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

[RickyScott]

What hate proton people? Protons are more expensive than IMRT, but both are cheap compared to IO. Infighting doesn’t help any of us.

I don’t look at it that way. There is a certain pot of money for xrt, and protons, which are 3% of cases are taking up 50% of that pot despite no proven benefits.

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[Lamount]

I don’t look at it that way. There is a certain pot of money for xrt, and protons, which are 3% of cases are taking up 50% of that pot despite no proven benefits.

Is it a zero sum game? If not for protons, would that money be divided up among those delivering IMRT?

 

[Lamount]

There was a clear therapeutic benefit to IMRT vs 3D with a much lower difference in incremental cost. The proton people have had several years to "show us the money", yet they continue to have relatively nothing

Really? When it first went prime time?

 

[RickyScott]

Is it a zero sum game? If not for protons, would that money be divided up among those delivering IMRT?

I would argue it is a bit of a zero sum game. Total money spent on radiation may increase a few percent each year but nothing like what’s going on with protons.

 

[Lamount]

I would argue it is a bit of a zero sum game. Total money spent on radiation may increase a few percent each year but nothing like what’s going on with protons.

This does not demonstrate causality. Are their any data showing IMRT reimbursements have gone done specifically BECAUSE of protons?

 

[ROforbetterorworse]

This does not demonstrate causality. Are their any data showing IMRT reimbursements have gone done specifically BECAUSE of protons?

im not seeing it has happened yet

But by continually drawing attention to IMRT origins, proton ppl put it at risk

they are the only ones who seem to bring it up

well to be fair also academic nerds too

 

[TheWallnerus]

Really? When it first went prime time?

Literature wise no. Not when it first went prime time.

But I was very new to rad onc however had treated a fair amount of opposed lateral H&N with posterior electron strips and AP sclavs. Man did those guys do not so great. I will never forget my first IMRT H&N and how much better he was doing, and the differences in physical exam changes at week 3 onward. I was totally a newbie but no one had to tell me IMRT was better I could see it with my own eyes. I didn’t need to see a trial. If the proton guys know in their heart of hearts they’re doing that much good for people vs IMRT, and see it in clinic day in and day out, then more power to protons. However, if you have to bribe a statistician to show me protons are better, down with protons.

 

[RickyScott]

This does not demonstrate causality. Are their any data showing IMRT reimbursements have gone done specifically BECAUSE of protons?

No, but surely a few 300k proton bills quickly gets payors focused on xrt utilization.

 

[RickyScott]

Literature wise no. Not when it first went prime time.

But I was very new to rad onc however had treated a fair amount of opposed lateral H&N with posterior electron strips and AP sclavs. Man did those guys do not so great. I will never forget my first IMRT H&N and how much better he was doing, and the differences in physical exam changes at week 3 onward. I was totally a newbie but no one had to tell me IMRT was better I could see it with my own eyes. I didn’t need to see a trial. If the proton guys know in their heart of hearts they’re doing that much good for people vs IMRT, and see it in clinic day in and day out, then more power to protons. However, if you have to bribe a statistician to show me protons are better, down with protons.

Same true with anal.

 

[Lamount]

im not seeing it has happened yet

But by continually drawing attention to IMRT origins, proton ppl put it at risk

they are the only ones who seem to bring it up

well to be fair also academic nerds too

Looking at the thread… the first stone was cast TOWARD the proton folks. Frank was merely posting a picture of ducks… and, don’t get me wrong, ducks anger me as much as anyone (kidding!), but my point remains.

 

[TheWallnerus]

This does not demonstrate causality. Are their any data showing IMRT reimbursements have gone done specifically BECAUSE of protons?

Exsqueeze me. Baking powder. APM?

 

[ROforbetterorworse]

Looking at the thread… the first stone was cast TOWARD the proton folks. Frank was merely posting a picture of ducks… and, don’t get me wrong, ducks anger me as much as anyone (kidding!), but my point remains.

