Thoughts from a PGY-5

[scarbrtj]

this is the biggest crock of BS.

There is over-fractionation. And it is clearly done for money or RVUs or 'appearing to look busy' depending on what scope of practice you are in. It is certainly not for the patient's sake when you do 20 fractions for a bone met. So stop the blathering.

The blathering is that the "20 fractions for a bone met" is somehow common. It's not. Probably less than 1% of any bone mets patients get even more than 15 fractions. Well maybe it's not blathering by you; instead lathering the mysterious, evil, unscrupulous, blatant multi-fractionators.

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[xrthopeful]

The blathering is that the "20 fractions for a bone met" is somehow common. It's not; probably less than 1% of any bone mets patients get even more than 15 fractions. Well maybe it's not blathering by you; instead lathering the mysterious, evil, unscrupulous, blatant multi-fractionators.

The point was that people over fractionated for money so it should not be surprising that they will also work for evicore for money. It’s a small percentage of people either way, but it happens.

 

[RickyScott]

The point was that people over fractionated for money so it should not be surprising that they will also work for evicore for money. It’s a small percentage of people either way, but it happens.

Why is evicore the bad guy? That kind of oversight/utilization review is invited/ invetable/obligatory when centers negotiate absurd radiation reimbursements by virtue of their name or geographic monopoly.

Somehow evicore is the “bad guy,”not the university employing the doc during the day and charging absurd rates?

if your negotiated rates are so high, you can “charge imrt rates for protons” and still break even/turn a profit, certainly insurances will get players like evicore involved and moral fault lies with the university not evicore.

and no, I don’t work for evicore/do insurance reviews

 

[scarbrtj]

The point was that people over fractionated for money so it should not be surprising that they will also work for evicore for money. It’s a small percentage of people either way, but it happens.

Maybe I'm just 100% dense this AM but WHO ARE THESE PEOPLE OVER-FRACTIONATING FOR MONEY. First, the insurance companies won't allow it. And second, evidently CMS thinks we all are over-fractionating and their answer to that is potentially the APM. And people working for Evicore aren't unscrupulous or doing it "for the money" unlike the still-hidden Masked Multifractionating (68-Hyperfractionating?) Villains. You generally have to give Evicore 40 hrs/week now and the salary is about 250K. So people working for Evicore are doing it "for the money" like the guy at McDonald's drive-in window is working there "for the money."

 

[RickyScott]

Maybe I'm just 100% dense this AM but WHO ARE THESE PEOPLE OVER-FRACTIONATING FOR MONEY. First, the insurance companies won't allow it. And second, evidently CMS thinks we all are over-fractionating and their answer to that is potentially the APM. And people working for Evicore aren't unscrupulous or doing it "for the money" unlike the still-hidden Masked Multifractionating (68-Hyperfractionating?) Villains. You generally have to give Evicore 40 hrs/week now and the salary is about 250K. So people working for Evicore are doing it "for the money" like the guy at McDonald's drive-in window is working there "for the money."

If there is an overfractionation bubble- and cms believes there is- what does that mean for the job market when it is popped by the APM or evicore like expansion. If you believe there is a lot of overfrationation supporting radoncs out there, you should be very concerned for job market when it dissapears?

 

[scarbrtj]

And lastly if there is an overfractionation bubble- and cms believes there is- what does that mean for the job market when it is popped by the APM? If you think there is a lot of overfrationation supporting radoncs out there, you should be very concerned for job market when it dissapears?

This.
This is the bubble.
And the stage is "profit-taking."
(And it is not coming from over-fractionation.)

 

[deleted1002574]

In our neck of the woods, the RTTs rotate around the hospitals and clinics, as do the dosimetrist and physics

They say that at a few of the practices, no patient gets below 2 Gy fractions unless sbrt or SRS. No conventional patient gets less than 2 Gy. Just think about that.

This.
This is the bubble.
And the stage is "profit-taking."
(And it is not coming from over-fractionation.)

 

[RickyScott]

In our neck of the woods, the RTTs rotate around the hospitals and clinics, as do the dosimetrist and physics

They say that at a few of the practices, no patient gets below 2 Gy fractions unless sbrt or SRS. No conventional patient gets less than 2 Gy. Just think about that.

i assume you meant "above." I am sure those guys are going to be looking to hire more docs as soon as APM/ expanded utilization review forces a hypofractionated model!

 

[deleted1002574]

i assume you meant "above." I am sure those guys are going to be looking to hire more docs as soon as APM/ expanded utilization review forces a hypofractionated model.

