Red Journal BANGER

[deleted1111261]

https://www.redjournal.org/article/S0360-3016(23)08253-6/fulltext

This is impressive, even for Red Journal. They find that instrumentation into one of the most sensitive areas of the body is unpleasant/traumatic. Early in my career, I would wonder, why do so many patients find this to be pleasant and entertaining. Thankfully, the journal has published groundbreaking research showing that my experience was an aberration and that, in fact, it is quite hard on these patients.

Is there an editor? Do people read the papers when they review? Does anyone care about science any more?

Conclusion​

Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.

---

Members don't see this ad.

 

[BobbyHeenan]

I could often hear the patient voice from down the hall from the brachy room. You know, the one in residency where they did fully awake tandem and ovoids with a whiff of ativan and morphine. Things like "Oh GOD please stop" and "ouch, ouch" were common.

I should have taken some recordings and submitted it as a multimedia abstract for astro.

 

[NotMattSpraker]

using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations. However if you talk about SBRT instead of brachy, we will curse your family for generations.

Fixed it!

 

[Gfunk6]

https://www.redjournal.org/article/S0360-3016(23)08253-6/fulltext

This is impressive, even for Red Journal. They find that instrumentation into one of the most sensitive areas of the body is unpleasant/traumatic. Early in my career, I would wonder, why do so many patients find this to be pleasant and entertaining. Thankfully, the journal has published groundbreaking research showing that my experience was an aberration and that, in fact, it is quite hard on these patients.

Is there an editor? Do people read the papers when they review? Does anyone care about science any more?

Conclusion​

Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.

Null hypothesis (H0): "Jamming long metal objects into women's orifices persons with vaginas quickly and/or with minimal lubrication does not cause traumatic experiences or loud verbal feedback from the patient."

 

[Palex80]

I always listen to my patients. When they are sedated.

 

[fiji128]

https://www.redjournal.org/article/S0360-3016(23)08253-6/fulltext

This is impressive, even for Red Journal. They find that instrumentation into one of the most sensitive areas of the body is unpleasant/traumatic. Early in my career, I would wonder, why do so many patients find this to be pleasant and entertaining. Thankfully, the journal has published groundbreaking research showing that my experience was an aberration and that, in fact, it is quite hard on these patients.

Is there an editor? Do people read the papers when they review? Does anyone care about science any more?

Conclusion​

Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.

The quality/usefulness of what is being published in the Red Journal has noticeably gone down hill since Sue Yom took over.

 

[deleted1111261]

The quality/usefulness of what is being published in the Red Journal has noticeably gone down hill since Sue Yom took over.

So, a story ..

When I was trying to find some common ground w Astro and red journal, I made repeated entreaties to chat with Sue. She’d say yah, and then wouldn’t .. heard later she told my colleague because I wasn’t academic, i wasn’t worth talking to

 

[medgator]

The quality/usefulness of what is being published in the Red Journal has noticeably gone down hill since Sue Yom took over.

It's been **** before then

 

[Mandelin Rain]

The quality/usefulness of what is being published in the Red Journal has noticeably gone down hill since before Sue Yom graduated residency.

Fixed

 

[NotMattSpraker]

Haha academic publishing is such a dumpster fire.

https://www.clinical-lung-cancer.com/article/S1525-7304(23)00270-X/fulltext

These authors cant even get their little intro hook facts internally consistent in the same paper.

Im curious what people think will be the end of this fun little journey. What will academic publishing look like in 2035?

 

[ramsesthenice]

Haha academic publishing is such a dumpster fire.

https://www.clinical-lung-cancer.com/article/S1525-7304(23)00270-X/fulltext

These authors cant even get their little intro hook facts internally consistent in the same paper.

Im curious what people think will be the end of this fun little journey. What will academic publishing look like in 2035?

