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I am having trouble to understand the rationale.
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Palex80 said:
View attachment 383783


I am having trouble to understand the rationale.
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Because similar trials have been done? Or because 74 gy dose escalation failed

I think the concept of sbrt boost only to primary makes sense as primary disease harder to control than nodal disease.
Would make me nervous if primary is very central or endobronchial

Sounds like authors hypothesized improved oxygenation with up front sbrt
 
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RadRadRad said:
Because similar trials have been done? Or because 74 gy dose escalation failed

I think the concept of sbrt boost only to primary makes sense as primary disease harder to control than nodal disease.
Would make me nervous if primary is very central or endobronchial

Sounds like authors hypothesized improved oxygenation with up front sbrt
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The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.
 
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Ray D. Ayshun said:
The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.
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Heard Harvard takes it to 70 if it is safe? Joe Chang has posted on mednet about their 66/30 SIb approach
 
Ray D. Ayshun said:
The alternative to this is sib. 60/30 and 66/30 where it's safe. Many of us already do this, and i think standard at mdacc.
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I have thought about this alot and go back and forth between 60 vs 66 Gy, but not sure it makes any difference except to make me feel better b/c I think (with absolutely no proof) that 60 Gy is inadequate. It's funny but I think it really does make us feel better as one of the main reasons. If 74 Gy "hurts" or at best is neutral, what will 70 Gy accomplish? With that said I think if you go to 66 Gy, might as well go to 70 Gy?!?!? Sorry just thinking out loud in my confusion!
 
Of note RTOG 1308, which had finished accruing BTW, goes to 70/35 with photons and protons. Will be interesting to see results and compare them to RTOG 0617. There has been more recent negative trials of dose escalation in lung with modern isotoxic techniques, however.
 
Palex80 said:
View attachment 383783


I am having trouble to understand the rationale.
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It's fine. On the innovation thread we discussed the peculiarities of dose kinetics and it's an understudied space. This is a low risk trial. Phase III will probably be negative but would anyone really mind accruing to it out in the community?

There are phase II trials and there are phase II trials. This is a baby phase II trial.
 
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thecarbonionangle said:
Of note RTOG 1308, which had finished accruing BTW, goes to 70/35 with photons and protons. Will be interesting to see results and compare them to RTOG 0617. There has been more recent negative trials of dose escalation in lung with modern isotoxic techniques, however.
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Do you mind linking some of those studies if you have them? I would love to take a look.
 
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RadOncMegatron said:
Do you mind linking some of those studies if you have them? I would love to take a look.
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There hasnt been any new phase 3 studies that i am aware of recently like 0617. There are multiple smaller studies which are restrostepective, phase 1/2 which have looked at question (search for isotoxic dose escalation NSCLC) . Some have used PETCT. I have not seen a newer ph 3 study clearly showing a benefit to dose escalation which is why i don’t believe we have a positive study to fall back on. Some of the conclusions say it is “promising” or possible without increased toxiticy, worthy of study. I agree with you that it seems like more dose would be better but take a look at the negative oesophageal studies again and again. Higher dose for cervical oesophagus is now completely out of NCCN. I’m simply saying it does not necessarily help as far as I know based on best high level data we have. I do take it to 66 in 33 or 30 from time to time but i wonder if it is something I do for myself lol

If someone is aware of anything different please post too!

RTOG 1106


RTOG 1308 is unpublished
 
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RadOncMegatron said:
I have thought about this alot and go back and forth between 60 vs 66 Gy, but not sure it makes any difference except to make me feel better b/c I think (with absolutely no proof) that 60 Gy is inadequate. It's funny but I think it really does make us feel better as one of the main reasons. If 74 Gy "hurts" or at best is neutral, what will 70 Gy accomplish? With that said I think if you go to 66 Gy, might as well go to 70 Gy?!?!? Sorry just thinking out loud in my confusion!
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LS sclc should be 70/35 if you treat daily and follow the calgb/nrg intergroup protocol. Less for nsclc. Makes perfect sense
 
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Dose escalation in conv fractionation in context of chemo doesn’t do jack other than cause more toxicity. How many times and how many solid tumor types do we have to see it in. Harvard is nuts going to 70 for NSCLC
 
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In a thread about Direct Supervision, Ron is, as always, playing the scare tactic cards.

