Emergency Friday Consult

[Radonc 2013]

So we all know as radiation oncologists that Fridays seem to be a common day cord compressions becomes an emergency (even if the MRI was done 3 days ago). I have always been told, ever since my days in training, if we sim and start a emergency (ie cord compression) on a Friday, that we should treat the patient the next day. In this scenario we would usually would treat on Saturday, skip Sunday, and resume on Monday. We would treat 30 Gy/10 fractions and finish this hypothetical treatment course in 12 elapsed days.

What if in this scenario we gave 4 Gy x 3 on Friday, Monday, Tuesday, and then treated the rest at 3 Gy fractions. So 30 Gy/9 fractions. The number of elapsed days to complete the treatment course is the same as the above scenario. Even the number of elapsed days to get to 12 Gy is the same (I know somewhat arbitrary time point).

So the question is...am i coming in for 15 minutes for no reason on a Saturday the couple times a year that this happens? Am I a victim of Oncolore similar to when I was depriving patients of their regular deodorant and giving breast cancer patients anxiety about putting lotion on too close to their treatment time?

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[elementaryschooleconomics]

Yes! I love this. I can't wait for @scarbrtj's incoming dissertation.

I have also been taught the same, and everyone I know treats like that (urgent start Friday, treat Saturday, skip Sunday, resume Monday).

I 100% think this is Oncolore - I would love someone to present an argument to the contrary!

 

[medgator]

4Gy x 5. Lends itself to single fraction delivery on Fri or sat. Problem solved

 

[BobbyHeenan]

I come in waayyy too much on weekends I'd imagine.

But it just doesn't feel right to me to give one fraction then a two day break. So even if 20/5, I'd still probably treat Fri, Sat.

But that's just my "feeling," so until I get more burned out I'm going with it. My staff may revolt before then as well.

Would LOVE to see someone publish on this though, would make that feeling less intense.

 

[scarbrtj]

Yes! I love this. I can't wait for @scarbrtj's incoming dissertation.

I have also been taught the same, and everyone I know treats like that (urgent start Friday, treat Saturday, skip Sunday, resume Monday).

I 100% think this is Oncolore - I would love someone to present an argument to the contrary!

No dissertations. My wad's shot from all the oversupply analyses. But is there great evidence that 30/10 is better than 8/1 for cord compression? Maybe more evidence we should be consulting nsg on Friday than irradiating, but that's another topic. Just 8 Gy on Friday and save yourself a Saturday at the hospital? But the tx on Saturday thing... yeah, there's sure as heck no evidence there that it's necessary. It's like the old "hanging chad" from Bush v Gore. Don't want that "hanging fraction." Oncolore. The dose of 30/9 in the daily fractionation recipe as stated would put to rest any niggling radiobiological worries IMHO. It makes up for the tumoricidal BED being decreased by tx elongation. However, it would add ~10-15% ~5% more late BED... likely clinically inconsequential, but then so too is the minor BED Gy-10 loss from tx elongation. The gain by "accelerating" (either by tx'ing Saturday, or giving 33% more dose on 30% of the fractions) won't be what we get from, e.g., that.

 

[evilbooyaa]

Nothing wrong with a 4Gy Friday followed by resuming treatment on Monday. It's certainly attending dependent - I'd say 1/3rd to 1/2 of my residency attendings did 4Gy Friday and ended up doing a 30/9 regimen (or just 20/5) nearly exactly as you describe. Maybe not for every patient, but for those close to hospice, yeah that was the standard.

The thought is to feel like we are doing "everything we possibly can" for our patients, and to convince the patient, the referring, and the inpatient team of that as well, by being willing to come in on a weekend for an 'emergent' treatment.

Another factor that came into play was how stable the patient was otherwise - somebody who was having vitals issues (BP, HR unstable, or on significant new O2 requirements, etc.) we purposefully tried to avoid bringing to the department on a weekend, when back-up if patient crashed while in the Rad Onc department was non-existent.

 

[Radonc 2013]

Yes! I love this. I can't wait for @scarbrtj's incoming dissertation.

