What is emergent/urgent non-elective in Rad Onc?

[deleted956486]

Given what we have at the moment, what do you think? I'm not talking about non-elective just because you have residents.

I can think of one or two things. And given the risks currently out there, even those one or two things would likely not qualify.

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[Haybrant]

Check the Ontario guidelines in pandemic planning for oncology to get a framework of how to think about this.

 

[RadRadRad]

Given what we have at the moment, what do you think? I'm not talking about non-elective just because you have residents.

I can think of one or two things. And given the risks currently out there, even those one or two things would likely not qualify.

I think it depends on timeframe. Most anything (other than some urgent palliation) could be delayed a couple weeks. If you are talking 8 week delay the list gets much shorter. With a wait in your car(instead of lobby) and one in one out policy I would think risk of exposure is low.

 

[Palex80]

I think it depends on timeframe. Most anything (other than some urgent palliation) could be delayed a couple weeks.

I don't agree.

I wouldn't like to delay a LD-SCLC for a "couple of weeks".

I'd also not like to delay RT-start in a cT3 cN2b non P16-positive head&neck cancer by a couple of weeks.

The same applies for postoperative high-risk HNSCC cases.
We know that prolonging overall therapy from surgery to end of adjuvant treatment leads to a worse outcome --> Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer. - PubMed - NCBI.

There certainly are a lot of cases where one can delay RT or find some workaround (as with the LD-SCLC case noted above --> give him 1 cycle of chemo and start RT with cycle 2), but there are also quite a few situations where "a couple of weeks delay" is not a favorable option.

 

[evilbooyaa]

I feel like taking standard precautions and continuing with a relatively normal timeline for any new post-op H&N patient is prudent. We are still doing new starts without significant changes to our current on treatment schedule, although we are greatly limiting follow-ups and trying to minimize consults to minimize foot traffic in the department. But you can't make it zero, IMO.

*EDIT* - I completely agree with Palex's scenarios. Let's focus on delaying low hanging fruit (breast and prostate) before we start going after stage III H&N, stage III NSCLC, post-op H&N/Lung, etc.

 

[scarbrtj]

Women older than 70 with Stage I ER+ breast cancer should not be sent for post-lump XRT. Men older than 70 with Gl 6 or less CaP should not be sent for XRT. People matching these subsets preiously treated with XRT should no longer receive any XRT followup if asympt at last followup. Any early stage breast or prostate patient pending new consult otherwise can easily be postponed 2 months from today. You could say all benign XRT patients postponed, but what about H.O. hips e.g. preop/postop. If you look at any pending consult schedule, and sometimes even pts under tx, a Great Culling could be undertaken.

 

[medgator]

Bringing on new partners/employees into the practice from the class of 2020 likely won't be urgent either come July at this rate

 

[RickyScott]

until 70% of population is infected or we get a vaccine it is not going away. We functioned in polio outbreaks and some pretty devestating flu epidemics in 50s and early 60s.

 

[Neuronix]

Most of my practice is glioblastoma and brain mets these days. I don't think I'm going to delay many of my patients.

 

[taserlaser]

Bringing on new partners/employees into the practice from the class of 2020 likely won't be urgent either come July at this rate

I’ve already had one search and selection committee delay the search. Another move the interview to Zoom.

 

[scarbrtj]

until 70% of population is infected or we get a vaccine it is not going away. We functioned in polio outbreaks and some pretty devestating flu epidemics in 50s and early 60s.

People forget
POLIO: THE DEADLY SUMMER OF 1956

 

[RickyScott]

People forget
POLIO: THE DEADLY SUMMER OF 1956

If a radonc was in charge of polio at the time,
can you imagine how advanced iron lungs would be today?

 

[Mandelin Rain]

If a radonc was in charge of polio at the time,
can you imagine how advanced iron lungs would be today?

There would have been like 2 iron lungs available for the whole country.

 

[RickyScott]

There would have been like 2 iron lungs available for the whole country.

