SpaceOAR - Augmenix, Boston Scientific, and Conflicts of Interest

[NotMattSpraker]

Generalists contour just as well (or poorly, depending on how you look at it) as do the "experts".

The data in the paper supports this idea.

I agree with the other things you wrote. A lot of protocols are written poorly. A lot of people (apparently) can't follow directions as this finding is seen in many trials. There are a lot of reasons a revision may not be "bad" clinically, agreed.

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[NotMattSpraker]

I would say there’s a zero percent chance of Fournier’s gangrene from prostate RT tho

Right, but if someone got it during prostate RT, I bet you wouldnt say that the radiation oncologist did a malpractice

 

[RickyScott]

Right, but if someone got it during prostate RT, I bet you wouldnt say that the radiation oncologist did a malpractice

Maybe they recycled the gel or balloon?

 

[evilbooyaa]

I would like to see the COI for the guy touting balloon

"I also was an investigator in a recently completed FDA pivotal trial for a completely novel next generation spacer which is NOT a gel, but an injectable biodegradable balloon. It is a game-changer."

Did $$ change hands?

Not clear - company is not in Open Payments database. He is a co-author but not listed as a recipient of money, just two of the authors per the COI statement...

Multicenter, dual fractionation scheme, single core lab comparison of rectal volume dose reduction following injection of two biodegradable perirectal spacers - PubMed

Rectal dosimetry is more favorable for treatment with the balloon spacer compared with SpaceOAR. Further research, particularly in the context of a prospective randomized clinical trial design, is needed to assess the acute and late toxicity experience as well as physician satisfaction with...

pubmed.ncbi.nlm.nih.gov

 

[sirspamalot]

Its simple: Always use the AVOID technique to avoid devastating loss of testicles, need for skin grafts, permanent -ostomies, etc. The AVOID technique has a near 100% success rate. ASTRO should be promoting the AVOID technique!

Oh, and like the pancreas: DO NOT F WITH THE RECTAL WALL after seed implant/external beam/etc. I always tell patients, under NO CIRCUMSTANCES are they allowed to have anyone cauterize or do ANYTHING to them, I will be happy to reload them with PRBC should they need it but if you mess with that rectum you gonna regrettum...

 

[A_DeMichele]

this thread is probably the most depressing RadOnc text ever

 

[radoncftw]

crazy thing about that database is that it probably only captures a limited # of events.
In my time in training, we had several events at our institution with G3-5 toxicity from the hydrogel. I doubt any of them made it into that database.

 

[mheat3]

I specifically tell all my patients that nothing in medicine carries a 0% of toxicity. I would say the same thing as a witness.

Only a Sith deals in absolutes...

 

[sirspamalot]

this thread is probably the most depressing RadOnc text ever

Nah, the jobs thread should have done that for you. This.. this is just the cherry on top.

 

[Mandelin Rain]

Wrong thread. My mistake.

 

[TheWallnerus]

Can someone point me to the OLA thread? I have concerns.

This should be interesting

 

[Chartreuse Wombat]

Can someone point me to the OLA thread? I have concerns.

Not sure what you are referring to?

 

[medgator]

 

[Chartreuse Wombat]

Finally a denominator

 

[BobbyHeenan]

Finally a denominator

Good paper. I just skimmed it.

I wonder what % of adverse events aren't reported to MAUDE?
I've seen two rectal wall infiltrations (both asymptomatic but did require some anoscopy/monitoring) that I didn't report.
I know of another case in our area of acute urinary retention requiring catheter, also not reported.

 

[elementaryschooleconomics]

Finally a denominator

...wow

 

[OTN]

I know of at least one other grade 5 complication which didn't make it into MAUDE

 

[evilbooyaa]

Finally a denominator

0.47%... even if you say 50% of events are not reported and double that it's still less than 1%. Not bad.

 

[elementaryschooleconomics]

0.47%... even if you say 50% of events are not reported and double that it's still less than 1%. Not bad.

I agree in an absolute sense, of course, but it's painful to consider 1,000-2,000 men experiencing adverse events that absolutely didn't need to happen.

And...5 deaths???