Above !! Yes

 

[Mandelin Rain]

This.
This is the bubble.
And the stage is "profit-taking."
(And it is not coming from over-fractionation.)

All the academic types here and on twitter trying to shame practicing rad oncs should read this and be humiliated. How this isn't criminal, I have no idea.

TL;DR: There is an NCI institution out there charging CMS 400k for 28 IMRT fractions.

 

[Neuronix]

I don't understand why that study didn't have a supplement listing the prices with each institution. Should be easy enough to reproduce on here though if someone has the time.

 

[Mandelin Rain]

I don't understand why that study didn't have a supplement listing the prices with each institution. Should be easy enough to reproduce on here though if someone has the time.

Do you really not understand why the authors didn't choose to embarrass entire blood sucking, greedy "elite" institutions.

 

[Neuronix]

Do you really not understand why the authors didn't choose to embarrass entire blood sucking, greedy "elite" institutions.

Oh I understand. If I was the reviewer for that article I would have insisted though

SDN is made for this sort of thing. I just don't have the time to do it right now.

 

[RickyScott]

I don't understand why that study didn't have a supplement listing the prices with each institution. Should be easy enough to reproduce on here though if someone has the time.

Chargemaster prices are not whats charged and can be an order of magnitude off from negotiated prices, which are hidden by NDAs. Next year, Trump administration mandated actual negotiated rates be made public, but hospitals are going to fight this in court. Have been told anecdotally that can easily vary by factor of 5 between large NCI center and community radonc.

We really need to reassess Choose Wisely:

 

[scarbrtj]

In our neck of the woods, the RTTs rotate around the hospitals and clinics, as do the dosimetrist and physics

They say that at a few of the practices, no patient gets below 2 Gy fractions unless sbrt or SRS. No conventional patient gets less than 2 Gy. Just think about that.

All the academic types here and on twitter trying to shame practicing rad oncs should read this and be humiliated. How this isn't criminal, I have no idea.

TL;DR: There is an NCI institution our there charging CMS 400k for 28 IMRT fractions.

The "bubble" I refer to is the popularity of rad onc/the number of rad onc attendings/PP rad oncs/rad onc residents. (It was the "attending explosion" that foreran the resident explosion.) I somewhat leave price and cost out of it because I have made the arguments that the total cost of radiation oncology to society has been steady to decreasing the last ~5 years at least. So it's stuff like the massive attempt at profit-taking ("There is an NCI institution out there charging CMS 400k for 28 IMRT fractions" e.g.) that is keeping the whole ship afloat as best I can tell.* Because you need numerical outliers like that to keep the bubble from a-bursting. Not some guy doing ~15 fractions for bone mets vs 1-5 fx's--because in reality the price differentials there aren't that huge (certainly not 15x more expensive to do 15 fx's instead of 1) to account for the "evil trinity" of decreased CA incidence/decreased fractionation/decreased utilization.

* I made the rather startling discovery yesterday that the number of prostate cancer pts in America has fallen from ~240,000/yr in 2015 to ~165,000 today... a 32% decrease. And the number is falling. How is rad onc not getting totally financially destroyed by that? How can we keep adding attendings and residents? The answer: it's charge-upping, in the extreme, but of course only in the academic quarters. We can not "do that trick" in PP.

 

[scarbrtj]

Chargemaster prices are not whats charged and can be an order of magnitude off from negotiated prices, which are hidden by NDAs. Next year, Trump administration mandated actual negotiated rates be made public, but hospitals are going to fight this in court. Have been told anecdotally that can easily vary by factor of 5 between large NCI center and community radonc.

We really need to reassess Choose Wisely:

The Choosing Wisely is a farce, clearly. Exhibit one: that article.

 

[deleted1002574]

The "bubble" I refer to is the popularity of rad onc/the number of rad onc attendings/PP rad oncs/rad onc residents. (It was the "attending explosion" that foreran the resident explosion.) I somewhat leave price and cost out of it because I have made the arguments that the total cost of radiation oncology to society has been steady to decreasing the last ~5 years at least. So it's stuff like the massive attempt at profit-taking ("There is an NCI institution out there charging CMS 400k for 28 IMRT fractions" e.g.) that is keeping the whole ship afloat as best I can tell.* Because you need numerical outliers like that to keep the bubble from a-bursting. Not some guy doing ~15 fractions for bone mets vs 1-5 fx's--because in reality the price differentials there aren't that huge (certainly not 15x more expensive to do 15 fx's instead of 1) to account for the "evil trinity" of decreased CA incidence/decreased fractionation/decreased utilization.

* I made the rather startling discovery yesterday that the number of prostate cancer pts in America has fallen from ~240,000/yr in 2015 to ~165,000 today... a 32% decrease. And the number is falling. How is rad onc not getting totally financially destroyed by that? How can we keep adding attendings and residents? The answer: it's charge-upping, in the extreme, but of course only in the academic quarters. We can not "do that trick" in PP.

We can walk and chew gum at the same time

There ARE many people doing 15-20 fx for bone met large cities with well trained recent grads (not dinosaur docs), they just don't answer that way on a survey.

And, the academic centers/PPS-exempt places charge too much, AND sometimes have increased fractions.

These are two separate issues, IMO.

 

[deleted18755]

We can walk and chew gum at the same time

There ARE many people doing 15-20 fx for bone met large cities with well trained recent grads (not dinosaur docs), they just don't answer that way on a survey.

And, the academic centers/PPS-exempt places charge too much, AND sometimes have increased fractions.

These are two separate issues, IMO.

I'm honestly curious: aside from breast or prostate, how do they get away with 15-20 fractions for bone mets or any other routine of too many fractions?

How does it pass through insurance authorization (or is it all medicare patients or something?) Even if that were the case, wouldn't they have to do something crazy like go out of their way to appropriately hypofractionate privately insurance patients but administer more fractions to Medicare patients?

Wouldn't referring physicians quickly realize something was up if every time they refer to radiation oncologist x the patient gets more fractions then radiation oncologist y?

I'm honestly curious.

 

[RickyScott]

We can walk and chew gum at the same time

There ARE many people doing 15-20 fx for bone met large cities with well trained recent grads (not dinosaur docs), they just don't answer that way on a survey.

And, the academic centers/PPS-exempt places charge too much, AND sometimes have increased fractions.

These are two separate issues, IMO.

you are right, but the prices are a much bigger problem in health care than utilization. fraction shaming is a distraction for the hidden fleecing of the system by large monopolistic centers that are also expanding residencies and spreading financial toxicity among their patients.

not specific to radonc, but in general, we dont overutilize as much as overcharge., "The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations "

Health Care Spending in the United States and Other High-Income Countries

This Special Communication analyzes data primarily from 2013-2016 to compare potential drivers of health care spending in the United States with those of 10 other high-income countries.

jamanetwork.com

I'm honestly curious: aside from breast or prostate, how do they get away with 15-20 fractions for bone mets or any other routine of too many fractions?

How does it pass through insurance authorization (or is it all medicare patients or something?) Even if that were the case, wouldn't they have to do something crazy like go out of their way to appropriately hypofractionate privately insurance patients but administer more fractions to Medicare patients?

Wouldn't referring physicians quickly realize something was up if every time they refer to radiation oncologist x the patient gets more fractions then radiation oncologist y?

I'm honestly curious.

as you can see with omnipresent utilization review- it may be a limited issue and confined to straight cms/medicare cases. And, If it is a big issue, it will have a big impact on the job market when it is corrected. that being said, in any definitive case, I have never had someone from evicore tell me i cant use standard fract.

 

[deleted1002574]

No question. 100% agree with price issues.

But just like murder is a bigger problem than broken windows, maybe you start with the broken windows?
Everything ties in together, and I think idea of saying "well this is so much worse than that, so let's ignore that" is probably not optimal approach

 

[Mandelin Rain]

But just like murder is a bigger problem than broken windows, maybe you start with the broken windows?

I'd probably start with the "murder problem" in this scenario.

 

[RickyScott]

The "bubble" I refer to is the popularity of rad onc/the number of rad onc attendings/PP rad oncs/rad onc residents. (It was the "attending explosion" that foreran the resident explosion.)

so true

 

[deleted956486]

I'd probably start with the "murder problem" in this scenario.

Every so often, I literally lol. This was one time.

 

[20181121]

We should be in equilibrium which by definition would be replacing rad oncs lost per year (retirement... death... new jobs outside rad onc) with new rad oncs. And that would be ~125/year.

That number does not strike me as totally unreasonable. Does it not support some of my points in my original post, that medical students who are worried about the future can target the top X programs that add up to 125 slots (and X can be modified based on how pessimistic or optimistic a given individual is)?

Since the number of new rad onc patients/year is essentially not growing, this would be reasonable. (And keep in mind, wild as it sounds, the number of new pts/rad onc is not just not growing... it's declining.

I'd point out that you are citing one view of the future, and there are others that take the opposite view and predict an increase in American cancer incidence over time (e.g., to name just one, the World Health Organization - Cancer tomorrow - you can drill down by country, etc.).

 

[Mandelin Rain]

That number does not strike me as totally unreasonable. Does it not support some of my points in my original post, that medical students who are worried about the future can target the top X programs that add up to 125 slots (and X can be modified based on how pessimistic or optimistic a given individual is)?


I'd point out that you are citing one view of the future, and there are others that take the opposite view and predict an increase in American cancer incidence over time (e.g., to name just one, the World Health Organization - Cancer tomorrow - you can drill down by country, etc.).

"The key assumptions are that national rates, as estimated in 2018, do not change in the prediction period 2020–2040 and that the national population projections are correct for these years."

One could argue that cancer rates have already changed since 2018. Additionally, competing causes of death are on rise: vis a vis decline in life expectancy despite all time record decline in cancer death rates.

 

[scarbrtj]

I'd point out that you are citing one view of the future, and there are others that take the opposite view and predict an increase in American cancer incidence over time (e.g., to name just one, the World Health Organization - Cancer tomorrow - you can drill down by country, etc.).

Using their numbers, they're projecting ~2 million out of ~330 million U.S. population in 2018 and ~3 million out of ~380 million in 2040 incidence(s) of cancer. That'll be about a 1% rise in incidence per year. Will that buck last 20 years' trend?

Regardless, best/most optimistic guess is that cancer incidence will rise ~1% per year (in the U.S.). When I started med school, I thought the U.S. would need half as many physicians if smoking were banned. We're in the ongoing process of that "ban" now. About 5y ago prostate cancer was nearly the most common cancer at ~250,000 cases a year. That number is on target for about ~150K/year now. And we overdiagnose cancers in general (I know the idea of "harmless cancer," especially in axillary lymph nodes in breast cancer cases e.g., is anathema to some rad oncs, but the harmless cancer paradigm has way more intellectual validity than the soi-disant oligometastatic paradigm. Inconvenient truth.). Lung cancer getting less and less common. Cervical cancer getting darn rare.

But anyway, if we keep increasing residency class sizes ~5%/year, and the cancer incidence somehow "figures out" to grow ~1% per year, and rad onc utilization stays stable at ~30% (which would buck a declining trend), in ~20 years in 2040 there will be about 1 million rad onc new patients per year for about ~12,000 radiation oncologists. Right at 83 new patients, or less, per year per rad onc (down from ~100-110 now). So even factoring in Cancer Tomorrow's "optimism," (woe betide us if instead of "flipping" to +~1% a year it continues at <0%/year) it well agrees within the bounds of my projections. My view of the future (re: declining new pts/rad onc) is theirs, too.*

* Here's where things potentially get weird. The projections, depending on numbers chosen, show <1 new pt/year per rad onc in 20y, too. In a way, this mathematically predicts the end of radiation oncology. Sometimes mathematical predictions presage things that no one thinks are possible.

 

[Mandelin Rain]

(I know the idea of "harmless cancer," especially in axillary lymph nodes in breast cancer cases e.g., is anathema to some rad oncs, but the harmless cancer paradigm has way more intellectual validity than the soi-disant oligometastatic paradigm. Inconvenient truth.).

You couldn't help yourself

 

[Pointless]

Using their numbers, they're projecting ~2 million out of ~330 million U.S. population in 2018 and ~3 million out of ~380 million in 2040 incidence(s) of cancer. That'll be about a 1% rise in incidence per year. Will that buck last 20 years' trend?

Regardless, best/most optimistic guess is that cancer incidence will rise ~1% per year (in the U.S.). When I started med school, I thought the U.S. would need half as many physicians if smoking were banned. We're in the ongoing process of that "ban" now. About 5y ago prostate cancer was nearly the most common cancer at ~250,000 cases a year. That number is on target for about ~150K/year now. And we overdiagnose cancers in general (I know the idea of "harmless cancer," especially in axillary lymph nodes in breast cancer cases e.g., is anathema to some rad oncs, but the harmless cancer paradigm has way more intellectual validity than the soi-disant oligometastatic paradigm. Inconvenient truth.). Lung cancer getting less and less common. Cervical cancer getting darn rare.

But anyway, if we keep increasing residency class sizes ~5%/year, and the cancer incidence somehow "figures out" to grow ~1% per year, and rad onc utilization stays stable at ~30% (which would buck a declining trend), in ~20 years in 2040 there will be about 1 million rad onc new patients per year for about ~12,000 radiation oncologists. Right at 83 new patients, or less, per year per rad onc (down from ~100-110 now). So even factoring in Cancer Tomorrow's "optimism," (woe betide us if instead of "flipping" to +~1% a year it continues at <0%/year) it well agrees within the bounds of my projections. My view of the future (re: declining new pts/rad onc) is theirs, too.*

* Here's where things potentially get weird. The projections, depending on numbers chosen, show <1 new pt/year per rad onc in 20y, too. In a way, this mathematically predicts the end of radiation oncology. Sometimes mathematical predictions presage things that no one thinks are possible.

How many patients can you see on an average consult day? I don't mean the colloquial you, but literally you... it seems that your consultations would be very long affairs

 

[deleted1002574]

Oh man imagine the low-intermediate prostate patient, about 70, in good but not great health... could take 4 hours and maybe even come back after lunch (probably fried chicken and some killer Mac and cheese based on the location) for further discussion.

 

[20181121]

Reading others' points of view, I am wondering if we are observing different things firsthand - and I am wondering what the reasons for those things might be.

If I am interpreting people's posts correctly, you have been seeing a decline in heme (e.g., multiple myeloma), prostate, and lung patients on treatment in a given week. I have observed multiple academic centers - the main center and their satellites - seeing an increase in the number of these patients on treatment, to the extent that they are treating over long hours or that they simply do not have the capacity. Demand for things like prostate brachytherapy, lung/spine/prostate SBRT, consolidative and palliative treatment for, hematologic cancers, and others, are anecdotally increasing at my and other centers.

Do you think this reflects a shift toward treatment at academic centers and their satellites, or the possibility that emerging treatments that shift patients away from surgery - or patients who previously would not have been treated with radiation - toward radiation, has not yet fully disseminated away from a few academic centers? I take the latter view and think that non-academic practices are likely to see a net increase in patients on treatment over the coming years, but only time will tell if I end up being right or wrong.

 

[deleted947887]

Do you think this reflects a shift toward treatment at academic centers and their satellites, or the possibility that emerging treatments that shift patients away from surgery - or patients who previously would not have been treated with radiation - toward radiation, has not yet fully disseminated away from a few academic centers? I take the latter view and think that non-academic practices are likely to see a net increase in patients on treatment over the coming years, but only time will tell if I end up being right or wrong.

LOL. Gotta give you credit for trying...

 

[scarbrtj]

Reading others' points of view, I am wondering if we are observing different things firsthand - and I am wondering what the reasons for those things might be.

Youthful enthusiasm. Hoping for the best. (And nothing wrong with that.) Thinking that a single room is the extent of the universe

If I am interpreting people's posts correctly, you have been seeing a decline in heme (e.g., multiple myeloma), prostate, and lung patients on treatment in a given week. I have observed multiple academic centers - the main center and their satellites - seeing an increase in the number of these patients on treatment, to the extent that they are treating over long hours or that they simply do not have the capacity. Demand for things like prostate brachytherapy(????), lung/spine/prostate SBRT, consolidative and palliative treatment for, hematologic cancers, and others, are anecdotally increasing at my and other centers.

There has been a shift of rad onc care from outside academics into academics. Even if this is a possible explanation, it (the shift) can't last forever. And either your observations are correct re: increasing demand, and the literature ("Brachytherapy: Halting the Spiral of Decline", shortage expected etc.) and all the epidemiologic data is wrong... or your observations are not a true picture of what's actually occurring at least not at a true macro level. At the micro level, the ant on a picnic cloth thinks the whole world is made of food.

Do you think this reflects a shift toward treatment at academic centers and their satellites, or the possibility that emerging treatments that shift patients away from surgery - or patients who previously would not have been treated with radiation - toward radiation, has not yet fully disseminated away from a few academic centers?

At MGH, a large academic center obviously, they saw ~1100 patients in a pulmonary nodule screening clinic from 2012 to 2019. Of these 1100 patients, about 350 eventually got any intervention. About 250 got a surgery, and only 50 got (mostly SBRT, mostly without biopsy) radiation. So even at this center, where SBRT has its *best* and *most likely* chance of being utilized for mostly Stage I patients... surgery is used ~5 times more commonly than radiation! (Some smart CT surgeons really hate on the SBRT.) Know how many cardiothoracic surgeons there are? About ~3500-4000. And we've got ~5000+ rad oncs... who are doing about ~1/5 the sole-curative-modality work of the CT surgeons. Well. Anyway, I think there are anecdotes/hopes/feelings/thoughts/prayers. And then there's data.

 

[deleted18755]

Oh man imagine the low-intermediate prostate patient, about 70, in good but not great health... could take 4 hours and maybe even come back after lunch (probably fried chicken and some killer Mac and cheese based on the location) for further discussion.

