Rectal Filling During Prostate RT

[RadOncBeamer]

Hi all,

Silly question, wanted to get your thoughts. For standard frac or hypofrac prostate RT, if I’m doing daily CBCT and fiducials, why does rectal filling matter at all? I understand the dogma - a large rectum pushes the prostate anteriorly and so you could miss anteriorly and include more rectum if aligning to bony anatomy on daily kv imaging. But I feel this was more an issue in the non CBCT era. Now, if you can just align to the prostate itself, shouldn’t daily changes in rectal filling matter less? Unless you believe that the enlarged rectum actually deforms the prostate shape into something smaller, in which case I would agree it makes a difference, but I’d be happy to see data to support this if true.

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[seper]

yes, prostate would sometimes be deformed, SVs pushed out of the field

 

[Palex80]

Indeed, it can deform your prostate and SV-position.

The other matter is the reproducibility of your rectum DVH.
This depends on twhether you are using "rectum" or "rectal wall" constraints.
A full rectum can lead to a more favorable "rectum" DVH and a less favorable "rectall wall" DVH.

 

[TheWallnerus]

Hi all,

Silly question, wanted to get your thoughts. For standard frac or hypofrac prostate RT, if I’m doing daily CBCT and fiducials, why does rectal filling matter at all? I understand the dogma - a large rectum pushes the prostate anteriorly and so you could miss anteriorly and include more rectum if aligning to bony anatomy on daily kv imaging. But I feel this was more an issue in the non CBCT era. Now, if you can just align to the prostate itself, shouldn’t daily changes in rectal filling matter less? Unless you believe that the enlarged rectum actually deforms the prostate shape into something smaller, in which case I would agree it makes a difference, but I’d be happy to see data to support this if true.

For prostate-only RT with a tight margin, rectal filling, within limits, doesn’t matter much. If your fiducial spatial arrangements still perfectly match, it matters zero. The CBCT is a nice thing to have, but it certainly hasn’t been shown to lower rectal toxicity versus fiducial-only IGRT. And CBCT has not been shown to improve cure rates versus nothing, although that might be a positive study. But we already know it would probably be positive, right? Especially for hypofractionated regimens.

Final answer: if you’re happy with the match, but the rectum has filled, OK to treat. For boards or OLA, get the patient off the table.

OK, so that's the final answer. But here's the laser-beams-out-McMahon's-eyes answer. If a beam is "shining" through a rectal gas pocket into the prostate, i.e. posterior beams, the TPS has not accounted for that... so you get some dose variations in those beamlets, as seen by the prostate, into the prostate. Those variations can be ~20% (as measured by in vivo dosimetry) for those beamlets, but almost certainly <10% for the daily total dose to the prostate. However, this is why you will see me use lateralish-only beam/arc arrangements, e.g...

... for, say, the last 9 Gy of an 81 Gy regimen. (But also this really pushes rectal sparing, etc.)

Think of all the reasons why the below finding would not be seen in the modern era:

Increased risk of biochemical and local failure in patients with distended rectum on the planning CT for prostate cancer radiotherapy​

 

[Palex80]

And CBCT has not been shown to improve cure rates versus nothing, although that might be a positive study. B

Actually, there is this interesting French trial

Daily Versus Weekly Prostate Cancer Image Guided Radiation Therapy: Phase 3 Multicenter Randomized Trial - PubMed

Compared with weekly control, daily IGRT control in prostate cancer significantly improves biochemical progression-free and clinical progression-free interval, and rectal toxicity.

pubmed.ncbi.nlm.nih.gov

 

[RickyScott]

Hi all,

Silly question, wanted to get your thoughts. For standard frac or hypofrac prostate RT, if I’m doing daily CBCT and fiducials, why does rectal filling matter at all? I understand the dogma - a large rectum pushes the prostate anteriorly and so you could miss anteriorly and include more rectum if aligning to bony anatomy on daily kv imaging. But I feel this was more an issue in the non CBCT era. Now, if you can just align to the prostate itself, shouldn’t daily changes in rectal filling matter less? Unless you believe that the enlarged rectum actually deforms the prostate shape into something smaller, in which case I would agree it makes a difference, but I’d be happy to see data to support this if true.