I have also been taught the same, and everyone I know treats like that (urgent start Friday, treat Saturday, skip Sunday, resume Monday).

I 100% think this is Oncolore - I would love someone to present an argument to the contrary!

I was also looking forward to his answer as well! I can't see there being any clinical difference. Minimal differences in BED (both late and tumor). Total treatment duration the same. The only difference it may make is the potentially positive impression of a Rad Onc coming into treat on a weekend to the referring physician. Honestly, that may be reason enough...the show must go on!

 

[FrostyHammer]

Or, you could do 8 Gy x1 based on the randomized SCORAD III trial (statistical gymnastics on that trial notwithstanding)

 

[Palex80]

We don't treat on Fridays "emergency" consultations. We treat on Monday.
It's called the "weekend filter". Those who still have an indication for treatment on Monday were worth irradiating on Friday, the rest not.

 

[medgator]

If you aren't walking into my office outpatient, you aren't good enough PS to get 30/10.

 

[Ray D. Ayshun]

6 gy Friday, then 3 gy x 7? Same bed2 as 3x10. And same bed10. Seems like all compressions should be treated this way. Still 2 otvs as well...

 

[communitydoc13]

4Gy x 5 and problem solved, treat Friday, then Monday. But I'm out in community now and not treating at the hospital. The coming in on Saturday for the patient at a high powered academic hospital (more likely to be that young breast cancer patient) makes them and their family feel darn good. If I had residents, I might make them do this for that sake alone.

 

[RickyScott]

Radiobiologically first 4-6gy is killing 60-80% of initial cells. Remaining fractions/xrt killing much smaller absolute amount.
Also For cord compression and pain, main acute effect of radiation is probably due to killing inflammatory regional white blood cells.

 

[Mandelin Rain]

New supervision rules my dude. Just make your therapists do it while you sleep off the Friday night hangover you obtained while drinking away the thought that the patient was in the hospital for 9 days before they called you at 4:30 on Friday.


(Never actually do that. They’ll resent you instantly.)

 

[metallica81788]

Feels like so much of the "coming in on the weekend" is for optics. RadOncs have to convince other specialties that we work hard too!!!
I'd love to see the clinical outcome trial for starting urgent radiation on Sat/Sun vs Monday.

 

[w00tz]

What about Wednesday before Thanksgiving? 4Gy Wednesday, then treat Monday?

 

[Palex80]

We have pretty much abandoned 3 Gy or 4 Gy as fraction size for spinal mets.

Most patients get 5x5 Gy now, its done in a week and offers the same BED as 30/3.
Exceptions are:
a) the SBRT-patients when we want to ablate
b) the very, very long volumes like T2-L4 or something, where we would rather give 30/3 indeed
c) the very, very palliative cases where we would give 1 x 8 Gy for pain relief only

 

[RadOncDoc21]

We have pretty much abandoned 3 Gy or 4 Gy as fraction size for spinal mets.

Most patients get 5x5 Gy now, its done in a week and offers the same BED as 30/3.
Exceptions are:
a) the SBRT-patients when we want to ablate
b) the very, very long volumes like T2-L4 or something, where we would rather give 30/3 indeed
c) the very, very palliative cases where we would give 1 x 8 Gy for pain relief only

You sound like you did a fellowship!

 

[Ray D. Ayshun]

You sound like you did a fellowship!

Would you learn that in a "spinal mets" or "advanced radiation oncology" fellowship?

 

[Mandelin Rain]

Would you learn that in a "spinal mets" or "advanced radiation oncology" fellowship?

You need both.

 

[RickyScott]

We have pretty much abandoned 3 Gy or 4 Gy as fraction size for spinal mets.

Most patients get 5x5 Gy now, its done in a week and offers the same BED as 30/3.
Exceptions are:
a) the SBRT-patients when we want to ablate
b) the very, very long volumes like T2-L4 or something, where we would rather give 30/3 indeed
c) the very, very palliative cases where we would give 1 x 8 Gy for pain relief only

Do you deliver 5gy x 5 to cord?

