What type of surgery is done by Rad Oncs and how technically proficient do you need to be?
At all three places I have practiced, radiation oncology has been involved in SIRSpheres. Maybe rad oncs identify the patients who may benefit after considering all the other potential local options. Or maybe it was the 4 years of training in oncology, radiation delivery, and safety. Perhaps a radiation oncology has a little more to offer than pushing a syringe?Just to clarify: at no institution is SIRSpheres performed by radoncs; the vast majority of the procedure is endovascular and radiation administration involves a couple of syringe pushes. At a very, very few places radonc may be present for the injection component of it, this is primarily due to a historical lack of IRs certified to use y90; and the patients are primarily managed by either IR or HPB surgery. Witjin the past 5 years or so every IR fellow graduating now is certified to use y90 and will likely not want to split the RVUs.
The only place I've heard of where radonc is involvedin y90 therapy was was at Maryland and that was before they got a new section chief who is a bit of a big wig; so I'm not sure what that level of involvement is.
The NRC if anything disputes your point. Under "A", that basically includes nuc med and rad onc without additional caveats. IR in of itself cannot be an AU. They need quite a bit of additional training as outlined by the NRC.Rads residents in general and IR in particular get very thorough training in radbio and physics, we get ours from the same lecturer as the radoncs.
Here is the current record for who can use y90.
http://pbadupws.nrc.gov/docs/ML1128/ML11284A266.pdf
In "B" it says any user can be trained by an authorized user, in using y90, since IR is the only one currently doing this procedure it is unlikely they will teach or supervise docs from other specialties to do so. Particularly given what happened with a lot PAD work.
And in an economic sense it doesn't make sense to charge the patient for the presence of an additional MD, radonc or Nuc med, since the presence of either isnt required because any IR performing these at this point is an authorized user. Splitting the revenue doesn't make sense either since the IR does the labor intensive part and takes on all the liability for complications.
As I have said previously IR clinic is closer to surgery clinic than Radonc which is primarily outpatient. Many of the procedures we do for cancer therapy are all we can offer the patient, and after the therapy is completed we can't retreat and they get better or die. There are exceptions but much of what we treat has a defined end point.
No one is saying IR is trying to encroach on radiation therapy, in fact the only thing we do with radiation is y90; I used Zevalin/I131 as examples of other internal radiation therapy we get a lot of exposure to in residency.
Furthermore to elaborate o, the radiation delivery component, and that is it is more than just radiation delivery, it is also the emboliization part, and while we are embolizing we are making sure there is no a/v shunt, no dissection, no vasospasm etc. and let's be honest the additional training we get for just y90 is more than sufficient. The success of y90 therapy depends on dose delivery parameters like making sure there is no av shunt in the tumor, subselecting the correct vessel, etc in a way the radiation dose is almost incidental. Additionally these pts are not followed by rad onc after, so what exactly are they contributing?
What role do the surgeons play in your OR cases? Do they do exposures for you? Or help with placement in a surgical capacity? Or do they stand on the sidelines and clai
They need to be there because you're working within their domain?
If it's the latter I would argue they don't need to be there. If its the former than tne role they play it is critical to the success of the procedure.
As I have said previously IR clinic is closer to surgery clinic than Radonc which is primarily outpatient. Many of the procedures we do for cancer therapy are all we can offer the patient, and after the therapy is completed we can't retreat and they get better or die. There are exceptions but much of what we treat has a defined end point.
Since we are talking about y90: the therapy consists of arterial mapping, and as many therapy sessions as there are arteries feeding tumor, usually 2. This is spaced over 1 to 3 months. Pts then get follow up imaging and have follow up appointments about q3 months, within 3 to 6 months we can determine if their doing well and can have a transplant. If tumor recurrs or more often grows, as is the case more often then not then the pt is usually out of options. Our patients are different then rad onc pts, the ones that can be cured our cured with transplant we bridge to that. The ones that can't are there for palliation. How long is the oncologic follow up for your palliative patients?
There are are conditions which require long term f/up like PAD, complex AVMs, fibroids.
When a pt is done with radiation therapy do you continue to follow them?
And as a final note Nuc med is a section of radiology , in very few places are they an independent entity, no DR does I131 or Zevalin outside of fellowship trained nucs people .
Why in the world would rad-oncs want to be involved with Y90? It pays terrible and it seemed not satisfying or cerebral at all. Seemed like technician work to me.
Gyn brachy we do alone, the gyn onc only places the sleeve in the OR mid treatment during EBRT without our assistance, then I do all the implants myself. Prostate brachy the urologists places the US in the rectum and contours the prostate on the US, which we subsequently completely ignore. If they are late, we can do that part. Then we put in the needles and the seeds. They don't do post tx cysto, either. They do provide conversation and support, however, and it is appreciated. I don't know how the billing breaks out, but I presume they get something, because they show up.
Do you guys follow them for surveillance? (when you're talking about follow up years out?) which malignancies? Just for my own education?
We tend to follow patients indefinitely after we treat them (this does vary some and some Rad Oncs may not see a prostate after 10 yrs of fu and undectable psa). This is shorter for GBM/pancreas than breast or prostate. All procedures (including surgery) can have long term complications and you won't know if you don't follow your patients.
Bix do you guys do SBRT for liver? Or did you mean in general?