Managed decline is depressing. Mismanaged decline is insulting.

[scarbrtj]

Planning for Tsunami:
The Growing Oversupply of Radiation Oncologists in the U.S.

Has rad onc always had oversupply agita?! Maybe so.

I'm not going to spend a ton of time dissecting this and will instead let it (mostly) speak for itself. A "time capsule" from Daniel Flynn circa 1997. A few things I did notice...

First, Flynn attempted to calculate new patients per rad onc per year. This can be calculated two ways. First, you could determine what percentage of the approximately 1.8 million people per year who get cancer will get RT for their diagnosis upfront. That proportion is about 30% i.e. 550-600K per year (numerous peer reviewed data points on this). Second, you could just say "How many people per year get RT in the U.S.?" This is a bigger number. It's about 1.1 million per year; there are almost no peer-reviewed data on this however. (NB: there are about 5500 rad oncs in the U.S. now.) I believe Flynn is looking at the first example, not the second...

Re-citing my original chart, and adding in "Flynn data"... there's a definite trend (the yellow is new patients per rad onc)

Keep in mind this is not total number of patients irradiated per year per rad onc (in yellow). But the "new patients per year" is still a valuable metric I think. Again, "new" means recently diagnosed and getting RT as front-line therapy. The ~1.1 million a year getting RT will include a lot of retreats, ie palliative patients etc. If you use this as the numerator in the ratio (1.06 million RT patients per year amongst 5500 rad oncs), it's ~193 pts/rad onc/year.

Also, please read all the "utilization rate" data he talks about; if true, the utilization rate of RT has fallen SUBSTANTIALLY since the 1990s. No one knew the word "hypofractionation" back then, but he touches on "What would happen if fraction numbers drop?"

Finally, here's a cut/paste of a section where Flynn was particularly prescient IMHO:

Some of the dangers of oversupply are as follows:

1. It is likely that our specialty will be increasingly selected by less qualified medical school graduates, while more highly qualified graduates may choose specialties with better future practice opportunities. Programs that don't match with their choices of resident applicants will readily fill vacancies with less qualified candidates due to the increasing number of medical school, osteopathic school, and foreign medical graduates that total over 22,000 per year, nearly double that of twenty years ago.
   
   
2. Marginal practices, economically inefficient and with diminished technical capabilities, will be created. These facilities will have marginal staffing such as part-time physics (once/week) and diminished quality assurance. For example, two marginal competing centers, serving the same population area, may each treat for a half-day because there are not enough patients to keep them treating at full capacity. This is economically inefficient with a patient volume that would support one center being divided between two centers. Overhead-including the building, accelerator, simulator, service contracts, and personnel -is double. The cost of health care delivery is much greater. Manpower oversupply will encourage unnecessary marginal centers to be built because of readily available physicians to staff them in return for low compensation . Some of these marginal centers might be run by medical oncologists with the radiation oncologists as their employees.
   
   
3. Many practices will struggle to compete for patients and will be under great economic pressure not to refer complex cases to tertiary centers. The volume of patients at some tertiary centers will drop. Academic centers, non-academic regional centers, and cooperative trials will suffer as a result of fewer patients.
   
   
4. Some hospitals may close their medical staff and cancel the contract with the existing fee-for service radiation oncologists, put them on salary, and take a significant portion of the physician's professional collections in addition to the technical component that they already collect. If the physicians resist, they would be replaced by those readily available in an oversupply environment.
   
   
5. Some academic centers will seek to acquire existing community-based practices. This will be done either by competing for contracts up for renewal with the practitioners already practicing at the facility or, in some cases, the larger academic medical center purchasing the smaller community hospital. In either case, some private practitioners may lose their practice in favor of younger practitioners hired at low compensation to staff the academic satellite.
   
   
6. With an increased number of practitioners and radiation oncology facilities, the productivity of some facilities will drop. There will be a tendency for some to treat patients who might best not be treated, or to increase the number of treatment fractions in patients who might otherwise have been prescribed fewer fractions. This effect will increase the cost of health care and further stimulate other reimbursement models, such as capitation, to move more rapidly into non-capitated regions of the country.
   
   
7. An increasing number of graduating residents will be under-employed (unemployed or involuntarily employed part-time). Some graduating residents will be locked out of the workforce. This is already happening in Anesthesiology.

---

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[deleted969641]

Some hospitals may close their medical staff and cancel the contract with the existing fee-for service radiation oncologists, put them on salary, and take a significant portion of the physician's professional collections in addition to the technical component that they already collect. If the physicians resist, they would be replaced by those readily available in an oversupply environment.

