My only concern for Rad Onc

[ukdoc74]

Okay so I have it down to Heme Onc vs Rad Onc. Obviously, Rad Onc is much more competitive because it is a tremendous field. The blend of technology, patient contact, and intellectual content is unparalleled. With all that said, I have to be honest. After investigating the field, they dont seem like the traditional physicians that I think of in that sense. Heme Onc physicians get solid training in internal medicine which allows them to be clinically competent. Having clinical knowledge is very attractive to me. dont get me wrong, I believe radiation oncologists have superior knowledge of clinical trials and the literature. Still that clinical skill to be a true clinician bothers me.

My question is this. Is Heme Onc worth going through internal medicine to become a true clinician. Is clinical competence overrated. Also, the tumor boards I have seen seem like the Heme Onc guys run the show and the rad onc guys are supportive. I like to be the leader of a group so does this mean I will regret Rad Onc because it tends to be supportive staff in oncology to the clinical oncologists.

Lastly, I have a couple rad onc physicians say that they love the field but miss working up patients for the diangnosis. Are Heme Onc guys have exclusive rights to work up a patient to find the diagnosis. Rad Onc is a great gig but I prefer the intellectual pursuit of trying to find the diagnosois.

Thank yoi very much for your thoughts and experiences.

---

Members don't see this ad.

 

[ukdoc74]

If I enjoy being a clinical physician and/or the intellectual exercise of working up a patient to find the diagnosis will I regret going into Radiation Oncology?

 

[bragmt]

Tough question, to be honest I often found the actual diagnostic eval of patients...well...annoying. For about 90% of the patients that I saw in my one year of internal medicine I felt like I knew the diagnosis in about 5 minutes of them talking. "I wake up short of breath, and I need to sleep with 3 pillows" type of thing. Yea, got it. For about 9% I knew the diagnosis after a few lab tests. Well looks like the troponin was 3.4, bingo, that neck pain was an MI, heparin drip it is. Then there was about .5% that really required some extensive tests/consults/waiting not knowing if they would get better until we found something that was positive. OHHH, why did we not check the legionella titer. Of Course!! Then there was about .5% that we never found out what was going on. Often annoying.

I usually became interested when we actually found out what was going on, then I was curious to see well what evidence is there to the treatment of this disease? How can we make this person do better? I felt like the diagnostic work up was an annoying guessing game. It was nothing like an episode of House where the attending sits around and goes over extensive differentials in a well cut suit. It was more like lets toss the kitchen sink at this patient and hope something comes back positive. And I did a my year at a very large/respected academic medicine program.

Bottom line if you really enjoy the rare times when patients are a true mystery and need to be extensively "worked up" and you enjoy actually ordering the tests then Rad Onc may not be for you. Rad Oncers get our patients delivered as well packaged diagnoses with biopsies and imaging ready for our eyes to apply evidence to help them beat their cancer with minimally invasive and awesome technology.

The line about the Rad Onc's at your institution not running the show during tumor board is very cancer center dependent. As you know historically Rad Onc was very easy to match into, hence many of the old Rad Onc attendings may have typically been the types that sat back and did not speak up much. More of a "casually go with the flow" type. This personality of the "quite Rad Onc doc" has changed dramatically as our applicant pool is stacked with some of the most qualified and talented applicants that exist. Young attendings know their stuff and want to make sure everything is done in accordance with the best and most recent evidence that exists. They speak up a lot. If you go to some of the top cancer centers, such as MDACC ,Rad Onc dominates and runs the show pretty much all the time, so if you want to be a leader in a cancer center Rad Onc is a great way to do that.

 

[clintpark]

Still that clinical skill to be a true clinician bothers me.

I hear your concern (I too get frustrated that I have no idea what to give for my own daughter's otitis media --- but then, do I really want to manage it? No!). The truth of the matter is, nobody (after Dr. Osler) has the comprehensive knowledge of all the medicine and everyone works within the limited scope of their own training. Like bragmt said, there really isn't a great mystery in most diagnoses (like the ones you see in House, MD) and those rare diagnoses are made by specialists, not internal medicine docs, anyways. I do think we rad oncs should have enough clinical skills to recognize and, to a certain extent, manage our own complications to earn the respect of our peers.