I agree. Very hard to control rectal filling in elderly patients. fiber pills and semthicone don’t seem to do much, but we still push them. Negligible dosimetric differences will average out unless 5 fractions.

 

[Chartreuse Wombat]

Actually, there is this interesting French trial

Daily Versus Weekly Prostate Cancer Image Guided Radiation Therapy: Phase 3 Multicenter Randomized Trial - PubMed

Compared with weekly control, daily IGRT control in prostate cancer significantly improves biochemical progression-free and clinical progression-free interval, and rectal toxicity.

pubmed.ncbi.nlm.nih.gov

Overall survival was worse in the daily group than in the weekly group (HR = 2.12 [95% confidence interval (CI), 1.03-4.37]; P = .042).

Daily IGRT kills patients is the obvious conclusion

 

[evilbooyaa]

Hi all,

Silly question, wanted to get your thoughts. For standard frac or hypofrac prostate RT, if I’m doing daily CBCT and fiducials, why does rectal filling matter at all? I understand the dogma - a large rectum pushes the prostate anteriorly and so you could miss anteriorly and include more rectum if aligning to bony anatomy on daily kv imaging. But I feel this was more an issue in the non CBCT era. Now, if you can just align to the prostate itself, shouldn’t daily changes in rectal filling matter less? Unless you believe that the enlarged rectum actually deforms the prostate shape into something smaller, in which case I would agree it makes a difference, but I’d be happy to see data to support this if true.

An empty rectum and a full rectum cause different deformations of the prostate. It won't deform the prostate into being smaller by volume, just where that volume is located. Which obviously is a huge issue when we're talking about localization. A prostate that undergoes CT sim with an empty rectum and treated with a full rectum routinely will generally have more anterior displacement of the prostate at midline (resulting in higher dose to rectum) and more posterior displacement of prostate at the lateral edges (resulting in potential geographic miss assuming tight PTV margins) than the CT sim version. Imagine you have a thing of playdoh and you punch up in the middle of it. It doesn't actually make the prostate 'smaller' just moves it around.

That's not to say that everytime a prostate patient has just a smidgeon of gas they have to be taken off the table, but someone who had a 2cm diameter rectum at CT sim but now has a 4+cm diameter rectum at treatment is likely to have significant displacement of the prostate (fixable with table shifts), deformation of the prostate (not fixable with table shifts as above), as well as displacement of the seminal vesicles (relevant if in the treatment volume, depending on PTV margins) with potential for deformation compared to CT sim.

Similar concept when it comes to bladder.

Again, doesn't necessarily matter for 1 fraction out of 25-45 treatments if slightly off, but I wouldn't want it to become a routine thing, especially when going to the high doses we go to.

But who knows, we used to treat 3D and most patients did OK, so maybe for an individual patient it will never make a difference.

But to answer you rquestion, daily changes in rectal filling definitely matter less than it used to in the 3D, bony land mark without fiducial IGRT era.

Now adays, kVs tracked to Fiducial is probably just as good as CBCT with soft tissue evaluation.

Overall survival was worse in the daily group than in the weekly group (HR = 2.12 [95% confidence interval (CI), 1.03-4.37]; P = .042).

Daily IGRT kills patients is the obvious conclusion

Daily IGRT had worse "other cancer-free interval" - daily IGRT causes more secondary malignancies resulting in worse survival?

 

[Chartreuse Wombat]

An empty rectum and a full rectum cause different deformations of the prostate. It won't deform the prostate into being smaller by volume, just where that volume is located. Which obviously is a huge issue when we're talking about localization. A prostate that undergoes CT sim with an empty rectum and treated with a full rectum routinely will generally have more anterior displacement of the prostate at midline (resulting in higher dose to rectum) and more posterior displacement of prostate at the lateral edges (resulting in potential geographic miss assuming tight PTV margins) than the CT sim version. Imagine you have a thing of playdoh and you punch up in the middle of it. It doesn't actually make the prostate 'smaller' just moves it around.

That's not to say that everytime a prostate patient has just a smidgeon of gas they have to be taken off the table, but someone who had a 2cm diameter rectum at CT sim but now has a 4+cm diameter rectum at treatment is likely to have significant displacement of the prostate (fixable with table shifts), deformation of the prostate (not fixable with table shifts as above), as well as displacement of the seminal vesicles (relevant if in the treatment volume, depending on PTV margins) with potential for deformation compared to CT sim.

