M3 considering rad onc....

[ramses99]

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

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[deleted956486]

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?


Yes, you can match top 3. If i had to bet, market will not rebound for 20 years. Why? Read scarbj's posts for detailed analysis, but the short end is rad onc is being used less (so less ROs needed) and we are seeing more trainees. Also, leadership is not making any policy changes to address oversupply (what happened to pathology and nucleae med will happen to RO in my view).



2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?


No one, i mean no one can predict the future. But I will tell you where rad onc sux. We only treat one way and one thing. HOs can do IM for RVUs if clinic is slow (i know one who did tjis in the early 2000s when he was starting). My opinion is HO is much safer than RO because you get to do more. Even if immuno tanks, you can fallback on IM.

3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?

HO. Or just IM and be done in 2 years. More to life than chasing a career. Work, invest, retire at 40. Travel the world. So in short HO or IM.

4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Oligomets is still a phase II, 40 patient study. If you listen to the ASTRO debate this year, you'll see that its a lot of hyperbole. In fact, even the prostate stuff is based on subset data, which you really shouldn't do, but most people feel that it prolly doesnt hurt so, why not? Are we making people live longer by trx oligo mets with RT? There is no level 1 evidence for that-only weak (as in p=0.09) phase II data (20% of P1 and P2 studies make it to P3) and a subset analysis of a RCT. So do i think we are really making people live longer? I doubt it, but we probably aren't hurting them with a maximum of 20 minutes of treatment to limited sites, so why not? Let MSK and WashU make some $.

 

[elementaryschooleconomics]

You would probably have a shot at a Top 3.

The rest of your questions will essentially lead us to topics which we endlessly debate because the future is so uncertain.

Honestly, if I had to do it again, I would probably do Internal Medicine and consider Heme Onc. Even though Heme Onc seems to be on a decent trajectory now (compensation, job availability, etc) there's a non-zero chance CMS decides to slash reimbursement across the board for IO drugs, or gives mid-levels free reign to administer chemo without physician supervision, etc.

BUT, if you do Internal Medicine, you won't have to completely retrain if the bottom drops out of Oncology. You could stay in IM. You could do a Fellowship in one of 30 other specialties. It's a "safer" choice, stability-wise, with some obvious trade-off in terms of hours and compensation (though, if I can't get a job in RadOnc, a $200k/year job as a hospitalist would look mighty fine).

 

[scarbrtj]

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

I'm prob not telling you anything you don't know, but the rad onc/med onc comparison has always been difficult to make. Two such vastly different fields and pathways etc. But on the other hand, there are really only the two major oncology specialties. They do share that. So if you're "in to" cancer, it's got that appeal. Any individual med onc has a wider variety of cancer patients to see and treat too, as they on the whole treat a larger fraction of the nation's ~1.8 million cancer pts/year than the rad oncs do. And of course they keep on seeing these patients over time more than the rad oncs do, especially factoring in chronic long-term care. But anyway, do a med onc rotation. Only way you'll know if it's for you. (And here's what a semi-famous med onc thinks about the "emerging oligomet paradigm," a paradigm that is inchoate in the extreme... despite what we think... until med oncs also think it's a "paradigm.")

And an "off ramp"? Keeping in line with what our esteemed elders have already mentioned...
Y90 Embolization of Liver Cancer at Henry Ford Hospital
"One of the biggest growth areas in interventional radiology has been a subspecialty called interventional oncology; that's minimally invasive treatment of cancers that can be anywhere in the body."

 

[Ray D. Ayshun]

I don't disagree that the market's not great, but it has nothing to do with treating with one modality. It seems to work for surgeons.

 

[deleted956486]

I don't disagree that the market's not great, but it has nothing to do with treating with one modality. It seems to work for surgeons.

Works great when the market is great. Specializing not a good idea when the market is tight.

 

[RadRadRad]

GI, Derm, hemeonc, Interventional rads, plastics, neurosurg, ortho.

I think all of the above would be more stable fields than radonc in the near future (ie by the time you are done with training). This is intentionally a broad list. Hopefully you can find something in here that interests you. If not, radonc is a great field from a patient interaction and tech standpoint. Just have to know going into it that job market could be tight.

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

 

[Haybrant]

For someone super competitive im not sure why you would want to risk it. It feels nice and prestigious to get into a big 3 but even for their grads the prospects are way way less than other great fields in medicine. So why risk it, just not sure

 

[deleted774703]

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

Would only recommend doing radonc if you REALLY love it and can’t see yourself doing anything else

My experience is going through RO residency honestly sucks. Our job description is not intense at all, and actually quite fun! Yet academic attendings like to be overly intense and quiz you on minutia of DFS down to .x%. When me and my coresidents miss, they make it seem like the end of the world and we are dumb for not knowing. Those are the better teachers. The alternative is most don’t teach shiz

Ok so you hang in there for 2 years. Now it’s time to study for physics and rad bio boards. Guess what, vast majority of ppl can be excellent physicians without knowing a single phase in cell cycle.

alright finally in year 4. Time to study for clinical boards. I’m not even going to discuss the jobs fiasco

1 year out while living in Montana, you get the pleasure of studying for oral boards.

great you passed! You’re now BC. 6 years of your life are gone and you’re practicing in a rural town (not for me!). Then your hospital realizes they only need someone there 1 day per week thx to HOPPS....

So in summary, I love the patient care and overall potential fun of being a rad Onc. I hate going through residency (could just be my exp). I hate hate the unnecessary boards. Hate hate hate the job prospects (location and/or money).

Realized too late that I prefer flexibility even more so than money so I would do IM and stop. Could practice anywhere in the US whenever I want. Could even go overseas to cool country (New Zealand hello!) temporarily

 

[deleted956486]

Would only recommend doing radonc if you REALLY love it and can’t see yourself doing anything else

Going through residency honestly sucks. Our job description is not intense at all, yet academic attendings like to get all intense and quiz you on minutia of DFS down to .x%. Those are the better teachers. The alternative is most don’t teach shiz

Ok so you hang in there for 2 years. Now it’s time to study for physics and rad bio boards. Guess what, vast majority of ppl can be excellent physicians without knowing a single phase in cell cycle.

alright finally in year 4. Time to study for clinical boards. I’m not even going to discuss the jobs fiasco

1 year out while living in Montana, you get the pleasure of studying for oral boards.

great you passed! You’re now BC. 6 years of your life are gone and you’re practicing in a rural town (not for me!). Then your hospital realizes they only need someone there 1 day per week thx to HOPPS....

