Pelvic IMRT and Vaginal Dilators

[TheWallnerus]

Many women with anal cancer are quite elderly. My partner believes in dilators and I can tell you that is very tough on the patients at the end of treatment. I usually just give them dilators after they are finished. Same is true for rectal dilators while treating vaginal cancer.

I wonder if the rate of enforcing vaginal dilator insertion during anal ca treatment differs between male and female rad onc attendings. Honest question. (I have seen some female urologists dish out aggressive prostate DREs.) But I say again, this is an intervention begging for a well done randomized trial because I see pluses and minuses.

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[RickyScott]

While on the topic of anal cancer setup, i am not sure frog legging the patient would make much of a difference with imrt when a lot of the fluence is not coming from the ap. I generally don’t frog leg much, but make sure ptv is trimmed from 5 mm from skin and pay attention to dose fall off towards genitals.

 

[thecarbonionangle]

Interesting that some people treat IMRT anus prone. That seems like a less reproducible set up.

 

[TheWallnerus]

 

[elementaryschooleconomics]

Interesting that some people treat IMRT anus prone. That seems like a less reproducible set up.

Not if your PTV margin is 2cm

 

[elementaryschooleconomics]

"Ripping"?????

I'm pro-dilator and I think the "anti"-dilator responses in this thread had reasonable points.

...it got its own thread (broken off from the Twitter thread) so it could be discussed more thoroughly.

Does there need to be a banner at the top of this website that this is not an academic journal and informal conversation styles are used here?

Does SDN need a Zotero plugin and an Editor-in-Chief?

 

[TheWallnerus]

Interesting that some people treat IMRT anus prone. That seems like a less reproducible set up.

I recently had an anal ca patient (female) w/ extensive anal margin disease and extra-anal component; T-big/N-zero. I was worried repro would be harder daily w/out prone sim/setup. Used a hybrid electron/IMRT plan. I used the electrons, a high energy extended SSD 15MeV beam to INCREASE perianal skin dose (did not use bolus which I find to fidgety and non-repro in these settings), and higher electron energies have higher RBEs too, and let the IMRT "fill in the gaps" by using the e-plan as a base dose plan for the optimizer. The e field (which looks odd and non-covering, but again is there just to hit the superficial stuff very well pre-IMRT optimization):

Final plan, which was 36 Gy/20 fx to tumor and all ENI regions followed by 21.2 Gy/12 fx boost to gross disease/anal canal (57.6 Gy/32 fx). The Dmax of ~72 Gy is electron algorithm calc artefact; the volume of tissue >65 Gy is <5cc. Most of the gross tumor got ~59 Gy.

This was one of the first anal cases I tried prone. Was happy w/ the daily CBCTs, and the pt tolerated daily tx well. Had a great response, no tx breaks, but only finished tx 2 months ago.

 

[deleted1111261]

I do probe too

 

[TheWallnerus]

 

[elementaryschooleconomics]

1) Yikes

2) Exhibit A re: where my concerns about dilators and the RadOnc Department workflow are centered

 

[jondunn]

Not if your PTV margin is 2cm

you dont wanna miss

 

[elementaryschooleconomics]

I recently had an anal ca patient (female) w/ extensive anal margin disease and extra-anal component; T-big/N-zero. I was worried repro would be harder daily w/out prone sim/setup. Used a hybrid electron/IMRT plan. I used the electrons, a high energy extended SSD 15MeV beam to INCREASE perianal skin dose (did not use bolus which I find to fidgety and non-repro in these settings), and higher electron energies have higher RBEs too, and let the IMRT "fill in the gaps" by using the e-plan as a base dose plan for the optimizer. The e field (which looks odd and non-covering, but again is there just to hit the superficial stuff very well pre-IMRT optimization):

Final plan, which was 36 Gy/20 fx to tumor and all ENI regions followed by 21.2 Gy/12 fx boost to gross disease/anal canal (57.6 Gy/32 fx). The Dmax of ~72 Gy is electron algorithm calc artefact; the volume of tissue >65 Gy is <5cc. Most of the gross tumor got ~59 Gy.

This was one of the first anal cases I tried prone. Was happy w/ the daily CBCTs, and the pt tolerated daily tx well. Had a great response, no tx breaks, but only finished tx 2 months ago.

I've done this as well (IMRT/electrons), with a sequential electron boost done in a different position (IMRT supine, electron prone).

Electrons: the original ion therapy.

 

[Palex80]

Electrons: the original ion therapy.

There is only one TRUE BEAM.

Therac-25 - Wikipedia

en.wikipedia.org

 

[SneakyBooger]

"Music Man Stan, you're not crazy, I too was also taught about the benefits of a vaginal cylinder in residency and I too use it after graduating! I support you in my quest to reduce vaginal dryness!"

Alas I stand alone.

I use it in all anal ca pts.

 

[pikachu]

I do probe too

ahem

 

[ramsesthenice]

Therapists insert while prone. For anal patients who are overweight I treat supine frog legged (with bubble wrap in skin folds) and therapists also insert.

Also all of my female pelvic RT patients get dilator teaching at their 4 week follow-up.



I really thought somebody would come to my rescue and say "Music Man Stan, you're not crazy, I too was also taught about the benefits of a vaginal cylinder in residency and I too use it after graduating! I support you in my quest to reduce vaginal dryness!"

Alas I stand alone.

