Pediatric Radiation Oncologist

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UCLAMAN

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May be another dumb question...forgive me....but are there such doctors as Pediatric Radiation Oncologists? Would that require a Radiation Oncology residency followed by a pediatrics fellowship?

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Fellowships in Pediatric Radiation Oncology are few and far between. I think there is one at St. Jude's Children's Hospital in Memphis. But even the other big children's hospitals (Rainbow, CHOP, Boston Children's, etc.) don't have Radiation Oncology fellowships. Not sure why...they do treat children with radiation sometimes.

Yes, I think they would require a fellowship in Pediatric Radiation Oncology after completing your Radiation Oncology fellowship. There is probably not specific board certification in Radiation Oncology and hence the lack of fellowships available.
 
Most Rad Onc programs do contain some exposure to peds rad onc so a fellowship may not be necessary. However, if you are inclined to do a fellowship in peds or something else, some of the fellowship opportunities are listed at www.arro.org. Check it out.
 
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As someone fortunate enough to work with one of the best peds rad onc docs, let me reply;
First congrats on NW. One of my fav students is going there to start rad onc this year.

Peds rad onc does exists; if this is your interest you must either go to a center that has thisas a aspeciality or do a fellowship in the field. It is one of my main interests in fact. As mentioned, St. Jude's is a major center. Here at Johns Hopkins Moody Wharam Jr, MD is the man. UCSF and MSKCC are other big places.

Its a great field. while you are limited as to good places to practice later on, you benefit from the fact that few people want to do peds rad onc.
Steph
 
Agree with much of the discussion above. However, would like to note that in the vast majority of cases, including large cancer centers, pediatric oncology cases are often handled at the local children's hospital and referred to the (primarily adult) oncology center for radiation therapy only. So in many cases, the physician coordinating the radiation is an adult Rad-Onc (as noted, the residency covers some peds). Thus I would add that the job opportunities after a fellowship would be limited to very particular settings (i.e. certain highly specialized hospitals).
 
In my summer research program here at CHLA, we had a peds rad onc by the name of Lavey ,who is supposedly a pioneer in the field, come speak to us. I am under the impression that this program is geared toward peds rad onc, but I could be mistaken (its just how I perceived it).
 
I'm actually working in the Rad Onc dept at St. Jude this summer, and its completely different than adult rad onc - the complications are of a very different nature and planning is much more difficult - we use 10 fields or IMRT for cases that would take 4 fields in an adult.

St. Jude is, of course, the place of anything related to pediatric oncology.

Many residents cycle through here 4 weeks at a time to get enough pediatric cases for board certification in general rad onc - I believe they are booked through 2007. There are fellowships for ped rad onc as well.

If you have any questions please PM me, I'd love to fill you in.
 
St Jude is of course excellent for pediatrics. However the planning issues you raise aren't "Pediatric" in nature; the same complex multi-field, arc or IMRT planning is done in adult tumors, depending upon the situation.
 
I'm sure complex planning occurs all the time - tumors rarely locate mets in nice convenient locations. But several of our planners have been at major hospitals previously and talk about how the average pt. recieves a much more complicated plan than the avg pt. elsewhere (this is of course a function of $$$).

From what I understand, IMRT is a big moneymaker for a lot of folks (esp. consulting radiation folks). So its being pushed at clinics that have the room. $$ is not as much of an issue at St. Jude.

With peds it seems there are are special considerations for growing areas. All kinds of growth plates on bones you need to avoid, damage to optic chiasm and cochlea, effects on growth hormones, and a general lowering of IQ after RT (although 'conformal' therapy here by TE Merchant has reduced this). The planners talk about how this would take a simple adult case and make it IMRT or many fields.

Have you done a peds rotation in rad onc? What have you found? I am interested in finding more out about the differences.
 
Peds is my area of interest; Ive done 4 rotations on the pediatric service here with another to come. Its not very different from most rad onc to me; but you do deal with different late-and even acute- effects; kids for instance tolerate craniospinal xrt very well; adults don't. Kids can get far more growth and neurocognitive toxicity than adults. And you have to worry about late radiation induced tumors even more. So yes, the treatment plans are more complex at least in the sence that you have to worry about growth plates and symmetry more than in adults.

THe optic chiasm is a sensitive structure no matter who you're treating; there is a limit and that's that. Same with the Optin nerve (5400) and kidneys, liver etc.

THe thing about IMRT is this: people think its great cos its new and while it does have great applications, it is not always appropriate- beyond an issue of "needing it", sometimes conventional/conformal Xrt is favorbale because you want a broad beam; particularly this is typical prior to cone down. In peds you may be using IMRT more often for the reasons you mention, but it would be a mistake for a pediatric radiation oncologist (or any rad onc) doc to think that its always necessary-or indeed always desirable. Remember: subclinical disease is a big part of why we exist. Also, Eli Glatstein (prof at Penn) discussed his concerned about low dose that is now being delivered to more normal tissue with therapies such as IMRT. Its an interesting concept- we "spare" organs by spreading the beam out, but on the other hand are we going to see more stochastic effects from therapies that dont cause enough damage to create typical side-effects-but that may be sufficiently mutagenic to cause late tumors? I don't know; interesting point. Anyway I am hardly trying to IMRT bash. Its a great thing; but as always, not a panacea for all.
 
Agreed.

Other negative aspects I see in IMRT are ultra-fractionization and increased importance of registration.

With such high dose gradients shifts that would be considered allowable in normal therapy now pose a threat to the very structures that IMRT is designed to protect... I saw IMRT on a foot, and every time the patient moved his arms the leg would shift by 2 or 3 mm - this made a significant difference in what was in and out of the treatment fields. No point in using IMRT at all, IMHO.

Also, as an engineer, with start-up ramp effects IMRT may lead to underdosing or overdosing. Instead of 25 treatments*6 beams = 120 something cycles, you now have 25 treatments*50 fields/beams = 1000 cycles, any systematic errors in the electronics will rear their heads. For this reason I have seen many places place limits on the number of IMRT fields, or a minimum on the individual field energy.

Perhaps its just immaturity in the technique, and all of this will improve with time.

Oh, and if peds is your area - have you been to St. Jude, in our dept?
 
I haven't had the pleasure of visiting St. Judes. I know its one of the finest in the world of course for pediatrics; Dr. Wharam is my mentor and attending which has been a marvelous experience all around. I've taken care of a good number of pediatric cases, and have had the pleasure to work with Robert Arceci in peds onc here (and hope to do some bench work with him). I do hope to visit some other good pediatric centers to see the different ways in which they do things.

The point you made about dose-gradient is exactly the problem I was circling around regarding the value of appreciating the role of "conventional" and 3D- conformal therapy.
 
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