Todd Scarbrough
@toddscarbrough
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Sixty percent of the time, the things I try work every time. Radiation oncologist. Thaumaturgist. Todd Scarbrough is an anagram for 'doc brought rads.'
Whereabouts Unknown
Joined August 2009
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HOLY SHNIKES
Ladies
Gentleman
Our long national nightmare is over!
I want to thank my parents, my kids, The Accelerators,
@WinshipAtEmory
,
@VarianMedSys
,
@ASTRO_org
, The Academy, and
@ABIMFoundation
Long hard slog but we made it! We made it!
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was wondering...
can we go ahead and eliminate "SABR," or at least "ablative," from the (radiotherapeutic) lexicon
may happen organically, in prostate at least... but never hurts to ask
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@DGlaucomflecken
Death is nothing to worry about. If you’ve ever had a colonoscopy they give you an injection and you’re out. And it’s black and peaceful, and nice. And so death is like a colonoscopy. The problem is life is like the prep day.
- Woody Allen
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One personal twitter post from me for all time, promise
My "little girl" graduated med school this past weekend
Congrats Haley
(my mom @ left)
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In today’s
@NEJM
Omission of RT in favorable risk luminal A breast cancer in women age 55-plus
Local recurrence VERY low at 5y… 2.3%
The number needed to tx for LC here is in the 40-100 range
Time to recommend omission for these patients?
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#ChatGPT
Write a radiation treatment
#radonc
plan for irradiating an early stage
#breastcancer
in the style of President Donald Trump.
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Helluva drug(s)!
CMS spends ~$8B/yr on
Keytruda,Opdivo,Rtxn,Avstn,Hcptn
CMS spends ~$1.5B/yr on
ALL RADIOTHERAPIES (proton included!)
If CMS finagled a 1% discount/yr on these 5 drugs it would save more than RO-APM is projected to per year
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When I took this photo five years ago, this person was not a doctor.
Now she is an OB/GYN (resident) having a huge impact on women's health in W Va. Rumors are she is an excellent surgeon.
Happy Bday Dr. Scarbrough
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Hasn't gotten much press or
#radonc
attention imho
But here's a new std of care in oncology
Tumor treating fields (TTF) + std systemic therapy (SST) improved OS in stage IV
#lungcancer
versus SST alone
From
@WinshipAtEmory
et al and
@TheLancetOncol
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1/29
End of year rad onc economics (Freakonomics?) ruminations
Herein, “Mcr” equals Medicare.
(To start, this very busy graph…)
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Substantial changes (as of Aug 1, 2022) in United IMRT
#radonc
*commercial* medical policies
Notably:
IMRT is now medically necessary for
any breast ca patient receiving 5 fx partial breast RT
and all Stage III NSCLC patients getting chemoradiation
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Really saddened me reading one of the latest interviews on the
@ASTRO
website
Being a co-author of a couple of the textbooks and having met Luther many times, he seemed a very nice guy
But wow rad onc and medicine have such a fraught history re: women
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1/26
BREAST IMRT
(and Fake News)
A thread.
(Warning: long.)
Chronological events first…
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It's BIG (literally) for DCIS
11 countries, 136 centers
Boost decr LRs absolute ~4-5%, no OS benefits obv, and increased some late effects as much as that or more
I can't tell if boost helped in hypofx (!!!)
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The
@ASTRO_org
PBI breast cancer guidelines are published
Two observations:
1) 26 Gy/5 fx for PBI gets credence here (ed. note: this should be the std!)
2) If you're doing those ~38 Gy/10 fx PBI EBRT regimens, or 40 gray(!), etc., you're doing it wrong!
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I'll be presenting this in a Grand Rounds soon
but such an incredible stat, I need to tweet it!
In the UK prior to COVID, ~90% of *all* breast ca pts were treated w/ 15 fractions or less
Since COVID, ~80% of *all* br CA pts tx'd w/ 5 fractions or less
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Reminiscing
#ACRO2022
; my favorite talk
By Charles Thomas Jr
The Luther Brady Lecture
His effect on others' lives and career in medicine, in and outside rad onc, incalculable
If he ever wore a graphic T-shirt, this is probably what would be on the front:
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Here is a visual explainer
Payment rates for some radiation treatments for breast and prostate cancer will drop by about 13%, and by more than 22% for advanced lung cancer treatment, under the
@CMSGov
proposed RO cuts.
