Never knew the med onc hatred for us was this bad

[RTOGsaveRadonc]

Can’t recall the specifics but had a case a colleague told me about a couple of months prior, NSCLC T3ish no nodal disease but positive margins on the resection. We never got the referral for any adjuvant treatment (no further resection was planned). Don’t know the case so I assumed maybe his molecular profile Was very favorable or I didn’t have all the facts.

Fast forward a couple of months, whatever therapy he has been on clearly isn’t working and now has a spinal lesion the colleague who spoke to me thought was favorable for SBRT. Turns out the med onc at the earlier encounter stated “we need to do whatever we can for this guy…except radiation… anything BUT radiation,” and said it again with the aforementioned lesion.

My thing is…They hate us this much? It’s always been bad but I feel things have really taken a turn post COVID. They keep spitballing with immunotherapies and other off label treatment as much as they can before referring out. Very sad

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[BobbyHeenan]

This is very market/med onc group specific.

Some are like this. But others are sending me stuff to treat or "?can you just sbrt that?" which arent' really too appropriate for radiation rather than more systemic therapy.

I advise new grads that it is very important that they follow their patients regularly after treatment until they get a handle on which patients (esp palliative) can be a "return prn" and which they need to follow. Nothing worse than seeing that patient on HUGE doses of narcotics due to cancer pain when they could have been treated months ago when met burden was low and chance for successful palliation from XRT was way higher.

 

[RadOncDoc21]

Rad oncs hate us so not surprised med oncs do also.

 

[CaesarRO]

Can’t recall the specifics but had a case a colleague told me about a couple of months prior, NSCLC T3ish no nodal disease but positive margins on the resection. We never got the referral for any adjuvant treatment (no further resection was planned). Don’t know the case so I assumed maybe his molecular profile Was very favorable or I didn’t have all the facts.

Fast forward a couple of months, whatever therapy he has been on clearly isn’t working and now has a spinal lesion the colleague who spoke to me thought was favorable for SBRT. Turns out the med onc at the earlier encounter stated “we need to do whatever we can for this guy…except radiation… anything BUT radiation,” and said it again with the aforementioned lesion.

My thing is…They hate us this much? It’s always been bad but I feel things have really taken a turn post COVID. They keep spitballing with immunotherapies and other off label treatment as much as they can before referring out. Very sad

Don't know specifics, but this kind of thing makes me want to reach out for a sit down with the med onc to establish a relationship.

Definitely out there. Depressing.

 

[elementaryschooleconomics]

This is very market/med onc group specific.

Some are like this. But others are sending me stuff to treat or "?can you just sbrt that?" which arent' really too appropriate for radiation rather than more systemic therapy.

I advise new grads that it is very important that they follow their patients regularly after treatment until they get a handle on which patients (esp palliative) can be a "return prn" and which they need to follow. Nothing worse than seeing that patient on HUGE doses of narcotics due to cancer pain when they could have been treated months ago when met burden was low and chance for successful palliation from XRT was way higher.

I want to echo this 1000-fold.

I have encountered docs who hate radiation on principle.

I have encountered docs who think radiation borders on miraculous.

NOTHING IS MORE IMPORTANT THAN STUDYING LOCAL REFERRAL PATTERNS AND HOLDING ON TO PATIENTS YOU SHOULD HOLD ON TO.

I know in my residency institution, and I would hazard a guess it's most of them - most attendings tried to discharge followups ASAP.

Do not pick up that habit.

If a patient comes to me from someone I consider a "bad doctor", I hold on to them for dear life.

If a patient comes to me from someone I consider a "good doctor", I happily hand them back over.

Fortunately, the good doctors (or, at worst, average doctors) VASTLY outweigh the bad. I love most of my colleagues.

The trick is knowing the difference.

 

[Fpg1245]

Don't know specifics, but this kind of thing makes me want to reach out for a sit down with the med onc to establish a relationship.