 

[Lamount]

Radiobiologically first 4-6gy is killing 60-80% of initial cells. Remaining fractions/xrt killing much smaller absolute amount.
Also For cord compression and pain, main acute effect of radiation is probably due to killing inflammatory regional white blood cells.

But most of those cells don’t actually die until they try to divide (except lymphoma)...

 

[seper]

Long weekends are dreadful times for hospital-based RadOncs.

 

[McConaughey]

I agree we do not know if 2 fractions (Fri/Sat) is superior, but it is a very common/defendable approach, if the situation does not have a good outcome.

 

[Palex80]

Do you deliver 5gy x 5 to cord?

Yes! No hotspots allowed. Never seen an issue so far.

 

[evilbooyaa]

To round out the discussion, can someone post the link to that paper that shows inpatient consults spike on Fridays for Rad Oncs?

Can't find it and certainly relevant to topic at hand.

I would not be a fan of 5x5 to cord... even if I do 4Gy x 5 I like spine hotspot to be < 105%.

Long weekends are tough - for Thanksgiving (assuming clinic is closed Friday) would probably do Wednesday, then either Thursday OR Friday, before resuming on Monday.

 

[taserlaser]

Always on a Friday? Time pattern of referral for spinal cord compression

Always on a Friday? Time pattern of referral for spinal cord compression - PubMed

For patients with spinal cord compression, radiotherapy should be initiated as soon as possible to optimize the chances for restoration of neurological function. The speed of referral in the region of our radiotherapy institution with nine general hospitals was analysed based on a tumour and...

pubmed.ncbi.nlm.nih.gov

 

[drewdog1973]

I agree we do not know if 2 fractions (Fri/Sat) is superior, but it is a very common/defendable approach, if the situation does not have a good outcome.

Alright, alright, alright... Long time lurker, first time poster.

Defendable in terms of what? What situation would you be trying to defend yourself from? "Your honor, my client would be walking if they gave my patient 3 Gy on a Saturday." Seems like an absurd thing to say, when 8/1 is considered a completely reasonable option based on randomized controlled trials. People that think too much about this are the ones that get themselves in the most trouble. Just treat the patient, not the jury, for crying out loud.

BED3 for cord is ~60 for 30 Gy/10 fx, 66 for 25 Gy/5 fx, both easily below max. Hardly any benefit noted with multi-fraction regimen. But I guess you gotta pay for that TSLA (I mean the shares, not the ridiculous computer status symbol vehicle, or as my friend Raj calls it - "A Stupider Looking Chevy Volt"). The Friday special (>4-6 Gy on Friday, restart on Monday) is a beautiful creation of the community physician, no academician could come up with this gem. The amount of expenditure to warm up a linac, bring in a therapist, bring in a radonc to treat 1 fraction on a palliative patient is literally one of the most cost-INeffective things we can do, and likely one of the more medically ineffective done.

Coming in on a weekend to treat a cord for one fraction, as someone said above, is purely performative. "Oncology theater" would be a way to describe it. Not a way I would describe it, but some of the more annoying people on this forum may speak like this.

My message to my fellow SDN Deplorables (as opposed to those elites on the Bird) ... focus on eating gluttonous amounts of food, drinking cocktails at an absurdly early time of the day (justified by being forced to spend time with a mandated small group of people you love, like your deadbeat husband and terribly annoying children), and telling the referring doctor you will see the patient tomorrow, or maybe Monday.

This place is the worst. I feel at home.

 

[Ray D. Ayshun]

Alright, alright, alright... Long time lurker, first time poster.

Defendable in terms of what? What situation would you be trying to defend yourself from? "Your honor, my client would be walking if they gave my patient 3 Gy on a Saturday." Seems like an absurd thing to say, when 8/1 is considered a completely reasonable option based on randomized controlled trials. People that think too much about this are the ones that get themselves in the most trouble. Just treat the patient, not the jury, for crying out loud.