It will look mostly like what it is now. Journals exist to make money and they won’t fill themselves…

 

[Radonky]

https://www.redjournal.org/article/S0360-3016(23)08253-6/fulltext

This is impressive, even for Red Journal. They find that instrumentation into one of the most sensitive areas of the body is unpleasant/traumatic. Early in my career, I would wonder, why do so many patients find this to be pleasant and entertaining. Thankfully, the journal has published groundbreaking research showing that my experience was an aberration and that, in fact, it is quite hard on these patients.

Is there an editor? Do people read the papers when they review? Does anyone care about science any more?

Conclusion​

Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.

I thought you fabricated the conclusion to make fun of it. But that's actually what they wrote.

 

[Mandelin Rain]

Haha academic publishing is such a dumpster fire.

https://www.clinical-lung-cancer.com/article/S1525-7304(23)00270-X/fulltext

These authors cant even get their little intro hook facts internally consistent in the same paper.

Im curious what people think will be the end of this fun little journey. What will academic publishing look like in 2035?

To Crush or Not To Crush is the name of my upcoming swipe based app.

 

[medgator]

Im curious what people think will be the end of this fun little journey. What will academic publishing look like in 2035?

 

[elementaryschooleconomics]

What will academic publishing look like in 2035?

Splintered.

I think about this a lot, because this isn't a situation that can exist long-term.

My current guess is it will follow what we're seeing in media/journalism, which is a rise in "alternative" platforms. Before too long here, we're going to see "Human Preservations", that is, journals with an overt mission to "slow down" and ban any work done with the help of AI. Ironically, AI will be used to help moderate content.

But there will be a recognition that the volume of trash research being published at an exponential rate, with a publishing fee of >$4,000, is a flipped signal-to-noise ratio, and it's actively harmful.

Unfortunately, it will be a lot harder to get a strong "alternative" community going than what we'll see in media. The parasitic journals are a creation of the careerist, brass-ring worshipping, empty-headed "academicians" who will continue to think getting a paper in NEJM is some indicator of quality.

I'm really unsure of what the post-collapse landscape looks like, because seeing how Medicare Advantage and the benefit manager companies have accelerated the hedonic destruction of the economy of medicine, there's a race between journals and insurance for "who explodes first", and one will affect the other, and...

Who knows.

It just makes me really sad seeing the culture inside the RadOnc Ivory Tower at the moment. Each time some trash "hypothesis generating" study based on SurveyMonkey data shows up in a flagship journal, I immediately think of all the authors aggressively updating their CV, and then counting up their total number of publications like:

 

[RadRadRad]

2035 might look a lot like 1985
If you read journal articles from 40-50 years ago they often were shorter, with less scientific rigor and less stats. I think that’s where we are headed

 

[medgator]

2035 might look a lot like 1985
If you read journal articles from 40-50 years ago they often were shorter, with less scientific rigor and less stats. I think that’s where we are headed

Representative of the caliber of people matching in...

 

[deleted1111261]

2035 might look a lot like 1985
If you read journal articles from 40-50 years ago they often were shorter, with less scientific rigor and less stats. I think that’s where we are headed

I found older articles very clear / straightforward to read and with rather elegant stats (I guess my word for simple).

Read like Al-Sarraf nasopharyngeal chemo article or Sauer German rectal or go back further and read VA Larynx study. These are clean and questions are asked and answered.

 

[Mandelin Rain]

I found older articles very clear / straightforward to read and with rather elegant stats (I guess my word for simple).

Read like Al-Sarraf nasopharyngeal chemo article or Sauer German rectal or go back further and read VA Larynx study. These are clean and questions are asked and answered.

100%.

1 important question based upon improving on the the previous trial.
Large enough patient cohort.
2 KM curves (local recurrence and overall survival)
1 toxicity table
Well described methods.

Those days, things made sense. It seemed coherent and coordinated. Now we have a bunch of silos doing their own thing, that sometimes match but often contradict. An agreed upon standard? For anything? Nope.

 

[Palex80]

1 important question based upon improving on the the previous trial.
Large enough patient cohort.
2 KM curves (local recurrence and overall survival)
1 toxicity table
Well described methods.

