50 Years of Radiotherapy Research. Not Looking Good.

[TheWallnerus]

Highlights​

• The number of publications by the 10% most productive last authors more than doubled in the last 15 years. (The Usual Suspects?)
• Between 1970 and 2000, the proportion of first authors that will not publish articles as a last author increased from 58% to 84% (is our children publishing?)
• Compared to other cancer therapies the proportion of radiotherapy research output has declined from 64% to 31% in the last 50 years. (Is Rad Onc dying?)
• Three of the four journals that publish much of the most cited research in the field have impact factors ∼5. (Red Journal is about #45 out of 242 oncology journals)
• Africa and South America representing 23% of the world’s population contributed to ∼3% of radiotherapy articles in 2019. (likely a nothing burger with mayo to the U.S. RO SJW literati)

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[TheWallnerus]

Germane:

Two Mt Sinai junior rad onc attendings get $4m in grants (Early Independence Awards from the NIH, $2m each) to:

1) Study a therapy med oncs will give (CAR-T)
2) Study sexual function changes after RT and improve QOL after RT

So, basically, viewed from afar (open to being corrected), doing nothing to obviously advance their own specialty.

 

[elementaryschooleconomics]

Wow.

Ouch.

Though this article studies global trends, seeing this in black and white makes it feel like the abysmal state of American Radiation Oncology was almost inevitable, and set into motion before many of us were even in undergrad. Artificially propped up by our healthcare system's preferential reimbursement of procedures, the past 20 years of RadOnc were really gilded with more hype than substance.

But hey, I can count myself among the whopping 84% of first authors who will never publish as last author, so I imagine I'm in good company...just by sheer probability, of course.

 

[seper]

Germane:

Two Mt Sinai junior rad onc attendings get $4m in grants (Early Independence Awards from the NIH, $2m each) to:

1) Study a therapy med oncs will give (CAR-T)
2) Study sexual function changes after RT and improve QOL after RT

So, basically, viewed from afar (open to being corrected), doing nothing to obviously advance their own specialty.

Nice achievement , Dr. Marshall. I'm also surprised there are $2 mil to be had in studying vaginal scarring, ovarian failure, microbiome

 

[jondunn]

I think you meant this to be a slight to the junior faculty, but I congratulate them. Hard to get funding in today’s environment, I will always give kudos to securing it. Takes a lot of work.

 

[seper]

No, not meant to be negative. Just noting that for those who want NIH money bad enough, they can have it

 

[Palex80]

 

[elementaryschooleconomics]

Man, I've been just perseverating on the decline in first authors becoming last authors since this thread was posted. It really bothers me. We went from essentially a 50/50 shot to a "one-in-ten" kind of deal over 30 years...and this only takes us to the year 2000.

As the RadOnc bubble hit, and academic publishing became more and more necessary to Match...I have to imagine it's even worse now. I'm just picturing all the Boomer Docs assuring me that academic Radiation Oncology was a strong career path and not to worry about it (using that darn "the sky is always falling in RadOnc" line they love to use). Those same Boomer Docs hold, with an iron grip, their positions of power (for DECADES), profiting off the MLM scheme they've created. It's awful hard for young physicians and scientists, who we convince to matriculate into the system every year, to get jobs and funding, when funding remains stagnate and jobs are occupied by people in their 70s.

Paul Wallner graduated from medical school in 1968. There are many people like him, still sitting in positions in this specialty, still gobbling up opportunities so Gen-X and Millenial docs just have to sit back and wait, while the existing leadership continues to undermine RadOnc so when they finally retire, there's nothing left.

 

[jondunn]

I don’t think that phenomenon is rad onc specific, is it? Academic publishing has boomed in general, with many first authors who never become senior authors, because researdh productivity in Med school (to get into residency) and during training (as part of expectations of an academic residency) has skyrocketed in all fields

 

[elementaryschooleconomics]

I don’t think that phenomenon is rad onc specific, is it? Academic publishing has boomed in general, with many first authors who never become senior authors, because researdh productivity in Med school (to get into residency) and during training (as part of expectations of an academic residency) has skyrocketed in all fields

Oh yeah totally agree, not necessarily RadOnc specific. It's why I would never encourage people to do a straight PhD without a well-thought out plan for what to do with it, because the oversupply for PhDs is real as well.

It's more that...PhD oversupply is well known and acknowledged, while there's a lot of denial on RadOnc today.