BED3 for cord is ~60 for 30 Gy/10 fx, 66 for 25 Gy/5 fx, both easily below max. Hardly any benefit noted with multi-fraction regimen. But I guess you gotta pay for that TSLA (I mean the shares, not the ridiculous computer status symbol vehicle, or as my friend Raj calls it - "A Stupider Looking Chevy Volt"). The Friday special (>4-6 Gy on Friday, restart on Monday) is a beautiful creation of the community physician, no academician could come up with this gem. The amount of expenditure to warm up a linac, bring in a therapist, bring in a radonc to treat 1 fraction on a palliative patient is literally one of the most cost-INeffective things we can do, and likely one of the more medically ineffective done.

Coming in on a weekend to treat a cord for one fraction, as someone said above, is purely performative. "Oncology theater" would be a way to describe it. Not a way I would describe it, but some of the more annoying people on this forum may speak like this.

My message to my fellow SDN Deplorables (as opposed to those elites on the Bird) ... focus on eating gluttonous amounts of food, drinking cocktails at an absurdly early time of the day (justified by being forced to spend time with a mandated small group of people you love, like your deadbeat husband and terribly annoying children), and telling the referring doctor you will see the patient tomorrow, or maybe Monday.

This place is the worst. I feel at home.

First time poster?

 

[Palex80]

I would not be a fan of 5x5 to cord... even if I do 4Gy x 5 I like spine hotspot to be < 105%.

Really?

4 x 5 Gy is less BED than 10 x 3 Gy, even assuming an alpha/beta of 2.

 

[FrostyHammer]

To round out the discussion, can someone post the link to that paper that shows inpatient consults spike on Fridays for Rad Oncs?

Can't find it and certainly relevant to topic at hand.

I would not be a fan of 5x5 to cord... even if I do 4Gy x 5 I like spine hotspot to be < 105%.

Long weekends are tough - for Thanksgiving (assuming clinic is closed Friday) would probably do Wednesday, then either Thursday OR Friday, before resuming on Monday.

5 x 5 to any palliative site is great. Nearly same BED/EQD-2 and half the treatments for patients. Nothing but good luck with this regimen. I don't even use 30/10 anymore for the most part.

 

[medgator]

Hardly any benefit noted with multi-fraction regimen. But I guess you gotta pay for that TSLA (I mean the shares, not the ridiculous computer status symbol vehicle, or as my friend Raj calls it - "A Stupider Looking Chevy Volt").

Still focused on fractions rather than place of service/PPS exemption? So 2K bruh.

This place is the worst. I feel at home.

Welcome. Rad Onc SDN.... "Hey at least it's not radoncrocks Twitter"

 

[RickyScott]

Still focused on fractions rather than place of service/PPS exemption? So 2K bruh.

Welcome. Rad Onc SDN.... "Hey at least it's not radoncrocks Twitter"

Technical component of inpatient radiation is not reimbursed so hospital is actually eating cost and labor for those extra fractions. Of course this does not apply if pps exempt!
Was just called in for a cord compression and will probably now have to forego camping out at Best Buy for a cheap tv.

 

[medgator]

!
Was just called in for a cord compression and will probably now have to forego camping out at Best Buy for a cheap tv.

They should be all online this year also Amazon loves to price match deals, time limited of course

 

[Burt Radnolds]

The effect of a single fraction compared to multiple fractions on painful bone metastases: a global analysis of the Dutch Bone Metastasis Study - PubMed

The global analysis of the Dutch study indicates the equality of a single fraction as compared to a 6 fraction treatment in patients with painful bone metastases provided that 4 times more retreatments are accepted in the single dose group. This equality is also shown in long term survivors. A...

pubmed.ncbi.nlm.nih.gov

4Gy x 6 also well supported and safe if 5 x 5 makes you nervous but you a looking for a little more pop. I also try to keep 105% out of the cord, realizing its mostly meaningless. My main rationale is if you find yourself in a retreat situation, makes me feel better to see no prior hotspots in cord.

Also, I don't bat an eye at giving a fraction Friday and resuming Monday. The cell kill of that single treatment will continue to unfold over the next few days. Could even argue that the edema from back to back treatments could worsen the situation more than help it (I don't believe that either, just saying).

Perhaps one of the palliative fellows can clarify these issues 😉 ?