Im not going to come to your rescue but I am going to say very clearly, Music Man Stan, you are not crazy. Conceptually, nothing you are considering is wrong. Its just a matter ROI. Your practice is pretty intensive with a relatively unproven benefit. To your credit, I think female sexual health for non-Gyn malignancies is way overlooked and I am very glad to see you thinking so much about it.

Here are my thoughts on the issue:

1) I give every female patient after pelvic RT for Gyn, Anal, Rectal, or bladder RT a dilator and instruct them to use twice per week (if not having regular intercourse) AFTER any acute effects have worn off. Stenosis (aka fibrosis) is a late effect and there is absolutely no rush to start this.

2) Prepare women for the fact they are likely to experience vaginal dryness. This is a low dose phenomenon and not something I think using a dilator during RT is going to help in any significant way. Lubricants will be their friend in the future.

3) Always remember that premenopausal women are probably going to experience ovarian failure somewhere between 6-12 months after you are done. This should be mentioned before starting treatment and reminded at the end. I really only consider transposition for rectal cancers. Since you cover internal iliacs for essentially all other pelvic diseases, you are hard pressed to sufficiently spare a transposed ovary (at least one in the pelvis which is all our folks do) even with IMRT. And before thinking about even recommending a transposition, think about the kind of chemo they are getting. If they will be getting 8 cycles of FOLFOXIRI...that ship has sailed.

4) There is probably no real reason to send everyone for post-treatment pelvic floor PT. Its a great resource that enough people don't utilize enough, but again the ROI if sending everyone is probably not that high.

Last and most important...
5) F***ing ask them how their sexual function is during follow up. Unless they are really savvy, it will not cross the mind of a surgical oncologist, med onc, FP, or anyone other than you or (if they have one) a gyn onc. Sexual dysfunction after cancer therapy is normal and usually treatable. The biggest barrier most of the time is just getting someone to recognize it.

 

[TheWallnerus]

Prepare women for the fact they are likely to experience vaginal dryness. This is a low dose phenomenon and not something I think using a dilator during RT is going to help in any significant way.

That's what I thought at first too.

Always remember that premenopausal women are probably going to experience ovarian failure somewhere between 6-12 months after you are done.

100% of women not on HRT in a postmenopausal state are going to complain of vaginal dryness (and pain w/ intercourse etc).

 

[ramsesthenice]

100% of women not on HRT in a postmenopausal state are going to complain of vaginal dryness (and pain w/ intercourse etc).

Im referring to the whole gambit of symptoms. Fatigue, weight gain, etc. Its not really a mystery why this constellation of symptoms comes about. But the FP is probably going to look at the wrong hypothalamic axis if/when they see this.

 

[elementaryschooleconomics]

Im not going to come to your rescue but I am going to say very clearly, Music Man Stan, you are not crazy. Conceptually, nothing you are considering is wrong. Its just a matter ROI. Your practice is pretty intensive with a relatively unproven benefit. To your credit, I think female sexual health for non-Gyn malignancies is way overlooked and I am very glad to see you thinking so much about it.

Here are my thoughts on the issue:

1) I give every female patient after pelvic RT for Gyn, Anal, Rectal, or bladder RT a dilator and instruct them to use twice per week (if not having regular intercourse) AFTER any acute effects have worn off. Stenosis (aka fibrosis) is a late effect and there is absolutely no rush to start this.

2) Prepare women for the fact they are likely to experience vaginal dryness. This is a low dose phenomenon and not something I think using a dilator during RT is going to help in any significant way. Lubricants will be their friend in the future.

3) Always remember that premenopausal women are probably going to experience ovarian failure somewhere between 6-12 months after you are done. This should be mentioned before starting treatment and reminded at the end. I really only consider transposition for rectal cancers. Since you cover internal iliacs for essentially all other pelvic diseases, you are hard pressed to sufficiently spare a transposed ovary (at least one in the pelvis which is all our folks do) even with IMRT. And before thinking about even recommending a transposition, think about the kind of chemo they are getting. If they will be getting 8 cycles of FOLFOXIRI...that ship has sailed.

4) There is probably no real reason to send everyone for post-treatment pelvic floor PT. Its a great resource that enough people don't utilize enough, but again the ROI if sending everyone is probably not that high.

Last and most important...
5) F***ing ask them how their sexual function is during follow up. Unless they are really savvy, it will not cross the mind of a surgical oncologist, med onc, FP, or anyone other than you or (if they have one) a gyn onc. Sexual dysfunction after cancer therapy is normal and usually treatable. The biggest barrier most of the time is just getting someone to recognize it.

Something I learned recently:

6) Tell your patients the dilator is not single-use/disposable.

Scene: 3 month follow-up, RN telling me patient is ready -

Me: "Is she using the dilator?"
RN: "Um, she did, once."
Me: "Ah, what happened?"
RN: "She threw it away."
Me: "What?"
RN: "She thought it was disposable."
Me: "..."
RN: "..."
Me: "Can we give her another one?"
RN: "Already did."
Me: "Neat."

 

[ramsesthenice]

Something I learned recently:

6) Tell your patients the dilator is not single-use/disposable.

Scene: 3 month follow-up, RN telling me patient is ready -

Me: "Is she using the dilator?"
RN: "Um, she did, once."
Me: "Ah, what happened?"
RN: "She threw it away."
Me: "What?"
RN: "She thought it was disposable."
Me: "..."
RN: "..."
Me: "Can we give her another one?"
RN: "Already did."
Me: "Neat."

