Radiation Oncology

Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED. Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED.

"Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium. "Internal" radiation or brachytherapy involves use of a variety of radioactive isotopes which are placed inside or near the tumor/cancer. By doing so, radiation does not have to go through the normal tissue between an external source and the target of radiation. Depending on whether the radioactive isotope is placed permanently or used temporarily, brachytherapy is categorized into two categories of permanent and temporary.

The most common form of permanent brachytherapy is prostate seed implant. In this form of treatment either Palladium (Pd-103) or Iodine (I-125) seeds are implanted inside the prostate. These seeds would irradiate the prostate gland and the cancer inside it as long as they are radioactive but eventually become inert.

Depending on the strength and therefore speed of delivery of radiation, temporary brachytherapy is categorized into Low Dose Rate and High Dose Rate brachytherapy. The most common example of temporary brachytherapy is the use of either Low Dose Rate (LDR) or High Dose Rate (HDR) forms of brachytherapy for the treatment of gynecological cancers specifically cervical and endometrial cancer. Through special catheters either cesium-137 (LDR) or iridium-192 (HDR) would be inserted nearby the tumor. During the period of time when the catheters remain in area, the prescribed dose of radiation would be delivered to the target. This would take about 48 hours in LDR but only a few minutes in HDR treatment.

HDR brachytherapy is also used in the treatment of breast cancer. This form of radiation for breast cancer is called Accelerated Partial Breast Irradiation or APBI. After a lumpectomy a special applicator such as Mammosite or Contura balloon catheter or a Savi applicator is placed inside the lumpectomy cavity. Using HDR technology an iridium-192 radioactive source is inserted into any of these catheters to deliver radiation to the wall of the lumpectomy cavity.

Intraluminal brachytherapy is also used for the treatment of endobronchial tumors, esophageal cancer and cancers of biliary tract. Other forms of temporary brachytherapy include radioactive eye plaque in treatment of choroidal melanoma and Strontium-90 applicators for treatment of pterygium.

A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive! A patient may not be eligible to receive radiation treatment either because radiation therapy is not indicated for treatment of that particular cancer or stage of the disease or because, even though indicated, it would not be safe to receive radiation.

Contraindications to radiation therapy are often categorized as relative or absolute contraindications. Generally speaking autoimmune/connective tissue diseases increase the risk of acute and chronic side effects of radiation therapy. These patients may be at risk of severe skin reaction, severe scarring and even soft tissue necrosis. Depending on the type and level of activity of this form of diseases, radiation can be relatively or absolutely contraindicated. For example Scleroderma and active lupus are considered absolute contraindications to radiation therapy but an inactive, or limited Lupus such as Discoid Lupus and Rheumatoid Arthritis are considered relative contraindications to radiation therapy.

In recent years and with the invention of sophisticated radiation technology such as CyberKnife and Steroeotactic Radiosurgery, a traditional contraindication to radiation therapy due to previous radiation to the same target area, has been challenged. Without this precise form of targeting the tumor, a relatively significant dose of radiation was given to adjacent normal tissues. Each critical organ in our bodies has a certain tolerance to radiation. That is the dose an organ can safely receive without permanent and irreversible damage. Traditionally we could not reirraidate the same target area because we would have exceeded the safe dose an adjacent organ could tolerate. With this new technology, we can deliver additional doses of radiation to the same target without exceeding the safe dose to the adjacent organs. Despite this technology, at some point, we may reach a point when no additional radiation can be safely delivered and that would make a patient ineligible for additional radiation.

Patients' ineligibility for receiving radiation is a very compelling reason for a multidisciplinary approach to the treatment of cancer. As an example would it not be a shame to subject a patient ineligible for radiation therapy to a lumpectomy when radiation is a critical part of breast conservation therapy? That would sadly would subject the patient to a second operation, a mastectomy, because lumpectomy without radiation would not adequately address the risk of a recurrence in that breast. To avoid similar scenarios, consult all the members of a treatment team before initiating any form of treatment and undergoing any form of procedure. Be proactive!

