Difficult Lymphoma Case

[bachiraki]

Hi SDN friends,

I would like to run by you all a difficult Lymphoma case.

40 year old male when presented with Fevers, is diagnosed with DLBCL with bulky 11.3 cm para-aortic mass, cervical, axillary, Supra-clavicular, mediastianal, bilateral common iliac, bilateral internal and external iliac Lymphoma masses. Largest mediastinal (Sub-carinal and left para-tracheal) is 2 x 0.8 cm with SUV uptake of 9.3.
After 3 cycles of R-CHOP, interim PET/CT showed excellent response with resolution of all FDG avid masses except mediastinum with activity in paratracheal, and sub-carinal nodes with largest node measuring 1.7 x 1.0 cm with SUV of 5.0. After 6 cycles of R-CHOP, Right para-tracheal node is 8 mm with SUV of 6.36 and Sub-cardinal node of 10 mm with SUV of 5.26.

Hematologist thinks these residual uptake in these mediastinal lymph nodes is not significant or maybe due to inter-current infections. Since the size of these mediastinal lymph nodes is smaller, Heam/Onc thinks no residual disease in these lymph nodes. Pt says he had some symptoms of URI, cough before both PET/CT. So Hematologist doesn’t want to consider him for high dose Chemotherapy with autologous BMT and referred him for radiation to originally bulky region that is para-aortic nodal region only. Heam/Onc wants to consider him for BMT if follow up PET/CT or CT shows increase in the size of these mediastinal nodes. So Pt is also not interested in BMT now.

Heam/Onc asked not to include mediastianal nodes in the radiation field.

I personally think the residual uptake in these mediastinal nodes is significant and want to do mediastinal RT to 45Gy and Para-Aortic RT to 36Gy.

Questions.
1. Is it reasonable omit radiation to mediastinal lymph nodes?
2. What is the benefit of radiation to these PA (completely FDG resolution) originally bulky nodes if pt ends up needing BMT eventually?


Thanks a lot!

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[OTN]

Residual uptake in the mediastinum should be considered lymphomatous involvement unless proven othewise. I would treat the mediastinum and PALNs.

 

[Palex80]

I agree.

Residual uptake in the mediastinum should be considered lymphomatous involvement unless proven othewise. I would treat the mediastinum and PALNs.

You could always ask for a biopsy, even if that means a mediastinoscopy.

 

[Mandelin Rain]

EBUS bx of rt partracheal and subcarinal. Med would be better, but may be able to negotiate down to EBUS with med onc.

 

[Lamount]

If the patient has new uptake in LNs that were not previously involved, I may buy that it is due to infection... but if the residual uptake is only involving those LNs that were enlarged and hot on pre-treatment imaging, I think it would be foolish for the heme/oncs to assume it is an infection. Lastly, save a fairly significant PNA (that too would be present on imaging), it's not SUPER common to have elevated uptake in the mediastinum -I mean, it does happen... but not every day.

Why did they bother getting a PET scan if they weren't going to believe the results?

 

[Palex80]

Why did they bother getting a PET scan if they weren't going to believe the results?

To tell the patient that they cured him (not) from lymphoma.

 

[TheWallnerus]

Hi SDN friends,

I would like to run by you all a difficult Lymphoma case.

40 year old male when presented with Fevers, is diagnosed with DLBCL with bulky 11.3 cm para-aortic mass, cervical, axillary, Supra-clavicular, mediastianal, bilateral common iliac, bilateral internal and external iliac Lymphoma masses. Largest mediastinal (Sub-carinal and left para-tracheal) is 2 x 0.8 cm with SUV uptake of 9.3.
After 3 cycles of R-CHOP, interim PET/CT showed excellent response with resolution of all FDG avid masses except mediastinum with activity in paratracheal, and sub-carinal nodes with largest node measuring 1.7 x 1.0 cm with SUV of 5.0. After 6 cycles of R-CHOP, Right para-tracheal node is 8 mm with SUV of 6.36 and Sub-cardinal node of 10 mm with SUV of 5.26.

Hematologist thinks these residual uptake in these mediastinal lymph nodes is not significant or maybe due to inter-current infections. Since the size of these mediastinal lymph nodes is smaller, Heam/Onc thinks no residual disease in these lymph nodes. Pt says he had some symptoms of URI, cough before both PET/CT. So Hematologist doesn’t want to consider him for high dose Chemotherapy with autologous BMT and referred him for radiation to originally bulky region that is para-aortic nodal region only. Heam/Onc wants to consider him for BMT if follow up PET/CT or CT shows increase in the size of these mediastinal nodes. So Pt is also not interested in BMT now.

Heam/Onc asked not to include mediastianal nodes in the radiation field.

I personally think the residual uptake in these mediastinal nodes is significant and want to do mediastinal RT to 45Gy and Para-Aortic RT to 36Gy.

