Letter to Medical Students

[radoncradonc]

Dear Medical Students,

As the time to submit your ROL gets closer, I would like to write this letter to help your decision making process. In case you haven't paid attention to the recent discussions on SDN about the future of our specialty, here is a summary of the events that have occurred:

The number of residency positions in rad onc have doubled in the past 10-20 years while the indications for radiation have progressively decreased. We are now treating less DCIS, early stage breast, low risk prostate, lymphoma, pediatric patients, etc. In patients we do treat, we are now using about half the number of fractions due to hypofractionation in breast/prostate or even less fractions in the case of SBRT. The increase in residency slots in rad onc is also out of proportion compared to our other oncology colleagues--medical oncologists now have many more types of immunotherapy that actually increase overall survival but the increase in med onc fellowships have occurred at a much slower rate compared to rad onc. I cannot remember the exact numbers, but they were mentioned in a previous thread and also available from NRMP. It appears from graduating seniors that the job market has gotten a lot tighter, and PGY5s who have geographic restrictions limiting their employment to big cities in the coasts are not finding jobs already.

The situation is only going to get worse. This is because half of the department chairs in the country are planning to expand their residency programs. Half of the chairs also think that fellowship training should be required instead of optional. Please refer to a recently published paper referenced in a previous thread if you doubt these numbers. The irony is that there is not a single ACGME accredited fellowship in the US. Dept chairs essentially want cheap labor when they mention the word "fellowship" as most of what we learn as a fellow probably can be learned independently or through reading journals/textbooks.

There are only 3 ways to save our specialty:

1. Cut the number of residency slots by half. As you can imagine, this is not going to happen because of our dept chairs. However, ABR seems to be doing this already by failing half of the graduating PGY5s this year...very sad way to go about this. Do you really want to enter a specialty where you have a 50% chance of failing your boards after putting in 5 years?

2. Ability to do biopsies. This is the approach favored by Zeitman. To my knowledge, not a single program offers training to do prostate, breast, or lung biopsies. Knowing how to do biopsies would secure a patient referral base.

3. Dual board eligibility in rad onc and med onc. This is the "Clinical Oncologist" model practiced in the UK. Seems to work well for them. It would allow us to tailor our practice in any way we like and give us maximum flexibility for any job market/geography. From what I've heard, the med onc fellows are having a very easy time finding very lucrative jobs now.

The winter for radiation oncology is already here. Whether this winter will turn into an ice age will depend on what department chairs do.

At this moment, I do not recommend medical students enter our specialty. I think medical oncology is a better choice given the recent spectacular advances with immunotherapy and future career outlook.

---

Members don't see this ad.

 

[solitarius]

^ Pretty sure internal medicine will fight you tooth and nail for med onc boarding, and with good reason. Cancer patients are really sick, frequently admitted, and servicing them requires IM training.

 

[Fpg1245]

Dear Medical Students,

As the time to submit your ROL gets closer, I would like to write this letter to help your decision making process. In case you haven't paid attention to the recent discussions on SDN about the future of our specialty, here is a summary of the events that have occurred:

The number of residency positions in rad onc have doubled in the past 10-20 years while the indications for radiation have progressively decreased. We are now treating less DCIS, early stage breast, low risk prostate, lymphoma, pediatric patients, etc. In patients we do treat, we are now using about half the number of fractions due to hypofractionation in breast/prostate or even less fractions in the case of SBRT. The increase in residency slots in rad onc is also out of proportion compared to our other oncology colleagues--medical oncologists now have many more types of immunotherapy that actually increase overall survival but the increase in med onc fellowships have occurred at a much slower rate compared to rad onc. I cannot remember the exact numbers, but they were mentioned in a previous thread and also available from NRMP. It appears from graduating seniors that the job market has gotten a lot tighter, and PGY5s who have geographic restrictions limiting their employment to big cities in the coasts are not finding jobs already.

The situation is only going to get worse. This is because half of the department chairs in the country are planning to expand their residency programs. Half of the chairs also think that fellowship training should be required instead of optional. Please refer to a recently published paper referenced in a previous thread if you doubt these numbers. The irony is that there is not a single ACGME accredited fellowship in the US. Dept chairs essentially want cheap labor when they mention the word "fellowship" as most of what we learn as a fellow probably can be learned independently or through reading journals/textbooks.

There are only 3 ways to save our specialty:

1. Cut the number of residency slots by half. As you can imagine, this is not going to happen because of our dept chairs. However, ABR seems to be doing this already by failing half of the graduating PGY5s this year...very sad way to go about this. Do you really want to enter a specialty where you have a 50% chance of failing your boards after putting in 5 years?

2. Ability to do biopsies. This is the approach favored by Zeitman. To my knowledge, not a single program offers training to do prostate, breast, or lung biopsies. Knowing how to do biopsies would secure a patient referral base.

3. Dual board eligibility in rad onc and med onc. This is the "Clinical Oncologist" model practiced in the UK. Seems to work well for them. It would allow us to tailor our practice in any way we like and give us maximum flexibility for any job market/geography. From what I've heard, the med onc fellows are having a very easy time finding very lucrative jobs now.

The winter for radiation oncology is already here. Whether this winter will turn into an ice age will depend on what department chairs do.

