Basic science career in Rad Onc

[buster]

Hello,

I've recently discovered this forum and found it to be a valuable source of information. I've got a question for those in the forum.

I'm an M3 who has recently finished a PhD and is back in clinics. I'm starting to think about residency choices and Radiation Oncology seems appealing for a lot of reasons. My career goals at the moment are to go into academics and run a basic science lab. However, my research interests are primarily in basic tumor biology (my thesis work was in tumor immunology), and not radiation physics, or even radiation biology (as I understand it). I find the kind of work being done in the fields of cancer stem cells and targeted tumor therapies more interesting. Is radiation oncology a good choice for me? If so, what residency programs will best prepare me for such a career?

Thanks in advance.
Buster

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[Pewl]

Based on your interests, it sounds like you would really enjoy medical oncology. Targeted therapy is a hot topic.

 

[Gfunk6]

There have been some excellent threads in recent years on this topic:

1. http://forums.studentdoctor.net/showthread.php?t=249727
2. http://forums.studentdoctor.net/showthread.php?t=323850

I suggest reading these carefully and posting any follow-up questions/comments here. This is a topic that's near and dear to my heart.

 

[buster]

There have been some excellent threads in recent years on this topic:

1. http://forums.studentdoctor.net/showthread.php?t=249727
2. http://forums.studentdoctor.net/showthread.php?t=323850

I suggest reading these carefully and posting any follow-up questions/comments here. This is a topic that's near and dear to my heart.

Thanks for the reply Gfunk. I have read through those threads, and I must say the landscape does not look all that promising. I know that there currently aren't a lot of scientific luminaries from Rad Onc relative to other fields; however, I felt that was changing as more and more research types drifted into the field. Can you give me a sense of whether this is so? In 5, 10, 20 years will be seeing some superstar Rad Onc scientists? Are there young newly minted Radiation Oncologists with the means and institutional support to perform truly groundbreaking research?

 

[Dishevelled Doc]

This was definitely something I was trying to figure out as I made my way through the interview trail this year. The answer I basically came up with is that I am cautiously optimistic that the field will be more and more open to basic science oriented physician-scientists over time (of course, I'm really biased since I have to believe this to be true or else I'm going into the wrong field...). I guess what gives me hope is that there are now a number of Holman pathway grads who have had to find jobs and, in doing so, have created a demand for the 80/20 basic-science/clinic positions, which departments are starting to supply.

Still, the field has a LONG way to go. Apparently there are only 12 R01 funded radiation oncologists nationally, which was a shockingly low number to me. Also, on the interview trail the only interviewer who REALLY talked with me about my research was Dr. Powell (chair at WashU, now chair at MSKCC). Outside of that the only other interviewer who discussed research in depth with me (though not my research really) was Dr. Hallahan (chair at Vanderbilt, a program that only interviewed MD-PhDs with first author papers and which encourages all residents to do the Holman pathway). The rest of the programs I interviewed at (most of which have been described on this site as research-oriented programs) did little more than say how much time they offer for research and described some of the opportunities available.

There are two big problems (as I see things) that RadOnc has for basic scientists. The first is a financial one - a practicing RadOnc makes so much money for a hospital that there a big disincentive for the administration to be accomodating. This is in contrast to Medicine, where a good grant will bring far more in overhead than what the clinical work can. The second problem is a logistical one - in Medicine you can just be the service attending for a month or two and be in the lab the rest of the year. Alternatively, you can be in clinic a day (or half a day) a week and be in lab the rest of the time. In RadOnc, you have so many different days of clinic (Consults, Sims, OTVs, Follow-up) that it's harder to do the one day a week thing, and since we don't manage the floors, there just isn't the same need for the service attending. There are programs out there that are making it work, but it's definitely a challenge.

All of that having been said, I think that if you are clinically passionate about radiation oncology, then there's no question it's worth the risk that you'll have to work harder to find the 80/20 job than if you went into MedOnc (also worth the other risks described on this site like the prospect of lower reimbursement, etc). Personally, if I went into Medicine, I'd just be looking forward to getting back into the lab as quickly as possible, while with RadOnc I'm really excited about the clinical training I'm going to get (assuming this whole match thing actually works out...). I am a firm believer than you have to be passionate about what you do to make it as a physician-scientist (or anything else, for that matter) and if the clinic doesn't excite you, I don't see how it can inspire you to answer interesting questions.

 

[Teeka]

As Dishevelled doc suggests, there are challenges. The main problem is that the field is very small compared to med onc, and only a fraction the size of IM. That said, there are some programs with well funded investigators(NIH dollars). Yale has 13 R01 grants spread over 6 investigators, a >10 million dollar Program project grant in DNA repair (P01), a variety of other NIH funded grants including a T32 training grant, many PhD scientists in the department and over 25 post docs. Stanford has a large number of R01s, P01x2, a T32, etc. Penn, Vanderbilt, Michigan, Wash U., Duke have active programs and there are others....
Some of these programs have better facilities than others and some have more collaboration with other scientists in other departments than others.

