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radoncftw said:
I have been shocked how little time our med onc colleagues spend with patients.
they don't seem to give patients time to ask much if anything.
i don't always use the full hour for consults (SBRT to an oligomet to the lung is pretty short for me...), but always make sure to address all of their concerns at the initial visit.
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Yes.

I've had multiple patients schedule their own follow ups with me to ask me whether they should do certain chemo/IO's because I answered more questions about chemo than their med onc. I obviously defer to med onc, but patients trust their rad onc a lot - especially in sites like lung or head/neck or prostate when you see patients for a couple of months regularly.
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BobbyHeenan said:
Yes.

I've had multiple patients schedule their own follow ups with me to ask me whether they should do certain chemo/IO's because I answered more questions about chemo than their med onc. I obviously defer to med onc, but patients trust their rad onc a lot - especially in sites like lung or head/neck or prostate when you see patients for a couple of months regularly.
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I have a few patients who schedule follow ups with me a few days after med onc so I can go through and explain med onc recommendations.
 
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It's not uncommon that I get patients from med onc who don't understand they have cancer.
Actually common that stage IV patients don't understand their cancer is not curable.
Frustrating that the specialty that wants to own all cancer management and views us as technicians punt on the most basic part of cancer patient discussion to other specialties.
 
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MidwestRadOnc said:
It's not uncommon that I get patients from med onc who don't understand they have cancer.
Actually common that stage IV patients don't understand their cancer is not curable.
Frustrating that the specialty that wants to own all cancer management and views us as technicians punt on the most basic part of cancer patient discussion to other specialties.
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This happened to me today something like...at least 3 times?

Just today.

It might have been 4, it was a rough day.
 
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drowsy12 said:
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What's the alternative? I'm guessing a push towards genomic risk stratification, although the scenario he mentions does not really support this...he's stating that volume of disease contextualizes the meaning of Gleason score, and I'm sure it does.

I love the Gleason score (obviously the most meaningful of the three traditional risk factors). I have a hard time believing that contemporary genomic or molecular tools are markedly better (what would you do with a GG5 and a low Decipher)?

MidwestRadOnc said:
all grade group 5 and PSA 20+ for Zytiga also
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GG5 bad. PG5 is really bad. I can't think of a published series that does not validate this. Zytiga not benign, so of course patient's age and comorbidities must be considered...but radoncs do this.
 
communitydoc13 said:
What's the alternative? I'm guessing a push towards genomic risk stratification, although the scenario he mentions does not really support this...he's stating that volume of disease contextualizes the meaning of Gleason score, and I'm sure it does.

I love the Gleason score (obviously the most meaningful of the three traditional risk factors). I have a hard time believing that contemporary genomic or molecular tools are markedly better (what would you do with a GG5 and a low Decipher)?


GG5 bad. PG5 is really bad. I can't think of a published series that does not validate this. Zytiga not benign, so of course patient's age and comorbidities must be considered...but radoncs do this.
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I'm biased because my PhD was in genomics but if you draw corollaries then perhaps it will allow more consistent gleason grading if they utilizing genomics, then again decipher is a gene expression assay initially made from microarrays and not necessarily a clear molecular defect pathway like for high grade gliomas.
 
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MidwestRadOnc said:
It's not uncommon that I get patients from med onc who don't understand they have cancer.
Actually common that stage IV patients don't understand their cancer is not curable.
Frustrating that the specialty that wants to own all cancer management and views us as technicians punt on the most basic part of cancer patient discussion to other specialties.
Click to expand...
This happens to me all the time as well.

Like what are you doing in that room?
 
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Ray D. Ayshun said:
Sure, that too. This strikes me as another attempt to suggest radoncs are thoughtless, as opposed to the surgeons doing rps on patients with gs 10 disease and positive nodes.
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To be honest I think you’re reading a lot into his post.
 
RO28 said:
This happens to me all the time as well.

Like what are you doing in that room?
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My honest guess:

The MedOnc doesn't use the word "cancer". They only say "the disease", "the malignancy", or the very precise name (p16+ squamous cell, for example).

Your average patient with no experience or knowledge in healthcare will NOT understand what that means.
 
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Ray D. Ayshun said:
Being upset with someone misrepresenting what we do on x? He made an untrue statement, no? Does each gs 4+4 patient you treat get 24 months adt? Essentially none of mine do.
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I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.
 