At this moment, I do not recommend medical students enter our specialty. I think medical oncology is a better choice given the recent spectacular advances with immunotherapy and future career outlook.

After a little editing, I think this should be a sticky at the top of the forum with a new title. PLEASE READ BEFORE PROCEDING: A WARNING TO ALL MEDICAL STUDENTS.

Also, maybe the last part where you outline options is a little too much. Just need to make the firm general point to all Studnts that come here.

 

[deleted947887]

https://rohub.astro.org/communities...-10ec-45b6-ad5f-5ff678d86fdd&tab=digestviewer

I'd also add that link to show the sentiment among real leaders in the field (not the bunch of panderers that are scared to say anything on twitter)

After a little editing, I think this should be a sticky at the top of the forum with a new title. PLEASE READ BEFORE PROCEDING: A WARNING TO ALL MEDICAL STUDENTS.

Also, maybe the last part where you outline options is a little too much. Just need to make the firm general point to all Studnts that come here.

 

[Fpg1245]

https://rohub.astro.org/communities/community-home/digestviewer/viewthread?GroupId=1561&MessageKey=458c4ffe-ba2d-4641-b8ea-c957da0752ca&CommunityKey=881f9cc8-10ec-45b6-ad5f-5ff678d86fdd&tab=digestviewer&ReturnUrl=/communities/community-home/digestviewer?communitykey=881f9cc8-10ec-45b6-ad5f-5ff678d86fdd&tab=digestviewer

I'd also add that link to show the sentiment among real leaders in the field (not the bunch of panderers that are scared to say anything on twitter)

Was surprised to see that sentiment among some of the leadership, but alas they wont be doing anything due to concerns about anti-trust lawsuits. The best we can hope for is that next year even less med students decide to pursue rad-onc. I think that is a solid and realistic goal for the people that contribute to this forum to continue letting medical students know in no uncertain terms that this field is a mess and fraught with more risk of unemployment, underemployement, excessive training/retraining, and financial insecurity. Any medical student that rotates in your respective departments and is "thinking of rad onc" especially before the ERAS apps are in should be actively steering them away. Clearly, we are on our own. I leave the attempts at trying to expand rad-oncs relevance to the brilliant and wonderful scholars of academic rad-onc to figure out for themselves but I honestly am not holding my breath.

 

[deleted950463]

Not sure if radonc training without additional diagnostic radiology fellowships of at least 3 years will allow an average radonc to safely perform image guided biopsy.

Both ultrasound and CT guided biopsies require extensive underlying ability of intepreting those imaging modalities. I would argue a practioner who isn’t certified to render final diagnostic read on those modalities shouldn’t do those biopsies.

For example, say you are asked to do a biopsy by a medonc to biopsy a lung nodule, will you be able to recognize an incidental nodal met from an unenhanced CT? How about an request for “biopsying liver mass plz” in a liver with prior ablation, TACEs, and hemangioma/FNHs? Do you suppose you shoold ask the diagnostic rad to mark the spot for you since the average radonc isnt training in diagnostic imaging?

What I mentioned above is simply a small part of the diagnostic aspect for the workflow approach to imagine guided biopsy, never mind the technical considerations.

Biopsy goes far beyond seeing one big blob on imaging and stick a needle into it.

 

[Bequerel]

Not sure if radonc training without additional diagnostic radiology fellowships of at least 3 years will allow an average radonc to safely perform image guided biopsy.

Both ultrasound and CT guided biopsies require extensive underlying ability of intepreting those imaging modalities. I would argue a practioner who isn’t certified to render final diagnostic read on those modalities shouldn’t do those biopsies.

For example, say you are asked to do a biopsy by a medonc to biopsy a lung nodule, will you be able to recognize an incidental nodal met from an unenhanced CT? How about an request for “biopsying liver mass plz” in a liver with prior ablation, TACEs, and hemangioma/FNHs? Do you suppose you shoold ask the diagnostic rad to mark the spot for you since the average radonc isnt training in diagnostic imaging?

What I mentioned above is simply a small part of the diagnostic aspect for the workflow approach to imagine guided biopsy, never mind the technical considerations.

Biopsy goes far beyond seeing one big blob on imaging and stick a needle into it.

I think a 3 year “diagnostic radiology fellowship” is bit ridiculous. I don’t think the PAs in the IR suite who do all my biopsies went through such a fellowship.

 

[deleted950463]

I think a 3 year “diagnostic radiology fellowship” is bit ridiculous. I don’t think the PAs in the IR suite who do all my biopsies went through such a fellowship.

This PA is also persumably supervised by an IR who went through 5 years of DR/IR training and have their even remotely complicated biopsy trajectory confirmed by the said attending.

I was told that the actual act of biopsying is the easiest part of doing the biopsy.

 

[medgator]

Both ultrasound and CT guided biopsies require extensive underlying ability of intepreting those imaging modalities. I would argue a practioner who isn’t certified to render final diagnostic read on those modalities shouldn’t do those biopsies.

For example, say you are asked to do a biopsy by a medonc to biopsy a lung nodule, will you be able to recognize an incidental nodal met from an unenhanced CT? How about an request for “biopsying liver mass plz” in a liver with prior ablation, TACEs, and hemangioma/FNHs? Do you suppose you shoold ask the diagnostic rad to mark the spot for you since the average radonc isnt training in diagnostic imaging?