Definitely out there. Depressing.

I had this very experience in residency. With a thoracic oncologist. Literally would throw up any argument he could to push out radiation. A few brainmets? **** you give TKI. Oligo mets? Immunotherapy. Stage III? Well the literature shows chemo surgery just as good as CRT so no radiation. An absolute prick till the end.

 

[OTN]

Can’t recall the specifics but had a case a colleague told me about a couple of months prior, NSCLC T3ish no nodal disease but positive margins on the resection. We never got the referral for any adjuvant treatment (no further resection was planned). Don’t know the case so I assumed maybe his molecular profile Was very favorable or I didn’t have all the facts.

Fast forward a couple of months, whatever therapy he has been on clearly isn’t working and now has a spinal lesion the colleague who spoke to me thought was favorable for SBRT. Turns out the med onc at the earlier encounter stated “we need to do whatever we can for this guy…except radiation… anything BUT radiation,” and said it again with the aforementioned lesion.

My thing is…They hate us this much? It’s always been bad but I feel things have really taken a turn post COVID. They keep spitballing with immunotherapies and other off label treatment as much as they can before referring out. Very sad

Fortunately, my experience with the medoncs in our groups has been the exact opposite.

 

[theradiator]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

 

[Fpg1245]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

This is the trend. And we are dependent on them for referrals. Once my med oncs start becoming “woke” I won’t have a job

 

[TheWallnerus]

Can’t recall the specifics but had a case a colleague told me about a couple of months prior, NSCLC T3ish no nodal disease but positive margins on the resection. We never got the referral for any adjuvant treatment (no further resection was planned). Don’t know the case so I assumed maybe his molecular profile Was very favorable or I didn’t have all the facts.

Fast forward a couple of months, whatever therapy he has been on clearly isn’t working and now has a spinal lesion the colleague who spoke to me thought was favorable for SBRT. Turns out the med onc at the earlier encounter stated “we need to do whatever we can for this guy…except radiation… anything BUT radiation,” and said it again with the aforementioned lesion.

My thing is…They hate us this much? It’s always been bad but I feel things have really taken a turn post COVID. They keep spitballing with immunotherapies and other off label treatment as much as they can before referring out. Very sad

I think we have to be very circumspect. And realize we don’t see what we don’t see. We never see cancer patients that never got referred for RT and the med oncs see thousands per year. While there’s confirmation bias sure, there’s a possibility they really do notice things like patients “doing better” (nebulous) not getting RT. One interesting thing about your positive margin lung case is that it’s not obvious the patient failed locally.

 

[Fpg1245]

I think we have to be very circumspect. And realize we don’t see what we don’t see. We never see cancer patients that never got referred for RT and the med oncs see thousands per year. While there’s confirmation bias sure, there’s a possibility they really do notice things like patients “doing better” (nebulous) not getting RT. One interesting thing about your positive margin lung case is that it’s not obvious the patient failed locally.

what exactly are they seeing though? RT necrosis. Horrible pneumonitis? Bladder issues for life? Lots of second cancers? If so I never even hear about it honestly and I work pretty closely with med onc

 

[Lamount]

Our field is a mysterious black box to most other docs...

Many physicians outside our field have only had a few experiences with us. If those experiences involve caring for patients with unmanaged RT toxicities, or "radiation technicians" who checkout at 4 pm. That is exactly what they think we are all right... unless you prove otherwise.

All you have to show up at tumor boards and develop a reputation as a problem solver. There are so many problems that RT can solve when other modalities have nothing.

 

[RTOGsaveRadonc]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

These are the scenarios I’m referring to. They don’t know anything about our field but are happy gambling the lives of patients who come to them for information. If patients were able to make informed decisions they would opt for what gives them the best chance vs spitballing by med oncs. We need an additional 1-2 yrs so we can be a cancer “generalist” on hospital admissions without a need to rely on med oncs with a bias and limited knowledge

I don’t know if the patient failed locally, but this is one example in many. A lot of setups (it is incentivized for the hospital system) where surgeons, med oncs, rad oncs all get a consult for a patient where their modality may be indicated. If no indication or unfavorable they sign off. Again I’m not speaking from a perspective of self interest, it’s really what I would want for my own family members.

