interventional oncology

[youngdoc8205]

saw this online, thought it might be interesting: I think they are working with surgeons pretty closely

http://www.cc.nih.gov/centerio/index.html

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[fiatlux]

where are you getting this info that they are working with surgeons? the interventional staff are all DR trained and drs. chang and wood are renowned IR physicians.

 

[Charles_Carmichael]

Genuine question here, but how much actual cancer/oncology training do you get in DR/IR? I mean, cancer is an incredibly broad disease that, IMO (as a researcher), requires a ton of knowledge in order to adequately treat. So, I'm just curious as to how much pure oncology training one can get during an interventional oncology fellowship.

 

[fiatlux]

well it depends on your fellowship program and the inherent strengths of the faculty and patient population that exist. if you're an IR fellow at sloan-kettering, northwestern, or hopkins (just to rattle off a few) you will get plenty of longitudinal care with an intense oncology population in clinic. and you will have at least one day a week in clinic. it is akin to a surgical oncologist and his/her level of knowledge in his niche field of interest.

most IR onc fellows are likely very well versed in solid tumors amenable to intervention but even more important for them is knowing what they can not do. and this is where they acquire the 'general knowledge of an oncologist'. now this isnt to say that PCP will send a liver mass to IR without having a medical oncologist on board. thats crazy. most chemo treatments are the domain of medical oncologists, but sometimes a surgical oncologist or interventional oncologist may choose to order something if he/she feels completely comfortable with it.

 

[Gvataken]

The main cancers that I treat with IO techniques


1. hepatocellular carcinoma
2. unesectable cholangiocarcinoma
3. met colorectal cancer /unresectable with either poor tolerance or response to folfox/folfiri etc or a patient on a chemo holliday

4. stage 1 kidney cancer
5. Lung cancer
6. Bone mets (palliative for pain)

then rare tumors treated include but are not limited to

1. neuroendocrine tumor
2. ocular melanoma mets to liver
3. angiosarcoma


So, we have a fairly focused amount of oncology that we learn.


Hepatocellular carcinoma is pretty straightforward. You need to understand basic liver disase and the treatment algorithm and the basic underlying data.

for eg
1. etiology of cirrhosis/hcv/hbv/nash/autoimmue/wilsons/hemochromatosis/etc
2. portal hypertension and cx and treatment
-ascites (diuretics/tips)
-encephalopathy
-varices (b blocker/banding/tips etc)
3. liver dysfunction/inr/tbili etc

the staging of liver cancer
-milan criteria (for transplant purposes)
need to be >2 cm for MELD exemption a total of 22 points
-vascular invasion
-extrahepatic spread (lungs, regional ln, adrenals, bones)

Once you stratify them based on liver disease and tumor staging you can offer them the appropriate therapy
1. transplant
2. resection/ablation
3. chemoembolization
4. nexavar (sorafenib) SHARP trial

Also, you need to feel comfortable with the diagnosis which is primarily based on imaging and not biopsy (false negs)

This is an example of one type of tumor that we treat and what is needed to feel comfortable with its treatment and so the same thing can be said for the various tumor types that we face.

 

[werewethere]

Is there any threat of the medical oncologists possibly attempting to hijack these procedures from IR?

There is always a theoretical risk, but onc is already pretty busy with trials, new meds, and chemo treatment and recovery. Do you see med onc people taking over rad onc? Surg onc? Subspecialty surgery? The complexity of the disease process is such that the multidisciplinary approach with skilled team members will remain the treatment of choice, assuming that IO people continue to be involved in patient management, multidisciplinary conferences, and continue to stay up appropriate clinical management.

 

[Dr.CCM]

There is always a theoretical risk, but onc is already pretty busy with trials, new meds, and chemo treatment and recovery. Do you see med onc people taking over rad onc? Surg onc? Subspecialty surgery? The complexity of the disease process is such that the multidisciplinary approach with skilled team members will remain the treatment of choice, assuming that IO people continue to be involved in patient management, multidisciplinary conferences, and continue to stay up appropriate clinical management.

