Harder vs easier disease sites to treat in RadOnc

[ChristianL]

Hello guys,

I am in the process of negotiating which disease sites to treat with an academic center. I know that each disease site has its challenges and advantages, and every department is different wrt clinical load, support staff, etc. Ideally, I want to pair an easier disease site with a moderately/highly challenging disease site for balance. I wanted to see if there was a consensus on which sites are *generally* easier, moderate, vs high based on 1. Complexity of cases 2. RT side effects to manage 3. Contouring duration plus other technical components of management 4. Disposition of the patients 5. Other unique considerations

This is my take:

Easier:
Breast
Lung
Sarcoma
GU

Moderate:
G.I
Gyn
Lymphoma
CNS

Challenging:
Head and Neck
Peds


Also, knowing what you know now, which sites would you choose to treat in tandem to ensure a good work life balance.

Thanks.

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[RadOncMegatron]

Hello guys,

I am in the process of negotiating which disease sites to treat with an academic center. I know that each disease site has its challenges and advantages, and every department is different wrt clinical load, support staff, etc. Ideally, I want to pair an easier disease site with a moderately/highly challenging disease site for balance. I wanted to see if there was a consensus on which sites are *generally* easier, moderate, vs high based on 1. Complexity of cases 2. RT side effects to manage 3. Contouring duration plus other technical components of management 4. Disposition of the patients 5. Other unique considerations

This is my take:

Easier:
Breast
Lung
Sarcoma
GU

Moderate:
G.I
Gyn
Lymphoma
CNS

Challenging:
Head and Neck
Peds


Also, knowing what you know now, which sites would you choose to treat in tandem to ensure a good work life balance.

Thanks.

Also think long term, overall usefulness of rad onc, and importance for the future not just the present. Are you just an adjuvant pawn or THE oncologist?

Rad Onc as "The Oncologist":

Head and Neck
GU
Gyn
Lung

Rad Onc as an "Important Member of the Team":

GI
Peds (not sure not enough experience)
CNS

Rad Onc as "The person we just send to after we are done with the important part of the cancer/hey point and shoot here you can pick the dose/Why do patients follow up with you?":

Breast
Lymphoma
Sarcoma

I am just kidding... sort of...

 

[levels]

I would bump gyn to challenging depending on brachy load (doing a lot of interstitial ect). Would swap lymphoma and lung (esp if population is mostly locally advanced lung).

Lung + GU is a good combo but probably also more sought after and new faculty may not get it

 

[Ray D. Ayshun]

They'll be happy to hear that not only would you be willing to do head and neck, but also something else in addition to it. Wouldn't pair h&n with anything, and academic gyn is probably doing a lot of hdr that got ebrt at the satellites. Would throw lymphoma in the easy group, and lung in at least moderate given all the oligomet stuff and reirradiation you'll have to think about.

 

[dieABRdie]

Hello guys,

I am in the process of negotiating which disease sites to treat with an academic center. I know that each disease site has its challenges and advantages, and every department is different wrt clinical load, support staff, etc. Ideally, I want to pair an easier disease site with a moderately/highly challenging disease site for balance. I wanted to see if there was a consensus on which sites are *generally* easier, moderate, vs high based on 1. Complexity of cases 2. RT side effects to manage 3. Contouring duration plus other technical components of management 4. Disposition of the patients 5. Other unique considerations

This is my take:

Easier:
Breast
Lung
Sarcoma
GU

Moderate:
G.I
Gyn
Lymphoma
CNS

Challenging:
Head and Neck
Peds


Also, knowing what you know now, which sites would you choose to treat in tandem to ensure a good work life balance.

Thanks.

I think you are lucky you are being afforded so much input in the matter.

I have about 50% breast... while its nice to have something not too stressful it also gets a bit boring Fortunately we are the only group for miles so we see enough uncommon pathology to keep it interesting.

I think the top three choices of mine would be head and neck, CNS and sarcoma. But man... a day full of head and neck or GBM patients can be soul sucking.

 

[Krukenberg]

Having a high volume of CNS patients can be a big time suck. Lots of intractable headaches requiring pointless steroid adjustments. I might move it to challenging just based on the time required for symptom management.

 

[ramsesthenice]

Hello guys,

I am in the process of negotiating which disease sites to treat with an academic center. I know that each disease site has its challenges and advantages, and every department is different wrt clinical load, support staff, etc. Ideally, I want to pair an easier disease site with a moderately/highly challenging disease site for balance. I wanted to see if there was a consensus on which sites are *generally* easier, moderate, vs high based on 1. Complexity of cases 2. RT side effects to manage 3. Contouring duration plus other technical components of management 4. Disposition of the patients 5. Other unique considerations

This is my take:

Easier:
Breast
Lung
Sarcoma
GU

Moderate:
G.I
Gyn
Lymphoma
CNS

Challenging:
Head and Neck
Peds


Also, knowing what you know now, which sites would you choose to treat in tandem to ensure a good work life balance.

Thanks.

