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Mark Storey
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Mark Storey
@ProtonStorey
Dr. Mark Storey MD - Radiation Oncologist. @OKProtonCenter. Background: #MDAnderson @VanderbiltU @BMESociety #RadOnc My blog: https://t.co/4S0MeQiWEI
Oklahoma City, OK Katılım Haziran 2019
442 Takip Edilen1.6K Takipçiler
@savadMG Medicare is federally run. Medicaid programs are state run and states got to "reset" payments when the federal program "restructured" radiation payments.
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$39 dollars for IMRT in CA. New Jersey at $21. These are real Medicaid rates post the CMS restructuring. Goal: 1) Raise awareness, 2) Actionable letter.
Rome burns.
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14 facility closures year to date. More than 20 considering closer by end of summer.
Industry has sold the US equipment and sees our market shrinking so their interest is elsewhere in the globe.
If you lead a large program - your voice is critical to these financial issues.
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AI says RayStation python scripting can handle this essentially in one click via the route you are discussing. Burning dose into the pixels so the "dumb" PACS end can display. We're busy and don't control the PACS but have a few doing projects - I'll see... What AI says vs. reality isn't always right, but it followed right along with your thread easily. 10 min of steps into a repeatable script. Again, give me a bit.
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Yes, me too! Sometimes I'll throw in some relevant RT DICOM slices in my notes but I don't expect my radiologist to pull it up when reading scans. As for radiology reads, typically will give brief history in the reason for exam when ordering imaging and that seems to help radiologists as well, though often history is too complex for a single line. Ideally they'd have a fused DICOM with overlying RT DICOM in their native PACS workflow
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1/
A very real problem in modern radiation oncology:
The treatment plan is often highly detailed.
The hospital record is often not.
The TPS knows exactly what we treated, where we treated it, and to what dose.
But much of that context never leaves the bunker.
#ESTRO26 #RadOnc
Jeff Ryckman@jryckman3
6/ Radiology has PACS. Radiation oncology really does not. Our TPS does an amazing job planning dose. But we lack the hospital-wide communication layer that lets any clinician understand: What was treated? Where? To what dose? With what expected imaging change?
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@Nat83052921 @HardenedBeam Maybe but 640 randomized pts point to far less tube requirements. It would be quite ironic for this to be bias in favor of protons.
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@ProtonStorey @HardenedBeam IIRC feeding tube policy was mandated in only 2 centers, so the higher feeding tube in IMRT might be due to more prophylactic tube placement due to center policy.
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This isn't quite right though. There were improvements even in the negative TORPEDO trial - just temporary. This is kind of the opposite take to leaning into an OS survival.
"No QoL". From a patient perspective, I'd think they 100% think these are improvements.
Pierre Blanchard, MD@PBlanchardMD
No QoL difference with IMPT vs IMRT in oropharyngeal cancer in the TORPEdO 🇬🇧 trial. How to explain the differences w/ @SJFrankMD 🇺🇸 trial? Planning? Patients? Crossover in the 🇺🇸 trial? Real absence of difference? Cc @EmmaHall71 @
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@_ShankarSiva @TheLancetOncol Did you call them all again to personally verify ZERO failures like you did with the earlier analysis? 🤣 Congrats man. To think this was radio-resistant two decades ago
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Thank you @TheLancetOncol for accepting the concurrent publication of the data…. To read more see QR code here; #ESTRO26 #radonc
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#ESTRO26 - 📣 FASTRACKII final results, median F/U of 5 years. Thank you patients, funders, investigators - #kidneycancer #kcsm
1) 100% Local Control: No local recurrences were observed at 36, 60, or 84 months.
2) 100% Cancer-Specific Survival
3) Grade 3 AEs remain at 10%
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@seanmmcbride @VedangMurthy Just have a good international plan for cell calls - haha. Yep, we've had a couple of conversations on the differences in workflows and patient demographics here vs. there over the years. Some things directly apply and others I'm less certain of like you say.
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@VedangMurthy is one of the smartest prostate oncologists out there and, when he presented at MSKCC grand rounds, he made the important point that, in India, the local disease they're seeing is much more advanced than in the US (and presumably Europe).
Recall, PEACE2 included MRI-defined T3 disease.
My conclusion, integrating PEACE2, the NRG data presented at ASTRO, and POP-RT, is that in screen-detected HR or VHR localized PCa, especially where PSMA PET is NED in the pelvis, the benefit of elective pelvic nodal irradiation is de minimis. Once these trials are published, I think SOC, in screen detected, PSMA PET imaged HR or VHR N0 disease, is prostate-only RT.