Questions.
1. Is it reasonable omit radiation to mediastinal lymph nodes?
2. What is the benefit of radiation to these PA (completely FDG resolution) originally bulky nodes if pt ends up needing BMT eventually?


Thanks a lot!

- bone marrow biopsy beforehand?
- tell us more about the lymphoma (what pathologist said about how it looked, markers, etc)
- 45 Gy sounds high; I'd do ~30 Gy to large bulky region that got a CR and ~36 Gy to the PR areas
- ignore med onc's field recommendations (it would not make any sense not to include the PET-suspicious dz)

 

[thecarbonionangle]

Whenever med oncs tell me how to do my job I nod and smile. I like to drop one of the most empty meaningless phrases, “i hear you”. They were heard. Then i do what I was trained to do and my best professional judgement. Never abdicate your job to med oncs. We bend the knee ENOUGH.

 

[bachiraki]

- bone marrow biopsy beforehand?
- tell us more about the lymphoma (what pathologist said about how it looked, markers, etc)
- 45 Gy sounds high; I'd do ~30 Gy to large bulky region that got a CR and ~36 Gy to the PR areas
- ignore med onc's field recommendations (it would not make any sense not to include the PET-suspicious dz)

Yes, Bone marrow biopsy negative,
DLBCL, Non-germinal center type

thanks for your input!

 

[evilbooyaa]

1. Hell no. If Heme/Onc wants you to not radiate mediastinal LNs, then would push for EBUS+Bx to rule out persistent disease. Sounds like a Deauville 4 response which is a partial. If it was MORE than initial SUV then would be worthy of definitely biopsing. It's one thing if they're going to do second line therapy and transition to high dose CT with autologous rescue.
2. I mean ISRT in bulky disease is a 'consider' per NCCN in stage III dz, so it's not mandatory here. If they really don't want you to radiate the mediastinum and won't let you biopsy I don't see a huge benefit in radiation para-aortic. Treating the lower risk region and not the higher risk region doesn't make sense to me.
I personally would do 30Gy to initially bulky area, but I think 40-45 to mediastinal LNs not unreasonable.

- bone marrow biopsy beforehand?
- tell us more about the lymphoma (what pathologist said about how it looked, markers, etc)
- 45 Gy sounds high; I'd do ~30 Gy to large bulky region that got a CR and ~36 Gy to the PR areas
- ignore med onc's field recommendations (it would not make any sense not to include the PET-suspicious dz)

NCCN suggests 40-55 for PR. While this is usually for Stage I-II disease, I think if you're actively trying to avoid salvage HDCT w/ SCR in this patient I'd go at least to 40Gy.

 

[bachiraki]

Excellent Input! Thanks a lot Everyone

Now that all of us agree about presence of residual disease in the mediastinal lymph nodes,

1. Should I push Heam/Onc and patient for High dose myeloablative chemotherapy with autologous stem cell rescue (BMT)
2. Or do consolidative Radiation for mediastinum and PA nodes and then do BMT in case of recurrence?
3. Is CART better instead of BMT in case of future recurrence after Radiation now?

Many centers are going for upfront BMT in case of residual disease in stage III and IV pts

 

[thecarbonionangle]

Would treat to 45 given residual disease after chemo. would give at least 36 if you wanna give less.

 

[communitydoc13]

I agree don't abdicate your job, but I also think omitting mediastinal nodes is reasonable here. (Just a little too cute in my opinion)

Sounds like medonc thinking that best data for consolidative XRT is to bulky or extranodal disease in NHL. Also, medonc is clearly approaching this as a CR with peculiar mediastinal PET findings. Why? I'm guessing because mediastinal disease so much smaller than bulky disease, no change in response from 3 to 6 cycles and other factors as above. If they didn't think this was a CR, they almost certainly would not be counting on XRT salvage in a 40 year old.

PET after 3 cycles and 6 cycles didn't change much and abnormal residual mediastinal uptake not that unusual. As per Palex on other lymphoma thread, even in primary mediastinal lymphoma, equivocal mediastinal findings are often observed.

I have no idea what the negative predictive value of EBUS is here (can anyone say?). If it is reasonable than EBUS a good option, but it may not be very good. Can anyone answer this?

The question is toxicity. How much toxicity do you cause by adding ISRT 36 to 45 to mediastinum. Do you compromise any salvage regimen? I don't think so. I would ask medonc what their concerns are regarding adding such a field.

I agree with 30 Gy to bulky site, 36 Gy to mediastinum if you are treating.

 

[TheWallnerus]

Sounds like a Deauville 4 response which is a partial.