There are definitely new investigators being funded as the field is populated with a higher percentage of scientifically oriented and MD-PhD graduates.

Programs with radiation oncologists (in the department of radiation oncology with a primary appointment there) with an MD or MD-PhD that come to mind rapidly(there are others) with R01/P01 funding and who see patients are: Michigan, Penn, Yale, Vandy, Wash U. now to MSK, Chicago, Stanford, Duke, UNC, Fox Chase, Wisconsin, Harvard, Jefferson so there are certainly more than 12 in the US.....(see previous post) as these are just off the top of my head. There would certainly be others within these and additional departments if those junior faculty with K-type awards were included.

The best way to evaluate what is going on in given departments is to use the CRISP system to look at funding of individual investigators.
http://crisp.cit.nih.gov/

Click on this link and download the medical school only data to evaluate funding of specific departments at various schools. The NIH groups diagnostic together with rad onc, but you can tell by the project title if it is a diagnostic project or rad onc.
http://grants1.nih.gov/grants/award/trends/AggregateData.cfm

For a prospective applicant interested in a scientific career, the most important things are likely 1)availability of scientific opportunity based on magnitude of what is going on in a given department and 2)potential for the leadership of the training program and department to support you being involved in said opportunities with time and mentorship.

 

[buster]

Thanks for the responses. They have been helpful.

There seems to be really two issues at play here. The first is the ability to get adequate research time while a resident. This seems to be primarily accomplished via the Holman pathway or post-residency post-docs. Given that there are now a number of programs supporting Holman scholars, can anyone point me to a website/data outlining which schools are supporting exactly how many? Also, is it possible to get individual scholars' research track records to see how productive they have been with this opportunity?

The second is the ability to get faculty positions with sufficient devoted research time (80/20 etc). This seems to be much more uncertain. There still seems to be a paucity of major grants being awarded to Rad Oncs. As some have mentioned, their numbers in the overall pool are also small, so it should not be surprising to see IM PIs outpacing them. However, Rad Onc has an extremely high percentage of MD/PhDs. One would thus expect that they would in fact be over-represented in the RO1 pool. Yet this does not seem to be the case, probably for the reasons that have been outlined in this post.

So my question is this: given that the first hurdle (institutional support for research training in residency) is being met, at least for some schools, does it not necessarily follow that there will soon be a boom in 80/20 type positions opening? Or will it simply mean that a lot of highly trained MD/PhDs will be competing for a handful of positions?

I know no one here is an omniscient being and the future can't be predicted, but some of you must know which way the wind is blowing?

 

[Gfunk6]

Given that there are now a number of programs supporting Holman scholars, can anyone point me to a website/data outlining which schools are supporting exactly how many? Also, is it possible to get individual scholars' research track records to see how productive they have been with this opportunity?

Information on Holman scholars are not published as far as I can tell. This coming ASTRO, a couple of us have asked the powers that be to help us organize a meeting of Holman residents. This would be tremendously helpful to see how other programs hammer out the logistics of this research pathway.

One link which might be helpful is here. This is a listing of current RSNA resident grant recipients, most of whom are in the Holman pathway. Please note that this list includes both Radiology and RadOnc residents.

So my question is this: given that the first hurdle (institutional support for research training in residency) is being met, at least for some schools, does it not necessarily follow that there will soon be a boom in 80/20 type positions opening? Or will it simply mean that a lot of highly trained MD/PhDs will be competing for a handful of positions?

Yes, it would follow that more 80/20 spots would open. Not sure if that will happen. Keep in mind, however, that lot of MD/PhD residents go into private practice like all the rest. After ~15 years of post-undergraduate education, many cannot resist the allure of $$$.

Also of possible interest, Wake Forest has a 3-year fellowship geared for physician-scientists in RadOnc who want to pursue a 80/20 career. Link here.

ADDED
Unless you find clinical work in Radiation Oncology, specifically, compelling I would go with Medical Oncology. The ABIM research pathway is well-suited for churning out phsyician scientists and with the ability to work with many of the top cancer researchers in the country, you will be better off from a research stand-point.

I personally could not stand more than a single year of Internal Medicine and was wary of signing "another" 7-year contract so I went into RadOnc. Thus far I am very happy but I know that my research career would have been better served if I did MedOnc.

