Race to the bottom

[TheWallnerus]

I disagree.

My understanding is that α/β is really only the ratio of the coefficients of a 2nd order polynomial used to "fit" outcomes (most classic example is fractional cell kill in vitro) relative to dose fractionation. In the clinical setting, you can take retrospective data and come up with outcomes vs dose fraction curves that are always going to be a little bit bendy, are almost always going to seem monotonic and the data is always going to be fuzzy. This means that fitting these outcomes with a 2nd order polynomial is fine and the added value of a 3rd order term is meaningless in the real world. So you can have an α/β for cell kill, or early clinical outcomes (diarrhea) or late clinical outcomes (bleeding, late cystitis). My confidence in the particulars of these clinical curves is very low.

This α/β is not a model (I guess I heard some handwaving regarding 1 vs 2 photon interactions back in the day) it's just a fit. And by definition it is a fit regarding a single outcome. Most of our clinical and pre-clinical data does not control very well for time course of treatment (not explicitly included in α/β calculations), and the various relative contributions of "the 4Rs" as you shrink treatment time or course from 20-10-5-3-1 treatments is not well defined to my understanding. So you can claim that "cell kill for prostate cancer" demonstrates an α/β less than any pertinent competing toxicity risk, but still believe that single fraction or 3 fraction treatment is not prudent and is not the sweet spot in terms of therapeutic ratio.

I agree with your disagreements. And we really aren't disagreeing in our soul, only on paper. (And no one mentions that alpha beta is a "2nd order polynomial" line-fit thing but you're exactly right.) Interestingly, adding third or fourth (and so on) order components does increase the R^2 of the fit (a topic for another day). All your other points are valid too.

But just from a PURIST P.O.V. re: this 2nd order polynomial line fit (on a log linear graph), the mathematical point stands regardless whether one "believe(s) that single fraction or 3 fraction treatment is not prudent and is not the sweet spot in terms of therapeutic ratio." Even given that this fitting comes from data that's "fuzzy" (you're right about that too), the implication e.g.:

Now whether one "believes" this is up for debate. But if one believes 60/20 e.g. is going to give better prostate cancer control, and maybe no more or worse late effects than 81/45 e.g., the reasoning behind that can logically follow to the conclusion in this pictograph: both thoughts are based on the same (mathematical) logic. You could look at this and be seduced that 16 Gy would give better local control than 81/45 with less late effects than 81/45. The seduction is real.

---

Members don't see this ad.

 

[Mandelin Rain]

Agreed. The old guys love the 44 fractions. Especially the widowers.

It all seems like "fixing" a problem that never really existed.

 

[Chartreuse Wombat]

I disagree.

My understanding is that α/β is really only the ratio of the coefficients of a 2nd order polynomial used to "fit" outcomes (most classic example is fractional cell kill in vitro) relative to dose fractionation. In the clinical setting, you can take retrospective data and come up with outcomes vs dose fraction curves that are always going to be a little bit bendy, are almost always going to seem monotonic and the data is always going to be fuzzy. This means that fitting these outcomes with a 2nd order polynomial is fine and the added value of a 3rd order term is meaningless in the real world. So you can have an α/β for cell kill, or early clinical outcomes (diarrhea) or late clinical outcomes (bleeding, late cystitis). My confidence in the particulars of these clinical curves is very low.

This α/β is not a model (I guess I heard some handwaving regarding 1 vs 2 photon interactions back in the day) it's just a fit. And by definition it is a fit regarding a single outcome. Most of our clinical and pre-clinical data does not control very well for time course of treatment (not explicitly included in α/β calculations), and the various relative contributions of "the 4Rs" as you shrink treatment time or course from 20-10-5-3-1 treatments is not well defined to my understanding. So you can claim that "cell kill for prostate cancer" demonstrates an α/β less than any pertinent competing toxicity risk, but still believe that single fraction or 3 fraction treatment is not prudent and is not the sweet spot in terms of therapeutic ratio.