He had the audacity to post this:

1710109321880.png


Just a reminder, Ron had his therapist licensed revoked by the ASRT:

1710109381773.png


He managed to get this removed from the website list you can easily search (I believe you can...perhaps offer a "donation" if ~10 years have passed) but you can always call the ASRT to verify a revocation.

Now, who can say WHY his license was revoked. I mean, it sure would be weird if it was like, cheating on continuing education credits or something, right? Like that would be super weird for a guy like this, preaching his scary puritanical interpretation of regulations.

Guess it will remain a mystery!
 
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elementaryschooleconomics said:
In a thread about Direct Supervision, Ron is, as always, playing the scare tactic cards.

He had the audacity to post this:

View attachment 383827

Just a reminder, Ron had his therapist licensed revoked by the ASRT:

View attachment 383828

He managed to get this removed from the website list you can easily search (I believe you can...perhaps offer a "donation" if ~10 years have passed) but you can always call the ASRT to verify a revocation.

Now, who can say WHY his license was revoked. I mean, it sure would be weird if it was like, cheating on continuing education credits or something, right? Like that would be super weird for a guy like this, preaching his scary puritanical interpretation of regulations.

Guess it will remain a mystery!
Click to expand...

Types of Sanctions - ARRT

R.T.s can face a range of ARRT sanctions and additional actions as a result of ethics violations. Learn more about each type.
www.arrt.org www.arrt.org

Revocation for cheating on cme seems kind of harsh.
 
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RickyScott said:

Types of Sanctions - ARRT

R.T.s can face a range of ARRT sanctions and additional actions as a result of ethics violations. Learn more about each type.
www.arrt.org www.arrt.org

Revocation for cheating on cme seems kind of harsh.
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What if it was some sort of...ring? Like a cheating ring?

Just asking questions of course, who knows.
 
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Palex80 said:
View attachment 383783


I am having trouble to understand the rationale.
Click to expand...
Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.
 
Mandelin Rain said:
Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.
Click to expand...
Of course we don’t know if many weeks of traditional fx prior to the large fx kills the possibility of increased immunogenicity from the large fx or not.
 
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Mandelin Rain said:
Haven't read the paper, but wasn't it hypothesized that moderate doses such as 6-8 Gy have the best immunogenic response?

Shrinking tumor/volume with traditional fx and then boosting residual to potentially increase LC and immunogenicity right before IO starts; I kind of like it.
Click to expand...

But doesn't this do the opposite? SBRT to bring in all the immune cells. Then conventional fx RT to kill them all.
 
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evilbooyaa said:
But doesn't this do the opposite? SBRT to bring in all the immune cells. Then conventional fx RT to kill them all.
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Mandelin Rain said:
Whoops. Yes. You're correct. I like that less.
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If only we could figure out the right sequence of fractions, along with fraction sizes, to reliably usher in this illusive immunogenicity upon command. If you think about it, there’s probably at least a few hundred feasible combos. Maybe more! Are we like Dr. Ehrlich blindly but one day serendipitously happening upon compound 606? Or are we just blind. Time will tell! I predict I’ll be dead before it does.
 
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TheWallnerus said:
If only we could figure out the right sequence of fractions, along with fraction sizes, to reliably usher in this illusive immunogenicity upon command. If you think about it, there’s probably at least a few hundred feasible combos. Maybe more! Are we like Dr. Ehrlich blindly but one day serendipitously happening upon compound 606? Or are we just blind. Time will tell! I predict I’ll be dead before it does.
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For this trial, the rationale is more than immunogenicity of course, although it would be nice if some magic happened. The more prosaic motivation is to see if one can safely improve local control and thus maybe pFS and OS by judiciously dose escalating with a highly conformal and upfront boost.

This is a lot different than escalating all disease from 60-74 Gy...not exciting, but different.

Agree about the sequencing question though, and all these arguments come out with every negative concurrent XRT/IO trial.

