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.

3 thoughts on “A day in the life: palliative radiation oncology

  1. Jay, if you like “Pro and Con” thoughts (re. aid in dying) you may enjoy some of my writings, to be found via this path:

    1) righttodie.ca
    2) Researchers’ Buffet
    3) Pro and Con

    “Ion Effects” is my magnum opus and you will probably want to just dip into it now and then. Some of the more succinct things (such as the Quarterly Retorts) make good appetizers — here’s a sample, about palliative care:
    Issue 6:2 (Apr.-Jun. 2004)
    The World Health Organization Says:
    No country should consider legislation allowing for physician-assisted suicide or euthanasia until it has assured for its citizens the availability of services for pain relief and palliative care. (Cancer Pain Relief and Palliative Care, 1990)
    We Reply:
    The WHO makes two assumptions:
    (1) that there is an “either-or” relationship between palliative care and aid in dying, and
    (2) that palliative care is everyone’s first choice (people only settle for aid in dying if they can’t get palliative care).
    Neither of these assumptions is justified.
    (1) Many people want both options – they want palliative care during phases 1 through 6, then they want aid in dying so they can skip phases 7 and 8.
    (2) Even among people who are content with only one of the two options, a hastened death may be the first choice; some people have no desire for an extended experience of their final decline, preferring instead to “quit while they’re ahead”.

    The dessert course (last item on the menu) of the Researchers’ Buffet makes some important points too, in a subtle way. My favourite is the card player who knows when to fold.

    If you think that James Downar would enjoy my stuff too, please forward this e-mail to him. (For that matter, forward it to anybody you think would enjoy the material.)


  2. Hello Ruth

    I found your unmistakable hand in the Living Will on the Right to Die website. The will is entertaining in spite of the subject matter.
    I asked my GP if he would officiate at Physician Assisted Death if I should request it. He said, categorically, NO. But he would refer me to a doctor who would.
    Good to know you’re still pursuing your passion.


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