#StopTheCuts
.
#RadOnc
@HHSGov
@BrooksLaSureCMS
@SecBecerra
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Here's an excerpt from 'I Am Bolt' where, with the help of a
#radonc
(in Germany, natch) and
@VarianMedSys
linac technology, Usain Bolt receives low-dose XRT for tendonitis.
After this, he'd go on to win an Olympic gold medal.
Again.
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Just a week ago
@VarianMedSys
received Category B Investigational Device Exemption status for the
RADIATE-VT
(cardiac radioablation)
trial
Well done Varian!
This could be an incredible breakthrough in cardiology &
#radonc
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HERE ARE THE
TOP 10
STUDIES TO BE FEATURED AT THE
UPCOMING
@ASTRO_org
2023 MEETING
IN SAN DIEGO
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One of the more interesting
#radonc
presentations at the recent European Lung Cancer Congress
Long-term follow-up of CONVERT:
once-daily 66/33 vs twice-daily 45/30 for small cell
#LungCancer
Significantly more long-term esophageal toxicity for once-daily (as we might predict
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From
"Textbook of Radiotherapy"
Gilbert Hungerford Fletcher ed.
c 1980
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@VPrasadMDMPH
From their website:
Prost ca 13% incidence; MRI 69% sens/89% spec
............_ca+__ca-
MRI+ |90 | 96 | PPV =**48%**
MRI- |40 |774 | NPV=95%
............ 130 870
in other words, "When our MRI is positive, a coin flip gives better predictive power."
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@CancerConnector
Cost of Herceptin per year = $2B
Cost of RT to CMS for all diagnoses = $1.6B
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Dr
@ShannonMacDonMD
is gutsiest
#radonc
alive
If she prevails we (doctors, patients) all win
Time to start letting "physician autonomy" truly mean something
If we're smart & trusted enough to do surgery, we should be to make
@Apple
FaceTime calls too
Pediatric
#radonc
Dr
@ShannonMacDonMD
& one of her patients are brave enough to go to court to fight for the right to receive/provide
#telehealth
care across state lines. Limiting access to specialty care benefits no one & worsens
#financialToxicity
.
👉
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This will go in the Most Tone Deaf Statement by a
#Radonc
Ever Hall of Fame
As the kids say… we got Recht.
As the docs say… Rechtum? Damn near killed him.
But, that role will be smaller, Recht said. “To me that is a good thing, because I already got my kids through college,”
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@ryanclearyMD
recommending to you "The English Surgeon" re a giant in your field (and humanity). Quoting: "Every surgeon carries within himself a small cemetery where from time to time he goes to pray; a place of bitterness and regret where he must look for an explanation for his failures".
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@lauren_henke
has IMHO given the most “accurate and precise” and real-world-today clinically impactful talk at
#ACRO2022
on MRgRT. As much as we can be “tech skeptical” it’s everything I have been talking about since 2004 when I first started doing IGRT on almost all cases.
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@jryckman3
working on a
#radonc
presentation
wanted to add one more true fact
Medicare offers rad onc care to about 350,000 beneficiaries/yr at a cost of about $5000 per person
Mcr offers Keytruda to about 50,000 beneficiaries/yr at a cost of about $50K per person
CMS should♥️rad onc
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What a wonderful testimonial from a dentist about
#radonc
treatment for Dupuytrens
Reminds me of this excellent treatise by Ed Halperin about the etymology of the word “therapy”
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ASTRO now supports no mandated physical presence of the rad onc MD in the clinic
I think I'm not telling tales out of school to say
@ASTRO_org
has rather vehemently opposed this in the past for
#radonc
Letter to CMS today:
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WELCOME TO THE FUTURE
I clicked “T9-12.”
This is the most impressed I have ever been with Auto-contour.
Saved me 90 minutes, easily.
@Radformation
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A rather huge (N=26118) tridecadal retrospective study suggests:
Adjuvant RT for prostate cancer could be better than salvage RT for post-prostatectomy high risk/high stage prostate cancer
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Here's an excerpt from 'I Am Bolt' where, with the help of a
#radonc
(in Germany, natch) and
@VarianMedSys
linac technology, Usain Bolt receives low-dose XRT for tendonitis.
