a radonc's view of his/her own role in helping patients?

[medgrays]

As a med student interested in RadOnc, I was recently reading a document on irradiation of CNS tumors (that claimed that incidence of parenchymal necrosis for intracranial tumors is like 5-20%) and I got this sad feeling that as RadOncs you must always cause some serious destruction of tissue to effectively "help" the patient on the grand scale?

Is this true? This post is not meant to be a flame, just wondering how radonc attendings/residents feel about this aspect of their therapies? Does it ever seem that it might have felt more rewarding to be only performing solely curative therapy (e.g. surgical resection, etc.)?

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[radiaterMike]

FWIW- Much of surgery is not curative. Grater than 50% of patients treated with radiation receive curative intent treatment. Thos patients who receive palliative radiation are often thankful for it. Surgery is not without late effects (including fibrosis and necrosis) from tissue destruction, and neither is chemotherapy.

As a med student interested in RadOnc, I was recently reading a document on irradiation of CNS tumors (that claimed that incidence of parenchymal necrosis for intracranial tumors is like 5-20%) and I got this sad feeling that as RadOncs you must always cause some serious destruction of tissue to effectively "help" the patient on the grand scale?

Is this true? This post is not meant to be a flame, just wondering how radonc attendings/residents feel about this aspect of their therapies? Does it ever seem that it might have felt more rewarding to be only performing solely curative therapy (e.g. surgical resection, etc.)?

 

[IndyXRT]

As a med student interested in RadOnc, I was recently reading a document on irradiation of CNS tumors (that claimed that incidence of parenchymal necrosis for intracranial tumors is like 5-20%) and I got this sad feeling that as RadOncs you must always cause some serious destruction of tissue to effectively "help" the patient on the grand scale?

Is this true? This post is not meant to be a flame, just wondering how radonc attendings/residents feel about this aspect of their therapies? Does it ever seem that it might have felt more rewarding to be only performing solely curative therapy (e.g. surgical resection, etc.)?

Some doctors seem inclined to keep a scoreboard, where every patient they "save" is a win, and every patient who dies is a loss. Not that this is necessarily wrong, but people with this mindset would be miserable in radiation oncology. I try to view each patient encounter as an opportunity to help somebody. Perhaps I have a chance at curing their cancer, or maybe I can only help them require less pain medicine. Radiation does have side-effects, but so does just about everything we do in medicine. I find my job very rewarding.

The important thing, if you think you may be interested in radiation oncology, is to spend time caring for cancer patients. If you enjoy doing this, then radiation oncology is a great field. If you have trouble dealing with end of life issues and non-curative cases, then rad onc is not for you.

 

[deleted4401]

I do think of the 'collateral damage' a lot- we're using a toxic, potentially cancer-causing modality to treat sick people.

First thing in my mind when I see a patient is 'Can I spare this patient radiation?', then if I have to treat, 'How do I do it in a way to get them the least sick?'

But, every doctor/surgeon should think that way - all tests are invasive, all procedures have potential risks, the benefits are not always clear, and all patients respond differently to treatment.

First year, I don't think I admitted any of my head and neck patients. This last rotation, at week 5 or 6, all of them had to be admitted/PEG-tubed. Breaks your heart to take your friends to hell and back.

It isn't necessary to 'destroy the village in order to save it' and there are things you can do supportively to help out. But, man it gets rough and I do feel bad, but if it's the right thing to do, I can sleep at night.

S

 

[Palex80]

I would say 5-20% parenchymal necrosis seems a bit too much.
You seldom see PARENCHYMAL necrosis when treating Glioblastona with 60 Gy for example.
The rates definetely go higher the more aggressive one gets and the rate should be about 5-10% for example for retreating pre-irradiated Glios, I have seen at least 2 patients suffer normal tissue necrosis.

SimulD has a very good point there.
If one group of patients suffer the most during radiation therapy, it must be head and neck patients.
However I have developed the concept of giving pretty much everyone with a Stage IVa tumor a PEG-tube, knowing that sooner or later they are all gonna need it. And believe me it works. Even after 30 Gy, when the first problems arise, you can feed your patients with no problems whatsoever. And this is very helpful.

 

[deleted4401]

I think that institutional philosophy prevents us from putting PEGs in until the torture is at full steam. It's a "use it until you lose it" maxim.

Brain necrosis for GBM?? Who knows? They die too quick ...

S

 

[IndyXRT]

I would say 5-20% parenchymal necrosis seems a bit too much.
You seldom see PARENCHYMAL necrosis when treating Glioblastona with 60 Gy for example.
The rates definetely go higher the more aggressive one gets and the rate should be about 5-10% for example for retreating pre-irradiated Glios, I have seen at least 2 patients suffer normal tissue necrosis.

