November, 2015

Never Surrender

By Michael J. Katin, MD

Was it a coincidence that the 27th Annual Meeting of the American Society for Radiation Oncology was held in San Antonio, Texas, site of the Alamo? In fact, the Alamo is pictured on the cover of the supplement to the IJROBP as if to further emphasize the desperate plight of our specialty. The Alamo is the symbol of resistance to overwhelming odds, although the result was the death of nearly every defender. The eventual outcome of the conflict was the establishment of the Republic of Texas, which was later annexed by the United States of America in 1845. Less well known is that, despite the victory of the Texians (actual spelling) over the Mexican army in 1836, Mexico continued to threaten Texas independence, with San Antonio's having been recaptured as recently as 1842. After annexation,, Texas' geographical sovereignty was assured, with it becoming a valuable addition to the United States. Except, of course, until February 1, 1861, when it voted to secede from the Union. Texas was restored in June, 1865, giving rise to the Juneteenth holiday now celebrated In 43 states and the District of Columbia. Texas has remained a valuable addition to the United States ever since.

Does using the symbol of the Alamo indicate the sense of frustration of radiation oncologists in having to constantly fight against lowered fee schedules, incursion by other specialties, and, particularly, the threat of absorption by Medical Oncology if disease-based payment schedules are adopted? Do we, as did Texas, temporarily triumph over these odds only to be absorbed by a much larger entity? Or is it simply that San Antonio offered the best deal on convention center space and hotels? Probably.

The main goal of this month's column,, however, is to honor the most distinguished presentations given at the 57th Annual Meeting of the American Society of Radiation Oncology, not to anguish over the fate of our specialty. This was made somewhat more difficult this year by the embargo policy established in the letter of October 1 reminding us that this material was to remain confidential until the time of the actual presentation at the end of the month. Penalties for violating this confidentiality were not specified but would undoubtedly be harsh and merciless. I thought it prudent to not even look at any of the abstracts until after October 21 rather than risk violating this policy. It then turned out that for the first time poster viewing abstracts were not included in the printed supplement to the IJROBP, meaning that anyone who wanted to browse through at this or her leisure would have to do this on line, somewhat less convenient and more cumbersome. Was this an attempt to discourage granting appropriate recognition, as has been done in this column for the past three years? Suspicious.

In any event, despite these obstacles, it is still possible to recognize the efforts of thousands of clinicians and researchers who devoted untold hours of work on advancing the cause of science and, more importantly, padding their CVs

Category I: Too good to wait until 2016

Honoring the two abstracts assigned fractional numbers, obviously necessary to be intercalated into the 2015 abstracts because of their importance, or due to an error just as the list was being finalized. At least they got more attention this way.

31.5 Neoadjuvant IMRT with Chemotherapy for Esophageal Cancer Allows Cardiac Sparing Without Increasing Postoperative Pulmonary Complications MGH No patients experienced radiation pneumonitis.

202.5 Clinical Radiation Pneumonitis After Chemoradiation Therapy for Locally Advanced Non-Small Cell Lung Cancer: Do Taxane-based Regimens Increase the Risk? Wayne State 26% of patients developed clinical radiation pneumonitis.

Category 2: Preventing 202.5

344 Decreased Risk of Radiation Pneumonitis With Proton Beam Therapy in the Definitive Treatment of Non-Small Cell Lung Cancer MD Anderson 6% vs 13% for IMRT

346 Baseline Plasma Proteomic Analysis to Identify Glycoproteins for Prediction of Radiation Induced Lung Toxicity in Patient With Non-Small Cell Lung Cancer Find out in advance who shouldn't go to Wayne State

Category 3: Unexpected Outcomes

80 Comprehensive Geriatric Assessment as a Predictor of Quality of Life and Toxicity in Older Patients Receiving Radiation Pretreatment functional deficits went along with continued decline; in other words, patients who were sicker did worse.

271 Insurance Status Predicts Outcomes in High-Grade Gliomas: A Population-Based Study. Includes the observation that insured patients tended to live in areas with less poverty.

141 Impact of a Dedicated Palliative Radiation Oncology Service on the Use of Single-Fraction and Hypofractionated Radiation Therapy Among Patients With Bone Metastases Patients get treated on protocols at places whose mission is to set up protocols to be used.

