What is your Boomer/Mendoza Line?

[Palex80]

The bolded is something I’ve seen with new grads and it’s downright frightening. Probably a program-dependent issue, but maybe just a reflection of the decreased competitiveness and poor quality of trainees coming out.

And may I add the fact that the young generation is used to look everything up, they do not need to acquire knowledge, they rely on their smartphones.
It's what happens when you rely on youtube videos for literally everything.

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[xrt123]

I looked at the Head and Neck oropharyngeal outcomes via our cancer registry between the older and newer generation at 3 year survival and LRC. This is where I think contouring would make the biggest difference. Guess what...No difference. Therefore I have no line anymore.

But have fun talking to your online group to get your echo chamber needs fulfilled so you can sleep better knowing that you are superior to the person next to you!

 

[Palex80]

I looked at the Head and Neck oropharyngeal outcomes via our cancer registry between the older and newer generation at 3 year survival and LRC. This is where I think contouring would make the biggest difference. Guess what...No difference. Therefore I have no line anymore.

Odd. One would have expected that stage migration (PET-CT) alone would have enhanced your results.

 

[theradiator]

Odd. One would have expected that stage migration (PET-CT) alone would have enhanced your results.

Probably small sample size

 

[elementaryschooleconomics]

The bolded is something I’ve seen with new grads and it’s downright frightening. Probably a program-dependent issue, but maybe just a reflection of the decreased competitiveness and poor quality of trainees coming out.

I've seen variations of this behavior and, while it might be related to the "quality" of new grads, I think the root cause again stems from the older faculty/leadership.

Compared to my Internal Medicine intern year, I felt a distinct lack of "ownership" of patients with my residency program. It obviously wasn't 100% uniform, but there was an eagerness to punt wider patient care responsibilities to other services, mostly to maximize academic time for research and other pursuits that the institution incentivized.

If deferring to MedOnc (or Surgery) is the behavior that's modeled, of course new grads are going to follow suit when they get out into practice. The entire landscape of healthcare has changed rapidly over the last 20 years, and "systems" are the norm. So you start slapping on various academic titles and affiliations on folks, well, kids are going to continue to recognize a hierarchy and act accordingly.

I suspect widespread formation of bigger and bigger systems, with hierarchical titles given to people and positions which never had them before, is going to cause some interesting behavior across medicine, not just RadOnc.

 

[xrt123]

Odd. One would have expected that stage migration (PET-CT) alone would have enhanced your results.

70 patients over the same period of time and i looked at p16 status since it was in registry. Basically had to do a QA project and this seemed to fit the bill. This was done over a 5 year period. I was not comparing older partners to me from different eras but for all patients 2016-2021. Although maybe I am a boomer and don't realize it and I am just comparing Boomers to Boomers. That seems themost likley answer

 

[TheWallnerus]

I looked at the Head and Neck oropharyngeal outcomes via our cancer registry between the older and newer generation at 3 year survival and LRC. This is where I think contouring would make the biggest difference. Guess what...No difference. Therefore I have no line anymore.

But have fun talking to your online group to get your echo chamber needs fulfilled so you can sleep better knowing that you are superior to the person next to you!

Odd. One would have expected that stage migration (PET-CT) alone would have enhanced your results.

I could've told you "bad" versus "good" contouring doesn't make a lot of difference... even in head & neck. This was like plenary paper #002 at ASTRO 2008:

Purpose/Objective(s)​

Variability in interobserver target volume delineation has raised concern over potential marginal misses in head and neck IMRT. It has been assumed that areas not designated as PTV may not receive tumoricidal doses. We investigated the dosimetric impact of inter-observer contouring variation by examining the dose to tissue outside of the PTV.

Materials/Methods​

Plans from 10 sequential patients with locally advanced head and neck carcinoma (6 oropharynx, 4 larynx/hypopharynx) treated with definitive IMRT were evaluated. In accordance with current RTOG protocols, a high risk PTV70 (including all GTVs + 1 cm margin) received 70 Gy in 35 fractions, while elective regions in a low risk PTV received 56 Gy. To determine the dose to tissue outside of the PTV70, we performed 0.5 cm and 1 cm expansions of the PTV70 followed by subtractions of the original PTV70 to generate axial 0.5 cm and 1 cm “rings of tissue” concentric around the PTV70. Regions not at risk of harboring microscopic tumor (air cavities and the center of bone that did not abut GTV) were excluded from the tissue rings. DVHs were created for these rims, which were felt to be a surrogate for the tissue volume that is subject to reasonable interobserver variability.

