isnt Rad Onc a dying field??

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Isn’t radiation oncology a dying field?
The layman’s common misconception is that first there was only surgery to treat tumors. Radiation became the new modality of the early and mid-twentieth century. Then chemotherapy “superceded” radiation and soon there will be the magic bullet that will target cancer and when realized, bring a cure. In fact surgery, radiation and chemotherapy are complementary modalities. Pathology, surgery, patient related factors and other issues will sometimes determine which therapies are chosen, and more often than not, the multi-modality approach is used. In fact its become painfully clear that while chemotherapy is an essential component of anti-tumor therapy, it cannot single-handedly live up to the hope that it excited a couple of decades ago. Meanwhile advances is radiation delivery (radiolabeling, CT-based target verification, radiosurgery) permit us to improve outcomes by raising doses to tumor because we can simultaneously better protect normal tissue.

Additionally radiation oncology is likely to get more important if chemo gets better (keep reading). Why? Because as a generalization, chemo deals best with microscopic disseminated disease. As they get better at that, the issue of local control will be more important. That is, as minute mets- currently the thing that kills people- is controlled, we'll need to redress getting local disease (primary) under control or else people won't be cured. Literature well shows that better local control equals better survival, and that recurrence in some cases is a harbinger of poor prognosis.

This is already an issue in lung cancer.

Think of it this way:

Without hard numbers to support me, I'd guess that surgery is the primary curative treatment modality in about 70-80% of tumors, radiation in 35-45% (I know it adds up to over 100%, but there is considerable overlap w/ surgery), and chemotherapy in about 10% (lymphoma, leukemia, seminoma, and little else). Of course, there is a considerable body of literature supporting combined modality treatment in many tumor sites, and this means that chemo remains important as a complementary treatment modality, but primarily for sterilization of microscopic disease, as it is inadequate (with a few exceptions) for the clearance of gross disease.

Put another way, if oncology were Van Halen, surgery would be Eddie, radiation oncology would be David Lee Roth (let's just all agree that Van Hagar and that god-awful experiment w/ the lead singer from Extreme never happened), and heme-onc would be Michael Anthony; important to the overall product, yes, but pretty much only invited into the group because he had a van, and we needed the transportation to the gigs.

We ain't going nowhere.

G'ville Nole said:

Think of it this way:

Put another way, if oncology were Van Halen, surgery would be Eddie, radiation oncology would be David Lee Roth (let's just all agree that Van Hagar and that god-awful experiment w/ the lead singer from Extreme never happened), and heme-onc would be Michael Anthony; important to the overall product, yes, but pretty much only invited into the group because he had a van, and we needed the transportation to the gigs.

We ain't going nowhere.

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Freakin' fantastic. Love it.

OK...you are right. The truth must be told:

Yes, radiation oncology is dying field with no future. We really only treat enough patients to cover the fact that we don't work on weekends. After IMRT, there is nowhere left to go, for we have discovered all there is regarding radiation delivery and cancer therapy. As you can see, hardly any patients die of cancer anymore since Gleevec and the scalpel were invented, because advances in surgery and chemo have been so great. Please apply to a field with years of cutting edge innovation just ahead, such as family practice, rather than challenging your peers to a knife-fight for the residency spots in rad onc. Please do not read any of our journals, as all the cool stuff going on in our field is a cover for the fact that one visit from the Magic Chemo Fairy will send our lives into obsolescence.

also, please avoid radiology, because computer-aided detection algorithms, cardiologists, and/or replicants will replace them all.

What?s the job market/ salary like?
Right now, though getting a residency is difficult, the applicant is at the advantage come time to search for his/her first attendings position. This may change in the next few years as radonc programs graduate full classes but its hard to predict. About six years ago there was a national scare that there would be too many young radiation oncologists coming out of residency into the field. In response, residency spots were cut and some completely closed. In the light of day it turned out that in fact there were not enough trainees graduating and the field is now feeling the shortage. Academic jobs, which typically pay significantly less than private jobs, are feeling the squeeze in particular. This may (or may not) change over the next few years as the many MD, PhDs and research-oriented residents currently entering training leave residency.

While in medical school, one of my mentors expressed interest in radiation oncology and he was told it was a dead/dying field. This was around 15+ years ago. Sure, there is potential for us die off but it doesn't seem to be any more significant than the problems that other fields are facing. After all, aren't we all really trying to put ourselves out of work (i.e no sick people)?

G'ville Nole said:

Put another way, if oncology were Van Halen, surgery would be Eddie, radiation oncology would be David Lee Roth (let's just all agree that Van Hagar and that god-awful experiment w/ the lead singer from Extreme never happened), and heme-onc would be Michael Anthony; important to the overall product, yes, but pretty much only invited into the group because he had a van, and we needed the transportation to the gigs.

We ain't going nowhere.

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I mean come on. The world is in need of more metaphors like that.

Just had a lecture the other day at my institution by one of the best well-known breast cancer pathologists in the country. His words, not brought on by any questions of ours, just out of the blue, and paraphrased by me:

"So...incomplete genetic analysis of colon cancers revealed more than 100 separate genetic mutations which were thought to be responsible for the development of malignancy. Each tumor had more than 10 of these mutations, chosen seemingly at random from the more than 100 possible. Given the complexity of molecular genetics which leads to the development of malignancy, molecular targeting by medical oncology will never be able to effectively treat the vast majority of tumors. You guys will be around for a very, very long time. "

We liked him.