I guess this is perhaps a philosophical argument because I don't think there's a "correct" answer but: what is the magnitude of benefit necessary to justify a non-zero probability of death?

 

[medgator]

0.47%... even if you say 50% of events are not reported and double that it's still less than 1%. Not bad.

Really? That 0.47% had some bad **** in it, evil. Stuff that never happened in the pre gel era.

Watching an elective colostomy happen in my practice (not my placement) and seeing that a cystoprostectomy/APR occurred at utsw that was published is enough for me to never do it in my practice again, maude data just confirms that the juice just isn't worth the squeeze

 

[drowsy12]

I don't use spacer and don't see why anyone would.

the data is somewhat reassuring to the folks who use it but also alarming to the folks who don't. this wont change anyone's mind.

the proton folks demand it.

 

[Pointless]

For those of you steadfastly against SpaceOAR use, honest question, have you planned cases with a good gel placement? The rectal DVH (and bladder DVH, because you can push harder on bladder as a result of more space to the rectum) are so much better than anything you see without a spacer.

I totally respect anyone who evaluates the data and elects against offering spacers in practice, but I continue to be confounded by the level of animosity toward the procedure by what seems like the majority on this board.

 

[drowsy12]

For those of you steadfastly against SpaceOAR use, honest question, have you planned cases with a good gel placement? The rectal DVH (and bladder DVH, because you can push harder on bladder as a result of more space to the rectum) are so much better than anything you see without a spacer.

I totally respect anyone who evaluates the data and elects against offering spacers in practice, but I continue to be confounded by the level of animosity toward the procedure by what seems like the majority on this board.

I have no doubt the DVH looks better. I guess to me it's similar to organ only prostate proton therapy. how much clinical difference are we going to make at some point when standard treatment* is so well tolerated?


* to be clear I mean modern well planned VMAT with daily CBCT, small margins, and pushing your 50% IDL hard posteriorly on rectum.

second, as ESE said, the question has to be asked about what magnitude of clinical benefit is needed to justify 1% chance of severe tox.

 

[elementaryschooleconomics]

For those of you steadfastly against SpaceOAR use, honest question, have you planned cases with a good gel placement? The rectal DVH (and bladder DVH, because you can push harder on bladder as a result of more space to the rectum) are so much better than anything you see without a spacer.

I totally respect anyone who evaluates the data and elects against offering spacers in practice, but I continue to be confounded by the level of animosity toward the procedure by what seems like the majority on this board.

Yup

I trained with some of the docs that used to be on the front page of the SpaceOAR website (not sure if that's still true anymore)

I've used Goo Original, Goo VUE, Goo placed by "KOL" Urologists, Goo placed by resident Urologists at every level of training, Goo placed by Radiation Oncologists (both with and without prostate brachy experience), Goo placed in academia/VA/community, Goo placed in multiple states.

My personal animosity is driven by my 5+ years of personal experience with the stuff in more situations than I imagine most people have seen.

It's why I think it should be available, but not standard.

It's too expensive, the benefit too small, the risk of death too high for it to be standard.

 

[elementaryschooleconomics]

Yup

I trained with some of the docs that used to be on the front page of the SpaceOAR website (not sure if that's still true anymore)

I've used Goo Original, Goo VUE, Goo placed by "KOL" Urologists, Goo placed by resident Urologists at every level of training, Goo placed by Radiation Oncologists (both with and without prostate brachy experience), Goo placed in academia/VA/community, Goo placed in multiple states.

My personal animosity is driven by my 5+ years of personal experience with the stuff in more situations than I imagine most people have seen.

It's why I think it should be available, but not standard.

It's too expensive, the benefit too small, the risk of death too high for it to be standard.

Good Lord I just remembered it's 2024 now isn't it?

Ok so...it's more than 5+ years but I'm not fixing my math...

 

[communitydoc13]

I'm not a huge Spaceoar fan. My long term GU toxicity is excellent and I'm not sure pushing the dose down on the bladder more will be very meaningful. This is occasional bad toxicity.

However, despite what some on this board have said, I believe that late rectal bleeding is significant, and markedly increased in one population....those on AC.

The thing is, AC is freaking common, high grade prostate cancer increases with age, and we are treating guys in their 70s on AC all of the time.

Nearly all of my rectal bleeders have been on AC, and while none have been life threatening, it can be a hassle. I always check the dosimetry and it is usually very good. My suspicion is that low volume/high dose anterior rectal area is enough to cause some late bleeding in AC patients even if all volumetric constraints are beautifully met.

So I consider it in my AC patients and counsel them that the relative benefit is likely greater for them. (Maybe I'm wrong).

Long-term findings of rectal endoscopy and rectal bleeding after moderately hypofractionated, intensity-modulated radiotherapy for prostate cancer - Scientific Reports

To present rectal endoscopic findings and toxicity after definitive moderately hypofractionated, intensity-modulated radiotherapy (IMRT) for prostate cancer. We retrospectively reviewed patients who underwent IMRT for prostate cancer and underwent post-radiotherapy endoscopies between 2008 and...

www.nature.com

 

[Gfunk6]

For those of you steadfastly against SpaceOAR use, honest question, have you planned cases with a good gel placement? The rectal DVH (and bladder DVH, because you can push harder on bladder as a result of more space to the rectum) are so much better than anything you see without a spacer.

I totally respect anyone who evaluates the data and elects against offering spacers in practice, but I continue to be confounded by the level of animosity toward the procedure by what seems like the majority on this board.

Totally agree. I've been on this board for 20 years (just got my badge, yay!), but I don't see the point in spending my time and effort in contradicting the hate train on this thread. I've done 100s of cases and I've never had a complication, EVER. I am very conservative and in several cases opted against injection if there was any doubt that the rectal wall could be compromised.

I do CK all the time and treat to HDR-like doses, so I do find it to be helpful to me to achieve that.

 

[drowsy12]

I would agree that SBRT doses and anti coagulation are good use situations

 

[elementaryschooleconomics]

Totally agree. I've been on this board for 20 years (just got my badge, yay!), but I don't see the point in spending my time and effort in contradicting the hate train on this thread. I've done 100s of cases and I've never had a complication, EVER. I am very conservative and in several cases opted against injection if there was any doubt that the rectal wall could be compromised.

I do CK all the time and treat to HDR-like doses, so I do find it to be helpful to me to achieve that.

No! Contradict me! That's why I come to SDN!

So you might be the most clear example re: why I think it should be available/not standard.

I've never seen/used CK before. Well...I saw one in storage, once.

I stick with "boring" treatments (79.2 in 44, 70 in 28, or 60 in 20 if you put a gun to my head).

But if I were dose escalating with an external technique, I wouldn't think it's nuts to add Goo.

My main question:

Have you ever gone back to doing Goo-less treatments for any length of time?

I know you said you're conservative about holding off in questionable cases, but that sounds uncommon, yes?

Where I'm going with this is that I suspect people like you, who seem really thoughtful in their approach - I wonder if you would notice any difference in outcomes/side effects if you stopped doing the Goo routinely.

Because at this point, it's probably been many years since you were doing treatments "old school", as it were, right?

Are you doing the same style treatments now as you were before any hydrogel was on the market?

 

[Gfunk6]

My main question:

Have you ever gone back to doing Goo-less treatments for any length of time?

No, but in fairness, how many of you have gone back to 3DCRT for anal or H&N cancer for any length of time?

I know you said you're conservative about holding off in questionable cases, but that sounds uncommon, yes?

Yes, that's fair. A small number of people are ruled out before SpaceOAR is even scheduled (e.g. gross ECE) and a few more because prostate-rectal separation is ambiguous durig the ultrasound.

Where I'm going with this is that I suspect people like you, who seem really thoughtful in their approach - I wonder if you would notice any difference in outcomes/side effects if you stopped doing the Goo routinely.

I figured, but see above. If it ain't broke, don't fix it.

Because at this point, it's probably been many years since you were doing treatments "old school", as it were, right?

Well, I've always used SpaceOAR for CK so that doesn't really qualify. I don't typically use gel in moderately and conventionally fractionated plans for my own patients but I do it for my colleagues as requested.

