Future of Radiation Oncology?

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I came across this paper which brought some salient points about the future of rad onc that concerns me. http://www.ncbi.nlm.nih.gov/pubmed/18513631

In summary, it details how radiation oncologists have changed from their historical role as complete oncologists to becoming a "one-trick pony" with just a single modality for treatment. Being at the mercy of other doctor's referrals, there is a huge growth in surgeons controlling radiation therapy (i.e. neurosurgeons and urology) where they have a "token radiation oncologist" or perhaps none at all. In multidisciplinary practices, radoncs might end up working for medoncs who have now taken the baton as the "complete oncologist."

It seems like the authors feel that radonc's faustian pact with technology will make radonc irrelevant in the future given the trend for more automation that make human input less and less important. Whereas surgeons in the past were unable to administer radiation due to the vast amount of knowledge required about the side effects and the correct dose, modern technology has now made it much easier for surgeons to do the radiation therapy with the aid of ever increasing automation and ease of use.

I was wondering what you guys thought about this article and if radonc is in as a precarious position as the authors make it seem. If radonc takes a more assertive role in the administration of radiation therapy and if stark laws are enforced more vigilently, will this be enough to stave off threats that other specialties are posing? Or will there be a day of reckoning to come?

Read the FAQ. Do a search. There are at least 3 threads in the last few years with the exact same title as yours.

Nobody can predict the future. The practice of Rad Onc will change over time no doubt just like every other field in medicine. Reimbursement will drop and paperwork will increase just like every other field in medicine.

Rad Onc will not become obsolete in the conceivable future.

One of your observations is completely wrong. Namely that radiation was once harder to administer but is now much easier due to technology. The opposite is true. With increased technology has come requirements for ever increasing knowledge of detailed anatomy, radiation physics/biology, and QA. This is hard to explain to someone without knowledge of the field but if you compare a H&N IMRT plan with what was done 20 years ago, you would understand.

Finally a lot of problems are self-made by us. For every thread you see about Rad Oncs administering chemo you see fifty threads about salary, lifestyle and vacation. We have accepted our high salary and lifestyle as the cost of reduced autonomy. You can combat this somewhat in your own practice by taking ownership of your patients, visiting them as inpatients, and following up with them more meticulously. However in the end, I think multi-specialty oncology groups are the way of the future.

That paper was an interesting read. There is indeed a trend of urologists administering IMRT for prostate cancer and neurosurgeons doing gamma knife procedures for gliomas. The problem is that radoncs must take all their patients from referrals and the urologist has a high incentive to refer the patient to his own IMRT center rather than to another radiation oncologist. I agree that the more that technology increases, the more temptation there might be for other specialties to do the radiation themselves--epecially given the high billing codes.

Nobody has a crystal ball that can predict the future, but radonc is a small field and only recently became very popular. It is perhaps a bit more vulnerable than other specialties in my opinion, especially if this is a topic that comes up a lot on FAQs and multiple threads in many years.

I also found this article an interesting read:
http://jco.ascopubs.org/content/28/35/5160

This one doesn't look at the modality of radiation therapy itself, but rather the supply and demand of radiation oncologists and cancer patients.

As a summary, the article predicts a 22% increase in the number of cancer patients in 2020 compared to 2010, and a 2% increase in the number of radiation oncologists assuming the number of residency spots remains constant.

I think that speaks to good job security over at least the next decade.

Originally Posted by Gfunk6

Read the FAQ. Do a search. There are at least 3 threads in the last few years with the exact same title as yours.

Nobody can predict the future. The practice of Rad Onc will change over time no doubt just like every other field in medicine. Reimbursement will drop and paperwork will increase just like every other field in medicine.

Rad Onc will not become obsolete in the conceivable future.

One of your observations is completely wrong. Namely that radiation was once harder to administer but is now much easier due to technology. The opposite is true. With increased technology has come requirements for ever increasing knowledge of detailed anatomy, radiation physics/biology, and QA. This is hard to explain to someone without knowledge of the field but if you compare a H&N IMRT plan with what was done 20 years ago, you would understand.

Finally a lot of problems are self-made by us. For every thread you see about Rad Oncs administering chemo you see fifty threads about salary, lifestyle and vacation. We have accepted our high salary and lifestyle as the cost of reduced autonomy. You can combat this somewhat in your own practice by taking ownership of your patients, visiting them as inpatients, and following up with them more meticulously. However in the end, I think multi-specialty oncology groups are the way of the future.