I like to be the leader of a group so does this mean I will regret Rad Onc because it tends to be supportive staff in oncology to the clinical oncologists.

Come visit UT Southwestern's thoracic tumor board. It will instantly change your view on what role rad oncs can play in multidisciplinary tumor boards. Rad oncs truly have the greatest expertise in evidence based medicine among various modalities of oncology (surgeons don't have much of evidence based mindframe. Med oncs often put too much value on phase I or retrospective studies) and can play a huge role in directing the treatment, if you want to be assertive, probably the biggest role with the exception of pathologists. Remember, your title doesn't force you to take a more submissive role, often, it's individual rad onc's (or a surgeon's, or a med onc's) personality.

Are Heme Onc guys have exclusive rights to work up a patient to find the diagnosis. Rad Onc is a great gig but I prefer the intellectual pursuit of trying to find the diagnosois.

Heme oncs do not participate in diagnoses, either, really. They get called when imaging shows a big mass, labs are obviously unusual, or path already shows cancer. Pathologists make cancer diagnoses, not medical oncologists. What med oncs do is staging work-up, which is pretty much a list of checkboxes, and not very intellectually stimulating. By the time patients get to me, they usually have a lot of studies, but sometimes, it's not complete (especially, if they come directly from a surgeon). I often order those (again staging workup, not really a diagnostic study) myself and not infrequently find something that's going to change the management strategy.

If I haven't convinced you that the process of making diagnosis is overrated, perhaps, you could look into neurology; I hear it's intellectually very stimulating.

 

[medgator]

perhaps, you could look into neurology; I hear it's intellectually very stimulating.

that and derm would honestly bore me to tears.

 

[MD13]

I hear your concern (I too get frustrated that I have no idea what to give for my own daughter's otitis media --- but then, do I really want to manage it? No!). The truth of the matter is, nobody (after Dr. Osler) has the comprehensive knowledge of all the medicine and everyone works within the limited scope of their own training. Like bragmt said, there really isn't a great mystery in most diagnoses (like the ones you see in House, MD) and those rare diagnoses are made by specialists, not internal medicine docs, anyways. I do think we rad oncs should have enough clinical skills to recognize and, to a certain extent, manage our own complications to earn the respect of our peers.

Thanks for your input. I fact, what I bolded above is exactly my main concern in pursuing RadOnc as a specialty--that I will lose my 'general' medical knowledge and become so specialized that I cannot function in a basic capacity as a general physician.

Is it that one does not get significant exposure as an intern on IM? (certainly you must have treated otitis media then..) Or is it that your day to day practice causes you to simply lose what you dont practice in terms of skills/clinical knowledge/etc?

I am a medical student and absolutely love the idea of becoming a RadOnc, but this aspect is something that, quite frankly, bothers me quite a bit. Do you have any more advice or words of wisdom to impart?

 

[arthurdent]

Thanks for your input. I fact, what I bolded above is exactly my main concern in pursuing RadOnc as a specialty--that I will lose my 'general' medical knowledge and become so specialized that I cannot function in a basic capacity as a general physician.

Yes, but if you become a general physician, you'll have no idea what to give for a small laryngeal cancer with positive contralateral nodes.

In this day and age, there's no way to know everything about everything. "Clinical competence" isn't knowing how many days of what antibiotic to give, or which antibody is the most sens/spec for an SLE diagnosis. Its being able to assess your whole patient and their disease process in the right context, and to effectively communicate treatment options and the rationale behind your recommendations to patients, families, and your colleagues.

 

[eekthecat]

you could also look into interventional oncology, it's a sub-specialty of radiology, granted you don't see pt's for 4 years of DR residency, but interventional oncologists (really IRs who do a lot of oncology, but will liekly become a subspecialty of IR given how different it is from other components of the field) are developing new procedures all the time, TACE, RFA, cryo, many of which are starting to show equivalent efficacy in treatment to surgery, in addition they are shifting towards managing pt's other problems as well, many top fellowships are becoming 2 years to learn better clinical skills. Again, if the idea of doing a 4 year DR residency isn't your bag, this may not be the thing for you.

