Med oncs are the lynchpins of oncology and radiation and surgery is just one of their tools to fight disease

[Haybrant]

In fairness - I thought I would go into IM and end up in Cards/GI when I was in the first 2 years of med school. This was after exposure to Rad Onc.

Then I rotated through IM as a 3rd year medical student, realized I would have to do 3 years of caring about CHF and COPD and DM and all those other IM things and noped the hell on out of there. It was a process of elimination for me in regards to what I ended up in.

In regards to the bolded - I really don't think I would enjoy anything else in medicine nearly as much as I enjoy the day-to-day of Rad Onc. Heme-onc is just IM for a cancer patient. I was never going to be a surgeon. Radiology is not enough longitudinal patient contact.

I'm cognizant that others may feel how you feel, Ricky, but there are some (likely a low percentage of the current population) that maybe wouldn't be happy doing something else.

Heme onc is just IM for cancer patients? I would seriously consider spending time w real med oncs to understand how off base this is. I’m going to get grilled I know but we need to reconsider what we think of med oncs and what we think of ourselves. Med onc is purest of oncologic topics, why? bc biology really is king. Med oncs are the lynchpins of oncology and radiation and surgery is just one of their tools to fight disease, not the other way around. We are totally in the dark ages in radiation when it comes to the future of onco biology and that is a new discussion we need to be having bc the med oncs have totally and completely left us behind. As much as Im about discussing this current and related topics we should spend more time on the above than we have been. Rehashing the same points about residency expansion/future of jobs in the field is important and I was one of the first here doing it, it is a lot of energy spent with little resolution.

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[evilbooyaa]

Heme onc is just IM for cancer patients? I would seriously consider spending time w real med oncs to understand how off base this is. I’m going to get grilled I know but we need to reconsider what we think of med oncs and what we think of ourselves. Med onc is purest of oncologic topics, why? bc biology really is king. Med oncs are the lynchpins of oncology and radiation and surgery is just one of their tools to fight disease, not the other way around. We are totally in the dark ages in radiation when it comes to the future of onco biology and that is a new discussion we need to be having bc the med oncs have totally and completely left us behind. As much as Im about discussing this current and related topics we should spend more time on the above than we have been. Rehashing the same points about residency expansion/future of jobs in the field is important and I was one of the first here doing it, it is a lot of energy spent with little resolution.

I'm going to turn this into it's own thread to avoid further off-topicing the med student one.

Haybrant, IMO, it's that level of med-onc worship (which is not uncommon in rad onc unfortunately) that has led us to be considered as technicians, not oncologists.

I'm interested in what other people's thoughts are on this matter (in a new thread).

Haybrant feel free to rename the OP to whatever you would like (or let me know what you want it changed to if you cant for some reason). Just went with the line that jumped out at me from the post when I read it.

 

[radoncgrad2019]

Heme onc is just IM for cancer patients? I would seriously consider spending time w real med oncs to understand how off base this is. I’m going to get grilled I know but we need to reconsider what we think of med oncs and what we think of ourselves. Med onc is purest of oncologic topics, why? bc biology really is king. Med oncs are the lynchpins of oncology and radiation and surgery is just one of their tools to fight disease, not the other way around. We are totally in the dark ages in radiation when it comes to the future of onco biology and that is a new discussion we need to be having bc the med oncs have totally and completely left us behind. As much as Im about discussing this current and related topics we should spend more time on the above than we have been. Rehashing the same points about residency expansion/future of jobs in the field is important and I was one of the first here doing it, it is a lot of energy spent with little resolution.

this boy ain't right

 

[Haybrant]

I'm going to turn this into it's own thread to avoid further off-topicing the med student one.

Haybrant, IMO, it's that level of med-onc worship (which is not uncommon in rad onc unfortunately) that has led us to be considered as technicians, not oncologists.

I'm interested in what other people's thoughts are on this matter (in a new thread).

Haybrant feel free to rename the OP to whatever you would like (or let me know what you want it changed to if you cant for some reason). Just went with the line that jumped out at me from the post when I read it.

I don’t see it as worship, Obviously with a thread title like that it will make it seem this way but yes in metastatic disease RT is just one treatment tool as med oncs try to understand and characterize the important components that underlie oncologic behavior. We had a prime opportunity to make massive headway in immunotherapy but we missed it bc we’re not geared for the future of oncology and our energy is primed more towards $$, we all know it too.