Are you doing the same style treatments now as you were before any hydrogel was on the market?

Nope. And these CK treatments are *hot* like the gross-disease on MRI is getting 50-60 Gy in 5 fractions.

 

[evilbooyaa]

Fully agree with GFunk. Being able to take the entire prostate PTV to 40Gy in 5 fractions with spaceOAR VUE is enough reason for me to recommend it for prostate SBRT cases. We're doing FLAME style boosts as well, and escalating to 45-50Gy in 5 fractions to DIL even when posterior is doable with SBRT. Better coverage feasible in a posteriorly located tumor with the Goo for the DIL Dose.

Not something I routinely use in mod hypo or conv fx.

 

[elementaryschooleconomics]

No, but in fairness, how many of you have gone back to 3DCRT for anal or H&N cancer for any length of time?

Yes, that's fair. A small number of people are ruled out before SpaceOAR is even scheduled (e.g. gross ECE) and a few more because prostate-rectal separation is ambiguous durig the ultrasound.

I figured, but see above. If it ain't broke, don't fix it.

Well, I've always used SpaceOAR for CK so that doesn't really qualify. I don't typically use gel in moderately and conventionally fractionated plans for my own patients but I do it for my colleagues as requested.

Nope. And these CK treatments are *hot* like the gross-disease on MRI is getting 50-60 Gy in 5 fractions.

Ah excellent you're the perfect, real-life example of my main hypothesis around the hydrogel use.

So, I had the interesting experience of doing residency at a time and place where I could watch the shift from mostly conventional schemes for prostate to mostly hypofrac. I also did rotations at a community satellite where one of my attendings refused to do hypofrac even after the 2018 guidelines came out.

It was a weird, and, I suspect, uncommon experience. Obviously, when you're a resident, you are SUPER tuned in with the "ASTRO Culture". It's all you know, because it's all that's POSSIBLE for you to know.

It was my pre-Elementary School days, yet to really enter the blackpilled path - well, I guess this was one of the many black cobblestones.

From my perspective, my "blank slate" learning of clinical RadOnc started with drilling into my soul that 79.2 in 44 was "the way". Ok, cool.

But then, I was buried under an avalanche of "conventional is evil, hypofrac is the way, and if you do conventional, you're basically killing puppies".

Ok...well, message received I guess. But I was confused, because 79.2 in 44 seemed like it was working fine, and I had never really heard of these "non-inferiority trials" before, and...well. Message received.

But then I was out at the community satellite after the hypofrac guidelines came out and the GU attending was exclusively doing 79.2 in 44. He "didn't feel comfortable" using the bigger doses "away from main campus".

Now, even though this was a "community satellite", it wasn't one of those "academic institution merges with existing private practice, the old private practice docs stay, and they're academic docs in name only" sort of deals. So it wasn't the stereotype of "ancient boomer private doc can't get with the times".

This was a community satellite staffed, at the time, with a couple of the super research heavy faculty who were like 0.2 FTE. This GU attending was like a golden pedigree, multiple R01 kind of guy.

And thus, in a rather concentrated period of time, I was taught to treat prostate with conventional, but then that drastically changed and I was taught to treat prostate with hypofrac and further, if I didn't, I was evil, but then I was rotating with a guy who checked all the ASTRO Culture boxes as "perfect" and he was only doing conventional, and the most important part: I didn't really see any difference in the patients, other than the hypofrac guys had urinary issues earlier.

This is super long, like always, sorry.

Anyway: most people do not have this type of experience. What I noticed in my general resident cohort, and what I see coming out with new grads now, is they ONLY know hypofrac. They have never even seen a single conventional prostate!!

As I'm fond of talking about on SDN, I frequently have a mix of prostate patients on beam at the same time. I prefer conventional, from a side effects standpoint, and would use conventional on myself.

And I wonder, with SpaceOAR: are we seeing the same sort of phenomenon?

With your CK regimen, @Gfunk6 - is it possible you could do the exact same treatments without the SpaceOAR and see the exact same results?

I definitely think it's possible.

Will that trial ever be done? I doubt it.

Most importantly: if I were you, hearing how you do things, would I be willing to stop using SpaceOAR?