One of my more memorable conversations in the last 2 years.

Me: "Is she using the dilator?"
RN" "No, she needs another one."
Me: "Why, did she lose it?"
RN: "No, her grand daughter took it."
Me: "..."

 

[thecarbonionangle]

One of my more memorable conversations in the last 2 years.

Me: "Is she using the dilator?"
RN" "No, she needs another one."
Me: "Why, did she lose it?"
RN: "No, her grand daughter took it."
Me: "..."

Ive also heard from someone that they were told “husband threw it away”

 

[deleted1111261]

 

[evilbooyaa]

If it improved outcomes, would you recommend it?

People that treat GI tend to do it. You don’t get paid extra, it’s an irritation for the patient and it’s .. weird. I’d have a hard time believing GI specialists would do it if it didn’t help.

So, I think the believers see that it works. It seems most people that don’t do it haven’t tried it - unless I missed someone that had experience with it and stopped doing it.

Some of the people that do GI in academic centers seem to do it. Is there data that suggests it improves outcomes compared to using a vaginal dilator at conclusion of RT?

I have seen n=2 of patients who have increased pain from insertion of the cylinder during week 5 of radiation requiring narcotics for that (not the rectal or anal discomfort) because it's rubbing against a sunburned vagina while covering colleagues' patients. I do not know what the denominator is but it's low. Doing something without proven benefit which can cause pain severe enough to require narcotics (a Gr 2 toxicity) is not meaningless to me.

Therapists insert while prone. For anal patients who are overweight I treat supine frog legged (with bubble wrap in skin folds) and therapists also insert.

I really thought somebody would come to my rescue and say "Music Man Stan, you're not crazy, I too was also taught about the benefits of a vaginal cylinder in residency and I too use it after graduating! I support you in my quest to reduce vaginal dryness!"

Alas I stand alone.

I suppose the bolded comes down to ESE's point... you have therapists you trust to insert a cylinder while maintaining patient comfort in the prone position? I've never placed a cylinder in a prone patient.

I would be happy to read data suggesting the clinical benefit of this. All the data I have seen is on vaginal stenosis which, when compared to NOT giving a patient dilator ever... yeah I get.

 

[evilbooyaa]

My colleagues who treat gyn and anal all send patients for pelvic floor therapy by the first follow up. You are not alone

Prophylactically? Or because the patients all have symptoms requiring pelvic floor therapy?

Interesting that some people treat IMRT anus prone. That seems like a less reproducible set up.

Depends, as usual, on your immobilization and therapists. I did not train with it but I have seen very good reproducibility in my practice as an attending. But, sometimes patients cant tolerate prone. I don't frogleg my anus cancers routinely, but I do aggressively spare external genitalia and mons pubis...

 

[Music Man Stan]

Some of the people that do GI in academic centers seem to do it. Is there data that suggests it improves outcomes compared to using a vaginal dilator at conclusion of RT?

I have seen n=2 of patients who have increased pain from insertion of the cylinder during week 5 of radiation requiring narcotics for that (not the rectal or anal discomfort) because it's rubbing against a sunburned vagina while covering colleagues' patients. I do not know what the denominator is but it's low. Doing something without proven benefit which can cause pain severe enough to require narcotics (a Gr 2 toxicity) is not meaningless to me.



I suppose the bolded comes down to ESE's point... you have therapists you trust to insert a cylinder while maintaining patient comfort in the prone position? I've never placed a cylinder in a prone patient.

I would be happy to read data suggesting the clinical benefit of this. All the data I have seen is on vaginal stenosis which, when compared to NOT giving a patient dilator ever... yeah I get.

I'm a really simple guy so here's my logic:

1) My goal is 0% vaginal stenosis
2) Vaginal stenosis after radiation is dose dependent: Clinical and treatment factors associated with vaginal stenosis after definitive chemoradiation for anal canal cancer - PubMed
3) Putting a big dilator into a vagina is more reproducible than most people think (Reproducibility and genital sparing with a vaginal dilator used for female anal cancer patients - PubMed) and spares the anterior wall of the vagina from the full prescription dose which normally would have covered the entire vagina. Here's the DVH of that case that I posted earlier and keep in mind that I'm taking gross tumor (sup-inf extent cm on MRI was 7cm extending almost the entire length of the vagina) to 56Gy so if you're only going to 50.4Gy (or your tumor is way smaller), your DVH will look even better. Mean dose to the vagina is 29Gy and if I didn't have this 3.5cm dilator in place, the entire vagina would be in my high dose PTV and thus mean vagina dose would be >50Gy.
4) I still recommend the post radiotherapy vaginal dilators to get that stenosis probability as low as possible
5) Profit?

 

[Palex80]

Ive also heard from someone that they were told “husband threw it away”

I've had a patient tell me that she though the biggest size was too small. She was a brothel manager (treated for vulvar cancer).

