What You Should Know About Radiation Oncology: Anish Butala, Emily Martin and Evie Kalmar

Eric 00:11

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today?

Alex 00:15

We are delighted to welcome Anish Butala, who is a radiation oncologist at the University of Pennsylvania. Anish, welcome to the GeriPal Podcast.

Anish 00:24

Thanks so much for having me.

Alex 00:26

And we’re delighted to welcome Emily Martin, who is a palliative care doc at UCLA. Emily, welcome to GeriPal.

Emily 00:32

It’s good to be here.

Alex 00:33

And delighted to welcome Evie Kalmar, who’s a geriatrician and palliative care doc at UCSF. Evie, welcome to GeriPal.

Evie 00:41

Thank you.

Eric 00:42

So on this podcast, we’re gonna be talking about what every healthcare provider should know about radiation oncology. But before we do, we always start off with a song request that niche. Do you have the song request for Alex?

Anish 00:54

I do. My song for Alex is I Ain’t Worried by One Republic.

Eric 00:59

Why did you choose this song?

Anish 01:02

Well, I speak, you know, from a physician lens of some of the patients that I get referred, and by the time there’s. I’m sort of seeing them in clinic for consideration of palliative radiation, they have a lot going on. You know, it’s the symptomatic lesion that I’m sort of discussing with them, but many other things in their lives as it relates to their advanced cancers. And we take on the mantra of one day at a time. And I thought this song fit that sort of mantra really well of I ain’t worried about everything right now. We’re just going to focus on what we’re going to discuss. And so I thought this song fit that well.

Eric 01:38

Great.

Alex 01:52

(singing)

Eric 02:19

Excellent. Thank you, Alex.

Alex 02:20

That’s fun. Anything where I get to whistle is a great song choice. Future guests. I love whistling. It’s a lot of fun.

Eric 02:28

I can’t whistle on command. It just blows air if I even think about whistling on command. So. Well done, Alex. Evie, I’m going to turn to you for the first question. You are the person that instigated this podcast. You want to Do a podcast in radiation oncology and radiation therapy. Why?

Evie 02:46

Yeah, great question, Eric. This is something I’ve been grappling with a lot as a palliative care doctor, see patients who often get referred to radiation oncology from their oncologist and kind of come back and get told, this is a good option. This is not a good option. This is what it would involve. And there was one particular patient that I had a couple months ago who had squamous cell carcinoma at the base of his tongue. He. Unfortunately, the disease was progressing.

He was having more pain, more dysphagia, and radiation was offered. It was offered, I think, daily for multiple weeks. And just as I was kind of getting to know him and work with them to think about what would make most sense, I was just really curious, you know, what would radiation do for him? It was a huge amount of time, a lot going on, and so I just wanted to learn more, make sure that as a palliative care doctor, I knew what I needed to know to be able to support this patient and other patients and really considering the risks and benefits of radiation.

Eric 03:45

Yeah, I gotta say, also as a geriatrician, like, I see a lot of people who’ve had radiation therapy and like, maybe a couple years later, maybe they have some stranger symptoms. Is it late toxicity, like dysphagia symptoms, especially in people with head and neck cancer and, like, thinking that through, it’s so common, but we don’t get taught a lot about it all. Anish, can I ask you why you went into radiation oncology?

Anish 04:13

Yeah. So it’s a good question. Thank you. I was really fascinated not only with the medical side of things, but some of the. The physics and mathematics that went into radiation therapy planning. And as it speaks to this podcast, I found that radiation oncology also offered me the ability to treat patients with palliative intent treatment, both adults and children, and allows me to sort of treat every area of the body and focuses on anatomy. So just sort of having that unique blend of anatomy, technology, palliative intent, and just every sort of age group really.

Eric 04:49

Drew me to the field physics and math. That is not why I went into medicine. And, Emily, I got to ask you, you’re a palliative care doctor. You’re part of the Society of Palliative Radiation Oncology. You were the current president. Past president.

Emily 05:07

Past president as of January 1st.

Eric 05:10

How did you get interested in this as part of your academic career?

Emily 05:17

Yeah, it’s a great question. I knew I wanted to do palliative medicine pretty early Even in medical school. And I was particularly drawn to the cancer patient population and really thinking about that integration into standard care. There were a number of opportunities to be involved in medical oncology and doing medical oncology rotations as a medical student, as an internal medicine residential. But radiation oncology was really more or less like a black box. There really was very little. They had a different health record system, so they weren’t documenting. I didn’t know where they existed within the hospital.

