Nothing to do which is why people rant.
IMO three major problems for RO-
1) Increasing supply of RO doctors.
Resident expansion can only be fixed by SCAROP (and they are not interested). All the moaning about ABR, ACGME, ASTRO-it is not within their mission to reduce trainee numbers.
2) Decreased demand for RO doctors.
Supervision requirements and hypofractionation (sometimes extreme). The ship has sailed and when we discover that the horrible radiation disasters did not increase during COVID when supervision was even looser...hard to make the case (see scarb posts ad infinitum (not ad nauseum because that might trigger someone.)
3) Radiation Oncology has become a technopoly
. This is mentioned less but is evident behind the scenes and deeply embedded in the way many think within RO. If you don't know that a technopoly is the short version is here.
Longer version here
. Neil Postman defined a technopoly as a society in which technology is deified, meaning “the culture seeks its authorisation in technology, finds its satisfactions in technology, and takes its orders from technology." In RO it is manifest by engaging in DVH idolatry and accepting weak evidence that the newest technology (e.g. SBRT) is the best. The work that we do and the questions we ask are all defined by technology. The typical criticism is to cry "Luddite". Of course technology development is important but we seem to forget that the machines, etc are means to an end not an end in and of itself.
Thoreau warned us that humans "have become tools of our tools".
I agree with the spirit of your argument. As I see it (with my many months of wisdom) problems we face can be divided into two semi-distinct entities:
A) Problems facing Rad Onc as a profession.
Unbridled residency expansion, decreased radiation utilization (hypofx, better surgical/systemic options), decreased opportunities for re-reimbursement (decreased supervision requirements), and now we likely face a decrease in our patient population due to their disproportional susceptibility to COVID.
B) Problems facing Rad Onc as a discipline
Rad Onc is not very supportive of innovation. There is no greater past-time in our field then throwing stones at anyone who dares try something new (Particles? FLASH? Low Dose RT for COVID?... "why even bother looking?"). We struggle to translate some truly innovative lab research into the clinic and tend to shy away from testing uncoventional applications of RT. This is partly due to risk aversion (e.g. to paraphrase Weichselbaum, 'we have to be focused on how we look to other disciplines'); and partly due to an unhealthy degree of momentum behind current treatment paradigms.
The way I see it, we can't do much about A) for the reasons you said, but we can do something about B), and may end up helping A) in the process.
I also agree with the concerns about "technocracy" but, ironically enough, I think is also due to a lack of innovation. We are failing to stay ahead of our technology
-We treat DVHs as gospel but forget that it only represents the world as we hope it is. We will normalize a plan up or down by 0.5 Gy to meet constraints or get adequate coverage without acknowledging the possibility that the target or OAR may not be where we think it is. Rather than hanging our hat on what we think we know, we should get better at modeling error.
-SBRT isn't magical and radiobiology still applies
. If one is hitting constraints in 5 fractions, the therapeutic ratio will probably be better in 8, 10, or 15 fractions (except for low a/b tumors). The true advances that led to the expansion of SBRT were better conformality and better image guidance and these improvement has nothing to do with the number of fractions.
-Protons aren't magical either. They have an additional degree of freedom, which can dramatically improve conformality, but it comes at the cost of systematic errors. The failure to respect the impact of range uncertainties and LET on can result in real harm.
If we can't explain to ourselves (and any layman) the limitations of a technology, we probably don't know enough to use it safely and effectively.
*edited to fix some iPhone-related errors