What’s your least favorite shady practice?

[PhotonBomb]

The one that rubs you the wrong way when you see or hear about it being done?

I have two:

1) the people who bill SBRT courses back to back and make someone come for weeks in a row for multiple SBRT courses that should have been done at the same time.

2) the people who bill multiple sims and plans for a stage III lung chemoRT

I’ve seen this a lot in a local competitor and it makes me sick

---

Members don't see this ad.

 

[RadRadRad]

Out of curiosity, what do you do when a stage 3 lung is mid treatment and their obstructed airway opens up leading to notable changes in their intrathoracic anatomy?

didn’t rtog run a trial on weekly adaptive radiation for lung ca. Not suggesting that 6 plans is necessary but pretty common to need one replan for anatomical changes.

 

[deleted1002574]

Is this bad because of the actual clinical maneuver or because of the Extra billing? Because if it’s shady just because of the extra billing, then the billing rules are the problem...

Same with igrt. People used to say same thing about daily cone beam but now it’s basically standard of care.

 

[PhotonBomb]

Out of curiosity, what do you do when a stage 3 lung is mid treatment and their obstructed airway opens up leading to notable changes in their intrathoracic anatomy?

didn’t rtog run a trial on weekly adaptive radiation for lung ca. Not suggesting that 6 plans is necessary but pretty common to need one replan for anatomical changes.

When the anatomy changes then that’s a different story but I would not argue that’s ‘pretty common’ in lung.

I’m talking more about people who always do a stepwise 2 or 3 sim plan for lung

 

[PhotonBomb]

Is this bad because of the actual clinical maneuver or because of the Extra billing? Because if it’s shady just because of the extra billing, then the billing rules are the problem...

Same with igrt. People used to say same thing about daily cone beam but now it’s basically standard of care.

Daily imaging (even just KVs) has a point/purpose. That’s the difference

 

[RadOncDoc21]

I’ve had to Replan on many occasions due to significant changes in anatomy or if I’m trying to get my normal constraints down, equipment malfunction, etc.

 

[deleted1002574]

Daily imaging (even just KVs) has a point/purpose. That’s the difference

I get that, but honestly, just around when I started practicing daily imaging had the same purpose - and there were people in academics saying it was as you have said "shady". No kidding. Heck, look up some threads from even 5 years ago. People say all kinds of things are shady when they don't do it. I'm not saying re-plans are good or bad - I'm not a replanner, generally speaking. However, I don't fault those that say that adaptive planning has benefits. If you couldn't bill for each plan, we wouldn't call it shady. That's the point.

I don't love the APM, but an APM style of payment would mitigate some of these issues, but @scarbrtj has expounded on this much more eloquently (but with more words).

 

[PhotonBomb]

I should clarify that what I’m talking about isn’t adaptive. It’s like doing a plan to 50 then another sim plan to 70, on every single lung plan. for no reason. The poor patients just think this is how it’s supposed to go. Or one to 50, one to 60, one to 70

 

[deleted941485]

I should clarify that what I’m talking about isn’t adaptive. It’s like doing a plan to 50 then another sim plan to 70, on every single lung plan. for no reason. The poor patients just think this is how it’s supposed to go. Or one to 50, one to 60, one to 70

Is it really worth making a federal case out of? It’ll be a thing of the past ina few years anyway. So will most of those “shady practices” when they get “join” their local health system monopoly.

 

[deleted1002574]

Ugh. ThT sounds shady. Also going to 70.. some people will bite your head off for that. (Not me)

 

[RadOncDoc21]

I should clarify that what I’m talking about isn’t adaptive. It’s like doing a plan to 50 then another sim plan to 70, on every single lung plan. for no reason. The poor patients just think this is how it’s supposed to go. Or one to 50, one to 60, one to 70

Oh yea, I’ve seen this and def frown upon it. I worked with a “boomer” that did this for every disease site.

 

[ramsesthenice]

oooooooooh boy. One of the community practices in our state is an innovative leader in the field of WTF. Where to begin? How about their 50 fraction GYN cancer treatment delivered over 11 weeks? That’s right. The owner told me with a straight face it is too toxic to treat the pelvis and para aortic nodes in one plan. So they treat the pelvis in 25 fractions and then come back to start the PA nodes for another 25 fractions after a week off. What’s better than diarrhea for 3-5 weeks? Maybe diarrhea for 8-12 weeks? and what about the data supporting better outcomes if you finish in 8-9 weeks? In their “experience” a longer course just seems to work better.