This is a typical paper in the Lancet Oncology, nowadays.

 

[OTN]

I found older articles very clear / straightforward to read and with rather elegant stats (I guess my word for simple).

Read like Al-Sarraf nasopharyngeal chemo article or Sauer German rectal or go back further and read VA Larynx study. These are clean and questions are asked and answered.

We used to do Phase III RCTs to answer questions to push the field forward/further advance survival and outcomes. Now we do non-inferiority trials, which specifically look into ways to do something that's not any better than the standard of care.

 

[Ray D. Ayshun]

We used to do Phase III RCTs to answer questions to push the field forward/further advance survival and outcomes. Now we do non-inferiority trials, which specifically look into ways to do something that's not any better than the standard of care.

This is the thing I was getting at in an albeit vague post in a separate thread. Simultaneously, our field is publishing articles about the need to hear patients while also designing trials where a group of doctors decides the definition of a noninferior outcome for a specific scenario. I find this inconsistent. I'm not necessarily arguing one way or another with this observation, but I am perhaps more bothered by noninferiority trials than surveys that purport to objectively evaluate the level of "hope" amongst certain patient populations. We're not even looking for not any better, really, we're generally looking for <5% worse.

 

[medgator]

I found older articles very clear / straightforward to read and with rather elegant stats (I guess my word for simple).

Read like Al-Sarraf nasopharyngeal chemo article or Sauer German rectal or go back further and read VA Larynx study. These are clean and questions are asked and answered.

Crazy to think these were red journal pubs when you pick up a copy of the journal today.

Edit: Al-sarraf study felt like it belonged more in jco and that's where it was published back in the 90s

Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized Intergroup study 0099 - PubMed

We conclude that chemoradiotherapy is superior to radiotherapy alone for patients with advanced nasopharyngeal cancers with respect to PFS and overall survival.

pubmed.ncbi.nlm.nih.gov

 

[MidwestRadOnc]

We used to do Phase III RCTs to answer questions to push the field forward/further advance survival and outcomes. Now we do non-inferiority trials, which specifically look into ways to do something that's not any better than the standard of care.

We should do non-inferiority studies comparing outcomes with patients whose payors utilize third party PA services vs. those who don't. Not that a negative (not non-inferior) outcome would change anything because $$$.

 

[deleted1111261]

We should do non-inferiority studies comparing outcomes with patients whose payors utilize third party PA services vs. those who don't. Not that a negative (not non-inferior) outcome would change anything because $$$.

20/1 for a gr1 meningioma …

I think I helped a patient today
I know we will never find common ground, but your comments are helping me make a case to improve things, so I appreciate it MRO!

 

[Ray D. Ayshun]

20/1 for a gr1 meningioma …

I think I helped a patient today
I know we will never find common ground, but your comments are helping me make a case to improve things, so I appreciate it MRO!

? What'd you change, dose? Or just deny treatment?

 

[Mandelin Rain]

? What'd you change, dose? Or just deny treatment?

Yeah, I'm not sure what this one is about. Definitely higher dose than what I'd do typically, but not like completely bonkers. I randomly pulled up a few single institution case series and they all had SRS range up to 20Gy. Additionally, there is some (low-quality) data for dose-response in meningioma.

Dose-Response Relationships for Meningioma Radiosurgery : American Journal of Clinical Oncology

total of 101 consecutive patients (108 tumors) who underwent GKRS for benign, atypical, or malignant meningiomas between 1998 and 2011 were studied. Local recurrence was assessed. Cox proportional hazards and logistic regression analyses were used to determine the association of patient-related...

journals.lww.com

 

[deleted1111261]

Just had a nice discussion. Said 20 seems high. He said yeah, that’s true. I said I’m not denying, just not a usual dose. All good. He changed dose. Lower risk of necrosis at lower dose. Super pleasant. Has my cell for future issues

 

[RickyScott]

