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Advances from MSK researchers reported at 2023 ASTRO Meeting

Researchers from Memorial Sloan Kettering Cancer Center (MSK) were recognized for their achievements at the 2023 meeting of ASTRO, the American Society…

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Researchers from Memorial Sloan Kettering Cancer Center (MSK) were recognized for their achievements at the 2023 meeting of ASTRO, the American Society for Therapeutic Radiology and Oncology. Teams reported new findings about radiation-induced secondary cancers, a new guidance system for radiation therapy, and the consequences of insurance denials, among other topics.

Credit: Memorial Sloan Kettering Cancer Center

Researchers from Memorial Sloan Kettering Cancer Center (MSK) were recognized for their achievements at the 2023 meeting of ASTRO, the American Society for Therapeutic Radiology and Oncology. Teams reported new findings about radiation-induced secondary cancers, a new guidance system for radiation therapy, and the consequences of insurance denials, among other topics.

At the meeting, held from October 1 to October 4, 2023, in San Diego, Simon Powell, MD, PhD, FRCP, Chair of MSK’s Department of Radiation Oncology and Enid A. Haupt Chair in Radiation Oncology, was honored with ASTRO’s Gold Medal Award. This award is ASTRO’s highest honor, bestowed upon esteemed members who have made exceptional contributions to radiation oncology, including research, clinical care, teaching, and service.

In addition, MSK experts shared their work in more than 40 presentations and poster sessions. These are some of the highlights.

Risk of Radiation-Induced Secondary Cancers in Patients With Li-Fraumeni Syndrome

Li-Fraumeni syndrome is a rare hereditary condition that leads to an increased likelihood of developing multiple types of cancer, including breast cancer and soft tissue sarcoma. It is caused by an inherited mutation in the gene TP53.

Research led by radiation oncology resident Gustav Cederquist, MD, PhD, used records from several hospitals to study the risk of secondary cancers in people with Li-Fraumeni syndrome who received radiotherapy as part of their treatment for breast cancer. The analysis included medical records from 91 patients, 40 of whom received radiotherapy. The investigators found that after 15 years, the risk of developing a sarcoma within the area where radiotherapy was delivered was 12%, compared with a 0.3% among a matched control group that was representative of the general breast cancer population receiving radiotherapy. They also found that for people with Li-Fraumeni syndrome, the overall risk of developing any secondary cancer within that 15-year time frame was approximately 50%, regardless of whether they received radiotherapy or not.

The researchers wondered why some breast cancer patients with Li-Fraumeni syndrome received radiotherapy and others did not. They found that those who received radiotherapy were more likely to have aggressive breast cancer characterized by larger tumors and lymph node metastases. Interestingly, the patients who received radiotherapy did not have decreased overall survival despite more aggressive breast cancer and an increased risk of secondary sarcoma. The authors therefore conclude that the added risk of the radiation treatment should be weighed against its benefits for controlling the original breast cancer, especially in patients with more advanced disease. The risk estimates from this study should help clinicians formulate personalized treatment decisions for patients with this rare cancer syndrome.

A New Guidance System for Radiation Therapy in Prostate Cancer

Investigators at MSK are always looking for ways to improve radiation therapy for treating prostate cancer and make it more precise. That is because when this treatment spreads to areas beyond the tumor, it can lead to problems like having to urinate more frequently.

A study led by former MSK radiation oncologist Michael Zelefsky, MD, and medical physicist Pengpeng Zhang, PhD, looked at whether a new guidance system developed at MSK was able to reduce these side effects by delivering the radiation more precisely. It focused specifically on a type of radiation called stereotactic body radiotherapy (SBRT). SBRT uses fiducial markers, metal objects about the size of a grain of rice, to help line up the beams of radiation.

The technique uses a new system called MKIG (for MV and kV imaging guidance), which was developed to track the location of fiducial markers and better correct for patients’ natural body movements during treatment. An analysis of 271 patients with cancer that had not spread beyond the prostate found that the MKIG system was practical for clinical use and reduced the number of urinary side effects. The researchers plan to continue studying the technique, including in other cancers where SBRT is used.