They have also never met a metastasis that didn’t need radiation. Sequential courses, naturally. I swear to god they must think oligo is Spanish for less than 50.

 

[deleted1002574]

Incredible.

That PA / Pelvis thing is about the most egregious thing I've ever heard.

 

[w00tz]

41.4Gy in 23 fx for cord compression. Stopped after 2 treatments when there was an issue with insurance and sent to us.

 

[medgator]

Incredible.

That PA / Pelvis thing is about the most egregious thing I've ever heard.

I've heard of a notorious practice that BIDs most things... 1.05/day bid for many sites, ends up being 60-80 fractions for a lot of sites i would think

 

[Reaganite]

45fx prostate and 30 fx imrt breast at the local nci designated cancer center. 45 fx protons low risk prostate.

 

[Palex80]

I don't find re-siming for stage III NSCLC wrong. We do it always if it's concurrent chemo-RT.
From my personal experience: If you start RT with the first cycle of chemotherapy, you will find significant changes in the volume at week 2-3 in many cases. If you start RT with the third or fourth cycle of chemotherapy, then you will not find many changes. The same often applies to SCLC too. The earlier you start together with chemo, the more changes you are going to see, especially in patients with atelectasis.
Head and Neck is also an issue: a) weight loss can be an issue b) HPV-positive cases with bulky nodes undergoing concurrent chemo-RT may also show tremendous remission within 1-2 weeks into treatment.

Other than that, you can easily charge a lot more for early glottic cancer. Although many of us do not see alot of these patients, you can treat them with either hypofractionated RT with less than 30 fractions or with hyperfractionation bid with more than 60 fractions in total. And yes, the crazy thing is that you have the literature to back this up, especially in larger T1s or T2 tumors.

Another classic example of "overtreatment" is the "early" T3 rectal cancer in the mid-third of the rectum (with a widely clear CRM) getting 45/1.8 with capecitabine instead of 5 x 5 Gy (or simply nothing).

 

[PhotonBomb]

Is it really worth making a federal case out of? It’ll be a thing of the past ina few years anyway. So will most of those “shady practices” when they get “join” their local health system monopoly.

This isn’t a ‘federal case’

Also - the argument that the system will change soon so we should be unscrupulous and anti-patient centric while we can is........yeah.

 

[FrostyHammer]

I heard from a friend that his semi academic institution has a lung rad onc who treated central SBRT lung to 40 Gy in 5 fractions

 

[PhotonBomb]

I heard from a friend that his semi academic institution has a lung rad onc who treated central SBRT lung to 40 Gy in 5 fractions

Well that’s someone who is ‘conservative’ or if you want to be pejorative about it, chicken. But not really shady I wouldn’t say.

 

[medgator]

45fx prostate and 30 fx imrt breast at the local nci designated cancer center. 45 fx protons low risk prostate.

Double whammy of pps exempt pricing also.

 

[Palex80]

I heard from a friend that his semi academic institution has a lung rad onc who treated central SBRT lung to 40 Gy in 5 fractions

We treat the same way. 5 x 8 Gy at 60% isodose. What would you advocate for in central tumors?

 

[FrostyHammer]

We treat the same way. 5 x 8 Gy at 60% isodose. What would you advocate for in central tumors?

My post above referred to a high IDL. And doing it over a decade after the Onishi study

 

[Mandelin Rain]

One bad outcome can change your practice. With central SBRT, bad outcomes are REALLY bad.

 

[medgator]

We treat the same way. 5 x 8 Gy at 60% isodose. What would you advocate for in central tumors?

70/17 for ultra central. BED is kissing 100. Worked fine for me so far without killing someone (yet). If it is at the borderline of the bronchial tree, 50/5.

 

[FrostyHammer]

On bad outcome can change your practice. With central SBRT, bad outcomes are REALLY bad.

Shouldn't be like that. Killing many of one's future pts from recurrences after the first has been killed from toxicity. Also, in the most contemporary era (published data mostly do not correspond to this most contemporary time) from a specialist in lung SBRT, it's very rare to see a fatal toxicity unless there's endobronchial involvement.

 

[Mandelin Rain]

Shouldn't be like that. Killing many of one's future pts from recurrences after the first has been killed from toxicity. Also, in the most contemporary era (published data mostly do not correspond to this most contemporary time) from a specialist in lung SBRT, it's very rare to see a fatal toxicity unless there's endobronchial involvement.