 

[clintpark]

Is it that one does not get significant exposure as an intern on IM? (certainly you must have treated otitis media then..) Or is it that your day to day practice causes you to simply lose what you dont practice in terms of skills/clinical knowledge/etc?

BOTH:
I don't think I treated whole lot of otitis media as an internal medicine intern. I probabaly did a few cases as a medical student at an outpatient pediatrics clinic. But, the internal medicine internship is pretty much about adult hospital medicine (now being taken over by hospitalists)---rule out MI, CHF exacerbation, community acquired pneumonia, etc. It will become clear to you once you start your internship. Through internship, you will develop eyes to identify who's sick and who's not (sounds simple, but takes practice and exposure) and learn how the medical system/paperwork works. Also, along the way, you will come to appreciate it's pretty hard to kill someone or to prevent someone from dying. That's about it, I am afraid. So, even if I remembered everything from my internship, I won't necessarily be more clinically competent in the sense you are thinking about. (secret: even during internship, you won't know the antibiotics dose/schedule, you will just have a handbook handy to look it up)

AND MORE:
It may feel good right now to think that you will be clinically competent if you did more primary care/ internal medicine, but the truth (my truth, anyways) is that unless you are practicing that field, you really have no business offering opinions about another doctor's patient. You will know enough to say "you should see a [fill in specialty]" and interpret/translate for your loved ones so that they can navigate through all the medical jargon they'll come across, but stay away from managing them. In some ways, I think it's somewhat arrogant to think we can take care of family medicine/internal medicine/pediatric patients because those docs went through many years of training to know what they know and are good at. Saving your family members (or friends) copays of some $30 may ultimately be a great disservice to them.

Clinical competence... is being able to assess your whole patient and their disease process in the right context, and to effectively communicate treatment options and the rationale behind your recommendations to patients, families, and your colleagues.

Now, this is very true, and you will develop this as a rad onc. In fact, you may become better than most docs because our consults are much longer than the visits at PCPs and, guess what, your patients really listen to you.

 

[clintpark]

Do you have any more advice or words of wisdom to impart?

Guessing from your ID, you are an MS1? My advice is to look at all fields with honest assessment of who you are. For extremely competitive fields (of which rad onc is one), the earlier you find out what you want to do, the better. However, you should not decide that without at least considering the following.

Do you want to interact with patients vs. other docs vs. inanimate objects?
Are you intrigued by mystery vs. want things organized?
Does adrenaline motivate you vs. frustrate you?
Life style? Regular vs. erratic schedule?
Like hands-on procedures vs. technology vs. intellectual exercise vs. emotions?
Like to take charge vs. content to sit back and let others drive?
Want to feel generally competent vs. specialize and know only your stuff.
Do you get satisfaction out of taking care of your patients well or do you need life outside medicine?
I am sure there are more...

When you have answered these questions, you will have much clearer idea what you want to do.

 

[clintpark]

TACE, RFA, cryo, many of which are starting to show equivalent efficacy in treatment to surgery...

I do not think many IR procedures are compared to the surgical modalities in a prospective manner, let alone in a head to head comparison.

It would be one thing to say that it's effective (especially in palliative settings, it's very good primarily because it's less invasive than surgery...), but I don't know how one can say it's equivalent to surgery in efficacy without having a prospective, head-to-head comparison. Perhaps, I need to be updated on new data?

 

[Palex80]

It would be one thing to say that it's effective (especially in palliative settings, it's very good primarily because it's less invasive than surgery...), but I don't know how one can say it's equivalent to surgery in efficacy without having a prospective, head-to-head comparison. Perhaps, I need to be updated on new data?

The problem is that surgeons are generally not interested in head-to-head comparisons of other techniques with their own therapies.
We have yet to see randomized trials comparing primary radiochemotherapy and surgery for several types of cancer.