This post.

 

[fiji128]

I'm three years out from residency. I would tell my MS 3 not to pursue rad onc. I make good money now but you are just so limited in the opportunities you can pursue and nothing out there suggest this issue will be getting any better in the foreseeable future.

I probably would've pursued something in the surgical specialties like ENT or IM to HO if I could do it over again.

 

[RickyScott]

Just want to clear up a myth about this field. 10 years ago, there were jobs in all major metros (not always good ones)but you get something/a bit exploitative in la and nyc if you had to be there. Grads from top 3 most commonly would match in high end pp commmunity settibg in nyc,la, sf, Boston , dc etc with a small minority going academic, and no one taking academic satellites, and occasional a to a2nd/3rdtier city for a very high salary

 

[20181121]

I strongly disagree with what others have posted!

- Your step 1 score is good and it definitely helps that you are coming from a top medical school. These things will get you interviews at top 10 residencies, but where you ultimately land will depend more on the other aspects of your application (grades, letters, extracurriculars, research, etc.) and your interpersonal skills. Put another way, Radiation Oncology residencies across the spectrum, not just top 10, have medical students from top schools with high board scores. I suspect this is also true in other fields, but my firsthand knowledge is only for radiation oncology at my institution (a top program). I say this as a resident who reviews medical student applications for our residency program.
- I am VERY glad I went into Radiation Oncology.
- At a minimum, radiation achieves local control. That means that for many localized cancers, radiation is the curative modality. In others, surgery is the curative modality. Other nonmetastatic cancers require some combination of surgery, radiation, and/or chemotherapy to achieve cure. And like you said, we are seeing a lot more aggressive treatment of metastatic disease with radiation now. But with a very small number of exceptions, solid tumors require surgery or radiation for cure, and systemic therapy sometimes helps them work better.

I would recommend talking with the residents and faculty at your institution and other institutions you have connections with to get their insights!

 

[Mandelin Rain]

Radiation is a great field with a big math problem. Run it through the old brain machine and see what comes out.

 

[RickyScott]

I strongly disagree with what others have posted!

- Your step 1 score is good and it definitely helps that you are coming from a top medical school. These things will get you interviews at top 10 residencies, but where you ultimately land will depend more on the other aspects of your application (grades, letters, extracurriculars, research, etc.) and your interpersonal skills. Put another way, Radiation Oncology residencies across the spectrum, not just top 10, have medical students from top schools with high board scores. I suspect this is also true in other fields, but my firsthand knowledge is only for radiation oncology at my institution (a top program). I say this as a resident who reviews medical student applications for our residency program.
- I am VERY glad I went into Radiation Oncology.
- At a minimum, radiation achieves local control. That means that for many localized cancers, radiation is the curative modality. In others, surgery is the curative modality. Other nonmetastatic cancers require some combination of surgery, radiation, and/or chemotherapy to achieve cure. And like you said, we are seeing a lot more aggressive treatment of metastatic disease with radiation now. But with a very small number of exceptions, solid tumors require surgery or radiation for cure, and systemic therapy sometimes helps them work better.

I would recommend talking with the residents and faculty at your institution and other institutions you have connections with to get their insights!

Agree that practice and role of radiation are amazing and thankful and blessed to be in this profession just as pro athletes are to be in theirs.
Completely disagree with prospects for match here in big 3. Prestige taking nose dive.
It’s not about matching with homecoming queen/cheerleader anymore- these programs are more like a morbidly obese strumpet with drug resistant syphilis: selectivity is out the window.

 

[deleted18755]

H/O attendings have very nice schedules at every institution I have rotated. The fellowship generally includes 1-2 year of research. You work hard intern year and first year of fellowship. It seems like a no-brainer for you. You will match at top spots for residency and fellowship and walk into an attractive attending position in H/O. Go IM and don't look back.

Not sure if it’s just my experience, but I have met Heme/Onc physicians with the most variable schedules imaginable ... like literally part time outpatient oncology (a little heme but only boarded in onc) +/- inpatient consults but no admitting and minimal to no rounding to the opposite extreme of getting in at 6am to run from inpatient to outpatient clinic with 25-30 patients finishing at 5-6pm and maybe even doing an inpatient consult and then charting who knows when.

I would imagine the latter extreme is among the most highly compensated of all physicians and the former is quite content with lifestyle. Not sure how easy it is to land either type of set up.

 

[elementaryschooleconomics]

Would only recommend doing radonc if you REALLY love it and can’t see yourself doing anything else

My experience is going through RO residency honestly sucks. Our job description is not intense at all, and actually quite fun! Yet academic attendings like to be overly intense and quiz you on minutia of DFS down to .x%. When me and my coresidents miss, they make it seem like the end of the world and we are dumb for not knowing. Those are the better teachers. The alternative is most don’t teach shiz

Ok so you hang in there for 2 years. Now it’s time to study for physics and rad bio boards. Guess what, vast majority of ppl can be excellent physicians without knowing a single phase in cell cycle.

alright finally in year 4. Time to study for clinical boards. I’m not even going to discuss the jobs fiasco

1 year out while living in Montana, you get the pleasure of studying for oral boards.

great you passed! You’re now BC. 6 years of your life are gone and you’re practicing in a rural town (not for me!). Then your hospital realizes they only need someone there 1 day per week thx to HOPPS....

So in summary, I love the patient care and overall potential fun of being a rad Onc. I hate going through residency (could just be my exp). I hate hate the unnecessary boards. Hate hate hate the job prospects (location and/or money).