 

[Zap]

I agree that you should go into the field that interests you more, since there are many variables out of your control when it comes to finding the perfect job. I was trying to choose between pursuing a bench-based research career in med onc or rad onc. I personally did not really enjoy inpatient medicine, both imagining being a resident/fellow and later an attending. That made the choice much easier for me. Furthermore, I spent a lot of time on med onc rotations and got a sense for the clinical "acumen" of some MD/PhD "clinician"-scientists. Most did not impress me in the outpatient setting and the few I worked with on inpatient services seemed very unsure of themselves and unhappy to be there. And can you blame them? They spend 11 months of the year overseeing their labs with ~1 day a week in some narrowly focused clinic and suddenly have to be the physician of record for very sick patients with all sorts of oncologic problems. I felt that I would fall into the exact same mold if I went the med onc route.

Most of the Rad Onc attendings I worked with who also oversaw labs seemed different to me. I think not having inpatient responsibilities is part of that. I also think while certain things in rad onc make it harder to pull off being in clinic one day/week (i.e. on-treatment patients, small size of departments, etc.), the narrow focus that most academic attendings take (often one disease or organ system) seemed to make the clinical work more manageable. Plus, with residents or NPs in support, most of the day-to-day issues that are not mission critical don't require attending input. Also, not being a patient's primary oncologic physician makes it easier to be "available" only intermittently. That said, clinical radiation oncology is extremely complex and not something one can do half-heartedly. However, you can be confident that the 80/20 model can be successfully pulled off.

Finally, beware of the idea that there are so many more jobs in med onc for MD/PhDs. While this is true numerically, you have to remember that there are many more medical oncology fellows who will apply for 80/20 jobs than radiation oncology residents. In the end it's really the # of jobs/applicant that matters, and from talking to friends who are med onc fellows I'm far from convinced that getting a great 80/20 job is any easier there than in rad onc. The most desirable institutions only have a few med onc research jobs available and they are all highly sought after.

So, in short (this somehow got a lot longer than initially intended), pick the field you think you will enjoy more. That will be the most likely route to a fulfilling career.

 

[Newquagmire]

Unless you find clinical work in Radiation Oncology, specifically, compelling I would go with Medical Oncology. The ABIM research pathway is well-suited for churning out phsyician scientists and with the ability to work with many of the top cancer researchers in the country, you will be better off from a research stand-point.

I personally could not stand more than a single year of Internal Medicine and was wary of signing "another" 7-year contract so I went into RadOnc. Thus far I am very happy but I know that my research career would have been better served if I did MedOnc.

I'm surprised that this appears to be the general sentiment. Can anybody elaborate? Comments indicate that a general lack of support for basic science training (real or perceived) is the difference here. Am I missing something else?

 

[Gfunk6]

I'm surprised that this appears to be the general sentiment. Can anybody elaborate? Comments indicate that a general lack of support for basic science training (real or perceived) is the difference here. Am I missing something else?

Look at it from a purely mathematical perspective.

ABIM Research Pathawy (Med Onc only)
2 years of Internal Medicine
2 year fellowship in Medical Oncology
3 year post-doc in lab

Holman Pathway
1 year of Internal Medicine
1.75 years of lab work (80% protected)
2.25 years of Radiation Oncology

The ABIM pathway gives 100% protected research and nearly double the total research time.

There are many reasons RadOnc does not provide equivalent training. These were described very well by Dishevelled Doc,

There are two big problems (as I see things) that RadOnc has for basic scientists. The first is a financial one - a practicing RadOnc makes so much money for a hospital that there a big disincentive for the administration to be accomodating. This is in contrast to Medicine, where a good grant will bring far more in overhead than what the clinical work can. The second problem is a logistical one - in Medicine you can just be the service attending for a month or two and be in the lab the rest of the year.

An alternative to the Holman Pathway (possibly better) would be to do a dedicated post-doc after your residency. This could give you ~ 3 years of 100% bench work but at what cost? You are already a BC/BE radiation oncologist and are you prepared to suck it up to earn $60,000 x 3 MORE years while your colleagues (even the ones in academics) are eraning four times more?

In any case this arugment is moot in the case of > 90% of training programs who do not give 10-12 months of research time, let alone do Holman. As it stands, Rad Onc is simply not designed to produce physician scientists. Those that exist are exceptional and definitely not the product of a well-thought out system. Could it change in the future? Possibly, who knows?

 

[buster]

This discussion has been really informative. Thanks for all the input.

To be honest, I have not yet done the Rad Onc clerkship at my school, so I don't know how satisfying it will be. Clinical satisfication is, after all, a huge part of the equation. I do know that I was not particularly enamored with Med Onc. And considering that research dollars are never a guarantee, especially in the current climate, picking a residency based on clinical satisfaction may trump any gain in available research opportunies.

For those of you who have replied in this thread, I am assuming you are currently residents with basic science aspirations; if you don't mind my asking, how do you foresee the next few years—from Holman/research training to job search—going? If you aren't able to get high profile pubs in your research time, do you think you will bail on the research plans?