The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy. The three common treatment modalities in treatment of breast cancer can be given in different sequences. The most common sequence is to start with surgery, continue with chemotherapy if indicated and finish with radiation therapy. But in some cases chemotherapy is delivered before surgery and is followed by radiation therapy. There is one exception to this general rule of radiation therapy being the last modality in the sequence of treatments and that is when Accelerated Partial Breast Irradiation (APBI) using brachytherapy balloons such as Mammosite, Contura or Savi applicator is the form of radiation utilized. In APBI, radiation is delivered immediately after surgery and chemotherapy, if recommended, would follow radiation.

Therefore a "delay" in beginning of radiation treatment can be a planned or an unplanned one. For example we often recommend 4-6 weeks between surgery and beginning of radiation in order to make sure that all the surgical incisions are completely healed. One of the potential side effects of radiation is delay in healing of wounds and that is the reason behind that planned delay. We also recommend about 2-4 weeks of gap between last chemotherapy administered and beginning of radiation therapy. This form of planned delay in beginning of radiation is due to the fact that some chemotherapy agents are radiosensitizers and may potentially increase the risk of side effects from radiation therapy.

The unplanned or undesired delays in beginning of radiation therapy may be due to an unhealed surgical incision or persistent seroma or a hematoma in the lumpectomy cavity or in soft tissue pouches after a mastectomy. Radiation therapy is based on very accurate measurements and calculations of the volumes of tissue irradiated and the doses delivered. If the calculations and radiation plan is based on a certain size of breast and certain size of lumpectomy cavity and this volume is changed due to an enlarging seroma or hematoma, our calculations and therefore radiation doses would be off. Therefore we would await resolution of a seroma or a hemtoma either by giving it some time to absorb or by aspirating it before planning the radiation treatment.

With increase in the use of tumor genetic assay tests such as Oncotype DX, often there is a delay in determining whether a patient requires chemotherapy or not. In this scenario, the radiation oncologist would need to await the test result before starting patient's radiation because if the Oncotype DX result indicates benefit from chemotherapy, this treatment should be delivered before beginning of radiation therapy.

The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active. The best way to deal with fatigue from radiation therapy is creating a balance between getting enough rest and staying active enough. To succumb to the fatigue and give up physical activity would create a vicious cycle resulting in less energy and more fatigue. Yet you don't want to push yourself too much. It is all right to go to bed earlier, get up a little bit later or even take a nap during the day if one feels that tired but it is important to schedule a routine daily activity such as walking and stick with it throughout the course of radiation therapy. The other very important factor is to stay hydrated. Dehydration would negatively impact one's level of energy and may even interfere with their sleep pattern. This is particularly important during the warmer seasons and during the routine daily activity. Extremes of temperature should be avoided. A minimum of 8 cups of fluid per day will prevent dehydration. (That is 64 ounces, 2 quarts, or 1 half-gallon). Beverages containing caffeine do NOT count neither do alcoholic ones. Maintaining good nutrition can help you feel better and have more overall energy. Sticking to a regular schedules such as going to bed at a certain time and eating at regular hours would also be very helpful in creating that fine balance between resting and staying active.

Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first! Radiation therapy is a very technical treatment and takes a great deal
of work by the radiation oncologist, the dosimetrist and the radiation
physicist to create a radiation plan which would deliver the required
dose of radiation to the cancer while minimizing radiation dose to the
surrounding normal and critical organs. To create such a fine balance,
sophisticated technology and treatment planning software are utilized.

Traditional radiation therapy used plain X-ray films to map the target
area and radiation fields. This was a two-dimensional technique and
the exact dose of radiation to critical organs was not determined
carefully. Three-dimensional conformal radiation therapy uses CT scans
to carefully define each and every critical organ at risk of receiving
radiation as well as the tumor itself.

Over the past decade or so a more sophisticated form of
three-dimensional conformal radiation therapy called IMRT (Intensity
Modulated Radiation Therapy) has evolved. This technique utilizes
reverse planning. That is instead of learning how much of radiation
the critical organs would receive should we deliver a certain dose of
radiation to a tumor, we can set limits on how much of radiation these
organs can tolerate in advance.