 

[deleted1111261]

I'm a really simple guy so here's my logic:

1) My goal is 0% vaginal stenosis
2) Vaginal stenosis after radiation is dose dependent: Clinical and treatment factors associated with vaginal stenosis after definitive chemoradiation for anal canal cancer - PubMed
3) Putting a big dilator into a vagina is more reproducible than most people think (Reproducibility and genital sparing with a vaginal dilator used for female anal cancer patients - PubMed) and spares the anterior wall of the vagina from the full prescription dose which normally would have covered the entire vagina. Here's the DVH of that case that I posted earlier and keep in mind that I'm taking gross tumor (sup-inf extent cm on MRI was 7cm extending almost the entire length of the vagina) to 56Gy so if you're only going to 50.4Gy (or your tumor is way smaller), your DVH will look even better. Mean dose to the vagina is 29Gy and if I didn't have this 3.5cm dilator in place, the entire vagina would be in my high dose PTV and thus mean vagina dose would be >50Gy.
4) I still recommend the post radiotherapy vaginal dilators to get that stenosis probability as low as possible
5) Profit?

Strong logic compared to “it seems weird and uncomfortable” 😊

 

[RickyScott]

Im not going to come to your rescue but I am going to say very clearly, Music Man Stan, you are not crazy. Conceptually, nothing you are considering is wrong. Its just a matter ROI. Your practice is pretty intensive with a relatively unproven benefit. To your credit, I think female sexual health for non-Gyn malignancies is way overlooked and I am very glad to see you thinking so much about it.

Here are my thoughts on the issue:

1) I give every female patient after pelvic RT for Gyn, Anal, Rectal, or bladder RT a dilator and instruct them to use twice per week (if not having regular intercourse) AFTER any acute effects have worn off. Stenosis (aka fibrosis) is a late effect and there is absolutely no rush to start this.

2) Prepare women for the fact they are likely to experience vaginal dryness. This is a low dose phenomenon and not something I think using a dilator during RT is going to help in any significant way. Lubricants will be their friend in the future.

3) Always remember that premenopausal women are probably going to experience ovarian failure somewhere between 6-12 months after you are done. This should be mentioned before starting treatment and reminded at the end. I really only consider transposition for rectal cancers. Since you cover internal iliacs for essentially all other pelvic diseases, you are hard pressed to sufficiently spare a transposed ovary (at least one in the pelvis which is all our folks do) even with IMRT. And before thinking about even recommending a transposition, think about the kind of chemo they are getting. If they will be getting 8 cycles of FOLFOXIRI...that ship has sailed.

4) There is probably no real reason to send everyone for post-treatment pelvic floor PT. Its a great resource that enough people don't utilize enough, but again the ROI if sending everyone is probably not that high.

Last and most important...
5) F***ing ask them how their sexual function is during follow up. Unless they are really savvy, it will not cross the mind of a surgical oncologist, med onc, FP, or anyone other than you or (if they have one) a gyn onc. Sexual dysfunction after cancer therapy is normal and usually treatable. The biggest barrier most of the time is just getting someone to recognize it.

I've had a patient tell me that she though the biggest size was too small. She was a brothel manager (treated for vulvar cancer).

I had a resident steal the entire supply.

 

[thecarbonionangle]

I've had a patient tell me that she though the biggest size was too small. She was a brothel manager (treated for vulvar cancer).

Is the biggest size 3.5? Clearly there is business opportunity for 4+

 

[TheWallnerus]

Is the biggest size 3.5? Clearly there is business opportunity for 4+

a 3cm diameter dilator is right at 50%ile penis girth in US. Not that I have Googled this data or anything.

 

[evilbooyaa]

I'm a really simple guy so here's my logic:

1) My goal is 0% vaginal stenosis
2) Vaginal stenosis after radiation is dose dependent: Clinical and treatment factors associated with vaginal stenosis after definitive chemoradiation for anal canal cancer - PubMed
3) Putting a big dilator into a vagina is more reproducible than most people think (Reproducibility and genital sparing with a vaginal dilator used for female anal cancer patients - PubMed) and spares the anterior wall of the vagina from the full prescription dose which normally would have covered the entire vagina. Here's the DVH of that case that I posted earlier and keep in mind that I'm taking gross tumor (sup-inf extent cm on MRI was 7cm extending almost the entire length of the vagina) to 56Gy so if you're only going to 50.4Gy (or your tumor is way smaller), your DVH will look even better. Mean dose to the vagina is 29Gy and if I didn't have this 3.5cm dilator in place, the entire vagina would be in my high dose PTV and thus mean vagina dose would be >50Gy.
4) I still recommend the post radiotherapy vaginal dilators to get that stenosis probability as low as possible
5) Profit?

Hat tip for the bolded.

Couple of Qs:
Only 28 out of the 70 patients in that first trial reported using a dilator (since 16 of 28 had pain with it). Do we think stenosis was such a problem because usage of them was so bad (and is that driven by the patient, the physicians, or a mix?)

Just looked at my most recent (only) anal case as an attending, which was big bulky anal canal with extension along posterior anal margin - vagina is not getting 54Gy circumferentially across vagina vast majority of the vaginal length. In fairness, there is about 20-33% that is getting circumferential dose that could be spared with a daily cylinder.

But then, I remember how severe the patient's skin reaction and pain was in the perianal skin during treatment. Do I really think she would've tolerated a daily cylinder placement when she was on Oxycodone 4-6x/day simply for the pain in the perianal/perineum region? I would worry about tolerability of the distal vagina introitus to deal with both sunburn feel and then rubbing of a vaginal dilator daily in addition.

Maybe she would've been fine with it. Maybe... but your workflow of having therapists insert is likely a non-starter in most places.

