December 2000

Topical Depression

By Michael J. Katin, MD

Over the past four years I have tried to avoid dealing with current events topics since even though they could be a rich source of material for the short term, subtle references might prove obscure to readers in the future (The Best of Radiotherapy Opinion, Simon and Schuster, 2015). However, recent events scream out for inclusion and considering that the November 2000 column was remarkably prescient (and included the first reference to "Electile Dysfunction," put on line prior to the election and subsequently used by a myriad of writers and editorial cartoonists), I think it is justified to make an exception for this month.

We have seen the spectacle of post-election maneuvering in Florida with both Mr. Bush and Mr. Gore trying to get the 25 electoral votes to put them over the top to become President. Considering the faltering economy and escalating turmoil in the Middle East, this could be similar to fighting to get the last stateroom on the Titanic. All this has distracted our country from dealing with the major issue of our day, specifically, guaranteeing adequate reimbursement for radiation oncology procedures. We are even further taunted by the subplot of Dick Cheney's cardiac event, with the use of intracoronary brachytherapy apparently not performed and not even mentioned in the commentaries.

Still, it's a good idea to stay optimistic, as was I when in October I canceled December's schedule in case I was called to participate in the Nader/LaDuke transition team. We need to analyze events and distill out the essences, as is the basis of Santayana's philosophy.

Maybe the main leson would be that we might lose fewer patients to cancer if we didn't give up after the first several setbacks. I decided to test this hypothesis based on the example of the Miami-Dade/Broward/Palm Beach model. A patient with prostate cancer had been treated with external beam radiation therapy and was seen at his two-year follow-up to have a rising PSA level. Usually the next move would have been to put him through restaging and exploration of next-line therapies. Instead, I initiated a two-pronged attack. I started by requesting a recheck of the PSA. It came out to within 1% of the previous value but considering that was suspicious enough to question its validity, I initiated a request for another repeat but this time also including fractionation.

I then turned my attention to the treatment itself. He had been treated to 7200 rad and I questioned whether he would have done better if he had received a higher dose. I went back to the microdosimetry readings and isodose curve printouts and reviewed these with two observers. We were able to assign additional rads to the treatment based on the microdosimetry ("hanging rads") and then to identify additional rads that should have been included by reanalysis of the intention of the physicist and physician based on the matching up of the target volume and isodoses ("pregnant rads"). This got the total up to 7383 rad, which should have had a higher chance of producing local control.

I then settled it by disallowing the PSA reading entirely, since it had been ordered by me and I wasn't the principal physician under the patient's insurance plan.

email: mkatin@radiotherapy.com