Treat enough, for long enough and odds are you'll see something "rare" happen.

 

[medgator]

Treat enough, for long enough and odds are you'll see something "rare" happen.

Pure statistics. Shouldn't surprise anyone

 

[RickyScott]

Shouldn't be like that. Killing many of one's future pts from recurrences after the first has been killed from toxicity. Also, in the most contemporary era (published data mostly do not correspond to this most contemporary time) from a specialist in lung SBRT, it's very rare to see a fatal toxicity unless there's endobronchial involvement.

1) in theory you are correct about recurrences, but I have seen cases where a toxicity is exploited politically within a department and a lot of Monday morning qb goes on and someone’s life made difficult. It is lot easier to have this bravado when you haven’t had to deal with this.

Personally never had a major toxicity with sbrt (except for one death on pt with pneumonitis while on immuno) for lung and I had one of first cone beams on East Coast and have have been doing this a long to time.btw At time,chair of mdacc, lung specialist, was denigrating stereo.

“Specialist in lung sbrt” - reminds me of one time prominent academic who was a specialist in breast DCIS. If have doubt, give 100 bed with something like 17/70- Don’t be wedded to stereo-it’s just a name.

 

[RickyScott]

you can make the argument that the shadiest practice is the one being reimbursed by insurance 5x as much for the same service.

(10-15 years ago when there wasn’t such a spread in reimbursement, utilization was a surrogate for “shadiness” but not today. Why is mskcc with negotiated insurance rates of 2X for 8gy x 1 less shady than 21c charging X for 15 x250?

Addendum: 21c in many practices historically would treat uninsured, pretty much anybody. Mskcc doesn’t take many insurances, Medicaid etc. And while we are at it, let’s add ekgs on every breast pt, and charging for plan every single day on mri linac! Or how about all the special billing exceptions for nci centers, like charging inpt rates at output centers, apm exemptions, and extending billing exceptions through whole hospital system outside of cance care!

 

[evilbooyaa]

Standard fractionated whole breast, especially with IMRT. Protons for prostate off-protocol.

I prefer 60/8 for central/ultra-central lung SBRT, although will consider 70/17 when I graduate for ultracentral perhaps.

I would not treat 40/5 to a stage I NSCLC. Oligomet in an ultracentral location, sure.

That being said, the story about treating pelvis and PA nodes separately is literally malpractice, and I reallyw onder if people are not better off going after people's licenses for people that are that shady.

Routine hyperfractionation, treating by data that is 3 decades old before the advent of chemotherapy and extrapolating it to chemo settings and ignoring data.

 

[RickyScott]

Sequential pelvis and then pa has to be put in context.
It was not uncommon 15 years ago prior to imrt. Only way you could treat many elderly pts. Saw it in medschool at one of best departments in world.

 

[Mandelin Rain]

Sequential pelvis and then pa has to be put in context.
It was not uncommon 15 years ago prior to imrt. Only way you could treat many elderly pts. Saw it in medschool at one of best departments in world.

Yup. I've seen this before at academic centers, even since the advent of IMRT.

 

[RickyScott]

Imrt for pelvis and para Ortics was cutting edge research stuff 7-8 years ago even though many practices were doing it. Case series would make red journal.

 

[KHE88]

Worst practice I've seen is routine 40/20 whole brain. I do think there are some rare cases where it's justified.
Close second are the 30 fraction courses for tiny basal cells in MOHS-able locations on 95 year olds

Regarding lung question,
I do:

62.5/10 for ultracentral oligiomet = 100 BED
Consider going up to 65/10 to 70/10 for primary lung ultracentral

The comment about not doing 5x5 for certain rectal cancers was surprising.

Confession time. I have never done short course rectal. It was never done where I was trained and it's never been done in the practice I took over. All rectals get 50.4/28 with chemo. This is what I would say on boards. Am I going to get the stinkeye?

 

[OTN]

- Protons for breast cancer
- Protons for prostate cancer
- MRI-guided adaptive planning for immobile tumors
- Anything more than 30 in 10 for palliation
- Dermatologists fractionation schemes for superficial XRT.
- Whole brain RT + IMRT boost to gross disease

I've done 67.5 Gy x 10 for ultracentral NSCLC with great results.