We would have patients who would go. I didn’t really know, similar to what Evie was talking about, how to provide any anticipatory guidance or to know what to expect in residency. I started to seek out opportunities to learn more because that seemed like a really integral element of taking care of patients who have advanced cancer. So I ended up trying to do a rotation as a resident. Wasn’t able to because there was really no system for that. But in fellowship, early in fellowship was able to do essentially a sub I in radiation oncology, which was really challenging because I didn’t understand the first thing about it.

But it was a really good experience. I would say possibly even transformative in the context of seeing how many opportunities there were for collaboration and bi directional education and how many potential ways radiation could help patients and how little that was well integrated into my training. And so that’s sort of where it all started. And I’m a little bit of a radiation oncology groupie in that regard.

Eric 07:04

You actually created things like a curriculum for hospital medicine fellows in radiation oncology. How much do palliative care fellows and in general doctors need to know about radiation oncology?

Emily 07:18

I think there are key points that I think are really important. The content, I think is probably less important though, than the awareness of the potential and the overall specialty. And thinking about it as one of the possible options for patients and then having those communication channels so that they can coordinate with their radiation oncology colleagues.

Eric 07:45

Anish, do you feel like we send people to you too late or not at all? Or do you feel like we’re doing pretty good from a radiation oncology perspective?

Anish 07:54

I would say sort of echoing what Emily was just referring to is education is key. And sort of a few years ago, we would sometimes see referrals a bit later than we would have liked. But now that at least at the University of Pennsylvania, the radiation oncology department is sort of well integrated into the cancer center here, and we have a really strong relationship with the palliative care team and even the internal medicine residents whom we give talks to. We are Seeing referrals at an earlier time point, especially at a point that I feel that I can really help a patient. So I think education is key. And if that’s the case, we often see patients at the right time.

Eric 08:37

Yeah, go ahead, Evie.

Evie 08:39

I just had one quick question about that. Anish. Where we work at the va, we don’t have radiation oncology. So everything kind of goes through the oncologist. Is it normally the oncologist who’s making the referrals to you or do they come from people outside of oncology?

Anish 08:54

So the vast majority of the referrals to my service come through a nurse, navigator or a medical oncologist. But there are times that a primary care physician or an internal medicine physician may make the referral. But in my practice it’s usually from another oncologist, typically a medical oncologist.

Eric 09:13

Do you ever get it from a hospice agency?

Anish 09:15

So usually the patients are not enrolled on hospice care when they’re referred to me. Usually that’s. It’s sort of a discussion about can we provide palliative radiation before they transition? Yeah, I have had a patient that was sort of experiencing, you know, we’ll talk about this, I’m sure, but symptoms from a specific lesion. And there was discussion about whether he, he or she could come off of hospice to receive the radiation and then go back on. So there’s certainly collaboration that’s possible, but not typically from the hospice agency.

Eric 09:50

Emily, we always think about like these radiation emergencies, but I don’t think a lot of hospices use radiation oncology therapy. Is that your thought too on this?

Emily 10:04

Yeah, I mean, I think I actually was going to ask the same question that Evie was, just in terms of the referral pathways, because I think that there is really a missed opportunity to create some of those other channels that would at least open up the discussion. Even if it’s a discussion that is involving the primary care physician, the geriatrician, the medical oncologist, the surgical oncologist. I think that there’s a real opportunity to have more of that team based approach and thinking so that everybody knows when to loop in certain specialties and when that might be a good discussion to have. I think in terms of the hospice, I was really fascinated to learn that radiation based on Medicare guidelines really is very appropriate and very much falls under the hospice benefit.

But I think where it ends up causing problems is just if they’re going to have many sessions, transport to and from, and just the overall cost that can be essentially not feasible for the hospice. So if it’s part of a discussion, as part of the plan of care, as a patient goes and is enrolling in hospice, that shouldn’t be a barrier. It’s just, I think, emphasizes the use of fewer fractions and really making it very clear that this is intended for palliation of symptoms.

Evie 11:33

I would love to hear more about cost later because I’m so curious about that. But I wonder if we could take a step back and just like really basically Anish, talk about like, what is radiation? What is the goal of it? What do patients do when they come to radiation? Just so that we can all be on the same page about what it is our patients are going through.

Anish 11:52

Definitely. So radiation is sort of one component of the overarching model of cancer care, obviously the other two are surgery and systemic therapy. And systemic therapy can be chemotherapy, immunotherapy, etc. And then there’s radiation therapy. Radiation is the delivery of focused ionizing particles or ionizing photons that damage DNA that attack cancer cells. Specifically, we can think of radiation in two buckets. One is the curative type of radiation for a cancer that we are trying to eradicate or induce a patient into long term remission.

