@DrSpratticus Unfortunately I'm the wrong person to tag for this great Q! No technical revenue here.
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Ashwin Shinde
1.9K posts
Ashwin Shinde
@AshwinShindeMD
Radiation Oncologist at Vanderbilt Medical Center | City of Hope '20 | Drexel BS/MD '15 | Pittsburgh Steelers | Bourbon and Scotch | Tweets are my own
Katılım Mart 2020
188 Takip Edilen816 Takipçiler
#radonc Question about technical revenue not science. Repost please!
For the radoncs that have line of sight to their hospital/technical revenue, not simply their pro fees and wRVUs, how have the new CMS changes impacted your practice/center solely on the technical revenue side? Only answer if you have access and see tech revenue.
It appears for example what was charged for head and neck IMRT previously is now a level 2, which CMS pays drastically lower. Pro side may be fine for many, but what about tech side?
@ASTRO_Chair @jaguaranna27 @ACRORadOnc @AshwinShindeMD @abhiAsolanki @DigiaimoRon @EvanThomas84 @HimanshuNagarMD @jmmrad @jryckman3 @ACKoongMDPhD @SimonLo21054188 @LeilaTchelebi @ASTRO_org @NRGonc @TylerSbrt @SbrtSean @NehaVapiwala @nbn426 @themednet @rweichselbaum @subatomicdoc @ChadTangMD @BobTimmermanMD
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@johannboaz @amg3200 @SprakerMDPhD OK... and how many patients post prostatectomy need RT afterwards? And what's the denominator of all patients treated with RT locally for intact prostate cancer?
100% ED post-RALP is hyperbolic, but higher rates at any time point earlier than 10-years than RT, one can agree on?
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@amg3200 @SprakerMDPhD I don’t know what you are smoking but no one needs it second hand. I agree, 100% ED if you were operating. Meanwhile just scheduled a third Radical cystoprostatectomy this year within 10 years of Radical RT for CaP. Coincidence, surely.
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Radiation transforming a tumor into a worse malignancy is resilient dogma that lives on despite, like, zero evidence this happens ever.
Interestingly, I treat many recurrences where the surgeon previously followed the dogma and omitted radiation on the first resection.
Allison Fitzgerald, MD, PhD@allisonoconn
Today I learned about verrucous carcinoma — a rare subtype of squamous cell carcinoma that rarely metastasizes but is locally aggressive. Although controversial, some discourage radiation because of concern radiation induced anaplastic transformation, making the disease worse
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@SprakerMDPhD Yikes - no data for that. Whoever is teaching fellows that sort of thing based on 'feelings' is doing them a disservice.
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@DrSpratticus Diffuse abutment of equina I would limit to 105% of 70.2/39. Focal areas of equina probably can go to 77.4Gy as per the Delaney papers but I wouldn't take huge swaths of it.
I would probably stick with VMAT photons than deal with the 10-50% RBE uncertainty at end of Bragg Peak.
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#radonc
What does constraint would you use for the proximal parts of the sacral plexus and cauda you can identify in a 20+ cm sacral chordoma? Effectively takes up 70% of the patients axial anatomy. Amazingly has minimal neurological deficits yet.
Unresectable of course.
Will be using protons.
@SimonLo21054188
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@KamravaMD @Sushilberiwal 3Fx has a smaller therapeutic window than 4Fx which has smaller window than 5Fx.
Routine use of IC/IS to decrease tx to 3-4 compared to ICBT x 4-5 tx is an individualized decision.
I would rather do ICBT one more time than put pt at risk of bleeding 4 separate times.
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Cancer control and toxicity results of chemoradiation for cervical cancer using a three-fraction HDR brachytherapy boost - brachyjournal.com/article/S1538-…
Should 3 fx be standard approach? Don't think there will be RCT for BT fractionation. What is bar to change SOC?
@Sushilberiwal
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@AndresFCardonaZ @StasLazarev @MayoClinic jto.org/article/S1556-…
Median OS 9 months in a cohort that has excellent survival outcomes.
Seems like it'd only make sense in patients where Pemetrexed is part of conventional chemotherapy, like NSCLC....
Cool idea, doesn't mean we shouldn't do CSI in well-selected pts
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⚡️New study: Proton vs Photon CSI for leptomeningeal disease (@MayoClinic, n=36)
▶️No difference in serious CSI-related cytopenias
▶️OS ~3.0 mo (proton) vs 1.7 mo (photon), NS
▶️Photon VMAT-based CSI → a viable alternative when protons aren’t available or can’t be started quickly
🙌 Important real-world data
OS here was very poor compared with MSKCC (Yang et al, JCO 2022) Phase II trial where proton CSI yielded ~10 months OS in breast & NSCLC LMD.
⚖️ So here’s the key question: why is that and what’s missing from the paper?
