Choosing between med onc and rad onc after shadowing

[Carrot0123]

Hi everyone,

I've been doing some in person shadowing in a med onc clinic my PI set me up with and I've been trying to see the differences between the two so I can ultimately decide which I want to apply to (for now I have been told by my med onc PI and my older classmates I can just apply to both since I have research in each).

Hopefully this can help some students who haven't had the chance to try both to get a broad sense of what the differences are in clinics at least. (take all this with a grain of salt as I'm just a student this is just what I saw / felt)

This is in an academic center btw.

First thing I noticed was that the med onc clinic was way busier and ran way longer. Each patient took much longer to work up even if they were just follow ups there is a list of things you need to check up on, scheduling, logistics etc. I feel like I spoke to less patients but each one for much longer but they usually have a laundry list of things they need to talk to the physician about.

In the rad onc clinic most of what I saw was updating the patient about their latest imaging, checking up on a few side effects or explaining a radiation treatment if they are getting one. Saw many more patients per clinic and the visits were quicker. I felt like there was more time to talk to the patient about things other than their treatment because I now see that most of their health concerns get managed by the med onc and their other supporting physicians.

I've also noticed most of the rad onc's work is done behind the scenes (pre-clinic rounds, planning radiation, communicating with physicists and other colleagues etc.) while a lot more of the med onc's work is done in the clinic when they decide the next course of action for the patient based on their current situation the past couple of weeks.

The lead med onc who was running the clinic seemed a lot more swamped than the lead rad onc's in the other clinic and couldn't pop in to say hi to most patients unless the patient demanded it. This could just be site dependent as the rad onc site I followed is not super busy.

Overall I enjoyed both experiences for different reasons, I feel like once you get to do a check-up on your on patient on the med onc side things become much more interesting because they are relying on you some what to make sure all their concerns are addressed.

I liked that in rad onc you got to take more time to look at their imaging before and also during the clinic to really wrap your head around what has happened between scans and then the patient contact part is more of just an update on what's happening, addressing any side effects and giving your opinion if they need radiation or not and what their options are.

With med onc I felt you were juggling many more variables and addressing a broader range of concerns which isn't necessarily a good or bad thing just depends on what you enjoy I suppose.

I haven't felt like I've gotten any closer to deciding to be honest just that I know I wouldn't be upset in either field. In Canada the employment situation for either seems pretty similar for academics (for community I think med onc is more flexible). I also met a surprising amount of med oncs doing 2-3 year fellowships. I would like to choose the one I would enjoy and will also be able to be employed in relatively soon after residency.

If you have any advice on deciding or questions about other differences I didn't touch on let me know 🙂

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[medgator]

". I would like to choose the one I would enjoy and will also be able to be employed in relatively soon after residency."

Should be obvious which one to choose

 

[deleted1111261]

First thing I noticed was that the med onc clinic was way busier and ran way longer. Each patient took much longer to work up even if they were just follow ups there is a list of things you need to check up on, scheduling, logistics etc. I feel like I spoke to less patients but each one for much longer but they usually have a laundry list of things they need to talk to the physician about.

This is very true. They are way busier than I am.

 

[elementaryschooleconomics]

". I would like to choose the one I would enjoy and will also be able to be employed in relatively soon after residency."

Should be obvious which one to choose

Strongly agree.

That being said, because the Canadian healthcare system is different than America's I'll avoid the general job market stuff.

I would add that, regardless of what country you're practicing in, you're tied to a very expensive piece of equipment as a Radiation Oncologist. Obviously, the days of a MedOnc being able to "hang a shingle" and start practicing on their own are probably long past. However, practicing as a Medical Oncologist (even in a saturated system like Canada, if your MedOnc residents are doing multiple fellowships) just simply can't be as geographically limiting as the specialty which is practically chained to a linear accelerator. I think Medical Oncology likely offers more flexibility throughout your career, unless, in some dystopian future, chemotherapy must be dispensed in like, titanium cocoons, Matrix-style.