That’s typically the radiation that you hear about that occurs over the course of multiple weeks with daily fractionation. It can be up to four, six, seven weeks of treatment to a primary tumor. As we think about palliative radiation, which is the other bucket, these are the types of treatments that are delivered in a hypofractionated manner or limited number of fractions. Usually it’s on the order of 1:5 fractions, sometimes up to 10 treatments. The goal of palliative radiation in particular is to help alleviate symptoms or address a problem before it may happen. That’s the prophylactic side of palliative radiation.

Eric 13:16

And what exactly is a fraction? Is that just a divided dose?

Anish 13:20

Yeah. So the reason they use we use the word fraction, it’s a fancy word for treatment. And you know, over years of sort of studies, we know that giving all that dose upfront is unsafe for patients. And so we deliver the total cumulative dose in what we call fractions or daily treatments or every other day treatments or once weekly treatments so that normal tissue can repair in between the treatments and the cancer cells can get damaged. And we know that that’s how we can minimize side effects of radiation as well.

Emily 13:55

Maybe I can just jump in from a non radiation oncologist perspective. Something that was really helpful for me to understand is that radiation doesn’t not damage I guess if I can use a double negative, normal tissues. And obviously there’s a real focus on trying to have as targeted of a treatment. And there’s a lot of effort at that within the field. But even within trying to target the cancer, the radiation has to go through the skin and the immediate structures. And so that’s important, I think, for palliative physicians, geriatricians, primary care physicians to know, because it means that the symptoms that you can often expect are localized to the area that they’re getting radiation.

You can anticipate what symptoms they may expect, whether that’s either short term or long term. But it also means that the radiation oncologists are trying to think about that balance of how do they selectively damage the cancer cells while allowing the healthy cells time to recover. I think that’s the balance that often. And again, Anish, correct me if I’m wrong, but that’s sort of the balance that goes into kind of dose constraints and really thinking about how many fractions and what overall cumulative dose should be administered for that particular disease.

Anish 15:21

Yeah, so I totally agree. There’s many different ways one can approach treatment, from number of fractions to the type of treatment modality we choose. But I would like to go back to the side effect profile that Emily was referring to. And so, as opposed to systemic therapy, which goes all the way throughout the body, so patients can experience a myriad of side effects that may not be specific to the lung cancer that’s being treated with radiation, it is truly a localized treatment that’s directed to the tumor, the lesion that specifically is causing symptoms.

When I’m treating somewhere in the lumbar spine, for example, the bowels sit right in front of that area. I am counseling patients on the risk of not nausea or loose stools, depending on the treatment modality that’s used. But I’m not typically talking to them about shortness of breath or painful swallowing or dry mouth, just based on the location of the lesion. So I think that’s helpful for referring physicians to understand is that depending on where the lesion is, that’s the type of. That’s sort of what guides my discussion on radiation related side effects.

Eric 16:32

And I want to go back to what Evie asked too, because. So you have the initial conversation with the patient, then I always hear like there’s simulation and then they get the dose. What the heck is happening between the time you first see this patient, this simulation thing, and then them actually getting the dose?

Anish 16:52

Yes, great question. So that was sort of the next Topic. So, yeah, this is the part of radiation oncology that can be that black box where you’re not sure what’s actually happening. But the process and procedure for radiation is like a process map. So you have the consultation. The next step is that simulation that you’re talking about. And really what that is is a fancy word for a CT scan, maybe a CT scan and an MRI or some other imaging on the day of. We call it a simulation because it is a simulation of what treatment position the patient will be in during the course of their radiation therapy. So that might mean laying flat on your back with your arms up over your head, arms down by your side, arms crossed.

And what our therapists will do is sort of create or use immobilization devices and take photos and document carefully how the patient is positioned on the table so that it can be replicated on the treatment machine. Now, the question many, many people ask me is, they just had a diagnostic CT scan, like three days ago. Why can’t we just use that? Well, I will say we have advanced significantly as a field, and in certain populations, we can use the diagnostic imaging, but we’ll reserve that for another discussion. The reason that we cannot use that is the bore of the diagnostic CT scan is rounded, whereas the CT scan is flat in the radiation department. And that allows us to do some accurate, more accurate calculations for the dose that’s deposited, and it allows us to use the immobilization devices.

So there’s some specific things that we do at simulation that is not as easily transferable from the diagnostic CT scan. So from the simulation, the patient goes home, the physician and the physicist and the dosimetry department put together a treatment plan, and then the patient comes back for their actual fractions of their actual treatments. And so that’s sort of the stepwise process.

Eric 18:51

And when do they get the little tattoo marks? Is that in the simulation?

Anish 18:54

That’s that simulation, exactly. So that’s the immobilization. That’s when they make the immobilization and they put the tattoos to sort of use those as a reference on the treatment table.

Eric 19:04

So I’m guessing part of that is there are some people that probably are not great candidates for this, especially people who can’t sit still. Is there anything else that you would think about, like, I’m not sure about this, besides the cancer itself?

