RVU target in academics?

[deleted941485]

I think the other thing that deserves mention (again) is that academics are not always as badly paid as it might appear at first blush. The reported data is often base salary. I know where I trained the base was very low (low $200s for assistant professors) but their bonuses were frequently high 5 to low 6 figure. Add on all of the other incentives and you are talking real compensation in the neighborhood of high 300s for 60% clinical effort as assistant professors and low-mid $400s as associates.

I'll be transparent. My base last year was $335. Bonuses totaled $35 (so we are up to $370). Our 401K is stupid high: 2:1 company match up to 15.95% so they end up kicking in the IRS max which is just shy of $33 (now we are a little over $400). I don't count it as real money but I have great health care for my entire family and the hospital pays 100% of the premium. For 50% clinical effort as a relatively new grad (starting year 3) may pay is really not that far off from what I could expect in many PP situations these days. I certainly have a lower ceiling in the long run, but I am not hurting by any stretch.

So do you live in the south or Midwest?

---

Members don't see this ad.

 

[ramsesthenice]

So do you live in the south or Midwest?

yes

 

[medgator]

So do you live in the south or Midwest?

Good points. Something for people to keep in mind when considering if they want sub to low 200s in Palo Alto, Boston, etc or nearly double that in the south or midwest. Decisions and trade offs.

 

[deleted941485]

i think the word is out on these regions as well, I give it another 2-3years before they start low balling people as well.

 

[deleted941485]

Furthermore, people of the mindset that if I just stay in X region or Y region then things will work out are fooling themselves.

Geographic advantages change over time and can change quickly. Look at Texas places like Austin and Houston and even DFW were really good in the 2000s. Now? Not even close. Physicians responded by moving there en masse and now it’s just like every other major metro area.

There will always be the Lubbocks and the Alma’s of the world and they will be as undesirable as they ever were.

 

[MegaVoltagePhoton]

I think this is a great thread. I've worked at two different academic centers since residency (i'll leave out the pay structure at my actual residency institution as I'm sure there were behind the scenes things there).

The first did have an RVU bonus that was real, but it was not eat what you kill, but rather a small, capped bonus if you performed really well. Because it was relatively hard to get, there was minimal incentive and so if you wanted it, you could be aggressive and get it. A side bonus would be that you'd appear to be very busy etc and get out of the chair's sniper sights (which is always a good thing). In the end though, my research projects suffered (I was in the naive, I can do it all, honeymoon phase at my first job). I ended up leaving amicably and for family reasons, but I didn't really get anything done academically and I didn't make a ton of money (starting was 300, though, in a busy metro, and it did go up every year for three years).

The second has a higher bonus value to the RVU bonus. You still only get it after exceeding a certain threshold but it is more monetarily. SO more people want to get it and it's not so easy. I made the choice that I'd try to focus more on some academic stuff, so I only aim to hit a more minimal cutoff (which also exists) just so I don't seem lazy. Been slowly doing more research this way. Overall salary is not bad (380 three years out, busy area), but I don't think it will ever get much higher. Maybe if I get promoted, maybe mid 400 and then cap. But I have no delusions of making anything beyond that.

One other, unrelated note. There are certainly many high power PP groups that enroll tons of patients on trials and some PP folks hold leadership roles for NRG trials, etc, so it's not so cut and dry.

However, to be logically consistent, shouldn't the folks who are quick to shoot down anecdotes of new grads getting grade jobs etc. also be quick to point out that getting large grants outside academia (and even in academia for that matter) is very much the exception and not the rule?

 

[2014XRT]

I just got my year end review yesterday. At my institution, the target minimum is 1000 RVUs per 10% clinical effort. That is not hard at all. I am 50/50. Clinically, I average 2 HDR GYN procedures per week and carry an average of 15 patients on beam (20% SBRT, no SRS) and I hit just under 9000 for the year.

you seem pretty busy for average 50% person though? 15 on beam is on the busier side for academics, let alone 50%?

 

[KHE88]

you seem pretty busy for average 50% person though? 15 on beam is on the busier side for academics, let alone 50%?

