My reasons against a career in radiation oncology

[TheoLeo]

I am a german medical student approaching the end of medschool. With this thread I want to present the reasons that keep me from choosing radiation oncology. I thought this might be usefull for people who are indecisive as well. I am also very interested in hearing your opinions about my reasoning. I do not have experience or a great knowledge in the field of radiation oncology and therefore the reasons I present might be "immature".

These are the reasons that speak against going into radiation oncology:

1. Low potential for improval
As I see it, locoregional control can be achieved by surgery or RT with acceptable side effect in most cases and entities. Sure you can play with selective sensitizers/radioprotectors, fractionation, gene signatures for better predictions, in vivo imaging to assess tumor sensitivity, breathing gating, using more angles in sbrt, particle therapy and so on but in the end, what all this will do, is improving something that already is very good. The only big potential in cancer treatment lies in the control of systemic, disseminated disease.
I care about the potential for improvement, because I want to get paid for improving sth rather than maintaining sth.

2. Too much evidence for the evidence based medicine in radiation oncology
Every treatment should be as close to evidence based medicine as possible. I am all for it. I feel like the extremely (in comparison to other fields) close adherence to hard evidence is the number one requirement for being a good radiation oncologist. Its the one thing a radiation oncologist can be most proud of and where the big value of a radiation oncologist lies. He/she knows all the relevant studies and is able to interpret them and then give a very good estimate of how likely a specific patient is going to benefit to a specific degree from a specific dose/fractionation/modality. I think this has historic reasons, as this specialty tried to "tame" a very dangerous animal (=high energy radiation). But whats negative about it? Since radiation oncolists tried to find ways to use radiation in the most effective and save way, plenty of hard, objective evidence for its best use exists. These data are out there for everyone to read. So a radiation oncologist copies this data into his/her brain and matches his patients with this data to find the right treatment. Thats the first intellectual performance. When a patient doesn´t precicely fit certain criteria of study xy, the radiation oncologist needs to "improvise" a little by using his experience, basic medical knowledge, logic to find the treatment that gives the most benefit/least harm. Thats the second intellectual performance. However, the more hard evidence there is for every single tiny subgroup of patients, the less need there is for the second intellectual performance. And I feel like this is the case. Even if you "improvise", you improvise in a very narrow safety zone. Correct me if I am very wrong. If the need to improvise (=making decisions based on your unique, subjective knowledge instead of on guidelines) fades away, your only medical value lies in copying guidelines into your brain and matching patients to that. A computer could do this faster and better...
Therefore, I would not feel very valuable in my job. I want to do sth where I know that a pc isnt better at it. Take the skill to build and evaluate a good differential diagnosis as a gp for exemple: Here, my own unique experience and my ability to assess mimic/body language/social status etc withing a fraction of a second, make me very valuable as a human being (also because there is not such a good, close knit net of objective evidence for each decision as there is in radiation oncology).

3. We are not trained for it
95% of the knowledge that I developed in medschool, will not be needed in radiation oncology. I could maybe be a very good radiation oncologist with a 2 year training. I dont need to go to medschool for 6 years for it. I want to put the skills and knowledge that I developed over the years to its best use. And I think this will be in a field like general medicine/pediatrics.

As you can see, all my reasons are based on being valuable to my community. I know this is only a fraction of what can influence my or someone elses decisions (life style, physical disabilities
etc matter as well of course). But at least in Germany, medschool is for free and therefore I feel like I owe sth to my community rather than to a bank or to myself.

By the way, I already did 1 1/2 years of research in a lab for radiation biology because I considered this field as my future, but now I am very unsure about it.

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[RadOncDoc21]

 

[scarbrtj]

If the need to improvise (=making decisions based on your unique, subjective knowledge instead of on guidelines) fades away, your only medical value lies in copying guidelines into your brain and matching patients to that. A computer could do this faster and better...

This is actually pretty insightful. As the years have gone by, and things like software auto-contouring have appeared and are only bound to get better, I have foreseen the ability for a computer to do the job of a radiation oncologist. I know that seems far-fetched to some, but machine learning coupled with early A.I. could easily come up with a total plan--normal structures, target volume, dose fractionation, etc. Then what is the need for the human radiation oncologist? You could still have a radiation oncology department, just that the medical oncologist or surgeon will order chemoRT or post-op RT much like they'd order a PET or an MRI. The patient would go down to radiation oncology and the highly trained techs, dosimetrists, and physicists will administer the radiation as devised by the radiation software in a safe (and highly reproducible re: institution to institution) manner. Managing patients during and after radiation for side effects comes along with some rad onc-specific particulars and inside baseball, but it's nothing a medical oncologist can't handle (skin creams for burns, treatment breaks for neutropenia, medications for pain or nausea, etc.).

Fortunately, I don't think we'll be there for another good 20+ years, allowing me to finish this career I've chosen

 

[Get_schwifty]

 

[OTN]

I'll comment your third concern. Frankly, I've found that I use knowledge gained in medical school and even my medicine internship all the time in radiation oncology. During a course of treatment, as you'll be seeing every patient every week, in a way you become the de facto primary care physician for these patients. Sure, you're not adjusting diabetes medication dosing or working on other chronic conditions, but patients do ask about all kind of symptoms and all kinds of problems. In order to be a good radiation oncologist, and not simply turf each and every question to PCP, having a working knowledge of all of medicine is important.