Similar concept when it comes to bladder.

Again, doesn't necessarily matter for 1 fraction out of 25-45 treatments if slightly off, but I wouldn't want it to become a routine thing, especially when going to the high doses we go to.

But who knows, we used to treat 3D and most patients did OK, so maybe for an individual patient it will never make a difference.

But to answer you rquestion, daily changes in rectal filling definitely matter less than it used to in the 3D, bony land mark without fiducial IGRT era.

Now adays, kVs tracked to Fiducial is probably just as good as CBCT with soft tissue evaluation.


Daily IGRT had worse "other cancer-free interval" - daily IGRT causes more secondary malignancies resulting in worse survival?

To be clear I think is a spurious finding.

tylervigen.com

 

[ramsesthenice]

If I didn’t know any better, I might have thought these last couple prostate posts were started by an incognito MR Linac sales person. These are core parts of their pitches.

To the OP, I agree with you that in many situations a large rectum is not inherently a problem. Look at their previous imaging. Some people never have an empty rectum. For them, I think the real mistake is aggressively prepping them for sim as all you are doing is setting up something you will never be able to recreate on the treatment table.

 

[evilbooyaa]

If I didn’t know any better, I might have thought these last couple prostate posts were started by an incognito MR Linac sales person. These are core parts of their pitches.

To the OP, I agree with you that in many situations a large rectum is not inherently a problem. Look at their previous imaging. Some people never have an empty rectum. For them, I think the real mistake is aggressively prepping them for sim as all you are doing is setting up something you will never be able to recreate on the treatment table.

Agreed. Enemas prior to CT sim are silly unless you're going to daily enema them prior to treatment. Which I can somewhat understand if doing 5Fx, but 25+ that seems barbaric.

Nothing beats the barbarism of a daily rectal balloon for 44 treatments though...

 

[MidwestRadOnc]

Hi all,

Silly question, wanted to get your thoughts. For standard frac or hypofrac prostate RT, if I’m doing daily CBCT and fiducials, why does rectal filling matter at all? I understand the dogma - a large rectum pushes the prostate anteriorly and so you could miss anteriorly and include more rectum if aligning to bony anatomy on daily kv imaging. But I feel this was more an issue in the non CBCT era. Now, if you can just align to the prostate itself, shouldn’t daily changes in rectal filling matter less? Unless you believe that the enlarged rectum actually deforms the prostate shape into something smaller, in which case I would agree it makes a difference, but I’d be happy to see data to support this if true.

What does a lot of watery poop do to the dosimetry when you are delivering in an arc? Being able to have faith that your IMRT plan doses at the EOT what it promised to is what I care about.

Daily enemas recommended if they can't get it right most of the time.

 

[MidwestRadOnc]

Agreed. Enemas prior to CT sim are silly unless you're going to daily enema them prior to treatment. Which I can somewhat understand if doing 5Fx, but 25+ that seems barbaric.

Nothing beats the barbarism of a daily rectal balloon for 44 treatments though...

Sorry, but an enema is not barbaric. It is painless and takes one minute.

 

[medgator]

Sorry, but an enema is not barbaric. It is painless and takes one minute.

44 fx? Yep it is

 

[evilbooyaa]

Sorry, but an enema is not barbaric. It is painless and takes one minute.

or

Couldn't decide which one to go with. No idea if you're actually a boomer, but that's boomer mentality.

 

[MidwestRadOnc]

44 fx? Yep it is

Are you making the argument that this is psychologically barbaric or physically? If the latter, um, explain please. On a scale of 1 to 10 of awful things we do to patients, a squirt up the butt is maybe a 2 after holding an uncomfortably full bladder and soiling yourself at least once during treatment.

On the other hand, if this is standard per the NHS, perhaps I do need to rethink... https://flipbooks.leedsth.nhs.uk/LN003885.pdf

Edit: Ouch, the boomer burn stung.
Boomer prostate radiation is:
RTT sims patient with whatever bladder and rectum anatomy is present.
Dosimetry draws prostate and plans.
Boomer approves plan 4 weeks later when patient calls.
Boomer mindlessly clicks through daily imaging ignoring balloon sized gas bubbles and FOS rectums.

