How Important is Experience of Radiation Oncologist?

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Kark60
Regular Member


Date Joined Jun 2008
Total Posts : 91
   Posted 11/3/2010 3:56 PM (GMT -6)   
I'm looking for some advise from the collective knowledge and experience in this forum. Everyone (including me) agrees I am heading for SRT, but my dilemma involves where it will be done and by whom. Here are my options...

1) My surgeon is affiliated with a large teaching hospital connected with a major cancer center located in a large city 200 miles away from where I live. The radiation oncologist he referred me to is at that cancer center and 80% of his cases involve prostate cancer. He seems to be well-known in the research literature and, since I was referred to the surgeon by my local uro and the surgeon along with anyone he refers me to now are regarded as "in network" by my insurance, the cost is reasonable for me. The only problem is being 200 miles from home and so I would be away from my wife and kids, and having to pay living expenses for the seven weeks (or so).

2) I learned the most experienced and highly regarded radiation oncologist in town for PCA is in another hospital network considered out of network by my insurance company, unless I can have my doctor provide COMPELLING reasons why this doctor's services are "unique." I've investigated a bit and think proving this is going to be difficult and the surgeon doesn't seem to be willing to say much more in a letter than "I believe this is the best option for optimal care." I met with this guy, he has published papers on prostate cancer treatment, and he seemed very confident that he can handle my case with a good outcome. I really liked him. The problem is cost, since out of network providers double my deductible, double my out of pocket maximum, and are counted separate from all in network medical costs. Given the end of the calendar year approaching, I would be working toward a different deductible and out of pocket max beginning January 1. This would be a very expensive outcome.

3) The local radiation oncology practice considered in-network currently has only one doctor who is a "jack of all trades." I have an upcoming appointment to meet with her. The significant benefit is location and cost since this would be calculated with my family's overall insurance situation both this year and next.

I'm curious about other's thoughts on this situation. Is there a big difference in quality of care from radiation oncologists and likelihood of a good outcome to justify either the travel costs or much higher out-of-pocket expense? I realize I have one more shot at a cure and want to take the best approach I can...

Kark60
Regular Member


Date Joined Jun 2008
Total Posts : 91
   Posted 11/3/2010 4:24 PM (GMT -6)   
By the way... here is my information...
Age 47 when diagnosed (currently 50). Pre-surgery PSA: 13.7 Pre-surgery Gleason: 4+3=7. CT Scan, Bone Scan, PET Scan: Clear. LRP May 28, 2008. Left nerve bundle removed. POST-SURGERY PATH REPORT: Gleason: 4+3=7;10% of prostate with all quadrants involved; EPE at left base and apex; extensive perineurual invasion present. Bladder neck, lymphvasular space, seminal vesicles, 17 examined lymph nodes, and all surgical margins FREE of tumor. T3a. Four-week post-surgical PSA = 0.1; Seven-week post-surgical PSA = .01; October 2008 – April 2010 PSA = 0.0; April 2010 PSA =0.1; May 2010 and August 2010 PSA = 0.1.

Geebra
Regular Member


Date Joined May 2009
Total Posts : 476
   Posted 11/3/2010 5:12 PM (GMT -6)   
I had an easier dilemma. Drive 90 min to Loan Kettering or drive 10 min to local center with a good doc. I those Loan and don't regret.

Your situation is harder, but I would still go dir the best doc you can afford.

Just my take.
Father died from poorly differentiated PCa @ 78 - normal PSA and DRE
5 biopsies over 4 years negative while PSA going from 3.8 to 28
Dx Nov 2007, age 46, PSA 29, Gleason 4+4=8
Decided to participate in clinical trial at Duke - 6 rounds of chemo (Taxotere + Avastin)
PSA prior to treatment 1/8/2008 is 33.90, bounced on 1/31/2008 to 38.20, and down at the end of the treatment (4/24/2008) to 20.60
RRP at Duke (Dr. Moul) on 6/16/2008, Gleason downgraded 4+3=7, T3a N0MX, focal extraprostatic extension, two small positive margins
PSA undetectable for 8 months, then 2/6/2009 0.10, 4/26/2009 0.17, 5/22/2009 0.20, 6/11/2009 0.27
ADT (ongoing, duration TBD): Lupron started 6/22/2009
Salvage IMRT to prostate bed and pelvis - 72gy over 40 treatments finished 10/21/2009
PSA 6/25/2009 0.1, T=516, 7/23/2009 <0.05, T<10, 10/21/2009 <0.05, T<10