That said, when you have PSMA PET N0 HR/VHR disease that is so locally advanced that it's causing symptoms or where you have GS9 disease where an MRI shows EPE/SVI apparent to even a 1st year medical student, only then should one consider elective pelvic nodal RT.
My two cents.....#ESTRO26
Vedang Murthy@VedangMurthy
@HimanshuNagarMD @piet_ost @SprakerMDPhD This is mostly STAMPEDE HR staged with CT Bone scan... And surely surprised by the results! Would love to see the effect cabazitaxel is having in sterilising micro mets.. Biological interaction? Food for thought!
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@jryckman3 @TonyFelefly Wonder if you can do something similar in RS via scripting - simply dump at EOT.
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Our main priority is automating the process on the backend during chart closure, so that manual adjustments on a per-patient basis may be avoided. It is tricky but we think we can build this solution in the near future. The programmer at MIM I have been meeting with was confident he could come up with something soon
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@DrStish @seanmmcbride Wow. Proof read tomorrow's again a few times. Haha. But exactly. I think that is key. By keeping yourself in the loop, it is far easier to have pts get rt early and appropriately. As a specialty, we really do know a ton of broad oncology.
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@ProtonStorey @seanmmcbride I sure am! It helped encourage me to continue and grow the practice I’d started. By establishing yourself as the primary clinician for prostate patients and managing their care in a longitudinal manner it helps ensure MDT gets considered at appropriate points.
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Agree with Dan on the undervaluation of RT to the primary in the AUA advanced prostate cancer guideline. The data are stronger than the guideline indicates.
On the Daro question, I'd argue that the strength of the evidence is sufficient to include it in the same category as the other ARPIs. Yes, ARANOTE did not (yet) hit the OS target. But follow-up was significantly shorter and the trial suffered from being run in a landscape where more effective salvage therapies were available. And the comparative HRs for rPFS looked equivalent to the other ARPIs (see below from clinicalkey.com/#!/content/pla…). I imagine a Bayesian re-look at the ARANOTE data, using a neutral prior, would suggest with something like 99% probability that DARO+ADT is superior on the survival end-point to ADT alone.
There's also no a priori, biological reason to believe that DARO would differ from ENZA or APA in underlying efficacy (at least none I'm aware of).
I think what's becoming increasingly clear though is that Daro offers a superior side effect profile (another link below). I worry that formalistic, over-emphasis on OS risks us under-utilizing a drug that, with a high degree of certainty, offers equivalent OS and superior QOL to the other first-line ARPI choices for mHSPC.
nature.com/articles/s4139…
That said, I admit it's a contestable grey zone, but a zone within which I'd say guidelines can reasonably differ. #AUA26 #radonc
Daniel E Spratt@DrSpratticus
The #AUA26 advanced prostate cancer guidelines may be some of the clearest evidence of guidelines being influenced by bias and/or industry. EAU and NCCN recommend with consensus the use of RT to the primary in M1. EAU is “strong” evidence. NCCN is 2A, which is where most RCT data lands. AUA not only gives it grade C, but also conditional. That is where RWD lands usually. However, darolutamide doublet AUA gives grade A evidence despite only rPFS and no OS benefit. RT to primary showed OS benefit with or without docetaxel and an rPFS benefit with even triplet therapy in peace 1. STOPCAP confirmed robust PFS benefit of RT to primary. Unfortunate when “guidelines” are ways to push AUA or society members beliefs rather than facts. Not to mention the radonc on the AUA guidelines is amazing but Zietman is retired. Was told from AUA guideline authors that this 2026 update didn’t even circulate to all authors 🤔🤔 @ChadTangMD @HimanshuNagarMD @ndesai2005 @SbrtSean @Soum_Roy_RadOnc @TylerSbrt @PCaParker @jamesbyu @Prof_Nick_James @NehaVapiwala @fabiomoraesmd @aleberlin2 @DrAndrewLoblaw @I_Migowski @DrOmarMian @Alejogom @BobTimmermanMD @ASTRO_org
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@seanmmcbride 2/2 And one way IMO to lower barrier to comfort using these drugs is focusing less on which drug used specifically in which setting/trial but instead finding 1 or 2 you are comfortable managing. Payors and clinical context may force other options, but not as often as many think.
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@TonyFelefly @jryckman3 @5_utr Generally agree, but there is more data coming out on immune effects generated by low doses. So as immunotherapies ramp in OS importance, I don't think this should be auto shelved as false.