“The modern journal article based on hypothesis testing and “statistics” is purely a western construct propagated by the likes of Popper. It compeltely ignores richer explorations of epistemology and ontology such as the “narrative” voice or interpretative dance. Dei is not enough, we urgently need to decolonize radiation.”
- Claudine Gay

 

[Ray D. Ayshun]

Just had a nice discussion. Said 20 seems high. He said yeah, that’s true. I said I’m not denying, just not a usual dose. All good. He changed dose. Lower risk of necrosis at lower dose. Super pleasant. Has my cell for future issues

Don't disagree, just never had the dose thing come up.

 

[deleted1111261]

Don't disagree, just never had the dose thing come up.

Our nurses rely on published regimens and we are super inclusive - I.e. if it’s reasonable, doesn’t have to be Ph3. Like 14 Gy is associated with 98-100% LC

 

[NotMattSpraker]

“The modern journal article based on hypothesis testing and “statistics” is purely a western construct propagated by the likes of Popper. It compeltely ignores richer explorations of epistemology and ontology such as the “narrative” voice or interpretative dance. Dei is not enough, we urgently need to decolonize radiation.”
- Claudine Gay

LOL I've never tried this before. It is true that in any P2P, the treating physician is the oppressed. The insurance companies hold all the power.

Next time I will say something like "okay well my truth is that this is approved, have you considered that?"

Simul would that work? Hypothetically I mean.

 

[deleted1111261]

“The modern journal article based on hypothesis testing and “statistics” is purely a western construct propagated by the likes of Popper. It compeltely ignores richer explorations of epistemology and ontology such as the “narrative” voice or interpretative dance. Dei is not enough, we urgently need to decolonize radiation.”
- Claudine Gay

That is so good, lol

 

[MidwestRadOnc]

20/1 for a gr1 meningioma …

I think I helped a patient today
I know we will never find common ground, but your comments are helping me make a case to improve things, so I appreciate it MRO!

I am in complete agreement with you but wonder if we are missing the forest for the trees. If we have a system where people like us can't get 33 fractions of IMRT approved for LS-SCLC but people who prescribe 20 Gy x 1 for grade 1 meningiomas are still allowed to practice let alone remain board certified (lifetime certification grandfathered-in LOL), then the system is very broken. PA flowcharts don't usually prevent people from delivering too much dose, just too many fractions. Not a safety thing.

 

[deleted1111261]

MRO - I’m not sure what to say. I’m actively trying to improve a broken process. I give several examples of terrible care that I prevent, several examples where I approve things you said you’ve been denied and I’m asking for suggestions on how to improve things.

If the doctor prescribed 8 Gy/1, I would have called, as well. I’m not solely worried about cost. I am interested in the right amount of care. No more no less, as long as you are within the band of practice where some percentage of doctors would agree with you.

We 100% would approve IMRT for SCLC 33 fx. Both of us that review cases thinks it insane not to.

I don’t have a flowchart.

 

[MidwestRadOnc]

MRO - I’m not sure what to say. I’m actively trying to improve a broken process. I give several examples of terrible care that I prevent, several examples where I approve things you said you’ve been denied and I’m asking for suggestions on how to improve things.

If the doctor prescribed 8 Gy/1, I would have called, as well. I’m not solely worried about cost. I am interested in the right amount of care. No more no less, as long as you are within the band of practice where some percentage of doctors would agree with you.

We 100% would approve IMRT for SCLC 33 fx. Both of us that review cases thinks it insane not to.

I don’t have a flowchart.

That's great to have a process on the payors end to avoid paying for bad care, which makes sense as well if you're going to avoid paying for overtreatment or futile treatment. But how does that work? How do you check plans to prevent things like:

1. Boosting a sentinel node scar instead of a lumpectomy cavity
2. Lung SBRT with 2mm margins
3. Abdominal SBRT with large margins overlapping GI structures
4. Ipsilateral RT for oral cavity cancer (or worse, gross disease + margin only).
Etc.