I'd encourage you to write up your series and show a benefit compared to uniform recommendations from physicians to use a dilator post-treatment and determine if there is a significant clinical benefit of adding in dilators during treatment, compared to dilator post-treatment alone. Perhaps I'm coming around, but all of this seems quite invasive for an unproven clinical benefit. Same thing as daily rectal balloon for prostate cancer.

Is there a CPT code involved with daily insertion of the cylinder?

 

[deleted1111261]

Hat tip for the bolded.

Couple of Qs:
Only 28 out of the 70 patients in that first trial reported using a dilator (since 16 of 28 had pain with it). Do we think stenosis was such a problem because usage of them was so bad (and is that driven by the patient, the physicians, or a mix?)

Just looked at my most recent (only) anal case as an attending, which was big bulky anal canal with extension along posterior anal margin - vagina is not getting 54Gy circumferentially across vagina vast majority of the vaginal length. In fairness, there is about 20-33% that is getting circumferential dose that could be spared with a daily cylinder.

But then, I remember how severe the patient's skin reaction and pain was in the perianal skin during treatment. Do I really think she would've tolerated a daily cylinder placement when she was on Oxycodone 4-6x/day simply for the pain in the perianal/perineum region? I would worry about tolerability of the distal vagina introitus to deal with both sunburn feel and then rubbing of a vaginal dilator daily in addition.

Maybe she would've been fine with it. Maybe... but your workflow of having therapists insert is likely a non-starter in most places.

I'd encourage you to write up your series and show a benefit compared to uniform recommendations from physicians to use a dilator post-treatment and determine if there is a significant clinical benefit of adding in dilators during treatment, compared to dilator post-treatment alone. Perhaps I'm coming around, but all of this seems quite invasive for an unproven clinical benefit. Same thing as daily rectal balloon for prostate cancer.

Is there a CPT code involved with daily insertion of the cylinder?

Very strong points, Evil!
The pain sounds really brutal, too.

 

[TheWallnerus]

Hat tip for the bolded.

Couple of Qs:
Only 28 out of the 70 patients in that first trial reported using a dilator (since 16 of 28 had pain with it). Do we think stenosis was such a problem because usage of them was so bad (and is that driven by the patient, the physicians, or a mix?)

Just looked at my most recent (only) anal case as an attending, which was big bulky anal canal with extension along posterior anal margin - vagina is not getting 54Gy circumferentially across vagina vast majority of the vaginal length. In fairness, there is about 20-33% that is getting circumferential dose that could be spared with a daily cylinder.

But then, I remember how severe the patient's skin reaction and pain was in the perianal skin during treatment. Do I really think she would've tolerated a daily cylinder placement when she was on Oxycodone 4-6x/day simply for the pain in the perianal/perineum region? I would worry about tolerability of the distal vagina introitus to deal with both sunburn feel and then rubbing of a vaginal dilator daily in addition.

Maybe she would've been fine with it. Maybe... but your workflow of having therapists insert is likely a non-starter in most places.

I'd encourage you to write up your series and show a benefit compared to uniform recommendations from physicians to use a dilator post-treatment and determine if there is a significant clinical benefit of adding in dilators during treatment, compared to dilator post-treatment alone. Perhaps I'm coming around, but all of this seems quite invasive for an unproven clinical benefit. Same thing as daily rectal balloon for prostate cancer.

Is there a CPT code involved with daily insertion of the cylinder?

No CPT code for daily cylinder (any more than there is for daily bolus eg). So we can’t criticize for that!

 

[elementaryschooleconomics]

Hat tip for the bolded.

Couple of Qs:
Only 28 out of the 70 patients in that first trial reported using a dilator (since 16 of 28 had pain with it). Do we think stenosis was such a problem because usage of them was so bad (and is that driven by the patient, the physicians, or a mix?)

Just looked at my most recent (only) anal case as an attending, which was big bulky anal canal with extension along posterior anal margin - vagina is not getting 54Gy circumferentially across vagina vast majority of the vaginal length. In fairness, there is about 20-33% that is getting circumferential dose that could be spared with a daily cylinder.

But then, I remember how severe the patient's skin reaction and pain was in the perianal skin during treatment. Do I really think she would've tolerated a daily cylinder placement when she was on Oxycodone 4-6x/day simply for the pain in the perianal/perineum region? I would worry about tolerability of the distal vagina introitus to deal with both sunburn feel and then rubbing of a vaginal dilator daily in addition.

Maybe she would've been fine with it. Maybe... but your workflow of having therapists insert is likely a non-starter in most places.

I'd encourage you to write up your series and show a benefit compared to uniform recommendations from physicians to use a dilator post-treatment and determine if there is a significant clinical benefit of adding in dilators during treatment, compared to dilator post-treatment alone. Perhaps I'm coming around, but all of this seems quite invasive for an unproven clinical benefit. Same thing as daily rectal balloon for prostate cancer.

Is there a CPT code involved with daily insertion of the cylinder?

What I do for my anal cases is draw a "Genitalia" avoidance structure and ask Dosi to reduce dose to that area (I also draw a "Gluteal Cleft" structure and auto-segment "Bones" to represent bone marrow, all with vague requests to "reduce dose", I'm super popular). Obviously, being able to reduce dose to the area is dependent on the nature of the case ("easy" with a T2N0, never going to happen with T3N1).