Heck, you can just take the well known inverse correlation between total time frame of 5 fraction prostate SBRT and acute toxicity, combine this with the known possibility of "consequential late toxicity" or acute toxicity that becomes late toxicity (This may be particularly pertinent in prostate cancer, where CPPS is a known entity and total pain in the ass to manage.) and make a good argument for not going below 5 fractions and not treating more than 2x a week.

Regarding moderate hypofractionation, the same arguments apply. (BTW, I am not aware of any mature 7920 or 7800 vs 7000 or 6000 hypo trials.)



I agree with this entirely. I have converted to 28 fxns from 44 fxns because of convenience, cost and developing community standard. In fact, under an APM, I would probably be less hesitant to recommend 44 fractions because I wouldn't feel like I was causing undo financial toxicity.

What is the terrible sin of 44 fractions (particularly if it is compensated as 28 fractions)? Out in my community (I'm guessing many places apply outside of really high powered metro areas, where your average patient is rich and 60 yo), 44 fractions meant groups of older, retired men bonding with other similar patients in the waiting room while falling in love with the therapists and nursing staff, having minimal toxicity and believing that their radiation experience was great. They developed close bonds with the treating or covering physician. If even 1% of these men were spared CPPS, 44 fractions might be the way to go.

78 vs 60 is the PROFIT trial published in JCO in 2017

Randomized Trial of a Hypofractionated Radiation Regimen for the Treatment of Localized Prostate Cancer - PubMed

Purpose Men with localized prostate cancer often are treated with external radiotherapy (RT) over 8 to 9 weeks. Hypofractionated RT is given over a shorter time with larger doses per treatment than standard RT. We hypothesized that hypofractionation versus conventional fractionation is similar...

pubmed.ncbi.nlm.nih.gov

 

[dieABRdie]

What is the terrible sin of 44 fractions (particularly if it is compensated as 28 fractions)? Out in my community (I'm guessing many places apply outside of really high powered metro areas, where your average patient is rich and 60 yo), 44 fractions meant groups of older, retired men bonding with other similar patients in the waiting room while falling in love with the therapists and nursing staff, having minimal toxicity and believing that their radiation experience was great. They developed close bonds with the treating or covering physician. If even 1% of these men were spared CPPS, 44 fractions might be the way to go.

This was very much my experience in the community.

I explained "well.... we could do this in 28 treatments instead of 40. I really would hate to make you come back and forth that many times... although there might be some possibility for worse side effects with the shorter course."

"Um doc.... I'm retired... Its easy to come back and forth. And why would I want worse side effects?"

I usually would still talk them into hypofractionation. Now with FLAME published I'm routinely offering 36 fractions with integrated boost (assuming not a candidate for SBRT). If I had prostate cancer an wasn't a candidate for stereotactic, that's exactly what I would choose. And I'll still offer it with APM.

 

[elementaryschooleconomics]

I usually would still talk them into hypofractionation. Now with FLAME published I'm routinely offering 36 fractions with integrated boost (assuming not a candidate for SBRT). If I had prostate cancer an wasn't a candidate for stereotactic, that's exactly what I would choose. And I'll still offer it with APM.

Have you had issues with insurance with doing that? I'm very interested in doing that as well.

 

[RadOncMegatron]

My understanding is that α/β is really only the ratio of the coefficients of a 2nd order polynomial used to "fit" outcomes (most classic example is fractional cell kill in vitro) relative to dose fractionation. In the clinical setting, you can take retrospective data and come up with outcomes vs dose fraction curves that are always going to be a little bit bendy, are almost always going to seem monotonic and the data is always going to be fuzzy. This means that fitting these outcomes with a 2nd order polynomial is fine and the added value of a 3rd order term is meaningless in the real world. So you can have an α/β for cell kill, or early clinical outcomes (diarrhea) or late clinical outcomes (bleeding, late cystitis). My confidence in the particulars of these clinical curves is very low.