 

[ramsesthenice]

Oh yeah totally agree, not necessarily RadOnc specific. It's why I would never encourage people to do a straight PhD without a well-thought out plan for what to do with it, because the oversupply for PhDs is real as well.

It's more that...PhD oversupply is well known and acknowledged, while there's a lot of denial on RadOnc today.

As someone who did a traditional PhD and then did med school and has sat on many a thesis committee I am not as troubled by this discrepancy. We have a dumb system set up and for most people publications are just a means to an ends during training. They never intended to become senior authors or independent researchers. MD PdDs are definitely included in this. Want to get into a competitive specialty/med school? Better publish. I have seen limited evidence this discrepancy is because people want to become senior researchers and can’t.

 

[elementaryschooleconomics]

As someone who did a traditional PhD and then did med school and has sat on many a thesis committee I am not as troubled by this discrepancy. We have a dumb system set up and for most people publications are just a means to an ends during training. They never intended to become senior authors or independent researchers. MD PdDs are definitely included in this. Want to get into a competitive specialty/med school? Better publish. I have seen limited evidence this discrepancy is because people want to become senior researchers and can’t.

That's fair, I'm sure there are folks out there with more positive experiences than what I've seen. To be clear, I'm speaking more broadly about PhDs and academic-based science and not just RadOnc. Putting the pandemic issues beside, Nature published a special issue about this in 2016:

Early-career researchers need fewer burdens and more support

Young scientists under pressure: what the data show

I'm specifically thinking about this graph:

I have innumerable anecdotes supporting this issue (as I'm sure you may have innumerable anecdotes in the opposite direction). I was just catching up with a faculty member who was on my PhD committee, and who is one of my favorite people on the planet. I had thought this person was planning on retiring shortly after I defended...coming on a decade ago. But no, now into their 80s, this individual had just gotten a new R01, so they were sticking around.

Obviously there's nothing wrong with that on the individual level. That person does good work and is a great mentor. But the pipeline has a constant influx of new trainees and stagnate funding. Bloomberg has an article on this from this year:

America Is Pumping Out Too Many Ph.D.s

From the article:

So if you have seen limited evidence that the discrepancy of first authors not becoming last authors is not because people want to but can't, I find that somewhat surprising.

The supply/demand issue isn't inherently good nor bad, it just needs to be acknowledged and planned for.

 

[medgator]

I don’t think that phenomenon is rad onc specific, is it? Academic publishing has boomed in general, with many first authors who never become senior authors, because researdh productivity in Med school (to get into residency) and during training (as part of expectations of an academic residency) has skyrocketed in all fields

Lots of ROs hanging out in practice as septa/octagenarians, I feel like you just don't see that to the same degree in other specialties.

 

[RickyScott]

Lots of ROs hanging out in practice as septa/octagenarians, I feel like you just don't see that to the same degree in other specialties.

Departmental babysitters.

 

[ramsesthenice]

That's fair, I'm sure there are folks out there with more positive experiences than what I've seen. To be clear, I'm speaking more broadly about PhDs and academic-based science and not just RadOnc. Putting the pandemic issues beside, Nature published a special issue about this in 2016:

Early-career researchers need fewer burdens and more support

Young scientists under pressure: what the data show

I'm specifically thinking about this graph:

View attachment 344457

I have innumerable anecdotes supporting this issue (as I'm sure you may have innumerable anecdotes in the opposite direction). I was just catching up with a faculty member who was on my PhD committee, and who is one of my favorite people on the planet. I had thought this person was planning on retiring shortly after I defended...coming on a decade ago. But no, now into their 80s, this individual had just gotten a new R01, so they were sticking around.

Obviously there's nothing wrong with that on the individual level. That person does good work and is a great mentor. But the pipeline has a constant influx of new trainees and stagnate funding. Bloomberg has an article on this from this year:

America Is Pumping Out Too Many Ph.D.s

From the article:

View attachment 344458

So if you have seen limited evidence that the discrepancy of first authors not becoming last authors is not because people want to but can't, I find that somewhat surprising.

The supply/demand issue isn't inherently good nor bad, it just needs to be acknowledged and planned for.

