IMRT experience - how often was your treatment interrupted?

For those who've received IMRT treatments, how reliable was the x-ray machine you were on?  Did it act the same every time, or were there issues?  Did you ever outright miss a treatment day because of it?

I was to receive my 11th treatment (of 44) today.  Didn't happen.

The hospital's one-and-only, big, fancy-shmancy, super-whoopie, Varian Trilogy RapidArc Superman ray gun machine went down around lunch time, and they cancelled all the afternoon treatments pending repairs.  (Of course, not until I'd spent an hour and a half waiting for that delightful news, plus the nearly two hour round trip there and back.)

This thing was balky two other times in the last few days, though they were able to deliver therapy with it.  You get used to they rhythm of the treatment process, and it's unnerving when it changes. 

The first glitch: they rotated to first position for the first x-ray locator image (for IGRT), and then it paused so long the tech came in to tell me they had a "computer glitch".  Well, I work with industrial equipment, and I was mighty uncomfortable laying there with that mutha pointed at me while they (I suppose) rebooted the computer.  The delivery gantry head clicked a few times, then after more delay it finally revolved around and got going normally.

The second glitch: everything went ok until after the first treatment pass (there are two).  Then again the long pause, followed by a never-before-seen rotation of about 90 degrees with no delivery happening (you can hear the buzz when the linac is putting out).  Then another pause.  I called out, "What's happening?" because they weren't saying anything.  They said they were working out a small issue and treatment would resume shortly.  It then rotated back down into position, and the second treatment pass happened normally.  Afterward, they said the beam-shaping MLC leaves sometimes don't position right, and they found that moving the gantry and returning it to position would clear the error.  (It won't deliver if the MLC leaves aren't right.)

So far, for 11 scheduled treatments, I've had 8 normal ones, two with "issues", and today was a total failure.

Is this normal for these machines?  Or, is somebody dropping the ball with preventative maintenance or something?

They'll just add a treatment day onto the end of course, but my RO was fairly concerned about my leaving when we were debating whether to stay or not pending the repair.  He said he'd rather we stayed to wait out the repair estimate than just bail out, in case we might need to do that again at another time.  As it turns out we couldn't receive treatment today after all.  How many skipped days can happen before it screws up the treatment?

As if having the stupid disease isn't aggravating enough, to have erratic treatment equipment is just over the top.

Humph.

One of the questions I asked my rad onco was how often they did preventive maintenance on the machine and how did they insure accurate dosing and calibration. I don't recall the specifics of his reply but at the time the answer was sufficient to gain my confidence.

I had 45 sessions and not one was interrupted by malfunction or postponed for operational issues. You are right to question the operation of the machine.

Don

Out of my 39 treatments on the Varian, I probably got canceled 4-5 times due to various issues. The Radiation Oncology Center at UT Southwestern had two of the machines (more at other sites on the campus) and I can't recall a time when both were down at the same time. However, it was a high-volume center and when one machine went on the fritz, the PC guys were the first to be deferred so that folks with brain tutors, melanoma and the "more serious" cancers could stay on schedule.

There are so many things that need to be exact in the process that even a small burp will cause them to shut things down just for safety. I never had any hitches during an actual treatment and could always count on both of my 45-second passes to complete just fine. It was the skipped days that I experienced.

Evidently, missing a few days here and there is not that big a deal. I had a business trip I could not skip during the last few days of my treatment. Finished #37 on a Friday then picked up the last two visits on the next Thursday and Friday. Also had a long holiday weekend or two in the mix.

I can testify that the interruptions in service did not affect me.

...did not affect me.
...did not affect me.
...did not affect me.
...did not affect me.

..

My machine had minor issues but I never missed a session.

I was cancelled twice. Each time I was called in the morning and told the machine was down and my treatment plan was extended.

I don't think missing a day or two is a big deal. (I was always told that having two days off per week is good in terms of letting the body recover from the radiation, but given that the two days off just happens to coincide with the weekend it felt a bit disingenuous.)

I'd have to say there is a tremendous leap of faith in undergoing external radiation. You have to assume the RO has concocted the right plan. Then they have to execute it right. Next, that machine has to be accurate to the smallest tolerance with the precise amount of radiation. So when problems like this happen, it can sure jar your faith in the whole process.

Yep. Happened to me 2-3 times where they had to reboot the Varian RapidArc machine.

This is a stressful time and it was unnerving.

Mel

Yes - these are very complex and delicate machines. Being a high tech guy and having worked on similar systems, I am amazed that they get as many people on those things in a day as they do. Frankly I am surprised they don't break down more often given the number of motors, interlocks and safety systems plus the high end computer driving the whole thing.

