opposed to radiation?

[kimplera]

Just starting my third year and been thinking about radonc. However, I have a hard time thinking of radiation as a treatment modality that I'd like to see around in 30 years due to its non-specific nature. How would this attitude be accepted in the field. I understand that it works for many different types of cancer, but I have to believe that there are better options that will be developed. I am interested in eventually being at a medical school where I can see patients and run a basic science/translational science lab.

thanks for any input.

rk

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[stephew]

Hi RK.

You present the CLASSIC misunderstanding of rad onc. Well I think... Im not quite sure of what youre saying; you like rad onc but you DONT want to see it around or dont THINK it will be around? In either event your understanding of rad onc seems a little misguided if you'll please excuse me for putting it that way. People simply dont understand radiation as a therapy; If one wanted to be consistant, one would be similarly unsure about chemo- they are in fact both therapies that work on the DNA level to kill cells, and have preferential killing of malignant/neoplastic cells. You say its non-specific-only insofar as chemotherapy (or for that matter surgery) is.

THe typical thinking goes like this: Surgeyr USED to be the mainstay and then there was radiation. Then chemo came in and when that's perfect with the magic bullit, then that will take over. This is wrong. Both theoretically and empirically. Surgery can quickly debulk a tumor and in some cases be presumed curative. However radiation can deal with local disease (and be focused enough for high dose in things like tomotherapy and stereotactic therapy) It can deal with microscopic disease that the surgeon cant see or get to safely and give locala control and improve survival. Chemo can deal with (usually) small numbers of cells in the systemic setting or as an adjunct to radiation. These modalities cant live without each other and they aren't replacements for what came prior. And the whole "we'll cure cancer in our lifetime" bit from the Nixon era... well unfortunately we know that cancer isn't one disease with one solution and we're unlikely ever to really cure it (in the foreseeable future anyway).

So your understanding of radiation as "non-specific" is a bit flawed if youre thinking in comparison to some other modality and indeed, the likihood of something "specific" is vanishingly small. Finally if you are looking to create the magic bullit, why study radiation to begin with? Radiolabeled targeting would be the closest thing we have with regard to this (in which case not so "nonspecific afterall!) or perhaps med onc is more your thing?

 

[stephew]

and please excuse my inability to spell "bullet"

 

[tinwindow33]

there is no doubt that radiation oncology is a unique field, nor that it is extremely useful. However, my opinion is that it's conceivable targeted molecular therapies could be seen in our lifetimes. If you're concerned that the field of radiation oncology will be left behind, I wouldn't worry about your lifetime. Like stephew said, cancer is many different diseases that behave similarly. While molecular therapies may be successful for some diseases, there will probably always be mutants and tougher cancers that cannot be cured within our lifetimes.

I just started my rad onc rotation. There are two notable differences in this field that I've seen after teh first day. 1) the information is delivered in a highly evidence based manner, often with multiple studies cited and complex algorithms. 2) the doctor is able to spend quality time with the patient. The result is that it's closer than any other field I've seen to how I THOUGHT medicine was practiced when I applied for medical school. The snap decisions and vast uncertainty plaguing modern "ward" medicine is far different from rad onc.

 

[stephew]

I find some of your comments interesting;
First, I do not believe in the magic bullet. Im happy (very much so) to be wrong, but the more I learn about medicine the less I believe in it. I wonder if over the course of your education you will think more or less the way I do.

The second thing which you mentino that particularlly interests me is your observations about rad onc. Ive very impressed actually as Ive never heard anyone articulate these points so well and in such a short amonth of time. Rad onc is highly evidence based- and what pleases me is that there is plenty of room for clinical judegement as well; but the general approach is as you say deliverd in a highly evidence based manner. I too felt that the delivery of care in rad onc was closest to how I envisioned being a doctor would be. That is the sum of information pertaining to that patient is amassed, sifted through and a plan designed and applied- with the utilization of complex algorithms as you say-tailored to that patients needs in an EBM way.

Its very intellectual and academic with practical application, exactly what I become a doctor for.
steph

 

[tinwindow33]

Well, I don't know what to say. Rad Onc is truly an amazing field. Despite its competitiveness, I think I would also have a good shot at matching. It has a lot to offer.

But it's just not for me. There's something missing that I actually found in my first choice, pathology. I feel guilty because we all like to say how much we love helping patients when we enter medical school, but I found that patient contact just doesn't turn me on like I thought it would. I like people, but I think I prefer the science of medicine more. To each his own, I guess.

Funny thing is, I can think of many reasons in addition to the one prior why rad onc is so great. 1) no more colds, well child visits, medication refills, garbage inpatient admits. Each patient that comes in has a serious issue that needs careful planning and study. 2) the ingenious technological advances make for an exciting, dynamic field. I can't tell you how cool it is to read about gamma knife (although the book I read says it has not demonstrated a survival benefit) or proton beams (!!!!) and how they work. 3) the highly competitive nature of the field has resulted in a select pool of applicants, who are your future colleagues and the people who will be in charge of rad onc's future. The future is indeed bright. 4) Radiation works! It is so much more effective than I ever thought. 5) Sure it's taboo to talk about, but quality of life is a major issue in today's medical world. Want a well-rounded life? Rad onc has great flexibility, little call, and great compensation. You could arrange it so that you work hard 3-4 days a week and still earn a fantastic living, and it would be satisfying work (i.e. you wouldn't feel like a cop out).

Anyway, I have nothing to gain by saying that it's a great field. I'm not going to apply for it. I think, however, that every person, particularly those who love patient care, should do a rotation in it to see how great it is. For those of you surfing this board because you're curious about the field, I encourage you to try it out, or even just shadow a couple days (I picked up a lot of stuff just in four days so far).

 

[stephew]

You express a common sentiment- we all want to help people but sometimes, its a dirty business; much like the early PEace Corps volunteers who would come back absolutely frustated complaining how they had traveled so far to help people they saw in their mind's eye as victims of circumstance and who, given the support, would rise and make a better life etc; only to find that very often, the people they were helping seemed fairly apathectic about what was being offered. The real world is different frmo that of our imagination which is more a reflection of our wishful thinking of how things can be. All this doesn't minimize the worl dof the peace corp volunteer of course, or of the doctor (of course). But sometimes its not so glorious.

I happen to like patient involvement and clinical work, but not in ever incarnation. Ther e is no way I'd be happy as an ER doctor. And to my own surprise, I dont think Id enjoy internal medicine as much as I thought I would. THe day to day realities are different from the abstract. Which is all a long way to say you dont have to be a people hater to decide minimizing pt contact suits you better.

Path is a great field and very intellectual. My husband is a pathologist (actually doesnt do clinical work just teaches).

Anyway you sound like you've got a terriffic mind and view to make a great doctor; hope to hear how things go for you.
All the best,

 

[tinwindow33]

Thank you for your thoughts. I enjoyed and agreed with almost everything you said, even right down to the phrasing. I think we have similar minds.

thanks, good luck to you too.