That said I do believe that radiation is the biggest bang for buck in cancer and it’s not even close and when it comes to local therapy we are the kings over surgeon and med oncs and run circles around them clinically. However instead of leading the charge on understanding the biological underpinnings of immunotherapy in localized disease (we could partner w top basic science researchers!) we will cede even this to the meds oncs in favor of running a few co-op trials and some big data sets while the rest of the field churns through patients with limited if any protected time to do good meaningful work. Nope, gotta babysit them machines bc Astro said so.

 

[StIGMA]

To be fair, most basic research in oncology is not conducted by medical oncologists. It is conducted by basic scientists who have an interest in cancer, and this research happens to benefit the field of medical oncology significantly more than radiation oncology or surgery due to the nature of our treatments. We certainly need to dedicate a significantly larger effort to study how radiation functions with targeted agents (and a thousand other cellular nuances). But medical oncology as a field is really not driving basic cancer research- they just reap the benefit of having the ability to prescribe these drugs. Who says we can't prescribe more of these agents if we show indications for use with radiation (like ADT)? As a field, we should fight for this.

In regard to the funding comment, I have had 4 radiation-specific grants funded by non-radiation societies/federal government (0 rejected) and 2 of 2 rejected by radiation-specific societies this year. It would be nice if our leadership could fund our own research better.

 

[StIGMA]

Who does the research is irrelevant. It’s the support that matters. If a researcher is hired and supported by a medically oncology department, it’s a feather in their cap, not ours.

And besides there are a LOT more academic medical oncologists with basic research labs than there are radoncs with the same.

I understand your point. Again, most basic cancer research is not done by or within or supported by medical oncology departments. It is done by curious scientists in several departments at each university (and outside of universities as well). And the research benefits them significantly more than us. For an example, I cannot do radiation cancer research without also benefiting the field of medical oncology in some way (because I study fundamental concepts in cancer biology). This is because they have access to the drugs and we dont.

 

[RadOncMegatron]

Isn't the elephant in the room here the referral pattern? If rad oncs received all the referrals first then we would be the folks on top - am I wrong? It's SO FRUSTRATING that we are 2-3 steps removed from the patient. Most our patients run through med onc, urology, ENT, pulm, neurosurgery, gyn onc, etc. before they see us. If we were the hub ie direct referral line from family medicine, outpt IM, OB/GYN, etc. then we would be the major players. As it is, everything runs through med onc. Isn't ridiculous that it goes family medicine --> pulm --> med onc --> cardiothoracic surgery --> rad onc for someone who ends up getting SBRT?!?!

Our national leaders in academics who are genuinely incredibly gifted and smart should not stand for this and try to change this referral pattern. They should go to AAFP to broker a deal to directly refer to rad onc.

 

[CaesarRO]

Clinically he isn’t. But speaking more broadly, medical oncology is light years ahead of radiation oncology when it comes to the quality of research produced in major academic departments. We attract very little funding and produce almost nothing of value. ASTRO is the bush leagues compared to ASCO. While medonc is pumping out high quality basic science and practice changing clinical trials, we are doing statistically questionable retrospective crap and still spinning our wheels on abscopal effect case reports.

Radiation Biology has hardly advanced since DNA was discovered. Our flagship journal publishes low quality survey data for god’s sake.

Radiation oncology academia is an absolute joke compared to medonc. We’re lucky we have physicists, because the last 20 years of our research has essentially just been making dose more conformal and *gasp* that means you can give larger fractions!

Here's a thread making the opposing argument from the guy behind the Plenary Session podcast. EBM doc who likes to highlight how corrupt many of the recent Med Onc clinical trials are from industry influence. Just another perspective.

 

[CaesarRO]

And besides there are a LOT more academic medical oncologists with basic research labs than there are radoncs with the same.

There are a lot more medical oncologists in the US than radoncs period. Would be curious to see the relative proportions with basic research.

I think the resources of big pharma make a big difference in terms of funding and enabling a lot of research on the MedOnc side that we just don't have access to A RadOncs

Sent from my Pixel 2 XL using Tapatalk

 

[medgator]

From a clinician standpoint, we have the most oncology training out of all of the onc specialties. We know surgery better the med oncs do and systemic therapy better than the surgeons

How many med oncs do you know that look at their own scans instead of reports or can stage an anal, lung or h&n pt? A med onc wants to do a dre or pelvic to help stage cancer, as much as I want to learn the clotting cascade

 

[RadOncDoc21]

Isn't the elephant in the room here the referral pattern? If rad oncs received all the referrals first then we would be the folks on top - am I wrong? It's SO FRUSTRATING that we are 2-3 steps removed from the patient. Most our patients run through med onc, urology, ENT, pulm, neurosurgery, gyn onc, etc. before they see us. If we were the hub ie direct referral line from family medicine, outpt IM, OB/GYN, etc. then we would be the major players. As it is, everything runs through med onc. Isn't ridiculous that it goes family medicine --> pulm --> med onc --> cardiothoracic surgery --> rad onc for someone who ends up getting SBRT?!?!