I got delayed three times but never completely canceled. The center I went to had 3 varian machines and I was told once that they were going to switch me to another machine and then the tech was able to get the machine I was scheduled on fixed. Two of the problems were nothing to do with the machine - the tech couldn't get to the hospital database to download my ID info and machine program. One time the machine did a bunch of fits and starts. They call Varian tech support and a tech was there in like 15 minutes and got it going again - some kind of calibration problem. Didn't get details.

In each case I was offered to skip or hang around and see if they could fix. My longest wait was an hour.

Since my job is working on high tech gear, I was never worried since I could ask technical questions and always got answers that made sense. They were very upfront about what was going on.

Still, it's a bit worrisome to have problems on a machine like that and I was always move than a bit nervous about being the first one back on the machine after a problem. And the water thing always played into - once I couldn't hold, peed and had to drink another bottle.

All the best,
Andrew

Thanks for the feedback, everyone. I manage a lab with quite a few large, complex, and delicate machines so I do understand how they fault out periodically. Even with preventative maintenance, unpredictable things can happen.

Michael, you make a great point. I think the amount of trust involved in this treatment plan is a big part of the problem. There are so many links in the treatment chain that having issues with the machine does cause one to question everything. As with just about everything else, it's about my control issues.

There's no point in worrying about it at this point, since this isn't in my control anyway.

An interesting observation though, I realized on the way home that the radiation treatments do make me feel a bit "off" afterward. It wasn't clear if that was just a side effect from the ADT2, but I felt quite a bit different (better) than usual after a radiation treatment happens. After one it feels a bit like one does when coming down with something, a little flu-like. None of that yesterday. So it's not a total loss; we did learn something :)

Thanks again!

I had some skipped days that were added on at the end but, while I was apprehensive at first, I thought about it a bit and decided not to worry. I figured that I had a two day break every weekend and no one ever thinks to be concerned about those so an extra off day here or there couldn't be a big deal.

I also reasoned that cumulative is cumulative. I was getting the same amount of radiation and, if there is all this concern about adding more radiation down there even years in the future then a day or two couldn't make much of a difference.

I met with my radiation oncologist weekly throughout my treatments. When I had a question/concern I asked and got reasonable answers.

Allen, it seems to me the machines will eventually be able to track the actual organs, and apply a desired dose parametrically. The machine would take a scan, present it as a 3D image, and the doctor would highlight what's to be treated and by what extra margin. Then the machine watches the actual organ or tumor as it treats, and sculpts the dose to the exact tissues right where they are in real time. Everything we're doing today approximates that vision, but with more detailed imaging technologies someday I think they'll do it in one integrated process.

Or, they bail on radiation entirely once a fully-effective immunotherapy process is developed.

Anyway, today the machine was back up and ran just fine, so I enjoyed another treatment. Apparently it had a bad cable, which had to be procured, delivered, and installed. They got it running this morning.

And, now I am feeling a little woozy, and a little tired, which I now realize is a noticeable side effect of the radiation even though I'm just 11 into the series.

Thanks again all for the perspectives on this. I'm not going to sweat it if there's a day here and there. But, the sooner I'm done with this the better; it's definitely an endurance event.

The only cure I know for radiation-induced fatigue is exercise. Of course I know it's the last thing you feel like doing now

I think Tomotherapy works somewhat like you describe -- no fiducials -- it uses a realtime CT scan of the organ during treatment. If I had any money I'd bet on nanotechnology as the most promising future therapy - but it's a long way off.

Hey IMRT guys,

I had my 19th of 41 IMRT treatments yesterday. Our center does not use the Varian, but does utilize cone beam CT. I was delayed one morning due to repairs but got the treatment later the same day. On the se front, I have just started increased frequency of both no. 1 and 2, otherwise everything is going well according to my RO.

Best to all,

Robert
NC

Funny this thread should pop up again today.

I just had treatment #16 of 44. My appointment was at 12:45. I didn't get into the room until 1:40, almost an hour late. Needless to say, my bladder was about to bust. They were having various little delays with their equipment (and patients), and were running quite late. They finally called me into the treatment room, and I said I'm only good for about 10 more minutes.

Wouldn't you know, the machine stalled during the initial x-ray positioning, and then there was a looonnnggg pause. I asked what's up, and they said they had a small problem. After about one more minute, I called out to be let down because the flow was about to release! They couldn't even lower the table, so I had to climb down on a chair. Freakin' machine!

So, quick-step to the head for blessed relief. Then, another 20 oz of water and wait another 45 minutes. It took them about 20 more minutes to fix the machine, did another patient, then called me in and had a successful treatment.

So, I'm underwhelmed by the Varian's reliability. It really sucks to sit there with increasing pain from a distended bladder. But if by some off chance they actually call me in on time (only happened once), I want to be sure I'm full.

Timing this water torture is rough if the actual time hitting the table varies by an hour!