 

[theradiator]

Our field is a mysterious black box to most other docs...

Many physicians outside our field have only had a few experiences with us. If those experiences involve caring for patients with unmanaged RT toxicities, or "radiation technicians" who checkout at 4 pm. That is exactly what they think we are all right... unless you prove otherwise.

All you have to show up at tumor boards and develop a reputation as a problem solver. There are so many problems that RT can solve when other modalities have nothing.

I'm particularly proud that less than 1/3 of my referrals are from medical oncology.

what exactly are they seeing though? RT necrosis. Horrible pneumonitis? Bladder issues for life? Lots of second cancers? If so I never even hear about it honestly and I work pretty closely with med onc

Medical oncology and even family members often conflate failure to thrive in a widely metastatic patient after receiving radiation (and systemic therapy of course) as toxicity attributed to radiation oncology. Always easier to blame someone else than to look in the mirror and conclude that the >$10000/month systemic therapy they recommended was ineffective.

 

[RadOncDoc21]

Our field is a mysterious black box to most other docs...

Many physicians outside our field have only had a few experiences with us. If those experiences involve caring for patients with unmanaged RT toxicities, or "radiation technicians" who checkout at 4 pm. That is exactly what they think we are all right... unless you prove otherwise.

All you have to show up at tumor boards and develop a reputation as a problem solver. There are so many problems that RT can solve when other modalities have nothing.

Yea but that requires us not speaking out of turn, making sure the surgeons and med oncs take a break from talking before we utter a word. When we do speak, we need to impress them all, know all the studies and p values! Even the most audacious and outspoken rad oncs know their place in the heirarchy. The ones who thrive, picture themselves amongst the surgeons and can “speak their language.” After 5 yrs, they may even ask for your input, better yet, they may even invite you to sit next to them in the cafeteria!

Of course, many will chime in and say “that doesn’t happen at my tumor board, I’m well respected!” Let me be the one to tell you that you’re not.

I’m ok with being a bottom feeder, I live in a nice area of the country, I’m paid well and I’m still married… life is good!

 

[CaesarRO]

what exactly are they seeing though? RT necrosis. Horrible pneumonitis? Bladder issues for life? Lots of second cancers? If so I never even hear about it honestly and I work pretty closely with med onc

I've been told that "anecdotally, patients don't tolerate further line chemotherapy after RT" (specifically that was in the context of consolidation for small cell, which inevitably needs further line chemotherapy... but makes me wonder if that sort of thing might be noticed in the context of The Wallnerus's comment)

 

[Lamount]

Yea but that requires us not speaking out of turn, making sure the surgeons and med oncs take a break from talking before we utter a word. After 5 yrs, they may even ask for our input.

Of course, many will chime in and say “that doesn’t happen at my tumor board, I’m well respected!” Let me be the one to tell you that you’re not. I’m ok being a bottom feeder.

Who hurt you, brotha (or sista)?

It works like this.

Med Onc: "What can we do for patient X with this enlarging obstructive mass? Systemic therapy is likely to be unhelpful and they couldn't tolerate another surgery. This is their ONLY site of progression, and it is going to kill them"

Rad Onc: "I have an idea"

Surgeon: "What, radiation? You can't do SBRT to that location... don't you know that?!? And palliative RT is going to fail in a few months"

Rad Onc: "I can get in near-ablative doses safely to that location using more than 5 fractions"

Med Onc: "...but I don't want them to have awful esophagitis -they are frail enough as it is"

Rad Onc: Either 1) Tumor is on the right side, so that won't be an issue. or 2) "I can dose reduce adjacent to the esophagus with a dose painting technique, getting the most dose in while keeping them relatively comfortable"