Nowadays we also have the capability of fusing MRI and PET images with
our CT scan images to enhance the quality of our contours and mapping
of the target areas. By doing so we can be more precise in focusing
radiation on the areas requiring radiation.

So in general before starting radiation treatments a planning session
or simulation is required. During this session immobilization devices
are used prior to obtaining CAT scan of the area which requires
radiation. Once the images are obtained, a radiation oncologist would
define i.e. contour the target area as well as adjacent critical
organs. Radiation oncologist would set limits on how much of radiation
these organs can safely receive and also prescribes the required dose
of radiation to the tumor.

Using sophisticated treatment planning software, the dosimetrist would
generate one or more plan for the radiation treatment. Radiation
oncologist would review the plans and chooses the plan which has
optimized the dose of radiation to the target and adjacent organs.
Once the optimal plan is chosen, the physicist would review the plan
for quality assurance and subsequently approved by radiation
oncologist.

Prior to delivering the very first fraction of radiation, patient
would undergo another simulation consisting of obtaining films on the
radiation table (AKA Port Films). Radiation oncologist would review
these films to make sure that everything is aligned with what has been
planned. Once the radiation oncologist approves these films, the
actual treatments can begin.

Patients are anxious to begin radiation immediately but as you can
appreciate, a considerable amount of time and work is spent in
preparation for radiation. Our moto as radiation oncolgoists: safety
first!

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started). Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Whether you have initiated the visit or another physician involved in your care, has referred you to a radiation oncologist, you are there to learn whether radiation therapy is indicated as a part of your treatment. If indicated, you will also be given information on the area where radiation would be focused on, the total dose of radiation. the number of radiation treatments necessary as well as its potential acute (aka early) and late (chronic) side effects. The radiation oncologist may also share the data supporting his/her recommendation.

How you can prepare yourself for your first visit with a radiation oncologist is very similar to visiting any other specialist but what makes it unique and in some instances challenging, is the many myths around radiation therapy. So the best you can do for yourself and the radiation oncologist you are seeing is to remove any myth from your mind. The experience your grandmother or neighbor had with radiation treatment is totally irrelevant to your situation. Maybe they had a different form of cancer. Maybe their cancer was the same but presented at an earlier or later stage. With the rapid and progressive improvement in radiation technology, comparing radiation treatment your grandmother received 10 or 20 years ago with yours, would be comparing apples and oranges. So do your best to remove the myths and fears and receive the information with an open mind.

The information one can find on the internet is as good as its source. So unless you have been given a reliable source of information, do not trust everything you find on the internet. Acquiring misinformation would not only not be helpful to you, it may increase your anxiety and apprehension about radiation treatments.

In general, I would recommend the following for preparation for your visit:

1. It is a great habit to obtain a copy of all pertinent information prior to your visit. Even though, with your permission, physicians offices communicate these vital information prior to your visit, any missing information can interfere with having a productive consultation.
2. It is extremely helpful to have your own version of your medical and surgical history to include all your past medical issues, the medications you are taking (including the supplements you might have bought at GNC or given by your chiropractor), your allergies, and very importantly your family history of cancer. Your family history of cancer may lead into genetic testing and completely change the recommended treatment for your specific cancer.
3. It is helpful to have someone accompany you. You will be given plenty of new information making it almost impossible to retain all of it. Having a second pair of ears and eyes, especially if your company would take notes, would be extremely helpful in recording and retaining the information.
4. Prepare questions ahead of time and do not hesitate to ask about anything you do not understand. As smart and intelligent as you are, you are not a radiation oncologist and are not expected to understand all the technical details of it.
5. At the end of your consultation, repeat a summary of the information you have received. It is not unusual to misunderstand something and you can only correct that by comparing your understanding with what the radiation oncology meant to tell you.
6. If you feel that you have not grasped all the information or have remaining questions, do not hesitate to ask for a second visit when you can spend more time clarifying those matters with your radiation oncologist.
7. Please understand that that final decision regarding your treatments is yours. If you do not feel comfortable with the information you have been given, do not hesitate to seek second opinion.
8. If you have received radiation in the past, please make sure to have details of your previous treatment, because that is crucial in determining whether you can receive radiation again or not.
9. Please understand that preparation for your radiation treatments may take anywhere from days to weeks. Do not expect to start your treatment on the day of your consultation.
10. Breaks during your radiation treatments would negatively impact the outcome of your treatments. So be prepared to cancel a trip you had scheduled a year ago if your radiation oncologist finds it detrimental to delay start of your radiation treatment.
11. Sometimes radiation and chemotherapy are recommended together. Even though your radiation oncologist and medical oncologist would do their best to coordinate your treatments, consider yourself a member of the treatment team and have all the information you can get to facilitate the coordination.
12. If it alleviates your anxiety ask for a tour of the department, take a look at the radiation machine and meet all the members of radiation team including radiation therapists, the dosimetrist and the physicist.
13. It is often helpful not to rely on your imagination so ask your radiation oncologist to show you some images of radiation plans and beams. It may put your mind at ease.
14. Just as you do at radiology department, please notify your radiation oncologist if you are pregnant or there is any possibility you might be pregnant
15. And last but not the least ask your radiation oncologist for reliable sources (books, websites, brochures) to educate yourself not only on your radiation treatments but also its potential side effects and your nutrition throughout the course of treatment. Whether you have initiated the visit or another physician involved in your care, has referred you to a radiation oncologist, you are there to learn whether radiation therapy is indicated as a part of your treatment. If indicated, you will also be given information on the area where radiation would be focused on, the total dose of radiation. the number of radiation treatments necessary as well as its potential acute (aka early) and late (chronic) side effects. The radiation oncologist may also share the data supporting his/her recommendation.

How you can prepare yourself for your first visit with a radiation oncologist is very similar to visiting any other specialist but what makes it unique and in some instances challenging, is the many myths around radiation therapy. So the best you can do for yourself and the radiation oncologist you are seeing is to remove any myth from your mind. The experience your grandmother or neighbor had with radiation treatment is totally irrelevant to your situation. Maybe they had a different form of cancer. Maybe their cancer was the same but presented at an earlier or later stage. With the rapid and progressive improvement in radiation technology, comparing radiation treatment your grandmother received 10 or 20 years ago with yours, would be comparing apples and oranges. So do your best to remove the myths and fears and receive the information with an open mind.

The information one can find on the internet is as good as its source. So unless you have been given a reliable source of information, do not trust everything you find on the internet. Acquiring misinformation would not only not be helpful to you, it may increase your anxiety and apprehension about radiation treatments.

In general, I would recommend the following for preparation for your visit:

1. It is a great habit to obtain a copy of all pertinent information prior to your visit. Even though, with your permission, physicians offices communicate these vital information prior to your visit, any missing information can interfere with having a productive consultation.
2. It is extremely helpful to have your own version of your medical and surgical history to include all your past medical issues, the medications you are taking (including the supplements you might have bought at GNC or given by your chiropractor), your allergies, and very importantly your family history of cancer. Your family history of cancer may lead into genetic testing and completely change the recommended treatment for your specific cancer.
3. It is helpful to have someone accompany you. You will be given plenty of new information making it almost impossible to retain all of it. Having a second pair of ears and eyes, especially if your company would take notes, would be extremely helpful in recording and retaining the information.
4. Prepare questions ahead of time and do not hesitate to ask about anything you do not understand. As smart and intelligent as you are, you are not a radiation oncologist and are not expected to understand all the technical details of it.
5. At the end of your consultation, repeat a summary of the information you have received. It is not unusual to misunderstand something and you can only correct that by comparing your understanding with what the radiation oncology meant to tell you.
6. If you feel that you have not grasped all the information or have remaining questions, do not hesitate to ask for a second visit when you can spend more time clarifying those matters with your radiation oncologist.
7. Please understand that that final decision regarding your treatments is yours. If you do not feel comfortable with the information you have been given, do not hesitate to seek second opinion.
8. If you have received radiation in the past, please make sure to have details of your previous treatment, because that is crucial in determining whether you can receive radiation again or not.
9. Please understand that preparation for your radiation treatments may take anywhere from days to weeks. Do not expect to start your treatment on the day of your consultation.
10. Breaks during your radiation treatments would negatively impact the outcome of your treatments. So be prepared to cancel a trip you had scheduled a year ago if your radiation oncologist finds it detrimental to delay start of your radiation treatment.
11. Sometimes radiation and chemotherapy are recommended together. Even though your radiation oncologist and medical oncologist would do their best to coordinate your treatments, consider yourself a member of the treatment team and have all the information you can get to facilitate the coordination.
12. If it alleviates your anxiety ask for a tour of the department, take a look at the radiation machine and meet all the members of radiation team including radiation therapists, the dosimetrist and the physicist.
13. It is often helpful not to rely on your imagination so ask your radiation oncologist to show you some images of radiation plans and beams. It may put your mind at ease.
14. Just as you do at radiology department, please notify your radiation oncologist if you are pregnant or there is any possibility you might be pregnant
15. And last but not the least ask your radiation oncologist for reliable sources (books, websites, brochures) to educate yourself not only on your radiation treatments but also its potential side effects and your nutrition throughout the course of treatment.

Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first. Even though the new radiation technology has given us the capability to spare patients from significant skin burns, depending on the type of cancer and its location, sometimes either the skin itself is the target of radiation or it is impossible to spare it completely. Skin burn from radiation in many ways is similar to a sunburn. There are a number of products that radiation oncologists may recommend to alleviate the discomfort from the skin burn. These include but are not limited to Aquaphor ointment, Miaderm Lotion, Aloe Vera gel, Calendu, RadX Radiation Therapy cream, Radia-Guard lotion and many other products. If the skin has blistered or the shiny and moist part of skin is exposed Silvadene cream and/or a variety of gel wound dressings may be recommended. In worst case scenarios, your radiation oncologist may decide to advise a break in the course of treatment but this has to be weighed carefully against the negative impact of breaks during radiation on the final outcome of treatment. Avoiding sun exposure and products containing alcohol is advisable. Cleaning the area with mild and fragrance-free soap and water to prevent infection is essential. If the affected area is in perineal area, sitz baths with water and Hydrogen Peroxide would be helpful. Women should avoid wearing wired bras if the treatment area includes the chest. Please do not use any product without consulting your radiation oncologist first.

Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine. Traditionally the indications for post-mastectomy radiation have been as following:
- A tumor 5cm (2 inches) or larger
- 4 or more lymph nodes involved by cancer
- Inflammatory Breast Cancer
- when the surgical margins of the mastectomy specimen are grossly or closely involved with cancer

About a decade ago, studies from Denmark and Canada revealed benefit of post-mastectomy radiation for women with 1-3 involved lymph nodes. Even though initially in the US we were slow to accepting these data, independent studies in US have convinced most of radiation oncologists in the US to recommend post-mastectomy radiation not only to post-menopausal but also premenopausal women with less than 4 lymph nodes involved.

Even though the above-mentioned factors continue to be indications for radiation after mastectomy a few challenges have been introduced to these seemingly straightforward indications in the past decade. This is mainly due to sentinel lymph node biopsy replacing most of complete axillary lymph node dissections, introductions of PET imaging and also increase in use of neoadjuvant chemotherapy.

The challenge sentinel lymph node biopsy has introduced is that often the number of lymph nodes removed are less than 4. The question of whether additional nodes need to be removed if one or more of these sentinel lymph nodes are involved, has been subject of debate amongst surgical, radiation and medical oncology experts for years. The recent publication of the results of the American College of Surgeons Oncology Group trial (Z0011) put this issue to rest because it showed that completion axillary dissection in these patients did not add local control or survival benefit. But it also left radiation oncologists in a dilemma regarding the necessity for irradiating the lymph nodes for patients with positive SLNs who do not undergo ALND is uncertain. So this issue is often addressed by assessing the individual's risk of having residual disease in the axilla.

When chemotherapy is administered prior to mastectomy, it can potentially completely destroy the cancer cells. That is an ideal outcome but would not eliminate the need for mastectomy. In such a scenario, the challenge for the radiation oncologist is whether postmastectomy radiation is necessary or not. If a sentinel node biopsy is performed prior to the administration of chemotherapy, the status of the lymph nodes prior to chemotherapy may provide helpful information regarding this dilemma, otherwise the radiation oncologist does not have such a basis for making the recommendation. The jury is still out on this issue and individualized recommendations must be based on taking other factors predictive of risk of local recurrence.

PET scans might suggest involvement of internal mammary nodes. Because of the risk of false-positivity and the fact that these nodes are not normally sampled or dissected, the decision regarding treating these potential positive lymph nodes by irradiating them becomes another subject of discussion at tumor boards.

So as you can appreciate, practice of radiation oncology, like many other fields in medicine is moving away from one size fits all towards individualized medicine.

The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment. The duration of radiation treatments are also determined by the type and stage of the courses. Before prescribing any dose of radiation, a radiation oncologist has to first determine what the intention of the treatment would be. Treatment intent is either palliative or definitive.

Palliative treatment are usually given either to palliate pain, remove compression of tumor on a vital organ such as spinal cord, preventing fracture if the cancer has spread to a weigh-bearing bone, or in the case of brain metastasis to relieve the life-threatening pressure inside the brain. Palliative treatments are often given in short courses of 2-3 weeks not only because the radiation dose per individual treatments (aka fractions) is usually higher but also because the total dose of radiation is lower. Palliative radiation is often used stage IV. That is when the cancer has spread to other organs and even though it might be treatable, it is not curable.

Definitive treatment is given when, based on the stage of the cancer, statistically there is a chance for its cure (i.e. stage I-III). Depending on the type of cancer, definitive radiation can take up to 9 weeks not only because the radiation dose per individual treatments (aka fractions) is usually lower but also because the total dose of radiation is higher. Definitive treatments are given to the primary site of cancer (i.e. original site where the cancer started).

Radiation is normally given five days a week Monday through Friday. In some instances twice a day radiation may be recommended. In this case the two treatments are at least six hours apart. How long each individual treatment would take depends on many factors including the dose per fraction, the number of fields used to treat a target, the technology used and the energy and form of radiation.

Brachytherapy (aka "internal radiation") is usually given in much fewer number of treatments. For example prostate seed implant requires one procedure to place the seeds in the prostate. In treatment of gynecological cancers depending on whether Low Dose Radiation (LDR) or High Dose Rate (HDR) radiation is used anywhere between 2 to 6 treatments often one to two weeks apart is given. In a similar manner systemic radiation, in the form of an injection or oral intake, would require much fewer number of treatments. For example treatment of thyroid cancer using I-131 often requires only one treatment.

What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both. What form of radiation a radiation oncologist would recommend depends on many factors but mainly the type of cancer, the stage of cancer and its location. What equips a radiation oncologist is not only four years of specialty training including radiation physics and biology but the evidence supporting these forms of treatments based on decades of research in the field. For each type of cancer there is a standard of care basically dictating what the appropriate radiation should consist of. For example for cervical cancer a combination of external radiation and brachytherapy is used. For prostate cancer one can use either external radiation or seed implant of a combination of both.

Good question, complex answer. I'll do my best.

In early stage cervical cancer, surgery is often possible but sometimes an organ-preserving approach is preferable and radiation can be used alone. In more advanced disease, surgery isn't possible but cure still is, so radiation is combined often with chemotherapy.

In these cases, radiation can be given partly with external x-rays, but to focus the dose some internal radiation treatment is also given. Usually, this is intracavitary brachytherapy (meaning close treatment in a cavity) by placing radioactive sources into the vagina, cervix and uterus.