 

[MHotep]

IMHO, medical oncologists (especially as they become more "seasoned") do not know how to manage bread and butter medicine as well as a PGY-3 internal medicine resident. At least that has been my experience being at a very large tertiary care center. Most of the medical oncologists at my institution are not even boarded in internal medicine...unless they are very junior or are grandfathered in from the 1980s so they are not required to recertify. Medications and recommendations are constantly changing for management of basic medicine conditions like COPD, CAD, Diabetes, and medical oncologists do not necessarily need that information--no more than a cardiologist needs to have knowledge of chemotherapeutic agents (other than maybe doxorubicin).

And in terms of diagnosing cancer, at my institution medical oncology refuses to see patients without a tissue diagnosis, which makes sense. The only recommendation they can make is do a biopsy at that point.

 

[ukdoc74]

Agree with MD13.

It is not that simple.

There is no doubt that radiation oncologists know the cancer literature much more than the medical oncologists.

However, radiation oncologists spend a lot of timing during residency learning radiation and physics. Most clinical oncologists are board certified or board eligible in internal medicine. That is 3 years of medical treating patients inpatient and outpatient.

That is what bothers me the most.

Radiation oncologists is a great field but let's be frank. The physicists and dosimetrists actually give radiation treatments to the patients. The radiation oncologists oversee everything. Also, seeing patients outpatients. If there is a need for admitting a patient a radiation oncologist needs to call a medical oncologist to take over. This lack of clinical competence seems frustrating.

Sure some radiation oncologists do treat patients in the outpatient setting but one could argue that they have the same practical clinical competence of a nurse practioner.

Am I reading too much into this?

In the United Kingdom, where I was born things are different. But, are radiation oncologists considered a "physician" in the traditional sense that a medical oncologist is viewed?

Radiation oncologists have superior knowledge of Cancer and the Cancer literature but 3 years of internal medicine training and 3 years of clinical oncology on the floors seems tough to overcome.

Any thoughts?

Are radiation oncologists essentially the de facto Knowledge Sages of Oncology rather than "complete" clinical physicians such as medical oncologists?

Plus, the patients flow from the medical oncologists to the radiation oncologists so it seems like there is a lot of politicking to get patient referrals and being willing to be treated like a second citizen to the medical oncologists to be in good "political" standing. It would be the other way around if most radiation oncologists were the primary oncologist and gave referrals to the clinical oncologists. But it isn't that way.

The clinical oncologists seem like they control the patient flow thus have the political capital to treat radiation oncologists with less respect.

 

[arthurdent]

Agree with MD13.

If there is a need for admitting a patient a radiation oncologist needs to call a medical oncologist to take over. This lack of clinical competence seems frustrating.

If you think that "clinical competence" is only defined by the ability to write admission orders and manage patients in a hospital setting, then its becoming clear that rad onc is not the specialty for you...

 

[deleted4401]

I can't manage acid-base issues any more, I'm hesitant with acute chest pain and immediately send people to the ER, I can't trach someone or put a line in, etc. If you drop me in Haiti, I'm not going to offer as much to the victims as a general surgeon or an ICU doc. No need to be defensive about what we do. Holy crap.

But, I don't want to do any of those things. It's not interesting to me. Therapeutic management of cancer ... now that's interesting.

Depending on where you work and the specific contract situation, there is a fair amount of politick-ing/working for consults. In markets like Atlanta, multiple radoncs working independently share a linac or two (professionally, not technically) then go to the same tumor boards and beg for cases. Certain markets are monopolized by the rad-oncs in town. Makes life a bit easier.

-S

 

[clintpark]

ukdoc74, a lot of what you are saying here is a little disturbing and makes me curious how you were able to "have it down to Heme Onc vs Rad Onc." I would suggest you do more soul searching (see my previous post and ask yourself those questions) to see if rad onc really suits you.

Most clinical oncologists are board certified or board eligible in internal medicine. That is 3 years of medical treating patients inpatient and outpatient.