I have personally seen all of the above and much more, usually (but not always) from the ABR lifetime-cert crowd who haven't done any real CME in decades. But all of the above gets through flowcharts. How would you catch that as a concerned payor? Or make sure that your recommendations are enforced? You can enforce 30 fractions vs. 40 or 3D vs. IMRT by withholding payment. But how are you going to make sure your friend decreases the SRS dose to something appropriate?

 

[deleted1111261]

That's great to have a process on the payors end to avoid paying for bad care, which makes sense as well if you're going to avoid paying for overtreatment or futile treatment. But how does that work? How do you check plans to prevent things like:

1. Boosting a sentinel node scar instead of a lumpectomy cavity
2. Lung SBRT with 2mm margins
3. Abdominal SBRT with large margins overlapping GI structures
4. Ipsilateral RT for oral cavity cancer (or worse, gross disease + margin only).
Etc.

I have personally seen all of the above and much more, usually (but not always) from the ABR lifetime-cert crowd who haven't done any real CME in decades. But all of the above gets through flowcharts. How would you catch that as a concerned payor?

These are great points!

And something to aspire to. I don’t do actual contour review. I want to explore it on an optional basis. But, really, unclear on how to do this without it being completely voluntary and also .. I’m a community doc- so there are areas where I’d need help.

The fact that I’m in a position where I don’t argue about IGRT, am not making people do complex isodose and because I’m practicing full time I’m aware of time pressure and patient pressure - I feel this has been great for patients and doctors.

I have looked at imaging with doctors and had detailed discussions on challenging cases. I learned. They learned.

 

[pikachu]

The quality/usefulness of what is being published in the Red Journal has noticeably gone down hill since Sue Yom took over.

Which is really saying something tbh

 

[evilbooyaa]

I actually read the whole paper with interest, thanks for sharing. I think trying to quantify which part of it is the worst for patients has some value. That being said, I can understand that most ROs nationally (doubly so for those not doing brachy) think this is silly.

Simul, when's the last time you did a T&O case?

I think getting patient experiences and publishing the negatives are the best way to improve the process for patients. I would much rather read this in the red journal than another DEI or carbon footprint paper.

For same day/long procedures (tandem-based):
Pre-procedure/at consult - Have a real discussion about what brachy means and feels for the patient. Mentally prepare the patient that it's not going to be a pleasant experience but it's the best way to treat them with the lowest rate of long-term side effects. Discuss the whole day start to finish including time estimates at consult. Leave time pre-procedure to re-discuss a shorter version of the procedure. In regards to side effects, counsel extensively! Don't tell patients they're going to be fine when there's a very reasonable chance that they won't. Most side effects mentioned in the paper are more so from EBRT than brachy (with maybe exception of vaginal stenosis) or a combination of the two (bladder/rectum issues).
Counsel extensively on loss of fertility, and for the love of god don't mention 'feeling like childbirth' to someone who is never going to experience that (like a pre-menopausal cervical cancer pt)

Insertion - Do it while the patient is fully asleep or fully anesthetic from a spinal/epidural. Placing a tandem in an awake patient with just oral meds should not be done in 2024. Just refer out. I'm wary of moderate sedation but some have felt it to be sufficient. Minimize packing as much as feasible (just anterior and posterior to the applicator, primarily at the level of the cervix, not necessarily to distend vagina near introitus or distend laterally) for comfort. Consider cervical block PRN.
Laying flat - minimize the time component of this by working as quickly as possible. Inform patient some movement is OK and if they complain of lower back pain, consider pre-emptively putting a pillow under their problem area to otherwise support.
Removal - Now is the most painful part for my patients - I've gone to offering pre-meds to everyone at first removal in hopes of improving patient experience.

Pain should be addressed (mostly) proactively, not reactively. If you're 'reacting' to severe pain, do more than what you would do proactively.
Talk the patient through every step of what's happening as it's happening, each time it's happening.