Anish 19:19

This is where it’s so critical to have, one, a conversation with your referring physician. But two, a very close relationship with potentially the palliative care physician or the individual who’s Sort of managing their pain, because the simulation itself can be 20 to 30 minutes of lying in that specific treatment position. If the patient has to keep their arms up, that could lead to shoulder pain or pain in other locations. So we need to have a discussion upfront about how we’re managing the patient’s pain. Sometimes individuals have lung tumors that make it difficult for them to breathe.

So we need to manage how they’re going to lie flat or slightly elevated in order to get them through both the simulation procedure. Procedure as well as the treatments. And so on the inpatient side, which I see a lot of inpatient consults here, a large portion of what I do before they even come down to my department is making sure that they would be candidates for the simulation and treatment for the reasons that I described.

Emily 20:17

I think that’s a really important point also from the palliative standpoint, because there may be concerns or there may be nuances in terms of the patient’s ability to. To withhold a certain position or a certain degree of anxiety or confusion or whatnot that might make this particularly difficult, if not really impossible. And there may need to be adjustments in the pain medication, the management of patients, kind of similar to patients who have a really hard time going through an MRI or whatnot. There may need to be a particular plan for that scenario. And when patients undergo the CT simulation, that usually will give you a pretty good sense in terms of how do they tolerate that. And was that okay?

Did their pain management last throughout that entire session? A lot of patients aren’t used to being in certain positions or laying flat on their back on a hard surface, or even the masks and stuff that they need to use for head and neck can be extraordinarily anxiety provoking. And what you don’t want is to have symptoms that are not well managed during a session that they then say that they don’t want to go back and complete the treatment because it has created a sort of an association or such a negative. It’s been such a negative experience. And so I just think that there’s a real attention to making sure that the symptoms are well controlled for patients and that those early sessions.

Eric 21:49

I can’t remember a time where, as a pal of care doctor, the radiation oncologist called me about what happened at the radiation oncology center that we send them to. Evie, can you.

Emily 22:02

No.

Evie 22:02

But I also think that speaks to kind of this liaison through oncology. I feel like I don’t have that direct channel that Emily was describing of communication between me as a Padded care doctor and radiation oncology.

Eric 22:14

Does the radiation oncologist ever manage some of these symptoms? I’m guessing they do. What’s the role of the radiation oncologist as far as managing and palliating symptoms?

Anish 22:27

I would say to a large degree I am involved in the management of the lesion that I’m treating or I expect potential side effects from. In our practice, I would say you will see dexamethasone or other steroids used more liberally in the radiation oncology practice. It is not only helpful for pain relief, but also for patients that we’re seeing for spinal cord compression or brain metastases with vasogenic edema could help ameliorate some of their neurologic symptoms.

So that’s something that we commonly prescribe here. And then more sort of basic pain management measures we’re relatively comfortable with. But of course, as we get into the more nuanced, complex pain management, pain management discussions, we are, of course, collaborating and relying, you know, on our on our supportive oncology and palliative care colleagues.

Eric 23:21

Does your use of steroids change at all now that we’re using a lot more immunotherapy? Like, is that part of your equation?

Anish 23:27

That’s such a great question. So, yes, one of the big questions or considerations I’m always keeping in mind when a patient may need dexamethasone or other steroids is what is their systemic therapy regimen? And if they’re on an immunotherapy, I try to use an alternate medication that may help their symptoms. And if that’s not doing the job, then I reach directly out to their medical oncologist to discuss a short course of immuno steroids to in combination with their immunotherapy. And usually by the time I’m making that phone call, the medical oncologist understands that, hey, this is sort of a situation that we need to deal with, you know, despite the potential downsides to it.

Emily 24:08

Yeah. You know, I think this kind of also comes back to this idea of role and scope of practice. And, you know, one of the things when I, when I did my sort of immersion into the radiation oncology world during fellowship was that, you know, the training program really didn’t have any dedicated education on pain management or, you know, any symptom. You know, it was very focused on the technical aspects of delivering palliative radiation. That was sort of the scope. You know, things have evolved and changed. And now there’s some very, very general guidance from ACGME in terms of at Least mentioning palliative care as something that they should sort of be exposed to.

Right. Like, it doesn’t, it doesn’t outline exactly any real topics that need to be addressed or the content. But I think that was really eye opening for me because, you know, there was a general discomfort in knowing what to do beyond kind of first line management. And I do think that there is, there are situations where patients may need more complex interventions just to get them through the treatment and that that’s kind of a real opportunity to, for some of that bidirectional education and to make sure that there are some open communication channels and so that there is a plan. I mean, it’s a tremendous missed opportunity if a patient goes down, can’t get their radiation, doesn’t complete the session. And it’s, it could have been something that could have been avoided.

