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future of radonc

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abcde

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Why is the question about RadOnc's future always deferred? When I ask residents this question they address it and say it is something that all radonc's are concerned about to some degree. I overheard a conversation about RNA targeting drugs at one point in reference to the future. The FAQ section is a very superficial answer to this question.
 

stephew

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reread the faq and then ask any specific questions you have. Youve only made comments, unless your question actually is "why is the question defered." In that case the answer is I can't say as I don't know what sort of replies you've received.
 

RadOnc10000

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Your seeming frustration about the future of radiation oncology is likely related to one simple fact: it is impossible to predict the future. One can make guesses, but no one can be sure. As far as the future of radiation therapy in cancer treatment is concerned you can imagine two extremes. #1: Somebody develops a non-radiation-based cure for all cancers and obviates the need for radiation therapy. #2: Advances are made in radiation oncology that lead to evidence-based treatment algorithms involving radiation in the treatment plan of every cancer patient. Obviously, both of these extremes are ridiculous. The fact that #1 may seem marginally more plausible than #2 does not mean that it will come to pass. The reality is going to fall somewhere in the middle.

Currently, there are a number of areas/tumors for which radiation therapy is playing a less important role (e.g. pediatric & Hodgkins) and for which it is playing a more important role (e.g. GI & organ-preservation) than in the past. However, even for areas where radiation is currently less favored, there are those that argue that this is just another example of the ebb-and-flow of cancer treatment and that with future advances such as more precise delivery (e.g. IMRT, stereotactic, etc.) or better radiosensitizers, this will be reversed. One thing that is certain is that we are facing an aging population in this country and that the absolute number of cancer patients will increase over the next few decades. The bottom line is that the exact future of radiation oncology (as that of pretty much everything else) is uncertain but it is extremely likely that radiation will play an important role in cancer treatment for a long time to come (if not forever). Said another way, multi-modality therapy is here to stay and radiation oncologists will continue to play a critical role in the treatment of cancer patients.

As far as research areas with the potential for major advances in radiation oncology (e.g. IMRT, organ motion, proton radiotherapy, radiosensitizers, systemic radiotherapy, functional imaging, oligo-metastases, stereotactic XRT, gene therapy, etc., etc., etc.), the list is long and the answers as to which ones will pan out are unclear. What is clear is that we are far from having optimized the use of radiotherapy to treat cancer patients.

If you are unable or unwilling to deal with the uncertainty of working in a fast-moving field which requires you to stay abreast of the latest research in order to best serve your patients, then radiation oncology is not for you. However, if you are excited by these attributes and maybe even interested in helping to refine or extend the uses of radiation in cancer treatment, then you should strongly consider it for a career.

[By the way, this topic has come up a number of times before on this forum and there are many informative posts about it. Seek and you shall find.]
 

stephew

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i would also say that if you are familiar with the very edge of the lit you'll note that the importance of radonc in peds and even lymphoma has been highlighted by the results when dose is lowered or omitted. In the kids, terrible failure, inthe lymphoma cases, more frequent failures leading to the use of harsher chemo for salvage. The salvage can often be done, but at a cost. its a very very complex situation but RT doesnt appear to be going away in these realms either.
 

RadOnc10000

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stephew said:
i would also say that if you are familiar with the very edge of the lit ........ its a very very complex situation but RT doesnt appear to be going away in these realms either.

Thanks for setting me straight. I'm clearly not familiar with the "edge" of the literature. :) Hopefully that will change over the course of my training...

When I mentioned peds as an example, I was specifically thinking about prophylactic WBRT for ALL. From my limited reading, it seems that the most recent protocols favor intrathecal chemotherapy over prophylactic WBRT. However, as you point out, the situation is very complicated. I think this is at least partially caused by reports in the literature often focusing on preliminary outcomes since final outcomes and long-term side effects (which are significant for chemotherapy and unknown for the new "biologics") can take many years to determine. It's difficult to say exactly what the future will look like, but it's clear that RT is here to stay.
 

stephew

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Oh well ALL, while still done, is hardly up there in terms of peds stuff we deal with. Ewings, Rhabdo, medulloblastoma, wilms, lymphoma, nephroblastoma, JPA, germcell tumors, ependymoma etc, retinoblasoma.; these are the main things.

