A day in the life: palliative radiation oncology

This is the first post in a running series where I describe a typical day in the life of a radiation oncology resident on a particular rotation, obviously from my own viewpoint. It seems to me that friends and family, as well as resident colleagues outside of oncology, don’t really know much about radiation oncology or what radiation oncologists do day to day and how we help patients. I’m hoping this series will shed some light on the specialty.

*Also please note that the patients described below are NOT actual patients but are fictional situations I routinely encounter.

I start my day around 8:30 am, when I finish preparing (I usually start the day or night before) for the patients I will be seeing that day by reading previous consult notes and reviewing their test results. In the morning there are typically 3-5 new referrals for palliative radiation and I typically see two or three of them. At 9 am I see a man in his seventies with a diagnosis of metastatic prostate cancer who was admitted to hospital overnight with back pain and leg weakness, and in whom an MRI of his spine showed spinal cord compression (tumor pressing on the nerves running up and down the spine). This is considered a radiation oncology emergency and after taking a full history and performing a physical exam, I will report to my staff and together we will carefully review all the imaging scans taken to date (which may include plain x-rays, bone scans, CT, PET or MRI scans). We will “consent” the patient, meaning explaining in detail why we are offering radiation to the spine (to help shrink the tumor to alleviate the compression on his spine), how it is given (one treatment per day for five days) and the side effects (pain getting worse the first day before it gets better, nausea). We then schedule his “planning” CT scan (so we can tell our radiation machines where to aim the radiation) for later that morning and his start of treatment (for an emergency such as this we start the same day, usually in the late afternoon). We also optimize his medications (giving a steroid, dexamethasone, to reduce the inflammation caused by the tumor in the spine, an anti-nausea medication, and sometimes altering their opioids for pain management).

By now it is 10:30 am and I go see my second patient of the day, a young woman in her fifties with metastatic breast cancer with progressively worsening pain in her right ribs and chest. After another history and physical exam, I review with my staff not only the CT scan and bone scan but the details of her previous radiation treatment to her right breast in comparison to where we propose to give radiation now to ensure there is no overlap (if there is overlap it may not be safe as re-irradiation can have toxic side effects). I organize a CT scan for noon but have to wait to schedule her radiation treatment until after I email her medical oncologist to discuss scheduling her radiation between cycles of chemotherapy in order to avoid increased side effects when chemo and radiation are given too close together. I may also put a wire on the patient’s skin in the area of pain to help me determine where to give radiation since rib metastases can sometimes be difficult to fully appreciate on planning CT scans.

The rest of the morning is spent scheduling and documenting these encounters on three different hospital computer systems and dictating notes on the phone. After lunch and/or educational rounds I go to the “planning” area to “contour”, which means outlining (by drawing with a mouse) the tumor seen on the CT scan (the one acquired that same day) that is causing the patient’s symptoms. After some other boring technical details regarding how to expand the contours to ensure the radiation has its intended effect, I sit down with the radiation therapist assigned to this case and describe the clinical situation and what I have contoured. The therapist (or “planner”) will then design a way for the radiation beams to be organized in order to physically provide radiation dose to the tumor that was contoured while minimizing radiation to the healthy surrounding tissue and organs. There is a time crunch for my patient with spinal cord compression since his radiation is starting in a few hours and the contours and final radiation plan has to be approved by the staff radiation oncologist (an MD) and reviewed and approved by a medical physicist (a PhD) before the plan is uploaded to the treatment machine. I do the same thing (but without the time crunch) for the patient with rib pain, but in her case we (the entire team involved) have to be extra careful to give radiation to the tumor in her ribs while avoiding overlap with her previous breast radiation, and minimizing dose to her right kidney (which is in the same vicinity) as kidneys are highly sensitive to radiation and we do not want to damage them and cause impaired renal function.

The rest of the late afternoon is spent doing miscellaneous activities. Most days I will take one or two calls from doctors at our affiliated hospitals (in internal medicine, urology, thoracic surgery, medical oncology, etc.) for patients they believe would benefit from palliative radiation. I triage the urgency and help organize who/when/how the patients will be seen. Once or twice a week I will walk to the hospital across the street or a few steps down the road to see an urgent consult and go through the same process (history, physical, organize CT scan and treatment, and contour). I also return calls from patients at home who recently completed radiation who have concerns or side effects of radiation, and review any test results (usually CT or MRI scans) I had ordered for patients I had seen previously.

By now if it’s not past 5:30 I will go pick up some or all of my children from school or daycare and head home, except for the once or twice a week I am on call in which case I will take over the responsibility for the inpatients admitted to radiation oncology (typically 15-20 patients) until 9 am the next day.

Diagnostic delays in cancer

My second post ever on this site was titled “Diagnosing cancer is hard”, where I argued that making a diagnosis of cancer (or making an appropriate referral) is difficult for primary care physicians in the setting of non-specific complaints that are normally *not* due to cancer. This week an excellent article on the subject was published at The BMJ called “Rethinking diagnostic delays in cancer: how difficult is the diagnosis?”, and I urge everyone to read the article.

Dr. Lyratzopoulos and colleagues do an excellent job describing which cancers are easier, intermediate, and harder to suspect and diagnose. They also discuss potential reasons why “multiple consultations” (three or more visits to a primary care physician before referral to a specialist is made) occur and how that leads to a delay in diagnosis and erodes the trust of patients in the healthcare system. I was quite honestly shocked that 80% of patients eventually diagnosed with cancer had only one or two consultations with a primary care doctor before the appropriate referral was made (presumably one to hear the complaint, and a second visit to go over test results stemming from the initial complaint). I was also surprised that the traditional ominous “red flags” have only a 5% (in women) or 10% (in men) positive predictive value for cancer.

What I feel is missing from the analysis in this BMJ article is the type of situation I recently encountered. A middle-aged man saw his family doctor for a complaint of back pain, and was reassured it was mechanical (using the evidence of a normal chest x-ray and spine x-ray). Three months later he developed acute onset bilateral leg paralysis from multiple-level spinal cord compression from an undiagnosed lung cancer. I would argue that this situation, a single visit with reassurance and eventually a catastrophic diagnosis, is more upsetting for patients than multiple follow up visits (usually with additional tests in between) leading to a moderate delay in referral to an oncologist. Situations like this are not adequately captured in the BMJ article since technically the number of visits is two (the trip to the GP and the emergency room visit post-paralysis).

My takeaway points from this discussion are that:
1) Multiple visits to primary care doctors are not necessarily a bad thing since persistence or progression of symptoms along with close follow up may reduce delays in a cancer diagnosis
2) We need a way to also capture delays in diagnosis in days/weeks/months rather than simply number of primary care appointments
3) Primary care physicians have an incredibly hard job balancing judicious use of resources and the appropriate level of testing indicated for vague or non-specific complaints related to an undiagnosed cancer

Overall I am quite happy to see this situation being studied and published, and I think all primary care doctors should keep the list of easier, intermediate, and harder cancers to suspect and diagnose in the back of their minds.