Our national leaders in academics who are genuinely incredibly gifted and smart should not stand for this and try to change this referral pattern. They should go to AAFP to broker a deal to directly refer to rad onc.

Great post! It’s ridiculous. I would even add brain Mets into the equation. Sometimes I’ll get the referral after med onc. I get neurosurgery but ultimately the patient is going to need radiation. We need to be in the frontlines more before they start trying to give immunotherapy before considering SRS.

 

[medgator]

Isn't the elephant in the room here the referral pattern? If rad oncs received all the referrals first then we would be the folks on top - am I wrong? It's SO FRUSTRATING that we are 2-3 steps removed from the patient. Most our patients run through med onc, urology, ENT, pulm, neurosurgery, gyn onc, etc. before they see us. If we were the hub ie direct referral line from family medicine, outpt IM, OB/GYN, etc. then we would be the major players. As it is, everything runs through med onc. Isn't ridiculous that it goes family medicine --> pulm --> med onc --> cardiothoracic surgery --> rad onc for someone who ends up getting SBRT?!?!

Our national leaders in academics who are genuinely incredibly gifted and smart should not stand for this and try to change this referral pattern. They should go to AAFP to broker a deal to directly refer to rad onc.

Agree but you can start things yourself. Go have lunch with your pulmonologist and CT surgeon and discuss the indications for sbrt, maybe collaborate together and educate the pcps on where and when to send patients for LD CT screening.

Why the hell should a med onc get a referral for stage I nsclc with an fev1 of a liter? Makes zero sense to me. There are some practitioners you can't change, but maybe some you can. Works both ways too.... Make sure to send all your combined modality patients to pulmonary for pfts ideally prior to starting chemo xrt. It's part of acr (and hopefully ASTRO Apex) guidelines.

I can't remember the last time I got an head and neck referral from a med onc. At an individual practice level, assuming you aren't in a multi specialty/employed model already, your goal should be to get direct specialty referrals pretty much leaving mets and lymphoma as the only things you end up getting from MO.

ROhub actually has a thread on this and someone posted a primer for pcps on RO in the cme section supposedly though I haven't checked it out:

https://rohub.astro.org/communities/community-home/

 

[Haybrant]

From a clinician standpoint, we have the most oncology training out of all of the onc specialties. We know surgery better the med oncs do and systemic therapy better than the surgeons

How many med oncs do you know that look at their own scans instead of reports or can stage an anal, lung or h&n pt? A med onc wants to do a dre or pelvic to help stage cancer, as much as I want to learn the clotting cascade

We’re the kings of local disease it’s true but we’re not so of oncology where biology is king. There isn’t anything wrong with that im not sure why we should be defensive about it. I personally love having the opportunity to cure so often. But it’s not lost on me that med oncs are the leaders of the cancer patient - general med oncs not so much but those that are specialized know cancer and the biology so incredibly in depth, there just are no rad oncs like them - and since immunotherapy came on the scene we have been left way behind.

The good thing is we can catch up! But we need to re-commit to learning the implications of immunooncology and biology so we’re part of these debates and discussions. I didn’t go to Astro but I’m Going to guess there were more dose/fractionation studies than biological discussions. That is wrong, we need to stop focusing our attention on this ridiculous issue and learn more comprehensive clinical management and biological underpinnings - it will make us much stronger clinicians and less technician but it is tiring to learn

It’s not lost on me that the influence and greed of pharma is part of this. The sad thing is pharma takes advantage of well meaning oncologists - many don’t fully comprehend they are contributing to make very minute changes in outcomes so some a-hole pharma company and execs can be enriched (many though do institutional studies on approved drugs with exquisitely beautiful biology) but that doesn’t change the overall above points.

 

[RadOncDoc21]

We’re the kings of local disease it’s true but we’re not so of oncology where biology is king. There isn’t anything wrong with that im not sure why we should be defensive about it. I personally love having the opportunity to cure so often. But it’s not lost on me that med oncs are the leaders of the cancer patient - general med oncs not so much but those that are specialized know cancer and the biology so incredibly in depth, there just are no rad oncs like them - and since immunotherapy came on the scene we have been left way behind.