 

[deleted1111261]

ESE- very possible.

 

[medgator]

Strongly agree.

That being said, because the Canadian healthcare system is different than America's I'll avoid the general job market stuff.

Canada and the states have both had cycles of rad onc oversupply over the last few decades. Canada supposedly getting better in recent years while the US is trending in the other direction.

Not aware of med onc having anything close to the same situation... like ever

 

[deleted941485]

Canada and the states have both had cycles of rad onc oversupply over the last few decades. Canada supposedly getting better in recent years while the US is trending in the other direction.

Not aware of med onc having anything close to the same situation... like ever

Who knows...cancer care is a different beast in Canada.

 

[RickyScott]

at the end of day, indications and patient numbers for radonc much less likely to grow vs medonc no matter what country you are in.

 

[Neuronix]

This is very true. They are way busier than I am.

Not in our shop. YMMV.

 

[TheWallnerus]

The lead med onc who was running the clinic seemed a lot more swamped than the lead rad onc's in the other clinic and couldn't pop in to say hi to most patients unless the patient demanded it. This could just be site dependent as the rad onc site I followed is not super busy.

This is very true. They are way busier than I am.

What if I were to say that it's great that rad oncs are less busy and can spend more time with patients. It's one reason I bet many of us found rad onc appealing.

What if I were to say it's also existentially frightening that rad oncs are less busy.

We are not way less busy because we are smarter and better at schedule optimization. We are not less busy 'cause we just love to chillax.

We can only stay way less busy for so long.

 

[medgator]

Not in our shop. YMMV.

Some of the private med oncs use extenders/NPs to cush their schedule... Less inpatient coverage, help with covering chemo etc

 

[w00tz]

Not in our shop. YMMV.

Yea, definitely varies.

In our private practice, we do decently well and are busy. We could hire part-time/full-time physician/midlevel to help out and make us less busy, but that costs money. Money that we may not have in the future with APM, decreased indications, declining reimbursements. If a rad onc is not busy now, they may find themselves with even more time on their hands in the future with less consults, fewer fractions, or, worst case scenario - no job.

 

[elementaryschooleconomics]

Yea, definitely varies.

In our private practice, we do decently well and are busy. We could hire part-time/full-time physician/midlevel to help out and make us less busy, but that costs money. Money that we may not have in the future with APM, decreased indications, declining reimbursements. If a rad onc is not busy now, they may find themselves with even more time on their hands in the future with less consults, fewer fractions, or, worst case scenario - no job.

This was an important consideration for me. The private practice I joined is significantly busier than what I often hear about from other groups/institutions, and I found that very appealing...since it seems likely I'll get to keep this job...hopefully.

 

[RickyScott]

What if I were to say that it's great that rad oncs are less busy and can spend more time with patients. It's one reason I bet many of us found rad onc appealing.

What if I were to say it's also existentially frightening that rad oncs are less busy.

We are not way less busy because we are smarter and better at schedule optimization. We are not less busy 'cause we just love to chillax.

We can only stay way less busy for so long.

on point. And there are plenty of radoncs seeing around 120 new patients per year, or less.

 

[medgator]

on point. And there are plenty of radoncs seeing around 120 new patients per year, or less.

Less busy than residency minimums by quite a margin. Many of us are well above 250 sims a year

 

[deleted1111261]

What if I were to say that it's great that rad oncs are less busy and can spend more time with patients. It's one reason I bet many of us found rad onc appealing.

What if I were to say it's also existentially frightening that rad oncs are less busy.

We are not way less busy because we are smarter and better at schedule optimization. We are not less busy 'cause we just love to chillax.

We can only stay way less busy for so long.

yes- that’s what I mean - I like more time with patients. Felt MO was hurry hurry hurry.

 

[deleted941485]

on point. And there are plenty of radoncs seeing around 120 new patients per year, or less.

My first year out I saw 180 and thought they would fire me. This year 200. But just you wait when BR007 gets going.