I was just summarizing what I read in the article. You're right in that I have no idea about the nuances and intricacies of the field and treatment plans, but I was assuming that Dr. Zeitman from MGH did.

"As radiation oncologists, we perceive ourselves to have a
holistic clinical outlook seeing patients at every stage of their
disease from curative to the most palliative. We see ourselves
as discriminating users of our modality, selectively picking
the arrows in our quiver and artfully manipulating dose, dose
rate, and fractionation to improve outcome. This skill-set
would appear to make us unique and secure in our field, but
this is a concept that needs close examination. As the therapeutic
options increase (and radiation is just one of several),
as others feel empowered to select treatment for us, and as
technology becomes increasingly automated, then our input
becomes progressively less relevant. Others could do this job
and indeed are. If there is less and less need for specialized
human input, there is less and less need for a specialist. If we
examine the nature of a radiation oncologist’s craft, we can
find a soft underbelly to many of the tasks that comprise our
working day. The initial evaluation of the patient for therapy
may be a formality that follows a decision already made by a
medical oncologist or surgeon. The simulation, the drawing
of volumes, and the treatment planning is now largely performed
by technicians and dosimetrists but is increasingly
automated and will increasingly be outsourced. The latter, in
particular, opens the therapy to nonradiation oncologists
lured by high reimbursement."

As a disclaimer, I am not trying to attack the field, and I seriously am considering doing radiation oncology. It's just that I want to weigh all the pros and cons before commiting myself to this career and wanted to see what other people who are similarly interested or are currently in the field felt about this. Quite frankly, this paper has scared the bejesus out of me and in a way maybe I'm just looking for some reassurance that everything Dr. Zeitman has said is not necessarily true. It seems like he wants to end the lifestyle and salary of radonc and make it more like medonc in order for the field to be more relevant. He also seems to have a strong aversion to technology which is the biggest draw to me about radonc

I've heard Dr. Zeitman give his presentation on this topic at ASTRO. I think he makes some excellent points in safeguarding the autoonmy of our specialty. Like I posted taking charge of our patients, etc. is important. Also it's vital to continue to educate other physicians about what we do.

Some things will never happen in my view like Rad Oncs administering oral chemo.

I think Dr. Zeitman's ultimate fear is that Rad Oncs may be employed as technicians (albeit well-paid ones) by other physicians if we don't take care to preserve our autonomy. I believe this is his main point, not that others will start administering radiation.

This is one of those things where each of us can make a positive impact on the field, but presupposes that we value our role of physicians more than a cushy lifestyle. This is not a given for all of us.

We do have a few things going in out favor that I should point out:

1. A better grasp of primary literature than others; we have more pure oncologic training than any other specialty

2. An understanding and good grasp of image-based anatomy; you'd be surprised at how many Med Oncs just read the radiology report without looking at imaging

3. We do a lot of procedures; outside the obvious brachytherapy we also do procedures like fiberoptic laryngoscopy

4. The number of Rad Oncs is tightly regulated to prevent any possible surplus

Could anyone post a PDF of the Zietman article?

Unlike derm or plastics, radonc hasn't been popular amongst med students for more than 5 to 10 years or so. In the past, radonc was what IMGs matched into but now the field is so uber-competitive that it probably rivals dermatology.

Things in medicine change so fast and everything is in a state of flux especially with the health care reforms. If you ask me, radonc certainly has the potential to go back to where it was a decade ago. If you examine the field very closely, there are no HHMI investigators, no members of the academy of sciences, and few people who routinely publish in Nature and Science. This is probably due to the fact that the people who matched in rad onc in the past were not the highest caliber students. Compare this to derm which has a ton of HHMI investigators despite the field being just as small and probably much less significant.

The fact that radiation oncology now attracts an increasingly higher quality pool of applicants is a reason that the field would become more prominent in the future, not a reason for it to fade into obscurity.

If you are worried that the field of radiation oncology will crater due to:

-scientific advances in magic chemotherapy/nanotherapy/magic which will obviate radiotherapy
-failure to attract "top" med students who would otherwise go into derm/ortho/whatever-makes-mommy-proud-cuz-its-competititve-this year
-reimbursement only being 3x what peds makes instead of 4-5
-urologists/med onc/HMOs/hospitals limiting rad onc autonomy

you are taking your eye off the ball. As Zietman notes, the goal is not to preserve "radiation oncologists" it is to kill cancer and save patients. As long as we put patients first, the rest is far secondary.