9000 wRVU for 15 on treat and 2 HDR a week? I have mid 20s on treat and am on target to be in the 8000 range. Basically no chance to bonus (need 9500 to start collecting a $70/wRVU bonus). I wonder if something is going wrong with my billing.

Do you get wRVU while on vacation? I get a lot of vacation so I miss some weeklies, and that has got to hurt too.

 

[PhotonBomb]

You do not get RVU on vacation, no

 

[KHE88]

You do not get RVU on vacation, no

Thank you for the snarky reply.

Let me rephrase. I assume the default scenario is that when you are out and your patients have an encounter, such as an OTV, the physician that signs the note (covering partner you signed out to or locums) gets those wRVUs.

Does anyone have a setup otherwise? Such that everyone gets the wRVUs for their own patients but not when they cover for someone else?

 

[evilbooyaa]

9000 wRVU for 15 on treat and 2 HDR a week? I have mid 20s on treat and am on target to be in the 8000 range. Basically no chance to bonus (need 9500 to start collecting a $70/wRVU bonus). I wonder if something is going wrong with my billing.

Do you get wRVU while on vacation? I get a lot of vacation so I miss some weeklies, and that has got to hurt too.

Brachy adds a lot of wRVUs that are not reflected in on-treat numbers.

That being said, would re-evaluate your billing situation to see if it's correct.

Some institutions have a policy such as what you describe (other folks cover you but you still get the RVUs), but I believe most transfer the wRVU for OTVs/film sign off to the person actually doing the task.

In a single coverage situation when you have locums I'm interested in whether locums bills the RVUs for the weeklies/film sign-offs. I'd imagine yes but I never see that being discussed on locums rates.

 

[seper]

Physician signing the image gets CBCT wRVU and the one seeing the OTV bills that.

Thank you for the snarky reply.

Let me rephrase. I assume the default scenario is that when you are out and your patients have an encounter, such as an OTV, the physician that signs the note (covering partner you signed out to or locums) gets those wRVUs.

Does anyone have a setup otherwise? Such that everyone gets the wRVUs for their own patients but not when they cover for someone else?

 

[PhotonBomb]

Thank you for the snarky reply.

Let me rephrase. I assume the default scenario is that when you are out and your patients have an encounter, such as an OTV, the physician that signs the note (covering partner you signed out to or locums) gets those wRVUs.

Does anyone have a setup otherwise? Such that everyone gets the wRVUs for their own patients but not when they cover for someone else?

Legit wasn’t meant to be snarky

 

[KHE88]

Legit wasn’t meant to be snarky

Thanks, we're good : )

In a single coverage situation when you have locums I'm interested in whether locums bills the RVUs for the weeklies/film sign-offs. I'd imagine yes but I never see that being discussed on locums rates.

In my set-up when I'm out, the covering locums gets these wRVUs, but as far as I know, he gets paid a daily rate or a fixed salary, so the wRVUs don't contribute to any potential bonus for him. I would be shocked if he has wRVU numbers tied to his compensation.

I didn't think about this going in, and it would have been helpful in contract negoiations. I potentially could have negoitated that all the wRVUs from the clinic are my wRVUs as I'm a solo provider and the locums is just manning the ship while I'm gone.

What I've also seen done, is that when somebody goes on vacation, they see their OTVs on Monday, then again on Friday. As you can count an OTV 5 days forwards OR backwards, this basically means this is ok as far as I know:

Monday: OTV
Tuesday: in clinic
Wednesday: in clinic
Thursday: in clinic
Friday: OTV (covers the next 5 treatments)
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: OTV (covers the previous 5 treatments)
Then again on Friday and the next Monday to get caught up and go back on track.

That way, you don't hand over your valuable OTV wRVUs to the locums

Obviously easier if you only are out for one week. But as far as I know this is OK. Can anyone confirm?

 

[seper]

Your admins will oppose you claiming locum's RVU's for obvious reason.

Thanks, we're good : )



In my set-up when I'm out, the covering locums gets these wRVUs, but as far as I know, he gets paid a daily rate or a fixed salary, so the wRVUs don't contribute to any potential bonus for him. I would be shocked if he has wRVU numbers tied to his compensation.

