FLASH, futurism, fate

scarbrtj

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I'm upping the odds on FLASH. If it all follows to the hinted-at logical conclusions, this could have some very (scary? existential?) important implications:
1) Radiotherapies (most?) in single sessions
2) Less need for "clinical hand-holding" due to diminished side effects, OARs will be antiquated notions e.g.
3) Much technology on IGRTing and motion tracking etc will be antiquated notions too
4) The radiobiology we learn today will have no application to clinical practice, the rules will need to be re-written, Hall thrown out, etc., and in essence there will be no "rules" per se (no cord tolerance concept e.g.?) because the radiation will be so safe
5) Others? Workforce (of course)?

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ramsesthenice

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I'm upping the odds on FLASH. If it all follows to the hinted-at logical conclusions, this could have some very (scary? existential?) important implications:
1) Radiotherapies (most?) in single sessions
2) Less need for "clinical hand-holding" due to diminished side effects, OARs will be antiquated notions e.g.
3) Much technology on IGRTing and motion tracking etc will be antiquated notions too
4) The radiobiology we learn today will have no application to clinical practice, the rules will need to be re-written, Hall thrown out, etc., and in essence there will be no "rules" per se (no cord tolerance concept e.g.?) because the radiation will be so safe
5) Others? Workforce (of course)?

SLEsY62.jpg

There are a lot of ways we could go with this. There are a million question marks surrounding FLASH radiotherapy so even if it eventually pans out we are many years away from doing this clinically (other than for superficial electron-based applications). To your point, if (and this is a BIG if) all of the assumptions of FLASH radiotherapy were to ring true it really would represent and existential threat to our current mode of existence. But we wouldn't necessarily be completely done. If it really were the holy grail advertised, what would be the point of continuing oncologic surgeries? We may very well go from afterthought to primary therapy for a lot of diseases we currently play little to no role. Would this make up for the losses suffered by transitioning to single (or very limited) fraction treatments? Probably not but could potentially make those of us already in the field more relevant with good disease outcomes. Bottom line (besides being way too early to tell): we have faced a lot of existential threats over the last 30 years. We are still standing and this is the first one to really come from within and the first that at least in theory may have some possible upsides for us. I wouldn't panic just yet.
 
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Lamount

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I'm upping the odds on FLASH. If it all follows to the hinted-at logical conclusions, this could have some very (scary? existential?) important implications:
1) Radiotherapies (most?) in single sessions
2) Less need for "clinical hand-holding" due to diminished side effects, OARs will be antiquated notions e.g.
3) Much technology on IGRTing and motion tracking etc will be antiquated notions too
4) The radiobiology we learn today will have no application to clinical practice, the rules will need to be re-written, Hall thrown out, etc., and in essence there will be no "rules" per se (no cord tolerance concept e.g.?) because the radiation will be so safe
5) Others? Workforce (of course)?

SLEsY62.jpg


FLASH seems like it can be a game changer, but there are several caveats that need to be considered:
1) Modality: It's fairly easy to achieve the required dose rates (>40 Gy/s) with electrons, using some -frankly- old LINAC technology. This is great for skin cancer and small animals, but not much else. You cannot achieve those rates with most available photon technology (unless you can fit a synchrotron X-ray light source in your clinic haha). Protons are the most logical modality to treat people, but even then there are some important barriers. Firstly, you can probably achieve those dose rates with a pristine brag peak, but what happens if you have a tumor more than a few mm thick... modulation techniques could dramatically degrade dose rate. We may have to use "shoot through" energies where the Bragg peak is beyond the patient and we don't get the advantage of no exit dose (there is some hope here but it requires thought).
2) The "FLASH effect" is only appreciated when normal tissues receive at least 7 Gy at 40 Gy/s... not just the target, but the normal tissues you are trying to spare. This means, if you use four beams to treat your target, they must each be ~7 Gy/fraction (i.e. your rx is 28 Gy)... even if you are only concerned with the normal tissues directly adjacent to the target (i.e. within the area of overlap of the four beams), you will be assuming that all 4 beams are delivered simultaneously.
3) At best, the FLASH effect is 30% sparing...we are still going to be losing a lot of the therapeutic ratio by requiring such a high dose per fraction. Even with the flash effect, how do you deliver the equivalent of 70 Gy/35 to a BOT cancer (a/b = 10) at 7 Gy/fraction? with a single field, 7 Gy x 7 will get you to EQD2 of 70 Gy for tumor and 100 Gy for normal tissues... even with 30% reduction, that means everything in the field is getting rx dose of 70 Gy (i.e. not conformal at all). If you wanted to use two fields, it would be 13 Gy x 3, which would give your normal tissues in the overlap 124 Gy - 30% = 87 Gy