While the long term effects in children are very real and more pronounced in adults (interestingly they short term stuff they handle better than adults) we know that 1) RT is needed and studies to eliminate limit have met with some dismal failures. DOse limiting has been more sucessful and combining with chemo (see medullo for instances) and 2) chemo has long term effects too, including secondary cancers.
 

jpro

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abcde said:
Why is the question about RadOnc's future always deferred? When I ask residents this question they address it and say it is something that all radonc's are concerned about to some degree. I overheard a conversation about RNA targeting drugs at one point in reference to the future. The FAQ section is a very superficial answer to this question.
Can you say proton beam therapy? Check out this video:
http://www.mdanderson.org/departmen...pn=9F6B9D32-924E-11D5-813100508B603A14#proton
Click on the streaming video. Technology in RadOnc is only going to get better, and the only thing that could threaten the field is chemo that can target selectively.
 

Adawaal

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Not to mention the increasing role of RT prior to BMT/HSCT/cords for a variety of diseases. As the acceptable age of transplant keeps rising, an increasing number of protocols are using RT or RT+melphalan/insert-your-CTx-agent-here as a nonmyeloablative prep. Now consider the use of tomotherapy (Steph's favorite, if I recall correctly) as opposed to traditional TBI for marrow targeting (and protocols are being written for this purpose as we discuss this). Finally, like most "new tools" in oncology, BMT/HSCT/cords are being used as a hammer where damn near everything looks like a nail (breast, SLE, neurodegenerative disorders, halitosis soon I'm sure), leaving even more room for radiation colleagues to work alongside transplanters. I guess the message is, just about every time something "new" comes along, someone smart figures out a way that radiation can play an important role. Somehow I'm not worried about becoming irrelevant anytime soon....
 

stephew

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jpro said:
Can you say proton beam therapy? Check out this video:
http://www.mdanderson.org/departmen...pn=9F6B9D32-924E-11D5-813100508B603A14#proton
Click on the streaming video. Technology in RadOnc is only going to get better, and the only thing that could threaten the field is chemo that can target selectively.
can you say "boutique treatment?" I can say this since we're allied with MGH: proton is fine, but people not in the field fail to realize its not superior to general external beam. Its for very specific uses and many times you wouldnt want to use the Bragg peak. Youll have to deal with this when patients come to you asking about totally inappropraite modalities because they've just heard of them and don't know anything other than its "new.". As for that magic bullet in chemo, see the FAQ.
steph
 

RadOnc10000

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jpro said:
Can you say proton beam therapy? Check out this video:
http://www.mdanderson.org/departmen...pn=9F6B9D32-924E-11D5-813100508B603A14#proton
Click on the streaming video. Technology in RadOnc is only going to get better, and the only thing that could threaten the field is chemo that can target selectively.

Proton therapy definitely has some advantages over conventional XRT, and these are very helpful for certain types of tumors. However, even if it were proven to be beneficial for the majority of cancers, I don't think that it could find broad acceptance until smaller, more affordable delivery systems are designed. In the end, economics will win out over a couple of percentage points of improvement in local control rate or survival. Otherwise, proton therapy could remain restricted to a handful of large centers and serve as good advertisement for patient recruitment (MD Anderson will have to cut that video down if they want to run it during the Super Bowl... ;) )

Many people in radiation oncology think that the future of the field lies on the biology rather than on the physics side. There will definitely continue to be further, exciting technical innovations, but major advances in local control or survival rates will most likely come from molecular interventions that potentiate tumor killing or protect normal tissues. Check out the Presidential Address by Ted Lawrence at the most recent ASTRO meeting (http://209.63.36.22/astro/Lawrence2/Lawrence_2.htm) or this recent review in Nat Rev Cancer (http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15343280) for some thoughtful discussions of this topic.
 