"Clinical oncologist" is a specialty that does not exist in the U.S. It is a British specialty that delivers both chemo and radiation (Dr. Zietman is a clinical oncologist, I believe.) Where do you even get that terminology? Are you a British med student? Hence your ID? If so, I don't know what rad oncs are like there, and I have nothing further to comment.

Radiation oncologists is a great field but let's be frank. The physicists and dosimetrists actually give radiation treatments to the patients.

Frankly, I give radiation treatments. Perhaps, you believe pharmacists who mix chemo drugs and nurses who hang the bags are the ones that actually give chemotherapy? One may argue that having competent physicists, dosimetrists, and therapists is much more important than having good chemo nurses, and that's definitely true. On the other hand, what I do for my radiation therapy has a lot more impact on how it is delivered compared to what med oncs do in writing their prescription. It's just that radiation therapy is just so much more sophisticated than chemotherapy and it needs more people working together.

If there is a need for admitting a patient a radiation oncologist needs to call a medical oncologist to take over. This lack of clinical competence seems frustrating.

You are right. I don't admit patients nor do I have hospital priviledges to admit patients even if I wanted to. I would call the patient's med onc or a hospitalist to admit them. So, if the clinical competence is measured by inpatient medicine skills only, I guess that makes me incompetent. I happen to disagree, but many people do share your opinion, so I can't be indignant. But, by that measure, hospitalists are the most competent clinicians and will soon be the "only" competent doctors.

Sure some radiation oncologists do treat patients in the outpatient setting but one could argue that they have the same practical clinical competence of a nurse practioner.

That's so uncalled for. Shame on you.

Am I reading too much into this?

Yes.

But, radiation oncologists considered a "physician" in the traditional sense that a medical oncologist is viewed?

... but 3 years of internal medicine training and 3 years of clinical oncology on the floors seems tough to overcome.

... "complete" clinical physicians such as medical oncologists?

Who's feeding you these lines?

The clinical oncologists seem like they control the patient flow thus have the political capital to treat radiation oncologists with less respect.

Your observation here is valid since many rad oncs do fit the mold you are describing. However, most med oncs won't have any problem if you disagree with them as long as we know our stuff (I said "our stuff", not general clinical medicine) and take good care of their patients. That's how we earn their respect. This is true of any specialists, including med oncs who rely on general practioners and hospitalists to "feed them." In fact, med oncs have to play nice with dozens of them while rad oncs work with a few surgeons and a few med oncs at most.

 

[ukdoc74]

Do you want to interact with patients vs. other docs vs. inanimate objects?
1. Interact with patients and other physicians. Definitely not inanimate objects.

Are you intrigued by mystery vs. want things organized?
1. Love the intellectual challenge of a mystery and the medical workup needed to find the answer.

Does adrenaline motivate you vs. frustrate you?
1. Adrenaline frustrates me. Have never considered ER or Surgery.

Life style? Regular vs. erratic schedule?
1. Regular schedule. Plan on having a wife and kids one day.

Like hands-on procedures vs. technology vs. intellectual exercise vs. emotions?
1. Hands on procedures are overrated. How many IJs does it take to get over the thrill. My over/under is 3. I prefer intellecutal stimulation over working with my hands.

Like to take charge vs. content to sit back and let others drive?
Half/Half. It depends. If I feel like the members of the team will not get it done I will step up. If I trust the team I will let them drive and watch closely.

Want to feel generally competent vs. specialize and know only your stuff.
Specialized and know your stuff.

Do you get satisfaction out of taking care of your patients well or do you need life outside medicine?
Both. I love taking care of patients but understand the importance of balance so I like life outside of medicine.

 

[ukdoc74]

Clint and others,
First of all, thank you very much for answering my questions. As you guys know, I am not the only one that has concerns about radiation oncology. Your answers are helpful not only for me but others that have the same concerns.

My belief is this. Every subspecialty (including rad onc) in medicine has pros and cons. Granted, majority of the rad oncs tend to be happier than almost any other specialty. There is no denying that. Still, there are a few (much fewer than any other medical specialty) that are not happy with radiation oncology. I am trying to figure out why. Because I don't want to be one of those people.