Don't get me wrong, I am a huge FLASH enthusiast... and if this pans out, there may be many applications for this technology in our clinics. And there may be ways to optimize deliver to allow for lower dose/fraction (i.e. faster rate?) or if there are some tricks that can be applied with modulation... I just wouldn't throw out classical radiobiology and our treatment paradigms just yet haha
 
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elementaryschooleconomics

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There are a lot of ways we could go with this. There are a million question marks surrounding FLASH radiotherapy so even if it eventually pans out we are many years away from doing this clinically (other than for superficial electron-based applications). To your point, if (and this is a BIG if) all of the assumptions of FLASH radiotherapy were to ring true it really would represent and existential threat to our current mode of existence. But we wouldn't necessarily be completely done. If it really were the holy grail advertised, what would be the point of continuing oncologic surgeries? We may very well go from afterthought to primary therapy for a lot of diseases we currently play little to no role. Would this make up for the losses suffered by transitioning to single (or very limited) fraction treatments? Probably not but could potentially make those of us already in the field more relevant with good disease outcomes. Bottom line (besides being way too early to tell): we have faced a lot of existential threats over the last 30 years. We are still standing and this is the first one to really come from within and the first that at least in theory may have some possible upsides for us. I wouldn't panic just yet.

This is my thinking as well. Yeah, it's a problem with our current reimbursement models, but if it renders a scalpel barbaric, it's probably a wash in the end.
 

ramsesthenice

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FLASH seems like it can be a game changer, but there are several caveats that need to be considered:
1) Modality: It's fairly easy to achieve the required dose rates (>40 Gy/s) with electrons, using some -frankly- old LINAC technology. This is great for skin cancer and small animals, but not much else. You cannot achieve those rates with most available photon technology (unless you can fit a synchrotron X-ray light source in your clinic haha). Protons are the most logical modality to treat people, but even then there are some important barriers. Firstly, you can probably achieve those dose rates with a pristine brag peak, but what happens if you have a tumor more than a few mm thick... modulation techniques could dramatically degrade dose rate. We may have to use "shoot through" energies where the Bragg peak is beyond the patient and we don't get the advantage of no exit dose (there is some hope here but it requires thought).
2) The "FLASH effect" is only appreciated when normal tissues receive at least 7 Gy at 40 Gy/s... not just the target, but the normal tissues you are trying to spare. This means, if you use four beams to treat your target, they must each be ~7 Gy/fraction (i.e. your rx is 28 Gy)... even if you are only concerned with the normal tissues directly adjacent to the target (i.e. within the area of overlap of the four beams), you will be assuming that all 4 beams are delivered simultaneously.
3) At best, the FLASH effect is 30% sparing...we are still going to be losing a lot of the therapeutic ratio by requiring such a high dose per fraction. Even with the flash effect, how do you deliver the equivalent of 70 Gy/35 to a BOT cancer (a/b = 10) at 7 Gy/fraction? with a single field, 7 Gy x 7 will get you to EQD2 of 70 Gy for tumor and 100 Gy for normal tissues... even with 30% reduction, that means everything in the field is getting rx dose of 70 Gy (i.e. not conformal at all). If you wanted to use two fields, it would be 13 Gy x 3, which would give your normal tissues in the overlap 124 Gy - 30% = 87 Gy

Don't get me wrong, I am a huge FLASH enthusiast... and if this pans out, there may be many applications for this technology in our clinics. And there may be ways to optimize deliver to allow for lower dose/fraction (i.e. faster rate?) or if there are some tricks that can be applied with modulation... I just wouldn't throw out classical radiobiology and our treatment paradigms just yet haha

I intentionally didn't get into all of the physics and science earlier but thank you for highlighting some of the many outstanding questions regarding FLASH. Despite what some proponents will tell you the reality is:

We don't know how to do it.
We don't know if we can do it.
We don't know if we should do it.

These minor details aside, things are looking pretty good. Logistically, we are probably closer to sending someone to Mars than we are using FLASH radiotherapy for anything other than the most superficial tumors. This is coming from a proponent with funding to study the technology.
 
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Palex80

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My true hope lies in antibodies and small molecules that will alter radiation effects to normal tissues and tumor.
In the past, we have only utilized amifostine for normal tissues and chemotherapy for tumor.

However, multiple agents are currently being tested and may profoundly change the way we treat diseases.
In fact, we may need to rethink the entire radiobiology dogmas.
 