- Can someone give quick pointer on preferred nomenclature re: Lugano or Deauville here
- Remember to use verb "irradiate" (ask Ed Halperin)
- This is CR/PR(?) (prob mostly CR-ish... *that* I would trust med onc moreso)

 

[evilbooyaa]

- Can someone give quick pointer on preferred nomenclature re: Lugano or Deauville here
- Remember to use verb "irradiate" (ask Ed Halperin)
- This is CR/PR(?) (prob mostly CR-ish... *that* I would trust med onc moreso)

Oops, I was wrong on my doses. You're right, was thinking refractory disease, but this would just be PR. 36Gy very reasonable.

 

[Lamount]

I agree don't abdicate your job, but I also think omitting mediastinal nodes is reasonable here. (Just a little too cute in my opinion)

Sounds like medonc thinking that best data for consolidative XRT is to bulky or extranodal disease in NHL. Also, medonc is clearly approaching this as a CR with peculiar mediastinal PET findings. Why? I'm guessing because mediastinal disease so much smaller than bulky disease, no change in response from 3 to 6 cycles and other factors as above. If they didn't think this was a CR, they almost certainly would not be counting on XRT salvage in a 40 year old.

PET after 3 cycles and 6 cycles didn't change much and abnormal residual mediastinal uptake not that unusual. As per Palex on other lymphoma thread, even in primary mediastinal lymphoma, equivocal mediastinal findings are often observed.

I have no idea what the negative predictive value of EBUS is here (can anyone say?). If it is reasonable than EBUS a good option, but it may not be very good. Can anyone answer this?

The question is toxicity. How much toxicity do you cause by adding ISRT 36 to 45 to mediastinum. Do you compromise any salvage regimen? I don't think so. I would ask medonc what their concerns are regarding adding such a field.

I agree with 30 Gy to bulky site, 36 Gy to mediastinum if you are treating.

The medonc may think it is a CR... but isn't one. The lack of change between 3 and 6 cycles of chemo may simply indicate chemoristance (i.e. double/triple hit perhaps).

 

[TheWallnerus]

Whenever med oncs tell me how to do my job I nod and smile. I like to drop one of the most empty meaningless phrases, “i hear you”. They were heard. Then i do what I was trained to do and my best professional judgement. Never abdicate your job to med oncs. We bend the knee ENOUGH.

Hey My Crocness I have told a med onc "I hear you" twice today already. Thanks for the pro tip.

 

[communitydoc13]

The medonc may think it is a CR... but isn't one. The lack of change between 3 and 6 cycles of chemo may simply indicate chemoristance (i.e. double/triple hit perhaps).

I don't know if it's a CR or not. But I do think that the recommendation from medonc here could well be a thoughtful one.

For high grade DLBCL with partial response standard of care is not consolidative ISRT. This is considered palliative for patients who are not candidates for therapeutic escalation (transplant, CART-T) and I'm just guessing that this 40 year old would be medically a candidate for such.

What I think medonc is doing here is hoping for the best (a CR) in an equivocal situation and trying to spare the patient potentially unnecessary and unfriendly therapy. They are referring for standard of care consolidation to initially bulky disease and are probably thinking that the likelihood of ISRT to the mediastinum if this is truly only only a partial response, is unlikely to significantly change prognosis or likelihood of progression.

Do we have data to justify consolidative RT in this setting in terms of good long term outcomes?

 

[Lamount]

I don't know if it's a CR or not. But I do think that the recommendation from medonc here could well be a thoughtful one.

For high grade DLBCL with partial response standard of care is not consolidative ISRT. This is considered palliative for patients who are not candidates for therapeutic escalation (transplant, CART-T) and I'm just guessing that this 40 year old would be medically a candidate for such.

What I think medonc is doing here is hoping for the best (a CR) in an equivocal situation and trying to spare the patient potentially unnecessary and unfriendly therapy. They are referring for standard of care consolidation to initially bulky disease and are probably thinking that the likelihood of ISRT to the mediastinum if this is truly only only a partial response, is unlikely to significantly change prognosis or likelihood of progression.

Do we have data to justify consolidative RT in this setting in terms of good long term outcomes?

Yes there are data showing that RT does exactly what you would think it would do.


...and I disagree that this is a well-thought out course of action. It’s a classic case of hoping the test is wrong. *fingers crossed 🤞 does not comprise a plan.

If he/she believes the PET, the plan should include some combo of consolidative RT and BMT (I don’t know the data for CAR-T). If he/she is concerned the PET is a false positive, do an excisional biopsy and prove it. If the patient refuses, that’s a different story.

 

[Radonc90]

- They (hemonc) should have consulted radonc after 3 cycles of chemo for input.
Anyway, radonc has more or less lost the battles in lymphoma over the last 20 yrs.

- Don't forget the "H" in R-CHOP. At 50 mg/m2 x 6 cycles, the Adria dose is 300 mg/m2!!!
The damage is to heart is subclinical, it is subtle and it is there.
So, if you decide to irradiate the mediastinum, take this graph into account in terms of cardiotoxicity...