Realized too late that I prefer flexibility even more so than money so I would do IM and stop. Could practice anywhere in the US whenever I want. Could even go overseas to cool country (New Zealand hello!) temporarily

Ah I love this post, it rings so true about our residency training.

"How do you NOT know the reported 5-year PFS for this one trial in this one disease to the second significant digit?"

"Ah, sorry. I do know about Monte Carlo modeling for..."

"What? No one cares."

 

[Haybrant]

Ah I love this post, it rings so true about our residency training.

"How do you NOT know the reported 5-year PFS for this one trial in this one disease to the second significant digit?"

"Ah, sorry. I do know about Monte Carlo modeling for..."

"What? No one cares."

I’d say this is taking it a bit far. As an attending I do want to know if the resident knows these numbers, but if they say 10% and the number is 8% that’s fine, and I’m pretty sure your attendings were the same they don’t freak out if you don’t know the exact number. But if they say 30% then yes, that is incorrect and the resident will counsel the patient incorrectly or worse yet they will cop out on the answer with the patient indirectly misleading them. Integrating a ton of info into a synthesis for the patient, It’s one difference between a good physician and a bad one. There are a lot of bad ones out there...and on this board

 

[FrostyHammer]

Lots of perceived doom and gloom in the above comments, but no balanced view of the positives sadly. Don't forget that rad onc is one of the few fields that doesn't involve routinely working evenings/weekends. As interesting as heme onc is, one price to pay is the evenings/weekends time. Yes, there are exceptions, but there are exceptions for nearly everything.

 

[Haybrant]

Lots of perceived doom and gloom in the above comments, but no balanced view of the positives sadly. Don't forget that rad onc is one of the few fields that doesn't involve routinely working evenings/weekends. As interesting as heme onc is, one price to pay is the evenings/weekends time. Yes, there are exceptions, but there are exceptions for nearly everything.

Why take the risk though when plenty of other great fields are available to a top tier candidate? Is rad onc the only field left with ok hours

 

[Mandelin Rain]

Hospitalists and NPs have abrogated many nights and weekends for med oncs.

 

[deleted774703]

I’d say this is taking it a bit far. As an attending I do want to know if the resident knows these numbers, but if they say 10% and the number is 8% that’s fine, and I’m pretty sure your attendings were the same they don’t freak out if you don’t know the exact number. But if they say 30% then yes, that is incorrect and the resident will counsel the patient incorrectly or worse yet they will cop out on the answer with the patient indirectly misleading them. Integrating a ton of info into a synthesis for the patient, It’s one difference between a good physician and a bad one. There are a lot of bad ones out there...and on this board

I think this is a difference in opinion. Not all patients want to know the trial numbers. Most just want to know what is the right treatment (guidelines, etc) and the reason why (decreases risk of recurrence by little, moderate, lot, increase OS, etc).

There are plenty of worse traits than not knowing the exact answer "for a studied sample of the population" (let's not get into deep stats but safe to say can't give an accurate exact answer on if individual patient will recur or not).

For example, we had an attending who knew all of the answers. Legit genius. However, was not the most emotionally sensitive doctor. I felt that patients did not click with this doctor b/c they were so data focused rather than providing emotional support for the patient.

Based on my experience, that physician would have been better if they spent less time memorizing numbers and more time building connections.

Finally, we also should remember most academic attendings treat a limited number of disease sites. I doubt my CNS attending knows the numbers in 0529. Therefore, those attendings should remember that residents are trying to learn EVERYTHING well during residency not just 1-2 things perfectly.

 

[scarbrtj]

I strongly disagree with what others have posted!
- At a minimum, radiation achieves local control. That means that for many localized cancers, radiation is the curative modality. In others, surgery is the curative modality. Other nonmetastatic cancers require some combination of surgery, radiation, and/or chemotherapy to achieve cure. And like you said, we are seeing a lot more aggressive treatment of metastatic disease with radiation now. But with a very small number of exceptions, solid tumors require surgery or radiation for cure, and systemic therapy sometimes helps them work better.

Radiation is a great field with a big math problem. Run it through the old brain machine and see what comes out.

Yes, if we pull out some simple math we can see OP20181121 is spouting some semi-fake news...

Math problem #1 & "with a very small number of exceptions, solid tumors require surgery or radiation for cure" & prostate as example:
Breast and prostate cancer were historically (~20-30y) the "bread and butter" of the rad onc's practice. Prostate used to be very common but the number of cases per year keeps dropping and dropping. (Lung's the biggest "dropper"... more on that in a sec.) Not too long ago, 200+K prostate cases a year but only about <170K/year now. And of those, how many get XRT? The "standard answer" is about ~33%. This would mean ~51K men/year getting XRT in America for CaP in ~2020.
Mathematical translation: There are ~5200 rad oncs in America in 2020. There are ~52K men with prostate cancer getting XRT every year. That's 10 men/rad onc/year. That's only about one new prostate cancer patient per month for every rad onc in America, and using the standard calc of [weeks of tx times new patients per week equals number under beam], that would be 6 (weeks of tx on average) times 0.25 (new prostate cancer patients per week) equals about 1-2 prostate cancer patients under beam on average for every rad onc in the U.S. Yikes.

Math problem #2 & "for many localized cancers, radiation is the curative modality":
Now let's calc radiation's role as the curative modality for the top 5 cancers:
The top 5 comprise about ~900K patients per year, how many of those even get any XRT?
Breast... ~135K/year* (out of 270K)
Lung... ~82K/year** (out of 228K)
Prostate... ~52K/year (see above, out of 165K)
Colorectal... ~40K/year*** (out of 145K)
Melanoma... ~<10K/year (my guess)**** (out of 96K)
XRT Total: 319K/year out of ~900K a year of the top 5 cancers ... and if we exclude adjuvant XRT (where XRT is not the curative modality)... we are really only talking like maybe 3/4 of prostate cases, and 1/4 of lung cases (when we treat Stage I), so that's:
~59K out of ~900K of the top 5 cancers where XRT is ***the*** curative modality.
Thus radiation is the curative modality in ~7% of the top 5 cancer cases.
Much better statement: for most localized cancers, radiation is NOT the curative modality.

