Breast RNI and IMN coverage Discussion.... Again. Breast is the worst x 3?

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temujim said:
Hear this a lot, but for most MDs it's just a feeling.
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Yep. Sometimes you have something to compare to.

If you have multiple dosimetrists, they won't all be at the same level. That being said, being a doc who picks their "personal dosimetrist" doesn't really fly in a practice large enough to have multiple folks in dosi.

Locums may come in. Some are baller. Others, you are like, "how do they even work"?

Docs who move around probably know better than most of us.
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temujim said:
How do you know you have great dosimetrists? Ever bench mark them?

Hear this a lot, but for most MDs it's just a feeling.
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I think the easiest way is to compare two to each other and see which one is unable to meet coverage/constraints consistently.

Some can just see what I’m trying to do and others you may have to hand hold and dig into a little more. If you’re working with a new one, double-triple-quadruple check everything because you can have a “good plan” come out that passes everything without meeting your goals (covering 100% of tumor, max dose off critical structures, etc).
 
RadOncDoc21 said:
I think the easiest way is to compare two to each other and see which one is unable to meet coverage/constraints consistently.

Some can just see what I’m trying to do and others you may have to hand hold and dig into a little more. If you’re working with a new one, double-triple-quadruple check everything because you can have a “good plan” come out that passes everything without meeting your goals (covering 100% of tumor, max dose off critical structures, etc).
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Yeah, it's pretty easy to tell when you have a few. Nice avatar.
 
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RadOncDoc21 said:
I have to say, yours is even better!!
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Donald Trump GIF by Election 2020
 
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Routinely planning every IMRT case is a bad use of physician time.

Having the knowledge to know when you can push harder on something and not accept ****ty constraints (because it just can't be met) and to know when anatomy/volumes are just going to lead to breaking constraints or sacrificing coverage is an excellent use of hpysician time.

I strongly recommend eveyr resident do a dedicated dosimetry rotation and learn at least the basics of IMRT planning.
 
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that ship has sailed. you do not do treatment planning as MD anymore
 
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temujim said:
How do you know you have great dosimetrists? Ever bench mark them?

Hear this a lot, but for most MDs it's just a feeling.
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A great aspect of my residency was that we had a really fantastic dosimetrist that would basically never give you a plan that wasn't already as good as it could get. I don't think I realized at first how good he was.

We also had one who was quite possibly the worst that has ever walked the earth. Usually he would just punch in the basic optimization objectives; hit optimize and calculate once. Then would send a text to let you know the plan was ready to review.... right after that he would get back to watching John Deere lawnmower videos on YouTube.

My third month as PGY2 I checked a prostate plan (80gy/40 fractions) and the prostate PTV wasn't covered well at all; like 95% at 70Gy. But there was a 90Gy hotspot in the Rectum.

The attending is like: "So what do you think of this plan?"

Me: "Um... Its bad?"

"Yes.... this is bad. Its very, very, very bad. Tell him to try again."
 
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Ray D. Ayshun said:
Good "oncology scan" in the red journal this month about imn coverage. Additionally, makes me feel justified in doing breath hold when I do right sided rni.
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I read that and did not think it was bad per se. But at the end I let out a loud sigh and said "breast is the worst".

I dont know. Can't explain it. Must be memosis or something.
 
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RealSimulD said:
I reviewed a vmat Vs 3D

The doc sent a vmat plan with 3x heart dose

She did 3D :)
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We need a good ol' "Heart Doses in Breast Radiotherapy" discussion!

Maybe I'll work one up.

In the meantime, someone else feel free to get the lively discussion going!

And lets absolutely discuss dose needed for radiographically positive mets.
 
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Ray D. Ayshun said:
That clinic doesn't need to be vmatting anything then. Good lord
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I don't entirely agree. We have a lot of women that despite cN+ will get immediate recon and their breast geometry is just not favorable for 3D. Sure, I can get a lower heart dose with 3D but at the expense of either 1) lung V20 > 40% or 2) treating directly through the contralateral expander/implant. Not infrequently I have to switch to VMAT even though it takes MHD from ~100-150 cGy to ~350cGy as a compromise to the above. I'm open to suggestions though about how others are handling those situations. Maybe I'm just big dumb.
 
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HolySmokes said:
I don't entirely agree. We have a lot of women that despite cN+ will get immediate recon and their breast geometry is just not favorable for 3D. Sure, I can get a lower heart dose with 3D but at the expense of either 1) lung V20 > 40% or 2) treating directly through the contralateral expander/implant. Not infrequently I have to switch to VMAT even though it takes MHD from ~100-150 cGy to ~350cGy as a compromise to the above. I'm open to suggestions though about how others are handling those situations. Maybe I'm just big dumb.
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If expanders, have the plastic surgeon deflate the contralateral expander.
 