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[RadOncDoc21]

Hey My Crocness I have told a med onc "I hear you" twice today already. Thanks for the pro tip.

This is the way!

 

[medgator]

Whenever med oncs tell me how to do my job I nod and smile. I like to drop one of the most empty meaningless phrases, “i hear you”. They were heard. Then i do what I was trained to do and my best professional judgement. Never abdicate your job to med oncs. We bend the knee ENOUGH.

I called out one of mine for giving 20 mg/m² weekly to one of my h&n pts... I'm like that's not even the minimum weekly wussy dose

I have no problem doing that since I'm either getting dual referred from ENT or, in many cases, referring to med onc. Much easier to have a spine when you don't depend on them as much for patients

 

[RadOncDoc21]

I called out one of mine for giving 20 mg/m² weekly to one of my h&n pts... I'm like that's not even the minimum weekly wussy dose

I have no problem doing that since I'm either getting dual referred from ENT or, in many cases, referring to med onc. Much easier to have a spine when you don't depend on them as much for patients

The way it should be.

 

[communitydoc13]

Yes there are data showing that RT does exactly what you would think it would do.

Interesting retrospective work. I'll let you figure out where this patient would fit into this study that preceded PET. Those mediastinal nodes would not be considered definitive residual disease by most of these docs, I suspect. The study itself had no imaging review and relied on doc's interpretation of imaging. Even if this patient only received XRT to the bulky site, he would have been included in the "received consolidative XRT" cohort in this study.

If he/she believes the PET, the plan should include some combo of consolidative RT and BMT (I don’t know the data for CAR-T). If he/she is concerned the PET is a false positive, do an excisional biopsy and prove it. If the patient refuses, that’s a different story.

Clearly they don't believe the PET. Without seeing the images myself, I cannot comment meaningfully on whether I would believe the PET.

If I were a medonc opposed to consolidative RT to the mediastinum here, I would ask radonc "What's the cost of waiting 3 months? If they grow in 3 months, we'll radiate and go to BMT. These Norwegian pts didn't even have PET and we know nothing about how they were salvaged. Do we know if we are costing the patient anything by waiting 3 months? We are likely avoiding some esophagitis now and potentially some compounding cardiac toxicity. If he never progresses, we are avoiding some 2nd malignancy risk and late cardiotoxicity forever."

So I wouldn't treat a medonc like sh... for coming up with this plan. I'd have to have some really good answers to these questions.

 

[RadOncDoc21]

Interesting retrospective work. I'll let you figure out where this patient would fit into this study that preceded PET. Those mediastinal nodes would not be considered definitive residual disease by most of these docs, I suspect. The study itself had no imaging review and relied on doc's interpretation of imaging. Even if this patient only received XRT to the bulky site, he would have been included in the "received consolidative XRT" cohort in this study.


Clearly they don't believe the PET. Without seeing the images myself, I cannot comment meaningfully on whether I would believe the PET.

If I were a medonc opposed to consolidative RT to the mediastinum here, I would ask radonc "What's the cost of waiting 3 months? If they grow in 3 months, we'll radiate and go to BMT. These Norwegian pts didn't even have PET and we know nothing about how they were salvaged. Do we know if we are costing the patient anything by waiting 3 months? We are likely avoiding some esophagitis now and potentially some compounding cardiac toxicity. If he never progresses, we are avoiding some 2nd malignancy risk and late cardiotoxicity forever."

So I wouldn't treat a medonc like sh... for coming up with this plan. I'd have to have some really good answers to these questions.

Not all med once are the same but this one seems to be crossing the line to me. We’re the ones who trained to review the imaging and come up with the treatment volumes and doses.... just sayin!

 

[communitydoc13]

Not all med once are the same but this one seems to be crossing the line to me. We’re the ones who trained to review the imaging and come up with the treatment volumes and doses.... just sayin!

I agree. And I would radiate mediastinal nodes if I were personally concerned. (36 Gy)

Admittedly, my intuition about lymphomas and how they behave after certain imaging findings and in certain clinical scenarios (IPI is a confounder in terms of meaning of imaging response) is not strong as the medoncs keep even pretty text book cases away from us.

I do see enough post-chemo imaging at tumor boards however to know that my good community rads are often unsure of what Deauville to call a case in borderline cases and to know that the absolute SUV values matter very little. It is not unusual for medonc to present a borderline imaging finding post-chemo and to move on with observation even after we present option for ISRT. We occasionally get to see these patients at progression.

 

[RadOncDoc21]

I’m just salty because I’m in an environment where the cancer care is usually initiated by the med oncs regardless of the primary (strong presence in the community) so I do see what it’s like when the med onc makes all the treatment/management decisions and it can be devastating.