I didn't think about this going in, and it would have been helpful in contract negoiations. I potentially could have negoitated that all the wRVUs from the clinic are my wRVUs as I'm a solo provider and the locums is just manning the ship while I'm gone.

What I've also seen done, is that when somebody goes on vacation, they see their OTVs on Monday, then again on Friday. As you can count an OTV 5 days forwards OR backwards, this basically means this is ok as far as I know:

Monday: OTV
Tuesday: in clinic
Wednesday: in clinic
Thursday: in clinic
Friday: OTV (covers the next 5 treatments)
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: OTV (covers the previous 5 treatments)
Then again on Friday and the next Monday to get caught up and go back on track.

That way, you don't hand over your valuable OTV wRVUs to the locums

Obviously easier if you only are out for one week. But as far as I know this is OK. Can anyone confirm?

 

[scarbrtj]

The way things should be done is if it’s your patient it’s your RVU. Simplest. Fair. I’d like Bernie Sanders’ opinion.

When I’m out I stay pretty on top of work. Eg I get a lot of planning and contouring done. Making someone hand off those planning and device and calc RVUs simply due to their needing some time away from the office would be awfully mean spirited.

 

[scarbrtj]

Thanks, we're good : )



In my set-up when I'm out, the covering locums gets these wRVUs, but as far as I know, he gets paid a daily rate or a fixed salary, so the wRVUs don't contribute to any potential bonus for him. I would be shocked if he has wRVU numbers tied to his compensation.

I didn't think about this going in, and it would have been helpful in contract negoiations. I potentially could have negoitated that all the wRVUs from the clinic are my wRVUs as I'm a solo provider and the locums is just manning the ship while I'm gone.

What I've also seen done, is that when somebody goes on vacation, they see their OTVs on Monday, then again on Friday. As you can count an OTV 5 days forwards OR backwards, this basically means this is ok as far as I know:

Monday: OTV
Tuesday: in clinic
Wednesday: in clinic
Thursday: in clinic
Friday: OTV (covers the next 5 treatments)
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: vacation
Tuesday: vacation
Wednesday: vacation
Thursday: vacation
Friday: vacation
Monday: OTV (covers the previous 5 treatments)
Then again on Friday and the next Monday to get caught up and go back on track.

That way, you don't hand over your valuable OTV wRVUs to the locums

Obviously easier if you only are out for one week. But as far as I know this is OK. Can anyone confirm?

The only remark I would make about locums is that when a locums comes in no one bills under the locums NPI. They bill locums work under the regular MD NPI with a locums modifier. AFAIK. And keep in mind when someone else gets some RVUs from doing some work on your patient, they now get liability with little reward if anything ever goes wrong on that patient... and whatever they do, they get some reward, and now you get the distinct honor of getting no reward from their work but having to burden increased liability from their work. In short why would people quibble?

Part Four: Locum Tenens Billing – Q6 Modifier (YES or NO)?

Ah, the debate on using Modifier Q6 (aka billing for services furnished by a locum tenens physician) rolls on. Much like the wording for an amendment on an election ballot, understanding the issue at hand to confidently give

www.allstarrecruiting.com

 

[medgator]

The only remark I would make about locums is that when a locums comes in no one bills under the locums NPI. They bill locums work under the regular MD NPI with a locums modifier. AFAIK.

That's how we do it. Q6 modifier for CMS

 

[seper]

Yes, mean spirited. However, lately, some larger departments that I know stopped permitting remote work. E.g. if you are scheduled to be off, you are not permitted to bill.

The way things should be done is if it’s your patient it’s your RVU. Simplest. Fair. I’d like Bernie Sanders’ opinion.

When I’m out I stay pretty on top of work. Eg I get a lot of planning and contouring done. Making someone hand off those planning and device and calc RVUs simply due to their needing some time away from the office would be awfully mean spirited.

 

[scarbrtj]

Yes, mean spirited. However, lately, some larger departments that I know stopped permitting remote work. E.g. if you are scheduled to be off, you are not permitted to bill.