Patient tolerates treatment with no esophagitis, has disease control for 1.5 years until failing distantly. Referrals ensue
--The End

My tumor board is great because the surgeons and med oncs I work with are genuinely nice people with whom I socialize outside of clinic so they always "respected" me a colleague... but I still had to work to increase referrals. It had nothing to do about respect and everything to do with showing that RT can be a useful tool to help their patients who were in a bind. Most of my practice is treating patients for whom there aren't other good options. You may call that "bottom feeding", but I like to think of it more as being the one guy who can help

 

[RadOncDoc21]

Who hurt you, brotha (or sista)?

It works like this.

Med Onc: "What can we do for patient X with this enlarging obstructive mass? Systemic therapy is likely to be unhelpful and they couldn't tolerate another surgery. This is their ONLY site of progression, and it is going to kill them"

Rad Onc: "I have an idea"

Surgeon: "What, radiation? You can't do SBRT to that location... don't you know that?!? And palliative RT is going to fail in a few months"

Rad Onc: "I can get in near-ablative doses safely to that location using more than 5 fractions"

Med Onc: "...but I don't want them to have awful esophagitis -they are frail enough as it is"

Rad Onc: Either 1) Tumor is on the right side, so that won't be an issue. or 2) "I can dose reduce adjacent to the esophagus with a dose painting technique, getting the most dose in while keeping them relatively comfortable"

Patient tolerates treatment with no esophagitis, has disease control for 1.5 years until failing distantly. Referrals ensue
--The End

My tumor board is great because the surgeons and med oncs I work with are genuinely nice people with whom I socialize outside of clinic so they always "respected" me a colleague... but I still had to work to increase referrals. It had nothing to do about respect and everything to do with showing that RT can be a useful tool to help their patients who were in a bind. Most of my practice is treating patients for whom there aren't other good options. You may call that "bottom feeding", but I like to think of it more as being the one guy who can help

I knew this would be the response I would get. I’m not hurt, for real I’m good, didn’t you read my last part where I said I’m good with being a bottom feeder?

I get along with the docs I work with but the role of the rad onc is to basically go with the flow and prove you belong in the room. It’s our nature, it’s how we were trained. We live in a world where we were told we were special throughout med school and residency but we’re not. We’re crabs in a bucket that is getting larger and larger every year. We’re Miami Heat Lebron James’s teammate (definitely not Bosh or Wade), maybe Haslem.

I’m just happy to get a ring, live in a nice area and get a pay check.

 

[RickyScott]

Can’t recall the specifics but had a case a colleague told me about a couple of months prior, NSCLC T3ish no nodal disease but positive margins on the resection. We never got the referral for any adjuvant treatment (no further resection was planned). Don’t know the case so I assumed maybe his molecular profile Was very favorable or I didn’t have all the facts.

Fast forward a couple of months, whatever therapy he has been on clearly isn’t working and now has a spinal lesion the colleague who spoke to me thought was favorable for SBRT. Turns out the med onc at the earlier encounter stated “we need to do whatever we can for this guy…except radiation… anything BUT radiation,” and said it again with the aforementioned lesion.

My thing is…They hate us this much? It’s always been bad but I feel things have really taken a turn post COVID. They keep spitballing with immunotherapies and other off label treatment as much as they can before referring out. Very sad

Have also had this experience with some medoncs for years. Very physician specific.

 

[medgator]

Fortunately, my experience with the medoncs in our groups has been the exact opposite.

Ditto. Happened once with a pretty old school one trained at the Anderson. Eventually got dual referrals to me and him once i was in town long enough. That helps

 

[sirspamalot]

Site and physician specific. I'm grateful my colleagues rely upon my advice for the overall plan of care, when needed. Total deferral, but we have real collegiality, thankfully.

Being face to face friendly with your peers makes a monumental difference in how the work gets done.