I guess I was looking at it more from what happened with the cardiologists perspective--cards became trained in these interventions for the heart and then since they control the market share and saw the potential capital, took over this work.

What would preclude the medical oncs from following in cardiology's footsteps especially with the recent cuts in chemo reimbursements? I mean if a cardiologist can learn a similar technique in 1-2 years of interventional fellowship surely a med onc could as well for the various oncologic procedures.

I ask this because as a medical student interested in IR, I am truly worried 10-20 years down the road IR will be paved with PICC lines and scraps from what the medical/surgical specialists don't want.

Are these legit concerns?

 

[2012mdc]

I guess I was looking at it more from what happened with the cardiologists perspective--cards became trained in these interventions for the heart and then since they control the market share and saw the potential capital, took over this work.

What would preclude the medical oncs from following in cardiology's footsteps especially with the recent cuts in chemo reimbursements? I mean if a cardiologist can learn a similar technique in 1-2 years of interventional fellowship surely a med onc could as well for the various oncologic procedures.

I ask this because as a medical student interested in IR, I am truly worried 10-20 years down the road IR will be paved with PICC lines and scraps from what the medical/surgical specialists don't want.

Are these legit concerns?

I'm not in the know at all (just MS3) but I feel like it's different. Cards guys are used to doing interventional procedures so I would assume it wasn't too hard for them to pick some of the stuff up. Med-Onc isn't as procedure driven and IR is getting more control of patients with clinic and stuff like that

 

[werewethere]

I'm not in the know at all (just MS3) but I feel like it's different. Cards guys are used to doing interventional procedures so I would assume it wasn't too hard for them to pick some of the stuff up. Med-Onc isn't as procedure driven and IR is getting more control of patients with clinic and stuff like that

I think you make a good point. There are other dynamics that also need to be considered. The difference in size (i.e. number of fellows entering the field) between oncology and IR is smaller, allowing for IR to be more competitive. Cancer, being a systemic disease and requiring multimodality treatment, is harder to corner into any single subspecialist group (i.e. the melanoma patient is going to a cutaneous oncologist with coordination with med onc, surg onc, other surgical specialties, IR while HCC will be hepatologist, maybe med onc, surg onc, transplant, IR, and RCC will be nephro/uro/IR/etc) making the clinical model much more multidisciplinary. Also, because of economic pressures there is much more emphasis on outcomes (i.e. Kaplan Meier curves and such) and multidisciplinary approaches rather than on single provider models (i.e. look at AHRQ, IOM, and other quality improvement organizations and their effect on the practice of medicine). Also, it is possible and quite common for mutiple disciplines to be competitive for the same procedure (i.e. PAD). Finally, I think IR is starting to correct one its most important issues beyond integrating clinical practice: having more practitioners. If you have the manpower to handle the cases in a easy, timely fashion and add value and convenience to a refering primary's doctor's patient care, you will get more referral and your practice will thrive, assuming you have the skills.

 

[Gvataken]

I think that IR now is becoming far different because now there are far more IR's with true clinics. I saw nearly 30 patients in the office this week as an example. IR's are also becoming far more clinical and so that has allowed us to become far better clinicians. For example with hepatocellular carcinoma we are able to give a prognotic data and hepatoma is truly an imaging diagnosis. We can also stage hepatomas based on imaging and then the treatment algorithm is something we have learned. Including transplant, resection, ablation, chemoembolization, drug eluting beads, Y90 Internal beam radiation therapy, nexavar, palliative care and hospice. Also with said organ I have started to develop some basic understanding of liver disease including ascites, encephalopathy, varices, so on and so forth.

So, the key difference is IR is continuing to become far more clinical and are following far more patients then in years past.