That’s an incentive for non continuity of care which is an incentive for bad patient care. I can do a contouring and plan much better than someone who doesn’t know the case and just as easy in office or from an airplane with fast Wifi. I don’t know if D3 still exists but of course that whole company was based on remote rad onc work. And as I’m wont to remind, the radiology complex is likewise built on thousands and thousands of doctors constantly doing voluminous amounts of remote work. Heck we can take care of ICU patients remotely. But not in rad onc. ITS WRONG.

 

[deleted1002574]

@KHE88 - Obviously, wRVUs are dependent on how many on beam, but also many other things, and also if staff is doing billing correctly. We had some issues, and it was nice to have someone comb through and sort it out. Added 5%-ish when we cleared up some problems.

At, 20 patients in a rural area, I feel you should easily hit that target, I'd have guessed more like 10,000 wRVUs. You probably see prostate+breast, HNC, GI, lung with maybe 60/40 split of curative/palliative. What percent of your patients are IMRT? You have alluded to fact you hypofx when possible - are you overdoing it with regards to that? Image guidance? I hope they are capturing all the planning charges, etc. You may want to talk to a billing company to do a small "work up" to make sure you are optimized.

I'm torn about coverage/rvus. We do internal coverage, and the "babysitter" gets the RVUs, and has compensation related to RVUs however she refuses to see curative cases and generally avoids any decision making, so ... I don't know how far it is. But, don't feel like making a stink.

 

[radiaterMike]

In our practice we have enough covering rad. oncs that we do not use locums.

Some of the highest billers for CMS (i.e. pathologists) are billing for work done by others, but their practice simply bills under one doctor. So in the case of locums, why not routinely bill under the 'real;' doctor, and credit the 'real' doctor with the RVUs. I understand that billing and RVUs are separate, so perhaps the billing is done this way ? and the RVUs not in some practices ?

 

[seper]

Agree, but allegedly remote work (planning) runs afoul of some internal rules and legal concerns.

That’s an incentive for non continuity of care which is an incentive for bad patient care. I can do a contouring and plan much better than someone who doesn’t know the case and just as easy in office or from an airplane with fast Wifi. I don’t know if D3 still exists but of course that whole company was based on remote rad onc work. And as I’m wont to remind, the radiology complex is likewise built on thousands and thousands of doctors constantly doing voluminous amounts of remote work. Heck we can take care of ICU patients remotely. But not in rad onc. ITS WRONG.

 

[deleted1002574]

That’s an incentive for non continuity of care which is an incentive for bad patient care. I can do a contouring and plan much better than someone who doesn’t know the case and just as easy in office or from an airplane with fast Wifi. I don’t know if D3 still exists but of course that whole company was based on remote rad onc work. And as I’m wont to remind, the radiology complex is likewise built on thousands and thousands of doctors constantly doing voluminous amounts of remote work. Heck we can take care of ICU patients remotely. But not in rad onc. ITS WRONG.

D3 was an incredible combination of conflict of interest and getting fed by the hands that feeds you. A small number of people made a large amount of money. Funny that everything at their major client was treated IMRT way before anyone was treating those sites with IMRT, and that the in house insurer never denied IMRT for anything... wish I had thought of the idea and had no ethics!!!!

 

[ramsesthenice]

9000 wRVU for 15 on treat and 2 HDR a week? I have mid 20s on treat and am on target to be in the 8000 range. Basically no chance to bonus (need 9500 to start collecting a $70/wRVU bonus). I wonder if something is going wrong with my billing.

I honestly don’t know the answer to a lot of this. we are provided with a high base salary to minimize incentive-based practice so I don’t really pay much attention. I am not trying to sound self righteous, I just don’t have much incentive to check. That being said, I did some digging and found a few sources of extra RVUs I have that you may not and I didn’t appreciate. I do a fair bit of hepatobilliary SBRT and hypofractionated RT (3-4 under beam at most times) and do a good bit of it using MR guidance (before starting a new discussion, I will be the first to say I am very selective on what I use this for and hepatobilliary tumors are one place it can help you immensely). Every time I use the adapt to shape function (maybe 20% of the time) it’s billed as a new plan. Second, I probably end up covering 6-7 SBRT cone beams per week for one of my partners who is 80/20 research and another 3-4 Gamma cone beams for another partner who is usually very busy on a day I am not. those probably add a good chunk of change.