 

[deleted941485]

yes- that’s what I mean - I like more time with patients. Felt MO was hurry hurry hurry.

I wish I didn’t care about that so much when I was picking a specialty but hey

 

[medgator]

My first year out I saw 180 and thought they would fire me. This year 200. But just you wait when BR007 gets going.

That study should be boycotted to ****

 

[beamotherapy]

That study should be boycotted to ****

What is the point of BR 007 - it seems very much like NSABP B 21 to me.

 

[RickyScott]

successor to br 07 will be ct dna liquid biopsies to determine if we can “personalize” radiation to only those with measurable ctdna. Mdacc hard at work here.

 

[medgator]

yes- that’s what I mean - I like more time with patients. Felt MO was hurry hurry hurry.

Because it is.

 

[fiji128]

What is the point of BR 007 - it seems very much like NSABP B 21 to me.

"There is Growing Clinical Interest to Reduce Breast Cancer Overtreatment with Radiation Therapy."

"Patient Experience of De-escalating Breast Conserving Therapy to Lumpectomy without Radiation is Needed."

"Evidence that Biomarkers can Identify Patients at Sufficiently Low Risk of Recurrence after Lumpectomy that Radiation can be Omitted:

Over the past decade, numerous biomarkers have emerged for guiding adjuvant systemic therapy decision making for early stage breast cancer (Harris 2016). The Oncotype DX™ Recurrence Score (RS) is a commercially available multigene assay using RNA expression profiling that has been demonstrated in a large phase III randomize trial to reliably predict the risk of distant metastasis and chemotherapy benefit in node-negative hormone sensitive breast cancer patients receiving endocrine treatment (Sparano 2018). This now allows tens of thousands of women annually to omit chemotherapy and its associated toxicities from their breast cancer treatment. The RS has proven to be prognostic for local regional recurrence (LRR) as well when retrospectively studied in node-negative, ER-positive breast cancer in NSABP B-14 and B-20 clinical trial samples (Mamounas 2010). In this analysis, among 895 tamoxifen-treated patients, 390 underwent lumpectomy and radiation, and the 10-year actuarial rates of LRR for the RS low, intermediate, and high groups were 6.8%, 10.8%, and 14.6%, respectively (P =0.043). For breast conservation cases, RS was an independent predictor of LRR, as well as patient age less than 50 years, in multivariate analysis. Similarly, among 388 women with hormone receptor-positive, node-negative breast cancer treated with chemotherapy plus endocrine therapy on the Eastern Cooperative Oncology Group (ECOG) E2197 study, the 10-year rates of local recurrence were 3.2, 2.9, and 10.1 % for low, intermediate, and high RS (p=0.17); but was significantly associated with LRR when RS was evaluated as a continuous variable, (HR 2.66; P = 0.03) (Solin 2012). This supports that the RS represents a reliable means of stratifying HS breast cancer by prognosis beyond the limits of standard clinical pathologic factors to identify a group that had a clinically acceptable LRR rate post lumpectomy without radiotherapy.

To address this clinical question, NRG Oncology Breast Committee submitted Concept 9584, A Randomized Phase III Trial of Adjuvant Radiotherapy versus Observation Following Lumpectomy in Patients with Biologically Low-Risk Hormone-Sensitive Stage I Breast Cancer Who Receive Endocrine Therapy in 2013. This concept proposed to test whether radiotherapy offers a substantial benefit in reducing breast cancer recurrence in patients with ER+, PR+, HER2- disease who have a low OncotypeDX™ recurrence score (< 18) and who receive lumpectomy and endocrine therapy. Given the EBCTCG meta-analysis findings (Clarke 2005, EBCTCG 2011), the concept design used as a primary endpoint of invasive or DCIS recurrence free interval (RFI) to avoid missing the potential for increases in life threatening regional and distant metastases with omission of radiation. A non-inferiority design required an accrual of 2,068 patients. It was reviewed at the NCI Breast Cancer Local Regional Task Force (BOLD) and Breast Cancer Steering Committee (BCSC) and while assessed as consistent with the BCSC scientific priority of de-escalating breast cancer treatment in low risk populations, the large targeted accrual was a major barrier at the time and the concept was disapproved.