However, so far, I don't see us getting hosed too badly in the future. If Ben Smith's article is believed, demand for us is going UP, not down. Med student applicant quality is skads better than any field (I'd be shocked if anywhere near 20% of derm residents had PhDs). Rather than becoming glorified technicians, the increased complexity of RT plans is placing a premium on Rad Onc clinical quality not reducing it. Finally, please realize everyone in medicine wants a cut of the money in every specialty; if you want UroRad to dissappear overnight, just cut reimbursement Real cancer centers will still be standing.

If you go into this field because you think it has a rosy job outlook, high reimbursement, high social esteem and professional autonomy, fine. Glad you picked RO over dentistry.

I'd rather you go into it because you want to help patients not suffer and/or die.

Sorry for the rant. PGY-5 almost over and I'm getting disinhibited.

In fact, in Europe, they are also discussing the future of radiation oncology, maybe chang is necessary.

http://www.thegreenjournal.com/artic...194-0/fulltext

Relying on a single modality is very risky in a rapidly changing world.

Originally Posted by PromisingCapita

Relying on a single modality is very risky in a rapidly changing world.

Relying on pithy one-liners from med students with little no/knowledge of Rad Onc is unwise.

Originally Posted by PromisingCapita

Relying on a single modality is very risky in a rapidly changing world.

Originally Posted by Gfunk6

Relying on pithy one-liners from med students with little no/knowledge of Rad Onc is unwise.

Zing!

Question for those of you further along:

Based on articles like Zietman's and the ESTRO article a few posts up, do you think that should factor in to a decision to pursue Radiation Oncology? Its hard for us in our third and fourth year to judge how legitimate these concerns are since we have such limited exposure.

With these concerns popping up, do you see them in your everyday practice?

If something were to come to pass like either of these authors fear what do you think would happen to Radiation Oncologists already practicing? Would they transition to the new model?

(Disclaimer: This post is NOT about financial concerns, or a cure for cancer. This is just about the concerns posited by Zietman and ESTRO)

Originally Posted by Sheldor

Question for those of you further along:

Based on articles like Zietman's and the ESTRO article a few posts up, do you think that should factor in to a decision to pursue Radiation Oncology? Its hard for us in our third and fourth year to judge how legitimate these concerns are since we have such limited exposure.

Sure, I think it is healthy and reasonable for med students to factor in everything they know and hear about their future specialty. However, many of these factors are not truly unique to Rad Onc. In an era of dropping reimbursements and increased paperwork, more and more physicians are trying to preserve their lifestyle at the expense of their autonomy. This is manifested in various ways:

1. Emergence and strength of mid-levels such as NPs and CRNAs; from a physician perspective, mid-levels were meant to complement MDs not replace them; however, mid-levels are now clamoring for independence in numerous states

2. The rise of the physician-employee; nowadays, more and more residency grads would rather clock-in and clock-out without having to deal with the B.S. of business management and have decided to go for salaried positions employed by hospitals or medical foundations; your bosses are no longer your fellow MDs but MBA types

3. Due to the shift in medicine to fee-for-service (specifically procedures) many MDs have attached their fate to high reimbursing modalities related to their specialty; this is manifested as Urorads in our specialty; other specialties have "pill mills," "cosmetic, cash-only business," etc; in these scenarios, MDs are not incentivized to take charge of patients but rather to perform a service

All three of these things = reduced physician autonomy. I don't think Rad Onc is particularly worse than any other field.

With these concerns popping up, do you see them in your everyday practice?

If something were to come to pass like either of these authors fear what do you think would happen to Radiation Oncologists already practicing? Would they transition to the new model?

Ultimately, you as a physician will be able to dictate your future. When you search for a job, you will have to decide what's important for you. Some people, unfortunately, are happy to be billed as technicians (or Radiation Pharmacists) if the pay and lifestyle are good. Others will be willing to take a hit on both to preserve the autonomy of their profession.

There are places in the country where a Rad Onc is considered a glorified tech and others where he/she is an Oncologist first with an expertise in delivery of radiation second.