It depends on what you want. I primarily do GI and GYN and I couldn't be happier. If you have interstitial capabilities brachytherapy can be a nice challenge from time to time but unlike head and neck it doesn't require you to deal with major morbidity on a frequent basis. GI has a number of different sites that can give you a decent bit of variety.

I strongly agree with whoever said above that if you are at a busy H&N center and doing H&N in anything other than a back up capacity you would be asking for a stressful existence trying to do H&N + something else.

I personally would rather treat livestock than breast cancer. I don't find it stimulating.

 

[Lamount]

I treat primarily lung (+/- 1-2 CRA cases a month). My chemorads patients tend to be on the sicker side because most have supraclav disease... but still probably not as bad as H&N. Lung is a good mix of challenging cases and easy cases. Getting IMRT approved for stage III is less of a struggle these days, and **knock on wood** I haven't been getting a ton of push back on SBRT/IMRT for my oligometastatic/oligoprogressive patients lately. Would echo the above comments that planning can sometimes be more time consuming in cases with re-RT or oligoprogressive bulky adenopathy, but that's part of the fun.

 

[medgator]

Also think long term, overall usefulness of rad onc, and importance for the future not just the present. Are you just an adjuvant pawn or THE oncologist?

Rad Onc as "The Oncologist":

Head and Neck
GU
Gyn
Lung

Rad Onc as an "Important Member of the Team":

GI
Peds (not sure not enough experience)
CNS

Rad Onc as "The person we just send to after we are done with the important part of the cancer/hey point and shoot here you can pick the dose/Why do patients follow up with you?":

Breast
Lymphoma
Sarcoma

I am just kidding... sort of...

Disagree on breast, sarcoma, esp breast.... Sometimes they do see us first and need us first (think dcis).

Lymphoma definitely. Getting back to the op, gi can go in the hard bucket for me along with h&n. Gu is a mixed bag imo... Prostate can be fairly straightforward and we definitely see a lot of it compared to bladder

 

[gmsquid]

I treat HN in an academic center. You have to absolutely love it (which I do) otherwise you’ll burn out fast. DM me if you have any questions.

 

[TheWallnerus]

I don’t know how to decide easy vs hard. Steve Leibel maybe had an easy disease site, although I think he would’ve said it was hard. He died of a heart attack so how easy was his disease site really. That said don’t accept the Peds and H&N service.

 

[Neuronix]

You can do it like I did it--negotiate one disease site and then treat something completely different

I mostly treat CNS for past few years. A lot of heartbreaking cases, (almost) everything is urgent which can be annoying when others don't understand the urgency, and if you screw up you know it really fast.

I usually hear the juniors at my shop called the "head, shoulders, knees, and toes" rad oncs by the residents. YMMV.

 

[RADONC4285]

One point to consider is RVUs. If you have to meet a certain number of RVUs then sbrt, SRS, and prostate are the best for that. More difficult to get RVUs from brachy and breast.

 

[Neuronix]

I hate that this mentality dumps lower reimbursing stuff (per unit effort) on the other faculty instead.

 

[medgator]

One point to consider is RVUs. If you have to meet a certain number of RVUs then sbrt, SRS, and prostate are the best for that. More difficult to get RVUs from brachy and breast.

Many of us would be fine subsidizing peds faculty imo. I wouldn't want to do it

 

[RADONC4285]

I agree it's horrible mentality. But I can tell you you I work at a place that doesn't care what you treat. We all have the same rvu Target. Our chairman understands and tries to protect us, but ultimately my value to the system is decided by corporate overlords who don't know what a photon is. Not saying decide what site based on rvus, but at least consider it and try to understand how your department and hospital evaluate these things given the amount of work is not really tied to RVUs.

 

[FrostyHammer]

I feel sorry for the academics who do nothing but breast and are expected to get the same RVUs as others. What a life...

 

[TheWallnerus]

I feel sorry for the academics who do nothing but breast and are expected to get the same RVUs as others. What a life...

Physician - Radiation Oncology - Radiation Oncologist - Breast - Top Academic Medical Center - Kansas City, KS job with University of Kansas Hospital | 628182

The Department of Radiation Oncology at the University of Kansas School of Medicine/ University of Kansas Cancer Center, an NCI designated Cancer C...

www.myhealthtalent.com

 

[RadOncDoc21]

Physician - Radiation Oncology - Radiation Oncologist - Breast - Top Academic Medical Center - Kansas City, KS job with University of Kansas Hospital | 628182

The Department of Radiation Oncology at the University of Kansas School of Medicine/ University of Kansas Cancer Center, an NCI designated Cancer C...

www.myhealthtalent.com

They prefer a “breast fellowship”

…

 

[ramsesthenice]

I feel sorry for the academics who do nothing but breast and are expected to get the same RVUs as others. What a life...

This is something new grads are poorly equipped to navigate. At centers like ours, the minimum targets set by hospital admin are really doable for any disease site so everyone, even our peds/sarcoma person (who has by far the lowest RVU output) is bonus eligible. Our bonuses are drawn up in a way that all of us get the max too (RVUs, publications, enrollment, teaching etc). That cuts both ways. None of us get huge bonuses but no one gets left behind either. Depending on your goals and perspectives that can be a good or a bad thing.