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I maintain that FLASH is interesting and requires additional evaluation to effectively translate to clinical practice.

Would be most interested in using it clinically in skin cancers. Would be very helpful if we could ablate all skin cancer in one treatment safely rather than say 30, even if it was in a cartilaginous location for example.

For deeper tumors, finding a way to do it effectively requiring protons makes it difficult, but if it can be proven to be feasible and be as exciting as the pre-clinical data, could explode the value of FLASH-capable proton facilities.
 
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scarbrtj

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I maintain that FLASH is interesting and requires additional evaluation to effectively translate to clinical practice.

Would be most interested in using it clinically in skin cancers. Would be very helpful if we could ablate all skin cancer in one treatment safely rather than say 30, even if it was in a cartilaginous location for example.

For deeper tumors, finding a way to do it effectively requiring protons makes it difficult, but if it can be proven to be feasible and be as exciting as the pre-clinical data, could explode the value of FLASH-capable proton facilities.
The first indication that FLASH (proton) therapy could offer much less tissue side effects: the story of a man who took, and survived, a pretty good-sized beam of about 200 Gy to the head:

 
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The first indication that FLASH (proton) therapy could offer much less tissue side effects: the story of a man who took, and survived, a pretty good-sized beam of about 200 Gy to the head:


Wow this is fascinating! Would the dose rate be in the FLASH dose rate? I guess no other explanation.
 

Palex80

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The first indication that FLASH (proton) therapy could offer much less tissue side effects: the story of a man who took, and survived, a pretty good-sized beam of about 200 Gy to the head:


Well, 11 Gy TBI in under a second will still kill you...
Although, 11 Gy in 1 second are not considered "FLASH", you'd probably need something like 40 Gy TBI in 1 second...

"Second incident"
 
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Gfunk6

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The time is now to diversify your career and skill set. Administration, entrepreneurship, or whatever. I wouldn't want to be in a position where ASTRO/SCAROP/ABR finally realize the problem years too late to do a damn thing about it.
 
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The time is now to diversify your career and skill set. Administration, entrepreneurship, or whatever. I wouldn't want to be in a position where ASTRO/SCAROP/ABR finally realize the problem years too late to do a damn thing about it.

Honestly, I this it's good advice to anyone doing clinical medicine in 2020 to have a diversified career and skill set. Depending on the status quo to provide whatever job (and income) you are currently enjoying just isn't a smart way to practice IMO. Some examples: volume of cardiothoracic surgery went down with interventional cardiologists. Med oncs are doing great now, but how they are paid for drug is changing with vertical consolidation of insurers and PBMs. GI is looking at a cut with validated stool tests replacing some routine colonoscopies. And for pretty much all US based docs, changes to payor models seem all but inevitable.

It's also important to consider the time horizon for FLASH. How many actual humans have been treated with it at this point? Now imagine how long it'll take to conduct studies with "long term" follow up for toxicity. Even if it blows up like IMRT, we are probably looking at 10-15 years from now.
 
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The timeline is far enough away for FLASH that I'm not too worried at the moment about an existential crisis. In addition, if this technique/tech lives up to its promises, we would see the indications for radiation increase, not decrease. Although patients could be treated in 1 fraction, you could have a much larger number who would need to be pushed through the process.

One of the aspects about radonc I liked, however, was getting to know patients during their tx course. Depressing to see that part of our field grow smaller and smaller over the last 15 years.
 
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elementaryschooleconomics

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The timeline is far enough away for FLASH that I'm not too worried at the moment about an existential crisis. In addition, if this technique/tech lives up to its promises, we would see the indications for radiation increase, not decrease. Although patients could be treated in 1 fraction, you could have a much larger number who would need to be pushed through the process.

One of the aspects about radonc I liked, however, was getting to know patients during their tx course. Depressing to see that part of our field grow smaller and smaller over the last 15 years.

I think about this a lot. "Time with patients" was a huge draw for me to RadOnc.

Well, I guess I can get to know them when I open my MedSpa.
 
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scarbrtj

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Something to look forward to if one gets a job in this field. From 5-5-5 to 1-1-1-1-1-1-1-1....etc

I'm happy if this can render most/all cancer surgery irrelevant

Cheers
Once this becomes reality, welcome to early retirement. One rad Onc per state.

then again, great for patients if this all turns out to be real.

anyone have good contacts in consulting? ;)
The time is now to diversify your career and skill set. Administration, entrepreneurship, or whatever. I wouldn't want to be in a position where ASTRO/SCAROP/ABR finally realize the problem years too late to do a damn thing about it.
They realize. Up is down, water isn’t wet, less work means more work.