Not gonna lie man, I’ve literally taken "lunch breaks" a few times in the middle of a consult before (almost literally as you describe above).

One of the most striking things I realized after leaving residency at a busy academic center is while working at a small practice there can be tremendous variability: if you're the only guy and center around you basically have no upper limit so when things get busy it can get really busy (10-12+ consults in a week with 35+ patients under treatment), but alternatively sometimes things can get ridiculously, mind-numbingly boring (literally zero consults and 3-5 patients under treatment) but you (at least had to) still sit there babysitting the office and LINAC (without even a fast internet connection!)

I can see spending hours with a patient who likes to talk who has a common interest during deer hunting or college football season and is undecided about how to proceed with his low-intermediate risk prostate cancer in the setting of "good but not great health for a 70 year old," especially when he starts talking about his friends cousin who had "prostrate" cancer in the 1970's and this and that while I'm sitting there with literally nothing else to do but confined to the walls of the office anyway!

Face to face consult is one thing, but I'm also curious as to what types of written material our friend scar provides during and after consults, especially to patients like the one above!

PS: I forgot what this thread is actually about...

 

[scarbrtj]

Not gonna lie man, I’ve literally taken "lunch breaks" a few times in the middle of a consult before (almost literally as you describe above).

One of the most striking things I realized after leaving residency at a busy academic center is while working at a small practice there can be tremendous variability: if you're the only guy and center around you basically have no upper limit so when things get busy it can get really busy (10-12+ consults in a week with 35+ patients under treatment), but alternatively sometimes things can get ridiculously, mind-numbingly boring (literally zero consults and 3-5 patients under treatment) but you (at least had to) still sit there babysitting the office and LINAC (without even a fast internet connection!)

I can see spending hours with a patient who likes to talk who has a common interest during deer hunting or college football season and is undecided about how to proceed with his low-intermediate risk prostate cancer in the setting of "good but not great health for a 70 year old," especially when he starts talking about his friends cousin who had "prostrate" cancer in the 1970's and this and that while I'm sitting there with literally nothing else to do but confined to the walls of the office anyway!

Face to face consult is one thing, but I'm also curious as to what types of written material our friend scar provides during and after consults, especially to patients like the one above!

PS: I forgot what this thread is actually about...

Once I had a (emergency spine) consult that literally started in one year and finished a whole year later

Like Socrates suggested, I try not to provide* any written material to patients:
The same is true of written words. You’d think they were speaking as if they had some understanding, but if you question anything that has been said because you want to learn more, it continues to signify just that very same thing forever. When it has once been written down, every discourse roams about everywhere, reaching indiscriminately those with understanding no less than those who have no business with it, and it doesn’t know to whom it should speak and to whom it should not. And when it is faulted and attacked unfairly, it always needs its father’s support; alone, it can neither defend itself nor come to its own support.

*jk

 

[OTN]

Reading others' points of view, I am wondering if we are observing different things firsthand - and I am wondering what the reasons for those things might be.

If I am interpreting people's posts correctly, you have been seeing a decline in heme (e.g., multiple myeloma), prostate, and lung patients on treatment in a given week. I have observed multiple academic centers - the main center and their satellites - seeing an increase in the number of these patients on treatment, to the extent that they are treating over long hours or that they simply do not have the capacity. Demand for things like prostate brachytherapy, lung/spine/prostate SBRT, consolidative and palliative treatment for, hematologic cancers, and others, are anecdotally increasing at my and other centers.

Do you think this reflects a shift toward treatment at academic centers and their satellites, or the possibility that emerging treatments that shift patients away from surgery - or patients who previously would not have been treated with radiation - toward radiation, has not yet fully disseminated away from a few academic centers? I take the latter view and think that non-academic practices are likely to see a net increase in patients on treatment over the coming years, but only time will tell if I end up being right or wrong.

I disagree with your latter view in the strongest terms possible.

Most of us in good community practices are already doing those "emerging treatments" and have been for years. Shift towards academic centers is a result of crony capitalism (340b program, payments to hospitals inexplicably larger than to freestanding centers for the same services), shifting payments to large academic, hospital-based systems, allowing them to both buy up non hospital-based systems and spend enormous amounts of money on marketing.

 

[RickyScott]

I disagree with your latter view in the strongest terms possible.