Evie 25:33

Say I want to hear and talk more about kind of what to expect and what to do after radiation finishes or while it’s happening. But I wanted to step back and just ask like, who should we be thinking about radiation for? Like who is the ideal candidate? Or what are like the little triggers in our mind that we should say, I wonder if we should think about referral to radiation oncology.

Anish 25:53

That’s a great question and I think it’s one of the key discussion points of this episode. Palliative radiation has a long track record in the literature of helping for a number of indications. Pain specifically is a big one, particularly for lesions that are bone metastases that are localizable that we can treat. We have data that shows that up to 60, 70% of patients have some degree of pain relief from as little as one treatment of radiation. That’s a big reason, reason for referral. Bleeding or hemostatic radiation is another reason that we think about referral. So this can be GI bleeds, GYN bleeds, bleeding from endobronchial tumors. If you’re seeing a patient, as little as one to five treatments can help curtail some bleeding.

Patients often develop obstructive type symptoms from the mass effect of their tumor, as we know. So this could be in the GI tract, it could be vasculature, it could be in the airway, and radiation can help cyto reduce any of these lesions to help improve organ function. So that would be a good reason if there’s a localizable lesion that you’re wondering if we could help shrink it to help ameliorate symptoms. That’s a big reason. The big one, and I’m pointing to the spine back here is any neurologic symptoms related to spinal cord compression or disease in the brain that’s causing symptoms. Radiation is a really helpful, helpful and tried and true modality for those types of symptoms.

Eric 27:27

And that kind of leads to the radiation therapy emergencies. Right. We think about spinal cord compression, brain edema, superior vena cava syndrome. Are those the three that you think about?

Anish 27:39

Yep. So spinal cord compression, brain herniation. In that case, we’re usually involving neurosurgery, leptomeningeal disease, hemorrhage, so sort of ongoing bleeding that’s not responsive to other therapies, and of course, airway obstruction. So those are the kinds of 2am phone calls that I get when I’m on call usually.

Eric 27:57

And for those, does everything just condense as far as consultation, simulation and dose? Like, is it just boom?

Anish 28:04

Yeah, yeah. So we kind of do everything on the same day. We’ll see the patient in the morning, get them simulated, and try to deliver treatment on the same day, depending on how urgent the cases.

Eric 28:14

Emily, from your experience as a palliative care doctor, when do you see the most use of radiation therapy?

Emily 28:22

I think, no question. In the setting of bone metastases and such. That’s the. I think bread and butter from the standpoint of the general patient population.

Eric 28:32

That’s mine too. I got some lightning questions. It’s okay if Evie and I threw out some lightning questions. I’m going to put you on the spot, Evie. I’m going to start off because I’m going to use Evie’s question from the start. Bony pain. Let’s talk about bony pain. Single fractionated or multifraction hypohyperfraction. How shall I even describe it? One dose or many?

Anish 28:55

Good question. So multiple randomized trials have demonstrated the equivalence in terms of pain relief between single and multi fraction regimens. So much so that a meta analysis basically said we shouldn’t study this anymore. So for uncomplicated bone metastases, meaning there’s no spinal cord compression, no pathologic fracture, fracture either offer equivalent pain relief. With some caveats in terms of increased retreatment rates in the single fraction patients, meaning there’s a little bit of an increased risk of down the line, they may need another dose of radiation.

Eric 29:28

Why then do so many people get multifraction doses still?

Anish 29:34

So there are patients for which multiple fractions, which may mean a higher dose, may be beneficial. So in my practice, I typically recommend multi fraction or higher dose regimens for patients who have extra osseous extension or complicated bone Metastases, which, you know, most of the data surrounding equivalency of pain relief is in this sort of uncomplicated bone metastasis population. But once you have things like spinal cord compression, extraosseous extension, neural element pain related to the disease, sometimes it makes sense to offer a little bit of a higher dose. That would be the reason that you might see that.

Evie 30:13

How quickly do you see that effect.

Anish 30:16

Effect of the radiation itself? Yeah, I counsel my patients that it can take a few weeks to see the full effect of radiation. I think of it as a bell curve. I have that occasional patient that gets pain relief after the first few treatments. And when they tell me that, I say, well, I wish all my patients were like you for this. Extremely rare. It’s usually four, six, eight weeks out as I see the maximum effect and then the tilt drops.

Alex 30:41

When’s the earliest that you start to see effect?

Anish 30:44

Like, like I just mentioned, there’s the rare patient that has it on treatment, but the earliest is typically one to two weeks.

Alex 30:50

If we do see it typically one to two weeks after you start to see a meaningful effect.

