Why we don’t usually give emergent radiation therapy

The first lecture in a radiation oncology residency program is “Radiation Oncology Emergencies,” to educate the new residents how to manage inpatient consultations and emergencies. While preparing my lecture this year, it occurred to me how useful this basic information would be to the physicians calling for the consultation. Sharing our thought process in triaging patient explains why we don’t rush to utilize radiation, even in cases of a cord compression:

1. Does the patient have cancer? Do we have a pathology report? If a patient has evidence of an epidural mass causing compression, radiation will only work if a cancer is causing the problem. Without pathologic confirmation of this, it’s unsafe to do radiation. Even a patient’s history reporting cancer isn’t enough. A pathology report is necessary, to avoid giving inappropriate (and potentially dangerous) therapy.

2. Has a neurosurgeon been consulted? Has medical oncology been consulted? In many instances, the patient should be taken to surgery right away. They may be eligible for radiation after their surgery. Some medical oncologists prefer to treat chemo-sensitive tumors with up-front chemotherapy. Cancer care is multi- and inter-disciplinary, and all the patient’s physicians must agree on a plan upfront. This is especially important because some treatments can only be given consecutively (not concurrently), and may also preclude future therapies in the future. Again, it’s a team approach.

3. What is the patient’s Karnofsky Performance Status (KPS)? If the patient is intubated and unresponsive we may not be able to give radiation safely and accurately. It’s also important to have a discussion regarding goals of care prior to initiating a course of radiation.

4. Is the patient’s pain well-controlled? Optimal pain control should be a priority. If the patient’s pain is not well-controlled, it is unlikely they will be able to tolerate a simulation (the CT scan necessary for radiation planning, wherein usually the patient lies on their back).

5. What is the discharge plan? If the patient is going to be discharged within the next few days, we usually recommend an outpatient radiation oncology consultation. A radiation oncology consultation takes approximately one hour. Inpatients usually see multiple physicians every day, and it gets confusing which physician said what, why and when. The discussion regarding risks/benefits may be more meaningful if the radiation oncologist has the patient’s full attention. Also, some patients have trouble traveling for daily radiation treatments. This needs to be discussed right away, so the optimal length and type of radiation therapy can be determined at the outset.

6. Has the patient had previous radiation? If a patient has had prior radiation, we need detailed records of the radiation they received, including: the dose, the fractionation, the area treated, and the dates. Re-irradiation is performed in select instances, but only when detailed information is available regarding prior therapies.

Yes, we take radiation very seriously. It’s a great treatment and it works! But it must be employed thoughtfully and safely. So go ahead and page radiation oncology for that cord compression. But don’t be frustrated if treatment doesn’t start ASAP; we need the above answers first.

Miriam A. Knoll is a radiology oncology resident.  She can be reached on Twitter @MKnoll_MD and on LinkedIn.

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