I searched the main text & appendix and couldn’t find it → the extent of extra-CNS disease & available systemic options for extra-CNS disease at the time of diagnosis with LMD. It is probably THE most important factor when deciding on CSI for LMD.
🎯 CSI only makes sense if:
✅Extra-CNS disease is controlled or has adequate systemic options
✅ You’re treating both compartments (craniospinal + systemic)
🔥If systemic disease is uncontrolled, CSI’s benefit is minimal. It doesn’t help to put out 50% of the fire. Any potential gain of CSI is quickly negated by extra-CNS progression.
🎯 Patient selection is key
#RadOnc #NeuroOnc #Leptomeningeal #MedTwitter #Oncology #BrainCancer #ProtonTherapy
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@SprakerMDPhD I wouldn't start Boswellia on someone who was having acute symptomatic RN who hadn't seen steroids. Someone who has asx RN, or has steroid refractory, or maybe some mild sx but isn't enthusiastic about steroids (say a DM2 pt)....
Those who study it will be enthusiastic about it.
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Sometimes yes, but often no.
Boswellia is a lot of pills, variable quality and people getting it from unclear sources, and we have decades of data for steroids.
If the stakes are high, it’s a bad choice for first line. Don’t get carried away with the shiny new thing.
Advances, an ASTRO Journal@Advances_ASTRO
Expanding the #radonc toolkit for ☢️necrosis (RN) tx after SRS for functional disorders In this case report, Boswellia serrata resolved RN in a pt w/ steroid-refractory RN after SRS (80 Gy) for OCD Should Boswellia be a 1st line tx for RN after SRS? advancesradonc.org/article/S2452-…
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@ProtonStorey @yuanjamesrao You're getting denials for daily CBCT on patients treated with IMRT? I... have not.
Daily IGRT (whether it be CBCT or kV) for 3D plans, yes I've seen push back.
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@AshwinShindeMD @yuanjamesrao Yes. If you note above it is included in 2026 and not in 2025. I worry the problem will be getting private payers to remove their local policies to get reimbursement beyond Medicare. Many deny 014 routinely today and have specific contractual language in place
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Medicare Physician Fee Schedule Proposed Rule 2026 released. Too much to digest quickly but it's out there for those who are interested in billing and policy. Table 14 describes major modification to delivery CPT codes, previously predicted by ASTRO. #radonc Link below
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@chr_huang @yuanjamesrao @ProtonStorey Dis-incentivize CBCT and IMRT. Truly, a step backwards for quality of Radiation Plans nationwide.
Equating IMRT with 3D for technical reimbursement when IMRT requires QA and daily imaging is a penny wise, pound foolish evaluation by CMS.
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@yuanjamesrao @ProtonStorey Looks like 77387 will be 0.70 RVUs, which also incorporates kV imaging. So Daily CBCT takes a hit but daily kV gets a bump.
How DIBH/intra-fraction monitoring will fare is not directly clear - seems like DIBH will get 'bundled' into 77387...
Dis-incentivizing good radiation/IGRT.
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@yuanjamesrao @ProtonStorey I was under the impression that 77014 was going to be 're-labeled' as 77387. So what matters is what is the RVUs of 77387, and how it compares to the 0.85 for 77014.
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Ashwin Shinde retweetledi
On the potential risk of gabapentin (Neurontin) for mild cognitive impairment and dementia
rapm.bmj.com/content/early/…
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@drdavidpalma Consent should be a physician task. Ideally the one developing the plan.
By approve re-plan, do you mean on-table adaptive?
Running RCTs is a great idea.
Many other tasks you're describing are done by dosimetrists in the US. Many CMDs are former RTTs with additional training...
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Great thread about Advanced Practice RTTs. In 🇨🇦 they are game changers!
Roles include consenting, ordering RT, contouring, leading QA rounds, attending setup at the unit, approving re-plans, and running RCTs! They make our team stronger. Feel free to message me if questions.
Sameer Keole@SameerKeoleMD
Is it time to rethink the role of the RTT in U.S. #RadOnc? What is an Advanced Practice Radiation Therapist (APRT)? Globally, APRTs are stepping into expanded roles—but in the U.S., that concept doesn’t yet exist. Should it? Let’s break it down. 🧵 #RadiationTherapy #APRT 1/7
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@johndavid_JDMD @NiuSanford @ESTRO_RT @UTSW_RadOnc What N have you treated since publication of OPRA/MORPHEUS?
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@NiuSanford @ESTRO_RT @UTSW_RadOnc Brachy boost has become an integral part of our rectal cancer practice! Fantastic tool for dose escalation!
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Great to see this @ESTRO_RT highlight on brachytherapy across GI subsites.
FYI the MORPHEUS trial is now open @UTSW_RadOnc.