The chair at my home program once told me that "they" had been predicting "doom and gloom" for this profession since he went into it back in the 70s. One could make a strong argument that it did go through a rough patch in the 80s, but the advancements over the past 20 years have made this field a cornerstone of cancer treatment. It would take radical new approaches/advancements to shut us down and that's assuming they weren't tools we would use. Each of us has to decide for ourselves what we believe.

Not a radonc, but going into interventional rads and further into intervetional onc and thought I would weigh in since similar things have been said about IR (rads in general).

It seems that each field is predicting every other fields demise every few years or so, read any other specialty forum on this site and you will find a "what is the future of xx specialty?"; radonc and IR are in particularly sensitive to this because both fields are dependent on referrals, so the existence of our fields is dependent on other fields and the main fear is what if the referring specialty decides to just do the therapies we offer themselves.

This has happened in IR to a certain extent with vascular (though a full 30% of PAD and almost all endovenous stuff is done by IR) and similar things happen with gamma knife (though from my rad onc friends it seems to not be quite as extensive); I personally find these kinds of things good for the field because it forces re-evaluation and strengthens the field that percieves itself to be threatened (i.e. survival of the fittest)

Like some people already said, there are places where radoncs are just glorified techs, and there are places where they run tumor board (like where I'm at); likewise for IR, you can be a proceduralist and rake in the money or you can be a doctor, take a small pay cut, but do the kind of medicine you want to practice

There are and will always be places for any physician to practice the kind of medicine that they want, whether it's assembly line or true comprehensive care.

The reason I decided to butt in, is because I almost switched out of IR for these exact same feelings, and had somebody not stepped in and said something to me I would have regretted that decision.

If you are choosing radonc (or any other field) for anything other than interest in the specialty you will invariably be disappointed.

From a more objective point of view, there is a big crackdown on self-referrals and a movement to the employee model will actually benefit tertiary referal specialties because there will be less incentive to do more work when you are drawing a salary.

Originally Posted by davidjones

From a more objective point of view, there is a big crackdown on self-referrals and a movement to the employee model will actually benefit tertiary referal specialties because there will be less incentive to do more work when you are drawing a salary.

Which never made much sense to me. We'll stop a private doc from referring to him/herself, but there's no problem with referring to your hospital employer who writes your paycheck and gives you "production bonuses" for referrals.

it actually does make sense.

I'm not 100% clear on urorad, but from what I can glean it is a urology group which owns radiation therapy equipment and employs a rad onc to use it (please correct me if I am wrong) therefore it is in the urologists' financial interest to send as many pts as possible to radiation therapy where there is a huge technical fee, and the rad onc gets the professional fee, which is significantly less.

A radiology example: ortho owns an MRI machine and sends all pts with back pain for an MRI of the spine, they collect a huge technical fee (often in the thousands of dollars), and send the images to be read by a rad group where they have a contract who then interprets the images and collects the professional fee (the professional fee for an MRI spine is somewhere in the range of a few hundred dollars, i.e. about 10% of the technical fee)

Now consider a hospital employed urologist and orthopod, where the hospital employs the rad or rad onc(who often gets a component of the technical fee, though nowhere near a huge cut); it is no longer in the financial interest of the urologist or orthopod to send their patients for imaging/rad therapy, as they get absolutely no benefit, and now really the major component that plays a role in deciding therapy is benefit to the patient and EBM. The hospital takes a huge cut, but at least the patient gets the appropriate imaging/therapy etc.

The reason this model works is because both rad onc and radiology can't self refer (except IR, which can and does, though infrequently and in multi-specialty groups for things like fibroids and post-chemo/radioembolization MRIs, but needs to stop as it is extremely hypocritical)

If you look at the driver for imaging overutilization, it's not radiologists, it's some 10% of doctors (ortho,cards, urology, neurosurgery etc) who account for an outrageous (something like >50% ) amount of imaging

No matter how much altruism we say we have as physicians or how much we claim we only do what is best for the patient, money is a huge motivator for self-referal; You take away that kind of incentive and you get something like the VA model, which in many places work, every specialty does what it is supposed to do and turf battles more or less don't exist. Of course the salary is lower, but none of us chose our specialties based on income right?


I don't want to hijack this thread, so if you have any other questions (or anyone else for that matter) please feel free to PM me

I call huge BS.

If the hospital owns the machinery, i.e., the technical component of the fee, then they are now the drivers of the decision making. There are at least a few ways they can do this, and many more that I'm not smart enough to think about. These are at least 3 that I know that major hospital systems utilize:

1) Incentivise the behavior of the referring physicians - the more MRIs your refer for, the greater your bonus; the more prostate cancers you refer for prostate IMRT, the greater the bonus

2) Incentivise the behavior of the referred-to physician - set up algorithms or "clinical pathways" to lead providers to utilize more expensive (and reimbursed for) techniques - i.e. all rectal/cervical/endometrial cases should be IMRT, and your bonus will be dependent on that; set up pathways to utilize specific fractionation schemes that may be more expensive

3) Incentivise referred-to physicians to utilize other profit-maximizing supplemental diagnostics and treatments - i.e. when a patient has breast cancer, push for breast MRI regardless of the clinical situation, because currently Medicare and everyone else is paying for it; when a patient has multiple brain metastases, have the algorithm point towards an SRS boost after WBRT, no matter what the situation, because most insurers are paying for it.

The hospital is not altruistic. The current mechanisms do not do anything to make them order less tests, order less treatments, and order less expensive tests/treatments. In fact, everything is place to make them spend more. It is naive to think that putting the decision/profit-motive in the hands of a CEO of a hospital (profit or non-profit) will make them more thrifty.

From what I've seen in private practice, the truth is, I'm cheaper than the average rad-onc, but if I was employed by the hospital, you'd better believe I'd be more expensive - too much pressure from management not to.

For any private practice docs out there, count the number of PET-CTs and MRIs ordered by the hospital for patients with stage I breast cancer. That will tell you right there whether or not the hospital is altruistic. Any hospital with it's own PET-CT and MRI will order them on every patient - T1aN0M0 included. Medicare is paying, so the hospitals will order ...

There are even smaller abuses that you see throughout the system in the community. Surgeons typically will do an excisional biopsy for a breast mass without a core biopsy for breast cancer. They get a diagnosis, and then they do a segmental mastectomy with SLN bx, and bill for that. Happens all the time where I work - quote - "I want to see what I'm working with." Never mind that a stereotactic-guided core bx is much cheaper and just as diagnostic.

Let's just run through this ... Say you got a fixed $15k per patient with prostate cancer no matter what you did. Say it cost you $10k to do a 3D-CRT treatment and $20k to do an IMRT treatment. Would you try to run a 3D plan to meet your rectal/bladder/PTV constraints if you collected the remainder, or would you just give IMRT to everyone and eat $5k loss? I think I know the answer to that. None of us (including me) are running 3D-CRT plans on our prostates to see if we can meet constraints without using IMRT. The reason is we have no incentive to do so at this time. We make more if we use IMRT, and less if we use 3D-CRT. You think someone that owns a hospital is going to act any differently than a rad-onc that owns a free-standing facility? We all know how to count.

Greed is greed, no matter if they wear a suit or a white coat.

S

Originally Posted by davidjones

it actually does make sense.

I'm not 100% clear on urorad, but from what I can glean it is a urology group which owns radiation therapy equipment and employs a rad onc to use it (please correct me if I am wrong) therefore it is in the urologists' financial interest to send as many pts as possible to radiation therapy where there is a huge technical fee, and the rad onc gets the professional fee, which is significantly less.

A radiology example: ortho owns an MRI machine and sends all pts with back pain for an MRI of the spine, they collect a huge technical fee (often in the thousands of dollars), and send the images to be read by a rad group where they have a contract who then interprets the images and collects the professional fee (the professional fee for an MRI spine is somewhere in the range of a few hundred dollars, i.e. about 10% of the technical fee)

Now consider a hospital employed urologist and orthopod, where the hospital employs the rad or rad onc(who often gets a component of the technical fee, though nowhere near a huge cut); it is no longer in the financial interest of the urologist or orthopod to send their patients for imaging/rad therapy, as they get absolutely no benefit, and now really the major component that plays a role in deciding therapy is benefit to the patient and EBM. The hospital takes a huge cut, but at least the patient gets the appropriate imaging/therapy etc.

The reason this model works is because both rad onc and radiology can't self refer (except IR, which can and does, though infrequently and in multi-specialty groups for things like fibroids and post-chemo/radioembolization MRIs, but needs to stop as it is extremely hypocritical)

If you look at the driver for imaging overutilization, it's not radiologists, it's some 10% of doctors (ortho,cards, urology, neurosurgery etc) who account for an outrageous (something like >50% ) amount of imaging

No matter how much altruism we say we have as physicians or how much we claim we only do what is best for the patient, money is a huge motivator for self-referal; You take away that kind of incentive and you get something like the VA model, which in many places work, every specialty does what it is supposed to do and turf battles more or less don't exist. Of course the salary is lower, but none of us chose our specialties based on income right?


I don't want to hijack this thread, so if you have any other questions (or anyone else for that matter) please feel free to PM me

I never said hospitals were altruistic (in fact I think hospital CEOs are among the least ethical of people), nor that they necessarily decrease wasteful management, I've heard of places where an MAA pulmonary shunt study is done prior to every single Y90/Doxybead therapy in the same patient, when only an initial one is required

but even with all the incentives a hospital may throw to the referring doc, it certainly cuts down on the self-referral; having a rad onc own their own equipment, or rads owning their own imaging center is not the same as having urology/ortho doing owning those things, which is the point I was trying to make.

The entire healthcare system is obviously heading for trainwreck. I only hope to pay off my loans before crash happens.

Originally Posted by SimulD

I call huge BS.

If the hospital owns the machinery, i.e., the technical component of the fee, then they are now the drivers of the decision making. There are at least a few ways they can do this, and many more that I'm not smart enough to think about. These are at least 3 that I know that major hospital systems utilize:

1) Incentivise the behavior of the referring physicians - the more MRIs your refer for, the greater your bonus; the more prostate cancers you refer for prostate IMRT, the greater the bonus

2) Incentivise the behavior of the referred-to physician - set up algorithms or "clinical pathways" to lead providers to utilize more expensive (and reimbursed for) techniques - i.e. all rectal/cervical/endometrial cases should be IMRT, and your bonus will be dependent on that; set up pathways to utilize specific fractionation schemes that may be more expensive

3) Incentivise referred-to physicians to utilize other profit-maximizing supplemental diagnostics and treatments - i.e. when a patient has breast cancer, push for breast MRI regardless of the clinical situation, because currently Medicare and everyone else is paying for it; when a patient has multiple brain metastases, have the algorithm point towards an SRS boost after WBRT, no matter what the situation, because most insurers are paying for it.

The hospital is not altruistic. The current mechanisms do not do anything to make them order less tests, order less treatments, and order less expensive tests/treatments. In fact, everything is place to make them spend more. It is naive to think that putting the decision/profit-motive in the hands of a CEO of a hospital (profit or non-profit) will make them more thrifty.

From what I've seen in private practice, the truth is, I'm cheaper than the average rad-onc, but if I was employed by the hospital, you'd better believe I'd be more expensive - too much pressure from management not to.

For any private practice docs out there, count the number of PET-CTs and MRIs ordered by the hospital for patients with stage I breast cancer. That will tell you right there whether or not the hospital is altruistic. Any hospital with it's own PET-CT and MRI will order them on every patient - T1aN0M0 included. Medicare is paying, so the hospitals will order ...

There are even smaller abuses that you see throughout the system in the community. Surgeons typically will do an excisional biopsy for a breast mass without a core biopsy for breast cancer. They get a diagnosis, and then they do a segmental mastectomy with SLN bx, and bill for that. Happens all the time where I work - quote - "I want to see what I'm working with." Never mind that a stereotactic-guided core bx is much cheaper and just as diagnostic.

Let's just run through this ... Say you got a fixed $15k per patient with prostate cancer no matter what you did. Say it cost you $10k to do a 3D-CRT treatment and $20k to do an IMRT treatment. Would you try to run a 3D plan to meet your rectal/bladder/PTV constraints if you collected the remainder, or would you just give IMRT to everyone and eat $5k loss? I think I know the answer to that. None of us (including me) are running 3D-CRT plans on our prostates to see if we can meet constraints without using IMRT. The reason is we have no incentive to do so at this time. We make more if we use IMRT, and less if we use 3D-CRT. You think someone that owns a hospital is going to act any differently than a rad-onc that owns a free-standing facility? We all know how to count.

Greed is greed, no matter if they wear a suit or a white coat.

S

Originally Posted by SimulD

Surgeons typically will do an excisional biopsy for a breast mass without a core biopsy for breast cancer. They get a diagnosis, and then they do a segmental mastectomy with SLN bx, and bill for that. Happens all the time where I work - quote - "I want to see what I'm working with." Never mind that a stereotactic-guided core bx is much cheaper and just as diagnostic.
S

I've never heard of this and it's a terrible disservice for their patients. Two separate procedures is a powerful predictor of poor cosmetic outcome

http://www.nytimes.com/2011/02/19/he...ncer.html?_r=2

Even disregarding targeted agents that may replace radiation in the future, what if chemo improves to such an extent that radiation provides only minimal survival benefit such that it isnt worth the side effects. There is a new study coming out soon that will compare the MAGIC trial with the MacDonald trial for adenocarcinoma of the stomach and GE junction. To briefly summarize, the MAGIC trial shows the survival benefit of chemo and surgery versus surgery alone whereas the MacDonald trial shows the improved survival of chemo + RT versus surgery alone. If this new study says that chemo + surgery is better than chemo + surgery + RT, then that's another cancer that won't be treated with radiation.

Acute lymphocytic leukemia used to be treated with radiation which made a tremendous difference. A once devastating pediatric cancer with very poor survival suddenly had kids living to their teens and beyond with cranial and cranial-spinal radiation. Chemotherapy could do nothing significant at the time. Radiation was the savior.

Now fast forward 20 years. How do we treat ALL? Chemo only. Radiation has almost no role and has been phased out.

Rad onc is a fascinating field and can be very rewarding, there is no question about that. But with just a single modality and little wiggle room for adaptation and expansion, there are risks pursuing the specialty as well. 20 years ago computers took up an entire room. Now they fit in the palm of my hand. Who knows what the future will bring?

Originally Posted by Heisenbergg

Who knows what the future will bring?

Obviously the future can and probably will bring some surprises. It seems unlikely that RT will be pushed to obscurity during our careers but tends could shift so that RT is used less creating an imbalance in the number of radiation oncologists versus the demand. This would make it hard for new graduates to find jobs and decrease patient volume (and thus paychecks) for those with jobs. Or the shift could go the other way and RT demand could increase.

Originally Posted by Heisenbergg

Even disregarding targeted agents that may replace radiation in the future, what if chemo improves to such an extent that radiation provides only minimal survival benefit such that it isnt worth the side effects.

Ask any H&N or cervix patient how much they value the local control benefit from XRT. It's not just about an OS benefit. Radiation is the curative modality in those situations. LC leads to the OS benefit.

Besides, most medical oncologists go gaga over PFS benefits from targeted agents, so even a minimal OS benefit from a relatively cheap modality like XRT is still a good thing in my book.

Alternatively, one could argue that as imaging and molecular diagnostics continues to improve (a near certainty), cancer will be caught at ever earlier stages. This will render radiation even more relevant for local control.

Also, one could argue that improvements in image guidance and widespread use of heavy particles will make hypofractionation of radiation more prevalent (a near certainty) and thereby render low-dose, radiosensitizing chemo worthless.

One could argue that despite $$$ spent on development of molecular therapeutics, medical oncologist still rely on archaic chemotherapy like CDDP, VP-16, Cytoxan, etc.

It's easy to prognosticate either way but who knows what the future will hold? I have full confidence that our specialty will evolve to remain relevant.

Originally Posted by Gfunk6

Alternatively, one could argue that as imaging and molecular diagnostics continues to improve (a near certainty), cancer will be caught at ever earlier stages. This will render radiation even more relevant for local control.

Also, one could argue that improvements in image guidance and widespread use of heavy particles will make hypofractionation of radiation more prevalent (a near certainty) and thereby render low-dose, radiosensitizing chemo worthless.

One could argue that despite $$$ spent on development of molecular therapeutics, medical oncologist still rely on archaic chemotherapy like CDDP, VP-16, Cytoxan, etc.

It's easy to prognosticate either way but who knows what the future will hold? I have full confidence that our specialty will evolve to remain relevant.

That's exactly what I was thinking (re: local control becoming more important in the future).

KarmaDoc - always good to be checking out the literature on this stuff. It is important to note that Anthony Zietman is one of our field's leaders (ASTRO president etc...). He has written these things to alert us/scare us (which is important) into keeping up with the pace of modern oncology. ~2/3 of all cancer patients receive radiotherapy as part of their treatment, and it is one of the most potent single tumoricidal agents out there. The increasing technology and automation makes treatments more precise, accurate, and allows for dose escalation, but it makes it even more difficult for non-radoncs to prescribe it. Indeed surgeons have now opened "urorads" centers where they treat prostate ca with EBRT, but these centers are staffed by radoncs (and they actually are unethical, self-referral issues etc...). No one can predict the future, but there is no reason to suspect that radonc will become obsolete, and there is no way medoncs will take over. However, we need more young folks to come into our field and bring translational research advances forward to keep our place in modern oncology.