This α/β is not a model (I guess I heard some handwaving regarding 1 vs 2 photon interactions back in the day) it's just a fit. And by definition it is a fit regarding a single outcome. Most of our clinical and pre-clinical data does not control very well for time course of treatment (not explicitly included in α/β calculations), and the various relative contributions of "the 4Rs" as you shrink treatment time or course from 20-10-5-3-1 treatments is not well defined to my understanding. So you can claim that "cell kill for prostate cancer" demonstrates an α/β less than any pertinent competing toxicity risk, but still believe that single fraction or 3 fraction treatment is not prudent and is not the sweet spot in terms of therapeutic ratio.

Very nice summary. I take you mean that the a/b is correlated with and may be useful to predict fractional cell kill, but it is not the scientific inference / rationale behind it.

 

[dieABRdie]

Have you had issues with insurance with doing that? I'm very interested in doing that as well.

Not yet. I was afraid some might give me a hard time routinely asking for conventional fractionation but doesn't seem like they are blanket denying in our area just yet. Adding the SIB doesn't increase their cost since its done in the same number of fractions.

 

[communitydoc13]

Very nice summary. I take you mean that the a/b is correlated with and may be useful to predict fractional cell kill, but it is not the scientific inference / rationale behind it.

Exactly. Now you can come up with a model (why I mentioned single vs multiple photon interactions) that references real things like single and double strand DNA breaks, number of photons per unit time and volume, DNA repair kinetics etc. that may explain a curve described by a linear quadratic equation, but the equation itself is not a model and I don't think this is really how we use a/b in clinical practice or in terms of estimates for alternative fractionation schedules. It's really just an expression of an empiric fit that we've all become comfortable with and know roughly what it means in terms of changing dose per fraction.

I am pretty comfortable using a/b in EQD2 calcs for figuring out dose painting doses between about 1.8 and 3 Gy per fraction for involved nodes in GYN, GU and rectal cancers. For everything else, I'm looking to see if I'm between relatively standard dose fractionations for treatment site. Fortunately, the UK hypo-fractionates everything, so you have published series in lung, esophagus, bladder (all pretty bad cancers) with large fields that provide my own sanity test.

 

[RadOncMegatron]

Exactly. Now you can come up with a model (why I mentioned single vs multiple photon interactions) that references real things like single and double strand DNA breaks, number of photons per unit time and volume, DNA repair kinetics etc. that may explain a curve described by a linear quadratic equation, but the equation itself is not a model and I don't think this is really how we use a/b in clinical practice or in terms of estimates for alternative fractionation schedules. It's really just an expression of an empiric fit that we've all become comfortable with and know roughly what it means in terms of changing dose per fraction.

I am pretty comfortable using a/b in EQD2 calcs for figuring out dose painting doses between about 1.8 and 3 Gy per fraction for involved nodes in GYN, GU and rectal cancers. For everything else, I'm looking to see if I'm between relatively standard dose fractionations for treatment site. Fortunately, the UK hypo-fractionates everything, so you have published series in lung, esophagus, bladder (all pretty bad cancers) with large fields that provide my own sanity test.

This is such a good point. I don't think I was taught this explicitly during my training, but I suppose the radiobiologists want more credit than I am willing to give lol! BUT to be able to make a predictive model for fractional cell kill between 1.8 and 3 Gy is no small feat and deserves praise and appreciation. It is just when extrapolating to SBRT that we need to pump the brakes.

 

[TheWallnerus]

This is such a good point. I don't think I was taught this explicitly during my training, but I suppose the radiobiologists want more credit than I am willing to give lol! BUT to be able to make a predictive model for fractional cell kill between 1.8 and 3 Gy is no small feat and deserves praise and appreciation. It is just when extrapolating to SBRT that we need to pump the brakes.

Plate cells, expose them to X-rays, count the daughters, and plot that data on a graph...

That's the original "model" and gives the cell survival curve(s), for single dose exposure, that are in every Hall.

