Hi Mamacita,
After making a few calls to the RO I finally will start radiation on Monday as well as Cisplatin 3Xs.
To answer your question about Cetuximab well when first diagnosed, the ENT surgical oncologist said that surgery was out of the question. It would be too extensive. He said I should consult someone for chemo with radiation. I went to a CCC, after speaking with the doctor about my wanting surgery, I was started on Cetuximab and after one week my lymph node responded, what I thought was very dramatically. After my second chemo I had my next scheduled visit with my ENT oncologist. He looked down my throat and said that he could do the surgery. I asked him about his previous comments. He shut me down by saying that he was the expert. He did not follow up with any other info. I continued with my chemo and told the CCC oncologist at the scheduled visit with her. She said that the ENT did not contact her with any info. She called him and he said that he didn't remember exactly what he had told me. I stopped going to that doctor. I went back to my second opinion ENT surgical oncologist. He had been more thorough at my first visit. He still stated that Cisplatin and radiation was the way to go. So, between scheduled office visits and misleading info all of July and most of August went by. That is why I was taking Cetuximab with no radiation.
I am wishing the best for you. Hang in there. Talk to you soon.
Steve

Pretty much all IMRT radiation these days is arc based. The very nature of how IMRT is delivered is the principle that lots of very tiny (pin point even) beams of radiation from an unlimited number of angles, intensity, and duration, provide the exposure. Hence the delivery head of the machine rotates in an arc around your head to do so.

The most important part of IMRT technology is having a great RO, dosimetrist and physicist to do the map of what is going to get radiated and how much to where. Considering the primary, the known pathways of metastasis to the neck, and all the vital structures you would like to avoid or touch as little as possible, they come up with a map of what your radiation exposure looks like, almost like a topographical hiking map of concentric forms, each band with a different intensity and duration and spread of radiation. So regardless of the type of IMRT machine, and the software that runs it, it is really up to the staff to get you the optimum map that will give you resolution of the cancer while avoiding vital structures if possible. To suggest that heliarc IMRT is somehow better, is negating the fact that someone has to program it properly, without which it is no different than any other machine or software.

RO's and the dosimetrists/physicists that they work with, have to know anatomy like a surgeon does these days to get the optimal results. But given how few institutions out there that have not converted to IMRT delivery systems in the last decade (hardly any, and certainly no bigger ones), this is a discussion that you don't have to have with them.

The old adage that you can give a monkey a typewriter but that does not mean he can write War and Peace, comes to mind. The variable in all this is not the piece of equipment or software (the real breakthrough) it is the knowledge and experience of the human team being applied to use that tool. Since this is in the big versus smaller institutions section, it can take years for this team to get really good at using the IMRT technology as it requires a great deal of sophistication in anatomy, and actually working with this breakthrough software that is so completely customizable. Bigger institutions may get up to speed on things faster given that just see huge volumes of patients compared to smaller institutions. I have been told by several RO's that there is a significant learning cure involved when all this technology came about.

http://www.ncbi.nlm.nih.gov/pubmed/20384272

http://oralcancerfoundation.org/facts/radiation.htm

http://oralcancerfoundation.org/facts/imrt_radiation.htm

Thank you, Brian. You always explain it best.

Hi Brian,

I'd like a bit of help clearing up the role of dosimetrist vs medical physicist. My experience had me believing the RO and dosimetrist worked together to create the map and dosage using the software planning tools.

My understanding of the role of physicist is to establish and monitor standards and procedures are being followed as well as calibrating and testing all the accelerator hardware and software and facilities. It did not seem the RO and medical physicist had regular interaction on each individual case as is the case with the RO and dosimetrist.

Not every facility has all three types of people, and those behind the curtain that we never see, are sometime one, two, or multiple people with different titles. While they are two different kinds of jobs, this is an issue of semantics when you look at it nationally. In some smaller institutions one person does the work of both job titles.

Bottom line a patient will never interact with these people and patients coming to the forum don't need to concern themselves with these individuals, as they do not interact with patients as a matter of routine, and we will never know or understand their job well enough to consider (scientifically ) what they do our how it might impact us, nor offer questions up to them that might change the direction of our treatments.

Suffice it to say there is a person who labors over your scans creating a computer map of what radiation, how intense, and of what duration and dispersion is going to hit you in all the right places. That person is a vital part of the working of it all. There is in every department in a cancer center an individual that see that equipment is in calibration, that proper protocols for the administration of things like radiation are being put in place and followed. Be it the radiation department or the pathology lab, there are oversight people who are ensuring that things are calibrated, state and national laws and procedures and protocols are being followed.

If someone really cares to dig into all this they should go here or have a conversation about it with their RO.

http://www.medicaldosimetry.org/generalinformation/medical_dosimetrist.cfm

http://www.aapm.org/pubs/reports/rpt_38.pdf


Going into detail of what all these vitally important people do is beyond the scope of the forum, and what patients need to know to navigate to a good institution or understand the care they are going to receive.

If anyone is really interested I will post more links on what all these different people do. While it's all interesting, it isn't something that you can evaluate or have a really informed opinion about that would alter your treatments. If it was we would have put up articles about it in the radiation section of the main web site. The review of that section of the site was done by OCF board member Dr. Kian Ang, who up until his death not long ago was head of radiation oncology at MDACC.

Thanks Brian,

I had the same links in my journal plus this one http://www.mdcb.org/ which is more for certification. Your description is much as mine is about these folks. I more equated it to the wizard of Oz, behind the curtain doing miraculous things but ultimately still a human being. :-)

Personally, at my radiation facility there is a wall with all the personnel there with their titles/roles. From my recollection, which could be way off, there was one medical physicist, two-three dosimetrists, and five radiation oncologist plus supporting staff.

The RO went over my map on paper, not the computer program, showing the targeted areas, the varying intensities and contouring. I was assigned to the Varian Trilogy for IMRT and I asked if they used Eclipse for the mapping. He was not sure so it seems this facility has the dosimetrists running the mapping programs.

Thanks again for your informative reply,
don