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November, 2020

Embargoncology

By Michael J. Katin, MD


Another mindless crime
Behind the curtain
In the pantomime
Hold the line
Does anybody want to take it anymore?
The show must go on
The show must go on, . . Queen, 1991

The world was engulfed with the worst pandemic in over 100 years, with 42,439,400 cases and 1,147,192 deaths from SARS-CoV-2 as of October 24. War was raging between Armenia and Azerbaijan. India and China are on the verge of major conflict over Ladakh. Ecosystems are being destroyed in Mauritius after a huge oil tanker spill and severely threatened in the Red Sea and Caribbean from two other oil tankers, each with more than 5 times the quantity of oil discharged by the Exxon Valdez. As of October 25, 20 wildfires were burning in California. A murder hornet nest was discovered in Blaine, Washington. Despite these harbingers of the End Times, the American Society for Radiation Oncology bravely moved ahead, virtually, with its 62nd Annual Meeting. As Najeeb Mohideen, MD, FASTRO, Senior Editor of ASTROnews expressed, "The Show Will Go On.....prepare to be teleported through the virtual doors of the Miami Beach Convention Center."
How closely the virtual doors resembled the real thing remains questionable, but there was no dispute as to the need to keep the outside world on edge about the proceedings. The pressure was on in earnest, with ASTRO members sworn to keep secret the abstracts ("embargoed ") to which they had access for several weeks until the presentations were officially made at the virtual meeting or an ASTRO press release. I personally received multiple inquiries from Reuters, RT Television, and Brian Williams, MSNBC, and I am relieved to report that I did not give in to their offers, although I hope my colleagues were equally resistant.
Fortunately, the time restriction has now passed, and it is now safe to recognize the ten most significant presentations at the Virtual 2020 ASTRO Annual Meeting.

  1. Being Incredibly Defensive about Accusations of Overtreatment Award: 1190, "Development and External Validation of a Nomogram to Predict Distant Metastases after Stereotactic Radiation Therapy in Early Stage Non-Small Cell Lung Cancer Patients."
    16% at one year for high risk, 6% for low risk. Too bad everything considered "high risk" doesn't turn out that well.
  2. It's All about Us Award: It's a Tie!!! 1013, "Burnout among Radiation Oncology Providers and Staff in a Large Academic Center." Sure, you've got metastatic anaplastic thyroid cancer. And COVID-19. But at least you're not suffering like a radiation oncology provider.
    107. "A Pilot Trial Using Telehealth in Radiation Oncology: The Future of healthcare is Virtual." Almost apocryphal considering the virtual Annual Meeting. For providers who are afraid to be in the same room with patients. Also the winner of the Rahm Emanuel Award for never letting a good crisis go to waste.
  3. Debbie Downer Award. 1067,"Tumor Volume after Radiotherapy: A Potential False Sense of Security." Lage volume reduction may correlate with worse overall survival. At least had a few weeks of encouragement. Alternative: Good news! The tumor didn't shrink!
  4. Andrew Yang Award: 143, "Association of Financial Burden with Symptom Burden and Health Related Quality of Life in Prostate Cancer Patients Receiving Radiation Treatment." Wouldn't this apply to ALL patients? What about ALL PEOPLE? UBI would solve a lot of problems, plus make patient experience and satisfaction data look better for MIPS. Everybody wins!
    Honorable Mention: 206, "The Financial Toxicity of Parking Fees for Radiation Treatment at NCI-Designated Cancer Centers." Collateral hardships. See #5.
  5. Maslow Hierarchy of Needs Award: 1039, "Utilization of Radiation Therapy and Predictors of Noncompliance among Syrian Refugees with Cancer Living in Turkey." Amazingly, residence in a refugee camp was significantly related to noncompliance with radiation therapy, as was also advanced stage of disease and use of chemotherapy. The impact of parking fees was not addressed. Also amazingly, it reports that Syrian refugees had free screening and treatment. Too overwhelming to process, including that this generated an abstract.
  6. (Platinum) Kitchen Sink Award: 1086, "Trimodal Therapy Consisting of DNA-PK Inhibition, PD-L1 Immune Checkpoint Blockade and Radiotherapy with Carbon Ions." Currently used in mice but could become standard of care, in a system that doesn't want to pay for us to use IMRT for lung cancer.
  7. Too Small to Fail Award: 1055, "Drivers of Medicare Spending: A 15 Year Review of Radiation Oncology Charges Allowed by the Medicare Physician/Supplier Fee-for-Service Program Compared to Other Specialties." Radiation Oncology charges are a whopping 1.4% of total charges allowed by Medicare in 2017. Barely a rounding error. Yes, we'd better rein that in.
  8. Too Big to Fail Award: 1149, "Conventionally Fractionated FLASH Treatment Planning for Head and Neck Cancer Using Transmission Beam Proton Therapy." Sounds great in principle. Can you imagine if it turns out to be the ultimate treatment? 1.4% will be a thing of the past!
  9. Actual Practical Science Award: 1043, "Isolated Low Left Coronary Artery Dose Exposure -- Reduces the Risk of Major Cardiac Events in Lung Cancer Radiotherapy: Should Mean Heart Dose Be Retired?" There had to be one clinically significant contribution in this whole collection!
  10. Promised Land Award: 14, "Focused kV X-rays for Preclinical Studies of Radiation-based Neuromodulation." The critical two sentences in the abstract: "The advancement of functional brain imaging has revealed regions of hypermetabolism that correlate with psychiatric illnesses. Radiation-based neuromodulation may offer an optimal tool to downregulate the hypermetabolic foci while preserving basic nerve functions." No matter how much Evicore and CMS want to downsize us, no one is against treating mental illness. Don't bail out on our specialty yet! There might yet be an ASTRO Annual Meeting in 2030!

Bonus: I Won't Concede (to the tune of "I Dreamed a Dream ")

Shortly after this month's column is posted, the Presidential Election will be held, with incumbent Donald J. Trump challenged by Joseph R. Biden, Jr., and Joanne M. Jorgensen. The following will probably appear in a tweet in the event of Mr. Trump's loss:

Life was more fun before I won
I could party with Ghislaine and Jeff
And the press was kindly
Then the voting was done. I shocked everyone
And the media said all I did was wrong
And then all my friends would malign me.
After I won
Then I didn't belong.


But this November I'll be strong
No way I'm losing to Joe Biden
I've got my base to stand by me
He's got a basement that he hides in.
All the people will recall
When the economy was thriving
They know we'll make it great again
And that a vaccine is arriving.


But Pelosi and her mob
Backed by all the never Trumpers
Want to take away my job
Cancel all that we've begun.
But what if I can't pull it off?
What if the people say, "You're fired?"
A stable genius can't feel lost
Is this a deal that can't be done?

The Southern District of New York
Will have me as its guest of honor
Wish I could get back Michael Cohen
To save me, Jared and Ivanka.

I took impeachment in my stride
I got the best of Robert Mueller
With house arrest can I decide
Either Trump Tower or Mar-a-Lago?


If I should lose I have a plan
I'm going to blame it all on COVID
Electoral College has to meet
I'll tell them Fauci said to close it.

And if we can't win on recounts
And the Supreme Court can't reward me
I'm locking down the White House grounds
They won't
Get me
I can't
I won't
Concede.


Asteroid JF1 Countdown: Asteroid JF1 will be impacting with or passing by Earth May 6, 2022, which, counting May 6, is 552 days from now. Plenty of time left to stock up on batteries, plywood, hand sanitizer, bubble wrap, hydroxychloroquine, and duct tape.