After this, he'd go on to win an Olympic gold medal.
Again.
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Dr. Wang throwing some red ! points (and shade) on Z0011; says "[H]as gone down in history as causing more controversy than it solved"(?)
How long will we continue to "litigate" this trial. It's the blue/gold dress of breast oncology (esp to rad oncs).
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1/5
Are ASTRO's
#radonc
partial breast RT guidelines and current NCCN partial breast RT guidelines at odds for breast cancer treatment?
Of course the answer is yes... at least re: BID treatment fractionation regimens
(read on...)
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@MikeOkuda
@MrFlickRocks
Whoever did the Mac computer graphics for transparent aluminum was very very clever!
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Please
Academic
#radonc
Trial this, study this
The world needs us, especially if there’s any chance LDRT can work for this disease
If you can prove this is beneficial for Alzheimer’s, will be as big, or bigger, as anything re: radiation for cancer
Alzheimer's disease is one of the biggest medical challenges today. Effective treatment options are urgently needed. Could radiotherapy be a potential approach?
Check our systematic review in
@IJROBP
@ASTRO_org
!
@alzheimerssoc
@alzassociation
#RadOnc
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🥁Here is the answer
Rad onc has had the greatest growth in ABMS certificate holders of any specialty in the last two decades
(Our Medicare spending is VERY stable over that time period)
But 🤷♂️ maybe there is no
#radonc
oversupply
Maybe salaries growing
Maybe water not wet?
According to the ABMS (), the number of urology certified diplomates increased ~32% (13076 vs 9884) in the US between 2000 and 2020
How much do you think the number of board certified
#radonc
in the US increased in that time period?
(Ans in 1h)
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We’ve been saying this for, oh, the entire century.
Would say we were saying this most of last century too, but actually… arguably radiation used to have better cachet.
Here’s a national WPS poster from a forerunner of the ACS, circa 1930’s.
(5/6) The myth that surgery offers the only curative treatment for cancer is pervasive in oncology and is a disservice to patients. The field of radiation oncology must do better to educate and advocate.
@ASTRO_org
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So hot, not even off the press
Alan Pollack showing RTOG 0543 SPPORT
Do we have a winner (nodes *cough*)
FFP was Phoenix definition
Other clinical benefits to PLNRT too
#ACRO2022
#prostatecancer
Looking forward to SPPORTs Center with
@_APollack
@ACRORadOnc
. Had to re-familiarize myself with the tx arms. You should too
@ACROresident
! Ready for that Arm 2 and 3 update. I’m sure
@WilliamGreenMD
@jennamkahn
@toddscarbrough
@NicholasZaorsky
@sophia_kamran
@MdElbanna
agree!
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pCRs after RT for NSCLC
#lungcancer
are rich
#radonc
data...
The INCREASE trial:
chemoRT(50Gy)+ipi+nivo
surgery @ 6wks post-RT
pCR: 63%
SWOG 9416 kind of similar setup, minus immunotx
chemoRT 45 Gy, surgery 3-5 weeks
pCR: 36%
.
@chris_dickhoff
presents results from INCREASE trial (surgery after chemoRT+I/O for borderline resectable NSCLC): 63% pCR, 79% major pathologic response, only 15% radiographic response (may be related to nodal flare?). Insightful discussion from
@PatelOncology
.
#WCLC23
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I posted this
@MayoClinic
proton breast cancer study press release today
Some of my colleagues have had time to view the paper/results…
ABSOLUTELY MIRACULOUS
Proton beam therapy may shorten breast cancer treatment
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CAR-T for GBM?
"One patient showed near-complete [recurrent
#glioblastoma
] regression on a scan done after 5 days... We’ve been surprised at how dramatic these tumor responses are"
Read more at:
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Here is an early stage left breast 42.5Gy/16fx radiotherapy
#radonc
VMAT (IMRT) plan for
#breastcancer
from Varian
Unfortunately as we all know early stage whole breast IMRT is bad and one should not actually use this nice looking plan from Varian
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Doing a presentation today, using this slide
Keep in mind I made it ~15y ago; might tweak a few numbers
But I wouldn't tweak much
Free for you to use... just tell everyone you're my friend!