The NRG Breast Committee subsequently collaborated with the BOLD Task Force in an alliance with the Cancer Intervention, Surveillance Modeling Network (CISNET) Breast Cancer Working Group to determine if the trial outcome could be adequately modeled based on prior trial data, and if an improved, more efficient trial design could be discerned (Jayasekera 2018). This collaborative study sought to replicate the goals of the NRG 9584 Concept to determine the effect of breast radiotherapy on local-regional and distant recurrence, breast cancer-specific and all cause mortality conditional on genomic risk assessments in a pooled analysis of breast cancer patients from seven clinical trials (EBCTCG 2011, Fyles 2004, Winzer 2010, Sparano 2015, Fisher 1989, Fisher 1997, Fisher 2002, Kunkler 2015, Blamey 2013, Potter 2007). The final sample included 1,778 patients from the seven clinical trials. Except for patients in the TAILORx study (20), there was no HER2 information, and the Oncotype Recurrence Scores (0-100) were imputed for the other six trials using a deterministic regression-based multiple imputation approach, and a population-based donor dataset with Oncotype DX™ recurrence scores (Jayasekera 2018). The imputation model included age, tumor size, tumor grade, ER/PR status, radiation, and HER2 status. The primary endpoint of the pooled analysis was recurrence-free interval (RFI), and included time from randomization/enrollment to any occurrence of local (invasive), regional, or distant recurrence, or death from breast cancer. Omission of radiotherapy significantly increased the risk of loco-regional recurrence events (adjusted HR: 3·9, 95% CI 1·8-8·4, 2p<0·01), but not the risk of distant recurrence or breast cancer death. At 5-years, the loco-regional RFI rate with radiotherapy was 98·6% compared to 93·7% without radiotherapy (absolute difference 4·9%, 95% CI 2·5-7·2%, 2p < 0.01). At 10-years, the loco-regional RFI rate with radiotherapy was 96·6% compared to 85·5% without radiotherapy (absolute difference 11·1%, 95% CI 6·8-15·4%, 2p < 0.01). A subset analysis demonstrated significantly more recurrences associated with age < 60 years and RS 11-18 (Jayasekera 2018). Overall, the results of the pooled analysis suggest that omission of radiotherapy after breast conservation in hormone sensitive low-risk patients could lead to higher relative differences, but small absolute differences in RFI rates. Moreover, omission of radiotherapy did not appear to increase distant recurrences or early death in this low-risk population. As clinical decision-making is usually based on absolute differences, the conclusion was that future trials should focus on an acceptable absolute difference in local recurrence in its design."

 

[RickyScott]

To clarify, I am not a Luddite. I just wouldn’t be recruiting and expanding residencies. Those who are engaged in this type of research should also be calling for responsibile stewardship of training slots, not the opposite. #womenwhocurie.

 

[fiji128]

If the trial is "positive" (its a non-inferiority trial that you can drive a truck through), Astro will really need to double down on their lets mentor med students efforts to get to those ERAS applications in.

 

[Carrot0123]

yes- that’s what I mean - I like more time with patients. Felt MO was hurry hurry hurry.

I felt this as well while shadowing. I enjoyed you only had a few things on the agenda and you got to know the patients pretty well with that extra time. the patients also don’t expect you to solve every problem in rad onc, really just things that pertain to the radiation and the site that is being treated.


but then again it is probably good to have A role in managing more than just your 1 type of treatment job security wise. I think I’ll just have to get over that its gonna be busy which I kind of felt like I did today, clinic was pretty enjoyable.

 

[Lamount]

I predict the conclusion to BR007 will be the following: “Although noninferiority of RT omission could not be conclusively demonstrated in this cohort, the authors conclude the that forgoing RT may be appropriate in select patients”.