 

[TheWallnerus]

what exactly are they seeing though? RT necrosis. Horrible pneumonitis? Bladder issues for life? Lots of second cancers? If so I never even hear about it honestly and I work pretty closely with med onc

Not saying they’re right. But like when @DoctwoB gets on here. Smart fellow. He has an opinion of prostate RT that I do not have eg. At the least I have to grant him that he literally sees RT side effects that I cannot (he’s got a cystoscope!).

 

[Lamount]

I knew this would be the response I would get. I’m not hurt, for real I’m good, didn’t you read my last part where I said I’m good with being a bottom feeder?

I get along with the docs I work with but the role of the rad onc is to basically go with the flow and prove you belong in the room. It’s our nature, it’s how we were trained. We live in a world where we were told we were special throughout med school and residency but we’re not. We’re crabs in a bucket that is getting larger and larger every year. We’re Miami Heat Lebron James’s teammate (definitely not Bosh or Wade), maybe Haslem.

I’m just happy to get a ring, live in a nice area and get a pay check.

I hear you… and I know this is often the case. I honestly don’t feel that way at all where I work. My inbox is filled with curbsides asking me to review cases to so if RT is possible or asking me to get patients in ASAP. It is probably more to do with the patient population/volume and less to do with me…

 

[HemeOncHopeful19]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

The OP patient with NSCLC made more sense but I don't get the frustration on this case. What combined modality therapy were you wanting to explore? Most Med Oncs are not going to be a fan of giving Cisplatin when there is no proven benefit.

Maybe I'm still just a youngin' but I see a lot more animosity toward Med Onc in this thread than I've ever seen toward Rad Onc in our clinic.

 

[RTOGsaveRadonc]

The OP patient with NSCLC made more sense but I don't get the frustration on this case. What combined modality therapy were you wanting to explore? Most Med Oncs are not going to be a fan of giving Cisplatin when there is no proven benefit.

Maybe I'm still just a youngin' but I see a lot more animosity toward Med Onc in this thread than I've ever seen toward Rad Onc in our clinic.

The animosity towards us isn’t manifested in terms of “talking bad “ etc. it’s manifested in terms of putting barriers towards radiation for patients who otherwise have indications for it. The result of that is the animosity (from our end) because we get cases that when everything goes to crap we’re given for a Hail Mary shot. These cases also hurt because we know we could maybe have made a difference if contacted early. The resultant cases expectedly don’t end well for the patient and their ongoing disease burden is pinned on toxicity as someone else mentioned.

This may sound isolated but the majority of rad oncs frequently have these interactions or cases. I did in residency but am seeing it happen way more

 

[deleted1111261]

Palliation of a breast mass routinely comes after mass is fungating and putrid after trying everything else.

I’ve noted that in employed world (when all members of team are employed), this is a less likely occurrence. Not pushing employment, but multi D care way more likely. For good and bad.

 

[TheWallnerus]

The animosity towards us isn’t manifested in terms of “talking bad “ etc. it’s manifested in terms of putting barriers towards radiation for patients who otherwise have indications for it. The result of that is the animosity (from our end) because we get cases that when everything goes to crap we’re given for a Hail Mary shot. These cases also hurt because we know we could maybe have made a difference if contacted early. The resultant cases expectedly don’t end well for the patient and their ongoing disease burden is pinned on toxicity as someone else mentioned.

This may sound isolated but the majority of rad oncs frequently have these interactions or cases. I did in residency but am seeing it happen way more

100% agree it’s happening more over time

 

[temujim]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

Seen this quite a bit lately... med onc declaring on their own a skin cancer patient not resectable and/or cannot get RT, and just giving IO.

 

[Fpg1245]

Seen this quite a bit lately... med onc declaring on their own a skin cancer patient not resectable and/or cannot get RT, and just giving IO.