Eric 30:55

And for bony mets, do you use a lot of steroids or not? Like I’ve always been confused when you use steroids for bony mats because it seems to help a lot with pain. I realize that there’s no issues with, you know, certain cancer therapeutics, but how do you think about that for steroids?

Anish 31:11

So there are two major randomized trials that were, that were done with this specific question in mind. One major randomized trial demonstrate a reduction of the incidence of pain flare with prophylactic steroids. And another showed a delayed incidence but not necessarily a reduction and the rate. All that in mind, I first say there’s no clear cut guidelines in how we use steroids, but in my practice I counsel on this risk of pain flare, which we haven’t talked about yet, but I think it bears mentioning that’s where the radiation itself causes increase in pain during or shortly after the radiation treatment.

And it can be mild, can be moderate increase in pain, or in rare cases, it can be a severe increase in pain at the treatment site. So to minimize the risk of that, I put patients on a dose of 8mg of dexamethasone with a four day course thereafter to reduce that risk. There are some, you know, analyses that have been done to predict who’s going to get a pain flare or not. But in my mind, patients with certain types of cancers, like renal cell carcinoma, patients who have baseline pain and who have soft tissue extension of their tumors are ones that I think think about steroids ahead of time because of their elevated risk of a pain flare. But it’s always a physician patient discussion because it has side effects, particularly the insomnia, the agitation that we can sometimes see with the higher doses.

Evie 32:39

How do you think about the durability of the effect?

Anish 32:42

It’s a great question. There was a trial published in the JCO a few days ago that looked at a technique called sbrt, which is a high dose of radiation and with sort of millimeter precision versus what we use the term of conventional radiation, which is sort of that lower dose per day, which is what’s been there for decades. And when we think about sort of the durability of the effectiveness of radiation, typically local control or tumor control is tied to the total dose that we use. And so if a patient has a more prolonged life expectancy, I may use a higher dose of radiation to control that tumor.

But the reason I bring up that trial is one of the discussion points with some emerging data is that this higher dose of radiation with SBRT may not induce pain relief more quickly than the conventional lower dose regimens, but it may induce longer term durability. We sometimes see higher complete pain response rates at three months and six months with this higher dose radiation compared to the conventional arm, which may be just a few months.

Eric 33:47

Can you re-irradiate?

Anish 33:51

These are really good. Yes. So you absolutely can re irradiate. That’s a large portion of my practice. And I give credit to the wonderful medical oncologists who have developed all these systemic therapies. Now patients are living so much longer that they’re coming back to my clinic after I’ve treated them with radiation. So there’s a number of sort of guidelines out there, but the general answer is yes, we just have to wait a sufficient time to allow for maximal tissue recovery. So, for example, when I’m treating over the spine, I typically like to wait six months to deliver a second course of radiation to allow for maximal spinal cord tissue recovery and minimize the chance of my lap of the or spinal cord injury with a second course of radiation.

Evie 34:33

And that’s to the same spot or to any spot in the spine?

Anish 34:35

Yeah, great question. So to the same spot, if I treated, let’s say T3 and then T10 needs treatment that does require six months. It’s really if you’re reradiating over the same portion of the spinal canal.

Emily 34:50

I think this is important in the context of something you said earlier Anish, which is single fraction versus multifraction for uncomplicated bone mets and the rate of RE irradiation and thinking about that as a sign of either treatment failure or limited durability, but also that clinical practice has evolved such that our understanding kind of as a medical system of what the body can tolerate and the overall benefit versus risk ratio for RE irradiation has evolved such that, you know, there has been a lot of hesitation about rerating a site if there has been multiple fractions that have been given to that site.

And so if it’s, I guess, more leniency or there’s been more comfort, I guess rearranging a site that has one. So I think that’s an important piece. Just in terms of thinking about the durability. I don’t know. Anish, if you can speak more to that from the radiation oncology practice standpoint, but that’s been something that’s been highlighted to me.

Anish 35:50

Yeah, I would definitely say from a palliative care and geriatrician standpoint, if a patient is reporting symptoms at a site that’s been previously radiated, I would not say that that’s a contraindication for a referral. I would say meet with your radiation oncologist. Because at least over the last 10 or 20 years, our treatment techniques have evolved so much that, you know, some patients are even receiving. One of my, one of my colleagues curbsided me about treating an area for a third time. And that’s sort of pushing the boundaries. But these are the types of discussions that I’m even having now of not only the second time radiation, but even a third sometimes.

Eric 36:28

So they have a really bad cancer. Maybe they’re dying from it. Like, what do you most worry about with reradiation?