Most of us in good community practices are already doing those "emerging treatments" and have been for years. Shift towards academic centers is a result of crony capitalism (340b program, payments to hospitals inexplicably larger than to freestanding centers for the same services), shifting payments to large academic, hospital-based systems, allowing them to both buy up non hospital-based systems and spend enormous amounts of money on marketing.

and in many cases, expand primary care base to feed the system. MDACC and MSKCC dont need that, but everyone else does including my present practice. For a specialty that attracts math-inclined, there seem to be a lot of "math truthers/deniers" out there. On youtube the other day, I was getting incessant MDACC advertisements.

 

[Mandelin Rain]

I think that resident purports to be from a "top academic center". What "top academic center" doesn't have a bunch of feeder satellites sending specialized procedures like SBRT/SRS/Brachy and diseases like hematologic malignancies to the main campus? The reason you see a lot of them is not because actual community docs aren't doing them, it's because the community docs in YOUR SYSTEM'S satellites don't do them at the behest (order) of your academic chairman.

Why? Perhaps these procedures have better outcomes in more specialized hands. Or perhaps because your NCI hospital is the one charging 400k for a course of treatment.

 

[scarbrtj]

and in many cases, expand primary care base to feed the system. MDACC and MSKCC dont need that, but everyone else does including my present practice. For a specialty that attracts math-inclined, there seem to be a lot of "math truthers/deniers" out there. On youtube the other day, I was getting incessant MDACC advertisements.

demand on the upswing, patient numbers are increasing, new oligometastatic paradigm, "we're not marginalized!" etc etc.
SDN: "I looked all that up, and it's wrong."
NOT SDN: "Well mister, that's because you looked it up in a book! Next time... try looking it up in your gut."

shifting payments to large academic, hospital-based systems, allowing them to both buy up non hospital-based systems and spend enormous amounts of money on marketing.

Yep.

 

[20181121]

Youthful enthusiasm. Hoping for the best. (And nothing wrong with that.) Thinking that a single room is the extent of the universe


There has been a shift of rad onc care from outside academics into academics. Even if this is a possible explanation, it (the shift) can't last forever. And either your observations are correct re: increasing demand, and the literature ("Brachytherapy: Halting the Spiral of Decline", shortage expected etc.) and all the epidemiologic data is wrong... or your observations are not a true picture of what's actually occurring at least not at a true macro level. At the micro level, the ant on a picnic cloth thinks the whole world is made of food.


At MGH, a large academic center obviously, they saw ~1100 patients in a pulmonary nodule screening clinic from 2012 to 2019. Of these 1100 patients, about 350 eventually got any intervention. About 250 got a surgery, and only 50 got (mostly SBRT, mostly without biopsy) radiation. So even at this center, where SBRT has its *best* and *most likely* chance of being utilized for mostly Stage I patients... surgery is used ~5 times more commonly than radiation! (Some smart CT surgeons really hate on the SBRT.) Know how many cardiothoracic surgeons there are? About ~3500-4000. And we've got ~5000+ rad oncs... who are doing about ~1/5 the sole-curative-modality work of the CT surgeons. Well. Anyway, I think there are anecdotes/hopes/feelings/thoughts/prayers. And then there's data.

When I take a close look at them, the data cited do not appear to support the arguments being made - I would encourage people to read the linked articles closely. I may be misunderstanding the point about lung SBRT, but we do 50 cases in a matter of weeks-to-months! Perhaps we have better relationships with our thoracic surgeons and pulmonologists? Yes, we are observing increasingly high demand and long wait times for brachytherapy. Keep in mind that a lot of pertinent data - e.g., up-to-date local demand - is, of course, important for local market competitiveness and not published.

 

[theradiator]

So MGH averages 8 lung SBRT per year from their lung nodule clinic and we're supposed to believe that you average >>50 lung SBRT a year in your center? I guess anything is possible.

 

[Pointless]

So MGH averages 8 lung SBRT per year from their lung nodule clinic and we're supposed to believe that you average >>50 lung SBRT a year in your center? I guess anything is possible.

8 lung SBRT per year at a large academic center seems absurdly low. 50 lung SBRT's every month or two at a small community center seems absurdly high.

Going out on a limb here... truth somewhere in the middle?

 

[RickyScott]

8 lung SBRT per year at a large academic center seems absurdly low. 50 lung SBRT's every month or two at a small community center seems absurdly high.

Going out on a limb here... truth somewhere in the middle?

That’s from lung nodule clinic. I am sure majority of cases don’t come from screening clinic. Ours don’t. I guess the notion is that a screening clinic is not going to add tons of lung sbrts.

 

[scarbrtj]

When I take a close look at them, the data cited do not appear to support the arguments being made - I would encourage people to read the linked articles closely. I may be misunderstanding the point about lung SBRT, but we do 50 cases in a matter of weeks-to-months!