Fair point. Ducks were cute!

Ralph threw a stone at a very big house in small community in Texas

doesnt affect many ppl

Proton ppl affecting IMRT reimbursement affects many states

 

[Lamount]

No, but surely a few 300k proton bills quickly gets payors focused on xrt utilization.

Maybe… but again, these charges are small potatoes to payers when compared to IO/TKI.

 

[Lamount]

Exsqueeze me. Baking powder. APM?

If anything, APM minimizes the impact of protons IMRT. Everyone gets paid the same, regardless of the modality. APM stands to hurt expensive treatments the most.

 

[Lamount]

Proton ppl affecting IMRT reimbursement affects many states

That is… IF protons was shown to have ANY impact on non-proton reimbursements.

 

[ROforbetterorworse]

That is… IF protons was shown to have ANY impact on non-proton reimbursements.

“Trying to impact”

 

[RickyScott]

If anything, APM minimizes the impact of protons IMRT. Everyone gets paid the same, regardless of the modality. APM stands to hurt expensive treatments the most.

Apm is only for cms. Doubt mdacc is suddenly going to be taking apm rates from commercial payors. (Actually they are excluded from the apm)

 

[medgator]

Really? When it first went prime time?

The data got out. Where's the proton data showing superiority over IMRT again?

Just saw another proctitis case from the 2000s with a guy who got protons .... Do you know what kind of field arrangements many of them were using after the turn of the century pre impt? IMRT was far superior to it I'd bet

 

[medgator]

Maybe… but again, these charges are small potatoes to payers when compared to IO/TKI.

We are looked at as the "radiation" pot according to CMS. Not compared to tki/io

 

[Lamount]

The data got out. Where's the proton data showing superiority over IMRT again?

Just saw another proctitis case from the 2000s with a guy who got protons .... Do you know what kind of field arrangements many of them were using after the turn of the century pre impt? IMRT was far superior to it I'd bet

Google Scholar

scholar.google.com

I don’t advocate proton for prostate

 

[medgator]

Google Scholar

scholar.google.com

I don’t advocate proton for prostate

That's the literally the only study you'll be able to find and it will absolutely not be enough patients to the move the needle and justify as many proton centers as we have.

Unfortunately many of your colleagues pimp protons for prostate because that is a major cancer dx we treat and literally part of the pro forma in making any proton center a financially viable one

 

[Lamount]

We are looked at as the "radiation" pot according to CMS. Not compared to tki/io

My point is… why would you only compare proton vs photon, and not RT vs IO? Why do RAD ONCS make this comparison? It’s like arguing about which candle burns brighter when the house is on fire

 

[medgator]

My point is… why would you only compare proton vs photon, and not RT vs IO? Why do RAD ONCS make this comparison? It’s like arguing about which candle burns brighter when the house is on fire

Because it has put our specialty on the radar in a bad way far worse than IMRT ever did, esp given the (lack of) data showing an improvement over IMRT, with a far greater cost differential than the bump we had from 3D to imrt.

Financial and clinical toxicity when you consider a major indication like prostate ca

 

[ROforbetterorworse]

My point is… why would you only compare proton vs photon, and not RT vs IO? Why do RAD ONCS make this comparison? It’s like arguing about which candle burns brighter when the house is on fire

It goes both ways

make sure you call out the proton ppl for complaining about IMRT too

I personally care more about majority of our field then the rich boy MDACC protons of the world

 

[ROforbetterorworse]

Google Scholar

scholar.google.com

I don’t advocate proton for prostate

They believed the results of this trial so much that NRG esophagus proton vs IMRT trial not using it as primary endpoint

meaning not so much….

 

[Lamount]

That's the literally the only study you'll be able to find and it will absolutely not be enough patients to the move the needle and justify as many proton centers as we have.

Unfortunately many of your colleagues pimp protons for prostate because that is a major cancer dx we treat and literally part of the pro forma in making any proton center a financially viable one

…then it sounds like you have an objection to a very specific application of the modality.
In my world, I would only use protons when it reduces metric that we know matters in terms of toxicity. If it dramatically reduces heart dose in esophagus or nsclc, great! If it reduces V20 42%->31%, who wouldn’t use it? Retreatment, HCC with poor liver function, NPX, peds etc... Would I try to use it in a single station N2 NSCLC off trial? Not based on the current data

Protons are better… when they are better

 

[Lamount]

It goes both ways

make sure you call out the proton ppl for complaining about IMRT too

I personally care more about majority of our field then the rich boy MDACC protons of the world

I don’t complain about IMRT… use it every day

you don’t have to exclude those “rich boys” from your circle of feels because they aren’t your enemies

 

[ROforbetterorworse]

…then it sounds like you have an objection to a very specific application of the modality.
In my world, I would only use protons when it reduces metric that we know matters in terms of toxicity. If it dramatically reduces heart dose in esophagus or nsclc, great! If it reduces V20 42%->31%, who wouldn’t use it? Retreatment, HCC with poor liver function, NPX, peds etc... Would I try to use it in a single station N2 NSCLC off trial? Not based on the current data

Protons are better… when they are better

i sincerely doubt ANY proton center is filled with only optimal proton cases….

Financial reward of 1 prostate proton patient worth all the headache and risk of denial etc

 

[Lamount]

They believed the results of this trial so much that NRG esophagus proton vs IMRT trial not using it as primary endpoint

meaning not so much….

There are trials comparing toxicity, and trials comparing efficacy… I’d argue that both are important.

 

[medgator]

…then it sounds like you have an objection to a very specific application of the modality.
In my world, I would only use protons when it reduces metric that we know matters in terms of toxicity. If it dramatically reduces heart dose in esophagus or nsclc, great! If it reduces V20 42%->31%, who wouldn’t use it? Retreatment, HCC with poor liver function, NPX, peds etc... Would I try to use it in a single station N2 NSCLC off trial? Not based on the current data

Protons are better… when they are better

No one is arguing against that. Does that number of patients justify 1 to multiple proton centers in every major city of the country at a significant multiple of cost as compared to a brand new vmat/srs/sbrt linac?

 

[Lamount]

No one is arguing against that. Does that number of patients justify 1 to multiple proton centers in every major city of the country at significant multiple of cost as compared to a brand new vmat/srs/sbrt linac?

I certainly agree with you on that.

 

[FrostyHammer]

Because it has put our specialty on the radar in a bad way far worse than IMRT ever did, esp given the (lack of) data showing an improvement over IMRT, with a far greater cost differential than the bump we had from 3D to imrt.

Financial and clinical toxicity when you consider a major indication like prostate ca

Then why aren't we talking about 20 fraction proton RT or 5 fraction proton SBRT as compared to 40-45 fractions of photon IMRT? I'm not on the side of protons for prostate either, but if that dissuades the boomer moneygrubbers to conventionally fractionate, I'm all for it.

 

[medgator]

Then why aren't we talking about 20 fraction proton RT or 5 fraction proton SBRT as compared to 40-45 fractions of photon IMRT? I'm not on the side of protons for prostate either, but if that dissuades the boomer moneygrubbers to conventionally fractionate, I'm all for it.

None of those regimens caused significant gi toxicity like doing simple non modulated field arrangements with protons did, thinking the bragg peak will take care of everything.

Intensity-Modulated Radiation Therapy, Proton Therapy, or Conformal Radiation Therapy and Morbidity and Disease Control in Localized Prostate Cancer

In a study of men with prostate cancer who received radiation treatment, Sheets et al used the Surveillance, Epidemiology, and End Results database to examine the comparative morbidity and disease control of intensity-modulated radiation therapy, proton therapy, and conformal radiation therapy.

jamanetwork.com

 

[drewdog1973]

This study is saying that 3D is slightly worse than IMRT, but protons are way way worse than IMRT for GI toxicity.