I think as a field, we have de-valued our role as an “oncologist” and I’m not willing to accept that as our fate. So I apologize if I seem upset anytime I see a med onc making radiation decisions regardless if it’s the right move or not.

 

[Palex80]

I’m just salty because I’m in an environment where the cancer care is usually initiated by the med oncs regardless of the primary (strong presence in the community) so I do see what it’s like when the med onc makes all the treatment/management decisions and it can be devastating.

I think as a field, we have de-valued our role as an “oncologist” and I’m not willing to accept that as our fate. So I apologize if I seem upset anytime I see a med onc making radiation decisions regardless if it’s the right move or not.

Shut up and go back to your basement to play with your cancer killing machine! Your job is to push the buttons.

 

[Radonc90]

The problem with medonc referral is more severe than that...

1. We radonc's are outnumbered by medonc's. In 2011, there were some 13,000 medoncs in the US per ASCO.
So you can see that for every 1 radonc, there are some 3-4 medoncs.

2. Medonc training is far behind time. They don't even have any surgical training like some of us do.
They don't even know the human anatomy that well.
They don't do Gyn, HN or rectal exam, it is not part of their training and pts get chemo anyway, why bother with the physical exam.

3. PCPs have little or no training in oncology, so the minute the PCP diagnoses their patients with cancer, they ship them to medonc bc in the PCP's mind, oncology is too complex (it is true), so PCPs use medonc as their "Air Traffic Controllers".
Except for the fact that the ATC sends the planes to the wrong airports about 40% of the time lol...

4. Medoncs that I deal with play a lot of stupid politics to their liking.

Here are some examples that I see repeatedly.

1. T1 or T2 lung cancer with bad PFT.
PCP sent pt to medonc!
Medonc sent the pt to Thoracic Surg.
Thoracic sent the pt to me!

2. Lung pt under the care of medonc, c/o of rectal bleeding.
They diagnosed hemorrhoids without looking down there.
Long story short, pts have anal cancer!

3. Colon ca s/p R hemi.
Developed 1 liver met one year later.
Chemo given for the solitary liver met to line their pockets.
Only when chemo stops working, they sent the pt to the liver surgeon.
My liver surgeon showed me the CT scan and just shook his head!

4. Vaginal bleeding.
PCP diagnosed Endometrial cancer, and sent to reg OB-Gyn.
OB-Gyn sent pt to GynOnc.
At least this time they are correct.

5. Lung ca pts undergoing chemo.
C/o sore palate.
They didn't look.
Long story short, pts have soft palate cancer.

I have about 100's of these stories.
It is not a good time to be a patient.

Every time a PCP sees cancer ---> refer to "Oncology". This is where things can get messy very quickly,
bc these medoncs don't have any training in surg or radonc.

If we collectively don't get aggressive and go to the front with PCPs in terms of triage, we are done.
Anyway, we are not alone, the surgeons complain about these medonc's too.

 

[medgator]

The problem with medonc referral is more severe than that...

1. We radonc's are outnumbered by medonc's. In 2011, there were some 13,000 medoncs in the US per ASCO.
So you can see that for every 1 radonc, there are some 3-4 medoncs.

2. Medonc training is far behind time. They don't even have any surgical training like some of us do.
They don't even know the human anatomy that well.
They don't do Gyn, HN or rectal exam, it is not part of their training and pts get chemo anyway, why bother with the physical exam.

3. PCPs have little or no training in oncology, so the minute the PCP diagnoses their patients with cancer, they ship them to medonc bc in the PCP's mind, oncology is too complex (it is true), so PCPs use medonc as their "Air Traffic Controllers".
Except for the fact that the ATC sends the planes to the wrong airports about 40% of the time lol...

4. Medoncs that I deal with play a lot of stupid politics to their liking.

Here are some examples that I see repeatedly.

1. T1 or T2 lung cancer with bad PFT.
PCP sent pt to medonc!
Medonc sent the pt to Thoracic Surg.
Thoracic sent the pt to me!

2. Lung pt under the care of medonc, c/o of rectal bleeding.
They diagnosed hemorrhoids without looking down there.
Long story short, pts have anal cancer!

3. Colon ca s/p R hemi.
Developed 1 liver met one year later.
Chemo given for the solitary liver met to line their pockets.
Only when chemo stops working, they sent the pt to the liver surgeon.
My liver surgeon showed me the CT scan and just shook his head!

4. Vaginal bleeding.
PCP diagnosed Endometrial cancer, and sent to reg OB-Gyn.
OB-Gyn sent pt to GynOnc.
At least this time they are correct.

5. Lung ca pts undergoing chemo.
C/o sore palate.
They didn't look.
Long story short, pts have soft palate cancer.

I have about 100's of these stories.
It is not a good time to be a patient.

Every time a PCP sees cancer ---> refer to "Oncology". This is where things can get messy very quickly,
bc these medoncs don't have any training in surg or radonc.