How anyone justifies going to 70 Gy in Stage III NSCLC when it was shown to have a survival detriment is beyond me.

When it comes to rectal cancer, remember that most are us are beholden to the preferences of the colorectal surgeons. Ours strongly prefer long-course, and there is some data showing long-term colostomy rates are bit higher with short-course and radial margins can be tougher to clear.

 

[metallica81788]

I was fraction-shamed at peer review for doing 79.2/44 for a high risk prostate by people that routinely use 50.4/28 for nodal breast. Not saying that is wrong, but you could do 50/25.

I get lots of outside old notes from bone mets treated in 2012-2014 for 15-20fx or so.

 

[RickyScott]

- Protons for breast cancer
- Protons for prostate cancer
- MRI-guided adaptive planning for immobile tumors
- Anything more than 30 in 10 for palliation
- Dermatologists fractionation schemes for superficial XRT.
- Whole brain RT + IMRT boost to gross disease

I've done 67.5 Gy x 10 for ultracentral NSCLC with great results.

How anyone justifies going to 70 Gy in Stage III NSCLC when it was shown to have a survival detriment is beyond me.

When it comes to rectal cancer, remember that most are us are beholden to the preferences of the colorectal surgeons. Ours strongly prefer long-course, and there is some data showing long-term colostomy rates are bit higher with short-course and radial margins can be tougher to clear.

Heard of one radonc in south Florida who has several mobile vans with brachy that go around to nursing homes treating basal cells on 100 year
Olds with hdr but conventially fractionated.

 

[KHE88]

I was fraction-shamed at peer review for doing 79.2/44 for a high risk prostate by people that routinely use 50.4/28 for nodal breast. Not saying that is wrong, but you could do 50/25.

I get lots of outside old notes from bone mets treated in 2012-2014 for 15-20fx or so.

Fraction shaming is dumb and virtue-signalling. Not surprising academics do it. Plenty legit reasons to do standard frac in prostate. I normally do 60/20 but I got a guy now I'm doing 44 fx due to bowel adjacent to prostate.

- Whole brain RT + IMRT boost to gross disease

I don't know about this one. For patients with good PS and 6-10 small mets, I will often do HA-IMRT with SIB to gross dz to 40 Gy in 10 fx. My rationale is if I'm doing IMRT already for HA, why not boost gross dz? Great results.

If you are talking about 10-15 fraction laterals followed by sequential IMRT boost, I'm with you for sure.

 

[Lamount]

70/17 for ultra central. BED is kissing 100. Worked fine for me so far without killing someone (yet). If it is at the borderline of the bronchial tree, 50/5.

For central/large tumors, I do 4.5-5 Gy x 15 with dose painting to spare airways, esophagus etc ... 5 Gy x 15 is equivalent to 12.5 Gy x 4 for tumor

 

[RickyScott]

Heard of one radonc in south Florida who has several mobile vans with brachy that go around to nursing homes treating basal cells on 100 year
Olds with hdr but conventially fractionated.

Here is lawsuit when pt receiving 2 months of treatment tripped and fell going from nursing home to van
FindLaw's District Court of Appeal of Florida case and opinions.

i guess they were delivering hyperthermia with 100$ over counter heat lamps and thermometers from home depot and billing 450$ for each hyperthermia procedure with each of these 30 hdr treatment for basal cell and other nonsense,

United States of America et al v. Pomper et al: AMENDED COMPLAINT against All Defendants, filed by The State of Florida, United States of America.

United States of America et al v. Pomper et al: AMENDED COMPLAINT against All Defendants, filed by The State of Florida, United States of America.

www.docketbird.com

 

[deleted1002574]

50.4/28 fx is still standard of care in the US. 5 x 5 is good, too.

50.4 is by far more toxic, acutely.
5 x 5 I have seen often crippling tenesmus/cramping 1-2 weeks after treatment (>50% of patients).
SCRT not so good for low lesions. Fine for upper/med. In fact, maybe better?

Again, a lot of this comes down to payment model.

 

[evilbooyaa]

We only do 5 x 5 routinely for metastatic rectal patients. A lot of our patients prefer eval for watch and wait and a CRC Surgeon who supports it, so we do 50.4-56 with Xeloda for the vast majority of our rectal cancers. I wouldn't call it shady practice, but of course it's not shady if I do it.

I think fraction shaming for 3 fractions (1.8 vs 2.0 for nodal breast) is dumb. I think fraction shaming for doing standard fx prostate after discussion of options with patient is also dumb.