I would love to see a trial with:

1) An arm using a dilator on-treatment
2) An arm using dilator post-treatment and avoidance structures
3) An arm using dilator post-treatment and "regular" consensus structures

Re: positioning and therapists. For my theoretical trial, in addition to daily CBCT, you could also get triggered images every 90 degrees or so (if using VMAT) and/or surface imaging (if your system allows for imaging during treatment) to check infra-fraction motion (hypothesis being initial setup is more difficult and a prone patient with a dilator inserted causing pain will have worse immobilization as treatment progresses).

Actually, I'd also throw the BeamSite in this trial for fun as well.

This trial is never happening, of course. But I come to the internet to dream.

 

[Krukenberg]

What I do for my anal cases is draw a "Genitalia" avoidance structure and ask Dosi to reduce dose to that area (I also draw a "Gluteal Cleft" structure and auto-segment "Bones" to represent bone marrow, all with vague requests to "reduce dose", I'm super popular). Obviously, being able to reduce dose to the area is dependent on the nature of the case ("easy" with a T2N0, never going to happen with T3N1).

I would love to see a trial with:

1) An arm using a dilator on-treatment
2) An arm using dilator post-treatment and avoidance structures
3) An arm using dilator post-treatment and "regular" consensus structures

Re: positioning and therapists. For my theoretical trial, in addition to daily CBCT, you could also get triggered images every 90 degrees or so (if using VMAT) and/or surface imaging (if your system allows for imaging during treatment) to check infra-fraction motion (hypothesis being initial setup is more difficult and a prone patient with a dilator inserted causing pain will have worse immobilization as treatment progresses).

Actually, I'd also throw the BeamSite in this trial for fun as well.

This trial is never happening, of course. But I come to the internet to dream.

Getting off topic, but is anyone using BeamSite? I’ve gotta say, there is something to the saying “ignorance is bliss”. Not sure I want that level of detail

 

[RickyScott]

What I do for my anal cases is draw a "Genitalia" avoidance structure and ask Dosi to reduce dose to that area (I also draw a "Gluteal Cleft" structure and auto-segment "Bones" to represent bone marrow, all with vague requests to "reduce dose", I'm super popular). Obviously, being able to reduce dose to the area is dependent on the nature of the case ("easy" with a T2N0, never going to happen with T3N1).

I would love to see a trial with:

1) An arm using a dilator on-treatment
2) An arm using dilator post-treatment and avoidance structures
3) An arm using dilator post-treatment and "regular" consensus structures

Re: positioning and therapists. For my theoretical trial, in addition to daily CBCT, you could also get triggered images every 90 degrees or so (if using VMAT) and/or surface imaging (if your system allows for imaging during treatment) to check infra-fraction motion (hypothesis being initial setup is more difficult and a prone patient with a dilator inserted causing pain will have worse immobilization as treatment progresses).

Actually, I'd also throw the BeamSite in this trial for fun as well.

This trial is never happening, of course. But I come to the internet to dream.

I don’t draw bone marrow because I want the dose pushed outward. It needs to have somewhere to go

 

[elementaryschooleconomics]

I don’t draw bone marrow because I want the dose pushed outward. It needs to have somewhere to go

Generally agree - I sometimes draw things and ask Dosi to do what they can. If it's not going to work, it's not going to work. But I won't know if I don't try.

(For the record - I'm generally against bone marrow as an OAR for exactly your reason)

 

[deleted1116990]

I'll add another vote here for using dilators. Totally ridiculous for someone on Twitter to lie and say everyone is anti-dilator here. This is obviously a discussion with differing opinions, which is a good thing (as opposed to the moral/social posturing and outrage addiction that fuels every twitter post). I only use them for anal cancer treatment, though. I find I can spare the vulva just fine without them in rectal. I was not trained to do this, but Chris Crane's arguments are compelling, and I generally respect the hell out of him and the way he approaches GI cases.

Also, with respect to a few comments about burdening your staff. When did we become such wimps (I've another less PC word I'd like to use here)? You're the doctor. If you want to use a dilator, you use a dilator. If you want to want to treat prone, you treat prone. If you want to do IV contrast on all your pelvic sims, you do it. If you want to put fiducials and spaceOAR in prostate and have the therapists verify and shift with conebeam anyway, then you do it, etc. It should not be a discussion.

You are the doctor. Other specialties do not have this problem, yet for some reason it plagues rad onc. Once you start letting RTT, dosi, department manager etc pushback and get away with telling you NO and affecting your clinical decision making, you have lost. There should not be a discussion. There is nuance to it, for sure, but at the end of the day there is a chain of command that needs to be respected if you want to have a functional clinic and not be walked all over.

 

[elementaryschooleconomics]

Also, with respect to a few comments about burdening your staff. When did we become such wimps (I've another less PC word I'd like to use here)? You're the doctor. If you want to use a dilator, you use a dilator. If you want to want to treat prone, you treat prone. If you want to do IV contrast on all your pelvic sims, you do it. If you want to put fiducials and spaceOAR in prostate and have the therapists verify and shift with conebeam anyway, then you do it, etc. It should not be a discussion.

This could be an entire thread and I could write several dissertations about this.

While what you're saying is logical, people are not logical. People are messy, with egos and pride and opinions. Environments and culture further complicate the issue.