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it really is crazy that over the years i have met more patients than i should who come to me and:

1) i am the first person telling they have cancer. Usually it is because med onc uses words like “mass”, “lump”, “malignancy” or another euphemism

2) i am the first person to tell them their cancer is incurable

3) first person who tells them their prognosis is very poor

4) first person to tell them something super important about their disease like positive margins (surgeon said they “got it all”), or something else

5) first person to spend over 30 minutes with them and hear often you are first to ever explain this

6) first person to tell them their stage
 
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MidwestRadOnc said:
I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.
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ADT is a different beast, esp in low volume high risk disease. And esp when a patient comes in with obesity/metabolic syndrome/CAD etc before your decide to add years of ADT into the mix
 
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MidwestRadOnc said:
I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.
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I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years
 
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Chartreuse Wombat said:
I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years
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Not only not worth it, would argue detrimental both in terms of health as well as qol to some of these pts
 
Chartreuse Wombat said:
I think this analogy is inapt. $4000 is not trivial but the toxicity of rabies vaccination is minimal and in this scenario the risks are death in short order or cure and regular life expectancy.

In the prostate cancer scenario the risk/benefit is very different. In the most optimistic scenario the absolute benefit in OS of LTADT versus STADT is in the low single digits at 10-15 years (RTOG 92-02 for example). It is arguable that the additional 18 months of ADT is "not worth it" in the average radiation prostate cancer patient of 70-72 years
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I’m aware but at the time 4k was very toxic I assure you, and I don’t give out ADT without consideration. You’re missing the point. If you’ve confirmed GS8 with random samples, even if it’s not a lot, it’s a signal you shouldn’t ignore and if you do, you are taking on significant risk to the downside.

Surveillance in this scenario is insane for anybody not in a nursing home IMO.
 
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I do not give 24 months of ADT for high-risk patients with only one high-risk feature. There is good data for 18 months.

pubmed.ncbi.nlm.nih.gov

Duration of Androgen Deprivation Therapy in High-risk Prostate Cancer: A Randomized Phase III Trial - PubMed

In this study, we report outcomes from high-risk prostate cancer patients treated with radiotherapy and either 36 or 18 mo of androgen deprivation therapy. There was no difference in survival between the two groups, with the 18-mo group experiencing a better quality of life.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

Also, bear in mind the Will Rogers effect.
Today’s high-risk patients staged with PSMA-PET-CT are likely more truly N0M0 than those in the past staged with CT & bone scan. The net benefit in these patients from prolonged ADT, esp. in the context of dose escalation and ENI of the pelvis (if you do that), may be even lower.
 
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MidwestRadOnc said:
I disagree with this.
The risk of overtreating usually is less than the risk of undertreating IMO. The reason being that the outcomes of guessing wrong are far from equal in severity.

I once got bitten by a bat. I asked my doctor, what are the odds it had rabies? He said, almost zero but if it did you will die. I paid $4000 for the shots I almost certainly didn’t need and don’t regret it.
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Generally, 4+4 gets 18 months from me
 
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Ray D. Ayshun said:
Being upset with someone misrepresenting what we do on x? He made an untrue statement, no? Does each gs 4+4 patient you treat get 24 months adt? Essentially none of mine do.
Click to expand...

I don’t think this was an attack on rad oncs at all. I realize that many of us feel the need to be aggrieved but this was not one of them in my opinion.

1) he’s talking about urologists too
2) he’s generally speaking about the SOC for high risk and the fact is it’s a reality that despite your practice most people are not as discerning as you and treat high risk with long term ADT, full stop.
3) this urologist often is pretty favorable to rad onc in general
4) I posted it initially thinking the AS for GS8 would be the controversial part
 
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RO28 said:
This happens to me all the time as well.

Like what are you doing in that room?
Click to expand...
Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”
 
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drowsy12 said:
I don’t think this was an attack on rad oncs at all. Not one iota. I realize that many of us feel the need to be aggrieved but this was not one of them in my opinion.

1) he’s talking about urologists too
2) he’s generally speaking about the SOC for high risk and the fact is it’s a reality that despite your practice most people are not as discerning as you and treat high risk with long term ADT, full stop.
3) this urologist often is pretty favorable to rad onc in general
4) I posted it initially more on the active surveillance part, not the ADT part.
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I understand. My issue isn't a product of feeling aggrieved. Rather, id simply like people to stop saying things that are wrong, however peripheral to their larger point. Perhaps I overstated his attack on radonc, but it is indicative of an absolute ignorance of the thought we put into the use of adt and anti androgens in pca. I spend as much or more time talking about testosterone with many guys.
 
