Protons are blowing Rad Onc's boat out the CMS water

[deleted941485]

View attachment 354864

I mean Seriosuly what else does RO have going for it?

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[jondunn]

Proton cash is absolutely keeping the job market alive.

It’s sick

 

[RickyScott]

Nancy Lee has the higher ground

I thought Nancy lee was implicitly criticizing protons, saying they have become too big too fail.

 

[Mandelin Rain]

Proton cash is absolutely keeping the job market alive.

It’s sick

Bubbles all around us.

 

[TheWallnerus]

I mean Seriosuly what else does RO have going for it?

EVERYTHING. Now, more than ever.

 

[medgator]

I thought Nancy lee was implicitly criticizing protons, saying they have become too big too fail.

Not what i got from her statements

 

[thesauce]

Wide scale adoption of protons will HAVE to lead to a steep price correction like IMRT, right??? Right???

Yes - if they are going to pay for an expensive technology that has higher toxicity (at least for prostate), they should definitely be increasing IMRT reimbursement because of the higher quality of care it offers. I am 100% confident this will happen.

 

[thesauce]

View attachment 354865

Star Wars saw all this coming years ago

 

[IonsAreOurFuture]

2 New proton centers were announced this week, both in Wisconsin: Madison and Milwaukee. The previous closest centers were in either Chicago or Rochester, MN, 2-3 hours away.

UW Health strikes deal with Leo Cancer Care for $60M upright proton cancer therapy technology

UW Health plans to offer proton therapy, a form of radiation treatment that more precisely targets tumors for patients with certain cancers, and will be the first location in the state of Wisc | UW Health plans to offer proton therapy, a form of radiation treatment that more precisely targets...

www.fiercehealthcare.com

It looks like it will be a $60 million center and includes a vertical chair gantry, to rotate the seated patient in front of a scanning beam, instead of a 100-ton rotating gantry and the patient lying down:

UW Health to use new device that sits cancer patients upright for radiation therapy. It could be a game-changer.

The machine, created by Middleton-based Leo Cancer Care, could make the most precise radiation therapy much more affordable and accessible.

www.jsonline.com

 

[jondunn]

from a source - I am now hearing that UHC is uniformly approving proton for prostate cancer, no fights needed. Proton lobby wins again. This must be a downstream effect of big lawsuits.

 

[medgator]

from a source - I am now hearing that UHC is uniformly approving proton for prostate cancer, no fights needed. Proton lobby wins again. This must be a downstream effect of big lawsuits.

And owning a piece i guess

 

[thecarbonionangle]

If i were a betting person, i’d never bet against the proton lobby. That my friends would be a very bad bet. At this point i think protons are basically saving this field, it seems so I am happy someone is making money and crushing APM

 

[BobbyHeenan]

from a source - I am now hearing that UHC is uniformly approving proton for prostate cancer, no fights needed. Proton lobby wins again. This must be a downstream effect of big lawsuits.

I was told from a source I would trust that UHC got much more proton friendly after they invested in the NY Proton center.

 

[RickyScott]

In a lot of these cases, uhc is just acting as a fiducial/middle man for the employer. (Unless Medicare advantage) Higher billing is better for their bottom line.
Uhc is our insurance and when I treat an employee, still goes through prior auth, but the hospital gets the bill. (Never had an issue with these auths!)

 

[TheWallnerus]

In a lot of these cases, uhc is just acting as a fiducial/middle man for the employer. (Unless Medicare advantage) Higher billing is better for their bottom line.

This is one of those pieces of info that if rad oncs and all academicians truly understood/came to grips with, we would all be so much better off

 

[RickyScott]

This is one of those pieces of info that if rad oncs and all academicians truly understood/came to grips with, we would all be so much better off

It’s a very ugly synergy between hospitals and payors at the heart of health care price dysfunction.

 

[TheWallnerus]

It’s a very ugly synergy between hospitals and payors at the heart of health care price dysfunction.

And ASTRO wants to gripe about urologists buying linacs and overutilizing (I thought RT is a valid tx option for any and every localized prostate cancer patient?) radiation therapy. I never had anything to do with a urorads type place nor knew anyone who worked there. But this was ASTRO attacking its own members who had chosen to go work in these settings. That’s when I had to drop my ASTRO membership because I knew that maybe one day I might be a member whose practice and employment they looked down on. Their open animosity got too vociferous.