If we collectively don't get aggressive and go to the front with PCPs in terms of triage, we are done.
Anyway, we are not alone, the surgeons complain about these medonc's too.

No reason you can't get direct Pulmonary, gi, gen surg, and ent referrals. Hell a couple of the gen surg guys have busy skin cancer practices so i end up getting skin referrals as well as breast referrals from some of them.

Takes years to develop those referral relationships but it absolutely can be done. Cross/reverse referrals help... You should be referring out for ports, pegs, pfts, biopsies etc

 

[Radonc90]

@medgator,

I agree with you.

Actually, although I am in academic practice, I am very aggressive (in a nice way) with certain docs.
- Pulm MDs: met them all the time, gave them short presentations on SBRT, and virtually all the pts with T1-T2 with poor PFT go to me.

- ENT: yes, I know all the ENT people, and I know my ENT stuff like the back of my hands. Plus I spent many months doing HN surgery, so I know my HN surgical anatomy very well and the ENT people know that. They always insist on pts seeing me only.

- GI and GenSurg: yes to that too.

What "bothers" me is the PCPs, there are too many of them out there, I cannot reach every single PCP, I can only reach certain number of PCPs.

Too bad the medonc's people have no training in gensurg and very little about radonc but given the carte blanche (by the PCPs) in many cities/communities in the USA and elsewhere, simply bc of PCP's lack of oncology knowledge. Pts don't get good overall care when they land at medonc's door.

The funny thing is: every time I come to talk to them about any patient, they are shocked at how much I know about their trade secrets. I know the exact chemo doses/schedules in 5-FU, MitoC, CDDP, Adria, Taxol, Carbo AUC...and they are scared when I went to great detail about chemo lol...

 

[JoeBiden69]

The problem with medonc referral is more severe than that...

1. We radonc's are outnumbered by medonc's. In 2011, there were some 13,000 medoncs in the US per ASCO.
So you can see that for every 1 radonc, there are some 3-4 medoncs.

2. Medonc training is far behind time. They don't even have any surgical training like some of us do.
They don't even know the human anatomy that well.
They don't do Gyn, HN or rectal exam, it is not part of their training and pts get chemo anyway, why bother with the physical exam.

3. PCPs have little or no training in oncology, so the minute the PCP diagnoses their patients with cancer, they ship them to medonc bc in the PCP's mind, oncology is too complex (it is true), so PCPs use medonc as their "Air Traffic Controllers".
Except for the fact that the ATC sends the planes to the wrong airports about 40% of the time lol...

4. Medoncs that I deal with play a lot of stupid politics to their liking.

Here are some examples that I see repeatedly.

1. T1 or T2 lung cancer with bad PFT.
PCP sent pt to medonc!
Medonc sent the pt to Thoracic Surg.
Thoracic sent the pt to me!

2. Lung pt under the care of medonc, c/o of rectal bleeding.
They diagnosed hemorrhoids without looking down there.
Long story short, pts have anal cancer!

3. Colon ca s/p R hemi.
Developed 1 liver met one year later.
Chemo given for the solitary liver met to line their pockets.
Only when chemo stops working, they sent the pt to the liver surgeon.
My liver surgeon showed me the CT scan and just shook his head!

4. Vaginal bleeding.
PCP diagnosed Endometrial cancer, and sent to reg OB-Gyn.
OB-Gyn sent pt to GynOnc.
At least this time they are correct.

5. Lung ca pts undergoing chemo.
C/o sore palate.
They didn't look.
Long story short, pts have soft palate cancer.

I have about 100's of these stories.
It is not a good time to be a patient.

Every time a PCP sees cancer ---> refer to "Oncology". This is where things can get messy very quickly,
bc these medoncs don't have any training in surg or radonc.

If we collectively don't get aggressive and go to the front with PCPs in terms of triage, we are done.
Anyway, we are not alone, the surgeons complain about these medonc's too.

And yet, when these patients have detestation complications of surgery or RT, they get admitted to the inpatient Med Onc service. I’m pretty sure our local rad oncs don’t even know our cancer center has an attached hospital.

 

[RadOncDoc21]

And yet, when these patients have detestation complications of surgery or RT, they get admitted to the inpatient Med Onc service. I’m pretty sure our local rad oncs don’t even know our cancer center has an attached hospital.

Not entirely true. A lot of hospitals are moving away from med onc floors and are using hospitalists. I don’t agree with this as we all know cancer patients are some of the most complicated patients and this adds yet another layer of complexity to the situation. A lot of the med oncs here don’t even see their own patients when they are admitted into the hospital.

I know med oncs want to be viewed as the “champion for cancer patients” but rad oncs have more years of oncology training and focus. Now when it comes to managing Eliquis or reading an endocrine panel...I’m clueless.