Just looking at traditional PhDs in cancer/molecular sciences (not straight chem) I would wager less than half even try for it. Again, one quirk is the only place you can do PhD training is in academics. A lot of people have no intention of pursuing the post doc to faculty route from the first day they apply. I went to a top program for my PhD (to 5 in NIH funding) and since 2000 only 40% of our grads have remained in academics. Lots of people go into industry or alternative careers (patent law, etc). And the graphs you have show why. Getting a senior author paper accepted and getting NIH grants funded (which you must do to get tenure) are 2 very different things. We were not quite talking about the same issues. Trust me. When you sit on study section you see the other issues loud and clear. “This is a really great idea. If they just had a few more papers and better track record of success on their own, we could fund it.” ☹️

 

[GadRads]

I believe the higher number of working elderlies (septa/octagenarins), reflects improved longevity, and probably financial pressures, all which encourage working longer into dying years. For example, I know a physician scientist in his/her 70s who wanted to retire, but had some debt he/she wanted to pay off prior to retirement. It's not uncommon to see professors die on the job at ages that would easily fall into retirement brackets. The downside is that opportunities for younger physicians and scientists aren't necessarily expanding in proportion.

 

[elementaryschooleconomics]

Getting a senior author paper accepted and getting NIH grants funded (which you must do to get tenure) are 2 very different things. We were not quite talking about the same issues.

Ah yeah, I see what you mean. I'm mentally interpreting the "first-to-senior author" conversion as a surrogate endpoint for many different things, which is distinct from what you're talking about.

I believe the higher number of working elderlies (septa/octagenarins), reflects improved longevity, and probably financial pressures, all which encourage working longer into dying years. For example, I know a physician scientist in his/her 70s who wanted to retire, but had some debt he/she wanted to pay off prior to retirement. It's not uncommon to see professors die on the job at ages that would easily fall into retirement brackets. The downside is that opportunities for younger physicians and scientists aren't necessarily expanding in proportion.

This is absolutely true. I know the argument of "darn old people won't retire" is fashionable right now (which I am clearly guilty of), but that argument makes the assumption that they're staying because they want to, not because they have to. Which then gets us into a whole different realm of economics, culture, and politics. I suspect the Ralphs and Pauls of the world are not facing the same financial pressure as the person you are referencing.

 

[Neuronix]

• The number of publications by the 10% most productive last authors more than doubled in the last 15 years. (The Usual Suspects?)

I think that there are certain people who have figured out how to play the database review, meta-analysis, and survey game and keep publishing work, often in rad onc's better journals, that has no actual role in moving science and patient care forward. The problem of course is that you need this stuff to get promoted at a lot of institutions, and this is fairly easy work to produce, so it's going to keep happening.

There are also the people on NRG and other committees with no term limits who just get added to protocols and papers by default.

There are also ways of gaming the system so that certain people and their friends approve each others papers and grants, while people in the out group get destroyed.

• Between 1970 and 2000, the proportion of first authors that will not publish articles as a last author increased from 58% to 84% (is our children publishing?)

As has been pointed out, there's been a lot of publishing just to get into the specialty and then as residents to help the faculty. I don't see this as a big deal. What percentage of rad oncs need to be publishing as senior author? 15%? Seems reasonable enough. As long as that 15% controls the residency positions and push their residents to publish, this is going to continue to be something we observe.

• Compared to other cancer therapies the proportion of radiotherapy research output has declined from 64% to 31% in the last 50 years. (Is Rad Onc dying?)

This is a side effect of funding limitations. As has been published repeatedly, radiation is mostly ignored and neglected by the NIH, while the radiation device manufacturers pay for very little research. Pharma has so much money it's insane. Also pharma doesn't pay for studies to use less of their drugs...

If you want an NCI grant today, the paylines are really low. Your grant has to score in the top 10% or better depending on the year. It's marginally better if you're new investigator, about 15th percentile nowadays. Here's how it looks today with the NIH's attempt to get the paylines up a little in the 2020s.

Here's how it used to be. People who started their careers in the early 2000s and before had a completely different landscape for launching a science career. This is the aging workforce--people who started then and are still successful. Meanwhile, there are greater and greater expectations and competitiveness for people just starting now.

• Three of the four journals that publish much of the most cited research in the field have impact factors ∼5. (Red Journal is about #45 out of 242 oncology journals)

We're a small specialty. This happens in all niche areas. The area I did my PhD in was similar--the biggest journals had impact factors in the 3-4 range. Grant funding is the equalizer in the PhD circles. Grants are generally reviewed by people in your own little area, and they recognize which are the key journals in their particular specialties.