Mandelin Rain said:
Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”
Click to expand...
Be grateful he sent you the patient pre vs post op. Damn good GU, bro
 
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thecarbonionangle said:
it really is crazy that over the years i have met more patients than i should who come to me and:

1) i am the first person telling they have cancer. Usually it is because med onc uses words like “mass”, “lump”, “malignancy” or another euphemism

2) i am the first person to tell them their cancer is incurable

3) first person who tells them their prognosis is very poor

4) first person to tell them something super important about their disease like positive margins (surgeon said they “got it all”), or something else

5) first person to spend over 30 minutes with them and hear often you are first to ever explain this

6) first person to tell them their stage
Click to expand...
>80% of my encounters
 
Mandelin Rain said:
Me: “So, what did your urologist tell you about your cancer, risk groups, prognosis, and treatment options?”

Dude: “Really nothing. He said you’d do all that. He just told me my surgery is on Tuesday. What kind of surgery is it?”
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lol i don't send too much shade.
i just do my thing and explain things to the patient and thank the urologist for referring the patient.
 
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radoncftw said:
lol i don't send too much shade.
i just do my thing and explain things to the patient and thank the urologist for referring the patient.
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Our med oncs are so busy and handle so much of the medical issues so I understand why they can’t sometimes spend as much time with the patient as I do in regards to the “cancer discussion.”

In regards to the surgeons, I don’t mind as long as I get the referrals.
 
RadOncDoc21 said:
Our med oncs are so busy and handle so much of the medical issues so I understand why they can’t sometimes spend as much time with the patient as I do in regards to the “cancer discussion.”

In regards to the surgeons, I don’t mind as long as I get the referrals.
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I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.
 
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StIGMA said:
I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.
Click to expand...
Well that’s another story!
 
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StIGMA said:
I've been seeing more patients recently with upfront medical oncology management who were not staged correctly (eg: called stage IV but were stage II or III and given wrong treatment). Usually outside referrals. I don't really care if they are busy- at least do the damn job correctly.
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Gotta be stage 4 to get the immunotherapy
 
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madchemist89 said:
Gotta be stage 4 to get the immunotherapy
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Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.
 
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temujim said:
Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.
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Same here.

They just start Libtayo for huge tumors and then send to me …but often they’ve already had a few cycles before I see them. So it’s challenging to know how long to run the IO before jumping to XRT. And do you stop it and add a platinum for sensitizing, etc.
 
BobbyHeenan said:
Same here.

They just start Libtayo for huge tumors and then send to me …but often they’ve already had a few cycles before I see them. So it’s challenging to know how long to run the IO before jumping to XRT. And do you stop it and add a platinum for sensitizing, etc.
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Biased bc only see once they've progressed. So not much of a question of IO anymore, just RT +/- chemo, though most of these older skin patients can't tolerate the cisplatin.

But once derm figures out what has been happening with their referrals (ie IO rather than standard surgery or RT), they won't send anymore and set up an infusion bay right next to the SGRT. Many of the local derms are prescribing vismodegib; med oncs never see.
 
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temujim said:
Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.
Click to expand...

Gawd what a nightmare
 
temujim said:
Somehow most of the locally/regionally advanced skin gets started on IO around these parts. I think the med oncs declare them surgically unresectable and just start. Some have told me straight up that IO > RT for cures. Cleaning up theses disasters has been a theme over the last few years.
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Why are Derms referring to med onc first?

Traditionally they try to resect aggressively or send to us if they can't, not med onc.
 
medgator said:
Why are Derms referring to med onc first?

Traditionally they try to resect aggressively or send to us if they can't, not med onc.
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My cases have been ER to inpatient (neglected, indigent patients). Admitted by hispitalist. ENT sees as inpatient, biopsies, says can’t resect and then hospitalist consults the med onc service…,and then libtayo gets started.
 
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While not standard of care, libtayo can be very effective in skin cancer. NEJM phase two study showed a 50% pathCR rate in unresectable disease.
 
Im okay with med oncs starting with cemiplimab in advanced cases, but rad onc should follow along and should be able to consolidate, patients should not be on the drug forever in the locally advanced setting

And the decision should happen in coordination with rad onc as well. I trust my med oncs for these cases, but they also discuss the cases with me. Cemiplimab is an amazing drug for cutaneous SCC.
 
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BobbyHeenan said:
My cases have been ER to inpatient (neglected, indigent patients). Admitted by hispitalist. ENT sees as inpatient, biopsies, says can’t resect and then hospitalist consults the med onc service…,and then libtayo gets started.
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Maybe they are getting drug free from the company... A thought.

I guess if you're rvu based you don't care that they are indigent but maybe med onc thinks they aren't getting surgery or try RT otherwise.

Very few skin ca if any come to me through the hospital...95%+ are outpt and insured and see me from derm. From there I refer to med onc for IO if it looks appropriate to do so
 
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