Anish 36:36

Depends on the site that we’re retreating. So we group radiation tox, as with any sort of, we group them into acute and late side effects. When I have a patient that’s approaching end of life, I focus much more heavily in my conversations on the acute side effects. So if I am thinking about retreating a thoracic spine lesion, I’m heavily counseling them on the risk of pain flare because that’s very noticeable immediately during and shortly after radiation.

And the risk of esophagitis. There are of course, longer term risks of fracture and myelopathy, but I always focus on what would be most pertinent to the patient at hand. And it just goes back to our earlier comment that sort of the, the side effects of the radiation we’re Giving is localized to, to the lesion in question. So in that example it would be what’s most pertinent to the patient in the short term setting, which would be esophagitis and pain flare. And then it could depend on what I’m treating.

Eric 37:36

And Emily, from a palliative care perspective, like what side effects should the palliative care doc, any doc, should know about and think about how best to treat.

Emily 37:45

Yeah, I mean I think mucositis, proctitis, you know, dermatitis, there’s a lot of kind of inflammatory responses that can occur. And so having a good understanding of those, I think another one that is maybe not a side effect per se, but it’s sort of in some ways just being aware of the overall time course. So that if somebody is anticipated to have lower overall opioid requirement need from as their pain improves after radiation, just to be thoughtful about that, sometimes we’ll have patients who are really needing kind of a higher dose.

But always keeping in mind of what was the timing of their radiation and how do we make sure that we de escalate as appropriate. That’s something to be thoughtful about. Also if there’s the need for de escalation of dexamethasone because there’s definitely been times that it has been started at some point in the patient’s course and it has been continued. Yeah, definitely. So I really liked, you know, the, the comment about, you know, ordering it for a certain number of days. But I think sometimes there’s a just a default and so being thoughtful about any other side effects that patients might experience from just prolonged use.

Alex 39:00

I have a follow up question about that. I find radiation mucositis one of the most difficult symptoms to treat. Any pointers, Emily or Anish?

Emily 39:10

Yeah, it’s really challenging and it creates an element of people’s time courses different. Sometimes it can be pretty severe, but short lived. Sometimes it can be a pretty durable symptom. Especially if they’re having a long treatment course for a head and neck cancer and where there’s kind of an ongoing use. I think in addition to systemic pain control and just appropriate management from that standpoint point, there are some topical solutions that can be helpful. I think you hit a point where any sort of swish and spit or swish and swallow or anything, you know, is just too painful in of itself.

Right. So then it kind of takes us back to just basic mucositis management and making sure you have systemic opioids on board. But yeah, I think that’s an area where there’s no real easy solution. Some things that work really well for one patient, you know, may or may not work for another. But I know there’s been a lot of looking into like doxepin and such just to see kind of what, what might be effective. I don’t know. Anish, if you have other experience.

Anish 40:15

Yeah, that. So I would agree with that. The topicals, the potential rinses. But the other thing I would guide is to try to loop in your nutrition or dietitian team if you have one available. They are so helpful in ensuring that those patients, in particular the head and neck cancer patients, receive appropriate nutrition and maintain their weight throughout. But yeah, it is a challenging side effect. And usually it’s sort of the things that have been mentioned.

Evie 40:45

Just going to ask kind of a similar related question. When should we be contacting radiation oncology after treatment? Like, what are the things that make us say, oh, we should move back in with the radiation oncology team when.

Eric 40:57

You yell in the middle of the night, why didn’t they call me before?

Anish 41:00

Yeah, so I could list 15 different things. But here’s the answer that might bucket everything is if the patient is having symptoms in a previously radiated area or something that could be related to that, please just loop us in. If it’s a lung lesion and the patient’s, you know, having shortness of breath or cough or some new bleeding as they cough, those are things to just notify a radiation oncologist. Same thing with the GI site or a bony site. New pain at a site that was previously treated. We want to know about it because we can help guide the workup. Usually that will include the physical exam, but also the type of imaging that would be helpful for us to have to guide what would be next steps.

Eric 41:42

Do you guys also for bony pain, is it radiation oncology that’s deciding also on bone targeting radioisotopes? Where does that fit?

Anish 41:51

Yeah, so radioisotopes certainly within nuclear medicine, but it’s a burgeoning aspect aspect of the radiation oncology practice. So much so that there’s sort of work groups surrounding it. So depending on where you are, the radiation oncologist is prescribing it versus the nuclear medicine doc, and it’s just institution specific.

Eric 42:10

And when should we consider those.

Anish 42:13

That is certainly within the purview of the referral from the medical oncology team. But certain of cancers, particularly prostate cancer, is one that typically merits the discussion with the radiopharmaceutical administrator.

Eric 42:28

So if it’s spread to like multiple.

Anish 42:30

Sites Metastatic prostate cancer. That’s right, Yep.