What I mentioned above is simply a small part of the diagnostic aspect for the workflow approach to imagine guided biopsy, never mind the technical considerations.

Biopsy goes far beyond seeing one big blob on imaging and stick a needle into it.

I think a 2 year fellowship might be enough.... many of us in rad onc are already using TRUS in prostate to place fiducials and spaceOAR.... not a hard jump to do prostate biopsies.

This is of course missing the forest for the trees. RO academic depts are basically in a prisoners' dilemma where no one wants to reduce spots first and together they are driving the specialty off a cliff.

 

[deleted950463]

I think a 2 year fellowship might be enough.... many of us in rad onc are already using TRUS in prostate to place fiducials and spaceOAR.... not a hard jump to do prostate biopsies.

I have no doubt that radoncs would have skillset in prostate and some organs. Lung, liver, and body CT and US guided biopsies need significant diagnostic imaging skills.

In my opinion, if you cannot final read the diagnostic imaging for that organ, you shouldn’t really biopsy that organ because you need to know the specific imaging interpretation for targeting.

Obviously random vs targeted biopsy require very different skill sets.

 

[RickyScott]

https://rohub.astro.org/communities/community-home/digestviewer/viewthread?GroupId=1561&MessageKey=458c4ffe-ba2d-4641-b8ea-c957da0752ca&CommunityKey=881f9cc8-10ec-45b6-ad5f-5ff678d86fdd&tab=digestviewer&ReturnUrl=/communities/community-home/digestviewer?communitykey=881f9cc8-10ec-45b6-ad5f-5ff678d86fdd&tab=digestviewer

I'd also add that link to show the sentiment among real leaders in the field (not the bunch of panderers that are scared to say anything on twitter)

Can you paste the statements for benefit of medstudents and those of us who are not members of ASTRO.

 

[deleted947887]

Can you paste the statements for benefit of medstudents and those of us who are not members of ASTRO.

It's too much to paste. Suffice to say there is a panderer from Fox Chase, while Mendenhall and Lee really live up to their positions as leaders.

 

[Burt Radnolds]

I have resigned myself to the idea that I may be forced to change careers at some point in my lifetime. I figure it's better to acknowledge this now and start scheming backup plans rather than let it hit me like a ton of bricks.

There is a real storm brewing over the specialty that will not clear unless very direct measures are taken, and there is not the slightest suggestion anyone is willing to step up.

If you choose to pursue a career in radiation oncology, you better be comfortable with the idea that you may have to make a hard pivot at some point in your life.

 

[deleted774703]

Most of these ideas presented are not exciting:

1) Biopsies - Seriously? Add more years of training for minimal return. Currently, rates of RP are increasing annually. Moreover, RO doesn't even receive a consult for every prostate cancer case. This is bc of 1) reflex consulting to urology with elevated PSA and 2) lack of awareness of RT among many PCPs. We aren’t going to break this trend by learning how to biopsy. Additionally, we will more likely spark further protectionist practices by urology.

2) Dual boarding is also not possible. You have to finish 3 years of IM and then 2-3 years of Heme Onc (can omit heme portion) before being eligible for Med Onc boards. Again impractical and extending our training

3) No good solutions for job market problem
-Unfortunately nobody is addressing oversupply
-With overall numbers of med students applying decreasing, how many unfilled spots will there be?
-Million dollar ? = will programs leave their spots unfilled for the greater good or choose candidates from SOAP who don’t care about RO just for free labor?

 

[deleted941485]

Most of these ideas presented are not exciting:

1) Biopsies - Seriously? Add more years of training for minimal return. Currently, rates of RP are increasing annually. Moreover, RO doesn't even receive a consult for every prostate cancer case. This is bc of 1) reflex consulting to urology with elevated PSA and 2) lack of awareness of RT among many PCPs. We aren’t going to break this trend by learning how to biopsy. Additionally, we will more likely spark further protectionist practices by urology.

2) Dual boarding is also not possible. You have to finish 3 years of IM and then 2-3 years of Heme Onc (can omit heme portion) before being eligible for Med Onc boards. Again impractical and extending our training

3) No good solutions for job market problem
-Unfortunately nobody is addressing oversupply
-With overall numbers of med students applying decreasing, how many unfilled spots will there be?
-Million dollar ? = will programs leave their spots unfilled for the greater good or choose candidates from SOAP who don’t care about RO just for free labor?

RO will become a new way for IMGs and International attendings to get into the US without the drudgery of Internal med. New and old RO programs alike with fill with SOAP candidates because they are desperate now. They are addicted to cheap labor. Subpar candidates are already making their way up the rad onc food chain and will eventually hit the hallowed institutions (Joint Center, MDACC). I have friends at mid-tier and upper tier programs that have been taken aback by the precipitous drop in academic performance and quality of their candidates but at the end of the day they NEED to match somebody because the services cannot function without them. I'm also hearing that there are some non-US RO attendings in the candidate pool this year. No doubt PDs would LOVE such a candidate as they essentially have an indentured servant do all their work while the supervising attending signs off and bills.