In my current department, perhaps 50% of the therapists have been doing the job for 15-25 years. They were born locally, trained locally, and haven't worked anywhere else. They've generally worked with the same few doctors in that time and have learned the practice patterns of those doctors. The way they think about the job, the way they do the job - it's carved into their soul.

I can absolutely promise you - if you ask (order) something to be done in that environment, there will be pushback. Even if it's something very small. After all - they haven't done it like this before, they have "almost 30 years of experience, don't you think [they] would have seen this???"

So then it's a tactical decision of which hill to die on. If everything else in your practice is operating at peak efficiency, then sure, doing the dilator is a good hill. However, if there are multiple other issues floating around - dilators while on treatment becomes an item for the future.

 

[TheWallnerus]

Also, with respect to a few comments about burdening your staff. When did we become such wimps (I've another less PC word I'd like to use here)? You're the doctor. If you want to use a dilator, you use a dilator.

Of course I agree. But... "Everyone has a plan until they get punched in the mouth."

 

[deleted1116990]

In my current department, perhaps 50% of the therapists have been doing the job for 15-25 years. They were born locally, trained locally, and haven't worked anywhere else. They've generally worked with the same few doctors in that time and have learned the practice patterns of those doctors. The way they think about the job, the way they do the job - it's carved into their soul.

I can absolutely promise you - if you ask (order) something to be done in that environment, there will be pushback. Even if it's something very small. After all - they haven't done it like this before, they have "almost 30 years of experience, don't you think [they] would have seen this???"

Trust me, I'm very aware of the "we've been doing it this way because that's how Dr. Boomer did prostates for 30 years, and that's the way WE treat patients here" mentality (oh and btw what a dear he was, that Dr. Boomer, what a great doctor he had that "feel" the new guys just don't have)

At the same time, if you think a patient should be treated with a vaginal dilator, and a therapist or a department manager is able to successfully talk you out of it because the therapists think it's icky (FWIW I have never had a patient or therapist complaint after showing them on the first patient -- it's simple, fast, and painless thing if done correctly and usually appreciated if the rationale of sparing the genitalia is explained to the patient) or might be 5 minutes late to their kids after school activities, then (1) either your clinical conviction for doing it in the first place wasn't strong enough to warrant doing it and you shouldn't be doing it or (2) you've let your clinical decision making be compromised by a non-clinician with non-clinical factors affecting your decision making.

The trick is standing your ground but doing it confidently and non-emotionally. There is where new grads can struggle. I certainly did and learned a lot of lessons the (very) hard way. It's almost like training a puppy. If you allow it to dump on the carpet, it's going to keep doing it. If you go through the painful (at first) motions of taking the dumb thing outside to the grass every 30 minutes eventually it will stop trying to dump on the carpet because its learned the rules. But you have to be nice to the puppy. After all, it's a dumb puppy and screaming at it for dumping on the carpet and getting in heated arguments with it about why the grass is better is actually counter-productive. Take it outside and say this is the way it's going to be and smile and wait, ignore the whining and blank stares, and give him a treat and a "good boy" when he finally gets it.

 

[elementaryschooleconomics]

Trust me, I'm very aware of the "we've been doing it this way because that's how Dr. Boomer did prostates for 30 years, and that's the way WE treat patients here" mentality (oh and btw what a dear he was, that Dr. Boomer, what a great doctor he had that "feel" the new guys just don't have)

At the same time, if you think a patient should be treated with a vaginal dilator, and a therapist or a department manager is able to successfully talk you out of it because the therapists think it's icky (FWIW I have never had a patient or therapist complaint after showing them on the first patient -- it's simple, fast, and painless thing if done correctly and usually appreciated if the rationale of sparing the genitalia is explained to the patient) or might be 5 minutes late to their kids after school activities, then (1) either your clinical conviction for doing it in the first place wasn't strong enough to warrant doing it and you shouldn't be doing it or (2) you've let your clinical decision making be compromised by a non-clinician with non-clinical factors affecting your decision making.

The trick is standing your ground but doing it confidently and non-emotionally. There is where new grads can struggle. I certainly did and learned a lot of lessons the (very) hard way. It's almost like training a puppy. If you allow it to dump on the carpet, it's going to keep doing it. If you go through the painful (at first) motions of taking the dumb thing outside to the grass every 30 minutes eventually it will stop trying to dump on the carpet because its learned the rules. But you have to be nice to the puppy. After all, it's a dumb puppy and screaming at it for dumping on the carpet and getting in heated arguments with it about why the grass is better is actually counter-productive. Take it outside and say this is the way it's going to be and smile and wait, ignore the whining and blank stares, and give him a treat and a "good boy" when he finally gets it.

Once my puppies learn to not quadruple book me, or tattoo the default laser position in the sim causing the setup to be off by 5cm at VSIM, or swap out the slant board for a chest board and hide it under a sheet, or remove the marks on a bolus placed by physics at the time of sim "because they don't make sense", or move an inpatient treatment from the end of the day to 9AM before the plan is even done "because there was an opening" (to go home early) -

then we'll work on dilators.

 

[elementaryschooleconomics]

Once my puppies learn to not quadruple book me, or tattoo the default laser position in the sim causing the setup to be off by 5cm at VSIM, or swap out the slant board for a chest board and hide it under a sheet, or remove the marks on a bolus placed by physics at the time of sim "because they don't make sense", or move an inpatient treatment from the end of the day to 9AM before the plan is even done "because there was an opening" (to go home early) -

then we'll work on dilators.