No. I know, without question, if I had been doing what you're doing, I would not be willing to stop using the gel.

If it ain't broke, don't fix it.

That's what I think has happened with SpaceOAR in America. I think my point of view is very uncommon, where I had not only the chance to see basically every prostate thing under the sun, I have been in positions in independent practice where I am able to do exactly what I want to do, without pressure from anyone else or department protocols.

I acknowledge the inverse is true: perhaps if I went back to SpaceOAR now, I would clearly see an improvement.

But I am not willing to start using the gel.

If it ain't broke, don't fix it.

I only stay on board the SpaceOAR Hate Train because I don't know if residents, current and future, get much exposure to the "anti-Goo" perspective. I suspect the majority of residency programs use the gel, and I suspect the residency programs are dogmatic zealots about using The Goo.

I'm here rattling my bottle of blackpills, hoping for a 1% conversion rate.

 

[taserlaser]

Ah excellent you're the perfect, real-life example of my main hypothesis around the hydrogel use.

So, I had the interesting experience of doing residency at a time and place where I could watch the shift from mostly conventional schemes for prostate to mostly hypofrac. I also did rotations at a community satellite where one of my attendings refused to do hypofrac even after the 2018 guidelines came out.

It was a weird, and, I suspect, uncommon experience. Obviously, when you're a resident, you are SUPER tuned in with the "ASTRO Culture". It's all you know, because it's all that's POSSIBLE for you to know.

It was my pre-Elementary School days, yet to really enter the blackpilled path - well, I guess this was one of the many black cobblestones.

From my perspective, my "blank slate" learning of clinical RadOnc started with drilling into my soul that 79.2 in 44 was "the way". Ok, cool.

But then, I was buried under an avalanche of "conventional is evil, hypofrac is the way, and if you do conventional, you're basically killing puppies".

Ok...well, message received I guess. But I was confused, because 79.2 in 44 seemed like it was working fine, and I had never really heard of these "non-inferiority trials" before, and...well. Message received.

But then I was out at the community satellite after the hypofrac guidelines came out and the GU attending was exclusively doing 79.2 in 44. He "didn't feel comfortable" using the bigger doses "away from main campus".

Now, even though this was a "community satellite", it wasn't one of those "academic institution merges with existing private practice, the old private practice docs stay, and they're academic docs in name only" sort of deals. So it wasn't the stereotype of "ancient boomer private doc can't get with the times".

This was a community satellite staffed, at the time, with a couple of the super research heavy faculty who were like 0.2 FTE. This GU attending was like a golden pedigree, multiple R01 kind of guy.

And thus, in a rather concentrated period of time, I was taught to treat prostate with conventional, but then that drastically changed and I was taught to treat prostate with hypofrac and further, if I didn't, I was evil, but then I was rotating with a guy who checked all the ASTRO Culture boxes as "perfect" and he was only doing conventional, and the most important part: I didn't really see any difference in the patients, other than the hypofrac guys had urinary issues earlier.

This is super long, like always, sorry.

Anyway: most people do not have this type of experience. What I noticed in my general resident cohort, and what I see coming out with new grads now, is they ONLY know hypofrac. They have never even seen a single conventional prostate!!

As I'm fond of talking about on SDN, I frequently have a mix of prostate patients on beam at the same time. I prefer conventional, from a side effects standpoint, and would use conventional on myself.

And I wonder, with SpaceOAR: are we seeing the same sort of phenomenon?

With your CK regimen, @Gfunk6 - is it possible you could do the exact same treatments without the SpaceOAR and see the exact same results?

I definitely think it's possible.

Will that trial ever be done? I doubt it.

Most importantly: if I were you, hearing how you do things, would I be willing to stop using SpaceOAR?

No. I know, without question, if I had been doing what you're doing, I would not be willing to stop using the gel.

If it ain't broke, don't fix it.

That's what I think has happened with SpaceOAR in America. I think my point of view is very uncommon, where I had not only the chance to see basically every prostate thing under the sun, I have been in positions in independent practice where I am able to do exactly what I want to do, without pressure from anyone else or department protocols.