So let it be known... we simply have too many rad oncs in the US. This would be a GREEEAAAAATTTT field if we did not.


* 270,000 cases a year (radiation never the curative modality, lowers LRR rates of ~25-33%% for whole population sans XRT by about ~2/3rds at most)... radiation utilization about 50%, many women opting mastectomy in Stage I and the surgeons don't want us to give after lumpectomy etc etc... so about ~135K/year
** No radiation commercials claiming it saves lives or changes the world like PDL-1 does, but it helps a lot but only ~36% of patients get any XRT so only about ~82K/year
*** Of the ~145K colorectal cases/year, about 45K/year are rectal and I would guess ~90% of those cases get XRT, so about ~40K/year here... we never use radiation in colon CA essentially
**** As well know radiation really never/seldom a curative component of melanoma tx nowadays

 

[ramses99]

Realized too late that I prefer flexibility even more so than money

Yup this applies to me - I'd be less concerned about 300 vs 400k than not being able to pick a city where a future partner can find work (inb4 biryani)

part time outpatient oncology (a little heme but only boarded in onc) +/- inpatient consults but no admitting and minimal to no rounding

You work hard intern year and first year of fellowship. It seems like a no-brainer for you. You will match at top spots for residency and fellowship and walk into an attractive attending position in H/O. Go IM and don't look back.

honestly, pursuing this path sounds pretty good right now.

- I am VERY glad I went into Radiation Oncology.
- At a minimum, radiation achieves local control. That means that for many localized cancers, radiation is the curative modality.

Thanks for the positive counterpoint. Rad onc is such a unique field that I imagine once you're in, you've gotta be pretty damn satisfied. I just worry that

So let it be known... we simply have too many rad oncs in the US. This would be a GREEEAAAAATTTT field if we did not.

I'm 10 years late to the party

One thing no one has commented on is DR - good job market right now and I feel that AI will be used more as a tool than as a replacement. Plus if I did breast rads I'd actually see patients and still have a good lifestyle. ANyone know anything more about this field?

 

[BobbyHeenan]

If geographic limitation/flexibility is important to you, I'd steer clear. This has always been an issue in this field, even before the current residency expansion.

Agree with you that AI will augment diagnostic rads, probably not replace...but you mentioned breast rads...if any sector is at risk for AI replacement, then that one has a bulls eye on it...though I bet in the initial uptick in usage of AI for rads it results in more biopsies first, then eventually less. Just my opinion though, I may be way off there.

 

[radiation]

Yes, if we pull out some simple math we can see OP20181121 is spouting some semi-fake news...

Math problem #1 & "with a very small number of exceptions, solid tumors require surgery or radiation for cure" & prostate as example:
Breast and prostate cancer were historically (~20-30y) the "bread and butter" of the rad onc's practice. Prostate used to be very common but the number of cases per year keeps dropping and dropping. (Lung's the biggest "dropper"... more on that in a sec.) Not too long ago, 200+K prostate cases a year but only about <170K/year now. And of those, how many get XRT? The "standard answer" is about ~33%. This would mean ~51K men/year getting XRT in America for CaP in ~2020.
Mathematical translation: There are ~5200 rad oncs in America in 2020. There are ~52K men with prostate cancer getting XRT every year. That's 10 men/rad onc/year. That's only about one new prostate cancer patient per month for every rad onc in America, and using the standard calc of [weeks of tx times new patients per week equals number under beam], that would be 6 (weeks of tx on average) times 0.25 (new prostate cancer patients per week) equals about 1-2 prostate cancer patients under beam on average for every rad onc in the U.S. Yikes.

Math problem #2 & "for many localized cancers, radiation is the curative modality":
Now let's calc radiation's role as the curative modality for the top 5 cancers:
The top 5 comprise about ~900K patients per year, how many of those even get any XRT?
Breast... ~135K/year* (out of 270K)
Lung... ~82K/year** (out of 228K)
Prostate... ~52K/year (see above, out of 165K)
Colorectal... ~40K/year*** (out of 145K)
Melanoma... ~<10K/year (my guess)**** (out of 96K)
XRT Total: 319K/year out of ~900K a year of the top 5 cancers ... and if we exclude adjuvant XRT (where XRT is not the curative modality)... we are really only talking like maybe 3/4 of prostate cases, and 1/4 of lung cases (when we treat Stage I), so that's:
~59K out of ~900K of the top 5 cancers where XRT is ***the*** curative modality.
Thus radiation is the curative modality in ~7% of the top 5 cancer cases.
Much better statement: for most localized cancers, radiation is NOT the curative modality.

So let it be known... we simply have too many rad oncs in the US. This would be a GREEEAAAAATTTT field if we did not.


* 270,000 cases a year (radiation never the curative modality, lowers LRR rates of ~25-33%% for whole population sans XRT by about ~2/3rds at most)... radiation utilization about 50%, many women opting mastectomy in Stage I and the surgeons don't want us to give after lumpectomy etc etc... so about ~135K/year
** No radiation commercials claiming it saves lives or changes the world like PDL-1 does, but it helps a lot but only ~36% of patients get any XRT so only about ~82K/year
*** Of the ~145K colorectal cases/year, about 45K/year are rectal and I would guess ~90% of those cases get XRT, so about ~40K/year here... we never use radiation in colon CA essentially
**** As well know radiation really never/seldom a curative component of melanoma tx nowadays

How about this thought experiment - the president of the United States makes you the newly appointed cancer health czar. He asked that taking into account cost-effectiveness and quality of life, what are the percentages of pts that SHOULD get radiation as the primary treatment for things like prostate cancer based on level 1 data?
Spoiler alert

https://www.nejm.org/doi/full/10.1056/NEJMoa1606221

 

[RadOncG]

How about this thought experiment - the president of the United States makes you the newly appointed cancer health czar. He asked that taking into account cost-effectiveness and quality of life, what are the percentages of pts that SHOULD get radiation as the primary treatment for things like prostate cancer based on level 1 data?
Spoiler alert
https://www.nejm.org/doi/full/10.1056/NEJMoa1606221

Unfortunately for urologists and radiation oncologists the answer to your question is that we should stop screening for prostate cancer based on level 1 evidence.