 

[Fpg1245]

Most of these ideas presented are not exciting:

1) Biopsies - Seriously? Add more years of training for minimal return. Currently, rates of RP are increasing annually. Moreover, RO doesn't even receive a consult for every prostate cancer case. This is bc of 1) reflex consulting to urology with elevated PSA and 2) lack of awareness of RT among many PCPs. We aren’t going to break this trend by learning how to biopsy. Additionally, we will more likely spark further protectionist practices by urology.

2) Dual boarding is also not possible. You have to finish 3 years of IM and then 2-3 years of Heme Onc (can omit heme portion) before being eligible for Med Onc boards. Again impractical and extending our training

3) No good solutions for job market problem
-Unfortunately nobody is addressing oversupply
-With overall numbers of med students applying decreasing, how many unfilled spots will there be?
-Million dollar ? = will programs leave their spots unfilled for the greater good or choose candidates from SOAP who don’t care about RO just for free labor?

Biopsies will save us! . The only way we will be doing them is if we literally just tell the uros and the IR people to F off. I’ll just pencil that in under stuff that won’t happen. Good luck with those referrals. It seems that in addition to being tone deaf on the job market we have also forgotten that we are not in control of the patient either. Honestly the more I think about it, the more depressing it is. Literally painted into a corner with like only one skill. Only a matter of time before residents and med students start to wake up to these facts.

 

[w00tz]

Dear Medical Students,

As the time to submit your ROL gets closer, I would like to write this letter to help your decision making process. In case you haven't paid attention to the recent discussions on SDN about the future of our specialty, here is a summary of the events that have occurred:

The number of residency positions in rad onc have doubled in the past 10-20 years while the indications for radiation have progressively decreased. We are now treating less DCIS, early stage breast, low risk prostate, lymphoma, pediatric patients, etc. In patients we do treat, we are now using about half the number of fractions due to hypofractionation in breast/prostate or even less fractions in the case of SBRT. The increase in residency slots in rad onc is also out of proportion compared to our other oncology colleagues--medical oncologists now have many more types of immunotherapy that actually increase overall survival but the increase in med onc fellowships have occurred at a much slower rate compared to rad onc. I cannot remember the exact numbers, but they were mentioned in a previous thread and also available from NRMP. It appears from graduating seniors that the job market has gotten a lot tighter, and PGY5s who have geographic restrictions limiting their employment to big cities in the coasts are not finding jobs already.

The situation is only going to get worse. This is because half of the department chairs in the country are planning to expand their residency programs. Half of the chairs also think that fellowship training should be required instead of optional. Please refer to a recently published paper referenced in a previous thread if you doubt these numbers. The irony is that there is not a single ACGME accredited fellowship in the US. Dept chairs essentially want cheap labor when they mention the word "fellowship" as most of what we learn as a fellow probably can be learned independently or through reading journals/textbooks.

There are only 3 ways to save our specialty:

1. Cut the number of residency slots by half. As you can imagine, this is not going to happen because of our dept chairs. However, ABR seems to be doing this already by failing half of the graduating PGY5s this year...very sad way to go about this. Do you really want to enter a specialty where you have a 50% chance of failing your boards after putting in 5 years?

2. Ability to do biopsies. This is the approach favored by Zeitman. To my knowledge, not a single program offers training to do prostate, breast, or lung biopsies. Knowing how to do biopsies would secure a patient referral base.

3. Dual board eligibility in rad onc and med onc. This is the "Clinical Oncologist" model practiced in the UK. Seems to work well for them. It would allow us to tailor our practice in any way we like and give us maximum flexibility for any job market/geography. From what I've heard, the med onc fellows are having a very easy time finding very lucrative jobs now.

The winter for radiation oncology is already here. Whether this winter will turn into an ice age will depend on what department chairs do.

At this moment, I do not recommend medical students enter our specialty. I think medical oncology is a better choice given the recent spectacular advances with immunotherapy and future career outlook.

Dear Medical Students,
.....
Sincerely,
- MS4 currently applying?

 

[Dare2Dream]

Currently, rates of RP are increasing annually. Moreover, RO doesn't even receive a consult for every prostate cancer case. This is bc of 1) reflex consulting to urology with elevated PSA and 2) lack of awareness of RT among many PCPs. We aren’t going to break this trend by learning how to biopsy. Additionally, we will more likely spark further protectionist practices by urology.

Anyone know if there has been a concerted effort to reach out to Family Meds/PCPs on a regular/annual basis at both their national and local conferences? I feel like they would welcome Oncologists (RO are the front line Oncologists for Prostate Ca) presenting to them on the screening/management options for prostate cancer at their annual meetings. Doing so will certainly help increase the consultation rate for these cases.

 

[Gfunk6]

Radiation Oncology residencies will always have warm bodies: yours (American Medical Grads) or theirs (International Medical Grads).

As noted in the ASTRO Hub discussion, the number of available residency slots < the number of AMGs applying to fill them. All that will happen is that we will have more IMGS fill Rad Onc residencies which will not solve the problem. See Pathology and Nuclear Medicine.

 

[deleted774703]

Radiation Oncology residencies will always have warm bodies: yours (American Medical Grads) or theirs (International Medical Grads).

As noted in the ASTRO Hub discussion, the number of available residency slots < the number of AMGs applying to fill them. All that will happen is that we will have more IMGS fill Rad Onc residencies which will not solve the problem. See Pathology and Nuclear Medicine.