I acknowledge the inverse is true: perhaps if I went back to SpaceOAR now, I would clearly see an improvement.

But I am not willing to start using the gel.

If it ain't broke, don't fix it.

I only stay on board the SpaceOAR Hate Train because I don't know if residents, current and future, get much exposure to the "anti-Goo" perspective. I suspect the majority of residency programs use the gel, and I suspect the residency programs are dogmatic zealots about using The Goo.

I'm here rattling my bottle of blackpills, hoping for a 1% conversion rate.

That is a very interesting point. I'll chime in to add I had a similar experience in my residency - long lists of patients on treatment with conventional fractionation for prostate cancer. Then CHHiP and PROFIT were published, and then came moderately hypofractionated treatment, along with our centre adopting HDR. The most fractions I've seen my colleagues give recently are up to 25 fractions, and I only learned how to insert SpaceOAR after completing residency (though I don't treat GU in my current practice). I doubt our current residents have seen conventionally fractionated prostate delivered - but they will learn instead on an MR-L. Whereas breast there is still regular use and advocates for conventional fractionation.

What a perspective. This may be similar to how I hear old staff describing using those china wax pencils.

 

[medgator]

. Whereas breast there is still regular use and advocates for conventional fractionation.

What a perspective. This may be similar to how I hear old staff describing using those china wax pencils.

 

[elementaryschooleconomics]

What a perspective. This may be similar to how I hear old staff describing using those china wax pencils.

Fun fact - which you may know, of course - "China Marker" isn't some kind of culturally insensitive slang. It's an actual name brand product, because the wax pencils were originally marketed as able to write on any surface - including ceramic, as in, Chinese ceramics.

I bring this up because I originally thought this was some kind of slang (obviously...I'm not from the wax pencil era).

But then, I discovered I was wrong, and I decided to decorate my office with them:

I might be the only RadOnc under the age of 50 who has not only purchased China Markers (from Amazon) within the last two years - I brought those China Markers into a RadOnc department.

Time is a flat circle.

Anyway -

That is a very interesting point. I'll chime in to add I had a similar experience in my residency - long lists of patients on treatment with conventional fractionation for prostate cancer. Then CHHiP and PROFIT were published, and then came moderately hypofractionated treatment, along with our centre adopting HDR. The most fractions I've seen my colleagues give recently are up to 25 fractions, and I only learned how to insert SpaceOAR after completing residency (though I don't treat GU in my current practice). I doubt our current residents have seen conventionally fractionated prostate delivered - but they will learn instead on an MR-L. Whereas breast there is still regular use and advocates for conventional fractionation.

Ok there's so much to unpack here, haha.

1) Aren't you Canadian????? Or at least practice in Canada? And you're in a place with residents? And there are people still advocating for breast conventional???

What?????

The first time I heard about breast hypofrac was probably 11-12 years ago when I was doing my PhD. For whatever reason I was down on the clinical side of the department and the faculty were talking about "Canadian fractionation". I was so confused. After the 4th time they used that term I asked them to explain what the heck they were talking about.

Last week, I was (for the 5th time in the last 12 months, because my life is weird) planning a breast re-irradiation case. The prior (Boomer) RadOnc I took over for had done her first plan in 2018. The prescription was literally named "Left Breast Canadian Fractions".

And so on and so forth.

Basically...I thought...isn't conventional for breast illegal in Canada?

But in regards to my overarching philosophy - yeah, I think we can apply this theory to like, everything weird in RadOnc (probably more than just RadOnc I guess).

One of the things that made me into the weird, obsessive creature I am today is the YEARS I spent UTTERLY PERPLEXED about so many fundamental beliefs and behaviors in Radiation Oncology.

There's just so many contradictions. It doesn't make sense.

It's part of why I'm so vocal against the echo chamber that is the establishment ASTRO culture. It's a very clique-driven, dogmatic, high-walled garden while the vast majority of Radiation Oncologists are brilliant, thoughtful, excellent doctors.

We have very extreme quirks and it pushes people out, never to return.

But let's go back to Canadians doing conventional for breast...

