Intellectually stimulating

[MD13]

Just curious--
From those residents/attendings who are doing this everyday-- what do you find to be the most intellectually stimulating part of the job? Is it the treatment planning? The patient follow-up (managing side effects of treatment)? The initial consultation? Something else?

I know that RadOnc is a very evidence-based field and so I am wondering:
1. if the treatment planning is more of a 'matching game' between the pts cancer and what the literature has to say, or rather more of an intellectually intensive process?
2. given the nature of the field, what aspects of practicing RadOnc (other than pursuing bench/clinical research) allow you to have diversity/creativity in your day?

Thanks!

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[Raygun77]

It seems like once the decision to treat radically is made, target and dose becomes pretty cookbook- based on the best evidence. I'm not sure if it's true for all disease sites, but patient's usually come to the rad onc worked up for primary treatment, it being straightforward to then tick the boxes to make sure they are elgible for radical rx (ie ECOG status, age, etc are all in line), then determine doses and targets based on the book. From what i've seen, some med oncs refer on to the rad onc with the assumption that the patient will recieve a set radiation dose actually written in their referral, the actual consultation being a bit of a formality to them.

However, 50% of the work you'll do is palliative. This is where the evidence becomes a lot more scarce and it's up to you to take everything into account. How long do you think the patient has left? What is their QOL? How big is the diseased area? Plenty more considerations no doubt. Plenty of variability. This is when you'll probably source that path and radiobiology knowledge at the back of your brain and think about what doses and fractions would best serve this patient, with this pathology.

 

[deleted4401]

I'd take what a med student says with a cupful of salt.

It's not really cookbook at all. That's equivalent to saying a medonc's job is cookbook, that they just give whatever dose of whatever juice that the protocol spells out. Oh wait...

In addition to what the ninja say, there is much variation in targets/dose, especially for head and neck, but also for GI/GU/pelvic malignancies. That is to say, all of them. There is no great "evidence" for the intermediate volume for an oropharynx cancer or whether or not to include the whole mediastinum for a LS SCLC. There is some "recommendations" from "experts", but this is not level one evidence. So, yeah, there's a fair amount of mental 'sturbing in this field, as well.

-S

 

[medgator]

I think all patients should be treated "radically," d00d.

But seriously, I don't agree that dose and target become cookbook. It certainly could be if you wanted it to be, but there's alot of room for interpretation.

Having just had a discussion with my attending regarding treating a definitive cervical esophagus SCC, I definitely have to agree as well. If you look an example of a plan in perez and brady, you see a dose of 50.4 Gy because that's what the data for esophageal cancer suggests is an appropriate dose. My attending (and I) both agree though that's a pretty piddly dose for a young guy with a cervical primary with a bad option for salvage surgery (larygnopharyngectomy along with the esophagectomy) so we are going much higher than that.

 

[medgator]

So, yeah, there's a fair amount of mental 'sturbing in this field, as well.

 

[MD13]

Thanks to everyone for the responses. It seems that there is definitely variability in the cases that you see and some creativity in the treatment options, however, as I have yet to do my RadOnc rotation, I am still unsure as to exactly how much creativity is involved in being a RadOnc physician--so I was hoping to phrase my initial question a bit differently.

Understandably, there is going to be a fair amount of monotony or routine work in every specialty; however, I am wondering if among the specialties that you considered/were exposed to, does RadOnc seem to have more 'routine' tasks (in terms of treatment or 'cookbook' as someone mentioned)?
If so, is RadOnc a field that self-selects students who have a certain personality who enjoy a certain level of routine work (ie like surgery) versus personalities that enjoy a lot of variability in their day?
Is this simply something that we all have to deal with regardless of what specialty we go into or is it more pronounced in RadOnc in particular?

Thanks again for taking the time to answer my questions.

 

[Raygun77]

Similarly, I'd take what most residents on this board say with a bagful of salt.

Good to have the residents weigh in though .

By radically i meant with curative intent- they're synonyms, right? Or well, the most dose you can pump into the region safely.