JTradonc

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RadOnc10000 said:
Proton therapy definitely has some advantages over conventional XRT, and these are very helpful for certain types of tumors. However, even if it were proven to be beneficial for the majority of cancers, I don't think that it could find broad acceptance until smaller, more affordable delivery systems are designed. In the end, economics will win out over a couple of percentage points of improvement in local control rate or survival. Otherwise, proton therapy could remain restricted to a handful of large centers and serve as good advertisement for patient recruitment (MD Anderson will have to cut that video down if they want to run it during the Super Bowl... ;) )

Many people in radiation oncology think that the future of the field lies on the biology rather than on the physics side. There will definitely continue to be further, exciting technical innovations, but major advances in local control or survival rates will most likely come from molecular interventions that potentiate tumor killing or protect normal tissues. Check out the Presidential Address by Ted Lawrence at the most recent ASTRO meeting (http://209.63.36.22/astro/Lawrence2/Lawrence_2.htm) or this recent review in Nat Rev Cancer (http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=15343280) for some thoughtful discussions of this topic.



It really is more simple than the cost. Plain and simple, protons are a niche therapy for very specific indications. (ocular melanoma, chordoma). Aside from X-rays, we already have excellent depth control with electrons which basically come with any LINAC. Brachytherapy also gives you very satisfying depth control when possible.
 

Doctor&Geek

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stephew

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JPaikman said:
If anybody wants to read this, and don't have a subscription (or your institution doesn't have one), I'd be happy to send it to you - PM me.
I beleive Eli Glatstein said it: " if radiation oncologists were left to cure polio, right now we'd be treating with a better designed iron lung". The physics tweaking is nice and has its place, but people get over excited about it just because its NEW!
 

kp99

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Congrats to everyone who has matched!!! :) Not to sour the mood, but I was wondering where people see the RadOnc field going in the next 20-30 years. Is it still going to be around or will we be starting new residencies in our 40's? We had a debate about this in one of our first year small groups. I was hoping to get the opinion of those of you currently in training or practice. I've been extremely interested in the field for a couple years now, but would really like some honest opinions.
 

f_w

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Chemotherapy will make rad-onc entirely superfluous.
(smart aleck heme-onc 1976)

Newer better chemotherapies will make rad-onc entirely superfluous.
(smart aleck heme-onc 1986)

Better surgical technology will make rad-onc entirely superfluous.
(inflated ego surgeon 1996)

Molecular nanotherapies will make rad-onc entirely superfluous.
(The wall-street journal 2006)


You get the idea.

30 years later, rays still kill cancer cells, its that simple.
 

3dtp

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JTradonc said:
It really is more simple than the cost. Plain and simple, protons are a niche therapy for very specific indications. (ocular melanoma, chordoma). Aside from X-rays, we already have excellent depth control with electrons which basically come with any LINAC. Brachytherapy also gives you very satisfying depth control when possible.



Stephew, you just gotta make the right propeller and spin it just so...just so long as the organs don't move. I think Eli was close. It would be a TomoLung with fully real time image guided 3D conformal breathing motions with real time display of Inspiratory-Tension Control Probability (TCP) and Normal Expiratory-Tissue Complication Probability (NTCP), including DVH (dyspnea volume hypoxograms) likely made as a two of a kind device by some Swedish outfit.

What I think most people don't realize is that protons are not high LET particles and behave more like electrons except for the dose distribution. So, if you need really precise dose distributions, and the organ motion is either well described and small or not critical, then protons are cool. But, I'm not sure it gives an advantage over conformal or well planned IMRT for, say, a prostate, even with a recurrence.
 

stephew

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protons do have an advantage over IMRT for some uses but certainly not all of them. Probably not even most of them. People get far too excited about new techology without understanding it. If used well its great but its a little disconcerting to see folks in the field get overly enthusiastic about the new without an appreciation of the context. the whole issue of the benefit of high LET particles is a complicated one in itself.
 
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