Do you regret rad onc?

[amakhosidlo]

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I should rephrase: Do you miss medicine? After one rotation, I get the overwhelming sense that the technical emphasis of this specialty comes at the price of reduced medical management and narrower scope of practice. Some attendings seem to embrace the "technician" role. Others are more clinically minded, but still very restricted in terms of scope of their responsibilities or concerns. I'm not sure if I'm OK with this or not. I'm trying to balance that narrow scope versus the cool technology, heavy research, great hours/lifestyle, etc., etc., but am not sure if I would be happy being unfamiliar/not involved with the medical management aspect of my patients' care. Rebuttals? Anyone else have this issue? My alternative would be med onc.

 

[RadOncDoc21]

I made a similar titled thread a couple of years ago when I first started residency... It sounds like you haven't done a rotation yet because you can become as medically involved as you want. Once the patient starts radiation treatment, we see them frequently to not only manage radiation side effects but tend to medical issues as well. I know most of us prefer to not manage medical problems, there are a few rad onc docs who believe they can manage htn, diabetes and psych meds... Not my preference though.

 

[amakhosidlo]

...you can become as medically involved as you want. Once the patient starts radiation treatment, we see them frequently to not only manage radiation side effects but tend to medical issues as well.

Are they seen often? Sure. But how exactly are they managed? Med onc seems to orchestrate chemotherapeutics (both oncologic and otherwise), and at the risk of stepping on toes, propriety would seem to dictate that those decisions be deferred to their good judgement. No?

 

[stems]

I should rephrase: Do you miss medicine? After one rotation, I get the overwhelming sense that the technical emphasis of this specialty comes at the price of reduced medical management and narrower scope of practice. Some attendings seem to embrace the "technician" role. Others are more clinically minded, but still very restricted in terms of scope of their responsibilities or concerns. I'm not sure if I'm OK with this or not. I'm trying to balance that narrow scope versus the cool technology, heavy research, great hours/lifestyle, etc., etc., but am not sure if I would be happy being unfamiliar/not involved with the medical management aspect of my patients' care. Rebuttals? Anyone else have this issue? My alternative would be med onc.

Do I miss medicine? As in do I miss managing DM, HTN, CHF (which accounts for 80% of what medicine is)?

Answer: Hell no! I feel blessed whenever I turf that to my medonc colleagues. It's pretty nauseating activity (which takes minimal brain power).

 

[HQAMIGO]

I'm a PGY-3 rad onc resident. I do NOT miss managing CHF and DM ("take you lasix and stop eating potato chips" x ad nauseum). Frankly, our time with patients is limited and if your spending 50% of your time reconciling HTN meds, your not leaving yourself much time to think about staging and treating the patient's cancer.

However, what I do feel sometimes is that we are missing the molecular biology/ targeted therapy revolution currently going on in medical oncology. The last 10 years have seen tremendous improvement in the physics of radiation oncology like SBRT, IMRT, IGRT etc. However, looking ahead, I'm not sure what major advances we can look forward to in the next 10 years. I'm not saying there aren't any, so please enlighten me if you have some knowledge. The only thing that comes to my mind are protons but frankly, I'm not too impressed by the data.

 

[Neuronix]

PGY-3 here also. I love rad onc. No regrets here.

I'd just add that this specialty isn't for everyone. Every specialty has its pros and cons. This specialty is not perfect. It's silly to pretend that it is, or not discuss the specialty's negatives. Given the competitiveness of radiation oncology, I would never try to convince someone to do it. If medical management of conditions other than cancer is your thing, maybe this isn't the specialty for you. But since you asked, no I don't miss that part of medicine at all.

 

[Sheldor]

As an intern right now on a medicine service, who spent last year doing aways I can honestly say that I will not miss this at all. Non compliant patients, discharge summaries, endless pages from nurses about about blood sugars (What should we do about a BS of 80? Seriously?), to spending most of your time managing 20 medications in my mind the lack of this is one of the huge positives of rad onc.

I think the disconnect lies in the fact that in medical school there is this doctor as healer concept, and then you get into the real world and see that it is actually doctor as paper work doer, who also deals with polypharmacy out the whazoo.

Anyway, in my limited experience you can be more involved in the medical management as a rad onc if you want to, but I don't know that I understand who would 🙂

 

[Radbio22]

It is unfortunate in my opinion that we will be left behind for sure by the med oncs, who's innovation far out paces ours at this point. It is a travesty as radonc attracts some of the brightest, many MD, PhDs however many programs do not truly offer enough time doing real research. Off topic I know, but true.

 

[thesauce]

It is unfortunate in my opinion that we will be left behind for sure by the med oncs, who's innovation far out paces ours at this point. It is a travesty as radonc attracts some of the brightest, many MD, PhDs however many programs do not truly offer enough time doing real research. Off topic I know, but true.

I don't really understand the concept of being "left behind." We should be wanting vast improvements in systemic agents as it opens up more doors for local therapy.

However, most of the targeted therapies that medoncs have come up with have provided very minor improvements at best. Their game has essentially been re-combining the same old chemotherapies. Almost every cancer still gets platinum, it seems.

I'm sure radoncs were saying that we had peaked before we got 3DCRT, then before IMRT and protons. Now we're saying it again. We need to have a little more faith. I don't disagree that programs should provide more research opportunities, but there are numerous companies working on enhancing radiation delivery methods and there are at least a few working on radiation response modifiers. I think we have a bright future ahead of us.

 

[thesauce]

I should rephrase: Do you miss medicine? After one rotation, I get the overwhelming sense that the technical emphasis of this specialty comes at the price of reduced medical management and narrower scope of practice. Some attendings seem to embrace the "technician" role. Others are more clinically minded, but still very restricted in terms of scope of their responsibilities or concerns. I'm not sure if I'm OK with this or not. I'm trying to balance that narrow scope versus the cool technology, heavy research, great hours/lifestyle, etc., etc., but am not sure if I would be happy being unfamiliar/not involved with the medical management aspect of my patients' care. Rebuttals? Anyone else have this issue? My alternative would be med onc.

It's a trade-off. From my brief experience on PCP rotations in medical school, it gets exhausting trying to manage the gamut of medical issues and medications that your average patient comes in with. You can choose to be as involved as you want in these issues as a radonc, but most of us choose to stay far away from anything that isn't cancer or pain related.

 

[RadOncDoc21]

It's a trade-off. From my brief experience on PCP rotations in medical school, it gets exhausting trying to manage the gamut of medical issues and medications that your average patient comes in with. You can choose to be as involved as you want in these issues as a radonc, but most of us choose to stay far away from anything that isn't cancer or pain related.

Great points! I also wanted to add that we are "oncologist" with the most extensive oncology training out of all the oncologic specialties. We play a key role in the process and although are numbers are small, our impact is huge in the overall care of our patients.

This makes managing other medical problems difficult and time consuming... Besides this is why they have pcp's and other doctors who specialize in that area.

 

[medgator]

Great points! I also wanted to add that we are "oncologist" with the most extensive oncology training out of all the oncologic specialties. We play a key role in the process and although are numbers are small, our impact is huge in the overall care of our patients.

This makes managing other medical problems difficult and time consuming... Besides this is why they have pcp's and other doctors who specialize in that area.

Important point...... we know surgical management better than the med oncs and chemo role and regimens better than the surgeons....

After all, we've gone through 4 years of pure oncology training, instead of 3 years combined with heme

 

[medgator]

It is unfortunate in my opinion that we will be left behind for sure by the med oncs, who's innovation far out paces ours at this point. It is a travesty as radonc attracts some of the brightest, many MD, PhDs however many programs do not truly offer enough time doing real research. Off topic I know, but true.

Until you realize that most cancers involve multiple pathways that are fluid in nature and can change....only radiation is non selective 😉 besides, it will only help systemic control, not replace locoregional radiation therapy

 

[Neuronix]

Their game has essentially been re-combining the same old chemotherapies. Almost every cancer still gets platinum, it seems.

After I signed up for ASCO membership, I started getting the med onc throwaway journals. I do often read them. I realized that there are a lot of targeted agents out there currently and in development. Most of them provide a progression free survival benefit only. Some do extend overall survival, though last year when I had a nice drug rep lunch (Chipotle!), the drug rep was telling me that only 4 targeted agents have ever extended survival greater than 4 months in solid malignancies due to the targeted agent alone.

These were: trastuzumab, ipilimumab, sipuleucel-T... I'm not sure what the fourth was. Let's say it's sunitinib. Costs: $70,000, $120,000, $93,000, $60,000/year.

The reality is that the studies you hear promoted in the throw away journals and in academic centers right now are all drug company funded because the agents are extremely expensive. Most are for the metastatic setting--read: maintenance chemo. Keep people on it a long time to increase profits. Many med oncs are on the edge of their seats to deliver these new targeted agents since they get a percentage of every bag they infuse (http://ascoaction.asco.org/Home/tab...nistered-Drugs-The-Evolution-of-Buy-Bill.aspx). Researchers are promoting these drugs heavily to get funding from the drug companies to keep their research time.

We don't have much similar in rad onc. The funding from the device manufacturers is very limited. We don't have some technique we can come up with in a lab to all of a sudden make millions. The closest we have and the latest fad is to combine these targeted drugs with radiation. At least some trial money comes in that way.

So the grass may look greener on the other side, but for research, like everything else, it's all about the green. As long as the government is not giving grant money for research, options are going to be very limited for residents and attendings alike. I don't like the idea of selling my soul to push minimally more effective, extremely expensive medications to make someone else rich.

 

[Seldon1985]

Until you realize that most cancers involve multiple pathways that are fluid in nature and can change....only radiation is non selective 😉 besides, it will only help systemic control, not replace locoregional radiation therapy

Then again, even many rad onc leaders think that the future of LRC could go towards minimally invasive surgeries such as robotic (after, say, induction chemo to enhance systemic and LRC). Lets face it, even small field XRT can be associated with long term issues like 2ndary cancers.

 

[thesauce]

Then again, even many rad onc leaders think that the future of LRC could go towards minimally invasive surgeries such as robotic (after, say, induction chemo to enhance systemic and LRC). Lets face it, even small field XRT can be associated with long term issues like 2ndary cancers.

Time will tell, but I'm skeptical. Robotic surgeries really haven't demonstrated the superiority we thought they would. And there will always be many that can't have surgery at all. Not to mention that the risk of secondary malignancies is very low for most of our patient population.

 

[medgator]

Then again, even many rad onc leaders think that the future of LRC could go towards minimally invasive surgeries such as robotic (after, say, induction chemo to enhance systemic and LRC). Lets face it, even small field XRT can be associated with long term issues like 2ndary cancers.

The best surgeon with the best robot in the world won't be able to properly address T3 prostate or T4 lung ca, at least now. Time will tell, but I do think our field's tombstone has been written prematurely way too many times

 

[Seldon1985]

The best surgeon with the best robot in the world won't be able to properly address T3 prostate or T4 lung ca, at least now. Time will tell, but I do think our field's tombstone has been written prematurely way too many times

Yes, there are certainly scenarios where induction and MIS wouldn't work. And scenarios where SBRT/SRS > chemo/surgical options. But with surgeons and med oncs being patient gatekeepers, it'll be interesting to see how things continue to evolve, and is indeed tough to say for sure.

 

[deleted4401]

No regrets whatsoever. Best field in medicine.
Medical management can be interesting and I truly enjoyed parts of my internship in medicine. But, radiation oncology is interesting, targeted, and we do some great things.
There are times when I wish I could handle something myself, but the nature of modern medicine had led to specialization. If I try to manage lipids and BP, I have a good chance of screwing things up by forgetting a contraindication or not having enough follow up to manage it correctly.
You'll miss it initially, but that feeling goes away. I moonlighted in inpatient oncology as a resident and it was a nice transition to never doing it again...

 

[Palex80]

Then again, even many rad onc leaders think that the future of LRC could go towards minimally invasive surgeries such as robotic (after, say, induction chemo to enhance systemic and LRC). Lets face it, even small field XRT can be associated with long term issues like 2ndary cancers.

Fast Forward to 15-20 years from now and we will be running tomotherapy-like machines with protons.

Now imagine that dose distribution... Helical Tomotherapy with protons... 😱😱😱

 

[Haybrant]

wasn't such a fan a year or two ago but now in my 3rd yr i get it. best field in medicine in all respects, hands down. Might take you a while to understand that but ull get it. Other MD's will try to make fun of us but they can say what they like and it's worthwhile to sympathize, they do have it rough.

 

[Seldon1985]

Fast Forward to 15-20 years from now and we will be running tomotherapy-like machines with protons.

Now imagine that dose distribution... Helical Tomotherapy with protons... 😱😱😱

👍 looking forward to it!

 

[medgator]

Fast Forward to 15-20 years from now and we will be running tomotherapy-like machines with protons.

Now imagine that dose distribution... Helical Tomotherapy with protons... 😱😱😱

Will everything be done in 5 Fx or less?

 

[radiation]

It is unfortunate in my opinion that we will be left behind for sure by the med oncs, who's innovation far out paces ours at this point. It is a travesty as radonc attracts some of the brightest, many MD, PhDs however many programs do not truly offer enough time doing real research. Off topic I know, but true.

Let's not limit ourselves in terms of thinking of only advances in external beam radiation. Can you name a chemotherapy that increased overall survival, improved quality of life, and had lower number(!) of total adverse events vs. placebo?

http://www.nejm.org/doi/full/10.1056/NEJMoa1213755

 

[clinonc]

>I do feel sometimes is that we are missing the molecular biology/ targeted therapy revolution

http://www.sciencedirect.com/science/article/pii/S0936655513002604

 

[HQAMIGO]

all the molecularly targeted agents are given out by med onc, that's my point....

 

[thesauce]

all the molecularly targeted agents are given out by med onc, that's my point....

And ours is that the revolution hasn't exactly revolutionized anything. Not to mention that many of the molecularly targeted agents (especially the oral ones) are given by the pharmacy.

If you are truly interested in helping to develop these agents, there's nothing preventing you from doing so. There are already many radoncs working on them.

 

[Neuronix]

And ours is that the revolution hasn't exactly revolutionized anything.

Exactly. But it has driven the cost of cancer care up to astronomical levels. I ran into the following article earlier today and it made me think of this thread.

http://onlinelibrary.wiley.com/doi/10.1002/cncr.28321/full

 

[BRCA1]

On a related note, any speculation as to why rad oncs don't give radiosensitizing chemotherapy in the US? I know in Canada (and elsewhere) it is the rad onc that manages chemo that is given explicity for radiosensitization purposes. If it were the case that med oncs administered ALL chemo it would be different, but why do gyn oncs manage weekly platinum for cervical patients undergoing EBRT (as one example)? Would it not be just as logical to have the rad onc prescribe and manage this?

Similarly, I know the issue of nuclear medicine vs. rad onc in administration of radiopharmaceuticals and radioimmunotherapy has been discussed ad nauseum, but this is another treatment realm that I would like to see radiation oncology take a more active role.

 

[medgator]

On a related note, any speculation as to why rad oncs don't give radiosensitizing chemotherapy in the US? I know in Canada (and elsewhere) it is the rad onc that manages chemo that is given explicity for radiosensitization purposes. If it were the case that med oncs administered ALL chemo it would be different, but why do gyn oncs manage weekly platinum for cervical patients undergoing EBRT (as one example)? Would it not be just as logical to have the rad onc prescribe and manage this?