My perspective comes solely from CNS clinic where my research is in- specifically GBMs. When it comes to primary (wouldn't call it curative unfortunately) treatment, its conformal EBRT 60/30, every time, with the margins done by the book- because nothing else has proven better than the Stupp protocol. The only exceptions would be for older persons or those with higher ECOG scores, in which case a shorter schedule is usually opted for, say 40/15. I think the trial is currently ongoing to establish 40/15 as the regime of choice for persons >65 with GBM.

When you have a patient with recurrent GBM though, and sadly you do for every primary GBM patient seen, the evidence thins out and you're flying solo more of the time. Here's where I'd say things get more 'creative'.

And by the way, I didn't mean to devalue what a rad onc does. I now know that cookbook carries with it negative connotations. Even though being evidence based is what all clinicians should aspire to!

 

[Gfunk6]

As I am currently training at a place that is regarded as cutting edge for CNS I have to say that treating GBMs is not cookie cutter. There is just a ton of innovation going on. My CNS attendings regard drawing the CTV the RTOG way (2 cm around T2 hyperenhancement) as simply for the masses who don't know better.

For instance there is growing recognition of non-enhancing tumor and the importance of identifying it (possible with functional imaging) and treating it. Also we try to avoid the SVZ when possible as it is a known repository of stem cells and likely increases the risk of necrosis.

There are also clinical situations where using RTOG protocol may be inappropriate such as rapidly progressing multi-focal GBM. In these cases you probably don't want to treat >60% of the brain with 2/60.

My point is at top academic programs even "routine" stuff can be cutting-edge.

 

[nod]

MD 13, your questions are difficult to answer. I think you will likely have a better feel for the field once you have actually done a rotation. There are many different types of rad onc docs out there. I am sure there are some who practice "cookbook medicine" as you call it, and do it by the the latest protocol and think as little as possible. Most of the rad onc attendings I know think about all the patient characteristics in a case, and tailor the treatment accordingly, in terms of target volume, normal tissue avoidance, dose, and fractionation.

I would also disagree with your labeling surgery as routine. I guess surgery can be routine if you practice the most basic procedures (appendectomy) all day, but when I think of the surgeons at our center, their cases are complex and dynamic and far from routine.

So I guess any field can be routine or dynamic, depending on what you make of it and whether you are interested in your work.

best of luck.

 

[Ionized]

I agree that even "routine" events and planning in rad onc could be very cutting-edge. There are evidence-based guidelines and protocols but each case is different. Sometimes you need combine your judgment with knowledge gleaned from major studies. There are just endless possibilities.

I also disagree that innovation is seen only at top academic centers. Many programs have their own distinct protocols and philosophies, often based on a combination philosophies from where the staff trained. This is another reason I believe 'inbreeding' should be avoided in rad onc. Part of what makes this field great is the integration of methodologies coming from various training programs.

 

[SchwettieBalls]

As I am currently training at a place that is regarded as cutting edge for CNS I have to say that treating GBMs is not cookie cutter. There is just a ton of innovation going on. My CNS attendings regard drawing the CTV the RTOG way (2 cm around T2 hyperenhancement) as simply for the masses who don't know better.

For instance there is growing recognition of non-enhancing tumor and the importance of identifying it (possible with functional imaging) and treating it. Also we try to avoid the SVZ when possible as it is a known repository of stem cells and likely increases the risk of necrosis.

My point is at top academic programs even "routine" stuff can be cutting-edge.

I just find it humorous that one could talk "cutting edge" and "tons of innovation" about radiotherapy for GBMs when basically everything under the sun has already been tried - blasting the whole brain with 60 Gy, dose escalating to smaller volumes with 90 Gy, adding SRS or brachy boost, blah blah blah - and you still get the exact same result... You are kidding yourself if you think theres some magical way of drawing CTVs/PTVs thats better than the cookie cutter RTOG contours.

 

[Gfunk6]

I just find it humorous that one could talk "cutting edge" and "tons of innovation" about radiotherapy for GBMs when basically everything under the sun has already been tried

Before Stupp's trial nobody thought anybody could improve chemo over concurrent BCNU. Now people talk about TMZ like it's the second coming when in reality it only increases OS by a couple of months in non-selected patients.