 

[PhotonBomb]

I honestly don’t know the answer to a lot of this. we are provided with a high base salary to minimize incentive-based practice so I don’t really pay much attention. I am not trying to sound self righteous, I just don’t have much incentive to check. That being said, I did some digging and found a few sources of extra RVUs I have that you may not and I didn’t appreciate. I do a fair bit of hepatobilliary SBRT and hypofractionated RT (3-4 under beam at most times) and do a good bit of it using MR guidance (before starting a new discussion, I will be the first to say I am very selective on what I use this for and hepatobilliary tumors are one place it can help you immensely). Every time I use the adapt to shape function (maybe 20% of the time) it’s billed as a new plan. Second, I probably end up covering 6-7 SBRT cone beams per week for one of my partners who is 80/20 research and another 3-4 Gamma cone beams for another partner who is usually very busy on a day I am not. those probably add a good chunk of change.

hmm I actually would like to know more about this, because my understanding is that there is one professional charge for SBRT. Say there is a 5-fraction lung SBRT plan, and you cover one of the cone beams at the machine for your partner. do you actually get any RVUs for that? I think each fraction is technical charge only and the professional RVU you don't get anything for covering one cone beam?

if it's single fraction GK then yes you do for sure.

 

[deleted1002574]

hmm I actually would like to know more about this, because my understanding is that there is one professional charge for SBRT. Say there is a 5-fraction lung SBRT plan, and you cover one of the cone beams at the machine for your partner. do you actually get any RVUs for that? I think each fraction is technical charge only and the professional RVU you don't get anything for covering one cone beam?

if it's single fraction GK then yes you do for sure.

It's one charge, I thought. We always cover each other, but as long as the treating physician was there for at least one fraction, she/he gets the RVU (it's like 11.9 or something).

 

[scarbrtj]

Every time I use the adapt to shape function (maybe 20% of the time) it’s billed as a new plan.

Wowsers.

hmm I actually would like to know more about this, because my understanding is that there is one professional charge for SBRT. Say there is a 5-fraction lung SBRT plan, and you cover one of the cone beams at the machine for your partner.

correct, one prof charge only. *All* of the prof and tech of the IGRT whatever it may be is rolled into the planning and deliver of SBRT. Thus you cover a CBCT for an SBRT at the machine, no RVUs for you and there is no MD charges at all for that day unless there's a seeing-the-patient charge. Just like Bernie says America is already socialist, much of our rad onc activities already trend APM (if you do a lot of SRS/SBRT).

 

[deleted941485]

Wowsers.


correct, one prof charge only. *All* of the prof and tech of the IGRT whatever it may be is rolled into the planning and deliver of SBRT. Thus you cover a CBCT for an SBRT at the machine, no RVUs for you and there is no MD charges at all for that day unless there's a seeing-the-patient charge. Just like Bernie says America is already socialist, much of our rad onc activities already trend APM (if you do a lot of SRS/SBRT).

Talk about getting your face ripped off with Sbrt.

 

[PhotonBomb]

I honestly don’t know the answer to a lot of this. we are provided with a high base salary to minimize incentive-based practice so I don’t really pay much attention. I am not trying to sound self righteous, I just don’t have much incentive to check. That being said, I did some digging and found a few sources of extra RVUs I have that you may not and I didn’t appreciate. I do a fair bit of hepatobilliary SBRT and hypofractionated RT (3-4 under beam at most times) and do a good bit of it using MR guidance (before starting a new discussion, I will be the first to say I am very selective on what I use this for and hepatobilliary tumors are one place it can help you immensely). Every time I use the adapt to shape function (maybe 20% of the time) it’s billed as a new plan. Second, I probably end up covering 6-7 SBRT cone beams per week for one of my partners who is 80/20 research and another 3-4 Gamma cone beams for another partner who is usually very busy on a day I am not. those probably add a good chunk of change.

also - so SBRT we all understand are nice RVU bang for the buck. but confused about why you mention Hypofractionated RT, because I don't think that really buys you anything? It just means less otvs? how does that get you more RVUs?