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/3/2010 5:47 PM (GMT -6)   
once the radiation oncologists plans and maps your radiation, and determines the needed gys, the rest is more mechanical, and comes down to the techs that deliver it. once you start, you most likley will only see the doctor once a week for a quick briefing and update. not convinced the parts about the doctor being published, etc, will have little bearing on your out come. The odds for most SRT is low, but it is most surgery guys last shot at a cure. having it done that far from home and your family will have its own negative effect, and if you end up having a hard time with the treatments, you may not want to be that far from hom.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3748
   Posted 11/3/2010 6:03 PM (GMT -6)   
Purgatory's advice is sound.. The Radiation Oncologist who will plan your treatment will be following set protocols and procedures that don't differ very much from shop to shop..Your treatment plan will take into account any "special circumstances" you may have..Once the treatment plan is approved, the doc has little to do with your treatment..A team of technicians will be doing the actual set-up and operation of the equipment. The doc will meet with you once a week to see how it is going...The skill level of the Radiation Oncologist is important but not critical..They hunt with a shotgun, not a sniper rifle..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2215
   Posted 11/4/2010 8:28 AM (GMT -6)   
When I first saw my RT doc he said he had already discussed my case with the surgeon's assistant. later on during RT I saw a different doc who said that she remembered me without having met me as she remembered when they had discussed my case plan before my RT started. Thus a group of experts discussed what needed to be done. For me there was thus collective expertise involved and it was not one individual making the decisions.

There is however an aspect of RT I do not and did not understand, namely why it is not geographically transferable.

By way of an analogy if my doc in Amsterdam prescribes me some meds I get given a piece of paper I can take to the pharmacy which is 200 yards from my front door - I do not have to travel to Amsterdam to get the meds from the doctor's pharmacy department.

So when I needed SRT I saw the RT specialist at the same hospital where my surgery was done. I was shoved into a CT Scanner and a "Plan" was drawn up by the team of experts to decide what amount of radiation needed to be aimed at what bits of me from what angles. Now I saw that plan: it is basically a piece of paper with some numbers on it. For seven weeks I had to travel to Amsterdam so that those numbers could be entered into the computer that controlled a standard RT machine.
Now what I don't understand is why I could not take that piece of paper with the plan on it down to the hospital that is about a mile from my home and ask the local Rad technicians to enter my numbers into an identical RT machine in that hospital and get my treatment so much closer to home.
It was not as if the hospital in Amsterdam gave it all a special expert or personalised touch. I was given a pass with a bar code on it and each day when I arrived I swiped the card under a reader and the attached screen told me which cubicle to go to. I sat in a waiting room, changed in a changing room lay on a table had my ID verified, was treated and then left. The whole thing could have been self service and automated. I never saw a single doctor in the RT centre in 7 weeks, just technicians & nurses. (Appointments during RT to see the doc for check-ups were arranged separately and happened once a fortnight in a different part of the hospital.)

I did ask why I could no0t take the plan and go somewhere closer to home but was told that that was not possible, my reading of the situation being that they didn't want me to do it not that it was not physically possible to do it. (IE the patient has to go along with what suits the doc and not that the doc has to adapt to suit the patient.)

Now this is the Dutch experience, maybe it works differently in the US. If anything like it is possible, then why not contract the best guys to draw up your plan and sub-contract the local guys to implement it.

Alf

Julietinthewoods
Regular Member


Date Joined Sep 2010
Total Posts : 309
   Posted 11/4/2010 9:33 AM (GMT -6)   
I think Alf has a good point, and you might pursue that.

My husband had his pre-treatment simulation (RT will be the primary treatment for him) this morning, and never saw the doctor at all. The technician he will see throughout his nine week course of radiation is the one who did the simulation. I know they did say the doctor does the post-simulation study and planning, along with a dosemetrist, and will check in once per week during the nine weeks.

I think what we did was choose the method of treatment (IGRT with gold seeds), and ask if the equipment was up to date. Beyond confirming that the doctor had walked a good number of men (nearly 1,000 according to him) through this process, we chose the nearest treatment center to my husband's workplace that was in our insurance network. Proximity to work was a huge issue for him. He plans to attempt to keep his life as normal as he possibly can.

The fiducial placement (if you have that) seems important to me, and must be done by someone with lots of experience. In my husband's case, he had to go to a nearby town to see a urologist for that procedure, as his own urologist does not do them. But that is just a one-time thing.

It seems to me that having the chance to continue with your daily family life could be an important de-stresser for you during this time. Just something to consider...

Good luck with your decision-making!

Juliet

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 11/4/2010 10:35 AM (GMT -6)   

Kark, you asked one question, but some of the responses are morphing into answering a different question.  The radiation oncologist creates your treatment plan, and will only accept his/her appropriate degree of responsibility for that plan if it is carried out by his/her “team” of technicians…this is professionally reasonable.

 

I think that your original question was related to the reason for selecting an expert radiation oncologist.

 

The key reason for selecting a radiation oncologist who is not a “jack-of-all-trades” is essentially the same as not selecting an inexperienced surgeon.  The lessons-learned by both radiation oncologists & surgeons (or just about any other technical profession) through direct experience result in tweaks, adjustments, expertise and knowledge to their craft which cannot otherwise be easily acquired. 

 

There is an old saying which goes something like:  Good judgment is based on experience. Experience is based on bad judgment.  Your PC radiation plan, if developed by an expert, will take into consideration that good judgment which has been gained by experience and lessons-learned from many prior patients with PC.  You don’t want to be among the first couple dozen prostatectomies that a surgeon learns on, but if the surgeon is specializing in prostatectomies he will go through that learning curve much quicker than a jack-of-all-trades who does one of everything. 

 

Mayo says it this way:

Each of Mayo Clinic's radiation oncologists specializes in treating just two to three types of cancer. At Mayo, even patients with rare cancers work with experts who are highly skilled at treating their condition. Patients should always choose a radiation oncologist based on the physician's experience with their specific condition.

 

If you want compassion, you can get that anywhere.  If you want expertise, you likely have to go to a major center and/or teaching hospital.


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 11/4/2010 10:53 AM (GMT -6)   
Alf:
 
I wonder if the reasoning involves the different machinery?
For example, suppose my local hospital and Ann Arbor (AA) has the exact same equipment.
 
I go to AA for the planning. I assume they focus their machine on me and make certain calculations.
 
If I then have it all done locally, even though it's the same machine, might there be some minute calibration differences (and precision is essential).
 
Also, if the machines are not quite the same, couldn't there be a bigger problem.
 
Casey -- you hit on a concern of mine. I really like my local radiation expert. But I guess he is a jack of all trades. But he has practiced here for probably 25 years. Let's assume he is very smart and competent. I would HOPE that in that time he has done plenty of SRT with PC patients. It's a tough call. I know our equipment is the latest and greatest. That is very important as it is supposed to have fewer side effects. But if I go to AA I probably get a more specialized radiologist (actually, I'm not even sure of that!). But I would have to drive there each day (2 hours each way). That would get old in 3 days. I can imagine in 4 weeks when I am in pain from radiation burns or rectal bleeding or whatever other juicy radiation problems I develop, such as extreme fatigue.  I could, however, rent a place for that time period and come home on weekends. Still, that would be very difficult.
 
Given that we appear to have a very good local radiologist and the best equipment -- this is THE major medical center for mid-Michigan - my probable decision will be to stay local. For me, local is a 10-minute trip each way.
 
Mel

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 11/4/2010 11:01 AM (GMT -6)   

Mel, I forgot to add the general caveat which I often include...but you and most people who understand statistics already knew:

There are exceptions to every rule.



compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 11/4/2010 11:10 AM (GMT -6)   
Casey:
 
I'm not sure if my situation is an exception to your rule.
 
If I knew that the AA radiologist just did PC (certainly I could find that out) and if I was less impressed with the local yokel, maybe I would be thinking differently!
 
Mel

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 11/4/2010 11:47 AM (GMT -6)   
mel, it would be a miracle if you found a rad oncologist that only did PC , I think that's asking a bit too much. Again, you need to understand, its the operators that are delivering the "plan". you have no guarantee on the calibration on anyone's hardware, and there's no way you are going to know that. i was on top notch gear, with a nationally known center, and still they had endless alignment problems when i went through srt. you can't worry to death over all the details that you either will have no knowledge about or control over. having it done 2 hours away would get old the first week, and do you really want to be seperated from home all week. i see you mentioned all the worse side effects in one post, fortunately for most men, they do not have to deal with most or all of that. what happened to me was extremely rare at best, not to be used as a norm.

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4157
   Posted 11/4/2010 12:33 PM (GMT -6)   
Kark, I will first qualify my comments by saying they are not based on personal experience and/or extensive researh but intuition and opinion only.  Having said that I must say that my opinion is that Casey makes excellent points and I believe his analysis is correct.  I just know that if I was dealing with a failed primary treatment and was looking at my last chance to defeat a local BCR I would want to take my best shot at finding excellence and would not let a little inconvenience stand in the way.
 
JMHO.
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643
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