No way! There's no way this would ever happen! What kind of self-respecting rad onc would ever allow that to happen?
I mean, even if there was such a glut of rad oncs out there that hospitals in big cities starting pocketing the professional collections owed to the physician, there's no way Victoria, TX and Marshfield, WI could ever get away with trying to do something so awful, right? Right?

 

[fiji128]

It will be interesting to see the total number of rad oncs residency positions filled this year. My guess is about the same as last year.

 

[deleted969641]

It will be interesting to see the total number of rad oncs residency positions filled this year. My guess is about the same as last year.

Definitely.

But lets do some more questionable back-of-the-napkin math. Just for fun.

Hospitals are currently keeping about 30-50% of rad onc professional collections.
In 2004, 172 patients/rad onc would generate about $820k/year in professional collections. Rad oncs back then would keep all of this.
In 2019, with 105 patients/rad onc (is anybody actually this low? I'm personally at about 250), this generates about $480k in collections. But that's only $240-330k after the hospital takes their cut.

With 50 patients/rad onc, that's $230k in collections, and $120-$160k to you. I think the dosimetrist gets paid more.
That will never happen! Wait, isn't Stanford already trying to pay junior rad oncs in the 130k range?

$130k. Med students, that's what you'll get after a decade of extra school and 4 board exams in desirable-to-live areas if the above scenario continues to play out.

Victoria, TX is licking its chops. Soon... soon......

 

[radiation]

Planning for Tsunami:
The Growing Oversupply of Radiation Oncologists in the U.S.

Has rad onc always had oversupply agita?! Maybe so.

I'm not going to spend a ton of time dissecting this and will instead let it (mostly) speak for itself. A "time capsule" from Daniel Flynn circa 1997. A few things I did notice...

First, Flynn attempted to calculate new patients per rad onc per year. This can be calculated two ways. First, you could determine what percentage of the approximately 1.8 million people per year who get cancer will get RT for their diagnosis upfront. That proportion is about 30% i.e. 550-600K per year (numerous peer reviewed data points on this). Second, you could just say "How many people per year get RT in the U.S.?" This is a bigger number. It's about 1.1 million per year; there are almost no peer-reviewed data on this however. (NB: there are about 5500 rad oncs in the U.S. now.) I believe Flynn is looking at the first example, not the second...

Re-citing my original chart, and adding in "Flynn data"... there's a definite trend (the yellow is new patients per rad onc)

Keep in mind this is not total number of patients irradiated per year per rad onc (in yellow). But the "new patients per year" is still a valuable metric I think. Again, "new" means recently diagnosed and getting RT as front-line therapy. The ~1.1 million a year getting RT will include a lot of retreats, ie palliative patients etc. If you use this as the numerator in the ratio (1.06 million RT patients per year amongst 5500 rad oncs), it's ~193 pts/rad onc/year.

Also, please read all the "utilization rate" data he talks about; if true, the utilization rate of RT has fallen SUBSTANTIALLY since the 1990s. No one knew the word "hypofractionation" back then, but he touches on "What would happen if fraction numbers drop?"

Finally, here's a cut/paste of a section where Flynn was particularly prescient IMHO:

Some of the dangers of oversupply are as follows:

1. It is likely that our specialty will be increasingly selected by less qualified medical school graduates, while more highly qualified graduates may choose specialties with better future practice opportunities. Programs that don't match with their choices of resident applicants will readily fill vacancies with less qualified candidates due to the increasing number of medical school, osteopathic school, and foreign medical graduates that total over 22,000 per year, nearly double that of twenty years ago.
   
   
2. Marginal practices, economically inefficient and with diminished technical capabilities, will be created. These facilities will have marginal staffing such as part-time physics (once/week) and diminished quality assurance. For example, two marginal competing centers, serving the same population area, may each treat for a half-day because there are not enough patients to keep them treating at full capacity. This is economically inefficient with a patient volume that would support one center being divided between two centers. Overhead-including the building, accelerator, simulator, service contracts, and personnel -is double. The cost of health care delivery is much greater. Manpower oversupply will encourage unnecessary marginal centers to be built because of readily available physicians to staff them in return for low compensation . Some of these marginal centers might be run by medical oncologists with the radiation oncologists as their employees.
   
   
3. Many practices will struggle to compete for patients and will be under great economic pressure not to refer complex cases to tertiary centers. The volume of patients at some tertiary centers will drop. Academic centers, non-academic regional centers, and cooperative trials will suffer as a result of fewer patients.
   
   
4. Some hospitals may close their medical staff and cancel the contract with the existing fee-for service radiation oncologists, put them on salary, and take a significant portion of the physician's professional collections in addition to the technical component that they already collect. If the physicians resist, they would be replaced by those readily available in an oversupply environment.
   