I'm convinced that radiation induced immunogenicity is a high variance problem in people. (Much less so in nude mice...why we have baller pre-clinical data.) In fact, I'm convinced that prior to the advent of targeted IO to conserved proteins like PD-L1, the high variance problem was why IO had been such a flop over 30 years of clinical research, despite clear evidence of periodic complete responses in patients.
 
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communitydoc13 said:
For this trial, the rationale is more than immunogenicity of course, although it would be nice if some magic happened. The more prosaic motivation is to see if one can safely improve local control and thus maybe pFS and OS by judiciously dose escalating with a highly conformal and upfront boost.

This is a lot different than escalating all disease from 60-74 Gy...not exciting, but different.

Agree about the sequencing question though, and all these arguments come out with every negative concurrent XRT/IO trial.

I'm convinced that radiation induced immunogenicity is a high variance problem in people. (Much less so in nude mice...why we have baller pre-clinical data.) In fact, I'm convinced that prior to the advent of targeted IO to conserved proteins like PD-L1, the high variance problem was why IO had been such a flop over 30 years of clinical research, despite clear evidence of periodic complete responses in patients.
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Agreed completely.
 
medgator said:
Inside joke?
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IMG_1055.jpeg


Revenue Cycle wrote a letter to CMS asking for abolishment of direct virtual in which it called itself the leading billing and compliance rad onc company in America.

And this leading company’s CEO called an anon twitter account “limpy.”

Strange times.
 
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Gfunk6 said:
[Edit] Wow if you read this physican's Twitter feed (she is a Med Onc), you can tell that she has some pent up issues. Maybe she ought to take up MMA or kickboxing to vent. Also, she REALLY likes N95 masks.
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Yeah. I almost feel bad reposting that public tweet. There's clearly a lot going on.
Unfortunately I know another another MD way waaayyyy farther off in crazy town. It blows my mind what people think is appropriate to post on X under their own name as professionals.

Edit: Her rage tweets about patients trashing their liver with supplements are not wrong. I'll give her that. I am tired of seeing patients with ALI from taking veterinary fenbendazole because some guy online (who also happened to be on IO coincidentally) had a CR using it.
 
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MidwestRadOnc said:
Everyone else is crazy but me...

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N95 masking in 2022, but not masking now as best as one can tell. "Do you not know that there comes a midnight hour when everyone has to throw off his mask," said Kierkegaard. Wonder when her midnight hour finally occurred. Would genuinely love to understand that logic.
 
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I still wear a mask, mainly because I can hide my facial reactions whenever patients say dumb 💩
 
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RadOncDoc21 said:
no that’s real!

View attachment 384389
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When the Canadian naturopathic clinics are telling you it's quackery, you know you are in another level. Kind of like that time Kanye made Alex Jones look normal.

www.simcoenaturopathic.ca

Fenbendazole - Is It Safe in Those with Cancer? (Joe Tippens Protocol)

The fenbendazole controversy was an incident in which inaccurate claims about the efficacy of fenbendazole, an anthelmintic primarily used to treat various parasitic infections in dogs, in curing terminal lung cancer gained widespread attention among patients.[1] This situation originated with...
www.simcoenaturopathic.ca www.simcoenaturopathic.ca
 
MidwestRadOnc said:
When the Canadian naturopathic clinics are telling you it's quackery, you know you are in another level. Kind of like that time Kanye made Alex Jones look normal.

www.simcoenaturopathic.ca

Fenbendazole - Is It Safe in Those with Cancer? (Joe Tippens Protocol)

The fenbendazole controversy was an incident in which inaccurate claims about the efficacy of fenbendazole, an anthelmintic primarily used to treat various parasitic infections in dogs, in curing terminal lung cancer gained widespread attention among patients.[1] This situation originated with...
www.simcoenaturopathic.ca www.simcoenaturopathic.ca
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Uh I take it this concept is going viral right now? Pun...somewhat intended...

I encountered this for the first time in my clinic two days ago.

"Is it OK to keep doing my holistic treatments during radiation?"

"What kind of holistic treatments?"