The good thing is we can catch up! But we need to re-commit to learning the implications of immunooncology and biology so we’re part of these debates and discussions. I didn’t go to Astro but I’m Going to guess there were more dose/fractionation studies than biological discussions. That is wrong, we need to stop focusing our attention on this ridiculous issue and learn more comprehensive clinical management and biological underpinnings - it will make us much stronger clinicians and less technician but it is tiring to learn

It’s not lost on me that the influence and greed of pharma is part of this. The sad thing is pharma takes advantage of well meaning oncologists - many don’t fully comprehend they are contributing to make very minute changes in outcomes so some a-hole pharma company and execs can be enriched (many though do institutional studies with exquisitely beautiful biology) but that doesn’t change the overall above points.

I don’t know, call me old school but I don’t buy systemic therapy as making such an impact in our field. There are so many other docs who already doing that (med onc, gyn onc, urologists) in which they are all competing against each other. I truly believe we need to make a stronger impact on the referral patterns along with introducing radiation more as a definitive treatment versus an adjunct and discussed sooner in patient care.

Most people don't choose to get a prostatectomy because the treatment is better. It’s all about opportunity and who is presenting the data. I don’t believe me understanding the mechanism of how a PARP inhibitor works is going to get more prostate cancer patients in my door.

 

[radoncgrad2019]

some med oncs are straight clowns. Not even their fault, it's the way they were trained. The worst offenders being the Heme Med Oncs who don't send appropriate lymphoma patients for consolidative RT because they can 'salvage' them with bone marrow transplants.

Let that sink in!

 

[gmsquid]

The reality is, most people think radiation is still cobalt. Well planned, well delivered radiation is much more effective, better tolerated, safer and easier than systemic therapy and surgery.

 

[Sheldor]

Reading through some of these threads is so disheartening, not because of residency expansion, but because it seems that most of the people who show up in threads complaining about job market/residency expansion then go on to bash radiation oncology as a field and suggest that what we do could be done by anybody. (I don't want to go reference it, but suggestions for radiology, etc.) This is madness! (NB: We should reduce residency spots back to 120 per year, but not the point of this post.)

Guys, we get more oncology training than ANY other oncology professional. Even if you do 12 months of research, your 36 months of clinical oncology training is more than Med Onc, Surg Onc, IR, etc. etc. We do AMAZING things. We literally cure Stage I lung cancer with the only side effect being some slight fatigue. We are an essential component of curative and palliative treatment in over half of all oncology patients. Stand up for yourselves, and fight for our field. Cardiologists don't beat them selves up and go online and talk about how the CT surgeons are the lynchpins of cardiac care, etc. We are freakin' oncologists AND physicians, act like it.

Rant over.

 

[Haybrant]

I don’t know, call me old school but I don’t buy systemic therapy as making such an impact in our field. There are so many other docs who already doing that (med onc, gyn onc, urologists) in which they are all competing against each other. I truly believe we need to make a stronger impact on the referral patterns along with introducing radiation more as a definitive treatment versus an adjunct and discussed sooner in patient care.

Most people don't choose to get a prostatectomy because the treatment is better. It’s all about opportunity and who is presenting the data. I don’t believe me understanding the mechanism of how a PARP inhibitor works is going to get more prostate cancer patients in my door.

This sort of proves the point. It’s about getting patients in the door in rad onc. It’s not wrong but our focus is what is our part of the pie, like the surgeons. If you looked at biology and genetics you’ll be able to select the appropriate patients for radiation over surgery. Instead we hide behind the “well urologists never put them on a study so we don’t have randomized evidence yet”. Our framework to stratify is stage and my point is that stage will go out of fashion faster than we think and we’re not equipped for that change

 

[Haybrant]

Off base and not introspective. Why so defensive. Yes we do all this and it’s great, I wouldn’t change that and I do think rad onc is the best. I loved using the ‘we have the most oncology training’ bit too. But our focus is not correct for the future of oncology and since Immunotherapy has rocketed off on the last 3-4 years we are getting left behind in the conversation

Reading through some of these threads is so disheartening, not because of residency expansion, but because it seems that most of the people who show up in threads complaining about job market/residency expansion then go on to bash radiation oncology as a field and suggest that what we do could be done by anybody. (I don't want to go reference it, but suggestions for radiology, etc.) This is madness! (NB: We should reduce residency spots back to 120 per year, but not the point of this post.)

Guys, we get more oncology training than ANY other oncology professional. Even if you do 12 months of research, your 36 months of clinical oncology training is more than Med Onc, Surg Onc, IR, etc. etc. We do AMAZING things. We literally cure Stage I lung cancer with the only side effect being some slight fatigue. We are an essential component of curative and palliative treatment in over half of all oncology patients. Stand up for yourselves, and fight for our field. Cardiologists don't beat them selves up and go online and talk about how the CT surgeons are the lynchpins of cardiac care, etc. We are freakin' oncologists AND physicians, act like it.