• Africa and South America representing 23% of the world’s population contributed to ∼3% of radiotherapy articles in 2019. (likely a nothing burger with mayo to the U.S. RO SJW literati)

I think much of Africa and South America have bigger issues with getting everyone cared for.

 

[elementaryschooleconomics]

As has been pointed out, there's been a lot of publishing just to get into the specialty and then as residents to help the faculty. I don't see this as a big deal. What percentage of rad oncs need to be publishing as senior author? 15%? Seems reasonable enough. As long as that 15% controls the residency positions and push their residents to publish, this is going to continue to be something we observe.

This is definitely true today. However, this data stops at the year 2000. I don't have a strong sense for this (as it was before my time), but had the arms race for medical students to publish begun by that point? Maybe for a select few specialties, but the Golden Bubble for RadOnc didn't hit until maybe 2002 or 2003, right? I would bet we're below 10% by now, perhaps below 5%, but that's an educated guess (I'll ironically have to go dig around to see if anyone has published that data yet).

 

[OTN]

Without data from other specialties, it's hard to know if this is truly radonc-specific. My guess would be 'no', as I've seen data that shows for all medical students and residents, the number of publications under their belt has skyrocketed over the last 20 years. Like me, the vast majority probably had zero interest in an academic career and were just jumping through hoops.

 

[TheWallnerus]

 

[communitydoc13]

Slowed canonical progress in large fields of science

The size of scientific fields may impede the rise of new ideas. Examining 1.8 billion citations among 90 million papers across 241 subjects, we find a deluge of papers does not lead to turnover of central ideas in a field, but rather to ossification of canon. Scholars in fields where many papers...

www.pnas.org

None of the trends above are specific to radonc IMO.

Nor do I blame existing radonc researchers for lack of actionable progress.

I do blame radonc leaders from circa 2005-2015 for believing that collecting talent like Horace Slughorn made sense, was moral and needed to be done more by expanding residency positions.

What we have instead of great (meaningful) research output is a brutal meritocracy and this:

Can too many brainy people be a dangerous thing?

Some academics argue that unhappy elites lead to political instability

www.economist.com

There needs to be room for great science to happen. The universe needs to conspire with our ambition. Medical oncology provides the nearly infinite space of cancer biology. Radiation oncology provides the much smaller space of radiobiology and cancer pertinent physics. Combine this limited space with the glut of talent and the small field of radiation oncology is acting like the large, stagnant fields referenced in the above PNAS article.

Very few radiation paradigm changes in last 25 years in radonc IMO. IMRT preceded me and is really nice (not quite a paradigm change), SBRT almost a paradigm change, move away from ENI almost a paradigm change. Protons not a paradigm change. IGRT not a paradigm change. All incremental and sometimes good. Mostly associated with fewer treatments. Very little survival benefit associated with these. Mostly physics driven.

In medical oncology, OMG. Personalized genomic medicine and a move to n of 1 personalized therapy. FDA approval of Herceptin (1998), Gleevec (2003), Yervoy (2011) and then every other immunotherapy agent. Next generation endocrine therapy in prostate cancer. Survival benefit speaks for itself.

No wonder many of the best radonc researchers have research only tangentially involved in radiation, and no wonder so many super smart academic radoncs looking for meaning in their work have turned to reduced utilization and disparities based research.

 

[TheWallnerus]

Slowed canonical progress in large fields of science

The size of scientific fields may impede the rise of new ideas. Examining 1.8 billion citations among 90 million papers across 241 subjects, we find a deluge of papers does not lead to turnover of central ideas in a field, but rather to ossification of canon. Scholars in fields where many papers...

www.pnas.org

None of the trends above are specific to radonc IMO.

Nor do I blame existing radonc researchers for lack of actionable progress.

I do blame radonc leaders from circa 2005-2015 for believing that collecting talent like Horace Slughorn made sense, was moral and needed to be done more by expanding residency positions.

What we have instead of great (meaningful) research output is a brutal meritocracy and this:

Can too many brainy people be a dangerous thing?

Some academics argue that unhappy elites lead to political instability

www.economist.com

There needs to be room for great science to happen. The universe needs to conspire with our ambition. Medical oncology provides the nearly infinite space of cancer biology. Radiation oncology provides the much smaller space of radiobiology and cancer pertinent physics. Combine this limited space with the glut of talent and the small field of radiation oncology is acting like the large, stagnant fields referenced in the above PNAS article.