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Regardless of methodology and not accounting for major factors here, does it even make sense to test if a Dmax of 7Gy to the SVC or the base of heart would correlate with OS?
This is a great example of trying to force-paint mortality events as radiation-driven
@jryckman3 @5_utr @DrewMoghanaki
Adela@adelapoite
Cardiac Dose and Survival Outcomes Following Stereotactic Body Radiation Therapy for Primary and Metastatic Lung Tumors: A Substructure-Based Analysis - Advances in Radiation Oncology advancesradonc.org/article/S2452-…
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"I just wish the discussion around the OS effect had been more realistic." I think our field has been quite cautious about jumping to this - if we had jumped to level of confidence, we'd be pushing for it to be standard - no? Maybe locally you are seeing things I haven't.
Certainly, I've always stated it needs confirmation - which as you note - hasn't shown up.
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Of course @SJFrankMD and the trial invesitgators should be commended for putting together this seminal study -- much of the other data will be very important for the field. I just wish the discussion around the OS effect had been more realistic. We are preparing the unpublished data above for publication with full details (stay tuned).
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Great letter by @SeanMcbride laying out real concerns with the OS claim in @SJFrankMD's proton vs. photon oropharynx trial. Compelling enough that Yingzhi Wu and @EChrisDee pulled our own data. We see no OS difference between protons and photons. Together with UK TORPEdO RCT, this adds to the concern that the randomized trial’s OS finding may be hypothesis-generating rather than causal.
Sean McBride@seanmmcbride
Our letter to the editor in The Lancet critiquing the MD Anderson-led trial of protons v photons for OPC. Appreciate @SJFrankMD's well thought out response. I think we can all agree on two points: 1) Steve deserves major kudos for bringing level 1 evidence to the debate on protons v photons for OPC. These trials are extraordinarily difficult to run, and Steve, et al pulled it off. Well done! 2) Longer term follow-up from TORPEdO will help tease out the extent to which protons improves OS in OPC. @CJTsaiMDPhD @drlorenmell @xrtGenomics @DavidSherMD #radonc #hncsm thelancet.com/journals/lance…
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@toddscarbrough Two of the next three. Few seem to appreciate.
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The #AUA26 advanced prostate cancer guidelines may be some of the clearest evidence of guidelines being influenced by bias and/or industry.
EAU and NCCN recommend with consensus the use of RT to the primary in M1. EAU is “strong” evidence. NCCN is 2A, which is where most RCT data lands. AUA not only gives it grade C, but also conditional. That is where RWD lands usually.
However, darolutamide doublet AUA gives grade A evidence despite only rPFS and no OS benefit. RT to primary showed OS benefit with or without docetaxel and an rPFS benefit with even triplet therapy in peace 1. STOPCAP confirmed robust PFS benefit of RT to primary.
Unfortunate when “guidelines” are ways to push AUA or society members beliefs rather than facts.
Not to mention the radonc on the AUA guidelines is amazing but Zietman is retired.
Was told from AUA guideline authors that this 2026 update didn’t even circulate to all authors 🤔🤔
@ChadTangMD @HimanshuNagarMD @ndesai2005 @SbrtSean @Soum_Roy_RadOnc @TylerSbrt @PCaParker @jamesbyu @Prof_Nick_James @NehaVapiwala @fabiomoraesmd @aleberlin2 @DrAndrewLoblaw @I_Migowski @DrOmarMian @Alejogom @BobTimmermanMD @ASTRO_org
Philipp Dahm@EBMUrology
Great value in side-by-side review of EAU and AUA prostate cancer guidelines in this new #AUA26 format. Good forum to review guideline methodology and reasons for discordance. Here @Tilki_De in session moderated by @Scarps_kristen
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@toddscarbrough I just won against an 800 ELO bot - what is your point. Haha
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1996 Deep Blue vs Kasparov...
KASPAROV wins
Rajesh Bhayana@RajeshBhayana_
"AI has gotten better than radiologists at doing scans" I put @DarioAmodei's claim to the test by pitting a radiology resident against a state-of-the-art Chest X-ray AI Agent built by my colleagues led by @BoWang87. What do you think?
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@drbeckta Out of the basement - that still fits man. Maybe your handle can be Dangerous Liaison moving forward.
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Well this seems like a great article to read while holding my uranium Rosary with my uranium teacup on my uranium saucer on my lap.
ASTRO@ASTRO_org
New in #practicalRO: Glowing Beauty: Collecting Uranium Glass—Dangerous Liaisons? #radonc tinyurl.com/promicke
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