 

[Mandelin Rain]

And ASTRO wants to gripe about urologists buying linacs and overutilizing (I thought RT is a valid tx option for any and every localized prostate cancer patient?) radiation therapy. I never had anything to do with a urorads type place nor knew anyone who worked there. But this was ASTRO attacking its own members who had chosen to go work in these settings. That’s when I had to drop my ASTRO membership because I knew that maybe one day I might be a member whose practice and employment they looked down on. Their open animosity got too vociferous.

...and don't get me started on pineapple ripeness.

 

[SneakyBooger]

You're not paranoid, it's true.

United Healthcare is trying to make money from protons. It is listed by the SEC as owning "ProHealth Proton Center Management, LLC" and is one of the major investors of the NYPC, along with Mount Sinai, MSKCC, and Montefiore:

New York State’s first Proton Therapy Center reaches completion

www.stantec.com

"New York Proton Management, LLC" is another subsidiary on this SEC document regarding UnitedHealthcare.

Document

www.sec.gov

I think this could be construed as a conflict of interest pretty easily.

United Healthcare.

Wonder what is happening with this?

https://www.classaction.org/media/cole-on-behalf-of-himself-and-others-similarly-situated-v-united-healthcare-insurance-company.pdf

 

[Chartreuse Wombat]

United Healthcare.

Wonder what is happening with this?

https://www.classaction.org/media/cole-on-behalf-of-himself-and-others-similarly-situated-v-united-healthcare-insurance-company.pdf

The suite you link to was filed in 2019

I can't find anything more recent than this

IN BRIEF: UnitedHealthcare can’t zap cancer survivors’ lawsuit over proton therapy

A federal judge in Boston on Monday allowed three cancer survivors to proceed with their potential class action against UnitedHealthcare Insurance, alleging it “deceptively and unfairly administered their ERISA plans by refusing to cover Proton Beam Radiation Therapy (PBRT) … because it is more...

www.reuters.com

 

[TheWallnerus]

United Healthcare.

Wonder what is happening with this?

https://www.classaction.org/media/cole-on-behalf-of-himself-and-others-similarly-situated-v-united-healthcare-insurance-company.pdf

When insurance companies came up with the phrase "Experimental and/or Investigational" to deny care for things like proton beam therapy (wholly on a different level versus snake oil, laetrile, etc)... or IMRT for whole breast etc etc... it was one of the greatest verbal legerdemains ever pulled.

It's like calling someone a racist or a Nazi in a debate. It shuts down all discussion. "Experimental" is a scary word. "They're doing experiments on me?!" It gives a veil of authority to the insurance company: "We know science, and this treatment is not scientific."

It's a minor turn of phrase. No one ever even thinks about it most likely. But it is quite effective.

 

[BobbyHeenan]

When insurance companies came up with the phrase "Experimental and/or Investigational" to deny care for things like proton beam therapy (wholly on a different level versus snake oil, laetrile, etc)... or IMRT for whole breast etc etc... it was one of the greatest verbal legerdemains ever pulled.

It's like calling someone a racist or a Nazi in a debate. It shuts down all discussion. "Experimental" is a scary word. "They're doing experiments on me?!" It gives a veil of authority to the insurance company: "We know science, and this treatment is not scientific."

It's a minor turn of phrase. No one ever even thinks about it most likely. But it is quite effective.

My monkey brain just sees it as so simple.

I don't understand why the insurance statement isn't:

"To this point we see no compelling data that proton therapy for prostate cancer presents any benefit or detriment over that of IMRT. We therefore agree to pay for proton therapy at previously negotiated IMRT rates until new research shows otherwise."

 

[radiaterMike]

My monkey brain just sees it as so simple.

I don't understand why the insurance statement isn't:

"To this point we see no compelling data that proton therapy for prostate cancer presents any benefit or detriment over that of IMRT. We therefore agree to pay for proton therapy at previously negotiated IMRT rates until new research shows otherwise."