Reading on twitter that latest modeling published In Science shows 80% cases transmitted by asymptomatic spreaders. Trying to wrap my head around this but wouldn’t that imply that quarantines/testing not going to be all that helpful? Seems like it would just spread everywhere no matter what you do if that is true. Maybe Boris Johnson has right idea at first.

 

[medgator]

Reading on twitter that latest modeling published In Science shows 80% cases transmitted by asymptomatic spreaders. Trying to wrap my head around this but wouldn’t that imply that quarantines/testing not going to be all that helpful? Seems like it would just spread everywhere no matter what you do if that is true. Maybe Boris Johnson has right idea at first.

Already scrapped

The UK abandoned its coronavirus plan after realizing it would have resulted in 'hundreds of thousands of deaths'

The previous UK plan would have caused 'hundreds of thousands of deaths' and overwhelmed the healthcare system, a new report estimates.

www.businessinsider.com

 

[Palex80]

Men older than 70 with Gl 6 or less CaP should not be sent for XRT.

"Or less" is not really cancer.

You could say all benign XRT patients postponed, but what about H.O. hips e.g. preop/postop.

Indeed. I may add that some of these benign indications can be rather very painful, for example heel spurs.
Weighing pros and cons of treatment now vs. treatment in 2 months should be undertaken and I think that patients should have the libery to decide too if they want treatment now or they want treatment later.

 

[Palex80]

Most of my practice is glioblastoma and brain mets these days. I don't think I'm going to delay many of my patients.

Delaying in some of them will mean cancelling at all...

 

[Palex80]

Reading on twitter that latest modeling published In Science shows 80% cases transmitted by asymptomatic spreaders. Trying to wrap my head around this but wouldn’t that imply that quarantines/testing not going to be all that helpful?

Quarantines won't solve the problem indeed, since as you state much of the spreading may be from asymptomatic spreaders. But not quarantining spreaders is going to make matters even worse.
STAY AT HOME is what needs to be done and is being done, for instance in Europe right now.

Everyone who doesn't HAVE to be out of home, should stay at home. That's why restaurants, bars, shopping malls, stadions, parks, etc are all shut down.

Seems like it would just spread everywhere no matter what you do if that is true. Maybe Boris Johnson has right idea at first.

No.

Not imposing any restrictions takes away all possible measures you may have in at least influencing (you can't really "control" it anyway) the speed the outbreak will happen. Which means that a lot of people may get seriously ill at the same time, rather than over a longer period of time. It's the "flatten the curve" issue.

Most health systems, especially the UK, do not have enough hospital beds and especially ICU beds. Worst case scenarios predict the NHS to become overwhelmed by Boris Johnson's approach and the UK to have 250k dead people, simply because the NHS won't be able to handle the volume of cases during a very fast growing outbreak.

 

[RadOncDoc21]

It’s funny how I’m one of those types of people that would absolutely stay at home but unfortunately can’t due to being a provider. We are basically running a skeleton crew with as little interaction as possible. I even started doing my inpatient consults from a distance unless the patient needs emergent RT. Our dosimitrist works from home, as our physicist as much as possible with staggered shifts for the rest of the team. We’ve limited follow ups but still treating most new cancers.

Yet, as we continue to show up and take precautions, I see people out in restaurants, bars, etc. I even see kids hanging out together. We can’t get basic grocery items because some a—-hole decided he wanted to purchase 72 packs of eggs and 100 packs of toilet paper. I even saw a “coronavirus challenge” where teens are trying to catch the virus to post on social media.

I wish I could just isolate myself but cant and if my staff, patients and I have to risk our lives everyday, the very least these a—-holes can do is stay home and cook those damn eggs!