IMRT vs 3D: (absolute risk, 13.4 vs 14.7 per 100 person-years; relative risk [RR], 0.91; 95% CI, 0.86-0.96)

IMRT vs protons (absolute risk, 12.2 vs 17.8 per 100 person-years; RR, 0.66; 95% CI, 0.55-0.79).

I don’t buy this for a second. Have you seen 3D for prostate? Ask your older nurses and RTTs

 

[Ray D. Ayshun]

This study is saying that 3D is slightly worse than IMRT, but protons are way way worse than IMRT for GI toxicity.

IMRT vs 3D: (absolute risk, 13.4 vs 14.7 per 100 person-years; relative risk [RR], 0.91; 95% CI, 0.86-0.96)

IMRT vs protons (absolute risk, 12.2 vs 17.8 per 100 person-years; RR, 0.66; 95% CI, 0.55-0.79).

I don’t buy this for a second. Have you seen 3D for prostate? Ask your older nurses and RTTs

It's saying if you get protons you're more likely to have a GI procedure (including colonoscopy). If you look at the population pre-propensity matching, 80% came from cali that got protons, probably all from an academic center where they were more likely to have regimented follow-ups, screening procedures, etc, making this paper simply more drivel.

 

[medgator]

It's saying if you get protons you're more likely to have a GI procedure (including colonoscopy). If you look at the population pre-propensity matching, 80% came from cali that got protons, probably all from an academic center where they were more likely to have regimented follow-ups, screening procedures, etc, making this paper simply more drivel.

Yeah since out in the real world, no one follows their patients for post-treatment toxicity evaluation

 

[Ray D. Ayshun]

Yeah since out in the real world, no one follows their patients for post-treatment toxicity evaluation

(including colonoscopy). Perhaps Loma Linda has a more regimented reporting system given they were on a registry, etc, etc. It's apples to oranges potentially, and once again, (including colonoscopy). I'm not a PCP.

 

[RickyScott]

I don’t buy this for a second. Have you seen 3D for prostate? Ask your older nurses and RTTs

3d -once radoncs learned how to contour- was very similar to imrt toxicity wise.
Michalskis rtog study of 78gy with 3d shows this. I was around for the transition as a resident and it was not obvious imrt was better. I am still not convinced imrt has a substantial benefit over 3d- I think most of the benefit we see in Prostate comes from the image guidance which was not widely available during the 3d era. I am sure the wallnerus can weigh in.

 

[medgator]

3d -once radoncs learned how to contour- was very similar to imrt toxicity wise.
Michalskis rtog study of 78gy with 3d shows this. I was around for the transition as a resident and it was not obvious imrt was better. I am still not convinced imrt has a substantial benefit over 3d- I think most of the benefit we see in Prostate comes from the image guidance which was not widely available during the 3d era. I am sure the wallnerus can weigh in.

Agree...i think tighter margins have been the bigger bang for the buck. Certainly not the same differential as going from 3 field to IMRT in h&n.

Even with 3D back then though, multiple field arrangements were utilized, vs the simple 2-4 field plans coming out of the proton centers where the priority was patient throughput

 

[FrostyHammer]

None of those regimens caused significant gi toxicity like doing simple non modulated field arrangements with protons did, thinking the bragg peak will take care of everything.

Intensity-Modulated Radiation Therapy, Proton Therapy, or Conformal Radiation Therapy and Morbidity and Disease Control in Localized Prostate Cancer

In a study of men with prostate cancer who received radiation treatment, Sheets et al used the Surveillance, Epidemiology, and End Results database to examine the comparative morbidity and disease control of intensity-modulated radiation therapy, proton therapy, and conformal radiation therapy.

jamanetwork.com

Exactly. In modern times, use IMPT, smaller margins with good IGRT, or SpaceOAR and it's a much different story.

 

[medgator]

Exactly. In modern times, use IMPT, smaller margins with good IGRT, or SpaceOAR and it's a much different story.