HolySmokes said:
I don't entirely agree. We have a lot of women that despite cN+ will get immediate recon and their breast geometry is just not favorable for 3D. Sure, I can get a lower heart dose with 3D but at the expense of either 1) lung V20 > 40% or 2) treating directly through the contralateral expander/implant. Not infrequently I have to switch to VMAT even though it takes MHD from ~100-150 cGy to ~350cGy as a compromise to the above. I'm open to suggestions though about how others are handling those situations. Maybe I'm just big dumb.
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VMAT is awesome for N+ breast and treating nodes.

It just should be done well.

If the coverage improves and lung dose is reduced, but you’re trashing the heart (example - 5 Gy MHD for right sided w VMAT Vs 2 Gy with 3D), that’s a problem. Misses aren’t an issue. Pneumonitis is not the issue. The issue is that RT for years led to worse outcomes in left sided patients.

If you have the tool, use the tool, but you should use it correctly.
 
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Mandelin Rain said:
If expanders, have the plastic surgeon deflate the contralateral expander.
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A lot of ours go straight to implant before RT. Even for those with expanders, often when they deflate there's still quite a bit of tissue so the chest wall still isn't flat allowing for the type of tangent angle you'd expect.

Are people treating tangents without including the entirety of the scar for those without primary tumor risk factors (skin involvement, inflammatory, margins, etc)? We'll see the lateral border of the scar go 3-4cm past mid axillary line which contributes to difficulty with tangent geometry.
 
Didn't the EORTC 22922 trial show that there were no excess cardiovascular deaths with IMN (vs no IMN) XRT in a study of thousands of patients followed 15 years? Of course it did.

Well then, how am I going to build my CV with crappy publications that do not blame radiation for every heart issue in a population of 350 pound people with diabetes, cardiomegaly, out of control hyperlipidemia, and slothuflness!! Who let the EORTC say such a thing?!! I have built my career on blaming radiotherapy for everything under the sun and now the EORTC comes along and ruins it!!!! What will I do without all that money I was making as an "Expert Witness"? We cannot allow this to happen! Please, everyone start publishing studies again on patients treated in the 1950's and 60's when we all smoked and loved it! Is it too late to bring back smoking? My career hangs in the balance!
 
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Interesting.

I would have thought that there was consensus that our old techniques of treating breast cancer hurt patients.

In a disease like breast cancer where the cure rates are phenomenally high, even with node positive disease, with patients getting anthracyclines, I practice in a way that minimizes heart dose and would accept higher doses to lung or decreased target coverage to protect the heart.

MROQC has very strict heart parameters (MI RO quality consortium) and it has reduced the cardiac doses statewide.
 
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"Well doc, I hafta die of something" said the patient, as they scrounged in their purse while a pack of cigarettes fell out.

We can go on and on about minutia but the reality of community practice is eons away from the sterile often highly elevated health and socioeconomic status of patients at bigly institution enrolled in big-name trials.
 
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sirspamalot said:
"Well doc, I hafta die of something" said the patient, as they scrounged in their purse while a pack of cigarettes fell out.

We can go on and on about minutia but the reality of community practice is eons away from the sterile often highly elevated health and socioeconomic status of patients at bigly institution enrolled in big-name trials.
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Does that mean we shouldn’t elevate our care, at least at the margins, to minimize harms from faulty care?

We have practices making millions a year not upgrading to have DIBH, routinely 4D Sim for thorax cases, undertreating curable disease, over-treating widely metastatic disease, etc.

I’m not using one anecdote of one clinic. I am seeing this nationally at academic and community practices.

Minutiae to you. Standard of care to me.
 
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RealSimulD said:
Does that mean we shouldn’t elevate our care, at least at the margins, to minimize harms from faulty care?

We have practices making millions a year not upgrading to have DIBH, routinely 4D Sim for thorax cases, undertreating curable disease, over-treating widely metastatic disease, etc.

I’m not using one anecdote of one clinic. I am seeing this nationally at academic and community practices.

Minutiae to you. Standard of care to me.
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You feeling loud n proud now?

Who said anything about deliberately poor care.

I'm saying that arguing, wait for it, minutiae.... Is downright silly when some patients don't even show up regularly, smoke thru treatment, and fail half their chemo regimen.

How's the weather up there?
 
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You called it minutiae, not me. You’re the one talking about patients that have cigarettes falling out of their shirt.

These people should still get up to date RO. And they don’t.
 
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I have a similar discussion with my colleagues. We use the same equipment, same dose constraints and similar doses, same staff, yet some feel their radiation “technique” is more superior then mine.