296 Survival Impact of Increasing Time to Treatment Initiation for Head and Neck Cancer in the United States Increased risk of death when treatment starts after more than 46 days. 46 days=more than 6 weeks! 40% of patients treated with chemoradiation at academic institutions had time to initiation of more than 46 days!!!!

Category 4: Never Hurts To Do It Right

194 Benchmark Credentialing Results for the first Multiple Metastases SBRT Protocol: NRG BR001 Only 9 of 22 institutions submitting benchmarks were approved the first time and only 16 of 22 eventually.

Category 5: Job Insecurity

272 Employment Following Radiation Oncology Residency: A Survey of the Class of 2014 4.4% to 7.4% unemployment 6-8 months after residency.

189 Single-Blind Trial of Knowledge-Based Automated Planning Versus Manually Planned Stereotactic Radiosurgery (SRS) In 83% of cases automated planning was superior or equivalent.

Category 6: Maybe this year

109 Nanoparticle Co-delivery of Docetaxel and Wortmannnin Improves Therapeutic Efficacy As Chemotherapeutic and Radiosensitizers. Annual abstract including the word "Wortmannin."

Category 7: Say what?

32 Validation of a Causal Factor Taxonomy Used in Radiation Oncology Incident Learning. Whatever.

291 Impact of Radiation Oncologist Provider Volume on Clinical Outcomes in Head and Neck Cancer. Oh. Not the target volume. Interestingly, for each additional head and neck cancer patient treated by an individual practitioner the risk of cancer-related death decreases by 0.8% Assignment: calculate how many one would need to treat to be able to cure every case.

Category 8: The price is right

206 Neurocognitive Preservation for Whole-Brain Radiation Therapy is Cost-Effective for Well Selected Patients. Calculates the incremental cost effectiveness ratio at $171,697 for whole brain irradiation and $241,567 for whole brain irradiation with hippocampal avoidance per quality adjusted life year gained. The threshold for cost-effectiveness is set at $100,000. Health states were cognitively intact, cognitively impaired, and dead. The conclusion was that neurocognitive preservation strategies may be cost-effective for patients cognitively intact at baseline with long expected survival. Not a surprise that "cognitively intact" was better than the other two states.

Category 9: Fine swine, wish he were mine

164 Restoration of Parotid Secretion Using Ultrasound Assisted Gene Transfer of Aquaporin-1: A Promising Preclinical Application. Seriously, may be a major advance, but so far done only in swine. They failed to benefit, however, since rather than having parotid biopsies afterward they were sacrificed to obtain the parotids and ribs.

And Finally:

Category 10: Real science

Just as our role in treating cancer patients seems to be eroding with the rise of immune modulators and vital therapies, at least some researchers are trying their best to bring us back into play.

322 The HIV-Derived Protein Vpr25-96 Has Antiglioma Activity in Vitro and In Vivo (used in conjunction with photon irradiation)

126 Clinical Outcomes of Melanoma Brain Metastases Treated With Stereotactic Radiation and Anti-PD-1 Therapy

149 Abscopal Responses in Metastatic Non-Small Cell Lung Cancer (NSCLC) Patients Treated on a Phase 2 Study of Combined Radiation Therapy and Ipilumumab: Evidence for the In Situ Vaccination Hypothesis of Radiation

Maybe this won't be our last stand after all.

Bernie Sanders (to the tune of Mr. Sandman )

Bernie Sanders, we have a dream
You'll win the White House in 2016.
We love your wit, your style and your vision
You put the social back in social-ism!

Bernie Sanders, give us a sign
Can you please make Janet Yellen resign?
Wipe out all of Wall Street's schemes
Bernie Sanders, bring us our dream.

Bernie Sanders, we all agree
Our education should always be free
Please make tuition unnecessary
And get us free ice cream from Ben and Jerry!

And we know that you can arrange
Ways to make sure that the climate won't change
Coal and oil are obscene
Bernie Sanders, bring us our dream!

Bernie Sanders, we want to be
A generation with equality
For poverty, you've got the solution
It's just a matter of redistribution

Bernie Sanders, we like your view
That billionaires are not paying their dues
We'll tax them mercilessly
Bernie Sanders, bring us our dream!

Fix our health care, it would be swell
If "single payer" would make us all well
The power structure you can untangle
You'll be the greatest guy since Marx and Engels!

Bernie Sanders, tell us your plan
To get our troops home as fast as you can
We'll all live amicably
Bernie Sanders, give us,
Please, please, please
Bernie Sanders, give us our dream!