Radiation Oncologist at Tulane/LSU/LCMC
New Orleans, LA
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Cancer stem cell biology is the ultimate driver of every step in cancer’s origins, progression, and resistance to therapy. Part 1 of our review of the potential for heavy ion therapy to solve this pressing clinical problem: appliedradiationoncology.com…
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Daniel Koffler, MD retweeted
Microwave ablation versus stereotactic body radiotherapy for oligometastatic colorectal liver metastases (LAVA-CRLM): a prospective, randomised, phase II trial
thelancet.com/journals/lanep…
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On Sept. 18, 2001, David Milch began a series of lectures called “The Writer’s Spirit.” On the 25th anniversary, we're sharing video for the first time. During the second lecture, David Milch read a passage from St. Paul’s 1st Corinthians which will be familiar to Deadwood fans.
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Daniel Koffler, MD retweeted
Radiology used to have something that was almost invisible because it was so routine:
The reading room consult.
Rounding teams came down.
Surgeons pulled up their cases.
Internists brought the scan that didn't quite fit the clinical picture.
Sometimes the radiologist solved the problem.
Sometimes the clinician supplied one piece of history that completely changed how the images were interpreted.
And usually everyone simply walked away a little sharper.
But something else was happening during all of those conversations.
We were learning each other.
As a radiologist, I learned what individual physicians cared about.
I knew which findings mattered to a particular surgeon.
Which measurements an oncologist was following.
Which details a specialist wanted emphasized.
What questions they were really asking, even when the order just said "pain."
And they learned me.
They knew who was reading their study.
They knew they could walk in, point at something, challenge an interpretation, or ask, "What do you think?"
That relationship created context.
It created feedback.
It created trust.
And over years, it created a kind of institutional knowledge that never appears in the medical record.
When radiology becomes a report produced by someone hundreds or thousands of miles away, we don't just lose proximity.
We risk losing that entire feedback loop.
The report may still be technically excellent.
But the radiologist knows less about the physician.
The physician knows less about the radiologist.
The radiologist sees less of what happened after the report.
And both sides lose opportunities to make each other better.
The reading room was never just a room.
It was where imaging became part of the clinical conversation.
We should think very carefully before designing that conversation out of medicine.
Inspired by a conversation yesterday with @PaleoOnc . Also @909One and @brianchiong .
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Daniel Koffler, MD retweeted
Important findings from the MAVERICK study. Cognitive toxicity is not an abstract endpoint! Memory, concentration, independence, work, driving, child care and simply feeling like yourself significantly impacts #QOL.
But surveillance isn’t burden free for patients & families. It’s regular brain MRIs, living with scan-xiety, time off work, transportation, access to timely imaging AND treatment when needed. We don’t want MRI surveillance to become a recommendation only available for people who have the resources and ability.
#WCLC26
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Daniel Koffler, MD retweeted
🚨🚨 Randomized Trial #WCLC26 Small Cell Lung Cancer MRI +/-PCI 🚨
• MRI alone superior cognitive outcome
• CFFS benefit of MRI alone similar in LS and ES-SCLC
• No diff OS
• MRI surveillance standard of care for SCLC
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Daniel Koffler, MD retweeted
Check out the first Spine Therapy Society consensus paper on a framework for pain phenotypes and spine oncology. It’s important to identify mechanical, biologic and/or radicular pain for tumor directed treatment. @ASTRO_org @CNS_Update @NeuroOnc
ascopubs.org/doi/10.1200/OA-…
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Daniel Koffler, MD retweeted
SWOG/NRG S1914: In patients with high-risk T1–T3N0M0 early-stage NSCLC who were medically inoperable or declined surgery, adding peri-SBRT atezolizumab did not improve PFS or OS and increased toxicity.
The trial was stopped early for futility.
thelancet.com/journals/lance…
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Daniel Koffler, MD retweeted
A drug priced at $450,000 per patient was thought not to be "reasonably likely" to have clinical benefit by multiple reviewers, who recommended against approval ... but one FDA official overruled them. Deja vu I guess.
A CBER official overruled reviewers to clear the path for Replimune's melanoma drug.
endpoints.news/cber-official…
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Daniel Koffler, MD retweeted
Another precision oncology failure! Zombie 🧟 premise: that we can identify the causal driver, that it’s singular, that inhibiting it collapses the network. We can’t. It isn’t. It doesn’t. The oncogene is not the disease. It’s the mutation we happened to sequence.
In a phase 1–2 study of daraxonrasib, 54% of patients with RAS-mutant non–small-cell lung cancer had grade 3 or higher adverse events, mainly pneumonia, diarrhea, and rash; more than 30% of patients had a response. Full study results: nej.md/4h0GHUW
ALT A graph showing progression-free survival in patients with RAS-mutant and RAS G12–mutant NSCLC who had received previous first- or second-line platinum-based chemotherapy and anti–programmed cell death 1 or anti–programmed cell death ligand 1 therapy but not docetaxel and received 160 to 220 mg of daraxonrasib.
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This is exactly what we found: post-op PET/CT sim detected early recurrence in 16.5% of resected OSCC pts vs 3.3% with CT alone (n=391, aOR 7.9). The highest risk was in the ECE/SM+ group, but the DFS/OS benefit was in intermediate-risk pts (HR 0.46). You can't unsee it
I now routinely perform PET-CT simulation for high-risk postop H&N cases and not uncommonly find residual (or progressive) FDG-avid disease.