Or when the puppies routinely "adjust" the vacloks during the course of treatment for patient comfort, or when the Dosimetry puppies give breast treatment plans for review 2 hours before QA is scheduled with mean heart doses of 5-6Gy, or when the physics puppies do 15 chart checks in 11 minutes, or when -

the point is, things like dilators during treatment (as opposed to adjuvantly) can give benefit when everything upstream is functioning well. If it's not, then you're just throwing a cup of water on a house fire.

 

[temujim]

Or when the puppies routinely "adjust" the vacloks during the course of treatment for patient comfort, or when the Dosimetry puppies give breast treatment plans for review 2 hours before QA is scheduled with mean heart doses of 5-6Gy, or when the physics puppies do 15 chart checks in 11 minutes, or when -

the point is, things like dilators during treatment (as opposed to adjuvantly) can give benefit when everything upstream is functioning well. If it's not, then you're just throwing a cup of water on a house fire.

I can't tell you how often I've seen the tail wag the dog. Many physicians these days are conflict avoidance masters. But there is something to be said for picking your battles, etc. Takes about 2 years to change a culture. Step by step. Keep at it ESE.

 

[elementaryschooleconomics]

I can't tell you how often I've seen the tail wag the dog. Many physicians these days are conflict avoidance masters. But there is something to be said for picking your battles, etc. Takes about 2 years to change a culture. Step by step. Keep at it ESE.

I'm mostly just disappointed that everyone before me allowed the culture to evolve to this point.

Conflict avoidance masters, indeed.

 

[medgator]

Trust me, I'm very aware of the "we've been doing it this way because that's how Dr. Boomer did prostates for 30 years, and that's the way WE treat patients here" mentality (oh and btw what a dear he was, that Dr. Boomer, what a great doctor he had that "feel" the new guys just don't have)

At the same time, if you think a patient should be treated with a vaginal dilator, and a therapist or a department manager is able to successfully talk you out of it because the therapists think it's icky (FWIW I have never had a patient or therapist complaint after showing them on the first patient -- it's simple, fast, and painless thing if done correctly and usually appreciated if the rationale of sparing the genitalia is explained to the patient) or might be 5 minutes late to their kids after school activities, then (1) either your clinical conviction for doing it in the first place wasn't strong enough to warrant doing it and you shouldn't be doing it or (2) you've let your clinical decision making be compromised by a non-clinician with non-clinical factors affecting your decision making.

The trick is standing your ground but doing it confidently and non-emotionally. There is where new grads can struggle. I certainly did and learned a lot of lessons the (very) hard way. It's almost like training a puppy. If you allow it to dump on the carpet, it's going to keep doing it. If you go through the painful (at first) motions of taking the dumb thing outside to the grass every 30 minutes eventually it will stop trying to dump on the carpet because its learned the rules. But you have to be nice to the puppy. After all, it's a dumb puppy and screaming at it for dumping on the carpet and getting in heated arguments with it about why the grass is better is actually counter-productive. Take it outside and say this is the way it's going to be and smile and wait, ignore the whining and blank stares, and give him a treat and a "good boy" when he finally gets it.

Once my puppies learn to not quadruple book me, or tattoo the default laser position in the sim causing the setup to be off by 5cm at VSIM, or swap out the slant board for a chest board and hide it under a sheet, or remove the marks on a bolus placed by physics at the time of sim "because they don't make sense", or move an inpatient treatment from the end of the day to 9AM before the plan is even done "because there was an opening" (to go home early) -

then we'll work on dilators.

Just had one of my therapists give her 2 weeks notice. She's been with us for years but saw an opportunity to travel and make some real cash as her kids are out of the house....

Apparently many are making $6-7k a week easy traveling through temp agencies throughout the country.

A labor shortage isn't a good situation to be training puppies in. $6-7k a week.... Not far off from locums wages in some radonc locales

 

[metallica81788]

Once my puppies learn to not quadruple book me

You need some better control of your schedule/schedulers. I'll have my therapists lecture me about why not to dilators all day before I let anyone mess with my schedule - that starts and ends with me.

 

[medgator]

Once my puppies learn to not quadruple book me, o

I'm with @metallica81788 here.... Schedule control is paramount and one of those issues that you need to address early on

 

[jondunn]

No reason you can’t have essentially four day clinic week if you can play it right with scheduling !

 

[elementaryschooleconomics]

I'm with @metallica81788 here.... Schedule control is paramount and one of those issues that you need to address early on

Totally agree. Obviously, getting into specifics will be on the internet forever, so - meetings, phone calls, and discussions have been had (about the schedule...about everything). It's multifactorial.

@temujim is exactly correct. People hate conflict, perhaps RadOncs more than others. I'm the first to say/do anything about it, either because I'm the first to know it's a problem or the first to care. It doesn't matter, really.

The larger point for on-treatment dilators or anything in that realm - forest for the trees. After months and months of "discussions", for example, I'm no longer routinely getting plans from Dosimetry with hotspots >115%. However, as far as they're concerned, it's a limitation of reality to get a plan below 110% hotspot, ever. Until I break Dosi of thinking a 112% hotspot outside the PTV is an OK thing to do, I'm not going to ask for on-treatment dilators.