Consequences of Initial Insurance Denials for Radiation Therapy

Health insurance companies sometimes decline to authorize coverage for cancer treatments recommended by doctors, including radiation therapy. A study led by radiation oncologist Jacob Shin, MD, looked at data from more than 200 MSK patients who were denied coverage in 2022 to determine how those denials affected patients. The study also reported how many of those initial denials were ultimately overturned and what additional measures were needed to obtain treatment authorization.

The researchers found that of 206 cases:

  • 127 patients were successful in eventually obtaining insurance authorization without having to make any changes to the treatment.
  • 56 patients had their treatment authorized after their doctors agreed to modifications requested by the insurance company — lowering the dose of treatment or providing a different type of radiation.
  • 23 patients did one of the following: proceeded with treatment via departmental administrative clearance (meaning MSK covered patients who couldn’t get coverage or the patient’s insurer eventually authorized treatment after the patient started radiation treatment), did not receive radiation treatment, or sought care at another institution.

Overall, a significant proportion of insurance denials led to delays in treatment, changes to the treatments that patients ultimately were able to receive, or both. The researchers say that there is a clear need for further investigation into the time and financial burdens caused by the increasing use of prior authorization by national insurers as well as the clinical impact of insurance denials on patient treatment and outcome. They want to establish more optimal ways to authorize and deliver radiation oncology care in a timely and cost-efficient manner.


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The Question You Should Ask Whenever You’re Wrong

“Never bet on the end of the world. It only comes once, which is pretty long odds.” — Arthur Cashin, New York Stock Exchange Floor Manager (“Maxims…

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“Never bet on the end of the world. It only comes once, which is pretty long odds.” — Arthur Cashin, New York Stock Exchange Floor Manager (“Maxims of Wall Street,” p. 110)

Since Joe Biden gave his State of the Union (or shall we say “Disunion”) speech last week, I’ve encountered a plethora of negative comments about the future of America.

Is the American Dream Over?

“If Biden is re-elected, it will be the end of the American Dream as we know it,” said one pundit on Fox News.

The critics are out in force. Supply-side economist Steve Moore writes, “Biden is intentionally trying to dismantle the American economy with his imbecile energy, climate change, crime, border, inflation, debt and high tax policies.”

Glenn Beck, the host of Blaze TV, recently warned that America may face multiple terrorist attacks in one day, similar to 9/11, given the open borders policy of the Biden Administration.

Recently, I attended a private meeting of political leaders and pundits who thought that President Biden’s address was the most polemical, shrill and divisive talk they had ever heard.

I’ve been watching State of the Union addresses all my adult life, by both Republicans and Democrats, and in many ways they are always polemical and divisive. What was amazing to me is how “sleepy” Joe Biden performed. He must have been well rested and jacked up with some pretty incredible drugs to do as well as he did.

President Biden did say some things that were crazy, such as when he asserted that voting for former president Donald Trump is a “vote against democracy.”

Hey, wasn’t it the Democrats who want to remove Trump from the November ballot in Colorado and other states? Talk about anti-democratic! I was glad to see the Supreme Court ruled 9-0 against the Colorado decision. Let the people decide. Isn’t that what democracy is all about?

Why Then Is the Stock Market at an All-Time High? 

Kevin Roberts, the new president of the Heritage Foundation, recently declared, “The American Dream is being threatened as never before!”

If that is true, why is the stock market at or near an all-time high? What are the prophets of doom and gloom missing?

That’s the question I always ask when I’m wrong about something:

“What am I missing?”

Wall Street is a good bellwether of what is going on the country. So far, the benefits outweigh the costs. The economy is recovering from the Covid pandemic, inflation is coming down, corporate profits are strong, new technologies are being introduced and there’s a strong movement to reverse the “cancel” and “woke” culture in the United States.

We have gridlock on Capitol Hill that is keeping a lot of bad legislation from becoming law. The Supreme Court has reversed many bad decisions by the lower courts.

We Remain Fully Invested

So, all is not lost after all. In my newsletter, Forecasts & Strategies, we remain fully invested, despite occasional corrections in the market.

We are also well diversified in some “contrarian” investments such as Bitcoin and gold, both of which continue to outperform and offset any selloffs in the stock market.

By remaining positive and fully invested, we have made good money in 2024.

The American Obituary Has Been Written Many Times

The American economy has been left for dead many times, only to be resuscitated with renewed vigor. We have survived civil and world wars, the Great Depression, the inflationary 1970s, terrorist attacks and more.

As J.P. Morgan once said, “The man who is a bear on the United States will eventually go broke” (“Maxims,” p. 111).

I encourage you to read my favorite J.P. Morgan story found on pp. 218-219 in “The Maxims of Wall Street.” See www.skousenbooks.com.

American exceptionalism is alive and well. We are still the Promised Land with millions wanting to live and work here.

Solving Our Unfunded Liability Problem: Look to Canada!

One serious problem in America is the irresponsible, out-of-control deficit spending and national debt, created by both Republican and Democratic leaders over the years. The trouble is getting worse, with rising interest rates to pay the debt and the growing unfunded liabilities from Social Security and Medicare.

Robert Poole of the Reason Foundation warns:

“The Congressional Budget Office (CBO)’s latest 10-year projection is frightening. CBO projects annual federal budget deficits to increase steadily, exceeding $2.5 trillion by 2034, assuming current policies continue… The federal government is projected to borrow an additional $20 trillion over the next decade, the CBO estimates.

“One driving factor is the impact of higher interest rates on the current $34 trillion (and growing) national debt… By 2034, annual interest expense is projected to be $1.6 trillion — more than one-fourth of all federal tax revenue.

“The Penn Wharton Budget Model suggests that the United States has about 20 years to fix this debt/deficit problem — ‘after which no amount of future tax increases or spending cuts could avoid the government defaulting on its debt.’

“On August 2, 2023, Fitch Ratings downgraded the federal government’s long-term debt rating from AAA to AA+. And on November 10, 2023, Moody’s Investors Service reduced its outlook on the U.S. credit rating from ‘stable’ to ‘negative.’ Standard & Poor’s did its downgrade in 2011. These are warning shots across the ship of state’s bow.”

Sounds ominous. What to do?

Canada faced a similar problem back in the mid-1990s. Deficits were getting out of hand, and the Canadian dollar was sinking. The Conservative Party and the Liberty Party of Canada worked together and resolved to cut government spending, lay off federal workers and then went on a supply-side tax-cutting program that resulted in economic growth and deficit reduction.

What about the unfunded liability problem, which causes national bankruptcy? Again, Canada offers an incredible example of solving the issue.

Last week, Andy Puzder and Terrence Keeley wrote an op-ed in The Wall Street Journal on the success of the Canadian social security system, which has earned a 9.3% annualized return over the past 10 years (versus almost zero return in our Social Security Trust Fund). They wrote:

“The Canada Pension Plan’s superiority stems from its asset allocation. The fund invests about 57% of its assets in equities and 12% in bonds; the rest is divided among real estate, infrastructure and credit. Over the past 10 years, the Canada Pension Plan has realized a 9.3% annualized net return. Similarly to how Social Security works, Canadian citizens pay into the program and are guaranteed lifetime benefits.”

At some point, the United States will need to imitate the Canadian model. Here is a chart on the difference between the two:

In sum, there are solutions to all of our problems — if we know where to look and remain optimistic.

Sound Advice from the ‘Investment Bible’

In my home, I have a whole section of my library devoted to dozens of books written by doomsayers and Cassandras, such as “The Coming Deflation”…. “How to Prosper During the Coming Bad Years”… “Bankruptcy 1995”… “The End of Inflation” and so on.

I’ve also collected a bunch of quotes on doomsayers and Cassandras in “The Maxims of Wall Street.”

Jim Woods, my colleague at Eagle Publishing, is a big fan.

Jim states, “I’ve always felt that a collection of wisdom from the best brains in that industry has been most special to me. And on this front, there is no better ‘how to’ anthology than the one by my friend, fellow Fast Money Alert co-editor and brilliant economist, Dr. Mark Skousen. The ‘Maxims of Wall Street’ is a collection of some of the greatest wisdom ever to flow from the biggest and brightest names on Wall Street. Great investors such as Jesse Livermore, Baron Rothschild, J.P. Morgan, Benjamin Graham, Warren Buffett, Peter Lynch and John Templeton are just a sneak peek at some of the names you’ll discover in this fantastic collection. Then, there is profundity from the likes of Ben Franklin, John D. Rockefeller, Joe Kennedy, Bernard Baruch, John Maynard Keynes, Steve Forbes and numerous other luminaries too copious to mention.”