 
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scarbrtj

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KO is either ignorant or deceitful. IGRT doesn't take that much time and complex planning is something that dosimetrists do or if you have decent software then a script can do all the heavy lifting
Less OTVs,
(which might mean less work, less patient mgmt work, etc... who knows???)
but replaced with going to machines for IGRT
NEW KO RULE: if it's hypofractionated and you're doing IGRT, you have to stand at the machine.
and more complex planning.
The planning (volume) is the same nine times out of ten; e.g., whole breast, rectal 25/5 vs 50.4/28, etc. Also, I have heard of dosimetrists who do planning? MDs are doing planning now though in KO's world so I guess fire the dosimetrists. In general the planning difference is a different Rx dose and fraction are typed into the TPS.
 
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OTN

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KO is either ignorant or deceitful. IGRT doesn't take that much time and complex planning is something that dosimetrists do or if you have decent software then a script can do all the heavy lifting

More work with abbreviated treatment schedules? I hold that falsehood to be self-evident.

He does come across as seeming to care about younger docs, so this take on his part makes him look as dumb as a bag of hammers.

Edit: for scarb
 
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The time is now to diversify your career and skill set. Administration, entrepreneurship, or whatever. I wouldn't want to be in a position where ASTRO/SCAROP/ABR finally realize the problem years too late to do a damn thing about it.

If Astro really wanted to help anyone theyshould literally dump all its lobbying to prevent by cuts to TC-blah blah who gives a crap technical code and just focus on making inroads with Med onc so that we don’t have to do 6 years of residency to give systemic agents which are clearly the future of everything in oncology.

Seriously, the sheer contrast between Med onc rad onc research paradigms and progress is so stark at this point it’s insane.


What’s missing from this trial? .oh that’s right what you all got 250s on boards for! Oh yeah right.
 
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Honestly, I think rad Onc training will look radically different in 5 to 7 years.

it makes much more sense as a 1 to2 year fellowship after a real residency:

- after MedOnc
- after Rads or IR
- you’re a thoracic surgeon and want to do SABR lung? Have at it!
- you’re a gyn Onc. You do it all anyway, including all the hard work for brachy. Might as well do a 1 year gyn RO fellowship!
- you’re a urologist and want to do SpaceOAR and SABR? Have at it!
- breast surgeon and you want to do external beam APBI? Maybe that’s a 3 month fellowship? ;)
- Neurosurg already does GK
- GenSurg and wanna learn liver SABR do you can bury it under your recommendations for RFA? Be my guest.
- Derm and wanna do skin applicator brachy? Be certified with a weekend course!

this makes so much more sense than our current paradigm.

lets be real. What we do isnt that hard. With the exception of a few sites (peds, HN, maybe pancreas?), what we do is just circle things. And the toxicity is minimal. There is no reason for a 4 year residency and we all know that. We make it harder than it really is bc we all had a-hole chairmen who quiz us on rad bio trivia and p-values, all the while they can’t even run the EHR without a resident...

sigh.

ok

at least we all have jobs right now ;)
 
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RadsWFA1900

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Honestly, I think rad Onc training will look radically different in 5 to 7 years.

it makes much more sense as a 1 to2 year fellowship after a real residency:

- after MedOnc
- after Rads or IR
- you’re a thoracic surgeon and want to do SABR lung? Have at it!
- you’re a gyn Onc. You do it all anyway, including all the hard work for brachy. Might as well do a 1 year gyn RO fellowship!
- you’re a urologist and want to do SpaceOAR and SABR? Have at it!
- breast surgeon and you want to do external beam APBI? Maybe that’s a 3 month fellowship? ;)
- Neurosurg already does GK
- GenSurg and wanna learn liver SABR do you can bury it under your recommendations for RFA? Be my guest.
- Derm and wanna do skin applicator brachy? Be certified with a weekend course!

this makes so much more sense than our current paradigm.

lets be real. What we do isnt that hard. With the exception of a few sites (peds, HN, maybe pancreas?), what we do is just circle things. And the toxicity is minimal. There is no reason for a 4 year residency and we all know that. We make it harder than it really is bc we all had a-hole chairmen who quiz us on rad bio trivia and p-values, all the while they can’t even run the EHR without a resident...

sigh.

ok

at least we all have jobs right now ;)

Sounds like a short certification course rather than a 1-2yr fellowship.
 

ramsesthenice

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lets be real. What we do isnt that hard. With the exception of a few sites (peds, HN, maybe pancreas?), what we do is just circle things. And the toxicity is minimal. There is no reason for a 4 year residency and we all know that.