Results​

For the 0.5 cm rim of tissue surrounding the PTV70, the median dose to 95% of the volume (D95) was 61 Gy (range 50-60Gy), while the median D50 was 68.3 Gy (range 67-70 Gy). For the 1 cm rim surrounding the PTV70 the median D95 and D50 were 54.7 Gy (50-60 Gy), and 68.3 Gy (67-70 Gy) respectively.

Conclusions​

While head and neck tumor GTV delineation is subject to significant interobserver variability in the axial dimension, there is still substantial dose to areas outside the PTV in the axial plane with IMRT planning such that an increase in marginal miss seems unlikely when transitioning from conventional to IMRT based planning. This agrees with published reports citing a predominance of central failures. IMRT establishes steep dose gradients near critical structures, but at the expense of dose “bulging out” into the remaining tissue. In contrast, with conventional fields, tissue 1 cm anterior or posterior to the PTV can receive less than 30% of the prescription dose and may actually present a greater potential for a marginal miss.

 

[communitydoc13]

I could've told you "bad" versus "good" contouring doesn't make a lot of difference

Yeah, like we've discussed before, good vs bad doctoring doesn't make the type of difference that you are going to pick up on a 100 patient series or using typical statistical tools.

It may be a couple patients a year in terms of big outcomes (like death, high grade toxicity).

The difference between a good and bad doc is certainly clinically significant but almost always statistically insignificant.

 

[Lamount]

Yeah, like we've discussed before, good vs bad doctoring doesn't make the type of difference that you are going to pick up on a 100 patient series or using typical statistical tools.

It may be a couple patients a year in terms of big outcomes (like death, high grade toxicity).

The difference between a good and bad doc is certainly clinically significant but almost always statistically insignificant.

Also hard to test some of the most important questions of acumen...

i.e. knowing which treatment approach is best in which circumstance

 

[TheWallnerus]

Yeah, like we've discussed before, good vs bad doctoring doesn't make the type of difference that you are going to pick up on a 100 patient series or using typical statistical tools.

Agree

My problem with boomer contours is often 1) they just look sh**ty or 2) they show the boomer doesn’t know anatomy

One messes with my OCD and the other is just sad

But the patients will do fine either way

 

[metallica81788]

Agree

My problem with boomer contours is often 1) they just look sh**ty or 2) they show the boomer doesn’t know anatomy

One messes with my OCD and the other is just sad

But the patients will do fine either way

Don't want to miss the target, right!?!?

 

[evilbooyaa]

I looked at the Head and Neck oropharyngeal outcomes via our cancer registry between the older and newer generation at 3 year survival and LRC. This is where I think contouring would make the biggest difference. Guess what...No difference. Therefore I have no line anymore.

But have fun talking to your online group to get your echo chamber needs fulfilled so you can sleep better knowing that you are superior to the person next to you!

The issue with (SOME) boomers is not that they have more LC (usually) - their issue is that the volumes and expansions are so big (draw it like the 3D days) that I would imagine their toxicity profiles are worse than those who treat in a more contemporary fashion.

There are a few rad oncs that are just catastrophically bad, but those are going to be considered outliers and unlikely to be the case in any academic institution. Not that that same proportion of doesn't exist, just that the residents 'protect the patient' against the boomer who doesn't know contouring.

 

[RadRadRad]

Didn’t mdacc throw their young attendings under the bus a few years ago and publish a paper about a high percentage of head and neck patients being recontoured after chart rounds presentation

 

[sirspamalot]

Anyone who does not comply will be isolated and destroyed. And that, kids, is why you stay solo.

 

[xrt123]

Didn’t mdacc throw their young attendings under the bus a few years ago and publish a paper about a high percentage of head and neck patients being recontoured after chart rounds presentation

You mean administrative physicians published a paper about how important administrative meetings (basically chart rounds) are? Im not surprised but something tells me this may have had some slight bias to it.

 

[RadOncDoc21]

You mean administrative physicians published a paper about how important administrative meetings (basically chart rounds) are? Im not surprised but something tells me this may have had some slight bias to it.

Very subjective. Been to multiple chart rounds in my career and the best ones are the ones where we know it’s just for rubber stamping. Anybody can be nit-picky but chart rounds should really be to catch significant major issues not a pissing contest.

 

[sirspamalot]

not a pissing contest

Well then, there goes 85% of the fun of radiation oncology in academic centers.