   
5. Some academic centers will seek to acquire existing community-based practices. This will be done either by competing for contracts up for renewal with the practitioners already practicing at the facility or, in some cases, the larger academic medical center purchasing the smaller community hospital. In either case, some private practitioners may lose their practice in favor of younger practitioners hired at low compensation to staff the academic satellite.
   
   
6. With an increased number of practitioners and radiation oncology facilities, the productivity of some facilities will drop. There will be a tendency for some to treat patients who might best not be treated, or to increase the number of treatment fractions in patients who might otherwise have been prescribed fewer fractions. This effect will increase the cost of health care and further stimulate other reimbursement models, such as capitation, to move more rapidly into non-capitated regions of the country.
   
   
7. An increasing number of graduating residents will be under-employed (unemployed or involuntarily employed part-time). Some graduating residents will be locked out of the workforce. This is already happening in Anesthesiology.

So what was the main thing that staved off the tsunami of 1997? IMRT? The thing the saved Rad Onc in the 2000s was the ability to bill more with a new technology? Or was it that they found a way to increase utilization

With many of these problems listed, I don't see how many of them get fixed by altering the number of residents this year or next. The oversupply storm is coming regardless of what we do now with spots so I think the disproportionate focus discussing oversupply like it is some sort of solution is not where most of our energy should be placed. There is clear oversupply, but that is one of the many problems in the field and I don't think we are in a much better place even if we "fix" the oversupply problem. The only way to get out of the tsunami is to increase the use of radiation

The cost of cancer drugs is unsustainable and most new drugs do not increase cure rates (pretty sure targeted therapy has never cured anybody but those pfs curves sure do look pretty). I would love to see a graph of med onc costs per cancer patient vs rad onc cost per cancer pt. Anybody that has been to a tumor board knows radiation is criminally underused. Imagine what the utilization rates would be if all gatekeeper specialties actually used evidence based medicine and all patients had an legitimate discussion regarding the their non-surgical options

 

[scarbrtj]

In 2019, with 105 patients/rad onc (is anybody actually this low? I'm personally at about 250)

The "real number" (average of new start RT patients) is about 195-200/year. (The 105/year as suggested on the graph is de novo recently diagnosed patients.) IMHO (like, totally just my opinion) the avg new starts/year should be 350, and 200 de novo new patients/year. The 350/200 was probably like how it was in the 90's when Flynn wrote this.

EDIT: Better explanation, maybe: some people don't get RT for years after their initial diagnosis. There are 1.8 million a year adding to a large cache of cancer survivors and "living with cancer" people out there. So in essence RT is having to treat more and more chrono-distantly diagnosed (relapsed, or palliative) patients to stay afloat.

 

[elementaryschooleconomics]

Some of the dangers of oversupply are as follows:

1. It is likely that our specialty will be increasingly selected by less qualified medical school graduates, while more highly qualified graduates may choose specialties with better future practice opportunities. Programs that don't match with their choices of resident applicants will readily fill vacancies with less qualified candidates due to the increasing number of medical school, osteopathic school, and foreign medical graduates that total over 22,000 per year, nearly double that of twenty years ago.

This will be super interesting to watch.

As RadOnc became more competitive over the past 10-20 years, the population was enriched for master test-takers, with average Step 1 scores creeping up constantly. However...pass rates for our ridiculous 4-exam sequence barely changed, implying that our board exams were becoming increasingly difficult (SOURCE).

How will this play out in the next 10 years, as RadOnc is filled with people who didn't really want to be here, or who were average/struggling test takers in med school? The exam process will likely adapt...eventually...after a period of shockingly low pass rates.

The training of Radiation Oncologists from 2020-2030 will be uncomfortable...only for those graduates to face a rocky job market.

 

[scarbrtj]

The only way to get out of the tsunami is to increase the use of radiation

That would be a great way. But how? Utilization rates have fallen steadily since ~1995. Prostate ca prevalence has fallen off a cliff versus 2010 due to decreased screening. Mastectomy is more popular than ever. Derms give more RT fractions per day in the US than rad oncs do (IMHO, that's the lowest hanging fruit). I don't think a scientific push will get us where we need to be. Would have to be a (almost improbable) legislative push. The "use of radiation" as you say is, to me anyways, also equivalent to: how many times... fractions... radiation is used. Radiation is/should be used 1/10th (8 Gy/1 fx vs 30/10) of what it was say 15 years ago. Bone met palliation is big proportion of insurance and Medicare RT expenditure. Breast RT use is ~1/2 what it used to be. We brought all that on ourselves as a field. RT patients got an average of 23 fractions in 2010 and it's 15 now.