OTN said:

"So...incomplete genetic analysis of colon cancers revealed more than 100 separate genetic mutations which were thought to be responsible for the development of malignancy. Each tumor had more than 10 of these mutations, chosen seemingly at random from the more than 100 possible. Given the complexity of molecular genetics which leads to the development of malignancy, molecular targeting by medical oncology will never be able to effectively treat the vast majority of tumors. You guys will be around for a very, very long time. "

We liked him.

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If you're talking about the recent study in Science by the Vogelstein group, there has been some discussion that they are seriously underestimating the number of common genetic mutations, not to mention the pile of epigenetic changes that might occur in tumorigenesis.

However, to treat cancer in a molecular context, one must not treat every perturbation, but only the critical one, as even one repair of the effect of a single critical mutation can be curative. For example, recent studies (one here) restoring wild-type p53 in mouse tumors indicate the power of a single genetic change to be effective in treating cancers. Furthermore each mutation does not lead to individual phenotypes cannot be attributed to single pathways - 500 different activating mutations might occur in the Wnt signaling pathway that could be treated with inhibitors against its downstream effector beta-catenin. Finally, advances in molecularly targeting drug to tumor, new nanotechnological approaches, and targeting of cancer stem cells were not addressed by this criticism.

That said, the creation of rationally designed therapies to cover heterogeneous malignancies such as lung, colon, or breast cancers is a challenge that will take years. But to say that this strategy will "never be able to treat effectively the vast majority of tumors" is very shortsighted.

amherstguy said:

hey guys i didnt mean to open a can of worms here. i actually like rad onc a lot, i think the relationship u can have with patients is just second to none. its just that the heme onc people seem to say that rt is a thing of the past... also just out of curiosity what is the job market like for fresh grads?? where do u see the field going in the future??

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its not a can of worms; the reaction youre getting is due to exactly the sort of thing that your medoncs are doing. Its been that way for decades. Ironically there are more medoncs who switch into radonc than the other way around.

No, to bottom line it, there are two and a half reasons radonc isnt likely going anywhere


1) Rt is the most effective modality in many many solid tumors. Yes more so that chemo. But its limited by being a local modality. We've found that pulling back with RT has often led to poor control in many tumors.

2) as we get to more targeted therapies, because radonc is so effective, radiolabeling them will be come more important. And radonc (and/or nuc med) will be doing this, not med onc. There are nuclear regulatory reasons for this thanks to a couple of radoncs (and unfortunately not because of radonc organizing well as a whole)

3) And as chemo works (hopefully)works better over the years, local control will become more important.

I say two and a half because these are interrelated reasons.

Its fine for a student to have questions like this. Not for a medical oncologist.

The concept of the magic bullet is really a vision that defines and refines approach. That is, trying to target at the molecular level. The reality is that successfully doing so ot the extent of eradicating tumors completely, and yet completely sparing normal tissue is an extremely elusive goal that we may indeed never actualize in total.

stephew said:

The concept of the magic bullet is really a vision that defines and refines approach. That is, trying to target at the molecular level. The reality is that successfully doing so ot the extent of eradicating tumors completely, and yet completely sparing normal tissue is an extremely elusive goal that we may indeed never actualize in total.

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Again, I think we're underestimating human ingenuity here. We can trot out Gleevec and its successors out, but the truth is targeted therapy for solid tumors has not yet fulfilled its promise. But I see no reason to be pessimistic.

Let me be clear that I agree that surgery and radiation for debulking tumors will be necessary, perhaps for a hundred years in the future (and therefore for the OP, RadOnc is not a dying field).

Doctor&Geek said:

Again, I think we're underestimating human ingenuity here. We can trot out Gleevec and its successors out, but the truth is targeted therapy for solid tumors has not yet fulfilled its promise. But I see no reason to be pessimistic.

Let me be clear that I agree that surgery and radiation for debulking tumors will be necessary, perhaps for a hundred years in the future (and therefore for the OP, RadOnc is not a dying field).

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im not pessimistic. I think great strides are being made but i think for the foreseeable future, this targeted therapy remains a new vision that gives us new approaches for attack. but it ultimately will be revealed to be far more complex than how we think of it now, and ultimately, the therapies designed on this paradigm will certainly help but not as we anticipate it now. Much like when chemo came along to "replace" sx and radiation (ie it didnt) and tumor supressors were turned out to be so complex it wasnt merely about synthesizing the missing protein "break" from a mutated TS gene. I might toally wrong on this. but its how I think it will go. I just think nature is far more complex than we can anticipate whenever we develop a paradigm

SimulD said:

The complicated nature of onco-genes and tumor supression makes my head spin. I've had a few patients talk about the 'cancer industry' and how 'the cure is out there' and how 'you're holding back the cure ... not you Dr. simul ... you're doing the best you can, i'm talking about The Man'. If the laymen only knew ...

S

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oh yeah, ive heard that and the like. I tell them, well, if there is a conspiracy, they're not letting me in on it.

I don't think radiation oncology is dying...but it is an old field, perhaps that's why so many wonder when we'll get along without it.

my question is: where is the field going? Is it a field that is living off the fat of the land because there is no better alternative...or is there something fantastic/exciting on the horizon with RT...a big change? i hope so.

Dying? Gasp.....gasp....gasp....

are you kidding me. There are more indications for RT (both benign and malignant) now than there were 10 years ago. Any with the advant of general usage of body radiosurgery with incredible results (ie Timmerman for lung, etc), it will only increase.

Cynics have said we've been dying for years.....funny that there are 30% more linear accelerators now than there were 15 years ago. With IMRT, IGRT, cyberknife, this field is here for the long run - and that's based on results - ie cure of prostate cancer, breast cancer, lymphomas, gi cancers, radiosurgery, etc.

In fact our medicare utilzation has gone from $800mil to over $1.6billion in the last 5 years alone.