Treatment approach, delivery, and follow-up evaluation for cardiac rhythm disease management patients receiving radiation therapy: Retrospective physician surveys including chart reviews at numerous centers

Abstract

In a 2-part study, we first examined the results of 71 surveyed physicians who provided responses on how they address the management of patients who maintained either a pacemaker or a defibrillator during radiation treatment. Second, a case review study is presented involving 112 medical records reviewed at 18 institutions to determine whether there was a change in the radiation prescription for the treatment of the target cancer, the method of radiation delivery, or the method of radiation image acquisition. Statistics are provided to illustrate the level of administrative policy; the level of communication between radiation oncologists and heart specialists; American Joint Committee on Cancer (AJCC) staging and classification; National Comprehensive Cancer Network (NCCN) guidelines; tumor site; patient׳s sex; patient׳s age; device type; manufacturer; live monitoring; and the reported decisions for planning, delivery, and imaging. This survey revealed that 37% of patient treatments were considered for some sort of change in this regard, whereas 59% of patients were treated without regard to these alternatives when available. Only 3% of all patients were identified with an observable change in the functionality of the device or patient status in comparison with 96% of patients with normal behavior and operating devices. Documented changes in the patient׳s medical record included 1 device exhibiting failure at 0.3-Gy dose, 1 device exhibiting increased sensor rate during dose delivery, 1 patient having an irregular heartbeat leading to device reprogramming, and 1 patient complained of twinging in the chest wall that resulted in a respiratory arrest. Although policies and procedures should directly involve the qualified medical physicist for technical supervision, their sufficient involvement was typically not requested by most respondents. No treatment options were denied to any patient based on AJCC staging, classification, or NCCN practice standards.

Introduction

Since the publication of the American Association of Physicists in Medicine (AAPM) Task Group no. 34 (TG-34) in 1994, medical physicists and radiation oncologists have struggled with how to manage radiation therapy for patients when heart rhythm devices remain implanted during treatment.¹ Such devices include implantable cardiac pacemakers (ICPs) and implantable cardioverter-defibrillators (ICDs). The evidence of this struggle was exhibited in a survey published by Solan et al. in 2004. They had statistically analyzed concerns and strategies for handling patients possessing either of these 2 devices during radiotherapy and also detailing the inconsistency in safety management for such patients among 71 responding ROs across the nation.² TG-34 guidelines for cardiac rhythm disease management (CRDM) in radiation oncology are now considered to be outdated. AAPM TG-203 has been charged with the effort to readdress all related recommendation.¹ TG-34 guidelines do not encompass modern technology and perhaps more importantly do not deal with ICDs at all. Still, this document widely remains the current practice standard within the community of ROs and medical physicists.

The intent of this research was to combine the outcomes of 2 independent studies about how patients possessing cancer with implanted CRDM devices are managed when dealing with their need for radiation therapy nearly a decade after the research by Solan et al.² First, in a survey study described here, 200 randomly selected physicians with either radiation oncology or vascular care specialties were asked to respond to various questions provided. The study design sought to qualitatively and quantitatively evaluate the number of patients seen by them annually, to assess their familiarity with dose limits and adequate management, and to explore differences in how patients were actually managed. Secondly, in a case review study described additionally, the medical records of 112 radiation therapy patients treated at 1 of 18 institutions were retrospectively examined to determine whether radiological concerns about damage to such devices were significant enough for a RO to invoke a change in the radiation prescription for the treatment of the targeted cancer, the method of radiation delivery, or the method of radiation image acquisition.