This is a curve for a (cancer) cell line that has an α/β of about 8. The curves are almost always plotted out well past typical single fraction SBRT doses. The idea that we can't use LQ at higher doses is a bit urban legend. I say "a bit"; there are sometimes problems in terms of fitting *clinical* data to the graph at many doses and not just SBRT-ish doses. But fitting "fractional (in vitro) cell kill" data to the graph at SBRT doses? Lots of data on that.

 

[FrostyHammer]

This was very much my experience in the community.

I explained "well.... we could do this in 28 treatments instead of 40. I really would hate to make you come back and forth that many times... although there might be some possibility for worse side effects with the shorter course."

"Um doc.... I'm retired... Its easy to come back and forth. And why would I want worse side effects?"

I usually would still talk them into hypofractionation. Now with FLAME published I'm routinely offering 36 fractions with integrated boost (assuming not a candidate for SBRT). If I had prostate cancer an wasn't a candidate for stereotactic, that's exactly what I would choose. And I'll still offer it with APM.

Well, I don't think doing the FLAME sib obligates one to use 36 fx. I use with 20 or 28 fractions but scale the sib to a similar EQD-2/BED as in FLAME. It's the principle that counts, not the rote repetition.

 

[Ray D. Ayshun]

This discussion prompts a question I've been wanting to ask as a separate thread:. When are people being creative, and why? Doing the flame reg from a phase 2 trial, or wev, is already a little uncomfortable for me given a ton of effective, well studied regimens, but modifying it by bed to fit a desired fraction number would keep me up at night the first time a guy mentions sharting. These modifications seem unnecessary in prostate, particularly off trial.

 

[FrostyHammer]

This discussion prompts a question I've been wanting to ask as a separate thread:. When are people being creative, and why? Doing the flame reg from a phase 2 trial, or wev, is already a little uncomfortable for me given a ton of effective, well studied regimens, but modifying it by bed to fit a desired fraction number would keep me up at night the first time a guy mentions sharting. These modifications seem unnecessary in prostate, particularly off trial.

People shouldn't have any issues with doing things not exactly like a trial. Why? There are conflicting and overlapping trials all the time.

For example:
- There are overlaps between some populations of MA.20/EORTC and Z11/AMAROS. So in those patients do you treat high tangents only or RNI? Whatever you pick, you're going to be doing "per ___ trial" and not "per ____ other trial".
- If you're doing TNT for rectal cancer, if you want to do RT "per" the only published randomized trial, you have to use 5X5. Yet there is another trial that has used conventional fx too.
- If you're treating a locally advanced NSCLC, do you have to add huge margins as in 0617 because that's also "per the trial"?

My point is that rote repetition "per a randomized trial" is a well recognized copout. Thinking instead of blindly doing something is always preferred.

 

[deleted969641]

This discussion prompts a question I've been wanting to ask as a separate thread:. When are people being creative, and why? Doing the flame reg from a phase 2 trial, or wev, is already a little uncomfortable for me given a ton of effective, well studied regimens, but modifying it by bed to fit a desired fraction number would keep me up at night the first time a guy mentions sharting. These modifications seem unnecessary in prostate, particularly off trial.

Why? Knowing that dose matters and not dose-escalating obvious gross disease would bother me more. I'll boost a nodule from a 20 fraction regimen to 66 Gy and to an 28 fraction regimen to mid 70s. Looks like there's room to go higher. Of course this involves some extra work. Cropping out boost volume near bowel and sacrificing boost coverage. Spacers help and fiducials with daily imaging with instructions to your therapists to prioritize matching the fiducial closest to the boost volume and making sure that it's not overlapping the rectum.

No trials comparing 70/28 to 60/20. And if one gets done we truly will have arrived at the bottom.