That being said, couple points I learned/that were reinforced that may affect my own practice:
1) applicator removal SUCKS for most women. Offer aggressive pre-meds, especially for those who are nervous. I wonder if it's worth pursuing some sort of nitrous or other short acting relaxing agent.... the worst (for me and for patients) is when they kegel aggressively during removal in anticipation of the discomfort.

2) I've never thought to compare applicator removal to childbirth, but I can be damn sure I won't ever do it go forward.
3) Having empathy to the feelings of patients (including vulnerability, trauma processing, loss of fertility, etc.) even if they did 5 weeks of EBRT with you.

 

[MidwestRadOnc]

Placing a tandem in an awake patient with just oral meds should not be done in 2024.

This was done at a practice I worked at. When I protested, I was told to "send the patient for a hysterectomy" if I had a problem with it. Profit margins would take a hit with the added time and expense to do it correctly. The decision makers were, of course, men. I'll let you guess if MR-guidance or adaptive planning or even placement verification sim was routine.

Oh, and the meds were of course a combination of benzos and opioids. Because that's fine, apparently.

I'm still angry about it.

 

[medgator]

1) applicator removal SUCKS for most women. Offer aggressive pre-meds, especially for those who are nervous. I wonder if it's worth pursuing some sort of nitrous or other short acting relaxing agent.... the worst (for me and for patients) is when they kegel aggressively during removal in anticipation of the discomfort.

Been a few years since i placed any but i don't remember this being an issue for HDR, just LDR T&Os (did those where i trained)

 

[MidwestRadOnc]

Been a few years since i placed any but i don't remember this being an issue for HDR, just LDR T&Os (did those where i trained)

The biggest issue I ran into was removing the tandem after removing the ovoids due to the guide tabs on the ring surrounding the tandem that the ovoids seat in. When pulling the tandem out of the Smit Sleeve, you had to fight the vacuum pressure keeping it locked into place, which was painful enough, but then the tabs would often get snagged on the vaginal tissue and tear the vaginal wall as it was coming out. You could sometimes guide it with your fingers but it was excruciatingly painful for patients even on "benzo-dope"

Of course, the smallest ovoids possible were always used uniformly for everyone, which is wrong.

Ridiculous this is done under anything but GA because profit-driven community centers don't want to invest in the resources to do it correctly but also don't want to refer it out.

 

[evilbooyaa]

Been a few years since i placed any but i don't remember this being an issue for HDR, just LDR T&Os (did those where i trained)

I mean removing a tandem and other devices whether its HDR or LDR shouldn't really matter? 4-5 hours vs 2-3 days isn't going to change the effect.

The biggest issue I ran into was removing the tandem after removing the ovoids due to the guide tabs on the ring surrounding the tandem that the ovoids seat in. When pulling the tandem out of the Smit Sleeve, you had to fight the vacuum pressure keeping it locked into place, which was painful enough, but then the tabs would often get snagged on the vaginal tissue and tear the vaginal wall as it was coming out. You could sometimes guide it with your fingers but it was excruciatingly painful for patients even on "benzo-dope"

Of course, the smallest ovoids possible were always used uniformly for everyone, which is wrong.

Ridiculous this is done under anything but GA because profit-driven community centers don't want to invest in the resources to do it correctly but also don't want to refer it out.

Every applicator is different I suppose...

That being said, I prefer my old titanium T&O set over the new plastic T&R set I got which has a hybrid cap to allow hybrid needle placement, in a case where intracavitary is sufficient. Removing the ovoids (even on the larger side) is easier than removing the ring for most patients, and the ring I have now is smaller than the ring we used in residency, so can't even imaging the level of discomfort from the older titanium T&R set from Varian.

Tandem is less of an issue at removal (worst is definitely either the ovoids or the Ring for most patients) but I can certainly understand any sharp bits scratching the vagina on the way out being a significant issue. God forbid you get into a serious vaginal laceration and the bleeding that entails from that.

