospital publishes their "single instution prospective trial" of single fraction SBRT citing 100% local control and 0% late toxicity with median 6 month follow-up.

The world keeps on spinning, ASTRO demands more money for their PAC and DEI initiatives.
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This is why I never censored on a Kaplan Meier graph without at least a personal phone call verifying that 6 month (toxicity) followup… being lost to followup can’t be graphed (or calculated). But, if looking at local control, this also would be a censor (and the patient would be local controlled until the heat death of the universe, or longer), so caveat emptor. Yet if plotting LRFS, it would be an event.
 
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Gfunk6 said:
The world keeps on spinning, ASTRO demands more money for their PAC and DEI initiatives.
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EMT probably another diversity hire causing unfathomable problems.

The rest of the post is spot on.
 
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I am indebted to the group at UAB for our single isocenter vmat brain stereo technique and appreciate emt coming on this site.
 
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