October, 2015

San Antonio Woes

By Michael J. Katin, MD

Later this month the cream of the specialty of Radiation Oncology will be gathering in San Antonio, Texas, for the 57th Annual Meeting of the American Society of Radiation Oncology. San Antonio is currently the 7th largest city by population in the United States and conceivably could move up to number 5 in the next few years. San Antonio has a lot of activities for visitors which, ,unfortunately, the attendees of the ASTRO Annual Meeting will probably not experience since they will be concentrating on business, but there are certain aspects that make one wonder if the location of the meeting at this time in our professional history may have inauspicious connotations. Will San Antonio spur us on to action, or will it be a last stand?

But first, for those who will be accompanying the active participants in the meeting and who will be able to appreciate the finer aspects of San Antonio, be aware that there are multiple historical and cultural opportunities to experience while your companions are in sessions

For animal lovers, the San Antonio Zoo gives a unique opportunity to see animals at close range in habitats far removed from their natural environments. This may not last indefinitely, since it is the only zoo in the United States listed among the five worst zoos in the world. . There still may be a chance to see "Lucky," the zoo's only elephant, and responsible for its being named the "Worst Zoo for Elephants" over the past several years. For those who are interested in seeing large aquatic creatures in cramped quarters, SeaWorld San Antonio is located only 15 miles (13.03 nautical miles) from downtown San Antonio Unfortunately, the dolphins at Dolphin Cove may be under restricted access right now. This is unfortunate, since they were so tame it was found that they would eat right off your hand Howl-o-Scream (which probably helps the marine mammals get the big picture ) will be contemporary with but not directly linked to the frightening events during ASTRO's Annual Meeting. Finally, for those who can't get to either location, there should be plenty of wildlife readily available locally.

History and culture can be had at the Institute of Texan Cultures, which originally was the Texas Pavilion at HemisFair '68. Special exhibits in October include Texas' clnema history, culinary developments, and interior design. One can then go the short distance to the Tower of the Americas, which was the tallest observation tower in the United States from 1968 to 1996 and which until 2007 was topped by the Eyes Over Texas revolving restaurant, which is now a Chart House, one of only 28 in the United States. Endangered sea bass for $41, anyone?

While in HemisFair Park, one can note the Lila Cockrell Theater, renamed for the four-term mayor of San Antonio, often, but incorrectly, listed as the first female mayor of a major United States City. This is adjacent to the Henry B. Gonzalez Convention Center, home of the ASTRO Annual Meeting, and named after Enrique Barbosa Gonzalez, elected to one partial and then eighteen full terms to the United States Congress. Interestingly, despite the large Tejano population in this area, Mr. Gonzalez was the first person of Mexican descent to be elected to the San Antonio City Council (although Juan Seguin was mayor from 1841-1842), first to the Texas Senate in 110 years, and the first elected to the U.S. House of Representatives from Texas. In addition to his many accomplishments, he is also noted for having been in the motorcade at the time of President Kennedy's assassination and having thereafter encouraged the creation (and later chaired) a House Select Committee to re-investigate that crime. He also filed bills in the House of Representatives to impeach President Ronald Reagan and twice against President George H. W. Bush. Officers of ASTRO may need to pay heed.

It is possible that visitors will be exposed to conjunto, a genre of music developed in that part of Texas, with artists such as Eva Ybarra, Flaco Jimenez, and Doug Sahm (and all the Texas Tornados ), but, in fact, the most well-known musicians originating in this area were famous for a more commercial variant (uno, dos,one, two, tres, quatro!) .

Having seen what San Antonio has to offer, why should there be concern about the significance of the selection of this city for ASTRO's 57th Annual Meeting? First, San Antonio is in Bexar County. In 2013, GlaxoSmithKline discontinued the manufacture and sale of Bexxar, a radioisotope-immunoconjugate which was not able to be successful due to competition from pharmaceuticals able to be administered by medical oncologists. Ironic that ASTRO's slogan is "Targeting Cancer Care" and a targeted therapy has been abandoned. Posssibly an extreme coincidence, but just the beginning.

The major musical event occurring during the time of the ASTRO Annual Meeting is the appearance of Jackson Browne at the Majestic Theater on October 20. One of his most famous songs, "Running On Empty," other than expressing what we all feel we're doing with our practices, includes the words "I look around for the friends I used to turn to, to pull me through, looking into their eyes I see them running too." Another of his most famous songs: "Doctor My Eyes." A coincidence? As if that were not enough, at the Alamo City Music Hall on October 19 will be appearing We Came As Romans, All That Remains, Red Sun Rising, and Like Moths To Flames. It's hard to believe all four supergroups will be appearing at the same venue, but note at least three have pessimistic names (Romans are long gone) and All That Remains had hits with "Asking Too Much " and "This Probably Won't End Well," obviously referring to the upcoming decision by CMS on the 2016 fee schedule. Like Moths To Flames recorded the ominous three titles, "What's Done Is Done," "Learn Your Place, " and "You Won't Be Missed." I can visualize the video for "Learn Your Place" being re-enacted at many oncology centers after CMS releases its final rule.

The final piece is obvious. It was on March 6, 1836, that a garrison of Texians (the term then) from multiple parts of Mexico, the United States, and Europe were overrun by the army of General Antonio Lopez de Santa Anna. The best-known of the defenders were Jim Bowie, William B. Travis, Brian Williams, NBC News, and Davy Crockett. Historical reports vary but there seemed to have been at the most one survivor, who later died from wounds.

Our specialty has been under siege both from pressure from numerically and logistically advantaged medical oncologists and financially from diminishing payment for radiation oncology, which is the most consistently proven treatment against cancer. The CMS decision in November may be devastating but not yet fatal, but plans for new payment models, including diagnosis-related bundling, may result in the final overwhelming of our defenses. As with the defenders of the Alamo, it was possible to hold out for a finite length of time but that time came to an end. It would probably, in retrospect, have been wiser to have held this annual meeting in a less symbolic location. It might be said that the Texians eventually prevailed, but also note that within ten years they joined with the United States rather than remaining independent. Could the analogy be any more obvious?

The music to be heard at the conclusion of ASTRO's 57th Annual Meeting will probably not be by Jackson Browne

Emanuel Countdown: The Emanuel Countdown will be suspended for several months, to be replaced by a tribute to each of the 37 persons currently seeking the position of President of the United States. The Emanuel Countdown will resume after the nominees of both parties have been selected. The clock, however, will still be running.

Carly Fiorina (to the tune of Mona Lisa )

Fiorina, Fiorina, you're contending
For the nomination of the GOP
And you hope the voters will be comprehending
You're the only one who could beat Hillary.

The campaign is moving onward, Fiorina,
But you'll have to get beyond your history
Thirty thousand lost their jobs at Hewlett-Packard
Did you cause it, while you bossed it?
Could another CEO have done it better,
Or was it just a cycle in the industry?

Fiorina, never held elective office
Barbara Boxer beat you back in twenty-ten.
But the other candidates should now be cautious
Since you've learned a lot of strategy since then.

You were trailing very badly, FIorina
But your polling numbers took a major jump
Two debates is what it took to make it happen
You outguessed them, and impressed them
Are you real, can you win it, Fiorina?
Or are you just the face that bothered Donald Trump?