Thread by @subatomicdoc

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Thanks for bringing this point up. If you haven't practiced in an underserved community in the U.S., you don't realize the degree of selection bias that exists in patient population. 1/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree In my career working in NH and MA, a significant minority of my patients who could not or would not leave the community for an academic center. In Massachusetts insurance is required but many aren't accepted at major academic centers. 2/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Many good people don't have the ability to go to major centers for care. They deserve the opportunity for options offered to healthier, wealthier, more mobile, and/or more educated people. 3/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree If you base a 'low volume' vs 'high volume' center argument upon U.S. data, you stand on quicksand. These studies show a correlation between high volume and better outcomes that may be partly based upon socioeconomic status, zip code, language barriers, or insurance. 4/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Some data do include SES/insurance in multivariate models, but what it proves is a correlation, not a causal relationship. Why? Because no one had studied carefully what it means beyond that better outcome. 5/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Specific to radiation oncology outcomes: Is it because of better support staff? More dosimetry and physics FTEs? Using certain processes in supportive care? Quick access to specialized care for complications? We don't know. 6/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Community based radiation oncologists do likely 'undertreat' in some circumstances partly because we access to care issues but also access to adequate information. 7/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree I've seen the low vs high volume argument based upon clinical trials data also. The problem with RTOG trials were they were liberal but experienced centers used tighter constraints. Experienced trialists learn before publication, the rest of us don't know unless told. 8/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Community doctors adjust when toxicity data are published. But that makes any secondary analysis of low vs high volume centers useless. If we had been given guidance how to do it while the trial was open we would have. 9/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree I have a couple of separate points I'll mention after I finish this thought. But to finish it and come back to the equity piece - if you do believe that high volume centers are better, then more needs to be done than just publish that they're better. 10/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree If there are critical factors to success in improving outcomes that high volume centers have learned, there is an ethical obligation to define those factors so we can improve care beyond academic centers. 11/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Point 2. Do keep in mind there is selection bias also in the physician population. Doctors choosing non-academic careers differ from those remaining in academics. A key problem is that non-academic doctors don't publish in peer-reviewed literature much at all. /12

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Because it's rare for doctors to move back into academics from non-academic positions (at least in U.S. radiation oncology, my bubble), experience from the community isn't part of the debates we have. 13/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Social media allows the 'silent majority' of community doctors to bring new perspective to the table often not addressed in peer-reviewed publication. I don't know whether we'll do it well or not, but the opportunity is there. 14/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree Point 3. Access to information. In circumstance of considering local recurrences potentially with a curative option but not great data, it would be great if IR, #radonc, thoracic surgery in this case pooled estimates of risk into one place for a non-specialist to access. 15/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree If non-academic oncologists have access to super-specialized data in an efficient way, we could probably help patients make more informed decisions for re-treatment either locally or at an academic center. 16/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree @SprakerMDPhD and I have discussed this related to sarcoma but it applies to all of us. Crowdsource information that we can't all keep up on, and 'generalist' radiation oncologists may be able to discuss risks/benefits of retreatment better. 17/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree @SprakerMDPhD That is one of the goals of @Rad_Nation but it's a matter of having time and resources, including human capital, to do it. 18/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree @SprakerMDPhD @Rad_Nation We can make resources available to help more patients beyond academic centers. But only optimally if we do it across non-academic/academic and specialty-specific boundaries. 19/

@MCWardMD @_ShankarSiva @biniamkidaneMD @maraantonoff @BrendonStilesMD @EvanThomas84 @gerryhanna @WashURadOnc @JeffBradleyMD @SBRT_CR @TomVargheseJr @fifimcdrmh @Mat_Guc @PercyLeeMD @OncoAlert @DrAndrewLoblaw @alison_tree @SprakerMDPhD @Rad_Nation I also agree with @biniamkidaneMD - in retreatment we must be explicit about potentially serious to lethal toxicities of re-irradiation or any retreatment, especially since cure may be less reasonable and QoL becomes increasingly important. 20/fin