 

[badasshairday]

"Past, present, and future of interventional oncology"

http://www.cxvascular.com/in-interv...present-and-future-of-interventional-oncology

 

[davidjones]

Thought I would resurrect this thread with an excellent review article:

http://www.sciencedirect.com/science/article/pii/S0093775410002332

 

[shark2000]

If you do not see yourself doing anything, but procedures go to a surgical subspecialty. IR is not a good choice. It can be very beautiful, but you may need to do a lot of DR besides.
Most IR jobs are a combination of IR and DR with DR almost 50% of what you do. The same is going for cardiology. They do almost 60% general cardiology. It is the environment in the pp, forget about your university.
And there is always turf issues. Be prepared to go back to DR. You may lose your turf to vascular surgeons. What happens if the oncology clinic starts sending the chemo-embos to vasc surgeons? I know, many IR people may start to argue. Even if it does not happen in a large scale, it may happen in your area. Nothing is in the realm of IR that can not be done by a surgeon. Don't forget that 15 years ago people where laughing at vascular surgeons and cardiologists for putting the catheter in IVC instead of Aorta. And now, IR fellows are begging for PVD cases.
Unfortunately many medical students choose IR as a short track to surgery. To many it is a way to escape the hardship of 5 years of surgery residency.
Don't take me wrong. IR is one of the greatest fields in medicine. It will likely thrive and expand. But always be prepared to switch back to DR and if you hate it, do not do IR. You have to do at least 50% DR in most places, job market may not be as good in the future, you may lose the turf at least locally and many other factors.Surgical sub-specialty is on the safer side.
Just know what you are doing to your life.

 

[davidjones]

While I agree with shark that you should at least be able to tolerate DR and that IR is not a backdoor to surgery. I pretty much disagree with everything else he says.

The oncology stuff is more than just sticking in a catheter and injecting little balls into a tumor, knowledge of tumor biology, complications related specifically to cancer patients all of which is out of the realm of vascular and cards, the reason turf issues m mexist there is they can self refer and frankly without angio vascular and cards are dead in the water do their backs were against the wall.

IR is in a similar position now hence all the changes in training paradigms and emphasis on patient care.
IRs also go to tumor board, hold clinic and admit patients.

Note also that PAD in IR isn't exactly dead, there are many many academic and PP practices where IR does lots of vascular work. With more IRs in clinic there will likely be more referrals for PAD from PCPs.

 

[IRpadawan]

I 100% disagree with shark. In fact most of what he says is completely false.

In actuality, all academic IR jobs can and almost always are 100% IR. The reason some private practice jobs are part IR and part DR is that there is not always enough IR at a small rural community hospital. However that trend is changing with numerous examples of 100% IR private practices and private practices where the IR group is separate from the DR group.

Turf issues occur because old timer IRs don't want to round and see patients in clinic. IR fellowships are now focused on provided clinical training and ensuring young attendings have the skills needed. Additionally, there are almost thirty IR residencies in the country that also do this. Thus, IRs can and are competing and winning some of those turf battles. Interestingly, in many places there are vascular surgeons losing turf battles to cardiologists also.

What I think the future holds and what is already happening in some areas are multidisciplinary groups focused on patient care. This means a surg onc, IR, med onc in a group or a vascular surgeon, CT surgeon, IR in a group. And they work together to do what is best for the patient since that is the ultimate goal here not fighting with each other. They all round and all see patients in clinic.

As reimbursements go down we will see if turf battles continue. In the end, the truf battles are a result of the money that can be made doing procedures.

While there may always be turf battles. IRs will always have jobs and be doing whatever procedures they decide they want to become disease experts in. The big key is knowing the disease process and treating the patient with an evidece based complete approach from start to finish. Preprocedure to postprocedure. IRs are capable and already doing that. Believe me, I have seen cases where vascular surgeons don't want to do that and have lost business.

Also, I know many medical students that choose IR for the technology, innovation as opposed to being able to escape surgery. As a previous surgical resident myself, I switched to IR because it was more interesting and I had the ability to affect and treat more patients.

People who do IR should ahve an interest in IR, but there is no reason you would ever have to go back to DR if you didn't want to.

 

[IRpadawan]

People who do IR should have an interest in DR, but there is no reason you would ever have to go back to DR if you didn't want to. That was a type above, and for that I apologize.

There are numerous fellowships across the country that incorporate significant vascular disease and therapy including arterial.

In the end, shark's statement is completely false and not factual at all.