The question boils down to this. I have worked so hard in medical school and undergraduate (like many other rad onc residents) that I am in a position to match at a top 10 internal medicine program and ultimately go for heme onc or land a rad onc position. This is such a tough decision. I have narrowed down like this.

Rad Onc Pros and Cons
----------------------
Pros
1. Perhaps the most complete oncologists. Treat almost every organ system except liquid tumors.
2. Hands down the most knowledgable oncologists of the medical literature. Rad Oncs are the de facto sages of oncology. Know more than any other oncologists.
3. Developing Technology that continues to evolve to treat cancer patients. Great toys.
4. Don't have to be the one that says someone has cancer. They come to radiation therapy after the diagnosis.
5. Great Lifestyle and Remuneration.
6. Make a tremendous impact on patient's lives.

Cons
1. Do not have the clinical acumen of medical oncologist. Cannot overcome 6 years of clinical care. Are radiation oncologists a "true physician". I would lump in radiology and pathology in that group. They have MDs but do they have the medical knowledge to treat patients in Haiti for example.

2. Have to be politically adept to keep receiving patients from medical oncologists. Some call it kissing arse and/or be willing to be treated like a second citizen since medical oncologist have the power to pull back the patients. Does anyone get tired of being a "salesman" to stay on the medical oncologist's good side.

3. Some say not as intellectually stimulating as medical oncology. Most physicians say that the most intellectually stimulating exercise is the diagnostic workup. Rad Oncs patients already have a diagnosis. Although it takes a lot of neurons to memorize the vast number of cancer literature, is memorizing studies truly stimulating? People keep saying rad onc is intellectually stimulating. But how?

4. Lack of Power and Autonomy. If a medical oncologist calls you for a patient referral at 4 pm. You have to defer and agree to see the patients. Does this bother anyone that the medical oncologists have the power to abuse rad oncs.

5. Have to learn Physics and know it extremely well. How many medical students truly love physics or is good at it. Isn't this the reason we went to medical school instead of getting a PhD in engineering or physics?

 

[DrJD]

Ukdoc, I can't speak for the residents and physicians on this board, but as a medical student it seems that a lot of the things in your "Con columns" I would throw over to my personal pro column.

 

[Gfunk6]

Dear ukdoc,

Do yourself a favor and go into Medical Oncology. You will be happier and so will your future colleagues in Radiation Oncology.

Sincerely,

Gfunk

 

[SRK Jerk]

You keep saying Rad Oncs don't diagnose cancer etc...as if med oncs do. This a point that has been responded to repeatedly, yet you seem to ignore it.

This seems to lead me to the conclusion that you're well-intentioned, but you are here in order to get turned-off by Rad Onc so you can go into Heme/Onc without feeling like you made the wrong choice. You asked this question hoping the answer would be "yeah if you like 'clinical medicine' go into heme/onc" -- when most of the replies pointed out that heme/oncs are also incredibly specialized, you chose to ignore them and kept insisting that they are not.

I was in a similar position as you, to be honest, but I quickly realized that my conception of the heme/onc being some House-like diagnostic wizard was way off. Sure, you manage complications related to chemo etc (which to be fair, could involve a fair deal of organ system stuff) -- but radiation isn't sans organ-specific side effects which the Rad onc must manage, so that's not really a major difference. Your IM clinical acumen will degenerate as you go further and further as a heme/onc attending.

If you're not able to convince yourself that rad onc is intellectually stimulating enough for you -- which appears to be the case -- just seriously reconsider whether heme/onc will do the trick either.

Just my $0.02 from someone who was basically in your shoes not too long ago.

 

[deleted4401]

Oh and by the way, nobody is abusing radiation oncology except the New York Times and the New England Journal, both of which can't hide their joy when there is a radiation error or if there may be a removal of an indication for RT.

If there is a 4pm consult, it's not a big deal - it doesn't happen a lot, and you as a caring person would see it, regardless of if you gave a crap what the med onc thought.