Very few radiation paradigm changes in last 25 years in radonc IMO. IMRT preceded me and is really nice (not quite a paradigm change), SBRT almost a paradigm change, move away from ENI almost a paradigm change. Protons not a paradigm change. IGRT not a paradigm change. All incremental and sometimes good. Mostly associated with fewer treatments. Very little survival benefit associated with these. Mostly physics driven.

In medical oncology, OMG. Personalized genomic medicine and a move to n of 1 personalized therapy. FDA approval of Herceptin (1998), Gleevec (2003), Yervoy (2011) and then every other immunotherapy agent. Next generation endocrine therapy in prostate cancer. Survival benefit speaks for itself.

No wonder many of the best radonc researchers have research only tangentially involved in radiation, and no wonder so many super smart academic radoncs looking for meaning in their work have turned to reduced utilization and disparities based research.

Lot of deep thoughts in here, all of them good, including that obtuse Harry Potter reference. I would add a paradigm change though to your list of almost-paradigm-changing things. (And I think it's always just intellectually honest, and not self-flagellating, to point out that major changes in RO last quarter century not really associated with any survival benefits. I also agree that IMRT not a paradigm change.) The MAIN paradigm change in RO in the last 25 years, and we are in the change right now, is hypofractionating. It is the sibling of RO-APM, and the sibling of regulatory changes in RO, and whatever will come (and it will be worse, and it will be for private insurance too) after RO-APM.

 

[medgator]

Lot of deep thoughts in here, all of them good, including that obtuse Harry Potter reference. I would add a paradigm change though to your list of almost-paradigm-changing things. (And I think it's always just intellectually honest, and not self-flagellating, to point out that major changes in RO last quarter century not really associated with any survival benefits. I also agree that IMRT not a paradigm change.) The MAIN paradigm change in RO in the last 25 years, and we are in the change right now, is hypofractionating. It is the sibling of RO-APM, and the sibling of regulatory changes in RO, and whatever will come (and it will be worse, and it will be for private insurance too) after RO-APM.

Already occurred. Evilcore got it handed to them on a silver platter

 

[Palex80]

Lot of deep thoughts in here, all of them good, including that obtuse Harry Potter reference. I would add a paradigm change though to your list of almost-paradigm-changing things. (And I think it's always just intellectually honest, and not self-flagellating, to point out that major changes in RO last quarter century not really associated with any survival benefits. I also agree that IMRT not a paradigm change.) The MAIN paradigm change in RO in the last 25 years, and we are in the change right now, is hypofractionating. It is the sibling of RO-APM, and the sibling of regulatory changes in RO, and whatever will come (and it will be worse, and it will be for private insurance too) after RO-APM.

I totally agree that the change that will reshape the future of radiation oncology is hypofractionation.

However, I believe that hypofractionation (in any form) was only achieved due to modern technology, including IGRT, IMRT, SBRT and more accurate dose calculation.

Hypofractionation for breast cancer was pursued before the 90s as well and ended up yielding excessive toxicity (both acute and chronic). The reason was probably the photon energies used back then as well inadequate dose calculation (2D-planning).

Prostate hypofractionation (and ultimately SBRT) would not have been possible without accurate dose calculation, IGRT and IMRT.

 

[TheWallnerus]

I totally agree that the change that will reshape the future of radiation oncology is hypofractionation.

However, I believe that hypofractionation (in any form) was only achieved due to modern technology, including IGRT, IMRT, SBRT and more accurate dose calculation.

Hypofractionation for breast cancer was pursued before the 90s as well and ended up yielding excessive toxicity (both acute and chronic). The reason was probably the photon energies used back then as well inadequate dose calculation (2D-planning).

Prostate hypofractionation (and ultimately SBRT) would not have been possible without accurate dose calculation, IGRT and IMRT.

You make good points. I don't disagree. At the end of the day, in the argument of "What is THE paradigm shift in rad onc in the 21st century?" you have to pick one answer and one answer only. It's like arguing "Why is 'All About Eve' the greatest movie of all time?" You'll have your reasons and I'll have mine

 

[deleted941485]

Nice achievement , Dr. Marshall. I'm also surprised there are $2 mil to be had in studying vaginal scarring, ovarian failure, microbiome

That is literally all the funding available. Like this one person probably has all the funding anybody would be willing to part with.