Are you being serious here? If all you do is draw circles your toxicity is not minimal. If you think it is you are either young or you don’t follow people long term.
 
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scarbrtj

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The guy's hypotheses are not readily falsifiable.
Honestly, I think rad Onc training will look radically different in 5 to 7 years.

it makes much more sense as a 1 to2 year fellowship after a real residency:
- after MedOnc : What does a clinical oncologist do?
- after Rads or IR: Henry Kaplan, MD, founding Chair of the Department of Radiology, developed the first high-energy linear accelerator for therapeutic use in the 1950’s.
- you’re a thoracic surgeon and want to do SABR lung? Have at it!: If they can do immuno, they can do SABR?
- you’re a gyn Onc. You do it all anyway, including all the hard work for brachy. Might as well do a 1 year gyn RO fellowship!
- you’re a urologist and want to do SpaceOAR and SABR? Have at it!
- breast surgeon and you want to do external beam APBI? Maybe that’s a 3 month fellowship? ;): Hello, I'm Jayant Vaidya.
- Neurosurg already does GK: Hello, I'm Jonathan Adler.
- GenSurg and wanna learn liver SABR do you can bury it under your recommendations for RFA? Be my guest.
- Derm and wanna do skin applicator brachy? Be certified with a weekend course!: Dermatologists are already, by their own profession, the primary purveyors of skin cancer radiotherapy in the United States.

Sixty years ago Buschke asked "What is a radiotherapist?" How close are we to that ideal today. How close can we get with a consult and a few 15-minute office visits for treatment...

While the patient is under our care, we take full and exclusive responsibility, exactly as does the surgeon who takes care of a patient with cancer. This means that we examine the patient personally, review the microscopic material, perform gynecological examinations, take a specimen for biopsy if necessary, examine the larynx, bladder, or whatever is necessary. On the basis of this thorough, clinical investigation, we consider the plan of treatment that we suggest to the referring physician and to the patient. We reserve for ourselves the right to an independent opinion regarding diagnosis and advisable therapy, and, if necessary, the right of disagreement with the referring physician. In some instances, we may even differ with the pathologist if the integration of equivocal microscopic findings into the entire clinical picture suggests the necessity for re-interpretation and change of diagnosis. During the course of treatment, we ourselves direct any additional medication that may be necessary, such as antibiotics or sedatives, blood transfusions, etc. We are ready to be called in an emergency, such as laryngeal edema or uterine hemorrhage, at any time.
 
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Radonc is sufficiently complicated - at least at a robust training program - to warrant 3-4 years of training. It is reasonable to question whether one needs to be trained in every disease site - but oncology and delivering the best care -- if your mentors actually are good -- takes time to learn.

FLASH is very hyped. We are talking about some reasonable increase in therapeutic benefit with normal vs. tumor tissue. However this cannot be delivered conformally. It is really yet to be seen what the potential is with this. It may or may not make a major impact on the field... however it's a safer bet at this time that it will be something more like MR linac... with specialized uses that benefit a very small group of people (those who are eligible, narrowed by those who have access). There's zero evidence at this point we are going to start curing GBM, pancreas etc. with this technology.
 
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KHE88

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Umm. I was reliably informed that I was incompetent to draw circles if I didn't know which part of the cell cycle WEE1 kinase was involved in.

That was a thing that happened. Anyone remember that?

What a joke.

The one thing that has bugged me even more about this field is how we like to draw arbitrary discrete lines in the sand and pigeonhole all patients into a handful of groups and proclaim moral virtue at anybody who dare blur these lines.

Far, far too much time wasted in residency memorizing trivial trial data, performing useless "research" and being a scut monkey rather than learning the nuances of actual clinical practice: managing on treatment patients, evaluating plans, following patients, clinical setup and devices, etc. All of the latter could easily be taught in two years, likely one for the vast majority of disease sites.

The above poster is not wrong with his suggestion that we seem to make an effort to make mastery of this field far harder than it actually is. Cognitive dissonance maybe?
 
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The above poster is not wrong with his suggestion that we seem to make an effort to make mastery of this field far harder than it actually is. Cognitive dissonance maybe?

What you are describing is bad training which sadly is out there. Could you learn how to handle the technical aspects of radiation in 2 years? Sure. And you would be a highly qualified technician at the end of the referral chain.

I was lucky enough to be trained by a true visionary who explicitly said they would be disappointed in us if we did too well on our in service exams because it would mean we were probably not focusing on the right stuff. My program was serious about being trained as an oncologist first. If your residency actually spent the time training you about the relevant issues for surgeons and medical oncologists you might feel differently.