That’s a straight up scum bag move. Sorry. As bad if not worse than the Mohs surgeons who terrify patients about radiation. But then again at least surgery is a standard of care

 

[medgator]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

Last time I'd ever refer to them and i probably send an io skin pt over at least once or twice a month

 

[madchemist89]

That’s a straight up scum bag move. Sorry. As bad if not worse than the Mohs surgeons who terrify patients about radiation. But then again at least surgery is a standard of care

I think it is usually incompetence rather than anything malicious. They just don't know what is standard of care. They certainly don't know any actual data, so they rely on experience and minimal oncology training.

 

[RadOncDoc21]

I hear you… and I know this is often the case. I honestly don’t feel that way at all where I work. My inbox is filled with curbsides asking me to review cases to so if RT is possible or asking me to get patients in ASAP. It is probably more to do with the patient population/volume and less to do with me…

Personally, I moved away from the curbside consults but agree in an area where you have to compete, that’s better then none. I actually found a good niche where I don’t actively seek consults because they come in regularly so I’m not as aggressive as I once was in the past but have experienced both sides of the equation.

My experience with rad oncs has been mixed. Although, I believe most do a great job, I always feel like there is a level of competition amongst each other either in regards to treating with less fx or better modalities in a race to the bottom.

Let’s take a T1 breast, 70 y/o, ER+ case. Rad onc A is eager to treat and he’s been practicing for 90 years, so he recommends standard fx, boost… med onc A who knows rad onc A well trust his care and only sends to him. Younger Rad Onc B, says hey I can treat in 3 weeks… med onc A is not feeling him. Rad Onc C says I can treat in 5 fx, now Med Onc A’s ears perk up and is like “continue…” So now Rad Onc C who is fresh out of residency say “I can treat in 0 fractions” and of course now all the med oncs go along with him.

That’s just one stupid example, but I’ve seen so many tumor boards where the rad oncs go back and forth and honestly it’s a sad sight to see. The med oncs and surgeons on the other hand, usually are in full alignment with each other. Now this could be just my experience but I’ve been around the block a few times.

 

[RickyScott]

Personally, I moved away from the curbside consults but agree in an area where you have to compete, that’s better then none. I actually found a good niche where I don’t actively seek consults because they come in regularly so I’m not as aggressive as I once was in the past but have experienced both sides of the equation.

My experience with rad oncs has been mixed. Although, I believe most do a great job, I always feel like there is a level of competition amongst each other either in regards to treating with less fx or better modalities in a race to the bottom.

Let’s take a T1 breast, 70 y/o, ER+ case. Rad onc A is eager to treat and he’s been practicing for 90 years, so he recommends standard fx, boost… med onc A who knows rad onc A well trust his care and only sends to him. Younger Rad Onc B, says hey I can treat in 3 weeks… med onc A is not feeling him. Rad Onc C says I can treat in 5 fx, now Med Onc A’s ears perk up and is like “continue…” So now Rad Onc C who is fresh out of residency say “I can treat in 0 fractions” and of course now all the med oncs go along with him.

That’s just one stupid example, but I’ve seen so many tumor boards where the rad oncs go back and forth and honestly it’s a sad sight to see. The med oncs and surgeons on the other hand, usually are in full alignment with each other. Now this could be just my experience but I’ve been around the block a few times.

It’s mirrors my experience as well. Virtue signalling about less fractions or in the case of Ben smith, imrt, is very common. Somehow, all that goes out the window when it comes to ultra expensive protons.

 

[RadOncDoc21]

It’s mirrors my experience as well. Virtue signalling about less fractions or in the case of Ben smith, imrt, is very common. Somehow, all that goes out the window when it comes to ultra expensive protons.

Oh, don’t get me started on the “modern technology” portion of the argument and how every rad onc can treat everything with “pin point accuracy” guaranteeing 100% cure rates and absolutely no toxicities. The chair with the protons makes an argument for using it every single time. We have become gloried used car salespeople.

 

[Grubbe-a-dub-dub]

I've seen this happen as well. One med onc I work with regularly avoids referral to rad onc. He even brings up omission trials every chance he gets at tumor boards and informal conversations.

He went as far as to say that he's seen trials of omission of radiation in locally advanced H&N cancer. I politely corrected him by using the word de-escalation. But no, he was referring to omission...

I think it's a pure ego thing - he thinks everything can be solved with immunotherapy, which is just not the case. Sadly, he's one of the few med oncs actually from this rural town so he's revered like some god that walks amongst us.

 

[Fpg1245]

It’s mirrors my experience as well. Virtue signalling about less fractions or in the case of Ben smith, imrt, is very common. Somehow, all that goes out the window when it comes to ultra expensive protons.

Which is why I don’t hypofrac nearly what I used to or fall in line as much when the virtue signalers at the main site get all bent out of shape. You wanna treat them? Come on down. Meanwhile protons march forward. The moral force just isn’t there but I’m starting to think it never was in the first place.

 

[TheWallnerus]

I've seen this happen as well. One med onc I work with regularly avoids referral to rad onc. He even brings up omission trials every chance he gets at tumor boards and informal conversations.

He went as far as to say that he's seen trials of omission of radiation in locally advanced H&N cancer. I politely corrected him by using the word de-escalation. But no, he was referring to omission...

I think it's a pure ego thing - he thinks everything can be solved with immunotherapy, which is just not the case. Sadly, he's one of the few med oncs actually from this rural town so he's revered like some god that walks amongst us.

Rad onc faces future headwinds that even the best workforce analyses will struggle to account for. All the more reason to cut spots!

 

[theradiator]

I had a cordial conversation with Dan Von Hoff at a meeting some time ago. Super nice guy. He blithely told me that he advises the local radiation oncologists to hold off on buying that boat because medical oncology will be putting radiation oncology out of business. Now he has been wrong for the past 4 decades but who knows maybe its different this time.

 

[sirspamalot]

Sounds like a D-Bag who needs some healing rays soon.

 

[OTN]

I had a cordial conversation with Dan Von Hoff at a meeting some time ago. Super nice guy. He blithely told me that he advises the local radiation oncologists to hold off on buying that boat because medical oncology will be putting radiation oncology out of business. Now he has been wrong for the past 4 decades but who knows maybe its different this time.

doubt

 

[communitydoc13]

I had a cordial conversation with Dan Von Hoff at a meeting some time ago. Super nice guy. He blithely told me that he advises the local radiation oncologists to hold off on buying that boat because medical oncology will be putting radiation oncology out of business. Now he has been wrong for the past 4 decades but who knows maybe its different this time.

It won't happen this way, and I'm sure Von Hoff knows this and is just pissing on you. He is also old enough to know a bunch of rich AF radoncs his age, who he thinks didn't deserve all of that.

It would have been fair circa 2005, before Ipi, and thus before better IO, and in that little bit of a lull after Gleevec, and with IMRT and IGRT and SBRT emerging right around you, to have been pretty excited about your global role in clinical oncology for the foreseeable future.

But things have changed, and they are accelerating (as things do once we start to get tech right) and the space for molecular medicine is infinite while the space for high energy therapeutics in a disease that by definition almost always kills with distant progression is limited.

So we will become less and less over time (unless we redefine who we are).

 

[Fpg1245]

It won't happen this way, and I'm sure Von Hoff knows this and is just pissing on you. He is also old enough to know a bunch of rich AF radoncs his age, who he thinks didn't deserve all of that.

It would have been fair circa 2005, before Ipi, and thus before better IO, and in that little bit of a lull after Gleevec, and with IMRT and IGRT and SBRT emerging right around you, to have been pretty excited about your global role in clinical oncology for the foreseeable future.

But things have changed, and they are accelerating (as things do once we start to get tech right) and the space for molecular medicine is infinite while the space for high energy therapeutics in a disease that by definition almost always kills with distant progression is limited.