 

[ramsesthenice]

also - so SBRT we all understand are nice RVU bang for the buck. but confused about why you mention Hypofractionated RT, because I don't think that really buys you anything? It just means less otvs? how does that get you more RVUs?

The replanning with the MR. The only justification for using MR guidance with plan adaption is the higher doses per fraction (to avoid adjacent bowel). If I end up adapting the plan 3 times over a 15 fraction course then it gets billed as 4 plans.

 

[MegaVoltagePhoton]

The replanning with the MR. The only justification for using MR guidance with plan adaption is the higher doses per fraction (to avoid adjacent bowel). If I end up adapting the plan 3 times over a 15 fraction course then it gets billed as 4 plans.

As it should be. For the love of god do not argue otherwise especially here!

 

[ramsesthenice]

As it should be. For the love of god do not argue otherwise especially here!

I wouldn’t dare.

 

[scarbrtj]

As it should be. For the love of god do not argue otherwise especially here!

I wouldn’t dare.

"The best laid plans of mice and men oft go awry." However, laying down multiple plans evidently treats the patient more better (and racks up a lot of RVUs to boot). Now I see how the MR-linac salespeople can generate salivation-inducing proformas

 

[ramsesthenice]

Now I see how the MR-linac salespeople can generate salivation-inducing proformas

Yep. The similarities between this and protons abound. “If you can do something more precisely, why wouldn’t you?” Having been to one of the MR consortium meetings I can attest that well over half the crap people are proposing is mental masturbation at best. There are a handful of things it will let you do that you otherwise couldn’t but it won’t stop people from filling it up with prostate patients for 70/28 and adapting 2-3x per week.

 

[Neuronix]

Post deleted. I don't really know the limits to adaptive radiotherapy. I'd like to be educated.

 

[scarbrtj]

There's a limit to how many adaptations you can get paid for, I believe it's 4 (5 total plans).

There is no codified limit. You can bill as many as you want,* especially for Medicare patients where pre-auth etc doesn't exist. PROVE ME WRONG.

* back in the day where I trained, we had ExcacTrac IGRT. This was well antecedent any IGRT codes. Guess what the attendings did. They billed a simple sim every day. For prostate patients: 45 simple sims or more in total. And it got paid.

 

[deleted1002574]

Holy crap. That is insane!!

 

[ramsesthenice]

Post deleted. I don't really know the limits to adaptive radiotherapy. I'd like to be educated.

My understanding from a billing perspective is that it’s the Wild West and you can adapt as much as you want.

In practice, there are many reasons over adaptation for anything other than 3-5 fraction SBRT is undesirable. Most notably, if you honestly think you have to adapt frequently from a patient safety perspective, you are probably asking too much of the technology. There is still a “margin of error” to be considered and if you can’t meet your goals without changing your delivery even half the time I think your kidding yourself. These things can be a perfectionists worst nightmare. Most of the time when a structure is technically off it is painfully obvious that it is still safely within criteria and there is no clinically-meaningful reason to fiddle with it. Similarly, if you meet your duodenal constraint 7 days in a row, you don’t necessarily have to change the plan on day 8 just because it’s a little warm that day. Fractionation has its advantages. There is also a significant time factor to consider. These can easily balloon to 45-60+ min slots if you are contouring multiple structures and re-running 9 field IMRT plans. It is a lot more effort than signing a cone beam and collecting charges. Everyone’s return on investment horizon is different, but as someone doing other procedures and research this can frankly be a pain in the tail if you are not selective who you use it on.

 

[Neuronix]

This is a philosophical discussion. Clinically, I love my daily adapted high dose 1-5 fraction treatments with all the pretty IGRT and motion tracking without fiducials that MR-IGRT provides.