 

[Reza Rajebi]

I disagree with Shark as well. As IRpadawan pointed out, 100% IR jobs are available nationwide and exactly for the same reason, the new IR pathways were developed. Although you become a board eligible diagnostic radiologist as well in these pathways, the main purpose for having these residencies is training IRs who are disease experts.
For the same reason, nowadays the mainstay of IR training in the topnotch fellowships is also focused on training clinicians who not only can provide high-end minimally invasive interventions but also manage underlying diseases longitudinally. In other words, they are now training patient focused interventional clinicians.
If you become a disease expert in the field that you want, I can guarantee that you'll have so many patients in your practice that you will never need to be prepared to go back to DR.
Ultimately, whoever can provide the best patient care should perform the procedure and yes that is a battle. However, I believe radiology residents are among the best and most talented medical students in their school and there is no reason for them to not be able to master the disease processes that they are dealing with.
The field of medicine is a dynamic platform with a wide range of opportunities and challenges. You may experience multiple ups and downs during your professional career but what keeps you going is not winning the turf battle, it is doing what you love. IR is the future of medicine as many new techniques, treatments and devices are developed within the field of IR and innovation in this field is exceptional.

 

[DThor]

If you are hoping to do any specialty and do the same procedures for the next 25 years - no matter what specialty you chose you will be disappointed, however saying that it is impossible to do 100% IR is rediculous. Yes you should have some interest in diagnostic imaging because what separates you as a minimally invasive proceduralist is your knowledge of the anatomy and imaging. IR does a lot more then transarterial chemoembolization, is it a big part of practice now? yes will it continue - probably. There are just some procedures that are unlikely to go away do to technical factors as well as expertise. How many Heme Onc docs do you know that have a fluoro suite in their office? How many are likely to spend 1.5 million dollars to buy one to do a procedure that they might do 3 times a week? Vascular surgery and Cardiology are a different animal as they already have fluoro suites and so are competing for procedures. Keep in mind though that if we as radiologists are willing to follow our patients we will still have the procedures. Cardiologists and vascular physicians only have so much time to due procedures and with the recent data on carotid endarterectomies and the data coming from the VA on aortic aneurysms - someone has to do all those open operations. There is a reason that Tranjugular intrahepatic portosystemic shunts have been around for 20 years and no one does them but radiologists. There is also a reason that there are many Vascular surgery groups that are hiring interventional radiologist to do the endovascular work for their groups. The skill set that you have with respect to imaging and technique gives you a skill set that is difficult to match - so yes like diagnostic imaging it is a good idea but to state that you are not going to get to be a 'real' proceduralist and do full-time IR if that is your wish as an interventional radiologist is poorly informed

 

[shark2000]

The OP specifically asked about interventional oncology and not about PAD or other stuff.
I don't say you go jobless. I don't say you will lose turf. I only say, IR and DR are different animals. If you dislike DR, do not do IR. You may end up doing DR, you may not end up doing cancer work, ...
You guys seem to be residents at best, most likely MS. or may be a fellow in an academic center who has not entered a real world.
Sooner or later, you will apply for a job and in this market you will find out that it is the seller's market. You can never ever dictate the type of practice you are looking for, at least in desirable areas. For example the radiology group wants to sign a long term exclusive contract with the hospital and it can happen only if they turf their vascular work to vascular surgery. Or orthopods can only contract with the hospital if they leave all spine work to neurosurgeons. Or the cardiology group can sign the contract only if they move their outpatient clinic to the hospital (so all the technical fees of echo and stress test goes to the hospital).
My point is not only about radiology. My point is that turf wars are very common, even inside the group. Your seniors may want to do all certain type of procedures themselves. You are sort of doomed to join a group and do whatever you are told, with some flexibility. You have to like the backbone of your sub-specialized field (which is DR). At least in most groups outside academica, you have to do 40-50% DR. Don't like it, go and buy your 2 mil angio suit and your 4 mil 128 slice MDCT and start your own group.