 

[scarbrtj]

However...pass rates for our ridiculous 4-exam sequence barely changed, implying that our board exams were becoming increasingly difficult

Or there was some sort of nefarious rigging behind the closed doors to keep things steady, quell uprisings, be an opiate for the masses, etc etc. I predict that you could have a Confederacy of Dunces take the exam and the ABR overlords would still keep pass rates the same. They've learned their lesson... best not to mess with the sweet addicting flow of residents being produced.

 

[elementaryschooleconomics]

It will be interesting to see the total number of rad oncs residency positions filled this year. My guess is about the same as last year.

I think this year will be similar to last year. Previously, I had thought this year was probably the nadir of RadOnc applications since everything was virtual. The typical in-person gaslighting/brainwashing that old faculty can do to medical students was minimized.

However, a combination of 1) ASTRO releasing the workforce statement and 2) residents feeling more "safe" to openly discuss their job finding struggles might mean the bottom is yet to come. Sadly, regardless - I think SOAP will be heavily employed and we've reached a steady-state of # of new residents/year. So while we may Match 75-100 truly interested students every year, the additional 100 spots will find a way to be filled.

Do I desperately want to be proven wrong? Yes. I want someone to come on here in a couple of years and tell me how wrong I am. That would be AMAZING.

 

[RickyScott]

I think a lot of programs will aim low and not SOAP- FMG, DO, ex-cons etc

 

[ramsesthenice]

So Scar, as it pertains to the rad onc apocalypse, do you see yourself as the dragon, the beast, or one of the horsemen?

 

[RickyScott]

So what was the main thing that staved off the tsunami of 1997? IMRT? The thing the saved Rad Onc in the 2000s was the ability to bill more with a new technology? Or was it that they found a way to increase utilization

With many of these problems listed, I don't see how many of them get fixed by altering the number of residents this year or next. The oversupply storm is coming regardless of what we do now with spots so I think the disproportionate focus discussing oversupply like it is some sort of solution is not where most of our energy should be placed. There is clear oversupply, but that is one of the many problems in the field and I don't think we are in a much better place even if we "fix" the oversupply problem. The only way to get out of the tsunami is to increase the use of radiation

The cost of cancer drugs is unsustainable and most new drugs do not increase cure rates (pretty sure targeted therapy has never cured anybody but those pfs curves sure do look pretty). I would love to see a graph of med onc costs per cancer patient vs rad onc cost per cancer pt. Anybody that has been to a tumor board knows radiation is criminally underused. Imagine what the utilization rates would be if all gatekeeper specialties actually used evidence based medicine and all patients had an legitimate discussion regarding the their non-surgical options

IMRT and prostate saved XRT. Truth is that radiation may just have a limited role in cancer (new pancreatic study at ASCO again survival detriment?), just like the truth is that Trump did not win the election. Cant will something into existence in science. As a field, I would say, we are more focused on decreasing the indications and footprint of radiation.

 

[elementaryschooleconomics]

IMRT and prostate saved XRT. Truth is that radiation may just have a limited role in cancer (new pancreatic study at ASCO again survival detriment?), just like the truth is that Trump did not win the election. Cant will something into existence.

I firmly believe radiation will play an important role in cancer treatment for many years to come...

...just not a "200 kids/year" kind of role.

 

[scarbrtj]

So Scar, as it pertains to the rad onc apocalypse, do you see yourself as the dragon, the beast, or one of the horsemen?

Eh.... John the Elder. My writings are "hard for modern people to read."

 

[scarbrtj]

It should be noted even when people were predicting there would be an *undersupply* of radiation oncologists, those same predictions were based on seeing/acknowledging this (below) sort of RT utilization trend... but predicting there would be a blossoming of cancer. Plot twist: the blossoming forgot to appear. (And the utilization rate decrease didn't subside.)

 

[medgator]

It should be noted even when people were predicting there would be an *undersupply* of radiation oncologists, those same predictions were based on seeing/acknowledging this (below) sort of RT utilization trend... but predicting there would be a blossoming of cancer. Plot twist: the blossoming forgot to appear. (And the utilization rate decrease didn't subside.)

Not sure there has ever been a documented undersupply of rad oncs, only projected undersupply

 

[radiation]

That would be a great way. But how? Utilization rates have fallen steadily since ~1995. Prostate ca prevalence has fallen off a cliff versus 2010 due to decreased screening. Mastectomy is more popular than ever. Derms give more RT fractions per day in the US than rad oncs do (IMHO, that's the lowest hanging fruit). I don't think a scientific push will get us where we need to be. Would have to be a (almost improbable) legislative push. The "use of radiation" as you say is, to me anyways, also equivalent to: how many times... fractions... radiation is used. Radiation is/should be used 1/10th (8 Gy/1 fx vs 30/10) of what it was say 15 years ago. Bone met palliation is big proportion of insurance and Medicare RT expenditure. Breast RT use is ~1/2 what it used to be. We brought all that on ourselves as a field. RT patients got an average of 23 fractions in 2010 and it's 15 now.