Rant over.

 

[scarbrtj]

Radiation oncology was, is, always will be a neurotic pursuit. Are we oncologists who irradiate or radiotherapists who treat disease, cancer included? (Harvey Cushing said that a neurosurgeon is a neurologist who operates e.g. Of course when he said that he was essentially the only neurosurgeon in the world.) There is no chapter on benign disease in Cancer. Can you imagine if there were a radiation oncology textbook and someone tried to entitle it "Cancer?" There'd be a revolt! One day there may be "radiation oncologists" who don't even treat cancer. Could happen. Maybe already has. "We are freakin' oncologists AND physicians, act like it." I will! I haven't rounded on patients on the oncology floor in years but I'm headed up there now 😉

 

[Sheldor]

Off base and not introspective. Why so defensive. Yes we do all this and it’s great, I wouldn’t change that and I do think rad onc is the best. I loved using the ‘we have the most oncology training’ bit too. But our focus is not correct for the future of oncology and since Immunotherapy has rocketed off on the last 3-4 years we are getting left behind in the conversation

So you're issue is with the PhD's and whatever are docs involved in research? I suppose it was, so maybe I'd argue I was on a different base. You say "we need to..." But the truth is most physicians see patients. I have no say in radiation oncology research or the field write large, nor do I want to frankly, I want to take care of patients. So on your point, I agree, those in our field who have decided they enjoy research so take a page out of your book and focus on keeping us in the conversation.

I suppose my gripe is for the 95% of us who "just" see patients.

 

[Sheldor]

Radiation oncology was, is, always will be a neurotic pursuit. Are we oncologists who irradiate or radiotherapists who treat disease, cancer included? (Harvey Cushing said that a neurosurgeon is a neurologist who operates e.g. Of course when he said that he was essentially the only neurosurgeon in the world.) There is no chapter on benign disease in Cancer. Can you imagine if there were a radiation oncology textbook and someone tried to entitle it "Cancer?" There'd be a revolt! One day there may be "radiation oncologists" who don't even treat cancer. Could happen. Maybe already has. "We are freakin' oncologists AND physicians, act like it." I will! I haven't rounded on patients on the oncology floor in years but I'm headed up there now 😉

I am confused by your post. Is your quip that rounding on the floor is necessary to be an oncologist? Or a physician? Although honestly, I guess I am confused by the rest of our post. Why wouldn't we be oncologists who irradiate, I mean that is literally what we are yes?

 

[medgator]

Off base and not introspective. Why so defensive. Yes we do all this and it’s great, I wouldn’t change that and I do think rad onc is the best. I loved using the ‘we have the most oncology training’ bit too. But our focus is not correct for the future of oncology and since Immunotherapy has rocketed off on the last 3-4 years we are getting left behind in the conversation

Immunotherapy isn't curative

 

[Haybrant]

Immunotherapy isn't curative

Oh really you think there are no tails to the curves in pure IO studies. I’m guessing you’ve never looked

 

[medgator]

Oh really you think there are no tails to the curves in pure IO studies. I’m guessing you’ve never looked

Sure, just like chemo rt cures some pancreatic and esophagus patients too. The "tails" of those studies aren't going to change equation for radiation and certainly not in a negative way imo.

On the ground, in the clinic, we are integral to oncology care if we want to be.

I think I've sent 3 referrals in the last month to mo for libtayo since I'm the gatekeeper for skin cancer given my relationship with derms in the area. That certainly isn't lost upon the reps from sanofi/regn

 

[Haybrant]

Sure, just like chemo rt cures some pancreatic and esophagus patients too. The "tails" of those studies aren't going to change equation for radiation and certainly not in a negative way imo

The future is stratification by genetics/ bio markers / environmental markers not by stage. That’s not just academic and theoretical anymore. We’re not doing much to get ready for that change but we really should be and we should do it before the surgeons do

 

[w00tz]

I would agree that medical oncology as a field has made huge advances in the last 5 years and that's something I expect to continue. During one of the interviews for residency, a PD asked me where I think oncology is headed. I said that I think we will increasingly rely med oncs for immuno and targeted therapy, but radiation will still have a role. I think he agreed with me?

As we learn more about cancer biology, there will be more specific targets for systemic therapy address. Rad oncs will always just be targeting DNA, which limits our ability to make huge advances. We can make things more conformal, play with dose/fraction, and play with elective nodal coverage and maybe a couple of things. Not a whole lot of play with - but I don't think immunotherapy will ever eliminate the value we bring in local control. For the foreseeable future, we will still play a large role in many, many disease sites.