 

[Radonc 2013]

Perhaps one of the palliative fellows can clarify these issues 😉 ?

This thread might have yielded 4 or 5 projects for a palliative care fellow. We demand to be listed as one of the authors on any resulting publication (along with the chairman who has no idea what you are doing in the department and assumed you were one of the incoming residents).

 

[RadOncDoc21]

-

This thread might have yielded 4 or 5 projects for a palliative care fellow. We demand to be listed as one of the authors on any resulting publication (along with the chairman who has no idea what you are doing in the department and assumed you were one of the incoming residents).

Please only send your palliative cases to a high volume fellowship trained rad onc also!

 

[seper]

Paralyzed patients who to not get decompression are extremely unlikely to walk ever again. I’ve used all of these fx schemes, and my impression that chance of walking is <2%

 

[scarbrtj]

Paralyzed patients who to not get decompression are extremely unlikely to walk ever again. I’ve used all of these fx schemes, and my impression that chance of walking is <2%

Since we’re still talking about this. Assuming this stat is correct, that the “Saturday fraction” would be the difference-maker 100% of the time when walking recovery happens, and that on average the ordinary rad onc faces a Saturday treatment once every 15 weekends... then the average rad onc will make one additional patient walk with routine Saturday fractioning every 7 years. If this is what’s necessary for the patient, why stop there

A. Fri-wknd-M-F-wknd-M-Th = 14 elapsed days
B. Fri-Sat-wknd-M-Fri-wknd-M-Wed = 13 elapsed days
C. M-Fri-wknd-M-Fri = 12 elapsed days
D. Treat on sat/sun always = 10 elapsed days

If B is what’s needed to avoid A, and get closer to the ideal C, wouldn’t D be even better? Couldn’t we show that treating through Saturday and Sunday for all cord compression patients would be optimal? It should be a continuum... B better than A, C better than B, and D the best. Maybe another project for the palliative fellow.

 

[evilbooyaa]

Really?

4 x 5 Gy is less BED than 10 x 3 Gy, even assuming an alpha/beta of 2.

Yes. I get that it is probably overly conservative, but I think I'd get comments in peer review conference if I was doing 5x5 to cord. That being said, based on this discussion, I do suppose it is a reasonable fractionation scheme if somebody is so inclined.

 

[evilbooyaa]

Alright, alright, alright... Long time lurker, first time poster.

[snip]
This place is the worst. I feel at home.

Welcome to the depths of hell, first time poster!

 

[Lamount]

Since we’re still talking about this. Assuming this stat is correct, that the “Saturday fraction” would be the difference-maker 100% of the time when walking recovery happens, and that on average the ordinary rad onc faces a Saturday treatment once every 15 weekends... then the average rad onc will make one additional patient walk with routine Saturday fractioning every 7 years. If this is what’s necessary for the patient, why stop there

A. Fri-wknd-M-F-wknd-M-Th = 14 elapsed days
B. Fri-Sat-wknd-M-Fri-wknd-M-Wed = 13 elapsed days
C. M-Fri-wknd-M-Fri = 12 elapsed days
D. Treat on sat/sun always = 10 elapsed days

If B is what’s needed to avoid A, and get closer to the ideal C, wouldn’t D be even better? Couldn’t we show that treating through Saturday and Sunday for all cord compression patients would be optimal? It should be a continuum... B better than A, C better than B, and D the best. Maybe another project for the palliative fellow.

I confess, it’s hard to motivate my brain to find this topic interesting... but the Saturday treatment is probably more likely to matter in certain histologies with rapid treatment response
1) ones where radiation cell kill is mediated by apoptosis (I.e lymphoma, myeloma)
2) ones with rapid cell division where DSB will quickly cause mitotic catastrophe (SCLC, rapidly growing tumor)
3) random radiosensitive tumors (myxoid liposarcoma)

I favor treating cord compression with the above histologies with rapid clinical progression on Saturday when I start on Friday... even with 4 Gy x 5. Otherwise, I will just give 4 Gy on Friday and continue on Monday.

 

[McConaughey]

Welcome to the depths of hell, first time poster!

Thank you very little.