Why? There was a major trial just published in the salvage setting comparing 70 vs. 64 (186 vs. 173 BED and 128 vs. 118 for normal tissue while shaving off 3 treatments days. 60/20 vs 70/28 would test shaving off 8 treatment days with only a 6 Gy drop in BED with basically the same drop in normal tissue -- so we would hypothetically expect equivalent outcomes in a shorter time with potentially less toxicity as shown in this trial): Dose-intensified versus conventional dose-salvage radiotherapy for biochemically recurrent prostate cancer after prostatectomy: Six-year outcomes of the SAKK 09/10 randomized phase III trial. | Journal of Clinical Oncology (ascopubs.org)
Was this at the bottom?

There exists an optimal dose fractionation for all comers, and I guarantee you it is neither exactly 70/28 nor 60/20 delivered exactly 24 hours apart with weekends and holidays off. With the goal of continuous improvement, we should do all we can to find out exactly what our default should be and under what individual biologic conditions it should be deviated from and to what degree.

What are the important questions for trials? Publishing feel-good lip service fluff pieces about financial toxicity that accomplish nothing and social commentary about residents attitudes as victims of systemic overlord oppressors that guarantee an automatic publication? Maybe emulated hypothetical trials from SEER database?

Circling back, again I personally think it is super lame to choose 28 fraction over 20 simply because you want to be able to claim some moral high ground about doing the right thing and not over fractionating but want to pad your bottom line as much as you can at the same time. If we're worried about losing revenue by dropping fractions, then we as a field should be advocating to make sure that we are compensated fairly for our work regardless of the number of fractions we prescribe rather than doing mental gymnastics about how we're going to lose our shirt if a better way of doing things comes along. The amount of extra work that I do, from a professional level at least, to treat 28 fractions instead of 20 is about an extra 20 minutes, maybe. A prostate OTV takes 5 minutes, and a prostate OTV note takes about 2, and daily imaging review even less. For a 5 fraction SBRT prostate, I do more work than either.

I do think there are appropriate situations to choose 28 instead of 20, 45 instead of 28, 5 instead of 20.
My company's algorithm says that "grade group W, PSA X, under age Y must get regimen Z" smells like cookbook medicine to me. If our goal is to standardize things like that we are going to end up with a midlevel situation like every other field in medicine with dosimetrists and PAs staffing clinics on their own (I think most of us have encountered at some point THAT dosimetrist who loves to play armchair rad onc), seeing patients independently, hitting auto-contour and blowing up facebook most of the day while the computer calcs and single MD signs off on their plans along with those from dozens of other clinics. And I think ironically enough, if that really is the goal, we need trials like 20 vs. 28 to make it as dummy-proof as possible with super wide margins for error.

 

[medgator]

Circling back, again I personally think it is super lame to choose 28 fraction over 20 simply because you want to be able to claim some moral high ground about doing the right thing and not over fractionating but want to pad your bottom line as much as you can at the same time. If we're worried about losing revenue by dropping fractions, then we as a field should be advocating to make sure that we are compensated fairly for our work regardless of the number of fractions we prescribe rather than doing mental gymnastics about how we're going to lose our shirt if a better way of doing things comes along. The amount of extra work that I do, from a professional level at least, to treat 28 fractions instead of 20 is about an extra 20 minutes, maybe. A prostate OTV takes 5 minutes, and a prostate OTV note takes about 2, and daily imaging review even less. For a 5 fraction SBRT prostate, I do more work than either.

Which is probably why ASTRO should have spent all those years figuring out bundled payments instead of fighting urorads and pimping protons...

 

[TheWallnerus]

My company's algorithm says that "grade group W, PSA X, under age Y must get regimen Z" smells like cookbook medicine to me.

That said, the best meals I've ever prepared in my life are when I've studied a recipe in a cookbook very thoroughly and then attempted to replicate it as close as possible. I own A LOT of cookbooks.

Cookbooks can be bad though too. But in chess there is a concept of an "opening book," kind of like a cookbook. Some things are just best by test. The more advanced in years I get the more I appreciate (good) cookbooks.

 

[Mandelin Rain]

Y’all ever add jerk seasoning to your biryani?