What did the impt buy you though outside of the the added financial toxicity? And if impt was so good, why did you need the spaceoar when those of us doing conventional and hypofx (even SBRT!) don't need it with our cheaper and efficacious modality

 

[TheWallnerus]

Agree...i think tighter margins have been the bigger bang for the buck. Certainly not the same differential as going from 3 field to IMRT in h&n.

Even with 3D back then though, multiple field arrangements were utilized, vs the simple 2-4 field plans coming out of the proton centers where the priority was patient throughput

Margins are almost certainly the key, vs IMRT instead of 3D, in prostate. So it was really IGRT that lowered prostate RT toxicity and not so much IMRT, as no one had confidence to reduce margins without good IGRT. In early IMRT days I in fact saw MORE toxicity with IMRT because old docs carried over 3D block margins to IMRT PTV margins. (That was true in multiple disease sites, not just prostate.) That meant some guys were treating prostate with equivalent 2.5 cm block margins, with IMRT. However even with equivalent PTV margins you can beat (maybe by not a lot) a 3D rectal DVH with a good IMRT plan every time... unless perhaps you just use two lateral beams. Those 3D rectal DVHs can be made to look great (jk).

 

[TheWallnerus]

What did the impt buy you though outside of the the added financial toxicity? And if impt was so good, why did you need the spaceoar when those of us doing conventional and hypofx (even SBRT!) don't need it with our cheaper and efficacious modality

IMPT (pencil beaming) meant you didn't need a block room/block guy making dot.decimal style brass compensators all day long, and the room/block was not radioactive so right after the fraction was over you could head right in the room. Without IMPT I think you have to wait a few minutes and just leave patient sitting on table to let the whole room "cool off"? Famous radiobiologists also calculated that without pencil beam IMPT the rates of radiation-induced malignancies would be higher with protons.

 

[RickyScott]

Does every proton center use space oar or balloons?

 

[TheWallnerus]

Does every proton center use space oar or balloons?

They certainly did not used to so if they do now it's been a change. They might have got tired of the sizzling/crackling sounds coming from guys' rectums (jk again, sort of).

 

[MegaVoltagePhoton]

Lol at the idea of Loma Linda as an academic center. Good one.

 

[Ray D. Ayshun]

Lol at the idea of Loma Linda as an academic center. Good one.

Lol all you want, as far as I can tell loma Linda was the only Cali proton center in existence during the time period this paper covered, which means the comparison was made pretty much between IMRT patients and proton patients treated at Loma Linda, which were likely on a registry/trial and certainly contributed to publications. In turn, whatever protocols they had in place would influence the findings, including trials involving rectal balloons, which might necessitate a "screening" colonoscopy afterward, thus contributing to the higher number of GI procedures in the proton group, and potentially greater number of diagnoses in the proton group as the Gastros were expected to be more aggressive diagnostically. Have no idea, but the reality of it is, there was a comparison between two modalities, one of which was administered almost exclusively at a single institution. Beyond that, the bulk of the data/papers we discuss here any more are related to job market findings. So, Lol at there being an academic rad onc institution anywhere.

 

[drewdog1973]

So, literally, the treatment that “created” this field - IMRT for prostate cancer is not that good?

Eek

 

[OTN]

So, literally, the treatment that “created” this field - IMRT for prostate cancer is not that good?

Eek

(Gun pointing at astronaut) Never has been

 

[FrostyHammer]

What did the impt buy you though outside of the the added financial toxicity? And if impt was so good, why did you need the spaceoar when those of us doing conventional and hypofx (even SBRT!) don't need it with our cheaper and efficacious modality

I said "or", not "and". I don't think you got my point. I'm not supportive of protons for prostate, but I'm saying that the SEER study that was quoted isn't a good way to justify that point. I'm also saying that protons for prostate are much more palatable if they are used as a means to hypofractionate or SBRT. In other words...in general for prostate, protons <<< IMRT but proton hypofractionation/SBRT >>> IMRT conventional fractionation.