So we will become less and less over time (unless we redefine who we are).

Clinical oncologists…but never gonna happen here. But maybe pharma would help, they don’t necessarily care about who’s giving the drugs as much as selling them.

 

[TheWallnerus]

I had a cordial conversation with Dan Von Hoff at a meeting some time ago. Super nice guy. He blithely told me that he advises the local radiation oncologists to hold off on buying that boat because medical oncology will be putting radiation oncology out of business. Now he has been wrong for the past 4 decades but who knows maybe its different this time.

doubt

Our power dynamics are pretty skewed. It’s ‘Disclosure’ and we are Michael Douglas and med onc is Demi Moore. Ever since my first days in rad onc definitely got a vibe of med oncs wanting to eliminate radiation. I have never felt that way about chemo… may I should have.

Inverse optimization was the ultimate advance and inflection point in our field. If you look at some of the “med onc things” on the horizon what they are doing is inverse optimization too. Except it’s biological and at the cellular level (ok I know radiation is at the cellular level too)… and arguably way fancier than the fanciest IMRT. We are accurate to the millimeter and feel proud. Ultimately these cancer therapies are going to be accurate to the molecule.

“We will see,” I would say, if I were a stable genius.

 

[Palex80]

Instructive recent experience. I had a younger patient with a large inoperable squamous cell carcinoma of the skin. I decided to refer to medical oncology to explore combined modality therapy. I was told that he would be happy to administer immunotherapy instead of RT because it works really well as a single agent but he had no interest in adding immunotherapy to RT.

Another recent experience:

Patient with large oropharyngeal cancer cT4 cN2, scheduled to undergo primary radiochemotherapy with cisplatin.

He went asking for a second opinion and found an oncologist who is willing to give him "induction immunochemotherapy +/- refer him later for consolidation radiotherapy depending on response".

 

[RadOncDoc21]

Another recent experience:

Patient with large oropharyngeal cancer cT4 cN2, scheduled to undergo primary radiochemotherapy with cisplatin.

He went asking for a second opinion and found an oncologist who is willing to give him "induction immunochemotherapy +/- refer him later for consolidation radiotherapy depending on response".

Sounds about right. We keep decreasing the utilization of radiation, so I’m not surprised other specialties join in on the fun.

 

[Lamount]

Another recent experience:

Patient with large oropharyngeal cancer cT4 cN2, scheduled to undergo primary radiochemotherapy with cisplatin.

He went asking for a second opinion and found an oncologist who is willing to give him "induction immunochemotherapy +/- refer him later for consolidation radiotherapy depending on response".

Did you call the oncologist? In a case like this, I don't think I would have the self-control to keep my mouth shut

 

[RadOncDoc21]

Did you call the oncologist? In a case like this, I don't think I would have the self-control to keep my mouth shut

He (she/they) did and the med onc referenced this:

https://ascopubs.org/doi/full/10.1200/EDBK_351336

The med onc then said he works with a rad onc who is the co-PI of one of the trials.

 

[CaesarRO]

Did you call the oncologist? In a case like this, I don't think I would have the self-control to keep my mouth shut

Local academic Med Onc who trains fellows loves induction for big bulky high volume tumors. Claims he does it for LRC benefit despite all of our RCTs showing worse yox and no OS benefit.

Drives me insane every time I think of it.

 

[Lamount]

Local academic Med Onc who trains fellows loves induction for big bulky high volume tumors. Claims he does it for LRC benefit despite all of our RCTs showing worse yox and no OS benefit.

Drives me insane every time I think of it.

I don't mind induction therapy -not as SOC, but may have a role in select cases. Was more concerned about the "+/- refer him later for consolidation radiotherapy depending on response".

 

[OTN]

I don't mind induction therapy -not as SOC, but may have a role in select cases. Was more concerned about the "+/- refer him later for consolidation radiotherapy depending on response".

You'll be seeing that patient at some point, no doubt