I am a PGY-1 who is currently doing my internal medicine year before heading off to rad onc residency. I've given this topic a lot of thought recently.

As I see it, there are two major issues confronting the field. One is whether radiation for cancer care will become obsolete or at least marginalized. I think one of the truism of the modern age is that when technology advances so fast, entire fields can become obsolete over the course of a person's career. Technology has been on rad onc's side over the past 2 decades with the advent of imaged guided and perhaps heavy particle therapy however whether this pace of advancement will continue is hard to say. Having said that, given the central role XRT plays in prostate, breast and lung cancers, I think the chances that it will fall out of favor in any significant fashion over the next 20 years is minimal.

The second issue is whether "radiation oncology" as a field will maintain its independence from other specialists seeking to invade our turf. I think this is a distinct possibility. Working in a community hospital these past six months has definitively made me realize the importance of controlling the access to patients. I think at an academic center, patients are generally referred to a multidisciplinary tumor board which rad oncs generally have access to. So if the evidence is there, pts generally receive the radiation they need. On the other hand, at smaller hospitals, private practice clinics, this process is much more "ad hoc." Sometimes, the physicians doing the referring is a primary care physician who does not understand radiation and their gut reaction when confronted with a patient with cancer is to send that patient to the specialty which "owns" the anatomic area of the body like urology for prostate, thoracic surgery for lung etc. At this point, rad oncs are basically relying on their competitors to refer them patients. One would hope that the above physicians have the patient's best interest at heart when recommending treatment options. I think this is the case mostly. However, there are a lot of grey areas in which the evidence for radiation is unclear or there are other competing options which are just as good. In these cases, the patients sometimes never receive a referral to rad onc.

Third, many primary care docs/surgeons often seem to think that radiation is a "palliative" modality to be considered when surgery has been effectively ruled out.

However, I think some of these trends are reversing as radiation is gaining in the public's perception as a complimentary modality or even substitute for surgery rather than merely as a backup option. Furthermore, as reimbursements go down for things like IMRT, there will be fewer incentives for other specialties to "get a piece of the pie."

My view is that in order to meet these challenges, we rad oncs need to try to present ourselves first as "radiation ONCOLOGISTS" rather than "RADIATION oncologist" to use Dr. Zietman's expression. This will protect us in case the use of radiation decreases in the future. It will also gain us the confidence of more primary care/medical oncologists who sometimes (and rightly so) view us as mere technicians trained to deliver radiation but unable or uninterested in managing the patient or disease process as a whole. As to exactly how to achieve this emphasis, I am still trying to figure out, but I think knowing the problem is half the battle.

Originally Posted by Heisenbergg

Even disregarding targeted agents that may replace radiation in the future, what if chemo improves to such an extent that radiation provides only minimal survival benefit such that it isnt worth the side effects. There is a new study coming out soon that will compare the MAGIC trial with the MacDonald trial for adenocarcinoma of the stomach and GE junction. To briefly summarize, the MAGIC trial shows the survival benefit of chemo and surgery versus surgery alone whereas the MacDonald trial shows the improved survival of chemo + RT versus surgery alone. If this new study says that chemo + surgery is better than chemo + surgery + RT, then that's another cancer that won't be treated with radiation.

Acute lymphocytic leukemia used to be treated with radiation which made a tremendous difference. A once devastating pediatric cancer with very poor survival suddenly had kids living to their teens and beyond with cranial and cranial-spinal radiation. Chemotherapy could do nothing significant at the time. Radiation was the savior.

Now fast forward 20 years. How do we treat ALL? Chemo only. Radiation has almost no role and has been phased out.

Rad onc is a fascinating field and can be very rewarding, there is no question about that. But with just a single modality and little wiggle room for adaptation and expansion, there are risks pursuing the specialty as well. 20 years ago computers took up an entire room. Now they fit in the palm of my hand. Who knows what the future will bring?

This really demonstrates how slowly chemo has progressed. Why did it take 20 years for a systemic therapy to replace a local therapy for a cancer of the blood?