It makes me question whether the postop RT literature on intensification needs to be re-examined. How much is the benefit of chemotherapy, or prompt RT start, or even nivolumab, related to its efficacy in managing actual gross disease versus microscopic residual.
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Daniel Koffler, MD retweeted
Thanks @JCO_ASCO for highlighting our article on on age, IDH status, and prognosis in lower grade gliomas. Age >40 is a surrogate for IDH status but not an independent prognostic factor in IDH-mutant glioma and does not predict benefit from CRT. Age is not an indication for CRT.
Prognostic and Predictive Effect of Age in Molecularly Defined Lower-Grade Gliomas. Co-authored by @TonyWangMD.
Read the full article. bit.ly/4g5e6gU
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Daniel Koffler, MD retweeted
@DGlaucomflecken made a post about how worthless med student research is and how it’s just making an arms race to create vast quantities of garbage to get into specific specialties. Let’s be honest : for a good decade #radonc was possibly the worst offender. (1/n)
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Daniel Koffler, MD retweeted
Third study to watch - SWOG S1827 / Maverick. Is PCI still needed upfront or can we use surveillance and salvage as the better approach. What's the impact on OS, cognition, and brain control. Does limited vs. extended stage disease change the balance point?
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Daniel Koffler, MD retweeted
Total Neoadjuvant Therapy With Long-Course Radiotherapy Versus Chemoradiotherapy in High-Risk Locally Advanced Rectal Cancer (TNTCRT): A Multicenter, Randomized, Phase III Trial.
Read the full article. bit.ly/4pV4dFF
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Daniel Koffler, MD retweeted
Can we shorten glioblastoma radiotherapy from 6 weeks to 2?
In the Dutch randomized phase III GOLD trial, 6×6 Gy + temozolomide was inferior to standard 30×2 Gy + temozolomide: worse survival, PFS and HRQoL, with more radiation necrosis.
A clear answer: shorter is not equivalent. #GBM #RadOnc
thegreenjournal.com/article/…
@ATJvdBoog @Szabolcs_David @AnnA25_03 @NVRO_NL
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Daniel Koffler, MD retweeted
1/n This is some brilliant investigatory work by @drbeckta. Nothing to add to his substantive critique of the underlying evidence itself or the incorporation of flawed data into guidelines by benefit managers like EviCore. But how best to remedy? Brief 🧵#radonc #medtwitter
Let's keep adding context, but from a different angle:
EviCore was formally created in 2014/2015 through a merger of MedSolutions and CareCore National.
The oldest EviCore radiotherapy guidelines I personally have archived is from 2019. I believe this was close to, if not THE first...but they make this difficult to find (for obvious and shady reasons).
But we can say with certainty that EviCore themselves deemed LDRT for osteoarthritis "medically necessary" at least as far back as 2019.
So what changed?
Well, though LDRT started its journey of rediscovery in America in 2020/2021, it was still relatively unknown to the public and uncommonly performed in American clinics.
Because LDRT, you know, actually works - more and more of us started to offer it, and patients have the ability to like...talk to each other.
In my own practice, for example, I have never once advertised. All of my LDRT patients are word of mouth self-referrals, or referrals from local doctors after they saw me treat their other patients.
Naturally, as this happened across the country, the public took notice.
In 2025, the radiotherapy professional society ASTRO made benign disease/LDRT the theme of their yearly conference.
As you can see from the Google Trends data, Americans searching for "low dose radiation therapy" really took off in early 2025 - and kept going.
Recently, this culminated in an article appearing on NBC's "Today" website, authored by @LaVarsovienne.
It was a classic, feel-good story of LDRT literally making a person, well...feel good.
This article was published on June 16th, 2026, at 1:08PM.
As seen in the Google Trends data, June 2026 is currently the absolute pinnacle of public interest in LDRT.
Which makes sense. "Today" is a massive, international platform. A lot of people saw it.
Almost certainly the people at EviCore saw it.
Which is why the PDF metadata of EviCore's latest guidelines - the one where they abruptly reverse course on LDRT - is extremely interesting.
What are the chances that this PDF was created on June 17th, 2026, at 11:13AM?
As in: 22 hours after one of the biggest platforms in the world runs a story on the benefits of LDRT, the largest benefits manager in the country creates the PDF of their newest guidelines, reversing course on covering this exact treatment, after explicitly covering it for nearly a decade?
Based on a fraudulent AI slop meta-analysis paper?
Really?
I mean sure, it COULD be a coincidence.
Or it could be that EviCore had already drafted most (all?) of this new version, saw this "Today" article drop on a Tuesday, internally said "nope, shut it down", and within 24 hours created this nonsensical non-coverage.
That's quite a coincidence for a company known to utilize their own AI platforms to make immediate, slash-and-burn decisions.
Within that context, it could be considered a consistent pattern of behavior.
Has anyone re-read that @statnews investigation into EviCore lately? The one from last year?
It's certainly compelling!
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Daniel Koffler, MD retweeted
🚨 Trial Opening Alert: #METANOVA now open @MSKCancerCenter
#METANOVA: testing if targeted radiation on all metastatic sites improves outcomes for men with oligometastatic prostate cancer on long-term hormone therapy.
@MSK_RadOnc Site PI: @jjnaylor02
#PRIMR videos boost patient understanding.
METANOVA: testing if targeted radiation on all metastatic sites improves outcomes for men with oligometastatic prostate cancer on long-term hormone therapy.
Watch:
primrmed.com/cancer-clinical…
@DrSpratticus @angela_jia_ @RadOncUH @caseccc
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