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Doctors' HARD Call in the Case of an Older Patient with Pancreatic Cancer
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Jul 15, 2025
In this real case, we discuss the challenges of finding the safest and most effective treatment for an older patient with pancreatic cancer. When all the options do not sound promising, at times, you need to move outside of the box and be innovative. This does not mean you suggest a treatment based on no evidence; this means bringing proof, expertise, and state-of-the-art technologies together to solve a medical dilemma. The Link to the discussed study https://pubmed.ncbi.nlm.nih.gov/40208620/ https://jamanetwork.com/journals/jamaoncology/fullarticle/2777063 Connect with me via LinkedIn https://www.linkedin.com/in/arminshahrokni?utm_source=share&utm_campaign=share_via&utm_content=profile&utm_medium=android_app X https://x.com/GeriOncologist?t=QMpM6F9KTB9_2W66OiEOzw&s=09 Instagram
View Video Transcript
0:10
welcome to the deep dive we uh we unpack
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source materials to find those really
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key insights that's the goal and today
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we're looking at a pretty compelling
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case study actually it gets right into
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those tough decisions you know when you
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have a seriously ill patient but also
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significant risks involved with
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treatment yeah yeah and it forces the
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doctors to look way beyond the standard
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stuff we've been digging into sources
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all about this risk um medical
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innovation and how crucial teamwork
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collaboration really is right and our
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mission here for this deep dive is to
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pull out maybe the surprising facts the
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key takeaways about what happens when
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the usual options well they're just too
0:50
dangerous for the actual person sitting
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in front of you so the scene is set the
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standard approach not safe and everyone
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has to kind of rethink everything for
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this one patient exactly let's dive into
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the case itself from the sources we're
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talking about an 85-year-old person
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diagnosed with pancreatic head cancer
1:05
okay pancreatic cancer always
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challenging standard approaches are
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definitely considered there absolutely
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but the sources really pointed to the
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patients overall situation as the main
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hurdle not just the cancer diagnosis
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itself what do you mean what was it
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about their profile well they had quite
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a few significant pre-existing health
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conditions and this is key they were
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assessed as clinically frail frail okay
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we hear that term but what did the
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sources say it meant in this context
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sounds like more than just being 85 oh
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definitely more than just age the
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sources were clear frailty isn't about
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the number on your birth certificate
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it's uh it's about reduced physiological
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reserve physiological reserve yeah think
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of it like the body's battery its
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ability to cope with big stressors like
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well like major medical treatment it's
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diminished ah okay so even though this
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patient was still living independently
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dayto-day the assessment basically said
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that the massive physiological stress
2:00
from standard treatments it could cause
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a really rapid irreversible decline that
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assessment sounds critical then
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incredibly important it framed
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everything okay so high-risisk patient
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assessed as frail serious cancer what
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was the core dilemma when they look at
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the standard options well given that
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profile the standard stuff reviewed by
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the surgeons the medical oncology teams
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they just decided it was too risky plain
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and simple too risky how let's break
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that down surgery first right surgery
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for this cancer is Mhm it's huge a
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massive operation the sources called it
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a marathon surgery wow yeah massive
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physiological toll the recovery is
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famously long really arduous and for
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someone with limited reserve the chance
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of serious complications maybe even not
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surviving the surgery or recovery it was
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just deemed too high so the risks just
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outweighed the potential benefits in
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this specific case yes that was the
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conclusion okay what about chemo
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systemic treatment medical oncology
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looked hard at that too of course but uh
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similar conclusion really the potential
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for severe toxicity just overwhelming
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fatigue side effects that could really
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tank their quality of life was very real
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and those side effects could easily just
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wipe out any potential benefit from the
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chemo itself making things worse
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potentially not better exactly the
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sources use this great phrase the
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patient was caught in a therapeutic vice
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treatments meant to help could actually
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cause significant harm wow that's a
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tough spot a therapeutic vice so
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standard paths blocked what happens then
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it wasn't just give up right no not at
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all far from it that the sources show
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this wasn't a dead end it was a problem
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to solve and the key collaboration ah
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the team approach yes and specifically
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the multi-disiplinary tumor board that
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was the crucial space where this
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happened everyone got together and the
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focus shifted you said the question
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changed precisely it wasn't can we
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technically do the standard thing
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despite the dangers it became okay what
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is the absolute best thing we can do for
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this person taking everything into
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account yeah respecting the cancer yes
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but also their overall condition their
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frailty and critically their goals for
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life who's around that table the sources
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mentioned the key players and see you
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had the surgeons medical oncologists uh
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radiation oncology specialists and the
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paliotative care team and you mentioned
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paliative care the sources flagged their
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early involvement as really important
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why yeah that's a great point to
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emphasize paliative care isn't just
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about end of life which is a common
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misconception from day one their job was
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managing symptoms yes but also making
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absolutely sure the patients own goals
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and values like what does quality of
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life mean to them staying independent
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things like that were central to every
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single discussion so they kept the focus
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on the person not just the disease
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exactly grounding the whole conversation
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okay so this collaborative discussion
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happens and an innovative idea emerges
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what was it this is where radiation
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oncology stepped up with something
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called stereotactic body radiation
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therapy sprt okay break that down well
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the sources describe it as a kind of
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non-invasive radio surgery super precise
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it uses really advanced imaging like
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GPS- like tracking they said GPS for
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radiation sort of to deliver incredibly
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high very potent ablative doses of