I am very well respected as an oncologist by many of the surgeons and med oncs in my geographic area because I can look at the whole picture and I am rarely treated like the end of the referral chain. I get a say in sequencing of therapies. If I request it our oncologists will frequently hold or change systemic therapy. I am the PI of 3 drug trials with med oncs as sub Is. I am also a faculty mentor for a junior med onc. I can’t prescribe chemo but I guarantee you that I know more about medical oncology than they do about radiation.

Look at the posts by people like Palex, Seper, Scar, Gfunk, MedGater, etc. These guys really know their stuff inside and out and are quite fluent with clinical oncology as a whole. You don’t get there in 2 years.

My frustration really is not with you or the above poster. It’s just sad that more of our educators don’t help trainees reach or even see their potential. My best guess is they never did it themselves.
 
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KHE88

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What you are describing is bad training which sadly is out there. Could you learn how to handle the technical aspects of radiation in 2 years? Sure. And you would be a highly qualified technician at the end of the referral chain.

I was lucky enough to be trained by a true visionary who explicitly said they would be disappointed in us if we did too well on our in service exams because it would mean we were probably not focusing on the right stuff. My program was serious about being trained as an oncologist first. If your residency actually spent the time training you about the relevant issues for surgeons and medical oncologists you might feel differently.

I am very well respected as an oncologist by many of the surgeons and med oncs in my geographic area because I can look at the whole picture and I am rarely treated like the end of the referral chain. I get a say in sequencing of therapies. If I request it our oncologists will frequently hold or change systemic therapy. I am the PI of 3 drug trials with med oncs as sub Is. I am also a faculty mentor for a junior med onc. I can’t prescribe chemo but I guarantee you that I know more about medical oncology than they do about radiation.

Look at the posts by people like Palex, Seper, Scar, Gfunk, MedGater, etc. These guys really know their stuff inside and out and are quite fluent with clinical oncology as a whole. You don’t get there in 2 years.

My frustration really is not with you or the above poster. It’s just sad that more of our educators don’t help trainees reach or even see their potential. My best guess is they never did it themselves.

Well I'm just a backwoods country catfish radiotherapist, but I feel fairly confident in saying that all of us here know more about chemo than most practicing med oncs know about radiation.

WRT the rest of your post, really struggling not to post the Neil DeGrasse Tyson meme...

:rolleyes:
 
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thecarbonionangle

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What you are describing is bad training which sadly is out there.

My frustration really is not with you or the above poster. It’s just sad that more of our educators don’t help trainees reach or even see their potential. My best guess is they never did it themselves.

yes there are many aweful training programs with no education, mostly scut, and zero career development which does not allow people to be successful. It is not unusual in these places to feel like nobody taught you anything or cared about you. This only breeds more bitter catfish.
The solution is to close all these places down but sadly our field is not doing anythjng substantial to address this.
 
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KHE88

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I am very well respected as an oncologist by many of the surgeons and med oncs in my geographic area because I can look at the whole picture and I am rarely treated like the end of the referral chain.

Look at the posts by people like Palex, Seper, Scar, Gfunk, MedGater, etc. These guys really know their stuff inside and out and are quite fluent with clinical oncology as a whole. You don’t get there in 2 years.

do rad oncs really need to keep insulting themselves and their own field on a public forum? Come on.

Oh, I wasn't insulted by the insinuation that I don't really know my stuff and can't look at the whole picture like the fluent clinical oncologists mentioned. I guess my snarky reply was misinterpreted.

The hospital administration does far worse on a daily basis when it comes to insults and have really raised the bar in that regard.
 
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ramsesthenice

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Oh, I wasn't insulted by the insinuation that I don't really know my stuff and can't look at the whole picture like the fluent clinical oncologists mentioned. I guess my snarky reply was misinterpreted.

The hospital administration (the nurses who think they are my boss and are competent to decide how I should practice) does far worse on a daily basis when it comes to insults and have really raised the bar in that regard.

No one said anything about you or your abilities. It was you who complained (yet again) about your experiences during residency. I simply validated your opinion on the matter.
 
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KHE88

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No one said anything about you or your abilities. It was you who complained (yet again) about your experiences during residency. I simply validated your opinion on the matter.