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Attended
#ROCR
@ASTRO_org
town hall this afternoon
In UK, 80+% of all breast patients are 5-fraction now
American
#radonc
on ROCR town hall said "Americans aren't comfortable w/ 5 fractions"... and that many Americans' body habitus (ahem) not safe for five fractions
Uhhh
When a resident asks you to explain why this dose fractionation works over others.
#2gyadaykeepsthedoctoraway
#radonc
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"A few colleagues scoffed when
@fumikochino
said she was researching parking charges, but a growing number are concerned... 'It seems ethically incorrect to nickel-and-dime patients for parking charges' a trio of doctors wrote last year."
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Here's a pic of Ronald Reagan (and some unknown admins and therapeutic radiologists) at Baylor University in 1953 standing next to BU's new
@generalelectric
2 MeV resonant transformer for radiotherapy
Reagan was GE's natl spokesman for the new high-E cancer tx
@colorize_bot
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@Dr_Oubre
Husband and wife often show up together. If husband is patient, I ask “Is this your daughter.” (Works every time)
Also,
“Doc, will I be able to play piano after this tx?”
*takes tx, returns later*
“Doc, you lied! I can’t play piano after the tx. I couldn’t before either tho.”
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A poll of ~2500 physicians across multiple specialties by Doximity showed American Board of Radiology board certified radiologists think their specialty’s job market is the strongest…
while American Board of Radiology board certified
#radonc
radiation oncologists thought their
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Here's a really interesting and depressing article in press at PRO from Baumann et al
Medicare reimbursement in
#radonc
fell over 2010-2020... a lot
Enough to gag a buzzard
We need to end notion IMRT is really lucrative
SBRT kind of bankrupt-y
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Your excitement turns into disappointment
Laughter becomes tears
And love becomes just a formality.
#radonc
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@BobTimmermanMD
@UTSW_RadOnc
@utswcancer
Who can take a lung nodule?
Sprinkle it with dew...
Cover it with chocolate and a miracle or two?
Oh the Timmerman can.
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IMPORT 10y:
Late normal tissue effects at 10y ~5% in PBI arm vs ~30%(!!!!) in whole breast arm, and local control "better" with partial breast(!)
Frankly, whole breast radiotherapy is the *wrong* tx for older women w/ early, low risk
#breastcancer
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7 of the top 30 complex sim for radiation therapy (CPT 77290) users in the US are dermatologists (2019 Mcr data)
Skin ca is the 4th most common Mcr RT dx (and is excluded from RO-APM!)
Who makes better linac commercials: rad oncs or derms
🤔
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1/
The number of patients receiving radiation therapy (RT) per day in the U.S. has fallen ~35% over the past 20 years (115K/day to 75K/day)
The number "under beam" per day per radiation oncologist has fallen ~60% (33/day to 13/day)
Here's why the above are very likely...
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ABSOLUTELY MIRACULOUS
Proton beam therapy may shorten breast cancer treatment
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20 MeV electron in cancer therapy...
Velocity: 99.97% lightspeed
Travel time, gantry-patient: 3.34 nanosec (ns)
Time "experienced" by electron, ~40x time dilation: 0.08 ns
As electron stops over ~5cm in patient, it feels G-forces ~200,000x(!) greater than neutron star surface
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“Site visit” to WVU this weekend
meeting with GYN resident Dr. Haley Scarbrough
here is a
#windowseat
pic, layover at Reagan Intl
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@stephenfry
I’m going to be very surprised if I’m the first to reply to you with this Stephen
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That
@ASTRO_org
cannot support IMRT whole breast (numerous positive trials and prospective studies) but would support protons for early stage breast should infuriate the part of the brain involved with science, honesty
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This was 1st DVH ()
From 1979:
"Proton Radiation as Boost Therapy for Localized Prostatic Carcinoma"
(DVH was Goitein's)
Authors (Shipley, Tepper, Suit etc) said "initiating" a proton vs photon trial
42y later, results awaited!
Thursday Trivia
What was the 1st appearance of a radiotherapy
Dose Volume Histogram
in the published medical literature
Don't cheat and look at the Wikipedia page...
...I wrote most of the page ~10 years ago (that's trivia too)
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"Breaks on a stage, breaks on a screen
Breaks to make your wallet lean
Breaks run cold and breaks run hot
Some folks got 'em and some have not"
- Kurtis Blow, c. 1980
Med onc locums $4000+/day
Rad onc locums $1800/day
- Locums recruiters, c. 2023
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Woman with breast cancer gets wrong breast irradiated for a full 25 days of treatment
Per news, poor “notes” at fault
But
#radonc
eyeballs on patient on machine table on day one would help… and, this counts for an OTV!