That could be good. Or not.

 

[Ray D. Ayshun]

People shouldn't have any issues with doing things not exactly like a trial. Why? There are conflicting and overlapping trials all the time.

For example:
- There are overlaps between some populations of MA.20/EORTC and Z11/AMAROS. So in those patients do you treat high tangents only or RNI? Whatever you pick, you're going to be doing "per ___ trial" and not "per ____ other trial".
- If you're doing TNT for rectal cancer, if you want to do RT "per" the only published randomized trial, you have to use 5X5. Yet there is another trial that has used conventional fx too.
- If you're treating a locally advanced NSCLC, do you have to add huge margins as in 0617 because that's also "per the trial"?

My point is that rote repetition "per a randomized trial" is a well recognized copout. Thinking instead of blindly doing something is always preferred.

Those examples are perfectly defensible... I never said things have to be exactly like a trial. The question was about getting creative. I do it in virtually every patient. I don't adapt a very aggressive experimental fractionation scheme (adapted from a trial with a non-standard control arm) in the treatment of a cancer we're already likely to fix. I don't have access to Flame results, did they do stats on toxicity outcomes, how many grade 3 or >? And are people seeing late >grade2 GU toxicities in a quarter of their patients with modern treatment techniques and image guidance?

 

[drewdog1973]

What exactly is wrong with “cookbook” medicine? If there was a recipe that guarantees success (I.e. Nik Sharma’s lamb biryani), why would you not follow it? It’s like my boomer partners that just want to wing it, a little salt here, a rutabaga there, voila, chicken salad!

 

[Lamount]

What exactly is wrong with “cookbook” medicine? If there was a recipe that guarantees success (I.e. Nik Sharma’s lamb biryani), why would you not follow it? It’s like my boomer partners that just want to wing it, a little salt here, a rutabaga there, voila, chicken salad!

Agree. Nothing wrong with cookbook treatment for cookbook patients. Most of my definitive treatments are bread and butter SOC. The times I find myself venturing into “uncharted” territory is when a patient can’t get SOC and/or there is no SOC (e.g. oligoprogressive met in bad spot, can’t get chemo when CRT is indicated). These are the times I may end up breaking out some rad bio. It just so happens that these patients make up a pretty big chunk of my practice.

 

[RadOncDoc21]

What exactly is wrong with “cookbook” medicine? If there was a recipe that guarantees success (I.e. Nik Sharma’s lamb biryani), why would you not follow it? It’s like my boomer partners that just want to wing it, a little salt here, a rutabaga there, voila, chicken salad!

What’s biryani without ketchup?

 

[elementaryschooleconomics]

What’s biryani without ketchup?

 

[medgator]

What’s biryani without ketchup?

About as appropriate with ketchup as eggs are

 

[dieABRdie]

About as appropriate with ketchup as eggs are

 

[FrostyHammer]

What exactly is wrong with “cookbook” medicine? If there was a recipe that guarantees success (I.e. Nik Sharma’s lamb biryani), why would you not follow it? It’s like my boomer partners that just want to wing it, a little salt here, a rutabaga there, voila, chicken salad!

Seriously? All medical fields are moving towards personalized/individualized medicine and we're really going to be stuck on cookbook rad onc? SMH.

 

[drewdog1973]

Seriously? All medical fields are moving towards personalized/individualized medicine and we're really going to be stuck on cookbook rad onc? SMH.

Why can’t the cookbook be personalized / individualized? Doesn’t have to be mutually exclusive.

 

[Ray D. Ayshun]

Seriously? All medical fields are moving towards personalized/individualized medicine and we're really going to be stuck on cookbook rad onc? SMH.

You're conflating relying on proven dose/fractionation approaches with a one size fits all approach. Technically speaking, altering your practice to use the flame regimen is also cookbook. Otoh, going off early results from a trial with a nonstandard control arm is not an approach I'm comfortable with. If a recipe doesn't work, you taste it and throw it out. If 90 gy ebrt to the prostate has problems in the long run you might find yourself getting deposed.