Talk to me when you have been written up by the radiation department manager for taking a patient off the sim table and making them do an enema (because the previous boomer didn't waste time with such things and planned around Campbell's chunky soup cans in the rectum).

 

[evilbooyaa]

Are you making the argument that this is psychologically barbaric or physically? If the latter, um, explain please. On a scale of 1 to 10 of awful things we do to patients, a squirt up the butt is maybe a 2 after holding an uncomfortably full bladder and soiling yourself at least once during treatment.

On the other hand, if this is standard per the NHS, perhaps I do need to rethink... https://flipbooks.leedsth.nhs.uk/LN003885.pdf

Edit: Ouch, the boomer burn stung.
Boomer prostate radiation is:
RTT sims patient with whatever bladder and rectum anatomy is present.
Dosimetry draws prostate and plans.
Boomer approves plan 4 weeks later when patient calls.
Boomer mindlessly clicks through daily imaging ignoring balloon sized gas bubbles and FOS rectums.

Talk to me when you have been written up by the radiation department manager for taking a patient off the sim table and making them do an enema (because the previous boomer didn't waste time with such things and planned around Campbell's chunky soup cans in the rectum).

Agree that what you are describing is definitely boomer RO. What constitutes acting like a boomer in RO is more of a series of opinions than facts. OK to disagree.

If patients are, at minimum, peeing themselves once a RT course, your requests for bladder filling are too stringent, or your machines are running late. Some patients, especially salvage ones with poor control may have issues, but hopefully not a routine thing for an intact patient...

 

[Reaganite]

An empty rectum and a full rectum cause different deformations of the prostate. It won't deform the prostate into being smaller by volume, just where that volume is located. Which obviously is a huge issue when we're talking about localization. A prostate that undergoes CT sim with an empty rectum and treated with a full rectum routinely will generally have more anterior displacement of the prostate at midline (resulting in higher dose to rectum) and more posterior displacement of prostate at the lateral edges (resulting in potential geographic miss assuming tight PTV margins) than the CT sim version. Imagine you have a thing of playdoh and you punch up in the middle of it. It doesn't actually make the prostate 'smaller' just moves it around.

That's not to say that everytime a prostate patient has just a smidgeon of gas they have to be taken off the table, but someone who had a 2cm diameter rectum at CT sim but now has a 4+cm diameter rectum at treatment is likely to have significant displacement of the prostate (fixable with table shifts), deformation of the prostate (not fixable with table shifts as above), as well as displacement of the seminal vesicles (relevant if in the treatment volume, depending on PTV margins) with potential for deformation compared to CT sim.

Similar concept when it comes to bladder.

Again, doesn't necessarily matter for 1 fraction out of 25-45 treatments if slightly off, but I wouldn't want it to become a routine thing, especially when going to the high doses we go to.

But who knows, we used to treat 3D and most patients did OK, so maybe for an individual patient it will never make a difference.

But to answer you rquestion, daily changes in rectal filling definitely matter less than it used to in the 3D, bony land mark without fiducial IGRT era.

Now adays, kVs tracked to Fiducial is probably just as good as CBCT with soft tissue evaluation.


Daily IGRT had worse "other cancer-free interval" - daily IGRT causes more secondary malignancies resulting in worse survival?

I miss the fiducial/kv days. I'm constantly getting called to machine these days to check cbcts with empty bladders and full rectums. I find many therapists have difficulty aligning cbcts if bowel/bladder is even slightly off compared to sim ct. Then there's the inevitable handful of patients each day they get on and off the table to empty gas and stool...which sets the schedule back an hour and pisses off all the other pts. I appreciate the attention to detail, but wonder if it really matters as I never saw serious issues during kv/fiducial days.

 

[RadRadRad]

I miss the fiducial/kv days. I'm constantly getting called to machine these days to check cbcts with empty bladders and full rectums. I find many therapists have difficulty aligning cbcts if bowel/bladder is even slightly off compared to sim ct. Then there's the inevitable handful of patients each day they get on and off the table to empty gas and stool...which sets the schedule back an hour and pisses off all the other pts. I appreciate the attention to detail, but wonder if it really matters as I never saw serious issues during kv/fiducial days.