This is happening to some degree with decreased incidence, more active surveillance, and subsequently a declining number of patients getting prostate radiation.

Despite the hit to radiation oncologists business this is evidence based medicine in action.

 

[yesmaster]

Hey OP, thanks for posting here. I know SDN can be a little hyperbolic, so I'll try to answer your questions with references to people and experiences IRL.

1) Your credentials seem good but they wouldn't have been extraordinary a few years ago. My profile was similar to yours, and although I received a couple interviews at top 10 programs, I did not match to a top 10 program. Senior residents are privy to the applications of med students at some programs, and the applicant quality is significantly down recently based on objective metrics. Still, without knowing the rest of your application (clinical grades, AOA status, LOR's, extracurriculars, interview ability), I'm not sure that you could match to a big 3, but you'd have a good shot. As for the job market, I believe that the big 3 are to a large degree insulated from the job market woes of the untouchable masses of rad onc programs, because they've aggressively bought up or taken over independent hospitals and private practices, so you should be gainfully employed in 7 years.

2) The heme/onc job market outlook is very stable. From my interactions with heme/onc physicians around the country from conferences, etc., their hours can be quite good, 9-5 for instance with a 4-day workweek. Of course, some junior heme/onc physicians or those in rural areas may also be covering multiple sites or have hospital rounds for a couple weeks of the year, but lifestyle is good and starting compensation is ~$600k in at least one area of the country that I'm familiar with.

3) I would absolutely tell my M3 self to switch out of radiation oncology. Whereas the lifestyle as a resident is good, I've seen my chief residents graduate with perpetually worse jobs year-over-year. Next year, the general supervision requirement will affect the job market even more than this year, and APM may make its debut. These payor-related changes combined with an ever-increasing number of resident graduates will make my job search challenging, to say the least. Heme/onc and radiology are both good off-ramps.

4) Macro view. If you look at a snapshot of clinical trials, immunotherapy and targeted therapy is only expanding into more and more disease sites and stages of disease, with some immunotherapy studies even making their way to early-stage disease (!!!). Please contrast this with radiation oncology, in which many trials are either shrinking radiation (via hypofractionation), or eliminating it all together. Similarly, systemic therapy clinical trials are powered by a trillions dollar biopharma industry, whereas radiotherapy trials are powered by no one except cooperative groups that have a pittance of resources compared to the likes of Roche and Novartis. Similarly, if we look at the preclinical landscape, the lion's share of NIH/NCI funding goes to med onc. Today's investments, tomorrow's breakthroughs and standard-of-care.

Besides heme onc, radiology's job market is quite good. One of my good buddies is a breast radiology fellow and he's seeing starting offers of $600-700k in nice coastal USA cities. He's from an average med school and residency program, so his offers can be considered typical for breast radiology, at least. One of my other buddies was a superstar who I dissuaded from applying to rad onc. He's currently very happy at a top 3 interventional radiology program, which has the lowest match rate % of any specialty. Much better to be at the top of a hot field than at the top of, errrrr, whatever radiation oncology passes as these days.

OP, whatever you decide, we wish you the best!

 

[scarbrtj]

How about this thought experiment - the president of the United States makes you the newly appointed cancer health czar. He asked that taking into account cost-effectiveness and quality of life, what are the percentages of pts that SHOULD get radiation as the primary treatment for things like prostate cancer based on level 1 data?
Spoiler alert

https://www.nejm.org/doi/full/10.1056/NEJMoa1606221

Well hell I think 100% of CaP pts should get XRT.
But to have that we'd need 100% skin in the game from urologists.
But when that was tried, our own society pitched a royal f**king fit. I mean do we want good XRT utilization or not? But ASTRO's shortsighted silly shenanigans meant we'd never get, or will never have, 100% buy-in from the controllers and diagnosers of the patients.
And even if we got 100% of the prostate patients, that's "only" 150K pts a year (incidence and prevalence dropping).
Divide that by 5000 rad oncs (today... 6000+ 10y from now), that's ~3 patients/month per rad onc. Just barely 4-5 prostate patients under beam at any time if we got ALL the prostate business. I mean, ~5y ago we were at a ~quarter million prostate patients a year in the U.S. The proton folks, who built their centers quite squarely on the back of making profit on prostate cancer, have gotta be freaking out a bit (Is Proton-Beam Therapy Facing a Difficult Future?):

"Moreover, when a hospital-based proton center incurs a $200-plus million debt, it must amortize that liability with high-volume procedures. With 240,000 new prostate cancers diagnosed each year in the United States, this disease has been the mainstay of the proton therapy industry, accounting for two of every three claims and about 80% of Medicare spending on the procedure. So while the cost of building a treatment center is high, up until now, proton-beam therapy has presented a lucrative opportunity for those who are willing to make the investment. Proton-beam therapy for prostate cancer is reimbursed at a much higher rate than traditional radiation treatment for the same condition. Medicare pays about $19,000 for a full dose of standard radiation therapy for prostate cancer, but it pays more than $32,000 for proton therapy."

 

[KHE88]

For example, we had an attending who knew all of the answers. Legit genius. However, was not the most emotionally sensitive doctor. I felt that patients did not click with this doctor b/c they were so data focused rather than providing emotional support for the patient.

Based on my experience, that physician would have been better if they spent less time memorizing numbers and more time building connections.

Ah I love this post, it rings so true about our residency training.

"How do you NOT know the reported 5-year PFS for this one trial in this one disease to the second significant digit?"

"Ah, sorry. I do know about Monte Carlo modeling for..."

"What? No one cares."