Alex 42:34

I have a question about more conceptual question. You know, there’s this issue that many patients who are receiving chemotherapy that is quote unquote, palliative, which is, you know, often taken to mean any chemotherapy that’s not curative intent. Those patients nonetheless think that they’re getting the chemotherapy with curative intent. And I wonder if there are similar misconceptions around patients who receive radiation therapy.

Anish 43:00

Yes, it can be.

Alex 43:02

Do you use the term palliative radiation with patients? Do you use it with each other? And what does that mean and do you worry about these misconceptions?

Anish 43:10

Yes. Just to start this discussion, my specialty is within palliative radiation patients with advanced and metastatic disease. So I find it’s probably a little bit more commonplace for me to have this discussion. But when I have a patient sitting in front of me, the first thing I say is that the intent of this treatment is to help your symptoms. I never sort of say that it’s going to get rid of your cancer, but that’s often the question that the patient asks me next is, is this going to get rid of the cancer? And then I go into a discussion about why the dose that we’re using in the palliative setting, which is usually much lower than the curative setting, will not sort of get rid of their cancer.

Could help keep it at bay for a short period of time, and that is sort of helpful. I don’t always use the word palliative unless it’s a patient that is very medically literate or has that. That sort of background that would make sense. But I think sort of using that targeted language of helping your symptoms helps frame the discussion for the patient.

Alex 44:06

Thank you, Emily. Any thoughts on that or experience?

Emily 44:09

Yeah, I mean, I think. I think this is a really important question because I think that a hospitalization progression to a new line of systemic therapy, a new treatment modality, going to a radiation oncologist is a good time point to check in with the patient and understand what their illness understanding is, make sure that they understand the intent of treatment and such. And I would say not infrequently do I see patients who have a misunderstanding about radiation similar to their.

To their kind of systemic treatments. And so I think that it’s an important point to make sure that patients are making informed decisions and that that conversation is happening and that really that even just the referral to radiation for something is a good trigger for that to just check in and to make sure that those conversations are having the patient has the information that they need. And maybe that is a larger conversation that also continues in other contexts. But, but I think that radiation oncologists have a really key role in that consultation.

Eric 45:12

Evie, I’m going to give you the last question.

Evie 45:15

Gosh, I have so many. But I think the last question that’s on my mind as we talked about it earlier is cost. We talked about kind of risks and benefits of the treatment. And I just was wondering if you could speak a little bit about cost. Do patients tend to pay a lot for radiation? Like, what should they be expecting in that respect? I know, I’m sure it depends with insurance and where you are.

Anish 45:34

Yeah, usually the insurance company will cover the cost of the radiation therapy. There may be co pays or things like that. But we in our department are obtaining insurance authorization before the patient even gets on the table. So it’s not typically something that the patient experiences. That being said, some of our more advanced technologies, as they are more expensive, we do encounter some pushback from insurance companies and it may require phone calls, letters of medical necessity, et cetera, but not typically something the patient directly, directly experiences.

Eric 46:07

Is that like the difference between, like a stereotactic. What do they call it again? A stereotactic.

Anish 46:14

Sbrt.

Eric 46:15

Sbrt, yeah, that’s right.

Emily 46:17

And maybe just one other comment on that is that, you know, per fraction and per treatment increases the overall cost. So there is also that, that element of, you know, in thinking through. And that’s why, you know, a hospice agency may be able to accommodate a single fraction, but if they have like a 10 fraction regimen, that’s going to be exponentially more expensive.

Eric 46:38

Well, Anish, I guess that my last question then to you is like, as a, like for the, for the people who are listening, let’s say we have a patient who lives kind of far away. They’re in hospice. You know, hospice is getting like $160 a day. Are there things that the providers could say to help encourage single fraction versus multifraction that would work well with the radiation oncologist?

Anish 47:03

Yeah, I think the data surrounding the equivalency of single versus multi fraction is known and hopefully known throughout the field. And so if the referring physician or provider were to say, hi, I have a patient with an uncomplicated bone metastasis that may need a fraction of radiation for pain relief, that might sort of.

Eric 47:24

Move things in that direction, anchor them from the start. Behavioral economics right there. We’re going to nudge them to the single fraction.

Anish 47:32

You got it?

Eric 47:33

Yeah. Well, I want to thank all three of you for coming on. Before we end, I think Alex is going to take us home with. What’s the song title again?

Anish 47:40

Anish I Ain’t Worried By One Republic.

Eric 47:42

I ain’t worried.

Alex 47:57

(singing)

Eric 48:24

That was great, Alex. Don’t worry about it. Emily, Anish, Evie, thank you for joining us on the GeriPal Podcast.

Anish 48:32

Thank you so much.

Eric 48:34

And thank you to all of our listeners for your continued support.

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