 

[davidjones]

Shark is right. In any specialty you have to like the backbone of the specialty. IR is a different animal then DR and you have a different kind of doc going into each specialty but you do have to go through DR to get to IR for now, sort of like going into cards but just tolerating IM. It is possible to like and do both . I personally don't believe you can be the best a good IR while prating DR and vice versa, an IR is just not going to have the same accuracy and DR guys just won't have the same clinical skills.

The two specialties are diverging, but for the foreseeable future the two are intertwined. Likely within the next 5 years there will be a dual DR/IR residency and things will change.

Shark is also right that you may, MAY, have to compromise. Like any procedural specialty you will have to build a referral pattern, I've know a couple of orthopedists who thought that was too much effort and switched to anesthesia. Once you establish yourself as the person who brings a ton of business to the group or hospital you can pretty much dictate your terms, in academics the same is true if you bring in research money .

Everyone else is right too. Yes IR is becoming a separate specialty, yes you can find a job with 100 % IR in PP. And yes IR is an awesome field with a lot of potential. See the thread about the TACE to systemic chemo comparison

 

[werewethere]

If you do not see yourself doing anything, but procedures go to a surgical subspecialty. IR is not a good choice. It can be very beautiful, but you may need to do a lot of DR besides.
Most IR jobs are a combination of IR and DR with DR almost 50% of what you do. The same is going for cardiology. They do almost 60% general cardiology. It is the environment in the pp, forget about your university.
And there is always turf issues. Be prepared to go back to DR. You may lose your turf to vascular surgeons. What happens if the oncology clinic starts sending the chemo-embos to vasc surgeons? I know, many IR people may start to argue. Even if it does not happen in a large scale, it may happen in your area. Nothing is in the realm of IR that can not be done by a surgeon. Don't forget that 15 years ago people where laughing at vascular surgeons and cardiologists for putting the catheter in IVC instead of Aorta. And now, IR fellows are begging for PVD cases.
Unfortunately many medical students choose IR as a short track to surgery. To many it is a way to escape the hardship of 5 years of surgery residency.
Don't take me wrong. IR is one of the greatest fields in medicine. It will likely thrive and expand. But always be prepared to switch back to DR and if you hate it, do not do IR. You have to do at least 50% DR in most places, job market may not be as good in the future, you may lose the turf at least locally and many other factors.Surgical sub-specialty is on the safer side.
Just know what you are doing to your life.

The above comment is just simply wrong.

 

[Raygun77]

I see IR and DR as two components of the same job- at least in Australia. For example, at our GI/hep Onc MDMs we have representatives from gen surg (surg oncs by virtue of interest not formal training, unlike the US perhaps), transplant surg, hepatology, med onc, rad onc, ID (with special interests in hep B and C), as well as an interventional radiologist chairing the meeting and running through all the imaging. Often a gastro resident (gastro being the admitting unit most of the time unless it's a clearly surgical issue) will run through the H and P spiel, with the IR then going through the relevant imaging comparisons. Then a plan is formulated with all present- whether to transplant, resect, chemo/radio ablate, RFA, irradiate externally, systemic chemo, supportive care, all or any of the above.

I think Gvataken is absolutely right in saying that more and more diagnostic imaging is the crux of treatment planning, prognosticating and followup for cancer, so it would be silly for radiologists not to know the clinical details of a disease and the ramifications of their staging. I think the system above works great with an IR serving in both the diagnostic and interventional roles seemlessly, and effectively running the MDM show.

 

[shark2000]

The above comment is just simply wrong.

Nop, there are some points you are missing:

1- IO is not the bread and butter of community work. It is a multidisciplinary field needs oncologists, surgeons, radiologists, ... It is mostly limited to big cancer centers and tertiary hospitals.
2- More importantly, what makes you think vascular surgeons will not take over the interventional oncology? At least most of the tumors should first referred to a surgeon and once the surgeon finds it is non-operable it is referred for chemo-embo or Y 90. Half of the cases are referral from surgeons and what makes you think in the future they will not refer it to their other colleagues (vascular surgeons).
And if you think it is tough for a vascular surgeon to learn it, you are naive. It can be learned easily by everybody.
Catheter work, is easy to learn. That is the reason that everybody and their mother is putting stent somewhere in the body. You just can train a technician to do it.