Yes but it will openly prove that programs themselves are a serious part of the problem with only wanting cheap labor, not education.

That is only way for change to happen. Otherwise, they hide behind “SDN heresay”

 

[deleted774703]

Anyone know if there has been a concerted effort to reach out to Family Meds/PCPs on a regular/annual basis at both their national and local conferences? I feel like they would welcome Oncologists (RO are the front line Oncologists for Prostate Ca) presenting to them on the screening/management options for prostate cancer at their annual meetings. Doing so will certainly help increase the consultation rate for these cases.

Not that I’m aware of. There is an ASTRO academy lecture available for home viewing for PCPs.

As if PCP have nothing to do in life but watch 40 min PPT on this random general topic

 

[Palex80]

The British model of Clinical Oncologists is interesting, however there is also a "middle way" as well.
In Germany, radiation oncologists give chemotherapy/antibodies/ADT only when they also irradiate.

From what I have been told, the clinical oncologists in the UK will give systemic treatment to any patient, irrelevant whether or not this patient gets radiation. They are pretty much all-rounders in terms of oncological treatments and will only call the medical oncologists/hematologists to take over, when a case becomes very complex or intensive treatment is necessary.

In Germany the radiation oncologists will give chemo ONLY together with radiation (platinum/cetuximab for H&N, platinum for cervix, temozolomide for brain tumors and so on). They will not give all the chemo that is being given around radiation (for example they will not give the 3 months FOLFOX for a rectal cancer case, but they will give the 5FU that is given simultaneously with the radiation). I have also seen some that will back off and let the med oncs handle chemo, when the intensity of chemo gets heavy, for example they wont do platinum doublets for NSCLC alone, but will let the med onc handle that.

I think this is a possible middle way, that could be easier to follow than the British model. One can very well argue that the systemic therapy should stay in the hands of the radiation oncologists when giving RT, since only she/he can actually judge how intense systemic treatment should be based on the toxicity of the prescribed radiation therapy and what possible side effects may emerge or potentiate by combining both modalities.

 

[medgator]

One can very well argue that the systemic therapy should stay in the hands of the radiation oncologists when giving RT, since only she/he can actually judge how intense systemic treatment should be based on the toxicity of the prescribed radiation therapy and what possible side effects may emerge or potentiate by combining both modalities.

How much chemo training do you get in residency/post med school training?

 

[scarbrtj]

Honestly the more I think about it, the more depressing it is. Literally painted into a corner with like only one skill.

They say, "The main thing is to keep the main thing the main thing."
Rad oncs do have one skill.
If you have one needed skill, and there are few of you that do: good. You probably do not need new skills.
If you have one needed skill, and there are many of you that do: bad. You probably need new skills.
Like the T. Rex... great big mouth, itty-bitty arms... radiation oncologists: great big board scores, itty-bitty vision.

 

[KHE88]

radiation oncologists: great big board scores, itty-bitty vision.

Itty bitty vision? And you're not even talking about site-specific rad oncs.

Maybe I'm just missing something but I wasn't too thrilled about the idea of having a 2-part job where one part involved a single treatment on a single site and the other part involved researching how to eliminate that treatment. Once you finish that second part, your two part job becomes a no part job. Researching ways to minimize unnecessary treatment is well and good, but shouldn't you also at the same time be researching ways to offer another needed service to make up for the one you are making redundant? The whole "let me learn how to do as many things as possible" made a lot more sense to me. Whatever.

 

[Neuronix]

1) Biopsies - Seriously? Add more years of training for minimal return. Currently, rates of RP are increasing annually. Moreover, RO doesn't even receive a consult for every prostate cancer case. This is bc of 1) reflex consulting to urology with elevated PSA and 2) lack of awareness of RT among many PCPs. We aren’t going to break this trend by learning how to biopsy. Additionally, we will more likely spark further protectionist practices by urology.

I trained in how to perform prostate biopsies twice. During my training I spent several months with a urology group who taught me how to do prostate biopsies and cystoscopies. Also, I spent some training with a brachytherapy trained radiation oncologist who did prostate biopsies.

So why don't I recommend this?

Well, the radiation oncologist who did biopsies drew a few of his own referrals for suspected prostate cancer. He would also biopsy suspected recurrences. His referring and associated urology groups were furious when they found out. This created a huge political backlash within the cancer center, and he was essentially forced to stop doing them. Rad onc can't bite the hand that feeds its referrals. Unfortunately, that makes us beholden to those same hands.

 

[nkmiami]

The British model of Clinical Oncologists is interesting, however there is also a "middle way" as well.
In Germany, radiation oncologists give chemotherapy/antibodies/ADT only when they also irradiate.

From what I have been told, the clinical oncologists in the UK will give systemic treatment to any patient, irrelevant whether or not this patient gets radiation. They are pretty much all-rounders in terms of oncological treatments and will only call the medical oncologists/hematologists to take over, when a case becomes very complex or intensive treatment is necessary.

In Germany the radiation oncologists will give chemo ONLY together with radiation (platinum/cetuximab for H&N, platinum for cervix, temozolomide for brain tumors and so on). They will not give all the chemo that is being given around radiation (for example they will not give the 3 months FOLFOX for a rectal cancer case, but they will give the 5FU that is given simultaneously with the radiation). I have also seen some that will back off and let the med oncs handle chemo, when the intensity of chemo gets heavy, for example they wont do platinum doublets for NSCLC alone, but will let the med onc handle that.