 

[RickyScott]

Just thinking aloud. Obviously no action is bad policy. More of an intellectual question regarding the relative impact of quarantining only 20% of spreaders (symptomatic ones)
If most of this is spread asymptatically, only reasonable approach is to test whole country and quarantine entire country. Intuitively, other measures will not have much impact flattening a curve?
Lastly, there are all these models, but then there is China. The Chinese irresponsibly ignored the problem (after creating it- they could have closed wet markets after last SARS) for 2 months while millions of asymptomatic Chinese went on their way across China. There are at just a few thousand deaths now. I think as society we would take on their restrictive measures if it truly meant saving one million lives

 

[Palex80]

If most of this is spread asymptatically, only reasonable approach is to test whole country and quarantine entire country. Intuitively, other measures will not have much impact flattening a curve?

Quarantine the whole country is not feasible. There are still people that need to work. You still need food, water, power, health sector, police, fire department, etc... But you can certainly quarantine a very large proportion of your population.
If you do that, you do not really need to test the ones that are asymptomatic / only midly symptomatic. As long as they stay home, they can only infect those they live with. And even that can be prevented to some degree (if you have more that one bathroom for example). You can restrict tests to the ones that really are symptomatic, in order to know how to treat them.

The problem is whether or not you CAN quarantine everyone, without them being infected. I ahve serious doubts that we can impose the same rules of quarantining everyone like in China to a large degree in the western world.

Lastly, there are all these models, but then there is China. The Chinese irresponsibly ignored the problem (after creating it- they could have closed wet markets after last SARS) for 2 months while millions of asymptomatic Chinese went on their across China.

This is indeed one theory / assumption. But since we do not know how many Chinese actually had a ligh/asymptomatic form, I am not sure we can speculate on this course of action.

There are at just a few thousand deaths now. I think as society we would take on their restrictive measures if it truly meant saving one million lives.

I am not sure where we place the bar there, as a society.
Italy has over 2.500 dead by now. That's a lot of dead people. We are talking about 9/11 proportions.

 

[RickyScott]

Already scrapped

The UK abandoned its coronavirus plan after realizing it would have resulted in 'hundreds of thousands of deaths'

The previous UK plan would have caused 'hundreds of thousands of deaths' and overwhelmed the healthcare system, a new report estimates.

www.businessinsider.com

it was scrapped because in the event it turns out to be wrong there would be absolute hell to pay. Safest political course would be to do whatever everyone else is doing. Again thinking out loud here with no special insight: if disease is spread mostly by asymptomatic (kids and young adults may be super spreaders), isolating the 20% of spreaders who show symptoms doesnt seem like it would flatten curve much while the other 80% out there are exponentially spreading the virus. (like metastectomy in wide spread cancer) Only highly restrictive measures in general population while routinely testing almost everyone? Also curious whether there are different strains of virus with different mortality?

 

[medgator]

I am not sure where we place the bar there, as a society.
Italy has over 2.500 dead by now. That's a lot of dead people. We are talking abou

Keeping Americans apart could cut deaths by

Imperial College of London's latest study estimated how various strategies would affect the impact of the coronavirus on US deaths. The longer people can be kept apart, more lives may be saved.

www.dailymail.co.uk

Researchers at Imperial College London say that if the whole population doesn't hunker down, between 1.1 million and 1.2 million Americans will likely die of coronavirus, even if they are treated.

Their study, published Monday, predicts how the coronavirus pandemic is likely to pan out, depending on how the US and UK respond.

If the US and UK did nothing, they estimate that 81 percent of each population would become infected, and 2.2 million Americans would die, along with 510,000 Britons.

 

[kimplera]

The rates of survival following mechanical ventilation in China (https://www.thelancet.com/journals/...icnHeaGGQSRVdELTu4HK2cpybDxuaeNdAErIS5tc_RjVo) raise a very critical question of whether our focus on ICU beds and ventilators with the current treatments is relevant

 

[radoncgrad2019]

Summarize pleas

 

[RSAOaky]

Summarize pleas

"32 patients required invasive mechanical ventilation, of whom 31 (97%) died. "

 

[medgator]

"32 patients required invasive mechanical ventilation, of whom 31 (97%) died. "

Chinese, like the Italians, smoke way more heavily iirc

 

[theradiator]

By the way, please take the statistics/propaganda provided by the Chinese Communist Party with a grain of salt. I believe the Italian, Korean, Japanese data are much more credible and relevant.