I’m not saying we all have a complex but man rad oncs are a very special breed.
 
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RealSimulD said:
You called it minutiae, not me. You’re the one talking about patients that have cigarettes falling out of their shirt.

These people should still get up to date RO. And they don’t.
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DIBH is great if you have it, and I do, but if you don't.. now what.

You going to send patients 1 or even 2 hours away each day when you can perhaps treat them satisfactorily with IMRT without it? The patients don't want to go that far nor can many afford to even if they desired so.

Clearly you don't practice rural radonc and that's fine. But leave some oxygen for those that do down below you..being so judgemental is not a good look..
 
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sirspamalot said:
DIBH is great if you have it, and I do, but if you don't.. now what.

You going to send patients 1 or even 2 hours away each day when you can perhaps treat them satisfactorily with IMRT without it? The patients don't want to go that far nor can mnay afford to even if they desired so.

Clearly you don't practice rural radonc and that's fine. But leave some oxygen for those that do down below you..being so judgemental is not a good look..
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You're tying yourself into knots. Your hospital is earning a s**t ton. They can afford it. And it is complementary to IMRT - does not replace it - that is not how it works.

DIBH is standard of care now. If you think that is equivalent to protons or Reflexion or something, we definitely do practice on different planets. There isn't a center around in our state that doesn't use it.

This is why community practice gets a bad name. This is a necessary investment. But, I'm not surprised.
 
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RealSimulD said:
You're tying yourself into knots. Your hospital is earning a s**t ton. They can afford it. And it is complementary to IMRT - does not replace it - that is not how it works.

DIBH is standard of care now. If you think that is equivalent to protons or Reflexion or something, we definitely do practice on different planets. There isn't a center around in our state that doesn't use it.

This is why community practice gets a bad name. This is a necessary investment. But, I'm not surprised.
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Totally agree it is a bare minimum standard now. I have a family member that was not offered DIBH, I told her to run and get a second opinion.
 
RealSimulD said:
You're tying yourself into knots. Your hospital is earning a s**t ton. They can afford it. And it is complementary to IMRT - does not replace it - that is not how it works.

DIBH is standard of care now. If you think that is equivalent to protons or Reflexion or something, we definitely do practice on different planets. There isn't a center around in our state that doesn't use it.

This is why community practice gets a bad name. This is a necessary investment. But, I'm not surprised.
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You'll do great in the rural hospital setting by going thru the requisition process like a bull in a china shop. Lol. Trash community docs all you want, but FAFO the hard way when you run into someone who is capable of making your look like a jerk in front of your peers does so without mercy. You can't come back from that. And unlike academia, all you have is your reputation and ability to get along with your peers...

i seent it GIF



In summary:

DIBH is great, but if your site doesn't have it, you just not gonna treat people? I have it, I use it. But it didn't always exist, and if you don't have it and can't have (or won't be allowed to have) downtime, then you USE WHATCHU GOT.

Sure, you got money time and ability to transport, why not extrapolate that further.. to say everyone should just go to a major academic center. I mean, you want the best equipment right? Why, protons they say have the berry best conformality. We should use'm more often.

FFS Exempt has entered the chat

Get real.
 
Thought process:

75yo woman with AODM, mild obesity, lifelong smoker, on social security income. Tells you she is getting by but just barely. You're over an hour away from the next nearest center that offers DIBH. You set her up for L breast tangents free breathing. Best you can do is 1 cm lung to stay off the heart except for maybe a few mm of penumbra. You'll have to compromise and not treat some of the breast. You were planning on whole breast hypofrac for this ER+ g2 tumor, and fortunately it lived in the LOQ.

Your answer sir:

A. "Honey, sorry, but we don't have DIBH. I recommend you go to a center at XYZ about an hour away to minimize your heart dose" whereupon she begins to tear up saying she can't afford the gas

B. "You start Monday"

C. "Have you heard of our lord and savior PBI?"
 
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sirspamalot said:
DIBH is great, but if your site doesn't have it, you just not gonna treat people? I have it, I use it. But it didn't always exist, and if you don't have it and can't have (or won't be allowed to have) downtime, then you USE WHATCHU GOT.
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I started out in a rural clinic that didn't have DIBH or VMAT! I did in fact send people out who I couldn't either 1) treat prone (which I loathe, but it was better than nothing) or 2) offer partial breast RT. Anyone who was N+ and needed RNI I didn't treat. I never found step and shoot to produce the quality of plan I felt comfortable offering.

There's tons of financial assistance programs for rural cancer patients. I never used their situation to recommend less than standard of care. Sure, occasionally I was forced to come up with some "weird" dosimetry for the patients that absolutely refused to go elsewhere but that was always a last resort.
 