 

[taserlaser]

Fun fact - which you may know, of course - "China Marker" isn't some kind of culturally insensitive slang. It's an actual name brand product, because the wax pencils were originally marketed as able to write on any surface - including ceramic, as in, Chinese ceramics.

I bring this up because I originally thought this was some kind of slang (obviously...I'm not from the wax pencil era).

But then, I discovered I was wrong, and I decided to decorate my office with them:

View attachment 385354

I might be the only RadOnc under the age of 50 who has not only purchased China Markers (from Amazon) within the last two years - I brought those China Markers into a RadOnc department.

Time is a flat circle.

Anyway -



Ok there's so much to unpack here, haha.

1) Aren't you Canadian????? Or at least practice in Canada? And you're in a place with residents? And there are people still advocating for breast conventional???

What?????

The first time I heard about breast hypofrac was probably 11-12 years ago when I was doing my PhD. For whatever reason I was down on the clinical side of the department and the faculty were talking about "Canadian fractionation". I was so confused. After the 4th time they used that term I asked them to explain what the heck they were talking about.

Last week, I was (for the 5th time in the last 12 months, because my life is weird) planning a breast re-irradiation case. The prior (Boomer) RadOnc I took over for had done her first plan in 2018. The prescription was literally named "Left Breast Canadian Fractions".

And so on and so forth.

Basically...I thought...isn't conventional for breast illegal in Canada?

But in regards to my overarching philosophy - yeah, I think we can apply this theory to like, everything weird in RadOnc (probably more than just RadOnc I guess).

One of the things that made me into the weird, obsessive creature I am today is the YEARS I spent UTTERLY PERPLEXED about so many fundamental beliefs and behaviors in Radiation Oncology.

There's just so many contradictions. It doesn't make sense.

It's part of why I'm so vocal against the echo chamber that is the establishment ASTRO culture. It's a very clique-driven, dogmatic, high-walled garden while the vast majority of Radiation Oncologists are brilliant, thoughtful, excellent doctors.

We have very extreme quirks and it pushes people out, never to return.

But let's go back to Canadians doing conventional for breast...

Conventional fractionation for breast is so illegal. The mounties will hunt you down, lock you in an igloo, and feed you to the beavers.

Seriously though. I work in a large centre with almost a dozen breast ROs, who happen to harbour different views /interpret the evidence differently than neighbouring city/cities, and this is problematic when trying to harmonize/standardize provincial standards, let alone in the same centre. That, and add a lot of folk for where the planning has barely changed in 20 years, makes it quite hard to try and advance current standards.

(A)PBI off trial? Rare as hen’s teeth. 5 fr whole breast instead. I just groan at that
hint of nodal disease? RNI for everyone
Boost plans with 50% through huge swath of breast…
RNI plans off of old field based landmarks (think MA20) and POP for each and every axilla…

I think a lot of the nuance that would go into patient centred decision making is lost with such an approach, and so have taken the role of being now more of a stick in the mud for arguing for improved decision making & standards, esp when it comes to planning

My comment on conventional fractionation though is more so for reconstructed chestwall/breasts. Not uncommon to see immediate recon and so the defacto here is still 50 Gy, even with the recent RTOG trial. We moved from 50.4 to 50 Gy when RT CHARM started accruing and will take forever for that to report. 16 fr for each RNI plan otherwise

Rant over. Not egregious but I think there is so much room to do a lot better, but such is life

 

[TheWallnerus]

Conventional fractionation for breast is so illegal. The mounties will hunt you down, lock you in an igloo, and feed you to the beavers.

Seriously though. I work in a large centre with almost a dozen breast ROs, who happen to harbour different views /interpret the evidence differently than neighbouring city/cities, and this is problematic when trying to harmonize/standardize provincial standards, let alone in the same centre. That, and add a lot of folk for where the planning has barely changed in 20 years, makes it quite hard to try and advance current standards.