8 lung SBRT per year at a large academic center seems absurdly low. 50 lung SBRT's every month or two at a small community center seems absurdly high.

Going out on a limb here... truth somewhere in the middle?

That’s from lung nodule clinic. I am sure majority of cases don’t come from screening clinic. Ours don’t. I guess the notion is that a screening clinic is not going to add tons of lung sbrts.

"The data"... Hmm.

Approximately 228K a year get diagnosed with lung CA.
Approximately 25% of those have Stage I.
And about 25%, at best, of those will get SBRT (here, here, and here... at the MGH lung nodule clinic as we all know about ~14% of those treated got SBRT).
Thus ~14,250 people a year getting SBRT for lung CA in the U.S.

Also, as all know, given the number of rad oncs in the U.S., that's about 3 patients per rad onc, per year, for lung SBRT in the U.S. If we had rad oncs who just did lung SBRT, I reckon (if those rad oncs could see 10 new lung SBRT pts/week) we would only need ~30 rad oncs for the whole U.S. to do only that work.

And, as we all know, the absolute number of lung cancer patients per year is dropping.

Let's say every CT surgeon in America threw up their hands and said "Welp, that's it, no more surgery. We prefer the SABR to our knife." That'd still be only 1 new lung SBRT patient per month for every rad onc in America.

So anyone treating a ton of lung SBRT is obviously standing near the outlet of a very flowing hose. (E.g., at Penn I have calculated they treat about 20% of all the radiation cancer patients in Pennsylvania per year.)

 

[PhotonBomb]

but everyone here does more than 3 lung SBRTs a year.

so what gives? where is the math wrong?

 

[Pointless]

but everyone here does more than 3 lung SBRTs a year.

so what gives? where is the math wrong?

No, that is obviously false because math has proven it to be so. However many SBRT cases you think you do in a year, the actual number is 3. Because math.

 

[scarbrtj]

but everyone here does more than 3 lung SBRTs a year.

so what gives? where is the math wrong?

Ya gotta remember: this is an average.

Possibilities: either the number of lung cancers are fake, number of rad oncs are fake, average lung SBRT utilization is fake, percent of Stage I is fake.

But to me, the very most likely possibility is that there are rad oncs literally doing zero.* I know of one semi-famous thoracic rad onc that is at a place where lung cancer must be exceedingly common. However, because of equipment, he is unable to do lung SBRT. Has to send all of them out, or he might be hypofrac'ing. Up the road from me there's a full boomer with a beautiful Trilogy. But he's scared to do lung SBRT (or SRS for that matter); literally doesn't mentally compute for him. So what you probably have is some profound underutilization of lung SBRT, per rad onc, in the U.S. right now. It's really the only rational explanation for any individual rad onc's high SBRT numbers. (And statistically, as weird as it sounds, I guess you could say based on the numbers >10 a year would be... 90th %ile? 95th %ile? Given the mean and SDs?) As epidemiologically mentioned though, there's a hard ceiling even for this. And as not mentioned, the conversion of many lungs from standard frac to SBRT, at Medicare rates, means less of a money bag for rad oncs as a whole (esp if you couple in rad onc growth). But very good for society cost-wise.

No, that is obviously false because math has proven it to be so. However many SBRT cases you think you do in a year, the actual number is 3. Because math.

Not just math. Case reports. Hard data.

Over a ten year period (2004-2014), out of ~150K patients from the natl cancer database, anywhere from ~1% to ~25%, over time, got SBRT. Let's say it was about 20% on average. That would be only ~30K SBRT patients over 10 years from the National Cancer Database.

That's ~3000 patients per year on average. So, again, my math might be generous, and the reality is likely... worse, or less, or whatever you wish.

 

[Pointless]

Up the road from me there's a full boomer with a beautiful Trilogy.

This is making me laugh very much. I am going to start calling people in their 60's and up "Full Boomers".

 

[scarbrtj]

This is making me laugh very much. I am going to start calling people in their 60's and up "Full Boomers".

I'm early onset boomer

 

[RadOncDoc21]

I'm early onset boomer

I can relate

 

[Palex80]

In terms of fractions, we are not doing better in parts of Europe. At all.

https://www.thegreenjournal.com/article/S0167-8140(18)31634-7/pdf

Hypo- vs Normofractionated RT in Early Breast Cancer – Patterns of Care in German speaking countries
The majority of the 180 physicians who completed the survey use the normofractionated regimen of RT as standard treatment for early breast cancer (76.6%).

At least they were honest about it. 1 out of 3 said they wouldn't hypofractionate because of decreased revenue.