 

[drewdog1973]

You're conflating relying on proven dose/fractionation approaches with a one size fits all approach. Technically speaking, altering your practice to use the flame regimen is also cookbook. Otoh, going off early results from a trial with a nonstandard control arm is not an approach I'm comfortable with. If a recipe doesn't work, you taste it and throw it out. If 90 gy ebrt to the prostate has problems in the long run you might find yourself getting deposed.

Exactly. Having a “cookbook” (why that term is perjorative, I’ll never know) is an asset, not a liability. Mdacc’s is the most talked about, and they have done well enough to publish good results and market it nationally and internationally. Sloan has a cookbook. Upmc has a cookbook. CCF has a cookbook. Mayo has a cookbook. It’s only folks out in silos practicing solo that decry them - when they are the very people whose patients would benefit from them.

 

[OTN]

Exactly. Having a “cookbook” (why that term is perjorative, I’ll never know) is an asset, not a liability. Mdacc’s is the most talked about, and they have done well enough to publish good results and market it nationally and internationally. Sloan has a cookbook. Upmc has a cookbook. CCF has a cookbook. Mayo has a cookbook. It’s only folks out in silos practicing solo that decry them - when they are the very people whose patients would benefit from them.

[citation needed]

 

[RadOncDoc21]

Exactly. Having a “cookbook” (why that term is perjorative, I’ll never know) is an asset, not a liability. Mdacc’s is the most talked about, and they have done well enough to publish good results and market it nationally and internationally. Sloan has a cookbook. Upmc has a cookbook. CCF has a cookbook. Mayo has a cookbook. It’s only folks out in silos practicing solo that decry them - when they are the very people whose patients would benefit from them.

Does “cookbook” mean protons?

 

[Ray D. Ayshun]

I love the ability to think about anatomy in our specialty, but when it comes to definitive prostate, I'm this guy:

 

[TheWallnerus]

Seriously? All medical fields are moving towards personalized/individualized medicine and we're really going to be stuck on cookbook rad onc? SMH.

When I hear personalized medicine I think: some sort of biomarker is going to be looked at, in the patient, and that result will guide a therapy. We are far away from personalized medicine in rad onc; maybe DCIS will be the first frontier (but there we're talking radiation omission personalization). It's not personalized medicine to use a 0.8 cm PTV in one patient and 0.6 cm PTV in another because constraints can't be met any more than it's personalized medicine for a surgeon to start a Pfannenstiel incision from left-to-right versus right-to-left in another patient. If every little tweak is a "personalization" we need to redefine personalized medicine. We all should be tweaking I guess. The boundary of tweak versus "you didn't follow the recipe in the cookbook" can be argued; like obscenity though "I know it when I see it." A biomarker which could guide dose personalization in patients would be rad onc revolutionary. Not enough smart minds in rad onc are focused on it IMHO.

 

[FrostyHammer]

Gotcha. I think my definition of personalized or individualized medicine is different from yours then. My definition was to have some kind of twist that's different for every RT case, whether it's dose/fx/SIB level, degree of volumes covered, margins, etc. This I feel is far from what I define as "cookbook". But yes, our field is naturally limited by personalization based on genomic factors as compared to hemeonc for instance.

 

[theradiator]

Exactly. Having a “cookbook” (why that term is perjorative, I’ll never know) is an asset, not a liability. Mdacc’s is the most talked about, and they have done well enough to publish good results and market it nationally and internationally. Sloan has a cookbook. Upmc has a cookbook. CCF has a cookbook. Mayo has a cookbook. It’s only folks out in silos practicing solo that decry them - when they are the very people whose patients would benefit from them.

NCCN cookbook? Evicore cookbook?

 

[deleted941485]

NCCN cookbook? Evicore cookbook?

I haven't had the two come into conflict just yet but give it time.

I think they must take into consideration patterns of practice in the area.

