NRC regulation fractionated stereotactic radiation therapy

[Maforce]

Does anyone have a link to the NRC rule regarding the physical presence of radiation oncologist during the treatment of brain mets using fractionated stereotactic radiation therapy. In the past, the rad onc has to be present directly at the treatment station directly outside the vault. I have heard recently NRC loosened the regulation allowing the rad onc to be within "voice" distance of the treatment station. Appreciate your input.

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[medgator]

NRC only applies to gamma knife treatment not linac based srs FYI.

 

[Mandelin Rain]

I always thought the GammaKnife standard was earshot, i.e. the hallway is okay.

 

[medgator]

I always thought the GammaKnife standard was earshot, i.e. the hallway is okay.

Its the same as hdr /IR 192. You have to be at the console I think.

 

[scarbrtj]

The NRC is not legally proscriptive upon us unless there are isotopes (ie GKRS w/ Co-60, Ir-192, etc.) at play. In the case of X-ray production (ie linacs, or cyberknives), the NRC doesn't hold sway. So perhaps for you this "be at the console" thing is arising from a billing standpoint? But there are federal guidelines there re: supervision etc. None of them call for personal supervision, only direct, for CPT or G codes which deal with SRS, SBRT. As you can see e.g. in ACR practice parameters for SRS, NRC only comes into play w/ sealed isotope sources (and the ACR is mute re: where the rad onc must physically be/stand/sit during the procedure). The NRC doesn't compel radiation oncologists to be at the console of a machine generating megavoltage X-rays no matter the amount of X-rays being delivered.

To the point about gamma knives, there has been work on getting the physical presence thing changed. Don't know if it got across the finish line; somebody here probably knows.

 

[Maforce]

The NRC is not legally proscriptive upon us unless there are isotopes (ie GKRS w/ Co-60, Ir-192, etc.) at play. In the case of X-ray production (ie linacs, or cyberknives), the NRC doesn't hold sway. So perhaps for you this "be at the console" thing is arising from a billing standpoint? But there are federal guidelines there re: supervision etc. None of them call for personal supervision, only direct, for CPT or G codes which deal with SRS, SBRT. As you can see e.g. in ACR practice parameters for SRS, NRC only comes into play w/ sealed isotope sources (and the ACR is mute re: where the rad onc must physically be/stand/sit during the procedure). The NRC doesn't compel radiation oncologists to be at the console of a machine generating megavoltage X-rays no matter the amount of X-rays being delivered.

To the point about gamma knives, there has been work on getting the physical presence thing changed. Don't know if it got across the finish line; somebody here probably knows.

Thank you for the information, scarbrtj. Does anyone have reference to ASTRO/ACR guidelines regarding Linac based SRT? My office is about 20 feet down the hall way from the LINAC. I am within voice range from the LINAC station.

 

[evilbooyaa]

for linac-based SBRT/SRS we review the CBCT at the machine prior to treatment and the patient is treated while we are in the department. Our practice is not like it is for HDR brachy.

 

[seper]

Per institutional preference. I've seen SRS staffing rules ranging from just therapists to both physics and attending MD present while beam is on.

 

[medgator]

Per institutional preference. I've seen SRS staffing rules ranging from just therapists to both physics and attending MD present while beam is on.

Yup, unlike gk treatment where the rules are clear

 

[BobbyHeenan]

Per institutional preference. I've seen SRS staffing rules ranging from just therapists to both physics and attending MD present while beam is on.

Same in my experience.

At our practice both physician and physicist are present at linac for start of treatment. I 100% always check their imaging before the beam turns on. If no real-time imaging tracking I've walked off before (but still in department/clinic) while beam is on, but with a flattening filter free linac treatments are usually over quickly and I try to stay (though not sure of the utility of me staying by linac are on all patients uniformly).

I do think it's worthwhile to at least have a written SBRT policy that at least shows the suits that you've thought about what it means to be delivering SBRT and the team has decided on the policy, even if it seems lax (ie no doc present at linac).

 

[seper]

Personally, I've always found babysitting SBRT's a poor application of a physician's time. More common SBRT regimens used in the community involve: a) 5 fractions, so there is opportunity to correct CBCT alignment at the end of the day; b) pretty low fractional doses (e.g. 6 Gy per day), so chance of egregious harm to the patient is low.

Same in my experience.

At our practice both physician and physicist are present at linac for start of treatment. I 100% always check their imaging before the beam turns on. If no real-time imaging tracking I've walked off before (but still in department/clinic) while beam is on, but with a flattening filter free linac treatments are usually over quickly and I try to stay (though not sure of the utility of me staying by linac are on all patients uniformly).

I do think it's worthwhile to at least have a written SBRT policy that at least shows the suits that you've thought about what it means to be delivering SBRT and the team has decided on the policy, even if it seems lax (ie no doc present at linac).

 

[scarbrtj]

Same in my experience.

At our practice both physician and physicist are present at linac for start of treatment. I 100% always check their imaging before the beam turns on. If no real-time imaging tracking I've walked off before (but still in department/clinic) while beam is on, but with a flattening filter free linac treatments are usually over quickly and I try to stay (though not sure of the utility of me staying by linac are on all patients uniformly).

I do think it's worthwhile to at least have a written SBRT policy that at least shows the suits that you've thought about what it means to be delivering SBRT and the team has decided on the policy, even if it seems lax (ie no doc present at linac).

Personally, I've always found babysitting SBRT's a poor application of a physician's time. More common SBRT regimens used in the community involve: a) 5 fractions, so there is opportunity to correct CBCT alignment at the end of the day; b) pretty low fractional doses (e.g. 6 Gy per day), so chance of egregious harm to the patient is low.

8.5 Gy per day to huge fields: no standing by machine necessary.
6 Gy per day to tiny field: must stand by machine, chance of harm HIGH!
Kafkaesque. One of the worst things about our specialty: when someone else says something is bad, wrong, or dangerous, the genie can never be put back in the bottle no matter how ludicrous because it makes YOU dangerous to argue against it. In the early days of IMRT the machine was delivering close to 2000 MUs a day per patient for 2 Gy doses. Go figure.

 

[xrthopeful]

8.5 Gy per day to huge fields: no standing by machine necessary.
6 Gy per day to tiny field: must stand by machine, chance of harm HIGH!


Huh?

It's about real-time alignment by the physician and physicist before treatment when you're treating close to critical structures like the duodenum, looking at rectal interface etc etc etc with SBRT

kind of low iq to compare it to a clear palliative urgent treatment like 17/2

*EDIT* - Comment insulting SDN user removed by mod.

 

[scarbrtj]

8.5 Gy per day to huge fields: no standing by machine necessary.
6 Gy per day to tiny field: must stand by machine, chance of harm HIGH!


Huh?

It's about real-time alignment by the physician and physicist before treatment when you're treating close to critical structures like the duodenum, looking at rectal interface etc etc etc with SBRT

kind of low iq to compare it to a clear palliative urgent treatment like 17/2

*EDIT* - Comment insulting SDN user removed by mod.

Oh sure I may be low IQ, but just by hanging out and commenting on SDN instead of ever attending ASTRO e.g. I raise the average IQ both here on SDN and at ASTRO simultaneously. Today Robert Samuelson in the Washington Post wrote “[journalists] illuminate the inconsistencies, contradictions and confusions of our national condition.” I’m simply trying to fulfill that role for our radiation oncology condition.