This was one of the more frustrating parts of residency training IMO. Too much time was spent focusing on regurgitating trial data and too little time was spent on instructing regarding the nuts and bolts of rad onc practice. I suspect it has a lot to do with the more perceived cerebral aspect of being a walking encyclopedia (hence the tendency for the site specific attendings to show how smart they are by knowing every little last thing about every little last trial in their microcosm) rather than the mundane technician-level work (which is pretty important if you're a PGY-5 and have no idea how to check images on the machine/deal with setup issues/approve plans/etc). This is a shame.

I have seen a number of patient surveys returned where patients complained that the doctor spent too much time talking about "data" and "statistics" that they didn't understand and went over their head and thus ranked the physician poorly. If you're citing p-values or numbers off of trials or numbers in general that are anything other than ballpark estimates, you are doing something very wrong for the vast majority of patients IMO. Again, sadly this is not taught.

 

[Burt Radnolds]

But when that was tried, our own society pitched a royal f**king fit. I mean do we want good XRT utilization or not? But ASTRO's shortsighted silly shenanigans meant we'd never get, or will never have, 100% buy-in from the controllers and diagnosers of the patients.

Never thought about the ASTRO Urorads backlash in this context. We basically bit the hand that feeds whilst sitting around whining about how we don't get enough prostate patients wondering why. How short sighted indeed.

 

[scarbrtj]

Never thought about the ASTRO Urorads backlash in this context. We basically bit the hand that feeds whilst sitting around whining about how we don't get enough prostate patients wondering why. How short sighted indeed.

"We basically bit the hand that feeds..." Yeah, not even basically. It took a high level of hubristic geocentrism coupled with an inability to self-reflect and understand what other specialties think of us to pull that one off. In other words, it took a radiation oncologist!

 

[RadDoc11]

I personally feel that there is a little too much emphasis on training at a “top 3 program” at least as it is purported to translate into getting a good job. The hospital administrator or medical oncologist or even the Rad onc reviewing your CV likely may not be aware of or actually value where you trained as much as you may think. Many are not aware that, for example, Columbia is not considered a top 10 program or that U of Maryland has historically been considered a good program. The Columbia grad may actually be more marketable in fact. It’s more about your personality when you interview and other factors in your CV as a whole. Furthermore, as rad oncs, I think we all have been exposed to both the trainees from top programs who cannot function for one reason or another in real life settings as well as the trainees from lesser known programs who are gems. The job market doesn’t necessarily care about where you trained, for better or for worse.

Having been involved in the hiring process several times, I think students should be aware.

Long time lurker here. Ive read enough of your posts to understand the issues facing the job market ie overtraining, hypofrac, APMs. So I have an inkling what you all will say but still I am curious...

I am a third year who came into med school interested in rad onc. The pt population, stimulation of interdisciplinary whole body cancer care, and excellent lifestyle all appeal to me. As such I assembled a competitive application for rad onc (Top tier med school, >260 step one, modest research but do have ijrobp and astro citations) and believe I could match to if not a big 3, then likely a top 10 program.

I did a rad onc home elective last fall and really did enjoy it, but I could sense the negativity among the residents which to me represented a more muted IRL version of the despondence (I don't know what other word to use lol) on this board.

If I were to off-ramp, my likely targets would be radiology or IM -> hem/onc. Radiology has the pros of a better job market while maintaining the pager-off-at-6pm lifestyle, but the con of not working with patients (except in breast rads which I am pretty interested in.) Hem/onc has the pros of still seeing and treating cancer patients with the con of more of an intense residency, and having to do a whole extra match. As I liked my medicine clerkship all in all, and don't think i could give up seeing patients I would probably lean here.

QUESTIONS
1) Is it true that given my credentials and the downtrend in applicants I could match to a big 3? If I did this, is there a chance the job market rebounds (or at least plateaus) by 7yrs when I'm looking for jobs and I can get good jobs?
2) Is the hem/onc job market outlook pretty stable in the long term? Any big issues on the horizon there?
3) If you could go back and tell your M3 self to switch out of rad onc, would you? What would you suggest as the off ramp?
4) I have a limited knowledge of the radiation literature, and I'm getting the sense that as more studies come out the objective outcomes benefit of XRT are going to just become more limited in scope. e.g. everyone should be getting hypofrac for breast, or that while LR rates often improve OS rates rarely do with RT, or are there genetics/markers that predict who really needs RT. ON the other hand there is this emerging oligomet paradigm that perhaps we could be curing more stage IVs which is really exciting. In your expertise which way are we really going? Is RT really curing many cancers? Am I thinking about this all wrong?

Thanks all. If you could keep the overt negativity tamped down I would appreciate it but I recognize that is a big ask on this forum!!

 

[RadDoc11]

I personally feel that there is a little too much emphasis on training at a “top 3 program” at least as it is purported to translate into getting a good job. The hospital administrator or medical oncologist or even the Rad onc reviewing your CV likely may not be aware of or actually value where you trained as much as you may think. Many are not aware that, for example, Columbia is not considered a top 10 program or that U of Maryland has historically been considered a good program. The Columbia grad may actually be more marketable in fact. It’s more about your personality when you interview and other factors in your CV as a whole. Furthermore, as rad oncs, I think we all have been exposed to both the trainees from top programs who cannot function for one reason or another in real life settings as well as the trainees from lesser known programs who are gems. The job market doesn’t necessarily care about where you trained, for better or for worse.

Having been involved in the hiring process several times, I think students should be aware.

Forgot to mention, also keep in mind that the attending at MSK or graduate from MD Anderson likely entered the field at a time when no one wanted to be a rad onc. The 2013 graduate from random Midwest program, however, may have been super qualified and entered the field when it was extremely competitive. No hospital administrator is going to understand that but keep in mind that this diluted the strength of having graduated from one of these programs.

 

[RickyScott]

I personally feel that there is a little too much emphasis on training at a “top 3 program” at least as it is purported to translate into getting a good job. The hospital administrator or medical oncologist or even the Rad onc reviewing your CV likely may not be aware of or actually value where you trained as much as you may think. Many are not aware that, for example, Columbia is not considered a top 10 program or that U of Maryland has historically been considered a good program. The Columbia grad may actually be more marketable in fact. It’s more about your personality when you interview and other factors in your CV as a whole. Furthermore, as rad oncs, I think we all have been exposed to both the trainees from top programs who cannot function for one reason or another in real life settings as well as the trainees from lesser known programs who are gems. The job market doesn’t necessarily care about where you trained, for better or for worse.