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sirspamalot said:
Thought process:

75yo woman with AODM, mild obesity, lifelong smoker, on social security income. Tells you she is getting by but just barely. You're over an hour away from the next nearest center that offers DIBH. You set her up for L breast tangents free breathing. Best you can do is 1 cm lung to stay off the heart except for maybe a few mm of penumbra. You'll have to compromise and not treat some of the breast. You were planning on whole breast hypofrac for this ER+ g2 tumor, and fortunately it lived in the LOQ.

Your answer sir:

A. "Honey, sorry, but we don't have DIBH. I recommend you go to a center at XYZ about an hour away to minimize your heart dose" whereupon she begins to tear up saying she can't afford the gas

B. "You start Monday"

C. "Have you heard of our lord and savior PBI?"
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Easily option C - you could have made that example more difficult by lowering the age or upping the aggressiveness of the cancer
 
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LOL. Now we're down to no VMAT no DIBH and referring out of town. What is this, 2004 ?

Patients in rural america are NOT GOING OUT OF TOWN FOR BREAST TANGENTS. They just aren't. And while 5 field with a medial breast port is not ideal by current standards, it is probably fine for anyone over 70 who has any comorbidity or life expectancy less than 10 years and cannot for physical or financial reasons go over an hour away.

If they won't go, or cannot afford to go, out of town, what are you going to do - refuse to treat them?
 
It doesn’t really matter.

Your mind is always pre made up before the discussion

Even when someone else other than me (2 others) say they would send out - still no budge.

Defending not even trying to obtain DIBH in 2023 is a new one.
 
sirspamalot said:
Yes, a community consensus has been achieved with n=3. As ASTRO likes to say "Case Closed."

Sigh.

Good luck out there.


ps. Do you know what the #1 driver of medmal is? Hint: Its not your gee whiz understanding of exposure risks to sub-portions of the heart.

pss. I count n=3 hyperbolic and inaccurate statements in your comment. I think that pretty much cancels out anything I wrote lol.
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Ah come on- at least tell me what’s hyperbolic and inaccurate! Don’t leave me hanging !!
 
You don’t need DIBH (as much) if you treat prone ;)

But SirSpam in your example case, partial breast is the standard! (You definitely don’t need DIBH for partial breast IMPORT LOW style.)
 
I forbid anymore breast discussions on this forum…
 

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RealSimulD said:
It doesn’t really matter.

Your mind is always pre made up before the discussion
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Your prescience proceeds your pavlovian desire to one up your fellow radonc. Mind reading 101, I guess I failed that class in med school..

RealSimulD said:
Even when someone else other than me (2 others) say they would send out - still no budge.
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No budgie no budgie cause the patient ain't a goin'. Got nothing to do with me sending out anything.

RealSimulD said:
Defending not even trying to obtain DIBH in 2023 is a new one.
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Who said not trying to obtain? I said the manner in which you go about it matters. A lot. Maybe you'll get it, maybe you won't. But the patient is still in the waiting room. Maybe in academia you can be a holier-than-thou tool, but you won't last long in community settings.


There. Can we stop now?


I Cant Do That Marlon Brando GIF by The Godfather
 
QUESTION:

50YO female with no CV risk factor being treated with IMRT/VMAT incl. IMN "met" with MHD = 10 Gy.

What is her absolute risk of XRT related ischemic heart disease death by age 80YO? (Does this site allow polls???:shrug:)

0%?
1%?
2%?
5%?
10%?
15%?
20%?
50%?
100%
150%?
 
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HolySmokes said:
I started out in a rural clinic that didn't have DIBH or VMAT! I did in fact send people out who I couldn't either 1) treat prone (which I loathe, but it was better than nothing) or 2) offer partial breast RT. Anyone who was N+ and needed RNI I didn't treat. I never found step and shoot to produce the quality of plan I felt comfortable offering.

There's tons of financial assistance programs for rural cancer patients. I never used their situation to recommend less than standard of care. Sure, occasionally I was forced to come up with some "weird" dosimetry for the patients that absolutely refused to go elsewhere but that was always a last resort.
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Oof - static IMRT is routinely a better plan in terms of heart dose than VMAT for N+ disease.


For all practitioners:

If you don't have DIBH in 2023 for at least L-sided breast cancer who definitely need the lower portion of their breast treated, you should probably offer the patient referral to a center with DIBH.

I find it very funny to still have a center in 2023 that doesn't have VMAT. I interviewed at one a while ago, no VMAT, no CBCT, and was completely at a loss. It was like asking me to treat with Cobalt. And they wanted to start a 'spine SBRT' program. Nope, nope nope.
 
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