If you don't want to hear people complaining about stuff, this probably isn't the place to spend your free time.
I'm glad you went to the best residency and came out with an unusual level of expertise. Really. That's great.
I will say that I feel like I've learned more in the short time I've been on my own in a solo position than I ever did in residency.
 

scarbrtj

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I'm glad you went to the best residency and came out with an unusual level of expertise. Really. That's great.
I will say that I feel like I've learned more in the short time I've been on my own in a solo position than I ever did in residency.
Probably a truth across many specialties and not just rad onc: you learn more on your own than from other people. Not to be too treacly but look at good Will Hunting. He never went to Hahvahd but knew more than every kid there because he was intelligent and industrious. How ya like them apples.
 
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Chartreuse Wombat

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As a "professional educator" I completely agree with the sentiments above. Teachers and institutions of learning are vastly over-rated.

“Learning results from what the student does and thinks and only from what the student does and thinks. The teacher can advance learning only by influencing what the student does to learn.”

-Herbert A Simon

I think he is the only person to win a Nobel Prize and the Turing Award.
 
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Lamount

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As a "professional educator" I completely agree with the sentiments above. Teachers and institutions of learning are vastly over-rated.

“Learning results from what the student does and thinks and only from what the student does and thinks. The teacher can advance learning only by influencing what the student does to learn.”

-Herbert A Simon

I think he is the only person to win a Nobel Prize and the Turing Award.


I would agree that this is true about teaching in general... but not necessarily true in radiation oncology residency.

Sure, there are people trained by excellent physicians at world-class institutions whom I wouldn't want caring for my patients

...and there are people who have come from "low tier" places and gone on to do great things.

However, I believe that for a resident who wants to learn, there is a huge benefit to 1) working along side a thoughtful oncologist who can demonstrate how to navigate the complexities of a difficult case, 2) being at a high volume center such that you see MANY 'bread and butter' cases, and develop some experience treating the Zebras, and 3) having exposure to multiple treatment philosophies within a given disease site so that you can learn the difference between standard of care vs. practitioner bias.
 
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ramsesthenice

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If you don't want to hear people complaining about stuff, this probably isn't the place to spend your free time.
I'm glad you went to the best residency and came out with an unusual level of expertise. Really. That's great.
I will say that I feel like I've learned more in the short time I've been on my own in a solo position than I ever did in residency.

I came out with a good frame work. Like you and everyone else I learned more in my first couple years of practice than I did in residency.
 
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Chartreuse Wombat

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I would agree that this is true about teaching in general... but not necessarily true in radiation oncology residency.

Sure, there are people trained by excellent physicians at world-class institutions whom I wouldn't want caring for my patients

...and there are people who have come from "low tier" places and gone on to do great things.

However, I believe that for a resident who wants to learn, there is a huge benefit to 1) working along side a thoughtful oncologist who can demonstrate how to navigate the complexities of a difficult case, 2) being at a high volume center such that you see MANY 'bread and butter' cases, and develop some experience treating the Zebras, and 3) having exposure to multiple treatment philosophies within a given disease site so that you can learn the difference between standard of care vs. practitioner bias.
Yes the educational conceit. I agree with seeing lots of cases but the evidence to support "thoughtful" teachers doesn't exist.
 

KHE88

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I came out with a good frame work. Like you and everyone else I learned more in my first couple years of practice than I did in residency.

It was you who complained (yet again) about your experiences during residency.

I actually had a decent experience in residency with good teaching. I think you have me confused with another poster. I don't recall specifically complaining about my residency before. My complaints on this forum mostly have been about the ABR and virtue signalling/elitism in the profession. My comments above were listing some of the distractors in residency and referenced the residency experience in general, not my own specific residency. I got what I needed from training without too much ancillary nonsense compared to others, but my point was that I didn't need 4 years to do it and it could have been a lot more efficient (2 years probably. Certainly 3 years) if we focused only on teaching and clinical training. This is to be a competent oncologist, not just a point-and-shoot technician who draws circles and runs stuff through clearcheck and discharges after first follow-up. The really unfortunate residents are the ones that basically ONLY had a service component in their residency and resident-led didactics and come out 4 years later not competent to practice independently in common disease sites. That's not uncommon, sadly.

Example: I spent many nights and weekends my first year rote memorizing trial data so I didn't get eviscerated by the chair during chart rounds. Did this harm me? No. But it didn't ultimately make me come out with better clinical acumen and caused me to focus on the wrong things early in training.

If we made our residency 5 years or added mandatory fellowships, would that make feel even more competent as oncologists? Give us more street cred? Or would we just waste more time?
 
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Lamount

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Yes the educational conceit. I agree with seeing lots of cases but the evidence to support "thoughtful" teachers doesn't exist.

As 'thoughtfulness' cannot be quantified (or at least hasn't been, as far as I know), it is not reasonable to expect evidence...
Anecdotally, I often consider treatment strategies based upon imagining how those who trained me would treat... and critique literature based upon the rigorous standards of some of my mentors (n=1). Whether or not this leads me to be a wiser, better doctor is open to interpretation.

Won't argue about having a big head, though would argue I am in good company here haha ...
 
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RollTideRadOnc

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A lot of hot and bothered emotions on this thread!

just the because the basics of most single site xrt can be learned quickly does not impugn the potential benefits of deeper training. People need to get over themselves and their self importance it seems ;)

and as for “disparaging our speciality in public”... welcome to the world of anonymous, open discourse big boys and girls! All topics are on the table.

does anyone really think it would seriously take a thoracic surgeon more than a year to learn lung SABR, follow up and management of complications? How long would this realistically take to learn well?

I guess I had no idea that lung SABR is so terribly complex!!! I must have been doing something completely different all these years.

please, oh oracles of SDN, illuminate my darkness shrouded soul!
 
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ramsesthenice

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I actually had a decent experience in residency with good teaching. I think you have me confused with another poster. I don't recall specifically complaining about my residency before. My complaints on this forum mostly have been about the ABR and virtue signalling/elitism in the profession. My comments above were listing some of the distractors in residency and referenced the residency experience in general, not my own specific residency. I got what I needed from training without too much ancillary nonsense compared to others, but my point was that I didn't need 4 years to do it and it could have been a lot more efficient (2 years probably. Certainly 3 years) if we focused only on teaching and clinical training. This is to be a competent oncologist, not just a point-and-shoot technician who draws circles and runs stuff through clearcheck and discharges after first follow-up. The really unfortunate residents are the ones that basically ONLY had a service component in their residency and resident-led didactics and come out 4 years later not competent to practice independently in common disease sites. That's not uncommon, sadly.

Example: I spent many nights and weekends my first year rote memorizing trial data so I didn't get eviscerated by the chair during chart rounds. Did this harm me? No. But it didn't ultimately make me come out with better clinical acumen and caused me to focus on the wrong things early in training.

If we made our residency 5 years or added mandatory fellowships, would that make feel even more competent as oncologists? Give us more street cred? Or would we just waste more time?

My apologies then. And again, I seriously never tried to insinuate anything about you or your skills.

No doubt some educators push minutia more than they should and not only is it annoying, it can detract from what people should be learning. We are clearly on the same page here.

We can agree to disagree with how long residency can/should be. I basically have to give you 3 years though since I did a Holman and think I turned out fine with 30 months of clinical training LOL
 
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Gfunk6

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Here is my opinion:

1. Many of us are seasoned and experienced Radiation Oncologists. We are well-trained, have talented colleagues and stay up-to-date on literature. We are hyper-specialized and we repeatedly do the same set of things over and over. This extensive education combined with a deep pool of experience yields folks who work at a very high level. As such, it is very easy to lose your frame of reference in terms of your self-worth and value. Things that are "obvious" to us at this level and should be "easy" for any MD to pickup are anything but.

2. Linacs and comparable machines (protons, MRI-linancs, GK, CK) cost a lot of money and can do a lot of things. As such they require a "captain of the ship" to supervise their use. A linac should not be treated like an OR where anyone can do what they need to and leave. Therefore having thoracic surgeons, gyn oncs, general surgeons, neurosurgeons, etc. to each have their own patients on treatment is an asinine concept to me.

3. We need to evolve as a specialty. There have been tons of posts and comments about this. Since it is not feasible to come up with dozens of new indications for XRT, we will necessarily encroach on other fields whether that is oral chemotherapy, IR or whatever.

4. Many surgeons would acknowledge that a PA can perform straightforward surgeries solo. However, when the proverbial **** hits the fan you want a physician to be in charge. Ditto with complex procedures. Ditto with Radiation Oncology.
 
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communitydoc13

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We need to evolve as a specialty. There have been tons of posts and comments about this. Since it is not feasible to come up with dozens of new indications for XRT, we will necessarily encroach on other fields whether that is oral chemotherapy, IR or whatever.
Agree with entire post. I'd like to work another 15 years and I would take an 18 month certification (as long as I could keep working) to give oral chemo or weekly IV chemo, ADT, first and second line endocrine based therapies, bone strengtheners. It would open up so much to our specialty: Research opportunities for the prohibitive and underutilized talent pool that we've accumulated and market power for small hospital system jobs and multi specialty practices that would impact our entire jobs situation.

Making this happen of course...
 
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