Historically, radium was used. In the past 20 years, most of the brachytherapy has been with Cesium-137. Treatment required going to the operating room to place the applicator that would hold the radioactive sources, then determining how much Cesium to place internally for a period of 2-3 days while hospitalized. This is often referred to as LDR (low dose rate) brachytherapy because it's delivered slowly over time.

More recently there has been a move toward pulsed doses of HDR (high dose rate) brachytherapy with an Ir-192 source. This seems to be an equally effective approach with more radiation safety than LDR, but there are supporters for both approaches. The treatments are short but often more internal treatments are needed with HDR. Good question, complex answer. I'll do my best.

In early stage cervical cancer, surgery is often possible but sometimes an organ-preserving approach is preferable and radiation can be used alone. In more advanced disease, surgery isn't possible but cure still is, so radiation is combined often with chemotherapy.

In these cases, radiation can be given partly with external x-rays, but to focus the dose some internal radiation treatment is also given. Usually, this is intracavitary brachytherapy (meaning close treatment in a cavity) by placing radioactive sources into the vagina, cervix and uterus.

Historically, radium was used. In the past 20 years, most of the brachytherapy has been with Cesium-137. Treatment required going to the operating room to place the applicator that would hold the radioactive sources, then determining how much Cesium to place internally for a period of 2-3 days while hospitalized. This is often referred to as LDR (low dose rate) brachytherapy because it's delivered slowly over time.

More recently there has been a move toward pulsed doses of HDR (high dose rate) brachytherapy with an Ir-192 source. This seems to be an equally effective approach with more radiation safety than LDR, but there are supporters for both approaches. The treatments are short but often more internal treatments are needed with HDR.

Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on. Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on.

There are particular indications for using radiation therapy in the treatment in melanoma and broken down into three categories: primary disease, regional disease, and metastatic disease. For primary disease, radiation may be considered as adjuvant treatment (following surgery) for patients with desmoplastic type melanoma with extensive neurotrophism- findings determined by a pathologist examining the specimen under a microscope. For regional disease the following are indications after surgery: extracapsular extension, the involvement of 4 or more lymph nodes (two or more lymph nodes if cervical lymph nodes involved, size of the primary tumor >3 cm, and recurrent disease after prior complete lymph node dissection. Finally, for metastatic disease radiation therapy may be used to treat brain metastases alone or after surgical resection, and other symptomatic or impending symptomatic involvement of bony metastases or soft tissue resection. For more information please see The National Comprehensive Cancer Network (NCCN) Guidelines. Margins are determined by a pathologist reviewing the surgical specimen and measuring the distance from where tumor is seen to the nearest point of normal tissue. There are particular indications for using radiation therapy in the treatment in melanoma and broken down into three categories: primary disease, regional disease, and metastatic disease. For primary disease, radiation may be considered as adjuvant treatment (following surgery) for patients with desmoplastic type melanoma with extensive neurotrophism- findings determined by a pathologist examining the specimen under a microscope. For regional disease the following are indications after surgery: extracapsular extension, the involvement of 4 or more lymph nodes (two or more lymph nodes if cervical lymph nodes involved, size of the primary tumor >3 cm, and recurrent disease after prior complete lymph node dissection. Finally, for metastatic disease radiation therapy may be used to treat brain metastases alone or after surgical resection, and other symptomatic or impending symptomatic involvement of bony metastases or soft tissue resection. For more information please see The National Comprehensive Cancer Network (NCCN) Guidelines. Margins are determined by a pathologist reviewing the surgical specimen and measuring the distance from where tumor is seen to the nearest point of normal tissue.