I think this is a possible middle way, that could be easier to follow than the British model. One can very well argue that the systemic therapy should stay in the hands of the radiation oncologists when giving RT, since only she/he can actually judge how intense systemic treatment should be based on the toxicity of the prescribed radiation therapy and what possible side effects may emerge or potentiate by combining both modalities.

In the US, neuro oncologists, and gyn oncs, give their own chemo. They did not need permission for board of internal medicine to do this.

 

[medgator]

I trained in how to perform prostate biopsies twice. During my training I spent several months with a urology group who taught me how to do prostate biopsies and cystoscopies. Also, I spent some training with a brachytherapy trained radiation oncologist who did prostate biopsies.

So why don't I recommend this?

Well, the radiation oncologist who did biopsies drew a few of his own referrals for suspected prostate cancer. He would also biopsy suspected recurrences. His referring and associated urology groups were furious when they found out. This created a huge political backlash within the cancer center, and he was essentially forced to stop doing them. Rad onc can't bite the hand that feeds its referrals. Unfortunately, that makes us beholden to those same hands.

Same rationale as to why I asked every GU that referred to me whether they wanted to do spaceOAR or whether they were OK if I did.... Came out to about half.

Most GUs don't seem interested in giving hormones these days either

 

[deleted18755]

I trained in how to perform prostate biopsies twice. During my training I spent several months with a urology group who taught me how to do prostate biopsies and cystoscopies. Also, I spent some training with a brachytherapy trained radiation oncologist who did prostate biopsies.

So why don't I recommend this?

Well, the radiation oncologist who did biopsies drew a few of his own referrals for suspected prostate cancer. He would also biopsy suspected recurrences. His referring and associated urology groups were furious when they found out. This created a huge political backlash within the cancer center, and he was essentially forced to stop doing them. Rad onc can't bite the hand that feeds its referrals. Unfortunately, that makes us beholden to those same hands.

Similarly, even if a radiation oncologist, even after additional training and a "fellowship" (other than an actual medical oncology fellowship), could convince the medical community that he can administer systemic agents (anybody can order and hang an IV I'm talking about managing the all acute and late toxicities too) good luck with the politics of it!

I think we would be better off trying to think of ways to use our unique skill set and knowledge base to expand our practice rather than trying to break into existing territories, scopes of practice, or whatever that have been defined for decades and for which we would be inferior or at best equal for simple/straightforward cases . . . unfortunately I can't think of any that would have a significant impact.

 

[Mandelin Rain]

Meh, concurrent patients see me roughly 10x the amount they see the med onc. I manage almost all the acute toxicity. I send them with cytopenias so appropriate dose adjustment can be made, but that's about it. I would feel good with probably 75-80% of concurrent treatment with a 2 week course on renal dosing and dose reductions based on cytopenias.

At least 90% of it is covered by...
Cisplatin (weekly or q3)
Carbo/Taxol
Erbitux
Temodar
Cis/VP16
5FU or Xeloda

It's not like we'd be giving ICE or high dose MTX or IL2.

 

[nkmiami]

Meh, concurrent patients see me roughly 10x the amount they see the med onc. I manage almost all the acute toxicity. I send them with cytopenias so appropriate dose adjustment can be made, but that's about it. I would feel good with probably 75-80% of concurrent treatment with a 2 week course on renal dosing and dose reductions based on cytopenias.

At least 90% of it is covered by...
Cisplatin (weekly or q3)
Carbo/Taxol
Erbitux
Temodar
Cis/VP16
5FU or Xeloda

It's not like we'd be giving ICE or high dose MTX or IL2.

Also, most medoncs I practice with are vert busy w/ 30-40 pts/day and hard to get appointments with them.

 

[deleted18755]

Also, most medoncs I practice with are vert busy w/ 30-40 pts/day and hard to get appointments with them.

Meh, concurrent patients see me roughly 10x the amount they see the med onc. I manage almost all the acute toxicity. I send them with cytopenias so appropriate dose adjustment can be made, but that's about it. I would feel good with probably 75-80% of concurrent treatment with a 2 week course on renal dosing and dose reductions based on cytopenias.

At least 90% of it is covered by...
Cisplatin (weekly or q3)
Carbo/Taxol
Erbitux
Temodar
Cis/VP16
5FU or Xeloda

It's not like we'd be giving ICE or high dose MTX or IL2.

That’s very interesting since it’s so different in my neck of the woods ... I wonder how much variability there is among regions or even practices.

I also wonder if one of those guys who is super busy and doesn’t have an appointment for days would ironically enough get angry if you stepped on “his turf”

 

[medgator]

Also, most medoncs I practice with are vert busy w/ 30-40 pts/day and hard to get appointments with them.

Market dependent. Ours wouldn't take kindly to me giving chemo and there is some decent cross referral that I make back to them for sensitizing concurrent tx

 

[radiaterMike]

FWIW for radiation oncologists to give chemo would require an overhaul of the way things are done with respect to training and credntialing. Most (all?) hospitals would not credential you for chemotherapy administration if you are not trained in med onc, gyn onc or neuro-onc, health insurers would not pay if you were not board eligible or certified in those specialties nor would malpractice insurance cover you. Of course one could hang a shingle and get self-pay patients who (hopefully) don't sue- as seems to be the model these days for non board certified plastic surgeons (google 'dancing doctor').