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1/
Definitive Radiotherapy
&
Lung Cancer
in the U.S.:
(Incredibly Changing) Trends Over (Recent) Time
(There may be an Accelerators
@SprakerMDPhD
@annalaucis
@ParikhSimul
podcast re: "volume" in US soon? Will rehash then maybe)
(Attn:
@ASTRO
,
@CShahMD
et al)
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Role of Radiation Therapy for Borderline Resectable Pancreas Cancer
For (Joe Herman)
Against (Lisa Kachnic)...
"There seems to be no evidence to support my actual practice"(!!!)
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This patient deserves a gold medal for breath holding
Be still, my liver
Completing SABR to two isolated liver metastases in a single MR guided adaptive MRIdian treatment for this patient. This allowed for 5 vs 10 trips, adaptation helped spared duodenum 👇 larger tumor and set up deformation inherent in two lesions in one plan. Win-win for patient.
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This is so cool for this Australian physician
For American rad oncs in clinics in GA/AL/TN/VA/WV/SC/NC and doing IMRT or stereotactic, they have to be physically present one to two minutes from the linac at all times!
🥴
Clinicians now can review, adapt and approve
#MRgRT
plans from anywhere for Elekta Unity
#MRLinac
. This is a benefit for radoncs like Dr.
@Hendo_tan
, who works across different sites, sometimes 100+ km away. Hear how he's able to easily run any clinic ➡️
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@CostAnEffect
CMS spent ~$1.8B on rad onc in 2012, the most ever for rad onc. Now a decade later it is spending $1.5B/yr on rad onc. Rad onc had already “self saved” more per year than APM is projected to; our specialty has had about the most CMS cost containment of any specialty.
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Time to start omitting regional nodal irradiation in favorable-risk 1-3 N+/Oncotype <25 breast cancer patients?
In scndry analysis of (~4000! women in) SWOG S1007 out in
@JAMAOnc
5y LRR after BCS + RNI: 0.85%(!)
5y LRR after BCS and *NO* RNI: 0.55%(!!)
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1/
At age 52, my mother was diagnosed with DCIS of the left breast
A “Stage Zero” breast cancer
This was 1996…
@Icro_Meattini
@hoperugo
@toddscarbrough
@NEJM
@OncoAlert
Ask patients about the pain and problems they have years after radiotherapy, years after stopping ET. I am in contact with other breast cancer survivors for 16 years now. We all suffer from the problems caused by radiotherapy.
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"The first-ever AI-powered tumor auto-contouring solution." *First.* That true?
Vysioneer Receives FDA Clearance
"Freeing clinicians from the manual process allows more time to focus on quality patient care."
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If hyperfrac can work more better to cure cancer and prevent late tissue damage versus standard or hypofractionation for re-irradiation, why do we “rely” on a different radiobiologic theory for most other disease sites we treat for de novo irradiation?
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Dr. Spratt's "mega-analysis" of ADT + RT out in Lancet Oncology
I would re-tweet his tweet but I can't :)
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There will probably be more than a few young women who many years from now will be saying "I saw a rad onc on
@GMA
talking about breast cancer and that's what inspired me to go into rad onc."
@GMA
and ABC have always done well re
#breastcancer
;
@danbharris
dad is THE Jay Harris!
It was the honor of my lifetime to sit down with
@FLOTUS
@RobinRoberts
and our wonderful patient Sandra Cruz, to get the message out about the significant decline in
#breastcancer
screening due to
#COVID19
Please do not delay your cancer screening 🙏🏼
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A Simple Antibacterial Treatment Can Solve a Radiation Oncology Skin Problem -
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Evidence accumulates to give
#radonc
boost the boot in breast cancer whenever possible
For cT1-2N0-2a age <50, (higher dose) boost increases local control by ~2% at 10 years, but also increases moderate/severe scarring by ~20%
"'[LC] benefit does not justify the increased
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Seriously though
Who did this plan
They intentionally tucked this guys schlong into the RT field
No need to electively irradiate the penis if you have rectal cancer (I read this in Gunderson & Tepper iirc)
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