Stereotactic radiosurgery is a type of external beam radiation therapy utilizes very precise and multiple beams in a small number of treatment fractions (one to five), and with a high dose delivered per treatment fraction. Often times radiosurgery is a terminology people refer to for a single fraction and stereotactic radiosurgery when it is more than one fraction- up to five, but the terms are relatively interchangeable. There is no surgery or cutting involved, as the treatment is non-invasive. Radiosurgery can be used to treat lesions in the brain, such as brain metastases, for spine metastases, and in the body for primary lung tumors, lung metastases, other organ metastases, and now to the prostate as primary treatment. Because of the ablative response of the tumor to this type of treatment it is now also known as stereotactic ablative radiotherapy, or SABR. Stereotactic radiosurgery is a type of external beam radiation therapy utilizes very precise and multiple beams in a small number of treatment fractions (one to five), and with a high dose delivered per treatment fraction. Often times radiosurgery is a terminology people refer to for a single fraction and stereotactic radiosurgery when it is more than one fraction- up to five, but the terms are relatively interchangeable. There is no surgery or cutting involved, as the treatment is non-invasive. Radiosurgery can be used to treat lesions in the brain, such as brain metastases, for spine metastases, and in the body for primary lung tumors, lung metastases, other organ metastases, and now to the prostate as primary treatment. Because of the ablative response of the tumor to this type of treatment it is now also known as stereotactic ablative radiotherapy, or SABR.

Brachytherapy for the treatment of melanoma is used for the treatment of choroidal or uveal (intraocular) melanoma as an eye-sparing technique. It is also referred to as plaque brachytherapy and can be performed with several isotopes including Iodine 125 (125I), gold 198 (198Au), palladium 103 (103Pd), and others. Guidelines are available by the American Brachytherapy Society: http://www.eyephysics.com/PS/PS5/UserGuide/References/PDF/Red_J_Articles/AmerBrachyRec03.pdf Brachytherapy for the treatment of melanoma is used for the treatment of choroidal or uveal (intraocular) melanoma as an eye-sparing technique. It is also referred to as plaque brachytherapy and can be performed with several isotopes including Iodine 125 (125I), gold 198 (198Au), palladium 103 (103Pd), and others. Guidelines are available by the American Brachytherapy Society: http://www.eyephysics.com/PS/PS5/UserGuide/References/PDF/Red_J_Articles/AmerBrachyRec03.pdf

Radiation therapy is used in the palliative settings for nearly all types of cancers. For example, it can be used to treat pain related to bone metastases from different primary sites, improve respiratory symptoms from a tumor blocking airways, improve swallowing conditions related to esophageal tumors. Radiation therapy can also be used in the prophylactic palliative setting for brain metastases, lesions in vertebral bodies before they cause pain or neurological symptoms, or impending bone fractures. For the majority of times a tumor causes symptoms there is often a role for radiation to address and improve them palliatively. Radiation therapy is used in the palliative settings for nearly all types of cancers. For example, it can be used to treat pain related to bone metastases from different primary sites, improve respiratory symptoms from a tumor blocking airways, improve swallowing conditions related to esophageal tumors. Radiation therapy can also be used in the prophylactic palliative setting for brain metastases, lesions in vertebral bodies before they cause pain or neurological symptoms, or impending bone fractures. For the majority of times a tumor causes symptoms there is often a role for radiation to address and improve them palliatively.

Radiation therapy treatment schedules and the doses delivered per treatment vary depending on the intent to treat (definitive or curative intent versus palliative intent), the tumor type (breast, prostate, lung, etc), a patient's overall condition, and the accessibility of patient to receive radiation treatment. Furthermore, centers with more state-of-the-art equipment can offer different treatment options because of the capability of the technology. There are treatment guidelines within the radiation community, as well. We encourage patients to do their homework, know that often times there are multiple treatment options available (even if the first place they go to doesn't have them), and to even call some of our patients who have completed treatment for other opinions. Radiation therapy treatment schedules and the doses delivered per treatment vary depending on the intent to treat (definitive or curative intent versus palliative intent), the tumor type (breast, prostate, lung, etc), a patient's overall condition, and the accessibility of patient to receive radiation treatment. Furthermore, centers with more state-of-the-art equipment can offer different treatment options because of the capability of the technology. There are treatment guidelines within the radiation community, as well. We encourage patients to do their homework, know that often times there are multiple treatment options available (even if the first place they go to doesn't have them), and to even call some of our patients who have completed treatment for other opinions.