 

[medgator]

Regardless of the discussion as to whether we should administer concurrent systemic tx, we need to fix the underlying issue of oversupply, something acknowledged by multiple academicians over on the ASTRO forum thread.

Giving concurrent therapy, while worthy of discussion and further exploration, won't save us from the damage of doubling residency slots since 2000 and creating questionable and exploitative non - accredited fellowships

 

[scarbrtj]

questionable and exploitative non - accredited fellowships

"Back in the day" (ie around 2000) there was one rad onc fellowship I knew of in the U.S. There were probably more, but I just knew of one: Mayo Clinic, Jacksonville, FL. They did not have a residency program (of course the Mayo mothership up north did). They offered the fellowship to residents who had completed their residency but had failed boards and were at-risk. It was kind of a rad onc rehab program. It didn't have a bad reputation per se and the general feeling was it was nice that there was that rehab option for folks... as allegedly "rad onc boards [were] some of the most difficult in medicine to pass." Since that time, of course, they've gotten a residency program (and dropped the fellowship). Fast forward to now, and, as they say, that escalated really quickly.

 

[Palex80]

How much chemo training do you get in residency/post med school training?

You have to treat a minimum of 300 patients with a minimum of 500 cycles of chemotherapy, that's what the logbook says. Plus you need to train in supportive treatment (transfusions, 50 patients with iv feeding, etc). That's what the logbook says at least...

In the US, neuro oncologists, and gyn oncs, give their own chemo. They did not need permission for board of internal medicine to do this.

In many parts of Europe this is also the case. Pretty much everywhere gynecologists give chemo to all their patients. In fact I have met several med oncs who have no idea how to treat ovarian cancer, since they never get to see a patient.

On the other hand, gynecologists have also done stuff in the past that other specialties do nowadays. 100 years ago it was quite custom for gynecologists to deliver brachytherapy alone...

In many parts of Europe chemotherapy for lung cancer resides in the hands of pulmonologists and hepatologists treat hepatocellular cancer, no med oncs. Urologists are giving more and more extended ADT now (Enzalutamide, Abiraterone) and some are starting to give chemo too (the Docetaxel 50 mg q2 - regiment is quite easy to handle). However all these specialities feature a formal training within their residency programmes in delivering systemic treatment. And for the specialists who didn't get the chance to learn that, there are extra classes they can attend (like a mini-fellowship).


Giving chemotherapy is not that hard, at least not if you stay in the "low-range" in terms of intensity.


Platin doublets in NSCLC/SCLC can be challenging, but in the US the CarboTaxol regime is very popular (from what I have heard), which is really easy to handle (plus many of us are familiar with from esophageal cancer - CROSS-style). Weekly 40 mg cisplatin for H&N is quite popular in some parts of Europe, which is my opinion easier to handle than 100 mg q3 and which "we" are familiar with based on cervical cancer Tx too. I still don't like it für H&N, cause I feel it's inferior to 100 mg q3, but that's an other story.

To be provocative: if you can teach a radiation oncologist to treat with 10 difference chemotherapy regimes, you can pretty much cover 90% of what is given together with RT nowadays... Wouldn't that be nice?

 

[Mandelin Rain]

We already know the concurrent regimens, indications, dosages, and how to deal with the typical acute toxicity. Increased complexity arises in the case of unexpected/severe toxicity (potentially requiring hospitalization, which admittedly would be strange), or comorbid illness that requires attention. If you kept the scope of treatments administered narrow, I can't imaging it'd take too much longer to nail down some management specific training.

Even if you get boarded to administer only 5FU, Cisplatin, Carbo/Taxol, and Erbitux... you're probably capturing 75% of concurrent patients.

There would be political ramifications, however. I completely understand this. Many of the cases would be referred eventually. Rectals need FOLFOX. Lungs need durvalumab. People recur. Etc...

 

[deleted950463]

We already know the concurrent regimens, indications, dosages, and how to deal with the typical acute toxicity. Increased complexity arises in the case of unexpected/severe toxicity (potentially requiring hospitalization, which admittedly would be strange), or comorbid illness that requires attention. If you kept the scope of treatments administered narrow, I can't imaging it'd take too much longer to nail down some management specific training.

Even if you get boarded to administer only 5FU, Cisplatin, Carbo/Taxol, and Erbitux... you're probably capturing 75% of concurrent patients.

There would be political ramifications, however. I completely understand this. Many of the cases would be referred eventually. Rectals need FOLFOX. Lungs need durvalumab. People recur. Etc...

What if medonc make the argument for learning IMRT or radiation therapy?

 

[RickyScott]

What if medonc make the argument for learning IMRT or radiation therapy?

Most are too busy. Most try to get out of heme (the other part of their own name), but yes they could learn most of our field in 1-2 year fellowship.
edit (I am sure if radoncs wanted to take over benign heme, they would be our biggest cheerleaders)

 

[Mandelin Rain]

Most are too busy. Most try to get out of heme (the other part of their own name), but yes they could learn most of our field in 1-2 year fellowship.