Yes I do some conventional fractionation on our MR-IGRT system. It's mostly for research purposes, mostly not published, mostly not adapted, and I have no idea if it's good for anything so I will keep wasting money like a good academic.

Having adaptation in the back pocket is nice for some conventionally fractionated sites, like cervix or prostate to be able to correct for big motions. I recognize that MR-IGRT isn't the only way to do that--clearly we treat prostate and cervix for cure today. So this is where the academics wonder... What if you could shrink PTV margins? Would this allow more dose to be put in? Would this reduce toxicity? It wouldn't take much reduction in significant toxicity to make MR-IGRT cost-effective.

 

[ramsesthenice]

This is a philosophical discussion. Clinically, I love my daily adapted high dose 1-5 fraction treatments with all the pretty IGRT and motion tracking without fiducials that MR-IGRT provides.

Yes I do some conventional fractionation on our MR-IGRT system. What if you could shrink PTV margins? Would this allow more dose to be put in? Would this reduce toxicity? It wouldn't take much reduction in significant toxicity to make MR-IGRT cost-effective.

I couldn’t agree more. I think it has more potential to address unmet clinical needs than other experimental delivery systems and my fear is that the real utility will get drowned out by unscrupulous clinical practice or poorly-rationalized “research” and the end result being it never really catches on.

 

[Neuronix]

poorly-rationalized “research”

I'm triggered. Did you review my last grant?

 

[ramsesthenice]

I'm triggered. Did you review my last grant?

nah! Not just saying this, your posts here have always struck me as thoughtful. You know the kind I’m talking about...

 

[seper]

IMO, cervix is a poor application of adaptive re-planning. You need large elective volumes, anyway. GTV displacement occurs in many directions and is not predictable.

This is a philosophical discussion. Clinically, I love my daily adapted high dose 1-5 fraction treatments with all the pretty IGRT and motion tracking without fiducials that MR-IGRT provides.

Yes I do some conventional fractionation on our MR-IGRT system. It's mostly for research purposes, mostly not published, mostly not adapted, and I have no idea if it's good for anything so I will keep wasting money like a good academic.

Having adaptation in the back pocket is nice for some conventionally fractionated sites, like cervix or prostate to be able to correct for big motions. I recognize that MR-IGRT isn't the only way to do that--clearly we treat prostate and cervix for cure today. So this is where the academics wonder... What if you could shrink PTV margins? Would this allow more dose to be put in? Would this reduce toxicity? It wouldn't take much reduction in significant toxicity to make MR-IGRT cost-effective.

 

[medgator]

IMO, cervix is a poor application of adaptive re-planning. You need large elective volumes, anyway. GTV displacement occurs in many directions and is not predictable.

There's a reason the rtog protocols required multiple CT sims for imrt cervix....

 

[Neuronix]

IMO, cervix is a poor application of adaptive re-planning. You need large elective volumes, anyway. GTV displacement occurs in many directions and is not predictable.

You can see the displacement very clearly with the MRI. That's the point.

 

[evilbooyaa]

IMO, cervix is a poor application of adaptive re-planning. You need large elective volumes, anyway. GTV displacement occurs in many directions and is not predictable.

That's literally the point of adaptive planning, to be able to account for that without the massive margins (that would otherwise be necessary) on a daily basis.

 

[RickyScott]

That's literally the point of adaptive planning, to be able to account for that without the massive margins (that would otherwise be necessary) on a daily basis.

Any input on varian adaptive linac-ethos?

 

[evilbooyaa]

Any input on varian adaptive linac-ethos?

I don't know enough to give an informed opinion on it. My current institution is planning on installing a halcyon at some point but no concrete plans as of yet.

I'm not sure if ethos is also going to be available on the rest of varian's line, only have heard about it through halcyon

 

[OTN]

That's literally the point of adaptive planning, to be able to account for that without the massive margins (that would otherwise be necessary) on a daily basis.

Is there any comparative clinical data which shows MRI-adapted therapy leads to improved outcomes compared with non-adaptive IMRT and IGRT? Without that data it's hard for me to justify the increased cost.