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radiation right onto the tumor and the
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precision is amazing like sub millimeter
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precision sub millimeter that sounds
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incredibly focused how does the
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treatment course compare to say
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traditional radiation huge difference
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traditional radiation for something like
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this might be what 28 treatments 5 1/2
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weeks going in every day yeah that's a
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long haul with SPRT the sources said it
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was just five sessions over about a week
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and a half wo five versus almost 30 that
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alone sounds like a massive plus
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especially for an 85-year-old and their
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family making all those trips definitely
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the logistical ease is a big factor
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fewer trips less disruption but the
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clinical advantages the sources explain
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are really profound how so because that
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beam is so incredibly focused the
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analogy used was less like a flood light
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more like a laser beam okay I get that
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it means it spares the surrounding
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healthy tissues much much better things
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like the stomach the intestines which
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are really sensitive leading to fewer
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side effects dramatically fewer side
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effects and importantly the dose is so
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high it's given with ablative intent
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ablative intent meaning meaning the goal
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isn't just to shrink it a bit it's to
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completely destroy the tumor cells it
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offers a chance at long-term control
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maybe even cure that previously you
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really only thought possible with that
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big surgery so a non-invasive way to
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potentially achieve a surgical like
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outcome but without the massive risks of
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surgery for this patient that's the
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essence of it how did the patient and
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the family react when this was proposed
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according to the sources it was
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explained pretty clearly like using
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focused energy to do what a surgeon does
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with a knife they understood it was
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powerful but short and crucially lower
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risk for them compared to the other
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options which must have sounded like
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like hope yeah where before they saw
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these really difficult high-risisk
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choices now there was this other path
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they were immediately on board and the
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outcome did it work what did the sources
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say happened it was described as a
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resounding success wow yeah the patient
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tolerated the five treatments really
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well minimal side effects easily managed
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and the follow-up scans showed a
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fantastic response significant tumor
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shrinkage that's great clinical news but
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what about the patient's actual life did
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it achieve those quality of life goals
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that's the most important part isn't it
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and yes the sources emphasize they were
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able to maintain their independence keep
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doing their hobbies just live well
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without that huge recovery burden
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exactly no long painful surgical
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recovery no debilitating chemtoxicity
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they got a really effective treatment
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without the devastating side effects
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that everyone worried about with the
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standard approaches for someone assessed
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as frail this case really feels like it
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pushes back hard against some common
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assumptions doesn't it especially about
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treating older patients it absolutely
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does the sources frame it as a powerful
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rejection of um what's sometimes called
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therapeutic nihilism therapeutic
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nihilism yeah that kind of mindset that
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oh they're too old or they're too frail
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for any meaningful treatment especially
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treatment aiming for a cure or long-term
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control this shows that's not
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necessarily true right it shows the
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answer isn't always less treatment for
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high-risisk patients sometimes it's
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smarter treatment more targeted
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treatment and it highlights that with
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the right tech like SBRT and maybe even
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more critically the right team working
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together thinking outside the standard
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boxes you can offer highly effective
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even curative intent therapy to people
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who maybe just 10 years ago might have
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only been offered supportive care yeah
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just managing symptoms without really
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tackling the cancer itself it really
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opens up possibilities it raises an
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interesting point the sources touched on
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too about how we even structure those
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first consultations for patients like
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this older higher risk what that well
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instead of the default being just okay
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see the surgeon see the medical
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oncologist maybe radiation oncology
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should be involved right from the get-go
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in that initial workup ah bring them in
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earlier yeah treat it as another
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potential pillar of definitive treatment
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from the start not just an afterthought
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if the others don't work out that makes
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a lot of sense it could open up options
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much sooner for the right patients it
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really paints a picture of the future
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doesn't it more collaborative much more
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personalized using these amazing
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technologies and really driven by a team
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focused on the individual not just the
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protocol we're probably just scratching
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the surface of what's possible makes you
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wonder yeah how many other situations
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could benefit from that kind of thinking
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right from the beginning exactly so I
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think that's a really powerful core
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insight from this deep dive into the
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sources this case just shows beautifully
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how you know combining that
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collaborative expertise truly listening
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to the patients goals and using
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innovative tech like SBRT it can create
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real powerful options even when the
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standard roads look blocked it's about
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refusing to accept perceived limitations
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and finding a better way for that
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individual absolutely so here's a
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thought to leave you with building on
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what the sources suggest if bringing
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radiation oncology in earlier for
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high-risisk patients opens up this whole
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new pillar of definitive treatment what
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other assumptions what other standard
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workflows in complex care might we need
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to rethink where else could a different
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approach unlock smarter more
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personalized options exactly something
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to ponder definitely food for thought
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thank you for joining us for this deep
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dive
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[Music]
#Aging & Geriatrics
#Cancer
#Health Conditions