Pretty much this. The heme oncs I know, don't want to be saddled with anything else. They cringe at benign heme. Many are using hospitalists extensively. I manage most of the palliative care aspects. Can't imagine they'd be super excited about spending hours contouring/reviewing plans/con beams/etc... before rounding.

And yes. Rad onc wouldn't be difficult to pick up in a couple years for someone with an oncology background. But I feel that there is a slightly higher technical skill set required for even straight forward external beam planning than there is for clicking a few buttons in an EMR to get a standardized therapy plan together. Certainly, their anatomy and cross sectional imaging training would need a bit of work.

 

[RickyScott]

Pretty much this. The heme oncs I know, don't want to be saddled with anything else. They cringe at benign heme. Many are using hospitalists extensively. I manage most of the palliative care aspects. Can't imagine they'd be super excited about spending hours contouring/reviewing plans/con beams/etc... before rounding.

And yes. Rad onc wouldn't be difficult to pick up in a couple years for someone with an oncology background. But I feel that there is a slightly higher technical skill set required for even straight forward external beam planning than there is for clicking a few buttons in an EMR to get a standardized therapy plan together. Certainly, their anatomy and cross sectional imaging training would need a bit of work.

Totally agree, It depends on the heme-onc. Those that actually pull up scans and look at them would have a much easier time as opposed to those who just read the reports.

 

[medgator]

What if medonc make the argument for learning IMRT or radiation therapy?

To be fair, that would take them a lot longer to learn than the converse.

Most med oncs in my group read reports not scans. Some of them can't even stage a lung or h&n without running it by me first.

We already get tested on chemo quite a bit on the boards

 

[Mandelin Rain]

To be fair, that would take them a lot longer to learn than the converse.

Most med oncs in my group read reports not scans. Some of them can't even stage a lung or h&n without running it by me first.

We already get tested on chemo quite a bit on the boards

Yeah. I wouldn't advocate for radonc replacing med onc. Just a narrow focus of common concurrent regimens that we already know, are tested on, can recite the data for, and manage patients with. This wouldn't be learning the whole of a different oncologic discipline.

 

[RSAOaky]

To be fair, that would take them a lot longer to learn than the converse.

Most med oncs in my group read reports not scans. Some of them can't even stage a lung or h&n without running it by me first.

We already get tested on chemo quite a bit on the boards

Just tell them they'll need to take 4 additional board exams, 2 of which have a 75% pass rate, 1 of which focuses on arbitrary and irrelevant minutiae of clinical practice, and just as they're finally settling into their 8th choice job in sunny rural Mississippi they'll need to spend the next 4 months lubing up for their final hazing ritual in beautiful Tucson Arizona.

I'm not concerned about medoncs wanting to become radoncs.

 

[medgator]

I'm not concerned about medoncs wanting to become radoncs.

How much can change in a decade ...

 

[deleted18755]

How much can change in a decade ...

That's probably true for everything these days but so, so true for a field like ours that is not only limited in size but also scope (and referral based as well!).

I'm not even mid-career but have seen radiation oncology swing from largely foreign graduates to the absolute top of the best medical schools in the country with people making seven figures if they really want to or $500,000+ working 4 day weeks with 8-10 weeks vacation to headed back the other way AND can't believe I've also seen it go from a lifestyle specialty that medical students flock to specifically because we don't have inpatient responsibilities/round to people wondering how we can give chemotherapy and do biopsies!!!

 

[xyz01]

I'm also working in an european rad onc department where concommitant chemotherapy is given by radiation oncologists; sometimes we even do induction chemotherapy before rctx ; thou it feels like more and more deparments hire medical oncologist to do the chemo stuff or have a radiation oncologist who does morstly chemo managment and not much radiation treatment...
I also don't see who this would help the specialty that much as we are still dependent on reverals or tumor board decisions, and if the need for radiation treatments decrease we can't just go over to the med onc department and start giving chemo there....

 

[Palex80]

I'm also working in an european rad onc department where concommitant chemotherapy is given by radiation oncologists; sometimes we even do induction chemotherapy before rctx ; thou it feels like more and more deparments hire medical oncologist to do the chemo stuff or have a radiation oncologist who does morstly chemo managment and not much radiation treatment...
I also don't see who this would help the specialty that much as we are still dependent on reverals or tumor board decisions, and if the need for radiation treatments decrease we can't just go over to the med onc department and start giving chemo there....

It does however increase our visibility as a speciality among others. Our understanding of systemic treatment also requires and implies understanding of the biology as well. I have the feeling that med oncs are gaining more and more visibility in the past decade, because of new treatments becoming available which only they can give.

 

[medgator]

That's probably true for everything these days but so, so true for a field like ours that is not only limited in size but also scope (and referral based as well!).

I'm not even mid-career but have seen radiation oncology swing from largely foreign graduates to the absolute top of the best medical schools in the country with people making seven figures if they really want to or $500,000+ working 4 day weeks with 8-10 weeks vacation to headed back the other way AND can't believe I've also seen it go from a lifestyle specialty that medical students flock to specifically because we don't have inpatient responsibilities/round to people wondering how we can give chemotherapy and do biopsies!!!

It's a (preventable) tragedy that I hold the academic leadership of our field completely responsible for.

Not to mention unnecessarily sinking societal resources into training too many ROs while there is more of a need in primary care, urology etc