Phase III RCT of external beam v brachy boost for early-stage (T2/3, N0) rectal cancer w primary outcome of organ preservation (site PI: Aurelie Garant)
ESTRO@ESTRO_RT
💡 Spotlight on GI #brachytherapy! The GI GEC group is pushing forward rectal, anal & liver brachytherapy via: 📌 OPERA & CITRuS trials 📌 New HDR rectal guidelines 📌 Expanding liver BT 📌 Call for broader participation! 👉 bit.ly/3ZN5HG9
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@free_radical28 Royal Marsden paper (thanks for linking) is mostly M1 pts treated in a pre-ICI era.
7.5% is higher than the 4.5% from SABR-COMET which was in M1 pts, and that gave non-Rad Oncs a lot of pause of SBRTing oligomets disease.
This is closer in badness to HILUS...
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And within range of other studies; eg. Royal Marsden w/60-day peri-tx mortality in PDAC of 13% and another report showing that GI (2.4%) and H&N (2.9%) pts @ highest risk of 30-day post-RT death. So, I don't think 7.5% in 90 days for probably the sickest GI subgroup is outlier
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Yes, we saw a very strong dose response effect with higher risk of high grade toxicity with very-high (1-fraction) and high (3-fraction) BED regimens.
I don't think the 7.5% figure is particularly surprising; this is a pretty sick patient population (more below).
Ashwin Shinde@AshwinShindeMD
@free_radical28 @JNCCN Can't access the paper (JNCCN website seems to be down?) but 7.5% 90-day mortality seems very high for any RT modality, especially in M0 pts, does it not? Did you see a difference based on fractionation based on what we learned about 1Fx pancreas SBRT from Stanford?
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@KamravaMD @Sushilberiwal @DocGlaser @emmacfields @AnnKloppMD @ARRO_org 78% G3-4 tox is similar to GOG 279.... no mention of dermatitis in definitive vulvar treatment?
I get the draw but I'd be a bigger proponnt of studying further dose escalation with interstitial boost or more EBRT than just throwing more systemic therapy at the problem.
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@AshwinShindeMD @Sushilberiwal @DocGlaser @emmacfields @AnnKloppMD @ARRO_org Just add pembro it’s the new bev in gyn cancers. ascopubs.org/doi/10.1200/JC…
Some early data reported at asco recently
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Multi institution largest series for definitive chemo RT for cancel of vulva lead by Anupam Rishi from Moffet @DocGlaser @KamravaMD @emmacfields @AnnKloppMD @ARRO_org pubmed.ncbi.nlm.nih.gov/40513383/
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@ProtonStorey NHS cuts per google began in 2010, a year after enrollment on ProtecT stopped. Apparently accelerated in 2015 but I wouldn't know specifics. Presumably they have less inflation-adjusted resources now than they did back then.
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@AshwinShindeMD Protect trial: AS =annual visit with 6 mo PSA after yr1. Trigger was doubling of PSA in 12 months - or "concern". If that is stressing the system, it speaks to the system collective resources. And if they can't treat the IR or HR cancers, they find...
nejm.org/doi/full/10.10…
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Insufficient capacity?? Like UK can't draw blood on that many men? Wow... Obviously that is just poorly written - I hope. And I disagree, I think the data is quite clear.
Imperial Prostate@IP_London
Powerful opening from @LondonProstate1 to the #BAUS25 plenary session We have insufficient capacity and data to endorse screening in 2025. New evidence is critically needed first Watch this space for the £42M #TRANSFORM screening trial - Phase 1 will start later this year
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Ashwin Shinde retweetledi
More to learn from molecular based treatment for endometrial cancer @KamravaMD
ASTRO@ASTRO_org
New in the #RedJournal: MLH1 promoter hypermethylation was associated with worse recurrence-free survival compared to somatic dMMR and pMMR in stage I-II endometrial cancer treated with adjuvant radiotherapy. tinyurl.com/hathoutred
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@DrSpratticus Stage III Larynx/Hypopharynx, III/IVA p16- OPhx, any stage p16+ OPhx, why would one even do surgical resection rather than an organ preservation approach?
This is a ph III trial with no standard arm. The only groups that should be getting surgery is OC and T4 Larynx
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For those stating this approval was based on a surrogate endpoint this is incorrect. EFS in LA-HNSCC is not a surrogate endpoint for OS.
Thus, FDA approved this based on it believing EFS carried independent value.
Curious to peoples thoughts if that is a sufficient bar for a therapeutic that costs $100ks with real side effects realizing delaying recurrence is impactful.
Oncology Brothers@OncBrothers
Pembrolizumab now @FDAOncology approved in resectable LA-HNSCC based off KEYNOTE-689: - mEFS: 51.8 vs 30.4 most (HR: 0.73) - Benefit greater with CPS ≥10 (HR 0.66) - 2yr EFS: 75% vs 62% #OncTwitter #MedTwitter @OncoAlert #ASCO25 #AACR25
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