Agree. I feel like I have to say “align to the posterior edge of the prostate” once a week

 

[ramsesthenice]

I miss the fiducial/kv days. I'm constantly getting called to machine these days to check cbcts with empty bladders and full rectums. I find many therapists have difficulty aligning cbcts if bowel/bladder is even slightly off compared to sim ct. Then there's the inevitable handful of patients each day they get on and off the table to empty gas and stool...which sets the schedule back an hour and pisses off all the other pts. I appreciate the attention to detail, but wonder if it really matters as I never saw serious issues during kv/fiducial days.

This gets directly to my prior question of how much better is "better." My guess would have been that if CBCT was better at anything, it would have been reducing late rectal/bladder toxicity, not disease control since what it really adds to fiducial based KV is knowledge of normal tissue deformation. I have never taken the time to look closely, but IMO, its not obviously better in that respect. But it is great at getting me called to the machine

 

[MidwestRadOnc]

I miss the fiducial/kv days. I'm constantly getting called to machine these days to check cbcts with empty bladders and full rectums. I find many therapists have difficulty aligning cbcts if bowel/bladder is even slightly off compared to sim ct. Then there's the inevitable handful of patients each day they get on and off the table to empty gas and stool...which sets the schedule back an hour and pisses off all the other pts. I appreciate the attention to detail, but wonder if it really matters as I never saw serious issues during kv/fiducial days.

I started my career aligning to fiducials with kV daily with a CBCT once a week. It was fine and the match was always fine with the cbct on the 5th day giving me confidence with my margins. I got tired of arguing with the department manager who kept complaining to the ceo that I didn't know what I was doing. So yeah, sure, 45 daily cone beams now. And yes, invariably there will be a few times a lazy bony automatch sneaks through, which was not an issue when the option was lining up the fiducials on kV.

 

[medgator]

I started my career aligning to fiducials with kV daily with a CBCT once a week. It was fine and the match was always fine with the cbct on the 5th day giving me confidence with my margins. I got tired of arguing with the department manager who kept complaining to the ceo that I didn't know what I was doing. So yeah, sure, 45 daily cone beams now. And yes, invariably there will be a few times a lazy bony automatch sneaks through, which was not an issue when the option was lining up the fiducials on kV.

Data suggests kV and/or cbct with fiducials might be the most accurate/reproducible, esp once you start getting different therapists involved. Even some of the cbct studies suggest things are better if you combine with fiducials. Sounds like your experience jives with that

They didn't like you placing fiducials?

Evaluation of kV cone-beam ct performance for prostate IGRT: a comparison of automatic grey-value alignment to implanted fiducial-marker alignment - PubMed

CBCT with soft-tissue-based automatic corrections is not an accurate alignment compared with manual alignment to fiducial markers for prostate IGRT. We have concluded that a daily manual alignment to fiducials is one of the most reliable methods to maintain accuracy in prostate IGRT.

pubmed.ncbi.nlm.nih.gov

Daily patient setup error in prostate image guided radiation therapy with fiducial-based kilovoltage onboard imaging and conebeam computed tomography - Ye - Quantitative Imaging in Medicine and Surgery

 

[MidwestRadOnc]

Data suggests kV and/or cbct with fiducials might be the most accurate/reproducible, esp once you start getting different therapists involved. Even some of the cbct studies suggest things are better if you combine with fiducials. Sounds like your experience jives with that

They didn't like you placing fiducials?

Evaluation of kV cone-beam ct performance for prostate IGRT: a comparison of automatic grey-value alignment to implanted fiducial-marker alignment - PubMed

CBCT with soft-tissue-based automatic corrections is not an accurate alignment compared with manual alignment to fiducial markers for prostate IGRT. We have concluded that a daily manual alignment to fiducials is one of the most reliable methods to maintain accuracy in prostate IGRT.

pubmed.ncbi.nlm.nih.gov

Daily patient setup error in prostate image guided radiation therapy with fiducial-based kilovoltage onboard imaging and conebeam computed tomography - Ye - Quantitative Imaging in Medicine and Surgery

Agree completely.
Didn't like me placing fiducials? How about were completely unwilling to even entertain the idea. Would send to urology.
It was demoralizing after a decade of medical education to work for an admin who viewed you as unnecessary and really just a grossly overpaid compliance formality.
Dosimetry wanted to drive prescriptions (all prostates get 20 fractions here) and volumes. Plan is done. Sign here.
RTT wanted to drive sim and treatment prep. Prescribe ativan when we say so.
Manager wanted to schedule everything. Sims same day, whatever, just to keep Press Ganey scores as high as possible.
The MD's job was basically viewed as to write the entire note and sign off on documents so they could bill.