SimulD has a very good point there.
If one group of patients suffer the most during radiation therapy, it must be head and neck patients.
However I have developed the concept of giving pretty much everyone with a Stage IVa tumor a PEG-tube, knowing that sooner or later they are all gonna need it. And believe me it works. Even after 30 Gy, when the first problems arise, you can feed your patients with no problems whatsoever. And this is very helpful.

This works nicely . . . if you can convince the patient to use the G-tube. Many patients at our VA agree to get the G-tube, then refuse to use it until they are completely miserable (and sometimes not even then).

 

[stephew]

I think that institutional philosophy prevents us from putting PEGs in until the torture is at full steam. It's a "use it until you lose it" maxim.

Brain necrosis for GBM?? Who knows? They die too quick ...

S

i know. they dont all die too quick. It can happen but as you say, its rare. More commonly you see things like pseudoprogression or NPH.

We gave PEGs to most H&Ners getting chemo at JHH and the esophageal guys with concomittant chemorads.

 

[stephew]

As a med student interested in RadOnc, I was recently reading a document on irradiation of CNS tumors (that claimed that incidence of parenchymal necrosis for intracranial tumors is like 5-20%) and I got this sad feeling that as RadOncs you must always cause some serious destruction of tissue to effectively "help" the patient on the grand scale?

Is this true? This post is not meant to be a flame, just wondering how radonc attendings/residents feel about this aspect of their therapies? Does it ever seem that it might have felt more rewarding to be only performing solely curative therapy (e.g. surgical resection, etc.)?

I think the question (or the statement you read) is too broad. Necrosis of which tumors? From what therapy? And are you talking imaging changes or symptomatic (ie problematic) necrosis? And what about necrosis that requires intervention of surgery or causes death? I rarely have pts with necrosis requiring intervention. BTW Im a CNS specialist.

All docs sometimes hurt patients. there is no way around that. Precsribe a drug that causes a drug reaction; give someone an infection from surgery. Etc etc. Id say we dont do it and more or less than most docs; The goal is to develop processes to limit error, and to do evidenced based medicine when you can. But if you have a concern about hurting patients, that's good. That sort of caution is something all docs should carry with them. What we do is incredibly serious and privileged. All docs should be reflective of that.

 

[medgrays]

thanks everyone for your great responses. I will take them all into account as I carefully gauge in the future whether this field is right to me.

imo, even though radiation therapy is such a necessary component for cancer therapy, perhaps it is not a wise specialty for me - I can't imagine having patients who get collateral tissue damage, radiation sickness, secondary malignancies after my therapy (even though this may help in tumor size reduction/survival rate).

I'm not arguing against the field, I guess I'm realizing maybe I'm not a good match (and there's nothing wrong with that)

 

[Gfunk6]

I'm not arguing against the field, I guess I'm realizing maybe I'm not a good match (and there's nothing wrong with that)

Of course not!

Your still strong enough, smart enough and, gosh darn it, people like you.

 

[radiaterMike]

It is definitely important to find out what is the best match for you since you will ideally be spending the rest of your life in that career. All fields in oncology (and perhaps all fields in westernized medicine that treat a medical condition) cause collateral damage to some extent.

thanks everyone for your great responses. I will take them all into account as I carefully gauge in the future whether this field is right to me.

imo, even though radiation therapy is such a necessary component for cancer therapy, perhaps it is not a wise specialty for me - I can't imagine having patients who get collateral tissue damage, radiation sickness, secondary malignancies after my therapy (even though this may help in tumor size reduction/survival rate).

I'm not arguing against the field, I guess I'm realizing maybe I'm not a good match (and there's nothing wrong with that)

 

[stephew]

its an important insight to make. Id be lousy at surgery simply because there are elements of the lifestyle id just hate. I will say I think your perception of collateral damage, 2nd malignancies and "radiation sickness" (we do cause fatigue but not radiation sickness!) is probably off a bit. I doubt there is a field you'll get into where you dont cause "collateral damage" of some sort. In surgery it happens acutely usually. In medicine too. But you will also have long terms side effects. Some drugs can cause cancers etc etc. But if you get a better sence of these side effects as they really area and then it doesnt "Feel" like the right field, it probably isnt. Consider a rotation if youre still not sure. good luck.

thanks everyone for your great responses. I will take them all into account as I carefully gauge in the future whether this field is right to me.

imo, even though radiation therapy is such a necessary component for cancer therapy, perhaps it is not a wise specialty for me - I can't imagine having patients who get collateral tissue damage, radiation sickness, secondary malignancies after my therapy (even though this may help in tumor size reduction/survival rate).

I'm not arguing against the field, I guess I'm realizing maybe I'm not a good match (and there's nothing wrong with that)