This is the case with some insurers' contracts with some proton centers. As has been mentioned on this forum, the IMRT rate for those centers can still be excessive, and the negotiated rates would not apply to insurers (particularly if out of network) that don't have contracts with those centers

 

[RickyScott]

This is the case with some insurers' contracts with some proton centers. As has been mentioned on this forum, the IMRT rate for those centers can still be excessive, and the negotiated rates would not apply to insurers (particularly if out of network) that don't have contracts with those centers

Penn and Mayo love to publicize that they take imrt rates for protons without mentioning these imrt rates are 5-10 x cms

 

[fiji128]

 

[fiji128]

I didn’t realize MSKCC put the photon beam straight through the heart. No wonder they require those daily EKG’s.

 

[thesauce]

View attachment 359565

Wow. Just like photons.

 

[NotMattSpraker]

View attachment 359565

The preceding tweet. I chuckled

 

[elementaryschooleconomics]

 

[maxxor]

View attachment 359570

Need to do that technetium 99 localization / definitive radiotherapy noninferiority trial. I hear @TheWallnerus wants to start accrual asap.

 

[TheWallnerus]

Need to do that technetium 99 localization / definitive radiotherapy noninferiority trial. I hear @TheWallnerus wants to start accrual asap.

At a 36 month follow up I will put a drop of Tc-99m colloid on the nipple up against proton partial breast any day.

The NipDrip®

I feel like it's already happening.

 

[Mandelin Rain]

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Tell me you had to create a comparison plan for authorization without telling me you had to create a comparison plan for authorization.

 

[thecarbonionangle]

Tell me you had to create a comparison plan for authorization without telling me you had to create a comparison plan for authorization.

DING DING DING DING!!!

 

[Mandelin Rain]

DING DING DING DING!!!

It's this kind of equipoise and academic honesty you can expect in rad onc these days.

i.e. none

 

[OTN]

They should have been embarrassed to publish that "comparison" - I'd love to see an IMRT partial breast plan compared to their ridiculous proton grift.

 

[TheWallnerus]

Tell me you had to create a comparison plan for authorization without telling me you had to create a comparison plan for authorization.

They should have been embarrassed to publish that "comparison" - I'd love to see an IMRT partial breast plan compared to their ridiculous proton grift.

It’s hard to read a rad onc article in a journal these days without it making me mad; the type of anger you feel when someone tries to play you for a fool

 

[medgator]

It’s hard to read a rad onc article in a journal these days without it making me mad; the type of anger you feel when someone tries to play you for a fool

Red urinal isn't worth the TP it's printed on. Stick to JCO nejm jama lancet imo

 

[deleted1111261]

Red urinal isn't worth the TP it's printed on. Stick to JCO nejm jama lancet imo

Man RJ is so dismal now

So many of our seminal papers were from there in the past.

And now…

 

[medgator]

Man RJ is so dismal now

So many of our seminal papers were from there in the past.

And now…

Mirrors the health of our specialty

 

[Fpg1245]

Mirrors the health of our specialty

Saw they put out a whole review on LDRT for OA. I read every page of it and came away thinking gosh what the hell did I just put myself through.

 

[Ray D. Ayshun]

Stick to a journal? Am I the only one that's noticed you can pretty much do whatever you want in this field? Just take some shrooms, see what the cosmos says, Google it, and someone somewhere is doing it.

 

[deleted1111261]

Saw they put out a whole review on LDRT for OA. I read every page of it and came away thinking gosh what the hell did I just put myself through.

Hey now!

 

[OTN]

What's frustrating is that there is indeed low-hanging fruit that should be investigated IN PHASE III CLINICAL TRIALS:

1. neoadjuvant Chemoimmunotherapy followed by surgery vs chemoimmunotherapy + RT + immunotherapy for IIIA NSCLC
2. Dose escalation for NSCLC with IMRT required
3. Dose de-escalation for HPV+ H+N ca, but done in a way which makes sense (60 or 66 Gy vs 70 Gy with platinum perhaps?)
4. Chemoembolization vs SBRT vs RFA vs microwave ablation for liver mets
5. Appropriate dosing strategies in skin cancer (seriously it's the wild west out there)
6. Dose escalation to 50 Gy in 5 fx with SBRT for high-risk prostate cancer with SpaceOAR required
7. SBRT for oligomets - I know we have COMET II coming out, but we should have multiple institutions investigating multiple strategies to help determine when we can derive the most benefit from treating oligomets. That's not what I'm seeing.

