2023: A look back
"Just write" for one year...
Just write - for one year.
In March of 2022, I went part-time. I wanted to see if I could do something more beyond the clinic. Wasn’t exactly sure what - a year and a half later - still am not. Help the specialty move forward on some level beyond just the reach of my practice. Maybe on the business side. Maybe on the proton side. Maybe teaching or educating young residents. Maybe consulting. Who knows…
My three year commitment to lead the proton center in Oklahoma had ended in February of that year. We had successfully acquired, upgraded, and recapitalized the facility. We brought it out of Federal bankruptcy and a small team of us figured out how to make it work. The entity is now restructured and repackaged as a non-profit. The original investors who believed in our ability to turn this thing around were rewarded - quite rare in the world of proton therapy ownership. And I opted to follow through with stepping down from being Medical Director and then a few months later, turned the day-job into a part-time gig.
When I first arrived at the proton center now approaching 5 years ago, I wrote a blog on protons. It was much more marketing oriented. At the time, there were really 2 of us working on marketing content and how best to spread the word locally - we were the entirety of marketing team for a quarter or two. I thought I wrote some decent stuff but it was purposefully much more strongly slanted towards a vision of where protons can be better rather than a scientific approach to look at data.
The craziness of covid landed and during that time I stepped back from writing and stepped back from what I thought at the time was an especially crazy time on Twitter and in the medical literature (now I think that is just a new normal). About a year later, knowing that I was going to step down in my clinic hours, I wanted to write again on topics. This time far more focused on the data and how to read and interpret the data in the time of narratives.
I have a concern, I think more and more each year, that the medical literature broadly has lost it way - moving a step or two (or a leap or two) towards narratives over data. Further, media coverage of medical data is even more slanted towards narrative, by large factors of scale. I wanted a platform to pass along some of what I’ve learned over last few decades and pass along an engineering slant to a review of our literature. That is what I have attempted this year. I’ve added in some opinion pieces and a few business oriented topics because business and medicine are intertwined and I’ve always seen it through that light.
You see, my dad was a car dealer and certainly a business view was ingrained as part of my world perspective at a young age. And ironically, as I went part time, he was diagnosed with metastatic adenocarcinoma of the abdomen. He was diagnosed in March of 2022 - essentially the moment I went part-time - within just a few days of my one and only ambulance trip (ruptured appendix - but that is a different tale).
As we all know, life can throw curve balls. He had no clear primary. Struggled with systemic approaches. Years of training in oncology and there was no reasonable target for radiation. In January of this year, he passed.
So as this year began, I decided to return to writing as a way to stay involved and productive within the shift to part-time. I started with a goal of 20 articles in the year - at least 15 minutes every day. Most days, I spent far more time than that. That was the goal, just write - focus on good balanced content here on this site and at the end of one year, assess. Maybe it would lead somewhere… Maybe it would help just a few consider things differently…
And today, as the year ends, we’ll look back.
A Look Back:
We’ve hit 70 articles. We have now over 390 subscribers. Nearly every article hits 500 reads. Many of the more recent ones ending up well over 1000 reads as the site / community has grown. In the course of the year we’ve had well over 30,000 article views and hit a high water mark of 6,000 reads in a 30 day period as the site continues to grow.
Sincerely, thank you for the support.
In less than 1 year, this small nuanced radiation site has grown from 0 to its current scale - seems kind of crazy in ways. Probably small for the internet, but for what we do, and the topics I land on - quite crazy - after all, non-inferiority, PSA kinetics, and Bayesian statistics aren’t top of the wish list for many.
We’ve covered a variety of topics - I’ll touch on a few below, but from business, to trials, to technology, to a few current narratives, it has been a great year of reporting our progress and our struggle to achieve better outcomes. Mostly positive but not all. The goal was to be balanced and call balls and strikes - hopefully I’ve come close on that front.
MAIN TOPICS OF 2023:
BUSINESS: From ViewRay, to ROCR, to the business of Protons and Pharma
TECHNOLOGY: SBRT, MRI Linac, Proton Therapy to gel and diagnostics
TRIALS: MIRAGE, PACE-B, FASTRACK II, FLAME, PRIME, RADCOMP and more
ECLECTIC: AI, non-inferiority, current narratives, and statistics
We’ve highlighted some of the great advances in our field. And yes, I’ve touched on some areas where I think we can do better, but the focus on my part is really to push us towards better. I rely and use our community to find content and ideas - if I missed credit somewhere for someone, my apologies and thank you. I’m certainly amazingly proud and humbled to be a part of this community of specialists working to help those with cancer. I feel blessed and fortunate daily for the opportunity to do what we do.