 

[JoeBiden69]

Not entirely true. A lot of hospitals are moving away from med onc floors and are using hospitalists. I don’t agree with this as we all know cancer patients are some of the most complicated patients and this adds yet another layer of complexity to the situation. A lot of the med oncs here don’t even see their own patients when they are admitted into the hospital.

I know med oncs want to be viewed as the “champion for cancer patients” but rad oncs have more years of oncology training and focus. Now when it comes to managing Eliquis or reading an endocrine panel...I’m clueless.

I was an Onc hospitalist at one point in my life. I never, ever had trouble getting hold of a patient’s medical oncologist. Most I texted with. The surgeons were a bit harder to get a hold of but usually had a resident or APP who was easily reachable. Meanwhile, the rad oncs would flat out not respond to pages. They also did not document their treatments in Epic or ARIA so I had to go off by what the patient told me.

Also, I had to break it to you, but anticoagulation management and dealing with endocrinopathies are essential to treating Onc patients. Surely someone with extensive training in oncology should know this.

 

[RadOncDoc21]

I was an Onc hospitalist at one point in my life. I never, ever had trouble getting hold of a patient’s medical oncologist. Most I texted with. The surgeons were a bit harder to get a hold of but usually had a resident or APP who was easily reachable. Meanwhile, the rad oncs would flat out not respond to pages. They also did not document their treatments in Epic or ARIA so I had to go off by what the patient told me.

Also, I had to break it to you, but anticoagulation management and dealing with endocrinopathies are essential to treating Onc patients. Surely someone with extensive training in oncology should know this.

I can tell you have no idea what oncology training entails...I’ll give you a hint, it’s more then just inpatient management. And why would I manage endocrinopathies? Do you manage IMRT?

 

[mheat3]

I was an Onc hospitalist at one point in my life. I never, ever had trouble getting hold of a patient’s medical oncologist. Most I texted with. The surgeons were a bit harder to get a hold of but usually had a resident or APP who was easily reachable. Meanwhile, the rad oncs would flat out not respond to pages. They also did not document their treatments in Epic or ARIA so I had to go off by what the patient told me.

Also, I had to break it to you, but anticoagulation management and dealing with endocrinopathies are essential to treating Onc patients. Surely someone with extensive training in oncology should know this.

Oh oh my turn! Is this like when someone gets treated for prostate cancer with radiation but clearly it is documented by the hospitalist that his current swallowing issues are related to his "prior radiation." ? Or is this like when an asymptomatic patient with one brain met from breast cancer gets told that "hospice is their only option"?

Sorry the RO's where you are apparently don't document or respond to pages but that is not the norm in any sense. Point being, we can all point fingers at each other all day but you cannot argue the best things for (most) patients with cancer would be to meet with all onc folks. Its the bare minimum we would want for our friends and family.

 

[JoeBiden69]

I can tell you have no idea what oncology training entails...I’ll give you a hint, it’s more then just inpatient management. And why would I manage endocrinopathies? Do you manage IMRT?

The complex patients are inpatient, not to mention the fact that many diagnoses are often first made in the inpatient setting.

And no, I don’t manage IMRT. Again, I’m not a rad onc. I do need to be aware of its complications though, as the patient with radiation pneumonitis coming to the hospital with SOB has to managed by me, not by the rad onc who works 9-4 Monday through Friday and thinks albuterol is a town in the Middle East.

 

[JoeBiden69]

Or is this like when an asymptomatic patient with one brain met from breast cancer gets told that "hospice is their only option"?

Our brain met patients all had neurosurgery consults and we basically did what the neurosurgeon recommended. And that’s part of the problem with your field. You don’t own an organ system or even really that many diseases. It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

 

[RadOncDoc21]

The complex patients are inpatient, not to mention the fact that many diagnoses are often first made in the inpatient setting.

And no, I don’t manage IMRT. Again, I’m not a rad onc. I do need to be aware of its complications though, as the patient with radiation pneumonitis coming to the hospital with SOB has to managed by me, not by the rad onc who works 9-4 Monday through Friday and thinks albuterol is a town in the Middle East.

I’m going to call BS now. Pneumonitis isn’t rocket science and is usually managed as an outpatient and rarely symptomatic following steroids.

 

[Ray D. Ayshun]

Our brain met patients all had neurosurgery consults and we basically did what the neurosurgeon recommended. And that’s part of the problem with your field. You don’t own an organ system or even really that many diseases. It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

While I do like your screen name, sometimes you just gotta say, "go **** yourself."