But, it still is more "medicine-y" than rad-onc. I moonlight in-house for the med-onc services and the admissions are for complications of oncologic treatment, but also pneumonia, failure to thrive, pulmonary embolism, shortness of breath, abdominal pain, etc. I definitely have to take my time and step back to work these problems up, because I'm so far removed. The med-onc fellow on with me definitely knows the doses of the heparin or IV antibiotics whatever. They don't think I'm dumb or less competent - it's a matter of scope and what you see commonly.

We are for the most part outpatient docs. We have a scope of practice that is limited to therapeutic radiology, the side effects of such treatment, and long term follow-up of cancer patients. And this thought that across the board rad oncs know the most ... that's a load of crap. As a group, we probably do. Individually, there are med-oncs that know the literature just as much as we do. There's even head and neck surgeons, lung surgeons, and urologists that know as much as we do. You can't just assume they all as a group know less than you do.

I think everyone is getting really defensive. Spend a month doing both. To me (and most people on this board), there is no question that rad onc is more stimulating. If you get bored, you'll know the answer.

-S

 

[JumpingFrenchmn]

We have a scope of practice that is limited to therapeutic radiology, the side effects of such treatment, and long term follow-up of cancer patients.

I realize I'll learn this in a few months when I do my Rad Onc elective, but out of curiosity, what kinds of complications do you guys manage? I'm assuming Rad Onc docs take care of most complications that are a direct result XRT like pneumonitis, but what about complications of the patient's underlying malignancy? How about something like tumor lysis syndrome? Also, when/how does one decide when to include other specialists involved (e.g., Cardiologist for XRT-induced cardiotoxicity)?

Thanks in advance for all your insight.

 

[eekthecat]

in response to clintpark (not to hijack this thread) you're correct, there are few studies out right now doing prospective head to head comparisons of surgical vs. percutaneous cancer treatment, most Intervetional Onc cases are reserved for patients who are too ill for surgery or for palliative measures. But that is rapidly changing, unfortunately most of these studies are being done in Europe, regarding using SIRT(y-90) and RFA in early stages of CA, especially in hepatic CA (primary and metastatic). In an ideal world, we (rad onc, heme/onc, surge onc, and interventional onc) would all work together, but I guess it's still about the dollar bills.

not sure why I decided to post anyway, guess I have too much free time on call. good luck to all matching this year.

 

[Gfunk6]

I realize I'll learn this in a few months when I do my Rad Onc elective, but out of curiosity, what kinds of complications do you guys manage?

For H&N cancer there is: xerostomia (loss of saliva), mucositis, odynophagia, skin irritation

For prostate cancer there is: dysuria, urinary urgency, urinary frequency

For breast cancer there is: "sun-burn" type reaction which can progress to moist desquamation in some cases (esp. in women with large breasts breasts)

For CNS cancers there is: variety of transient neurologic dysfunction depending on area of brain/spine you are treating

These can all be managed pharmacologically or with prevention (e.g. for H&N treatments, don't drink liquids w/ acid content).

I'm assuming Rad Onc docs take care of most complications that are a direct result XRT like pneumonitis, but what about complications of the patient's underlying malignancy?

XRT pneumonitis is something that doesn't typically occur until several weeks after radiation. Nowadays, we have dosimetric parameters to minimize risk.

Tumor lysis syndromes are a result of chemotherapy and, therefore, are managed by medical oncologists. However in cases where patients are receiving concurrent chemo and XRT it is important for you to follow a patient's CBC with special attention to ANC/platelets because you may withold treatment if they run too low.

Also, when/how does one decide when to include other specialists involved (e.g., Cardiologist for XRT-induced cardiotoxicity)?

For some long-term radiation side effects there are no good curative solutions so we focus on prevention. For instance, quit smoking to minimize your risk of secondary lung malignancy or don't put on excessive weight/don't let cuts in your arm fester to mimize your risk of arm lymphadema after breast cancer XRT.

XRT-induced cardiotoxicity generally manifests as accelerated atherosclerosis (or so it is hypothesized) due to oxidative damage. If a pt has an MI 10 years down the road or so, then it will be managed normally by a cardiologist/CT surgeon.