I think I confused the heck out of the patient when I told them using an actual, honest-to-God drug was NOT something you can call "holistic"...
 
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Palex80 said:
View attachment 384371



View attachment 384372
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Unless NEJM is putting pronouns, race/ethnicity, and age in the author byline these days - this is not a Tweet you can make without intentionally doing detective work on each author's pronouns, race/ethnicity, and age...

It's unfortunate she's so preoccupied with labels. It doesn't seem like a very equitable opinion, and her Tweets on the matter seem quite exclusionary.
 
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elementaryschooleconomics said:
Uh I take it this concept is going viral right now? Pun...somewhat intended...

I encountered this for the first time in my clinic two days ago.

"Is it OK to keep doing my holistic treatments during radiation?"

"What kind of holistic treatments?"

I think I confused the heck out of the patient when I told them using an actual, honest-to-God drug was NOT something you can call "holistic"...
Click to expand...

Get a CMP on any patient coming in on any sort of dewormer.
The transaminase elevations will garner honorary membership at the local college fraternity.
 
MidwestRadOnc said:
Get a CMP on any patient coming in on any sort of dewormer.
The transaminase elevations will garner honorary membership at the local college fraternity.
Click to expand...
NEW GRAY ZONE CASE

SOMEONE CALL RED JOURNAL

(these tips are infinitely more useful than yet another 5 fraction case report)
 
elementaryschooleconomics said:
Unless NEJM is putting pronouns, race/ethnicity, and age in the author byline these days - this is not a Tweet you can make without intentionally doing detective work on each author's pronouns, race/ethnicity, and age...
Click to expand...

As an aside, I find it so interesting that for a while it was basically a cardinal sin to assume gender or ethnicity in these kinds of DEI papers.

Yet, the ones most vocal about it seem to do it all the time when it is really the only way to complete the "study".

The fact that this medical oncologist pointed out THAT aspect of THAT study as what she is mad about... man, oncology is so far gone :rofl: :cryi:
 
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NotMattSpraker said:
As an aside, I find it so interesting that for a while it was basically a cardinal sin to assume gender or ethnicity in these kinds of DEI papers.

Yet, the ones most vocal about it seem to do it all the time when it is really the only way to complete the "study".

The fact that this medical oncologist pointed out THAT aspect of THAT study as what she is mad about... man, oncology is so far gone :rofl: :cryi:
Click to expand...
Karen is upset!
 
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NotMattSpraker said:
As an aside, I find it so interesting that for a while it was basically a cardinal sin to assume gender or ethnicity in these kinds of DEI papers.

Yet, the ones most vocal about it seem to do it all the time when it is really the only way to complete the "study".

The fact that this medical oncologist pointed out THAT aspect of THAT study as what she is mad about... man, oncology is so far gone :rofl: :cryi:
Click to expand...

Some people make careers based on clinical trials.

Some make a career over being angry on social media. What they are angry about is variable, it's the being angry part that is what makes their career.
 
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NotMattSpraker said:
As an aside, I find it so interesting that for a while it was basically a cardinal sin to assume gender or ethnicity in these kinds of DEI papers.

Yet, the ones most vocal about it seem to do it all the time when it is really the only way to complete the "study".

The fact that this medical oncologist pointed out THAT aspect of THAT study as what she is mad about... man, oncology is so far gone :rofl: :cryi:
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i just don't get it.
i am all about equity, but DEI being applied to everything is just ridiculous.
Applying her logic - you can always find something to be upset about. If there were women on the paper, then the next logical step is...well are they diverse?

I mean should we start applying DEI to athletics? I guess there is some work in the NFL for head coaches.
 
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radoncftw said:
i just don't get it.
i am all about equity, but DEI being applied to everything is just ridiculous.
Applying her logic - you can always find something to be upset about. If there were women on the paper, then the next logical step is...well are they diverse?

I mean should we start applying DEI to athletics? I guess there is some work in the NFL for head coaches.
Click to expand...
The "DEI/Woke" pendulum swung too far.

We're back to another era of "let's get weird".

I wonder what's next?
 
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