Having been involved in the hiring process several times, I think students should be aware.

Absolutely. This Top program fetish is from a time when the field was getting bottom of barrel applicants and several top programs had a significant proportion of the training spots. Bar was low to train at said programs then, so some would figure that if you were decently qualified you could have gone to them.

 

[scarbrtj]

Forgot to mention, also keep in mind that the attending at MSK or graduate from MD Anderson likely entered the field at a time when no one wanted to be a rad onc. The 2013 graduate from random Midwest program, however, may have been super qualified and entered the field when it was extremely competitive. No hospital administrator is going to understand that but keep in mind that this diluted the strength of having graduated from one of these programs.

You've got, in general, a much better shot at any job, rad onc included, if you're a local or semi-local boy or girl as opposed to a complete carpetbagger with a Man's Greatest Hospital certificate.

 

[RickyScott]

Also the further out from residency, less relevant training program’s name. And vast majority of you will not have 1 job.

 

[FrostyHammer]

Why take the risk though when plenty of other great fields are available to a top tier candidate? Is rad onc the only field left with ok hours

I mean, us and derm have always been the two fields where that's by far the most applicable. No amount of hospitalists and PA/NPs can change that. Remember that a principle of life is that grass seems greener on the other side. I'm sure there are other parallel forums who always trash their own specialty regularly on SDN too...

 

[RickyScott]

I mean, us and derm have always been the two fields where that's by far the most applicable. No amount of hospitalists and PA/NPs can change that. Remember that a principle of life is that grass seems greener on the other side. I'm sure there are other parallel forums who always trash their own specialty regularly on SDN too...

Dem has never had periods of unemployment as far as I know like radonc in early 90s. Always been competitive specialty.

There are about 400 residents in derm per year. Doesn’t that somehow resonate? For every 2 derms, we are training 1 radonc. Look around, is that the ratio in your community or is that totally f up? And derm derive some of income from elective cosmetic procedures.

same thing with 325 urology positions...

 

[FrostyHammer]

Dem has never had periods of unemployment as far as I know like radonc in early 90s. Always been competitive specialty.

There are about 400 residents in derm per year. Doesn’t that somehow resonate? For every 2 derms, we are training 1 radonc. Look around, is that the ratio in your community or is that totally f up? And derm derive some of income from elective cosmetic procedures.

Just an FYI, in my post that you quoted, the "that" referred to the work hours, not periods of unemployment and such that you just mentioned.

 

[MegaVoltagePhoton]

You know the hate for using SBRT (or RT in general) for oligometastatic disease is crazy, both on this forum and at large in our specialty (like that ****show of a debate at ASTRO). Everyone always brings up immunotherapy and targeted therapy but those are NOT the magic bullets that one might think as most trials are either phase II or trials with surrogate endpoints and strawman control arms (listen to the Vinay Prasad podcast). While SABR-COMET is an RCT with an OS benefit and there are other trials with meaningful benefits like the Gomez trial. I don't understand why the same people on this forum who attack those in our field for "studying ourselves out of existence" ALSO attack treating oligomets as prelim. You should by hyping that up to your colleagues!

And the academics are guilty of this too. Our specialty is perhaps the worst when it comes to crapping where it eats. As a junior academic myself I can tell you the reviews from the red journal seem like *****s on a power trip nitpicking every last detail. And it's no better at PRO or lower tier journals. And that ASTRO debate was a great example. Like...are there debates about how immunotherapy is crap at ASCO? Certainly not debates where the side saying immunotherapy is crap WINS.

Our field needs a wakeup call. The radoncrocks crew needs to get off twitter and actually advocate for new indications in real life. And those of you who can, try not to undersell SBRT for oligmets!

 

[RadOncG]

(listen to the Vinay Prasad podcast). While SABR-COMET is an RCT with an OS benefit

Did you listen to Vinay Prasad's thoughts on SABR-COMET?

I certainly hope oligomet data pans out. I have seen this data used in very questionable treatment decisions at academic centers.

 

[scarbrtj]

While SABR-COMET is an RCT with an OS benefit

If SABR-COMET supports the "paradigm," then ~2 people (not dying) support the paradigm.

Not hating. But one of these days we're all going to have to get together on one of these things where everybody's honest. The "OS benefit" was a p=0.09, and we are talking ~6-7 patients in that year 4 in the SABR arm. ("Nearly half (46%) of the patients treated with stereotactic radiation were still alive after 5 years, compared to 24% in the control group, said Dr. Palma"... which is wrong... there was ~1 person out of ~66 alive at 5y with an instantaneous estimated probability of 5y survival of ~46% with HUGE error bars... I'd guess 0-80%... that aren't shown). If just 1 of those people had expired, the p-value would prob be less than 0.2 (their pre-spec'd p-cutoff in this trial). And we'd say "OS benefit at p=0.17" or something. Which seems weird. If two people had died, we'd say no OS benefit and would we even still mention the "oligometastatic paradigm?" Needless to say, whoever those two people are on the planet that decided not to die in the SABR arm on the trial we should all buy them lifetime supplies of champagne.

 

[MegaVoltagePhoton]

Did you listen to Vinay Prasad's thoughts on SABR-COMET?

I certainly hope oligomet data pans out. I have seen this data used in very questionable treatment decisions at academic centers.

I did. Worth investigating in a phase III trial was the conclusion. As is being done.

How many immunotherapies and TKIs have shown benefit in OS in a phase II trial?

 

[MegaVoltagePhoton]

If SABR-COMET supports the "paradigm," then ~2 people (not dying) support the paradigm.