If we are talking about individual medical oncologists, they are a mixed bag. Some are good physicians, but there's a good portion of them that I definitely wonder about what they know. As far as training goes, we should have the best foundation in oncology with 4 years of training, minus some for research. Med oncs have to spending part of their fellowship learning heme (eww).

 

[scarbrtj]

Why wouldn't we be oncologists who irradiate, I mean that is literally what we are yes?

I literally do not agree with that. Any more that I think we are literally orthopods who irradiate (HO), ophthalmologists who irradiate (Graves), neurosurgeons who irradiate (AVMs), podiatrists who irradiate (plantar fasciitis), etc. The knowledge zone which is [oncology] contains a subset [radiation oncology] whose size/scope vs [oncology] is rapidly shrinking because [oncology] is exploding. That just is. It is not a "bash" on rad onc, and it doesn't bother me. It's why the radiation biology course, aka cancer biology now, in most residencies has gone from 30 hours total to 60 hours total in the last ~15 years. Within this teaching, there is knowledge which is directly clinically useful to the practicing rad onc and knowledge which is not. So the proportion of useful/not useful teaching in radiation oncology itself is decreasing. I suppose if I have any point it is this: if we proclaim we are oncologists, that we have the most training in oncology (how much colon cancer do we treat? melanoma? multiple myeloma? renal cell?), there's going to be increasing cognitive dissonance. And hey that's really no biggie. Just throwing it out there for discussion. And who cares what we call ourselves. If there were two restrooms, one marked ONCOLOGIST and the other marked RADIOTHERAPIST, into which one would you go to poop? I think it's pretty unique, and pretty savvy, that there is no Department of Radiation Oncology at OHSU e.g. It's Radiation Medicine.

 

[radoncgrad2019]

so 95 percent of what we do is oncology focused, and because of the 5 percent of stuff we do that is NOT oncology focused, we are not oncologists?

Suit yourself, sir, but I am an oncologist. I am not a technician.

 

[scarbrtj]

so 95 percent of what we do is oncology focused, and because of the 5 percent of stuff we do that is NOT oncology focused, we are not oncologists?

Suit yourself, sir, but I am an oncologist. I am not a technician.

Dear Dr. L.:

You asked me the other day on the telephone a quite interesting question. You told me that one of your friends asked you, "What is this fellow Buschke actually doing… is he a radiologist, an internist, or what is he?" This question is, indeed, quite legitimate because the way we in this Institute try to practice our specialty is not orthodox according to the generally accepted subdivision of medical specialties and does not fit into any pigeonhole. This is, of course, due to the fundamental fact that neoplastic disease in all its forms cuts across the other fields of medicine and, while you may call such specialties, as urology, ophthalmology, and otolaryngology, vertical specialties, so that you can place them alongside one another, cancer therapy may be called a horizontal specialty that assumes a part of the functions of all the rest. You can, of course, say the same about cancer surgery, but then, the majority of surgeons are general surgeons and few limit their activities to the treatment of neoplastic disease, as we do with respect to radiation therapy. Both Dr. Cantril and I have in our offices the certificate of the American Board of Radiology, which certifies that we are "qualified to practice the specialty of Radiology." Thus, we will have to call ourselves radiologists, but, interpreted in the generally accepted fashion in which radiology is practiced, this means little indeed with reference to our actual work. In addition, we have limited our field to radiation therapy and do not practice diagnosis. Thus, we are primarily concerned with radiation therapy of neoplastic diseases. But we do not consider ourselves, as too many radiologists still do, technicians who deliver radiating energy to patients under the order of the referring physician. We try to be clinicians who treat the patient...

... What you want to call us, I leave to you.

 

[radoncgrad2019]

Man, someone needs to train this boy in modern day RT, before I do it myself.

this guy pulls more stuff from back in the day, useless stuff, nonsense stuff, irrelevant in 2019 stuff, than an old WWII war vet.

I wish our field had better mechanisms to keep people out of touch 'in touch'

 

[thecarbonionangle]

All of you love med oncs. They feed you. Love that tit

 

[scarbrtj]

Man, someone needs to train this boy in modern day RT, before I do it myself.

this guy pulls more stuff from back in the day, useless stuff, nonsense stuff, irrelevant in 2019 stuff, than an old WWII war vet.

I wish our field had better mechanisms to keep people out of touch 'in touch'

Can you believe this "useless stuff, nonsense stuff, irrelevant in 2019 stuff" is from the exact quote featured on p. 10 of the latest Perez&Brady. (I'm just telling this to others as you already knew that being 'in touch' and what not.)