 

[trublu]

Great conversation. I think the original poster is wise to be looking closely at this question.

I'd like to make a few comments. So you can put them in context, I'll give you a bit of background on myself. I'm an MD/PhD at a big rad onc program with a high ratio of MD/PhDs to MDs. I'm currently in my PGY-2 year.

This is a hot question amongst the residents in my program. We've had some long talks on this very topic recently with graduating residents, junior faculty, and even some big-wigs.

Drawing from these conversations, here's what I have to add to the discussion:

1. med onc vs. rad onc for a research career

First, I'll echo the previous postings by stating that this decision should be made primarily based on which interests you more clinically. That's really a more important issue than any of the others brought up in this thread.

That aside, I think med onc wins this fight, hands-down. Med oncs get far better research experience during training. The structure of their transition from training to faculty is much better suited to securing initial funding. They are much better protected from clinical responsibilities as faculty. The result: you are much more likely to succeed as a researcher if you go the med onc route.

2. med onc vs. rad onc for a basic science career

Here again, med onc is a vastly superior way to go. As a field, they are already reaping the rewards of their investment in basic science. This will fuel their support of basic science for a long time to come.

Rad onc, on the other hand, is a field where advances born of biology have been dwarfed by those born of physics. Those who sit in high places throughout our field have witnessed this decades-long lopsided battle and, with few exceptions, their perceptions are colored by that.

This severely limits the number of programs you could work in while enjoying true support for basic science research. If your own chairman doesn't honestly believe in the promise of what you're doing - and I'd argue that most in rad onc would not - you'll be fighting a losing battle.

3. potential influence of MD/PhDs currently coming through training

I think this is vastly overstated. As mentioned before, many of us will drop out of academics; even more will abandon research. Those who are left may be enriched for success, but their numbers will be so small that a major impact on the field is, I think, too much to expect.

And even if I'm wrong - even if all the current "interest" in rad onc physician-scientists translates into more R01 funding for the field - this won't likely make your job any easier. It'll probably only grease the wheels for the next generation.

4. best way to train for a research career in rad onc

So, if you want to ignore the above advice and pursue research as a radiation oncologist, you'll want to know how best to train in order to prepare for your career, right?

I think this question gets too much emphasis, too. Let's face it, one year of research doesn't compare with a post-doc. Neither does the Holman pathway. Your marketability for an 80/20 coming out of residency will depend in some part on your productivity during residency, but it will depend in much greated degree on your research track record as a whole, your job talk, and on how good a case you can make for your fit at the institution.

And keep in mind that residency is your only opportunity to get your formal clinical training. Assuming you'll be taking care of patients as some part of the rest of your career, you want to make sure you are well-trained. My advice, then, is to choose a residency program based on the quality of the clinical training you'll receive, not the quality of the research you'll do there.

That being said, your research time as a resident obviously has some importance. I'd recommend looking for a program that affords flexibility in their research component. Ideally, there'd be flexibility in length, timing, and location of research (i.e. within and without the home institution). Seeing that a program supports Holman candidates is a nice sign, even if you don't pursue that option.

5. best place to get a job

I don't know. If you figure it out, please tell me.

All the concerns I raised above apply. Ultimately, you need a chairman who can and will support you - ideally, one who's also invested in your vision. You need a research infrastructure to support what you want to do (including talented graduate students and post-docs, I think). You need potential collaborators. You need a clinical service that's not too busy and that has other faculty to cover you when things get rough (which they will).

And a partridge in a pear tree.

6. my personal plans

Honestly, despite all the above, I intend to pursue a research career in the field. We have the single most effective and widely-used cytotoxic therapy in oncology, and I think there are vast opportunities to use biology to advance our field in the coming years.

However, I try to have realistic expectations. I understand that I may have to accept a lower salary to get the protected time I need. I realize that during the first few years - and, perhaps, indefinitely - I'll need to have a translational focus on my research in order to keep my chairman and department interested.

If you couldn't stomach those types of compromises, I think this may not be the path for you...

 

[Neuronix]

Information on Holman scholars are not published as far as I can tell.

The ABR director for the Holman pathway can give you this information about which institutions support Holman pathway students. If you PM me I can send you her contact info or she can be contacted through:

http://www.theabr.org/RO_Holman.htm

 

[miamiradonc]

Just to give some additional data (two cents) on the subject:

1) I know that the Georgetown program has one alloted year for research.

2) I requested protected research time in my program and was given 2 months to do basic science research. Now, this may not seem like a lot of time, but I have been able to learn valuable techniques, get good reliable results, and establish a relationship with a basic science lab. So, for the rest of my residency ( during academic days, elective rotations) I can always partcipate in or design new projects with this lab. In a sense I have become an adjunct lab member. I would think many residency programs would be flexible in this regard and allow basic science research during your residency.