Looking back, in a year, there is a lot of radiation content. The above slide just emphasizes the point that if you are on the main page: at www.protons101.com or www.protons101.substack.com - the search box will initially ONLY show entries from my Substack. If you are looking for information, it has become a reasonable place to look for info. So if you type in “pace b”, three articles are displayed that mention that word / cover that topic. Obviously, I know what is in here, but about once a week I find myself searching to refresh details regarding a trial or approach. Maybe that helps one or two people out there.
I’m going to work on tags for organizing the content but it will be a slow process.
Central Themes Emerged:
We represent tremendous value.
We need to have a unified message of value due to our small size.
Technology is allowing for massive progress.
Financial pressures are real.
And with that, let’s look at the top 5 articles of the year - voted on by you guys based on reads.
Top Articles of 2023:
Number 5: That Money / Cost Thing
Whenever you link protons to the Deathstar, you have an internet winner and this one includes “The Deathstar of American Medicine”. It’s an old quote from an old story that headlines the piece. In this article that came out nearly 6 months ago, we talked about some of the fundamentals of the proton business and I tried to put that model into better context showing that yes, they are expensive, but so are college football practice facilities.
Number 4: SBRT for Renal Cell Cancer - FASTRACK II
Twenty years ago, who would have thought that a renal cell cancer trial would be at the top of any radiation site but FASTRACK II has well over 1000 reads and continues to grow. It was released during ASTRO and I had the opportunity to enjoy dinner and wine with the author. I think the included slides and details add value to the importance of this entry.
Number 3: A look at ViewRay
My look into ViewRay lands high on the list. I wrote it because, at the time I felt rather strongly that many in radiation oncology leadership were blindly disregarding the risk for the company. I think it lands here due to the timing and due to the fact that I had experience within Chapter 11 from our efforts here in OKC and when I write about business topics, the audience expands. Unfortunately for our field, much of what I worried about did, in fact, happen.
Number 2: Metastatic Disease - Massive Benefit
The most popular strictly science article of the year, this one benefits from coming on late in the year, but it really does have legs and continues to have an expanding reach. We talk about 4 randomized prospective trials from 2023 where radiation is clearly making progress improving the lives of patients. I think it speaks to the impact that, unfortunately, metastatic disease still has for our patients and a strong desire for us to improve their outcomes moving forward.
Number 1: If Radiation Were a Drug…
In what has become somewhat of a run-away winner, this editorial piece looks at bias in the literature. It was prompted by numerous articles over the course of the year, but really inspired by a scientific article looking at radiation coverage in the NY Times. I think it speaks to an understanding of the imbalances in the world today and acknowledges that we are, in fact, grossly outspent in the marketplace. And despite our amazing value (especially relative to many drugs), our work sometimes can fly under the radar of the headlines. But it shouldn’t. As I say repeatedly, we represent incredible value.
As I look back, I think we’ve done some interesting stuff. Maybe a few people consider things differently, and if so, we’ve done good. I put these together more as talks or stories and try to incorporate a broader view and describe how I think about things. Even if it helps just a few trainees learn just a bit, it has been well worth the effort. After all, the faster they can get up to speed, the sooner they can work on the next better thing. Nothing we do today is “good enough” - we must continue to search for better - our patients mandate that perspective.
Thank you for your support. It really does help in motivating things along at times. That said, I really enjoyed the year and the process and plan to continue. Certainly at the end of this one year I’ve met a ton of our community from across the globe. I’ve learned a ton in doing my work and made good friends along the way. No further promises at this time, but while it is enjoyable and good topics keep landing, I’ll keep writing.
My focus for the upcoming year is for each post to at least have one central topic or issue that I think is important for our field to address. I’m going to likely plan for every other week in the upcoming year. Weekly was fun but a lot of work and I only have so much experience and so many stories. Moving forward, I want to prioritize concepts - I do not want to be a “just a newsletter”.
I will also be turning on some form of payment / pledge / subscription option as we move into the new year - all content remains completely free, but I do wish to support Substack which provides an amazing writing platform and I want to have a better feel for AI and LLM usage / protection - we’ll see. Any monies pledged will be donated to charity - oncology based, undecided as of today. Again, all content will remain free - not doing this for revenue.
Here’s to witnessing a great year of progress in 2024 - that is my expectation. Keep up the great studies, and I’ll try to keep advocating for the great value we create.
Have a happy and safe New Years! Cheers to you for work you do in pushing for better outcomes for our patients!!
have really enjoyed your articles and perspective. Thank you.
Here's to another year of "just writing"...