I learned this is not uncommon in solo hospital practices that rely on locums. Would advise avoiding these jobs, especially right out of training.

 

[medgator]

Agree completely.
Didn't like me placing fiducials? How about were completely unwilling to even entertain the idea. Would send to urology.
It was demoralizing after a decade of medical education to work for an admin who viewed you as unnecessary and really just a grossly overpaid compliance formality.
Dosimetry wanted to drive prescriptions (all prostates get 20 fractions here) and volumes. Plan is done. Sign here.
RTT wanted to drive sim and treatment prep. Prescribe ativan when we say so.
Manager wanted to schedule everything. Sims same day, whatever, just to keep Press Ganey scores as high as possible.
The MD's job was basically viewed as to write the entire note and sign off on documents so they could bill.

I learned this is not uncommon in solo hospital practices that rely on locums. Would advise avoiding these jobs, especially right out of training.

Yeah F that.

 

[MidwestRadOnc]

The gaslighting is real.

The icing on the cake was what they did with RVUs.
Suppose you needed 3500 wRVU per quarter to make up your salary and you generated 4000 wRVU. You should get a true-up for 500 wRVU x your RVU rate. They would just not count the wRVUs for the last 3 weeks of the quarter or something and say "we're behind on billing, they'll be on the next report." Kick the can down the road indefinitely. They did it with every specialty and if/when doctors figured this scheme out they would quit.

They told me "This is how every hospital does it." They never paid out RVUs beyond the base unless you were so insanely productive that you were hitting your target in the first month and they couldn't hide it.

It was insane. Every peer I talked to about this said WTF.

Anyone else experienced this? I am extremely suspicious of "base+RVU bonus" schemes now. Prefer eat-what-you-kill. Pay me per RVU as the post or a percentage of collections as they come in, I don't care.

 

[DoctwoB]

An empty rectum and a full rectum cause different deformations of the prostate. It won't deform the prostate into being smaller by volume, just where that volume is located. Which obviously is a huge issue when we're talking about localization. A prostate that undergoes CT sim with an empty rectum and treated with a full rectum routinely will generally have more anterior displacement of the prostate at midline (resulting in higher dose to rectum) and more posterior displacement of prostate at the lateral edges (resulting in potential geographic miss assuming tight PTV margins) than the CT sim version. Imagine you have a thing of playdoh and you punch up in the middle of it. It doesn't actually make the prostate 'smaller' just moves it around.

That's not to say that everytime a prostate patient has just a smidgeon of gas they have to be taken off the table, but someone who had a 2cm diameter rectum at CT sim but now has a 4+cm diameter rectum at treatment is likely to have significant displacement of the prostate (fixable with table shifts), deformation of the prostate (not fixable with table shifts as above), as well as displacement of the seminal vesicles (relevant if in the treatment volume, depending on PTV margins) with potential for deformation compared to CT sim.

Similar concept when it comes to bladder.

Again, doesn't necessarily matter for 1 fraction out of 25-45 treatments if slightly off, but I wouldn't want it to become a routine thing, especially when going to the high doses we go to.

But who knows, we used to treat 3D and most patients did OK, so maybe for an individual patient it will never make a difference.

But to answer you rquestion, daily changes in rectal filling definitely matter less than it used to in the 3D, bony land mark without fiducial IGRT era.

Now adays, kVs tracked to Fiducial is probably just as good as CBCT with soft tissue evaluation.


Daily IGRT had worse "other cancer-free interval" - daily IGRT causes more secondary malignancies resulting in worse survival?

I wouldn't rule out that there is a compressive element that affects your effective prostate volume if there's a ball of stool in the rectum.