I'm no academician, and these are off the top of my head. So, there are probably some issues with them, and maybe there are trials in the works. We shall see.

 

[TheWallnerus]

Man RJ is so dismal now

So many of our seminal papers were from there in the past.

And now…

Would say they could offer us semenal papers now, but we are out of the testicular cancer game too so not even that

 

[deleted1111261]

Would say they could offer us semenal papers now, but we are out of the testicular cancer game too so not even that

Stretch

 

[taserlaser]

What's frustrating is that there is indeed low-hanging fruit that should be investigated IN PHASE III CLINICAL TRIALS:

1. neoadjuvant Chemoimmunotherapy followed by surgery vs chemoimmunotherapy + RT + immunotherapy for IIIA NSCLC
2. Dose escalation for NSCLC with IMRT required
3. Dose de-escalation for HPV+ H+N ca, but done in a way which makes sense (60 or 66 Gy vs 70 Gy with platinum perhaps?)
4. Chemoembolization vs SBRT vs RFA vs microwave ablation for liver mets
5. Appropriate dosing strategies in skin cancer (seriously it's the wild west out there)
6. Dose escalation to 50 Gy in 5 fx with SBRT for high-risk prostate cancer with SpaceOAR required
7. SBRT for oligomets - I know we have COMET II coming out, but we should have multiple institutions investigating multiple strategies to help determine when we can derive the most benefit from treating oligomets. That's not what I'm seeing.

I'm no academician, and these are off the top of my head. So, there are probably some issues with them, and maybe there are trials in the works. We shall see.

I’m going to also go on a rant on #5

I treat a lot of skin. A LOT. Orthovoltage, electrons, VMAT, you name it. Converting some of my breast consult space for even more skin space between my RO skin partner and I.

The wild west is probably a good way of putting it. I spent a lot of my time early on in my (still junior) practice on reviewing strategies here. I could go on a rant here for about an hour on how no one can agree on how to treat this.

I‘ll attach a few dose and fractionations that come from different sources. Note whiel there are some commonalities, in other cases they are WILDLY different.

ASTRO guidelines:

NCCN:

Some US dermatology guidelines:

This one I think is hilarious because it references ‘Total Dose Fractions’ and puts the units in Gy instead of its proper/original nomenclature.

Taken from the old Orton and Ellis tables courtesy this book:

From a UK patterns of practice survey, McPartlin BJR 2014

One opinion paper post covid suggests rather hypofrac/descalation of treatment for a lot of these frail patients:

Let alone some of the more recent skin SBRT publications looking at dose escalated treatment for more bulky skin cancers.

Heck, someone I used to train with used what is usually published as a HDR brachy dose with good effect, also not in any of these above. ‘The secret sauce’

One thing I’ve tried to come to terms with is what is an effective tumorcidal dose? It’s nice to try and say to give a 85 yr old 30 fractions but it’s really not practical and there are other good hypofractionation options that may be more suitable.

Also what’s hard with this - a lot of these institutional outcomes don’t report technique well. Few places have access to superficial radiotherapy, electrons are a lot more common in places that have linacs. Are these corrected for RBE, do they even need to be corrected to RBE? Are they being prescribed to 90%, is this being prescribed to Dmax? A lot of these details are not reported, and I think it matters.

What I will say which (somewhat) perplexes me and have given some thought to, is a lot of these doses if you look at more of the moderate/extreme hypofraction (eg 5-10 fr), the linear quadratic model starts to break down for what is tumorcidal for non-bulky tumors, as compared to conventional 2Gy/fr. There does seem to be a time element that is not well captured there. There may be something to using the tdf tables, for which most/all of these doses do fall along in the ‘sweet spot’ for. Probably because they are derived from this, and not vice versa. Is there difference in LC between a tumorcidal 5 fr/7 fr/10fr/20 fr/30fr regimen? Maybe? We can’t well tease it out from our current data I think.