I think we did ourselves a disservice by handcuffing our reimbursement to our fractionation schemes. Use of radiation should always have been measured in number of patients treated and not fractions given. Maybe APM will change that

Everybody on this forum agrees radiation is underused not because of clinical reasons, but because of system and gatekeeper effects. Are we going to fix that by decreasing number of residents?

 

[RickyScott]

I think we did ourselves a disservice by handcuffing our reimbursement to our fractionation schemes. Use of radiation should always have been measured in number of patients treated and not fractions given. Maybe APM will change that

Everybody on this forum agrees radiation is underused not because of clinical reasons, but because of system and gatekeeper effects. Are we going to fix that by decreasing number of residents?

We won’t fix that by decreasing residents. Frankly, decreasing residents won’t fix the oversupply because it is so bad. My goal is to impact the human cost- ie prevent medstudents from wasting their career and saving them from pain of this field.

 

[medgator]

We won’t fix that by decreasing residents. Frankly, decreasing residents won’t fix the oversupply because it is so bad. My goal is to impact the human cost- ie prevent medstudents from wasting their career and saving them from pain of this field.

Decreasing residents absolutely should be the first thing that's done. Stop the active bleeding before trying to fix the near death patient

 

[evilbooyaa]

I think we did ourselves a disservice by handcuffing our reimbursement to our fractionation schemes. Use of radiation should always have been measured in number of patients treated and not fractions given. Maybe APM will change that

Everybody on this forum agrees radiation is underused not because of clinical reasons, but because of system and gatekeeper effects. Are we going to fix that by decreasing number of residents?

Something something walk and chew gum at the same time

Push for multi-disciplinary prostate cancer clinics, multi-disciplinary discussion on bladder patients
VALOR (hope hope these results are OK)
SABR-COMET

 

[deleted941485]

We won’t fix that by decreasing residents. Frankly, decreasing residents won’t fix the oversupply because it is so bad. My goal is to impact the human cost- ie prevent medstudents from wasting their career and saving them from pain of this field.

the stakes are higher now its not like going into any specialty is a sure bet. Med students still have a fair amount of debt which makes it even harder and the decisions far more weighty. I mean if your specialty turns into a dead end for some reason I just think it shouldn't mean you need to leave medicine all together or spend what copious amounts of time in what amounts to indentured servitude to retrain.

RT is too far gone to hope for a miracle. Protons, SBRT mets, MRI linacs never gonna save you. Youre just spining your wheels faster just to hopefully keep from falling backwards. Drugs are the future of oncology as I think Ricky had alluded to earlier. What new RO grads really really need right now are decent options. A new technology isnt going to save us and if the last 5 years have been any indication of what tech will do to the avg RO attending it will just quicken their demise.

 

[RickyScott]

Only thing that can save rt is expanding skill set ie into systemic therapy, rads, somethinng.

 

[medgator]

Only thing that can save rt is expanding skill set ie into systemic therapy, rads, somethinng.

We're still needed.. but just a finite number of us.

 

[RickyScott]

Of course xrt is not going anywhere,

 

[deleted941485]

Only thing that can save rt is expanding skill set ie into systemic therapy, rads, somethinng.

More productive use of the ABR and ASTROs time rather than failing test takers or petitioning CMS for some narrow exemption to their arbitrary rules.

Doing what you love is great but doing something that pays the bills and keeps steady employment is far more important.

 

[elementaryschooleconomics]

Only thing that can save rt is expanding skill set ie into systemic therapy, rads, somethinng.

More productive use of the ABR and ASTROs time rather than failing test takers or petitioning CMS for some narrow exemption to their arbitrary rules.

I would sign on with some sort of "Immunotherapy Cert" or whatever so fast, your neck would break. Come on ABR!