If you don’t have an autographed copy of my collection of quotes, stories and wisdom of the world’s top traders and investors, please order a copy now.

It is in its 10th edition, having sold nearly 50,000 copies. It has been endorsed by Warren Buffett, Kevin O’Leary, Jack Bogle, Kim Githler, Bert Dohmen, Richard Band and Gene Epstein in Barron’s.

I offer it cheaply to my Skousen CAFÉ readers: Only $21 for the first copy, and all additional copies are $11 each (they make a great gift to clients, friends, relatives and your favorite broker or money manager). I sign and number each one, then mail it at no extra charge if you live in the United States. If you order an entire box (32 copies), the price is only $327. As Hetty Green, the first female millionaire, once said, “When I see a good thing going cheap, I buy a lot of it!”

To order, go to www.skousenbooks.com.

You Nailed it!

Friedrich Hayek Won the Nobel Prize 50 Years Ago

“Mises and Hayek articulated and vastly enriched the principles of Adam Smith at a crucial time in this century.” — Vernon Smith (2002 Nobel prize in economics)

March 23 is the anniversary of the passing of a giant in economics — the Austrian economist Friedrich Hayek (1899-1992).

He is most famous for his bestselling book “The Road to Serfdom,” written near the end of World War II, an admittedly a pessimistic book, warning the West that its move toward socialism, fascism and communism was indeed a “road to serfdom.”

Then, when he won the Nobel prize in economics in 1974, he warned again of the dangers of “accelerating inflation,” which he said, were “brought about by policies which the majority of economists recommended and even urged governments to pursue. We have indeed at the moment little cause for pride: as a profession we have made a mess of things.”

Fortunately, we have moved away from the road to serfdom, especially after the collapse of the Berlin Wall and the Soviet socialist central planning model.

But the road to freedom has been a checkered one, and we must always be alert to losing our liberties in the name of inequality, fairness and social justice.

Last month, Tom Woods interviewed me in honor of the 50th anniversary of Hayek’s winning the Nobel prize. Watch the interview here.

Mark Skousen, Friedrich Hayek and Gary North in Austria, 1985

I had the pleasure of interviewing Hayek for three hours in the Austrian alps in 1985. He was especially happy to hear I resurrected his macroeconomic model in developing gross output (GO). See www.grossoutput.com, a measure of Hayek’s triangles.

This week, Larry Reed, former president of the Foundation for Economic Education, wrote this wonderful tribute to Hayek.

Highly recommended.

Good investing, AEIOU,

Mark Skousen

The post The Question You Should Ask Whenever You’re Wrong appeared first on Stock Investor.

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Walmart and Target make key self-checkout changes to fight theft

Both chains are making changes customers may not like, but self-checkout isn’t going anywhere, according to one industry expert.

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In parts of the world, public bathrooms come with a charge, but people pay on the honor system. The money charged allows for better upkeep of the facilities and most people don't mind dropping a small bill or some coins into a lockbox and many of the people who don't are likely dealing with larger problems.

The honor system, however, requires honor. It's based on the idea that most people are trustworthy and that they will pay their fair share.

Related: Beloved mall retailer files Chapter 7 bankruptcy, will liquidate

In the case of a bathroom, people cheating the system are only stealing a low-value service. In the case of self-checkout, a variation on the honor system, people looking to steal by "forgetting" to scan an item can be a very expensive problem.

That has led retailers including Target, Walmart, and Dollar General to make changes. Target has limited the amount of items you can scan at self-checkout at some stores while Dollar General has literally eliminated it in some locations.

Walmart, like Target, has experimented with item limits and limiting the hours of operation for self-checkout. Now, in some stores, the chain has decided to designate some of its self-checkout stations for Walmart+ members and delivery drivers using the Spark app.

Advantage Solutions General Manager Andy Keenan answered some questions about Walmart, self-checkout, and theft from TheStreet via email.     

Target has made self-checkout changes at select stores.

Image source: John Smith/VIEWpress.

What Walmart's self-checkout changes mean

TheStreet: What are the benefits of reserving self-checkout registers for Spark drivers and Walmart+ customers?

Keenan: The benefits include exclusivity and perks of membership, speed, and convenience when shopping.

TheStreet: If this rolls out more broadly, what do you anticipate being the impact on non-Walmart+ customers?