 

[Lamount]

Our brain met patients all had neurosurgery consults and we basically did what the neurosurgeon recommended. And that’s part of the problem with your field. You don’t own an organ system or even really that many diseases. It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

Where I practice, a rad onc sees an inpatient same day, but with IR, it could take up to a week for the “right” provider to be available. We are consulted on just about every brain met, symptomatic spine/Bone/lung/H&N/GI/GU met. I guess it depends what sort of place you work at

 

[Radonc90]

And yet, when these patients have detestation complications of surgery or RT, they get admitted to the inpatient Med Onc service. I’m pretty sure our local rad oncs don’t even know our cancer center has an attached hospital.

Mr President,

I am afraid you are wrong (in my case). We all know where the main hospital is for good pt care.
My pts with complications get admitted under hospitalists' service.
My medoncs are too busy pushing chemo/IO stuff, they don't want to deal with inpatients complexity (complications from chemo, angina, COPD, minor strokes etc. etc.).

For best pt's care, I think hospitalists do the BEST job bc they are trained for multiple complex medical conditions.
They are up-to-date with these internal med stuff.
They are the true internists, medoncs are not true internists, sorry.

And guess what, I read all the notes written by the hospitalists so I can educate myself what is current in internal medicine, which I like a lot. We are not true MDs unless we love internal medicine, the back bone of medical field. So, when my pts get admitted for MI, I read all the notes from IM, Cardiology, and yes I learn a lot from these folks.

 

[lyltothend]

Our brain met patients all had neurosurgery consults and we basically did what the neurosurgeon recommended. And that’s part of the problem with your field. You don’t own an organ system or even really that many diseases. It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

This discussion is bit laughable. I am in my clinic right now sitting around waiting for a patient to come from the floors to simulate and treat that i saw in consult this morning after a medical oncology colleague paged me. Can we stop this drivel and just agree we all have strengths and weaknesses, but we all want what is best for our patients and we all succeed more when we are collegial.

 

[deleted969641]

Our brain met patients all had neurosurgery consults and we basically did what the neurosurgeon recommended. And that’s part of the problem with your field. You don’t own an organ system or even really that many diseases. It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

I'm sorry that you work with such crappy rad oncs. This is not how I practice. I regularly see same day consults to appease med oncs, even when totally inappropriate.

Also, stop wasting my tax dollars on losers. I got enough problems than to pay for other people's crap and bad decisions. Thx.

 

[TheWallnerus]

If we collectively don't get aggressive and go to the front with PCPs in terms of triage, we are done.

We are all products of our training... sometimes we escape our training, sometimes we do not. This "get in front of PCPs" mentality needs to happen during training so it makes sense to PCPs and becomes learned behavior for rad oncs.

I do need to be aware of its complications though, as the patient with radiation pneumonitis coming to the hospital with SOB has to managed by me, not by the rad onc who works 9-4 Monday through Friday and thinks albuterol is a town in the Middle East.

Al-Buterol is a city in the UAE, and Manual Labor is a guy from Mexico.

It’s the same situation with IR but IR overcomes it by making itself extremely available to the internists/Med oncs. Oh, surgery won’t place a port until two weeks from now? We’ll fit them in tomorrow. Rapidly expanding mass is causing hydronephrosis and urology can’t take to the OR until later this week? Here, we’ll throw some NTs in this afternoon. Rad onc doesn’t have this attitude.

Rad oncs need to watch this movie often.

 

[elementaryschooleconomics]

I think every faculty member in my department would line up to peel off my skin, slowly, if they EVER heard that I punted a radiation pneumonitis patient to a MedOnc...

 

[RadOncDoc21]

I think every faculty member in my department would line up to peel off my skin, slowly, if they EVER heard that I punted a radiation pneumonitis patient to a MedOnc...

Which is why I’m not buying his examples. Also, in regards to the patients that require urgent SURGICAL interventions. He mixes up inpatient management of a cancer patient and what constitutes an actual cancer workup and treatment. A diagnosis of cancer is only the beginning.

 

[JoeBiden69]

I think every faculty member in my department would line up to peel off my skin, slowly, if they EVER heard that I punted a radiation pneumonitis patient to a MedOnc...

So when your radiation pneumonitis patient is hypoxemic and requires inpatient hospitalization, you admit them to your service?

 

[RadOncDoc21]

So when your radiation pneumonitis patient is hypoxemic and requires inpatient hospitalization, you admit them to your service?

In my 10+ years of experience in this field, I have never seen such a complication (that either me or pulm couldn’t manage as an outpatient). I’m not sure what your rad oncs are doing or if they are even real.

 

[Ray D. Ayshun]

So when your radiation pneumonitis patient is hypoxemic and requires inpatient hospitalization, you admit them to your service?

Radiation pneumonitis is a diagonals of exclusion. Should they need to be inpatient to be worked up, we'll defer to the team. Otherwise we'll work them up, and then start roids. Kinda like when we get consulted by the inpatient team bc nsg didn't tell em how to taper roids. Sorry you work with ****ty radoncs. At the same, maybe they don't return your call for a reason.