 

[radiation]

Something something walk and chew gum at the same time

Push for multi-disciplinary prostate cancer clinics, multi-disciplinary discussion on bladder patients
VALOR (hope hope these results are OK)
SABR-COMET

Totally agree with this, but compare the number of posts talking about these issues vs oversupply posts. I would argue the things you have listed we actually have more control over on an individual basis, vs. trying to change the immoveable force that is the rad onc hierachy (which even if successful will not see any effect for at least 5 years)

Decreasing residents absolutely should be the first thing that's done. Stop the active bleeding before trying to fix the near death patient

As noted above, decreasing residents won't have any effect for at least 5 years. Enrolling on a radiation vs. surgery trial or an oligomet trial that reads out positive for radiation more likely to have meaningful impact in the next 5 years but that sort of thing doesn't make people angry enough to trend on twitter

 

[medgator]

As noted above, decreasing residents won't have any effect for at least 5 years. Enrolling on a radiation vs. surgery trial or an oligomet trial that reads out positive for radiation more likely to have meaningful impact in the next 5 years but that sort of thing doesn't make people angry enough to trend on twitter

Sure, the problem is we're a bunch of masochistic and self deprecating group of people and we'd find some way to trash any positive outcome while med oncs continue to get excited about DFS benefits with high priced systemic therapy.

So yes cut the damn spots

 

[elementaryschooleconomics]

Totally agree with this, but compare the number of posts talking about these issues vs oversupply posts. I would argue the things you have listed we actually have more control over on an individual basis, vs. trying to change the immoveable force that is the rad onc hierachy (which even if successful will not see any effect for at least 5 years)

You're right - so there's not much point in writing about it on the internet. I can show up to Tumor Board and through the strength of my arguments or relationships with referring docs drum up more patients on a local level. I don't need to take to the streets kicking up dust about things within my power.

However, I have absolutely zero control over the number of RadOnc residency spots in America, so my only course of action is to make sure it is a recurring topic of conversation on a national level, which I can do by posting on the main message board for the specialty.

 

[RickyScott]

You're right - so there's not much point in writing about it on the internet. I can show up to Tumor Board and through the strength of my arguments or relationships with referring docs drum up more patients on a local level. I don't need to take to the streets kicking up dust about things within my power.

However, I have absolutely zero control over the number of RadOnc residency spots in America, so my only course of action is to make sure it is a recurring topic of conversation on a national level, which I can do by posting on the main message board for the specialty.

In agreement. it is downright silly to argue that tumor boards/multidisciplinary this and that could substantially change number of patients on national level receiving xrt. We have also 20 years of top docs entering the field, so it’s not like we have had *****s advocating for xrt.

 

[radiation]

In agreement. it is downright silly to argue that tumor boards/multidisciplinary this and that could substantially change number of patients on national level receiving xrt. We have also 20 years of top docs entering the field, so it’s not like we have had *****s advocating for xrt.

What about supporting potentially practicing changing trials by opening up pro-radiation trials like LU-002 in the community? It has 150/400 enrolled pts after being open for 5 years. Or any of the other 50 radiation vs. surgery trials that closed early because lack of enrollment. The best way to substantial change number of pts on national level is to provide data on a national level that supports increased use of XRT

We have a long way to go in supporting our specialty on an individual basis. Its clear we have not optimized that aspect and to downplay the individual role we each play I think undersells our own power and responsibility. Sure its fun to trash the evil chairman etc, but at the end of the day I think the best "ground game" is to provide the data that xrt needs to be used more

 

[RickyScott]

So, the issue is we are “not doing enough” ? Again, as a field we have had 20 yrs of tip top, motivated high achieving medical students. If docs today aren’t up to your High standards (in terms of motivation or personal responsibility, or “living up to power”, or whatever other measure of quality or character),it can only be downhill from here as radonc vies with path for the bottom of the barrel.

 

[RadOncDoc21]

I’m done trying to “convince” the need for radiation. We can do trials and research all day but if we are not getting the patients, we are not getting the patients.

 

[RickyScott]

I’m done trying to “convince” the need for radiation. We can do trials and research all day but if we are not getting the patients, we are not getting the patients.

I have several medonc colleagues mskcc and Harvard trained, excellent docs and highly intelligent, who just have an anti radiation bent. They are friends, but I am just not going to “convince” them or shape their treatment philosophies anymore than I could convince a Jew to accept Jesus as the son of God.

 

[RadOncDoc21]

I have several medonc colleagues mskcc and Harvard trained, excellent docs and highly intelligent, who just have an anti radiation bent. They are friends, but I am just not going to “convince” them or shape their treatment philosophies anymore than I could convince a Jew to accept Jesus as the son of God.

I’ve seen it here as well as during my residency training and the “leaders” haven’t really helped us in those regards. Surgeons and med oncs do all they can to limit the need for radiation and when we do get involved, it’s to make it as fast and convenient as possible despite it being the appropriate treatment option.