Not hating. But one of these days we're all going to have to get together on one of these things where everybody's honest. The "OS benefit" was a p=0.09, and we are talking ~6-7 patients in that year 4 in the SABR arm. ("Nearly half (46%) of the patients treated with stereotactic radiation were still alive after 5 years, compared to 24% in the control group, said Dr. Palma"... which is wrong... there was ~1 person out of ~66 alive at 5y with an instantaneous estimated probability of 5y survival of ~46% with HUGE error bars... I'd guess 0-80%... that aren't shown). If just 1 of those people had expired, the p-value would prob be less than 0.2 (their pre-spec'd p-cutoff in this trial). And we'd say "OS benefit at p=0.17" or something. Which seems weird. If two people had died, we'd say no OS benefit and would we even still mention the "oligometastatic paradigm?" Needless to say, whoever those two people are on the planet that decided not to die in the SABR arm on the trial we should all buy them lifetime supplies of champagne.

It was a phase II signal finding trial of 99 patients. You could use a similar argument of chance to take to task multiple med onc trials that have other cause mortality issues etc. If an immunotherapy agent showed that in a phase II trial it would be in the next NCCN guideline.

 

[yesmaster]

You know the hate for using SBRT (or RT in general) for oligometastatic disease

Look this isn't tumor board or multidisciplinary clinic or a major academic conference.

This thread is regarding whether an MS3 should pursue radiation oncology or not. Yes, SBRT is promising for oligomets and I advocate for it IRL, but I wouldn't advise an MS3 to ignore pernicious job market problems, and hope for a deus ex machine salvation of his or her employment prospects in 7 years by a 100 patient phase II RCT today that to some degree has already infiltrated current utilization patterns.

In my experience, institutions have been treating oligometastatic and oligoprogressive disease with SBRT since before SABR-COMET was published, so we do believe in the spirit of SABR-COMET. My prediction is that SABR-COMET and similar studies will codify the exact clinical scenarios for which SBRT is appropriate, but won't generate massive new RVU streams since we're already using SBRT for oligomets to some degree.

 

[scarbrtj]

Dem has never had periods of unemployment as far as I know like radonc in early 90s. Always been competitive specialty.

There are about 400 residents in derm per year. Doesn’t that somehow resonate? For every 2 derms, we are training 1 radonc. Look around, is that the ratio in your community or is that totally f up? And derm derive some of income from elective cosmetic procedures.

same thing with 325 urology positions...

There are ~1 million skin cancers a year. Just gonna go out on a limb and say derms treat ~90% of those. And gonna go out on another limb and say that makes up, at most, slightly less than half of their new patient business. So ~2 million new patients a year for derm and there's about 10,000 of 'em. So about a 200:1 ratio. And I'm probably bad off, it's probably higher I'm sure (300:1? 400:1?)... they get like ~40+ million patient visits a year now.

The nation's ~5200 rad oncs only treat about ~300K new pts a year of just the top 5 cancers (again, brand new dx patients per year out of ~900K in the top 5). We will treat <600K, total, nationwide for sure (again, new dx pts per year). There's ~5200 rad oncs in 2020. So our ratio is 115:1. And we sure have <<40 million patient visits/year (to the doc).

We are upside down so bad our butts are sunburned.

 

[RadOncG]

I did. Worth investigating in a phase III trial was the conclusion. As is being done.

Yep. I hope phase III data shows something. In addition to concluding it was worth investigating in phase III, he said it is not practice changing currently, he is not optimistic about phase III data being positive. I think he said maybe 10% chance at most was his guess, and he was concerned the treatment was very toxic. Unfortunately SABR-COMET was very toxic with several treatment related deaths.

How many immunotherapies and TKIs have shown benefit in OS in a phase II trial?

None if they aren't powered to show it. Can't criticize med oncs for using surrogate endpoints and phase II data to drive treatment and then do the same thing ourselves. Again I hope it all proves to significantly extend OS in phase III randomized trial.

Back to OPs question as it relates to oligomets. I certainly hope it works but I would not be risking my entire training and career hoping this data pans out. Systemic therapy and med oncs by proxy will continue to contribute to survival advantages in the future as they previously had the most ground to make up. Local control is actually quite good which is good for patients but means our gains will be minimal moving forward.

 

[OTN]

SBRT for oligomets, even if Phase III trials are very, very good, will not be able to overcome the dramatic overtraining that occurred over the last 5-7 years.

 

[RickyScott]

You know the hate for using SBRT (or RT in general) for oligometastatic disease is crazy, both on this forum and at large in our specialty (like that ****show of a debate at ASTRO). Everyone always brings up immunotherapy and targeted therapy but those are NOT the magic bullets that one might think as most trials are either phase II or trials with surrogate endpoints and strawman control arms (listen to the Vinay Prasad podcast). While SABR-COMET is an RCT with an OS benefit and there are other trials with meaningful benefits like the Gomez trial. I don't understand why the same people on this forum who attack those in our field for "studying ourselves out of existence" ALSO attack treating oligomets as prelim. You should by hyping that up to your colleagues!

And the academics are guilty of this too. Our specialty is perhaps the worst when it comes to crapping where it eats. As a junior academic myself I can tell you the reviews from the red journal seem like *****s on a power trip nitpicking every last detail. And it's no better at PRO or lower tier journals. And that ASTRO debate was a great example. Like...are there debates about how immunotherapy is crap at ASCO? Certainly not debates where the side saying immunotherapy is crap WINS.

Our field needs a wakeup call. The radoncrocks crew needs to get off twitter and actually advocate for new indications in real life. And those of you who can, try not to undersell SBRT for oligmets!
[/QUOTE
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SBRT for oligomets, even if Phase III trials are very, very good, will not be able to overcome the dramatic overtraining that occurred over the last 5-7 years.

yes. Exactly. They are not our messiah. They won’tmake up for decreases seen in prostate revenue or hypofractionation let alone residency expansion

Re those phase ii trials that were randomized and showed survival benefit for drugs, abt 40% confirmed in phase 3 per medonc at Astro. His point (Corey langer) was odds not in our favor. Nevertheless, by time trials come out goalposts will have moved wIt’s newer drugs, so will probably keep treating even if negative.