The bar in GBM is, of course, set quite low and what is considered a "breakthrough" would be considered "ho-hum" in most other subsites. However, I find it humorous that someone would feel that simply because historical radiation studies have failed to improve endpoints that is absolutely worthless to try to continue to innovate. Baby steps.

 

[Raygun77]

As I am currently training at a place that is regarded as cutting edge for CNS I have to say that treating GBMs is not cookie cutter. There is just a ton of innovation going on. My CNS attendings regard drawing the CTV the RTOG way (2 cm around T2 hyperenhancement) as simply for the masses who don't know better.

For instance there is growing recognition of non-enhancing tumor and the importance of identifying it (possible with functional imaging) and treating it. Also we try to avoid the SVZ when possible as it is a known repository of stem cells and likely increases the risk of necrosis.

There are also clinical situations where using RTOG protocol may be inappropriate such as rapidly progressing multi-focal GBM. In these cases you probably don't want to treat >60% of the brain with 2/60.

My point is at top academic programs even "routine" stuff can be cutting-edge.

Fair enough. I'd be interested to follow up more specifically on this SVZ area though. Do you mean the sub-ventricular zone? Any data out there suggesting an increased risk of necrosis? If not it could be an interesting retrospective study to persue, though I'd imagine a major confounder being that more patients treated in this area with RT would have subependymal tumour and thus direr prognoses.

Also do you mean your attending treats with different CTVs in the context of a trial, or routinely? I'd be interested to know what they are, if you could PM me. My research is ultimately in using advanced MR sequences as well as amino-acid PET tracers to create 'more accurate' GTVs.

 

[Gfunk6]

Do you mean the sub-ventricular zone? Any data out there suggesting an increased risk of necrosis?

See PMID: 17398036

More robust clinical data is obviously needed.

Also do you mean your attending treats with different CTVs in the context of a trial, or routinely?

Both. One new modality we are using is high-resolution phased-array MRI at 7 Tesla. The images generated by this MRI have unbelievable resolution, it's almost like viewing a dissected slice of human brain. We are also high on mass spec. We are very fortunate to have one of the top radiology departments in the country and this is a huge plus for us for research collaborations.

BTW, my graduate studies were in GBM also.

 

[Gfunk6]

This is another reason I believe 'inbreeding' should be avoided in rad onc. Part of what makes this field great is the integration of methodologies coming from various training programs.

I absolutely agree. The junior faculty we have hired recently from outside institutions have brought fresh perspectives and innovations to our department.

 

[SchwettieBalls]

Before Stupp's trial nobody thought anybody could improve chemo over concurrent BCNU. Now people talk about TMZ like it's the second coming when in reality it only increases OS by a couple of months in non-selected patients.

The bar in GBM is, of course, set quite low and what is considered a "breakthrough" would be considered "ho-hum" in most other subsites. However, I find it humorous that someone would feel that simply because historical radiation studies have failed to improve endpoints that is absolutely worthless to try to continue to innovate. Baby steps.

I completely agree that novel chemotherapeutics/targeted agents are the key to improving outcomes in GBMs. My point is that there have been no advances in radiotherapy delivery in the past 25 years despite everything including the kitchen sink being attempted. When 60 Gy to the whole brain doesnt work, altered fractionation doesnt work, dose escalation doesnt work etc, I can promise you that treating a 7T MRI defined CTV with 60 Gy + TMZ will result in a 14 month median survival.

 

[deleted4401]

I agree - what a frustrating disease.

Reminds me a story that one of the guys that interviewed me for a job told me.

His mentor, Sause (from Utah), was an oral examiner. This was in the 80s. His examinee was a resident from Canada, and it was a stage III lung case. The answer (at that time) was definitive RT. The resident nailed it all - the work-up, staging, etc., etc. He drew the fields perfectly. Then Sause asked him the dose. The guy says: "30 Gy/10 fractions". He had scored him perfectly throughout the exam, and didn't want to fail him, so he asked him again, "Are you sure that's your dose? You don't want to go higher?" The resident says "Yes, I'm sure. 30 Gy/10 ... It's f---ing lung cancer." .... He passed him

-S