I do think that fraction shaming those who still do conventional frac for whole breast is OK. Guess that makes me a hypocrite, although hope we're all in agreement on not routinely conventionally fraccing an early stage breast anymore.

 

[RickyScott]

50.4/28 fx is still standard of care in the US. 5 x 5 is good, too.

50.4 is by far more toxic, acutely.
5 x 5 I have seen often crippling tenesmus/cramping 1-2 weeks after treatment (>50% of patients).
SCRT not so good for low lesions. Fine for upper/med. In fact, maybe better?

Again, a lot of this comes down to payment model.

Anus can not take high doses of radiation very quickly,

 

[w00tz]

I think the real shame that is to come is those choosing to do standard fraction prostate, claiming "more long term data" and "lower toxicity in their experience", but then immediately switching to hypofrac when APM comes out.

 

[evilbooyaa]

I think the real shame that is to come is those choosing to do standard fraction prostate, claiming "more long term data" and "lower toxicity in their experience", but then immediately switching to hypofrac when APM comes out.

I look forward to the scores of retrospective papers that will point out the obvious fact that people were doing standard fx for the money all along, about 2 years after APM begins.

 

[Mandelin Rain]

I look forward to the scores of retrospective papers that will point out the obvious fact that people were doing standard fx for the money all along, about 2 years after APM begins.

This will certainly advance the specialty!!!

 

[ramsesthenice]

Sequential pelvis and then pa has to be put in context.
It was not uncommon 15 years ago prior to imrt. Only way you could treat many elderly pts. Saw it in medschool at one of best departments in world.

I don't think that makes it any better. First, even with 3D you can easily treat healthy patients concurrently. You jut put your field boarder at the top of L5 and half-beam block to match. For patients with intact cervical tumors and uterine involvement I still usually treat the pelvis 3D and the PA nodes with VMAT using a half-beam block. I'll grant you for frail patients there was an argument to be made but.... this is their universal practice and not dependent on patient factors (the patient in the particular case I am discussing was only 44). Third, there is an expectation that you adapt with changing practices over time. Not saying you have to alter what you are doing as soon as new studies come out. But is highly questionable to on the one hand decide that you believe that IMRT reduces toxicity but then reject the notion that it sufficiently reduces toxicity to treat PA and pelvic fields concurrently in the face of a mountain of data and SOC guidelines. They are all in on radiating 3+ extracranial oligomets with SBRT. I guarantee you that is not something they picked up in residency 15-20 years ago.

Since you brought up historical practice patterns, it is worth mentioning that we use to do a lot more PA radiation than we do now. In most of the classic studies it was recommended for patients with common iliac involvement. Most open protocols and people I know are only using the classic chimney approach for frank PA involvement.

 

[evilbooyaa]

I don't think that makes it any better. First, even with 3D you can easily treat healthy patients concurrently. You jut put your field boarder at the top of L5 and half-beam to match. For patients with intact cervical tumors and uterine involvement I still usually treat the pelvis 3D and the PA nodes with VMAT using a half-beam block. Second, this is their universal practice and not dependent on patient factors (the patient in the particular case I am discussing was only 44). Third, there is an expectation that you adapt with changing practices over time. Not saying you have to alter what you are doing as soon as new studies come out. But is highly questionable to on the one hand decide that you believe that IMRT reduces toxicity but then reject the notion that it sufficiently reduces toxicity to treat PA and pelvic fields concurrently in the face of a mountain of data and SOC guidelines. They are all in on radiating 3+ extracranial oligomets with SBRT. I guarantee you that is not something they picked up in residency 15-20 years ago.

Agree with the rest of your post, but in regards to bolded, really? You're still doing 4-field box for Cervix pelvis? What about for the lymph nodes (assuming they have positive lymph nodes if you're treating PA)? Still doing just 45/25 to the lymph nodes?

All Gyn gets IMRT from me in this era. SIB LNs if present.

 

[ramsesthenice]

I look forward to the scores of retrospective papers that will point out the obvious fact that people were doing standard fx for the money all along, about 2 years after APM begins.

Yep. Remember how Urorads were evil for "magically" deciding IMRT was a good thing for localized PC once they owned the machines and the data showed it? You can bet everything you own many of that "old school" patterns of doing as much as possible will just as "magically" go away when reimbursement is not tied to effort.