Unfortunately, MRO, it seems that practice wasn't doing the greatest brachy. Fortunately, you seemed to be aware of it and understandably got the hell out of dodge.

 

[deleted1111261]

The biggest issue I ran into was removing the tandem after removing the ovoids due to the guide tabs on the ring surrounding the tandem that the ovoids seat in. When pulling the tandem out of the Smit Sleeve, you had to fight the vacuum pressure keeping it locked into place, which was painful enough, but then the tabs would often get snagged on the vaginal tissue and tear the vaginal wall as it was coming out. You could sometimes guide it with your fingers but it was excruciatingly painful for patients even on "benzo-dope"

Of course, the smallest ovoids possible were always used uniformly for everyone, which is wrong.

Ridiculous this is done under anything but GA because profit-driven community centers don't want to invest in the resources to do it correctly but also don't want to refer it out.

Let me push back a bit.

I am a community-guy who was trained under a guy who is known as one of the best in the country. When I was a resident, we learned it without general anesthesia. From 2006-2009 the vast majority of the cases being done were not under GA. 2010 I started seeing more general anesthesia, but nationwide, it was not common.

I started doing these cases. Horrible. So painful. I got into a routine, changed the meds up a bit, did some mild NLP to relieve anxiety, but it was so hard on the women (and me!) without GA. I did not want to do them any more. The closest academic center that had an experienced gyn rad onc was Johns Hopkins. I called them and said, "We need some help here for these cases, they should be done at an academic center, probably". The doctor says to me "Well, we will not do the brachy unless we did the EBRT". This was not Dr. Viswanathan, btw. She got there pretty much as I was leaving the region and said that she would have done it, but at that point we had connected with Mohindra at UMD.

So, they want me to send a patient 80 miles each way for EBRT if I want them to do the brachy? Who is the profit minded one? They want the IMRT and the brachy. I don't want any of it! But, I can't make them drive and I'm not going to let someone die of a curable disease. My hands were tied. I want the best care for my patients.

We can play the game of who's worse, but you've already made up your mind. I take it that no matter what I say about this, you'll assume I am greedy.

 

[MidwestRadOnc]

Let me push back a bit.

I am a community-guy who was trained under a guy who is known as one of the best in the country. When I was a resident, we learned it without general anesthesia. From 2006-2009 the vast majority of the cases being done were not under GA. 2010 I started seeing more general anesthesia, but nationwide, it was not common.

I started doing these cases. Horrible. So painful. I got into a routine, changed the meds up a bit, did some mild NLP to relieve anxiety, but it was so hard on the women (and me!) without GA. I did not want to do them any more. The closest academic center that had an experienced gyn rad onc was Johns Hopkins. I called them and said, "We need some help here for these cases, they should be done at an academic center, probably". The doctor says to me "Well, we will not do the brachy unless we did the EBRT". This was not Dr. Viswanathan, btw. She got there pretty much as I was leaving the region and said that she would have done it, but at that point we had connected with Mohindra at UMD.

So, they want me to send a patient 80 miles each way for EBRT if I want them to do the brachy? Who is the profit minded one? They want the IMRT and the brachy. I don't want any of it! But, I can't make them drive and I'm not going to let someone die of a curable disease. My hands were tied. I want the best care for my patients.

We can play the game of who's worse, but you've already made up your mind. I take it that no matter what I say about this, you'll assume I am greedy.

The situation you describe is not like one I have encountered. All of the academic centers (and non-academic centers that will use GA and treat with modern techniques) I have referred to in the midwest have readily accepted the referrals. That is ridiculous. You are going to end up with many patients refusing treatment in that situation and left to choose between SBRT boost or torturebrachy. Of course you are not that bad guy in that scenario.

 

[medgator]

I mean removing a tandem and other devices whether its HDR or LDR shouldn't really matter? 4-5 hours vs 2-3 days isn't going to change the effect.