 

[Lamount]

This conversation is marginally more substantive than a debate over the best flavor of ice cream (chocolate chip cookie dough)

 

[gmsquid]

This conversation is marginally more substantive than a debate over the best flavor of ice cream (chocolate chip cookie dough)

Actually mocha almond fudge

 

[RadOncDoc21]

Actually mocha almond fudge

Whatever my med onc likes!

 

[medgator]

This conversation is marginally more substantive than a debate over the best flavor of ice cream (chocolate chip cookie dough)

Didn't realize how much self hate/loathing and collective chips on shoulders there were in the rad onc community

 

[evilbooyaa]

Didn't realize how much self hate/loathing and collective chips on shoulders there were in the rad onc community

Daresay, collective chocolate chips.

which is the best ice cream.

Anyways - no more. I don't want this good discussion thread getting locked due to a tangent on ice cream flavors.

 

[theradiator]

Quick reality check. There are Heme/Onc practices that are bogged down seeing anemia consults, use hospitalists instead of admitting patients and only sporadically attend tumor boards. Just like us, they don't perform biopsies and use Palliative Care for end of life.

 

[scarbrtj]

Just like us, they don't perform biopsies and use Palliative Care for end of life.

Things that make you go "Hmmm."*

*Summary of [end-of-life care] themes:

The role of the radiation oncologist in end-of-life care is limited... Radiation oncologists lack the interest and expertise to deliver quality end-of-life care... End-of-life care is primarily the responsibility of medical oncologists... Radiation oncologists who engage in end-of-life care may face repercussions​

 

[medgator]

Quick reality check. There are Heme/Onc practices that are bogged down seeing anemia consults, use hospitalists instead of admitting patients and only sporadically attend tumor boards. Just like us, they don't perform biopsies and use Palliative Care for end of life.

Exactly why some specialists who are in the know will refer patients to the specialist with the most oncology training vs the specialist who spent half their fellowship learning heme

 

[scarbrtj]

Exactly why some specialists who are in the know will refer patients to the specialist with the most oncology training vs the specialist who spent half their fellowship learning heme

Now just for sake of full transparency to someone (med student e.g.) who doesn't know beans about rad onc (and assuming the specialist with the most oncology training = radiation oncologist), of the top 10 oncological diagnoses which ones should NOT be referred by those in the know to the specialist with the most oncology training? For my money I would cross colon, melanoma, thyroid, renal, leukemia off the list. Half of NHL. Could go on back and forth either way but you get the gist. (Wish we got more first consults on bladder but we know how that goes.) We have a big role to play. But there's a big but. We can argue we have the most oncological training. The best training. The most beautiful training. We could have a 20y long residency. Wouldn't mean we could, or should, get the colon ca, melanoma etc. consults.

 

[medgator]

Now just for sake of full transparency to someone (med student e.g.) who doesn't know beans about rad onc (and assuming the specialist with the most oncology training = radiation oncologist), of the top 10 oncological diagnoses which ones should NOT be referred by those in the know to the specialist with the most oncology training? For my money I would cross colon, melanoma, renal, leukemia off the list. Half of NHL.

You prefer to have your renal and melanoma brain met pts see med onc first? I don't. In fact, I do get primary melanoma referrals from the same derms that send me bcc and scc all day.

Guess I should tell them what I am and am not capable of seeing* 😉











* - much better to feed med oncs their opdivo/nivo and keytruda pts, given the choice

 

[scarbrtj]

You prefer to have your renal and melanoma brain met pts see med onc first?

Welllll.... if *I* God forbid had metastatic renal or melanoma, on a personal level, I'm going to be more interested in my med onc consult than my rad onc consult. And if I had to schedule the two, I'd schedule the med onc consult first. Brain mets are not an emergency 🙂 Obviously the approach to the mealnoma brain met patient is evolving, at least in the mind of the med onc. We of course can see anything. And come in and pinch hit for a brain met, a bone met, an oligomet, a choroidal met.

 

[Gfunk6]

Our group long ago merged with both Med Oncs and Surgeons. We have a wonderful relationship and learn from each other. The dichotomy posed on this thread pitting MO vs RO is really only present in academics and single-specialty shops.

 

[RadOncDoc21]

Our group long ago merged with both Med Oncs and Surgeons. We have a wonderful relationship and learn from each other. The dichotomy posed on this thread pitting MO vs RO is really only present in academics and single-specialty shops.

Had to come rub it in didn’t you?

 

[Gfunk6]

Had to come rub it in didn’t you?