 

[medgator]

I haven't had the two come into conflict just yet but give it time.

I think they must take into consideration patterns of practice in the area.

NCCN blesses conventional fractionation in prostate... Evilcore, not so much. Good luck getting evilcore to approve an SBRT oligomet either

 

[deleted941485]

NCCN blesses conventional fractionation in prostate... Evilcore, not so much. Good luck getting evilcore to approve an SBRT oligomet either

Haha SBRT oligomet

They have said we will approve hypofrac but not SBRT. Little pieces of ****.

The worst part is they have ROs in the other end of the line.

“Hi this is so and so I’m a radiation oncologist with evicore”

“Good morning traitor...”

 

[RadOncDoc21]

Haha SBRT oligomet

They have said we will approve hypofrac but not SBRT. Little pieces of ****.

The worst part is they have ROs in the other end of the line.

“Hi this is so and so I’m a radiation oncologist with evicore”

“Good morning traitor...”

Breadlines are making people desperate.

 

[RickyScott]

Breadlines are making people desperate.

I know docs who do this because they don’t have other options.

 

[RickyScott]

I know docs who do this because they don’t have other options.

I don’t have a dog in this game, but if hospitals are charging 10x cms rates, obviously this is going to prompt reviews and policies that will be applied bluntly without discretion. How are the reviewers implementing evercore’ s policy any more of a “traitor” than an attending at MSKCC charging the most expensive rates in the world as part of some legalized game of theft. Patients ultimately choose their insurances, and places like mskcc/mdacc steal from them (insurers/employers.)

 

[medgator]

I know docs who do this because they don’t have other options.

I know several, esp in the last year

 

[drewdog1973]

I know several, esp in the last year

I know felons that were offered the Rhinelander job. If they can’t get a job anywhere in the US and have to become Evicore reviewers, I’m going to bet they are either horrendous doctors or are far too picky.

 

[medgator]

I know felons that were offered the Rhinelander job. If they can’t get a job anywhere in the US and have to become Evicore reviewers, I’m going to bet they are either horrendous doctors or are far too picky.

Or maybe they are picky about the biryani and can eat the best damn woke biryani from the comfort of their urban dwelling while denying my igrt and sbrt requests. Probably better pay than some junior faculty and instructorship positions too i bet

 

[TheWallnerus]

Rather than bellyaching about Evicore--who we know is bad and is literally hurting people--why don't we DO something about it. Options?

 

[RickyScott]

I know felons that were offered the Rhinelander job. If they can’t get a job anywhere in the US and have to become Evicore reviewers, I’m going to bet they are either horrendous doctors or are far too picky.

Doc is decent and in great location, but couldn’t move due to family when hospital gave contract to another group, hence evercore.

 

[SubserviantToABR]

Or maybe they are picky about the biryani and can eat the best damn woke biryani from the comfort of their urban dwelling while denying my igrt and sbrt requests. Probably better pay than some junior faculty and instructorship positions too i bet

This is 100% true. It pays about the same as my current salary (with no incentives or bonuses) but only working 20 hours a week (so they say) whereas I am putting 60 hours a week in, working on my pathetic retrospective study to pad my CV for my promotion and maintaining a high clinical volume to make the university overlords happy.

 

[drewdog1973]

If you're making <$250k working 40 hours a week, then that's on you. MGMA says you're in the bottom 5-10th percentile. Either you're not working very hard or you have a terrible job and have to start looking elsewhere. A doc who can't contour a lytic bone lesion and has terrible haliotosis was offered the Salinas position earning far more than that.

 

[Mandelin Rain]

Rather than bellyaching about Evicore--who we know is bad and is literally hurting people--why don't we DO something about it. Options?

Write a letter to your congressperson. Guaranteed to get results!

 

[Mandelin Rain]

Seriously though, naming and shaming Evicore docs on social media, could be an effective tool.

 

[seper]

Evicore has a great benefit of WFH 100%.
For many people that is important.
Pandemic highlighted that benefit.