Pt on bedrest, necrotic tumor had some time to die off, felt like things just got more stuck in general over 48-72 hours.

I remember it being much more painful than HDR, even with packing, never really had a problem removing hdr setups in the vault after we were done treating

 

[evilbooyaa]

Pt on bedrest, necrotic tumor had some time to die off, felt like things just got more stuck in general over 48-72 hours.

I remember it being much more painful than HDR, even with packing, never really had a problem removing hdr setups in the vault after we were done treating

Fair enough - I'll defer to your experience. I've never done LDR Gyn.

 

[evilbooyaa]

Let me push back a bit.

I am a community-guy who was trained under a guy who is known as one of the best in the country. When I was a resident, we learned it without general anesthesia. From 2006-2009 the vast majority of the cases being done were not under GA. 2010 I started seeing more general anesthesia, but nationwide, it was not common.

I started doing these cases. Horrible. So painful. I got into a routine, changed the meds up a bit, did some mild NLP to relieve anxiety, but it was so hard on the women (and me!) without GA. I did not want to do them any more. The closest academic center that had an experienced gyn rad onc was Johns Hopkins. I called them and said, "We need some help here for these cases, they should be done at an academic center, probably". The doctor says to me "Well, we will not do the brachy unless we did the EBRT". This was not Dr. Viswanathan, btw. She got there pretty much as I was leaving the region and said that she would have done it, but at that point we had connected with Mohindra at UMD.

So, they want me to send a patient 80 miles each way for EBRT if I want them to do the brachy? Who is the profit minded one? They want the IMRT and the brachy. I don't want any of it! But, I can't make them drive and I'm not going to let someone die of a curable disease. My hands were tied. I want the best care for my patients.

We can play the game of who's worse, but you've already made up your mind. I take it that no matter what I say about this, you'll assume I am greedy.

If the options are bad brachy (in this case, in terms of pain control) vs NO brachy, pick bad brachy every time!

Certain academic centers who think their farts smell good giving the rest of them a bad name. I can't imagine turning down a referral from the community for someone looking for help. Ideally, I'd want to develop a pipeline where I saw them in a TIMELY fashion (which has been my biggest issue with community referrals) but I would never tell a referring doc "I won't do the brachy if you don't send them to me for the EBRT".

Ridiculous on JHU's part. Glad to hear it was pre-AW.

 

[deleted1111261]

If the options are bad brachy (in this case, in terms of pain control) vs NO brachy, pick bad brachy every time!

Certain academic centers who think their farts smell good giving the rest of them a bad name. I can't imagine turning down a referral from the community for someone looking for help. Ideally, I'd want to develop a pipeline where I saw them in a TIMELY fashion (which has been my biggest issue with community referrals) but I would never tell a referring doc "I won't do the brachy if you don't send them to me for the EBRT".

Ridiculous on JHU's part. Glad to hear it was pre-AW.

Yeah, it is very nice to see them in community, figure out if it is something you can handle, and if not, expedite it to academic center.

It is really amazing when done well. We are about equidistant from UMich and Henry Ford. Henry Ford essentially gives you a 'concierge' type person and it is awesome. Patients get in super fast and without too much run around. I send an email, nurse makes a phone call, and patient sees specialist ASAP and then sends patient back. At UMich, patient disappears forever - no notes and they are well known for keeping the patient and having them drive 50-100 miles each way for IMRT. Beaumont is very good, too, for proton referrals and other things that I cannot handle. Plus, HF and Beaumont let community docs present at tumor board.

I think profit-minded people are that way, regardless of the tax status of the organization. We operate far more like a charitable organization and we are for-profit, as compared to the two non profits I worked for.

(and it wasn't bad brachy! just painful!)

 

[evilbooyaa]

(and it wasn't bad brachy! just painful!)

Well, the paper you just linked has lead to some significant discussion as to whether painful brachy can be equated to 'bad' in a certain definition of the word

For all your original dislike on the paper in OP, lead to more discussion than 99% of what Red journal publishes!