Full disclosure: I got lucky. I had no idea how many RVUs were reasonable and I don’t honestly think I knew to even ask what my target was. I trusted my chair and admin and it worked out but that is not always the case. Our target is 1000 RVU/10% clinical effort. For our low volume services they fudge the denominator since specializing in peds outside of a regional hub there is only so much volume to go around. Our breast person never has trouble meeting this.

 

[medgator]

This is something new grads are poorly equipped to navigate. At centers like ours, the minimum targets set by hospital admin are really doable for any disease site so everyone, even our peds/sarcoma person (who has by far the lowest RVU output) is bonus eligible. Our bonuses are drawn up in a way that all of us get the max too (RVUs, publications, enrollment, teaching etc). That cuts both ways. None of us get huge bonuses but no one gets left behind either. Depending on your goals and perspectives that can be a good or a bad thing.

Full disclosure: I got lucky. I had no idea how many RVUs were reasonable and I don’t honestly think I knew to even ask what my target was. I trusted my chair and admin and it worked out but that is not always the case. Our target is 1000 RVU/10% clinical effort. For our low volume services they fudge the denominator since specializing in peds outside of a regional hub there is only so much volume to go around. Our breast person never has trouble meeting this.

There has to be an allowance for the peds, gyn, brachy people etc. Many of us don't want to be bothered and would be fine subsidizing those folks

 

[TheWallnerus]

They prefer a “breast fellowship”

…View attachment 338701

Can you a man say "I'm a breast fellow" in academics and not get fired?

 

[ramsesthenice]

There has to be an allowance for the peds, gyn, brachy people etc. Many of us don't want to be bothered and would be fine subsidizing those folks

So Gyn depends on how you do it. I will look up the numbers but if you are doing CT or MRI guided volume optimized treatment planning with each fraction the revenue is not too shabby (as opposed to the days of all pt pt a plans). The data from Europe strongly supports the approach in terms of local control and toxicity.

 

[medgator]

So Gyn depends on how you do it. I will look up the numbers but if you are doing CT or MRI guided volume optimized treatment planning with each fraction the revenue is not too shabby (as opposed to the days of all pt pt a plans). The data from Europe strongly supports the approach in terms of local control and toxicity.

Definitely better in the 3D planning era, plus a lot of downstream revenue if you're hospital based with the or time, mri scans etc.

I still think you come out ahead treating a ton of imrt locally advanced lung or h&n and it's a lot easier from a workflow standpoint to do that than try to run a combined brachy/external practice

 

[ramsesthenice]

Definitely better in the 3D planning era, plus a lot of downstream revenue if you're hospital based with the or time, mri scans etc.

I still think you come out ahead treating a ton of imrt locally advanced lung or h&n and it's a lot easier from a workflow standpoint to do that than try to run a combined brachy/external practice

Oh no question. It’s a matter of throughput at the end of the day.

 

[MegaVoltagePhoton]

I do primarily gyn, and some prostate and head neck. More prostate recently as a senior attending retired. I actually like gyn, I compromised otherwise to be in my preferred city.

At the end it is what you make of it. Yeah people hate gyn, but hey, I'm happy to be the person treating the cancer and not the one getting the multiple pelvics etc. because of cancer (that is what I tell myself anyway!)

 

[evilbooyaa]

Hello guys,

I am in the process of negotiating which disease sites to treat with an academic center. I know that each disease site has its challenges and advantages, and every department is different wrt clinical load, support staff, etc. Ideally, I want to pair an easier disease site with a moderately/highly challenging disease site for balance. I wanted to see if there was a consensus on which sites are *generally* easier, moderate, vs high based on 1. Complexity of cases 2. RT side effects to manage 3. Contouring duration plus other technical components of management 4. Disposition of the patients 5. Other unique considerations

This is my take:

Easier:
Breast
Lung
Sarcoma
GU

Moderate:
G.I
Gyn
Lymphoma
CNS

Challenging:
Head and Neck
Peds


Also, knowing what you know now, which sites would you choose to treat in tandem to ensure a good work life balance.

Thanks.

My personal opinions on this scale:

Easier:
Breast
GU (especially if mostly/all prostate)
Sarcoma
Lymphoma

Moderate:
GI
Gyn (can be challenging if heavy brachy volume)
CNS (if GBMs and you are responsible for steroid dosing/tapers)
Lung

Challenging:
Head and Neck
Peds

If you are H&N as your primary, I would not pick a back-up from anything besides one of the easier list.
I think trying to do Gyn where you're busy with brachy and simultaneously being responsible for on-treatment issues for H&N (even if you're back-up) is less than ideal.

Lung is nice and mostly all in clinic and can be paired with another moderate. Only issue with having H&N be back-up is whether you'll be responsible for covering all your own SBRTs. Same for CNS (if CNS means that you do all the SRS).

CNS can end up with mostly whatever (seen it with H&N, Lymphoma/Breast, Lymphoma/GU, Peds) in a 'doc covers 2 specialties' set-up.

 

[ChristianL]

Thank you, all. These have been very insightful observations!