In comparing MRI to TRUS prostate volumes, MRI will on average give you a 5cc larger volume, which on an average gland is around a 12-15% difference. While it could be that this is inherent to the imaging modality, more likely imo is that it is due to the presence of of the TRUS probe compressing the prostate. Would be interesting to compare TRUS volume to MRI using an endorectal coil, but those have gone the way of the dodo.

Prostate volume estimations using magnetic resonance imaging and transrectal ultrasound compared to radical prostatectomy specimens

We sought to evaluate the accuracy of prostate volume estimates in patients who received both a preoperative transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) in relation to the referent pathological specimen post-radical prostatectomy.Patients ...

www.ncbi.nlm.nih.gov

 

[DoctwoB]

The gaslighting is real.

The icing on the cake was what they did with RVUs.
Suppose you needed 3500 wRVU per quarter to make up your salary and you generated 4000 wRVU. You should get a true-up for 500 wRVU x your RVU rate. They would just not count the wRVUs for the last 3 weeks of the quarter or something and say "we're behind on billing, they'll be on the next report." Kick the can down the road indefinitely. They did it with every specialty and if/when doctors figured this scheme out they would quit.

They told me "This is how every hospital does it." They never paid out RVUs beyond the base unless you were so insanely productive that you were hitting your target in the first month and they couldn't hide it.

It was insane. Every peer I talked to about this said WTF.

Anyone else experienced this? I am extremely suspicious of "base+RVU bonus" schemes now. Prefer eat-what-you-kill. Pay me per RVU as the post or a percentage of collections as they come in, I don't care.

This sounds like lawyer time. Your contract should spell out your reimbursement structure including your RVU bonus. Not paying your wages or bonus in a timely fashion is wage theft and highly illegal. This is state dependent, but often comes with big penalties for the employer. In California, it can even rise to the level of a criminal offense with jail time.

The only way out of this I could see is if the contract has language that your bonus is solely at the discretion of the employer, in which case you should not EVER go work there.

 

[MidwestRadOnc]

This sounds like lawyer time. Your contract should spell out your reimbursement structure including your RVU bonus. Not paying your wages or bonus in a timely fashion is wage theft and highly illegal. This is state dependent, but often comes with big penalties for the employer. In California, it can even rise to the level of a criminal offense with jail time.

The only way out of this I could see is if the contract has language that your bonus is solely at the discretion of the employer, in which case you should not EVER go work there.

BTDT. Not interested in ever going through that again. Was just curious if anyone else had experienced this before.

What's shocking is the other MDs there that continue to put up with it. The med oncs are getting royally hosed.

 

[TheWallnerus]

Data suggests kV and/or cbct with fiducials might be the most accurate/reproducible, esp once you start getting different therapists involved. Even some of the cbct studies suggest things are better if you combine with fiducials. Sounds like your experience jives with that

They didn't like you placing fiducials?

Evaluation of kV cone-beam ct performance for prostate IGRT: a comparison of automatic grey-value alignment to implanted fiducial-marker alignment - PubMed

CBCT with soft-tissue-based automatic corrections is not an accurate alignment compared with manual alignment to fiducial markers for prostate IGRT. We have concluded that a daily manual alignment to fiducials is one of the most reliable methods to maintain accuracy in prostate IGRT.

pubmed.ncbi.nlm.nih.gov

Daily patient setup error in prostate image guided radiation therapy with fiducial-based kilovoltage onboard imaging and conebeam computed tomography - Ye - Quantitative Imaging in Medicine and Surgery

There are some same such studies which predate this

 

[evilbooyaa]

Agree completely.
Didn't like me placing fiducials? How about were completely unwilling to even entertain the idea. Would send to urology.
It was demoralizing after a decade of medical education to work for an admin who viewed you as unnecessary and really just a grossly overpaid compliance formality.
Dosimetry wanted to drive prescriptions (all prostates get 20 fractions here) and volumes. Plan is done. Sign here.
RTT wanted to drive sim and treatment prep. Prescribe ativan when we say so.
Manager wanted to schedule everything. Sims same day, whatever, just to keep Press Ganey scores as high as possible.
The MD's job was basically viewed as to write the entire note and sign off on documents so they could bill.

I learned this is not uncommon in solo hospital practices that rely on locums. Would advise avoiding these jobs, especially right out of training.

Oof man. This is the stuff that gives community RO a bad name.