Similarly, I know the issue of nuclear medicine vs. rad onc in administration of radiopharmaceuticals and radioimmunotherapy has been discussed ad nauseum, but this is another treatment realm that I would like to see radiation oncology take a more active role.

I've heard of this commonly occurring in certain areas of Asia, Europe and the UK. I believe in the UK, they are called "clinical oncologists" who give both radiation and chemo. I imagine that chemotherapy administration and management is taught during training in those countries.

In the US, we receive one year of clinical training in either a general medicine, surgery or a transitional internship. It is debatable whether that qualifies us enough to manage the complications of radiosensitizing chemotherapy in either IV or oral form as our 4-year radiation oncology residency specifically focuses on the therapeutic administration of radiation (teletherapy/external beam, brachytherapy, radio-isotopes etc).

In regards to radioimmunotherapy and radiopharmaceuticals, it's very much a geographical/institutional question as to who does what. Where I trained, nuc med administered it. In practice where I am at, it does done by rad onc.

 

[BRCA1]

I've heard of this commonly occurring in certain areas of Asia, Europe and the UK. I believe in the UK, they are called "clinical oncologists" who give both radiation and chemo. I imagine that chemotherapy administration and management is taught during training in those countries.

In the US, we receive one year of clinical training in either a general medicine, surgery or a transitional internship. It is debatable whether that qualifies us enough to manage the complications of radiosensitizing chemotherapy in either IV or oral form as our 4-year radiation oncology residency specifically focuses on the therapeutic administration of radiation (teletherapy/external beam, brachytherapy, radio-isotopes etc).

In regards to radioimmunotherapy and radiopharmaceuticals, it's very much a geographical/institutional question as to who does what. Where I trained, nuc med administered it. In practice where I am at, it does done by rad onc.

I understand the whole "clinical oncologist" paradigm, but do you really feel that gynecologic oncologists (again, just as an example) are any better qualified to manage the toxicities of radiosensitizing chemotherapy than radiation oncologists?

 

[HQAMIGO]

I think rad oncs should start with the low hanging fruit which is radio pharmaceuticals and hormone therapy especially for prostate cancer. I found it disappointing that the only real novel item at this year's ASTRO was Radium 223 which has been highly praised in the radonc literature only to find out that it is still nuclear medicine that administers this agent at our institution. It is interesting to note that Radium 223 was developed by a clinical oncologist in England trained in both radiation and systemic therapy.

Also, We routinely give ADT including GnRH agonists and anti-androgens during RT for prostate cancer so I don't see why we can't administer these agents for metastatic disease. Realistically, I think the problem is that we are a procedure based specialty in which high remuneration goes towards treating people with technically advanced radiation and not prescribing drugs. However, I feel we can't cede the entire domain of "medicines" to medical oncology without the risk of becoming marginalized by the molecular biology revolution.

Btw this line of thinking is not new see the following article by Dr. Zietman, however I don't really see what has changed in the last 5-6 years since this article was written.

http://www.ncbi.nlm.nih.gov/pubmed/18513631

 

[medgator]

I think rad oncs should start with the low hanging fruit which is radio pharmaceuticals and hormone therapy especially for prostate cancer.

http://www.ncbi.nlm.nih.gov/pubmed/18513631

We already do that in my practice, and I imagine it's more common than you think. We also used to give ADT sometimes in residency. The nuc med vs rad onc thing for radiopharma is very geographical and institutional from what I've seen. Nuc med gave it up north but down in the south it seems to be more rad onc

 

[QuantumJ]

I apologize if this is out of place but are there any rad oncs willing to discuss picking between med school acceptances based on an interest in radonc? (through PM's)

 

[thesauce]

...I hate SDN's new format

 

[Sheldor]

...I hate SDN's new format

My entire screen is an expanse of white. I hate it too.