Keenan: There is the potential for non-Walmart+ customers to become agitated, they are losing convenience because they are not enrolled. Customers who are looking for convenience will have fewer options for speed to check out. 

TheStreet: Do lane restrictions like limiting lanes to 10 items or fewer help reduce time spent waiting in lines?

Keenan: Yes, but retailers must have a diverse amount of check lane options including 10 items or fewer to ensure that the speed of checkout actually transpires.

TheStreet: Do you believe self-checkout is leading to partial shrink? If so, do you think that this move to shut off self-checkout lanes will help prevent theft in the future?

Keenan: Yes, self-checkout is leading to partial shrink. We believe this tends to be more due to errors in scanning and intentional theft. 

There are already front-end transformation tests going on in stores, reducing the number of self-checkouts and shifting back to cashier checkouts in order to measure the reduction in shrink. Early indicators show that a move back to cashier checkouts combined with other shrink initiatives will help prevent theft.

Self-checkout is not going away

While changes are ongoing, Keenan believes self-checkout is here to stay.

“Self-checkout is not, as one recent article called it, a failed experiment. It’s actually part of the next evolution of the retail customer experience, and evolutions take time,” Keenan said in a web post about the findings of the 2024 Advantage Shopper Outlook survey.

He makes it clear that rising labor costs and struggles to find workers make some for of self-checkout inevitable.

“Since the pandemic, there’s been a revolution on hourly labor,” Keenan said. “Labor in certain markets that would cost you $16 an hour now costs you $19 or $20 an hour, and it’s a gig economy. The people who once stood at a checkout stand in the front of a store are now driving for Instacart or DoorDash because the hours are more flexible. They want to make their own schedule, and it’s varied work. Today, most retailers can’t offer that.”

Basically, while there are kinks to work out, self-checkout simply makes sense for retailers.

“The notion that we’re going to pivot away from technology that helps offset labor needs and will ultimately continue to improve customer experience because of some challenges is far-fetched. We need to continue to embrace the technology and realize that it may always be imperfect, but it will always be evolving. The noise that, ‘Oh, self-checkout might not be working,’ that’s just a moment in time,” he added.

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Hitting Home: Housing Affordability in the U.S.

The Issue:
Housing is becoming unaffordable to a widening swathe of the American population. This deteriorating affordability directly impacts American…

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The Issue:

Housing is becoming unaffordable to a widening swathe of the American population. This deteriorating affordability directly impacts American lives, including where people choose to live and work. It has also been cited as a major contributor to key social problems like rising homelessness and worsening child wellbeing.

The Facts:

  • Median house prices are now 6 times the median income, up from a range of between 4 and 5 two decades ago. In cities along the coasts, the numbers are higher, exceeding 10 in San Francisco. 
  • The ratio of median rents to median income has also crept from 25 percent to 30 percent in two decades. 
  • Households — renters in particular — are increasingly cost-burdened, having to spend more than 30% of their income on rent, mortgage and other housing needs. Among homeowners, about 40 percent of those in the $35-49 income range are cost-burdened. The share of cost-burdened renters in that income range has risen sharply from under 40 percent of households in 2010 to over 60 percent today (see chart). 
  • Historically, rural and interior areas of the country have been more affordable. But, even prior to the pandemic, migration toward these locations has helped drive faster house price appreciation than in more expensive regions.
  • Demographic developments have contributed to the demand-supply imbalance. Supply is crimped by more older Americans opting to age in place. On the demand side, the biggest driver is new household formation. Americans formed about a million new households a year between 2015-2017, but the pace has almost doubled according to the most recent data, largely reflecting a pickup in household formation rates among millennials.
  • A long-standing lack of homebuilding, which partly reflects tight regulatory restrictions in many parts of the country, has also contributed to rising home prices. 
  • More recently, higher interest rates since 2022 have exacerbated these secular trends to make housing even more unaffordable. The mortgage rate on a 30-year home loan soared from 3 ½ percent in early 2022 to nearly 8% in October 2023 as the Fed raised policy interest rates; the mortgage rate had only eased to about 7% in March 2024 as the tightening cycle had peaked. The problem is compounded by mortgage lock-in: higher interest rates have left many homeowners — many of whom bought homes or refinanced at the lows of 2020-21 — with cheaper-than-market mortgages, reluctant to sell their house and reset their mortgage at current, higher rates.

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