The Zaorsky meta-analysis is good, but without good randomized data, I don’t know if one can’t really say I think since treatments can differ in technique by quite a bit.

What to do for definitive melanoma? What is effective palliation for melanoma/SCC on IO - is daily treatment truly the best?

This stuff drives me nuts. I wish we had better trials and data past - “we did this and it worked”

Also - if anyone has thoughts on above, would LOVE their insight & experience. I’m all ears.

 

[TheWallnerus]

I’m going to also go on a rant on #5

I treat a lot of skin. A LOT. Orthovoltage, electrons, VMAT, you name it. Converting some of my breast consult space for even more skin space between my RO skin partner and I.

The wild west is probably a good way of putting it. I spent a lot of my time early on in my (still junior) practice on reviewing strategies here. I could go on a rant here for about an hour on how no one can agree on how to treat this.

I‘ll attach a few dose and fractionations that come from different sources. Note whiel there are some commonalities, in other cases they are WILDLY different.

ASTRO guidelines:
View attachment 359637

NCCN:
View attachment 359638

Some US dermatology guidelines:

View attachment 359639
This one I think is hilarious because it references ‘Total Dose Fractions’ and puts the units in Gy instead of its proper/original nomenclature.

Taken from the old Orton and Ellis tables courtesy this book:

View attachment 359647

View attachment 359640
View attachment 359641
From a UK patterns of practice survey, McPartlin BJR 2014
View attachment 359642

View attachment 359643
One opinion paper post covid suggests rather hypofrac/descalation of treatment for a lot of these frail patients:

View attachment 359645


Let alone some of the more recent skin SBRT publications looking at dose escalated treatment for more bulky skin cancers.

Heck, someone I used to train with used what is usually published as a HDR brachy dose with good effect, also not in any of these above. ‘The secret sauce’

One thing I’ve tried to come to terms with is what is an effective tumorcidal dose? It’s nice to try and say to give a 85 yr old 30 fractions but it’s really not practical and there are other good hypofractionation options that may be more suitable.

Also what’s hard with this - a lot of these institutional outcomes don’t report technique well. Few places have access to superficial radiotherapy, electrons are a lot more common in places that have linacs. Are these corrected for RBE, do they even need to be corrected to RBE? Are they being prescribed to 90%, is this being prescribed to Dmax? A lot of these details are not reported, and I think it matters.

What I will say which (somewhat) perplexes me and have given some thought to, is a lot of these doses if you look at more of the moderate/extreme hypofraction (eg 5-10 fr), the linear quadratic model starts to break down for what is tumorcidal for non-bulky tumors, as compared to conventional 2Gy/fr. There does seem to be a time element that is not well captured there. There may be something to using the tdf tables, for which most/all of these doses do fall along in the ‘sweet spot’ for. Probably because they are derived from this, and not vice versa. Is there difference in LC between a tumorcidal 5 fr/7 fr/10fr/20 fr/30fr regimen? Maybe? We can’t well tease it out from our current data I think.

The Zaorsky meta-analysis is good, but without good randomized data, I don’t know if one can’t really say I think since treatments can differ in technique by quite a bit.

What to do for definitive melanoma? What is effective palliation for melanoma/SCC on IO - is daily treatment truly the best?

This stuff drives me nuts. I wish we had better trials and data past - “we did this and it worked”

Also - if anyone has thoughts on above, would LOVE their insight & experience. I’m all ears.

Great post!

 

[taserlaser]

Great post!

Thanks!

 

[deleted1111261]

Thanks!

Posted on twitter. It’s epic.

 

[taserlaser]

Posted on twitter. It’s epic.

I’m flattered. I’ll be curious to see if there is any thoughts from the broader bird audience. I would say from following a few of my predecessors patients as well as my own now, I’m starting to get a sense of what some of these be ‘hot’ and some of these ‘cool’ but not enough relapses for formal analysis sadly. Lot of reasons why people can relapse with appropriate prescriptions - not enough depth, treatment interruptions, marginal miss with tumor/inadequate margins, and just bad luck. Lot of good reasons to cool a prescription too. Thanks for sharing it