 

[scarbrtj]

What about supporting potentially practicing changing trials by opening up pro-radiation trials like LU-002 in the community? It has 150/400 enrolled pts after being open for 5 years. Or any of the other 50 radiation vs. surgery trials that closed early because lack of enrollment. The best way to substantial change number of pts on national level is to provide data on a national level that supports increased use of XRT

We have a long way to go in supporting our specialty on an individual basis. Its clear we have not optimized that aspect and to downplay the individual role we each play I think undersells our own power and responsibility. Sure its fun to trash the evil chairman etc, but at the end of the day I think the best "ground game" is to provide the data that xrt needs to be used more

First, reality.

The number one indication for RT is breast cancer. As a specialty we have dramatically lowered the number of treatments there. The incidence of mastectomy (and less RT) is rising; mostly patient-led. This means rad oncs need to nationally advertise to women to stop getting mastectomies(?).

The number two indication for RT is prostate. The incidence of prostate cancer has fallen about 20 percent the last ten years. And surgeons are using more surgery.

The number three indication for RT is lung. The incidence of this is falling significantly also. While there was a huge uptick of SBRT use over the last 10 years, it really hasn’t meant more (raw) RT utilization in lung cancer.

The number four indication for RT is bone mets. Rad oncs are giving, nationally, on average a third to a quarter of the RT treatments for bone mets today as they were 15 years ago.

In the midst of all this, people are surviving cancer more than ever before. (The fall of RT utilization is correlated with increased cancer survival.)

TL; DR... very very long rows to hoe.

 

[Ray D. Ayshun]

I have several medonc colleagues mskcc and Harvard trained, excellent docs and highly intelligent, who just have an anti radiation bent. They are friends, but I am just not going to “convince” them or shape their treatment philosophies anymore than I could convince a Jew to accept Jesus as the son of God.

TBH, we're under a lot of pressure. More so than any other specialty when I think about it. We're tasked with hitting the right spots and missing the wrong spots, and there is very well-documented proof of how we did. It's like an op note x infinity. Perhaps the desire to avoid RT is a face-saving way of getting out of the kitchen.

 

[BobbyHeenan]

First, reality.

The number one indication for RT is breast cancer. As a specialty we have dramatically lowered the number of treatments there. The incidence of mastectomy (and less RT) is rising; mostly patient-led. This means rad oncs need to nationally advertise to women to stop getting mastectomies(?).

The number two indication for RT is prostate. The incidence of prostate cancer has fallen about 20 percent the last ten years. And surgeons are using more surgery.

The number three indication for RT is lung. The incidence of this is falling significantly also. While there was a huge uptick of SBRT use over the last 10 years, it really hasn’t meant more RT utilization in lung cancer.

The number four indication for RT is bone mets. Rad oncs are giving, nationally, on average a third to a quarter of the RT treatments for bone mets today as they were 15 years ago.

TL; DR... very very long rows to hoe.

I am amazed at the patients that think getting a mastectomy and reconstruction is akin to a mommy makeover.

 

[RickyScott]

I’ve seen it here as well as during my residency training and the “leaders” haven’t really helped us in those regards. Surgeons and med oncs do all they can to limit the need for radiation and when we do get involved, it’s to make it as fast and convenient as possible despite it being the appropriate treatment option.

First, reality.

The number one indication for RT is breast cancer. As a specialty we have dramatically lowered the number of treatments there. The incidence of mastectomy (and less RT) is rising; mostly patient-led. This means rad oncs need to nationally advertise to women to stop getting mastectomies(?).

The number two indication for RT is prostate. The incidence of prostate cancer has fallen about 20 percent the last ten years. And surgeons are using more surgery.

The number three indication for RT is lung. The incidence of this is falling significantly also. While there was a huge uptick of SBRT use over the last 10 years, it really hasn’t meant more RT utilization in lung cancer.

The number four indication for RT is bone mets. Rad oncs are giving, nationally, on average a third to a quarter of the RT treatments for bone mets today as they were 15 years ago.

In the midst of all this, people are surviving cancer more than ever before.

TL; DR... very very long rows to hoe.

The coming tsunami of cardiac sbrt is going to make up for the millions of lost fractions.

 

[radiation]

First, reality.

The number one indication for RT is breast cancer. As a specialty we have dramatically lowered the number of treatments there. The incidence of mastectomy (and less RT) is rising; mostly patient-led. This means rad oncs need to nationally advertise to women to stop getting mastectomies(?).

The number two indication for RT is prostate. The incidence of prostate cancer has fallen about 20 percent the last ten years. And surgeons are using more surgery.

The number three indication for RT is lung. The incidence of this is falling significantly also. While there was a huge uptick of SBRT use over the last 10 years, it really hasn’t meant more RT utilization in lung cancer.