Always! It's my favorite talking point 🙂

 

[Haybrant]

Our group long ago merged with both Med Oncs and Surgeons. We have a wonderful relationship and learn from each other. The dichotomy posed on this thread pitting MO vs RO is really only present in academics and single-specialty shops.

This is true, the point however isn’t to claim that there is some superiority/inferiority but that the future is focused much differently than our society is taking us and we aren’t helping ourselves out by staying mired in the same topics of residency expansion and dose/fractionation.

Side note, This weeks JCO has a great rad onc/genomics article. This is the future

https://ascopubs.org/doi/full/10.1200/JCO.19.00761

 

[ramsesthenice]

To the OP, I don’t think you are totally off-base. Our leadership certainly has demonstrated that they are not great at the whole big picture thing. That said, I do think some of your comments are a bit misguided and reflect a lack of context in many regards. A few examples:

Too many trainees are caught up in the immunotherapy hype. I was in a cancer bio PhD program in 02 and that was when Gleevec and Herceptin were just getting going. This was the targeted therapy revolution that was going to make chemo and radiation obsolete! Almost 20 years later not a single targeted agent has replicated those early success stories. Immunotherapy is impressive but no where near close to shutting us down.

ASCO has all the good science and all ASTRO has is retrospective junk. Do you go to ASCO? 98% of it is institutional or phase 1/2 studies replicating some clinical study for the 7th time with a minor tweak. Like say, induction chemo for head and neck cancer.

Med onc has changed so much over 20 years and all we have done is make our delivery more precise. What exactly do you think we should have done? Invent a new form of radiation? Oncology had to come up with new drugs because the stuff they used in the 80s frankly didn’t work that well (especially without modern supportive care). In-field a photon beam still does a better job killing cancer than any systemic therapy. I also suspect you have never seen what someone who just finished up a course of 2D cobalt H&N RT looks like. The return on investment admittedly gets smaller with each iteration and I can understand being underwhelmed with each new proton vs photon trial that gets proposed but a lot more has happened in rad onc than you seem to appreciate

Red Journal is not “our journal,” particularly for biology. Pub Med people like Ralph Weichselbaum, Sylvia Formenti, or Max Diehn and look where their basic science papers are published. Nature Subjournals. CCR, etc. If you are measuring the scope of rad onc basic science from the red journal you are missing most of the impactful work.
Engaging with other oncology disciplines will always be the key to not getting left behind. Like Gfunk and Gator have said in our highly integrated (academic) system my spot at the dinner table keeps getting bigger, not smaller. For all of our issues as a field, we are not as simple, helpless, or clueless as many (including a surprising number from within) think.

 

[Krukenberg]

To the OP, I don’t think you are totally off-base. Our leadership certainly has demonstrated that they are not great at the whole big picture thing. That said, I do think some of your comments are a bit misguided and reflect a lack of context in many regards. A few examples:

Too many trainees are caught up in the immunotherapy hype. I was in a cancer bio PhD program in 02 and that was when Gleevec and Herceptin were just getting going. This was the targeted therapy revolution that was going to make chemo and radiation obsolete! Almost 20 years later not a single targeted agent has replicated those early success stories. Immunotherapy is impressive but no where near close to shutting us down.

ASCO has all the good science and all ASTRO has is retrospective junk. Do you go to ASCO? 98% of it is institutional or phase 1/2 studies replicating some clinical study for the 7th time with a minor tweak. Like say, induction chemo for head and neck cancer.

Med onc has changed so much over 20 years and all we have done is make our delivery more precise. What exactly do you think we should have done? Invent a new form of radiation? Oncology had to come up with new drugs because the stuff they used in the 80s frankly didn’t work that well (especially without modern supportive care). In-field a photon beam still does a better job killing cancer than any systemic therapy. I also suspect you have never seen what someone who just finished up a course of 2D cobalt H&N RT looks like. The return on investment admittedly gets smaller with each iteration and I can understand being underwhelmed with each new proton vs photon trial that gets proposed but a lot more has happened in rad onc than you seem to appreciate

Red Journal is not “our journal,” particularly for biology. Pub Med people like Ralph Weichselbaum, Sylvia Formenti, or Max Diehn and look where their basic science papers are published. Nature Subjournals. CCR, etc. If you are measuring the scope of rad onc basic science from the red journal you are missing most of the impactful work.
Engaging with other oncology disciplines will always be the key to not getting left behind. Like Gfunk and Gator have said in our highly integrated (academic) system my spot at the dinner table keeps getting bigger, not smaller. For all of our issues as a field, we are not as simple, helpless, or clueless as many (including a surprising number from within) think.

Young guns in rad onc are publishing multiple papers in Cell and Nature. Andy minn and Sam bakhoum