Reimbursement wise that is incorrect unless they agree to imrt prices. Still could be wildly expensive even then compared to a standard hospital or freestanding center if they negotiated a ridiculous rate for IMRT.
The loma linda chair is too busy hiring miltiple of his kids. Terrible proton machine. Terrible hell pit place.
I'm OK with a smaller difference in reimbursement. I think we all need to bear in mind that reimbursement wise, generously doing protons are still MUCH better than IO. Factor in the offlabel IO and it's no contest.Reimbursement wise that is incorrect unless they agree to imrt prices. Still could be wildly expensive even then compared to a standard hospital or freestanding center if they negotiated a ridiculous rate for IMRT.
Apm will screw proton centers the most by a mile
Blue Shield of California to curb coverage of pricey cancer therapy
Blue Shield of California to curb coverage of pricey cancer therapywww.latimes.com
Sure but that wasn't your original argument... Guarantee 44 fx of imrt at most places is still gonna be cheaper than 20 fx of protons in a similar setting, esp when you factor in the IMRT guy isn't going to feel compelled to place a $3k hydrogel with fiducials prior to sim
almost 2x that hydrogel cost where I am for the kit
Insane. Honestly disgusting to see that type of pricing for something of unclear benefit.... Financial toxicity² when you consider many proton places feel the need to
Interesting... Many here have zero interest, esp when they find out they need a special ultrasound setup with a stepper, different from the normal TRUS for transrectal biopsy/fiducial placement
Urologists here also have their own urorads setup.
Only way it makes sense. Very profitable if they are doing it on a lot of pts
Only group in town!
Maybe they can publish their own series on fistula/abcess toxicity rates!
OK but by how much? As I said I'm OK with small increases, because that'd be the price tag for more patient convenience. And I would logically think the SpaceOAR would be more likely placed for IMRT than protons, so that should be added to the cost of IMRT, not protons.
Why would you think that? The proton data hasn't shown any better GI toxicity outcome and anecdotally some worse outcomes. I've also heard the same for others, esp with places that weren't doing IMPT.
Because in practice, it's not really about data as much as it is about clinician comfort/gestalt. Clinicians are much less likely to place a SpaceOAR with protons because they often say "hey, it's protons, it's like having a built-in SpaceOAR". It may or may not be true, but the majority of people think adding a SpaceOAR with protons is just diminishing returns.
Nothing in the data has come out to actually prove that though, and some suggest otherwise. Again protons haven't come out with data on balance to prove they are superior in a way imrt was able to against 3D
Do you know of any data saying clinicians are less likely to place SpaceOAR with protons?
Nope, anecdotally it seems more likely as what @BobbyHeenan mentioned
I highly doubt it. If there are data, feel free to show me. Anecdotal evidence means nothing to me especially because it makes no logical sense that SpaceOAR is more likely placed in protons than IMRT.
To me it makes logical sense. Won’t delve into my reasons as to why it makes sense except to say I speculate (anecdotes, seen some things personally, etc) proton people have noticed generally more rectal toxicity in their proton patients and saw SpaceOAR as a salve for that.
Afaik there is no data to show protons have superior GI toxicity outcomes in prostate ca, but some data (argue against it all you want) that it might be worse and a lot of anecdotal experience from many of us regarding outcomes as well as the frequency of use of spacer gel by those practices
My general sense is (and sure I’m like a blind man commenting on a Picasso here) that proton shoppes used bigger PTV margins and infaust beam arrangements due to the various and sundry proton uncertainties. And, lo, protons were then found not to be in and of themselves magically rectal sparing.
And what is “fragmenting”
Learnin’ from the crocCarbon Ions
Carbon Ions Pascal Pommier, Stephanie E. Combs, and Tadashi Kamada PRESENT STATUS AND PERSPECTIVE FOR CARBON IONS Carbon ion therapy is an innovative radiotherapy modality that is mostly dedicated …oncohemakey.com
Look at figure 20.1
fragmentation refers to the tail of the carbon ion compared to protons (no tail)
This came out earlier this year.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
What about estimates of RBE increasing by 1.3 and 1.7 towards end of spread out bragg peak. It seems like there is a lot to work out here. Its not like RBE is a very precise/exact quantity and probably has tissue/tumor specificity and (maybe even fraction size) it is actually quite nebulous.
My anecdotal experience is that all proton centers use spacers or balloons. Anecdotes are meaningful when there are only a small number of centers...
The honest answer is yes it could be. There is a lot we don’t know. We know as much as we can know but also known uknowns and unknown unknowns. This has to be taken into account when pushing the limit on OARs with particle therapy so you don’t hurt someone
Can you really believe results from authors who capitalize the word “gray?”
Have heard rumors about Uf data and protons. 5 yr PFS of 99% in intermediate risk? Protons controlling regional nodal and distant disease?
Protons rev up the abscopal effect… Mic drops!
Yes less “low dose bath”, less inmunosuppression. DUH folks!
Let’s publish this in the red journal. We get a few big wigs, claim we are choosing wisely and we’re good!
Muti room proton centers are not viable without prostate.
Technically the one I posted above didn't either. It was only a trend. If there is a difference it is tiny. And probably very subject to exactly how the data is collected. But recall, the initial hypothesis was that protons are supposed to be better for toxicity. The idea that is universally so was silly at its conception. No technology is one size fits all.
pubmed.ncbi.nlm.nih.gov
The problem when using first principles before working out how to deliver the technology you think is better is that you end up with some kids with necrosed brainstems
pubmed.ncbi.nlm.nih.gov
Might be splitting hairs here but I wouldn't think first principle would really apply in this case (similar to the prostate story). There is no question that protons can reduce low and medium dose bath for disease sites like esophagus. There are a lot of questions as to how to deal with uncertainty related to RBE and BP when targets/OARs are closely associated. This again comes from a poor understanding of the physics of protons and the myriad of uncertainties associated with them. We often ask them to do things that they probably can't really do.The problem when using first principles before working out how to deliver the technology you think is better is that you end up with some kids with necrosed brainstems
National Cancer Institute Workshop on Proton Therapy for Children: Considerations Regarding Brainstem Injury - PubMed
Brainstem injury is a rare complication of radiation therapy for both photons and protons. Substantial dosimetric data have been collected for brainstem injury after proton therapy, and established guidelines to allow for safe delivery of proton radiation have been defined. Increased capability...
So despite superior dosimetry from PBT, clinical outcomes were the same as IMRT. So what did protons accomplish except increasing costs?
way it works in medicine: usually a drug or intervention looks better in a cohort, but then fails in the subsequent randomized trial.
Context...I posted that link as a response to that overrated seer paper and others that said GI tox with protons was worse and that was some supposed justification to use SpaceOAR more in proton patients.