(A)PBI off trial? Rare as hen’s teeth. 5 fr whole breast instead. I just groan at that
hint of nodal disease? RNI for everyone
Boost plans with 50% through huge swath of breast…
RNI plans off of old field based landmarks (think MA20) and POP for each and every axilla…

I think a lot of the nuance that would go into patient centred decision making is lost with such an approach, and so have taken the role of being now more of a stick in the mud for arguing for improved decision making & standards, esp when it comes to planning

My comment on conventional fractionation though is more so for reconstructed chestwall/breasts. Not uncommon to see immediate recon and so the defacto here is still 50 Gy, even with the recent RTOG trial. We moved from 50.4 to 50 Gy when RT CHARM started accruing and will take forever for that to report. 16 fr for each RNI plan otherwise

Rant over. Not egregious but I think there is so much room to do a lot better, but such is life

The ASTRO PBI guidelines from Nov last year were quite good and compelling imho

 

[taserlaser]

The ASTRO PBI guidelines from Nov last year were quite good and compelling imho

Don’t have to convince me haha. It’s convincing everyone else that 5 fractions isn’t the same as 5 fractions -_-

 

[elementaryschooleconomics]

Conventional fractionation for breast is so illegal. The mounties will hunt you down, lock you in an igloo, and feed you to the beavers.

Seriously though. I work in a large centre with almost a dozen breast ROs, who happen to harbour different views /interpret the evidence differently than neighbouring city/cities, and this is problematic when trying to harmonize/standardize provincial standards, let alone in the same centre. That, and add a lot of folk for where the planning has barely changed in 20 years, makes it quite hard to try and advance current standards.

(A)PBI off trial? Rare as hen’s teeth. 5 fr whole breast instead. I just groan at that
hint of nodal disease? RNI for everyone
Boost plans with 50% through huge swath of breast…
RNI plans off of old field based landmarks (think MA20) and POP for each and every axilla…

I think a lot of the nuance that would go into patient centred decision making is lost with such an approach, and so have taken the role of being now more of a stick in the mud for arguing for improved decision making & standards, esp when it comes to planning

My comment on conventional fractionation though is more so for reconstructed chestwall/breasts. Not uncommon to see immediate recon and so the defacto here is still 50 Gy, even with the recent RTOG trial. We moved from 50.4 to 50 Gy when RT CHARM started accruing and will take forever for that to report. 16 fr for each RNI plan otherwise

Rant over. Not egregious but I think there is so much room to do a lot better, but such is life

Ahhhh OK this makes a lot of sense.

I personally still do conventional for chest wall as well, though I have still protected my streak of "never conventional for whole breast" since leaving residency. How many more years can I continue my streak? Who knows!

I deeply believe in being a vanilla flavored, boring, by-the-book RadOnc. There's a few reasons I practice this way (none are taught in residency of course), but "chest wall conventional" illustrates one of my big ones:

Here in America, people love to sue doctors. Just love it.

I believe that I can reduce my risk of losing any potential lawsuit if I always stick to the most commonly used treatments as much as possible.

Do I think it's absolutely and totally fine to hypofrac chest walls based on available data?

You bet.

Is it common in America?

Nope nope nope.

Ergo, if a chest wall patient decides to sue me, my defense is (theoretically) stronger in appearance to a layperson because I was using a well-established, common regimen.

Could this all be imaginary nonsense I've invented in my mind to make myself feel better?

Of course!

 

[taserlaser]

That is one nice thing about practicing in Canada. Our legal representation is top notch, and it is very hard to successfully sue a Canadian physician. The CMPA does tend to take a scorched earth approach

 

[grenz]

Ahhhh OK this makes a lot of sense.

I personally still do conventional for chest wall as well, though I have still protected my streak of "never conventional for whole breast" since leaving residency. How many more years can I continue my streak? Who knows!

I deeply believe in being a vanilla flavored, boring, by-the-book RadOnc. There's a few reasons I practice this way (none are taught in residency of course), but "chest wall conventional" illustrates one of my big ones:

Here in America, people love to sue doctors. Just love it.

I believe that I can reduce my risk of losing any potential lawsuit if I always stick to the most commonly used treatments as much as possible.

Do you do FLAME style microboosts? I feel similarly to you, so I’ve been doing very modest mb to the GTV (like 0.2Gy/fx more than the prostate). I’m not sure that FLAME as done in the trial is standard enough that the plaintiff couldn’t find a credible expert witness.