The number four indication for RT is bone mets. Rad oncs are giving, nationally, on average a third to a quarter of the RT treatments for bone mets today as they were 15 years ago.

In the midst of all this, people are surviving cancer more than ever before.

TL; DR... very very long rows to hoe.

Personally I think the #1 source of pts should metastatic pts right now. All metastatic pts have local symptoms at some point. Palliation as a bread and butter is not very sexy but may be necessary for the incoming tsunami. If there is a way to find the integration with immunotherapy so it can improve a hard endpoint like OS that could be the gamechanger we need (but unlikely to happen). Imagine having every immunotherapy pt needing to see a rad onc to evaluate possible synergy (pipe dream i know). That might be one way to sneak into the immunotherapy game as a prescriber. Maybe we need to start thinking of radiation sensitizing systemic therapies vs the other way around. Only way to find out is to do (and enroll) the trials

 

[RickyScott]

Personally I think the #1 source of pts should metastatic pts right now. All metastatic pts have local symptoms at some point. Palliation as a bread and butter is not very sexy but may be necessary for the incoming tsunami. If there is a way to find the integration with immunotherapy so it can improve a hard endpoint like OS that could be the gamechanger we need (but unlikely to happen). Imagine having every immunotherapy pt needing to see a rad onc to evaluate possible synergy (pipe dream i know). That might be one way to sneak into the immunotherapy game as a prescriber. Maybe we need to start thinking of radiation sensitizing systemic therapies vs the other way around. Only way to find out is to do (and enroll) the trials

I totally agree.

 

[theradiator]

I totally agree.

Please tell the geniuses in the ivory tower to stop rejecting manuscripts on mixed metastases because they are too heterogeneous

 

[medgator]

I have several medonc colleagues mskcc and Harvard trained, excellent docs and highly intelligent, who just have an anti radiation bent. They are friends, but I am just not going to “convince” them or shape their treatment philosophies anymore than I could convince a Jew to accept Jesus as the son of God.

This seems to be more a problem with the older group of med oncs/docs in my experience. Younger MOs training at mid tier places seem to be just fine and dandy with xrt

 

[scarbrtj]

at the end of the day I think the best "ground game" is to provide the data that xrt needs to be used more

I have several medonc colleagues mskcc and Harvard trained, excellent docs and highly intelligent, who just have an anti radiation bent. They are friends, but I am just not going to “convince” them or shape their treatment philosophies anymore than I could convince a Jew to accept Jesus as the son of God.

Jews for Jesus

 

[dieABRdie]

Personally I think the #1 source of pts should metastatic pts right now. All metastatic pts have local symptoms at some point. Palliation as a bread and butter is not very sexy but may be necessary for the incoming tsunami. If there is a way to find the integration with immunotherapy so it can improve a hard endpoint like OS that could be the gamechanger we need (but unlikely to happen). Imagine having every immunotherapy pt needing to see a rad onc to evaluate possible synergy (pipe dream i know). That might be one way to sneak into the immunotherapy game as a prescriber. Maybe we need to start thinking of radiation sensitizing systemic therapies vs the other way around. Only way to find out is to do (and enroll) the trials

I'm getting a lot of patients for the sake of "getting more mileage" out of immunotherapy. New spot but everything else is negative? Zap it and keep going with immuno instead of switching to the next line that won't work.

 

[Reaganite]

The government needs to stop going after the low hanging fruit (Rad Onc) and aggressively pursue overutilization on the MedOnc side.

About 4 months into the pandemic I started receiving an absolute explosion of referrals, including bone mets. Local Med Oncs who hadn't sent me a bone met case in years were all of a sudden blowing me up with all the perfectly reasonable referrals I never saw. I thought perhaps they were trying to minimize clinic volume due to covid. No, turns out the local payors have started pursuing capitated med onc contracts...

 

[scarbrtj]

If you’d have told a rad onc twenty years ago that our field would be happy/excited/hopeful to switching to metastasis directed therapy they’d have thought you were either ignorant about cancer, a dunderhead, or Gil Lederman.

 

[RadOncDoc21]

If you’d have told a rad onc twenty years ago that our field would be happy/excited/hopeful to switching to metastasis directed therapy they’d have thought you were either ignorant about cancer, a dunderhead, or Gil Lederman.

Not to the forward thinking palliative fellowship trained rad onc. Those 30 Gy vs 20 Gy vs 8 Gy data is now considered good use!

 

[RickyScott]

If you’d have told a rad onc twenty years ago that our field would be happy/excited/hopeful to switching to metastasis directed therapy they’d have thought you were either ignorant about cancer, a dunderhead, or Gil Lederman.

That was my first thought. Not sure I would have found that very appealing as a medstudent.