 

[metallica81788]

Here's a situation I'm going to face this week and many of us may face soon:

Patient s/p lumpectomy loses their insurance after being laid off and has until end of the month before finding other options. This is someone you would normally 42.56/16 or 40/15 whole breast. Meets most criteria for Florence 30/5 but let's say has one "cautionary" point on the ASTRO APBI guidelines and the rest are "suitable." Do you offer 30/5 PBI to help them out (with appropriate counseling) and get it finished before they lose coverage? Or say tough luck you will have to use COBRA to help pay for the rest of this treatment, etc. Does that count as urgent enough? We're all going to have patients that have already been operated on that are waiting for adjuvant and may lose their insurance.

 

[radoncgrad2019]

Here's a situation I'm going to face this week and many of us may face soon:

Patient s/p lumpectomy loses their insurance after being laid off and has until end of the month before finding other options. This is someone you would normally 42.56/16 or 40/15 whole breast. Meets most criteria for Florence 30/5 but let's say has one "cautionary" point on the ASTRO APBI guidelines and the rest are "suitable." Do you offer 30/5 PBI to help them out (with appropriate counseling) and get it finished before they lose coverage? Or say tough luck you will have to use COBRA to help pay for the rest of this treatment, etc. Does that count as urgent enough? We're all going to have patients that have already been operated on that are waiting for adjuvant and may lose their insurance.

30/5 no question about it

 

[Mandelin Rain]

I'm seeing a 70+ yo woman with a stage I ER+ low grade breast ca. Normally a slam dunk observation patient. But... she developed this while on AI for a previous contralateral breast ca. Am I crazy for treating her?

 

[taserlaser]

I'm seeing a 70+ yo woman with a stage I ER+ low grade breast ca. Normally a slam dunk observation patient. But... she developed this while on AI for a previous contralateral breast ca. Am I crazy for treating her?

I would say nope, not crazy. Biology trumps observation here. I would try and get her through RT before things get really bad...

 

[BobbyHeenan]

I would say nope, not crazy. Biology trumps observation here. I would try and get her through RT before things get really bad...

Agree. I’d consider 30 in 5. I have been using this for a year or so and from a symptom standpoint it’s been fantastic. Patients love it.
Especially good for those 70+ cases where they don’t tolerate AI or decline it.

 

[radoncgrad2019]

Agree. I’d consider 30 in 5. I have been using this for a year or so and from a symptom standpoint it’s been fantastic. Patients love it.
Especially good for those 70+ cases where they don’t tolerate AI or decline it.

agree 30/5 all day

 

[deleted1002574]

3D or IMRT for 30/5 PBI?
Getting approval from insurance companies?

 

[scarbrtj]

3D or IMRT for 30/5 PBI?
Getting approval from insurance companies?

It "always" gets approved as IMRT as that's (APBI) been in Evicore's guidelines e.g. for a looong time. The rub has been SBRT vs IMRT. It's more like SBRT really, but insurance has been flatly refusing the SBRT. Medicare is always a different animal.

 

[deleted1002574]

I got denied (not sure if it was Evicore), b/c it was C50.411, maybe was Medicare. This was pre-virus, so didn't fight for it.

 

[Burt Radnolds]

I've been denied very recently for 30/5 IMRT right partial breast. Said only IMRT if left sided or hotspot > 110%. They didn't give 2 craps that I was using IMRT because thats how the protocol was done, etc. I even quoted PMID and study in my note. I then created a 3D plan with hotspot > 110% and it was then approved. Just FYI.

 

[radoncgrad2019]

Medical Mutual won’t approve IMRT

 

[BobbyHeenan]

I’ve had 100% approval for Imrt 30/5, even evicore this far.

At that fractionation scheme we have a P3 trial showing its good and not aware of any 3D data.

 

[radoncgrad2019]

Agree that evicore has no issue with 30/5 IMRT.

 

[scarbrtj]

per eviCorona: