Monday, December 4, 2017

Questions to ask on a first visit for primary radiation therapy (IGRT/IMRT)

IGRT/IMRT Questions for Doctors
  1. How many have you planned? 
  2. How has your practice of IMRT changed over the years? 
  3. What is your 5-yr freedom from recurrence rate for patients at my risk level? 
  4. What proportion of your recurrences were local? (see this link) 
  5. What kind of urinary and rectal reactions can I expect? 
    • How long can I expect them to last? 
    • What medications or interventions do you typically give for that? 
    • Should I expect those symptoms to recur later? 
  6. What is your rate of serious (Grade 3) adverse events? 
  7. Do you see urinary strictures? 
  8. Urinary retention requiring catheterization? Fistulas? 
  9. Rectal bleeding requiring argon plasma or other interventions? 
  10. What is the margin you will treat around the prostate? 
    • Is it less on the rectal side? 
  11. Will you include the pelvic lymph nodes? 
  12. What about the seminal vesicles -proximal or entire? 
  13. What are the prescribed doses to the planned target volumes? 
  14. If applicable, in light of my unfavorable risk cancer: 
    • do you think I need a brachytherapy boost to the prostate? (see this link
    • do you think I need hormone therapy? For what duration?
  15. In light of the 8 major randomized clinical trials on hypofractionation reported in the last year (see this link), do you recommend hypofractionation (fewer treatments) for me? 
  16. Does your hospital do SBRT monotherapy for patients like me? Why not? 
  17. Do you work off a fused MRI/CT scan for the plan? 
  18. What machine do you use? (any brand of VMAT or Tomotherapy are good) 
  19. Do you use fiducials or Calypso transponders? 
    • Do you do transperineal placement of them? 
  20. What system do you use for inter-fractional tracking? (cone beam CT or stereoscopic X-ray, probably) 
  21. Is the alignment automated? 
  22. In my treatment plan, what do you identify as “organs at risk” and what dose constraints do you put on them? 
    • What dose will my penile bulb receive? 
  23. Do you use angiography to locate and spare the pudendal artery? (see this link
  24. How long does each treatment take? 
  25. How will I be immobilized during each treatment? 
  26. Are there any bowel prep or dietary requirements? 
  27. Should I avoid taking antioxidant supplements during treatment? 
  28. In your practice, among men who were fully potent, what percent remained fully potent 3-5 years later? 
  29. Have any men retained some ability to produce semen? 
  30. What is your opinion of taking Viagra preventatively? (see this link) 
  31. Do you monitor side effects with the EPIC questionnaire? 
  32. In your practice, what percent of men experience acute urinary side effects? 
  33. In your practice, what percent of men experience acute rectal side effects? 
  34. In your practice, what percent of men experience late term urinary side effects? 
  35. In your practice, what percent of men experience late term rectal side effects? 
  36. What kind of PSA pattern should I expect following treatment? 
  37. What is the median PSA nadir you are seeing in your practice, and how long does it take to reach that, on the average?
  38. If there should be a biochemical (PSA) recurrence, what would the next steps be? (they have to prove it’s local but not distant) 
  39. Have you ever used SBRT, brachy, or cryo for salvage after a local IMRT failure, and was that focal or whole gland? 
  40. Are you open to email communications between us?

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