Second, we interface with many, many different specialties. You have to be able to talk intelligently with pulmonologists, cardiothoracic surgeons, urologists (maybe you can use small words with them at least), interventional radiology, medical oncology, surgical oncology, colorectal surgery, gastroenterology, etc, etc. Without a good base of medical training you would have no idea what the procedures they were doing really entailed, and you couldn't reliably talk to your patients about the risks and benefits of all the different options available.

The jury is still out for me when it comes to automation of our career. On one hand, I don't want to rule it out, as there's no saying what might happen over the next few decades. However, currently, auto-contouring programs can't even get the chiasm perfectly correct, so it's not even in the near future or on the horizon at this point. Too far away to speculate IMO.

 

[canadianoutlaw]

This is actually pretty insightful. As the years have gone by, and things like software auto-contouring have appeared and are only bound to get better, I have foreseen the ability for a computer to do the job of a radiation oncologist. I know that seems far-fetched to some, but machine learning coupled with early A.I. could easily come up with a total plan--normal structures, target volume, dose fractionation, etc. Then what is the need for the human radiation oncologist? You could still have a radiation oncology department, just that the medical oncologist or surgeon will order chemoRT or post-op RT much like they'd order a PET or an MRI. The patient would go down to radiation oncology and the highly trained techs, dosimetrists, and physicists will administer the radiation as devised by the radiation software in a safe (and highly reproducible re: institution to institution) manner. Managing patients during and after radiation for side effects comes along with some rad onc-specific particulars and inside baseball, but it's nothing a medical oncologist can't handle (skin creams for burns, treatment breaks for neutropenia, medications for pain or nausea, etc.).

Fortunately, I don't think we'll be there for another good 20+ years, allowing me to finish this career I've chosen

i respectfully disagree completely with everything the OP said and on many levels.

for starters...
1. radiation oncology is at no greater risk of being automated than any other medical specialty.
2. patient presentations are infinite and unique. no matter how detailed guidelines are they will never cover all the infinite complexities of cancer care
3. automation is a good thing and should be embraced. there will always be more for us to do.

 

[evilbooyaa]

Let me state that this answer will be as someone who trained in the US system, and I'm not privy to the (likely) differences between US and German medical education.

I'm all in support who previously show a strong interest in Radiation Oncology or Rad Bio changing their mind as they learn about the field and learn about what's important to them as a career in medicine.

This thread is going to, once again, become a discussion about the poor job prospects, expansion of fellowships, decreasing reimbursement, increasing hospital employment, etc., woe is me, sky is falling discussion that is in almost every thread that espouses the negatives of radiation oncology. For the record, I believe all of those things are extremely important to the health of the field as a whole.

However, I want to focus on the actual field of radiation oncology and OP's concerns.
Here's the main negatives about Rad Onc (as a field) for me:
Rarely have to use your diagnostic skills that are so emphasized in medical school.
Reliance on outside referrals from specialists as nearly all patients won't be sent to a Radiation Oncologist from the PCP.

There's a ton of positives, hence why I actually went into the field. I won't list all of those because I think there's too many.

I am a german medical student approaching the end of medschool. With this thread I want to present the reasons that keep me from choosing radiation oncology. I thought this might be usefull for people who are indecisive as well. I am also very interested in hearing your opinions about my reasoning. I do not have experience or a great knowledge in the field of radiation oncology and therefore the reasons I present might be "immature".

These are the reasons that speak against going into radiation oncology:

1. Low potential for improval
As I see it, locoregional control can be achieved by surgery or RT with acceptable side effect in most cases and entities. Sure you can play with selective sensitizers/radioprotectors, fractionation, gene signatures for better predictions, in vivo imaging to assess tumor sensitivity, breathing gating, using more angles in sbrt, particle therapy and so on but in the end, what all this will do, is improving something that already is very good. The only big potential in cancer treatment lies in the control of systemic, disseminated disease.
I care about the potential for improvement, because I want to get paid for improving sth rather than maintaining sth.

Locoregional control is NOT good in a multitude of locally advanced diseases - off the top of my head - Pancreatic Cancer, GBM (really most primary intracranial diseases), Cholangiocarcinoma, HCC, Sarcoma, some H&N stuff, to a lesser extent gastric cancer.
Yes, distant metastasis is a bigger problem for most patients with locally advanced cancers.
One thing that is always echoed by those who have experienced clinical radiation oncology - as systemic treatments become better and better, localized treatments will continue to have value if (more like when for metastatic patients) those drugs eventually fail.

So yes, the potential to prolong overall survival if you can come up with a magic systemic therapy is greater than with a new radiation technique, sure.
If your focus is on improvement for the entire population (through the development of novel systemic agents that are gonna blow all the current therapies out of the water), then honestly you need to become a primary researcher, be it a physician-scientist or a regular scientist. Clinical practice is mostly about maintaining stuff. Clinical trials can sometimes get into improving outcomes, but I think those are quite prevalent regardless of whether you go into rad-onc or med-onc.

2. Too much evidence for the evidence based medicine in radiation oncology
Every treatment should be as close to evidence based medicine as possible. I am all for it. I feel like the extremely (in comparison to other fields) close adherence to hard evidence is the number one requirement for being a good radiation oncologist. Its the one thing a radiation oncologist can be most proud of and where the big value of a radiation oncologist lies. He/she knows all the relevant studies and is able to interpret them and then give a very good estimate of how likely a specific patient is going to benefit to a specific degree from a specific dose/fractionation/modality. I think this has historic reasons, as this specialty tried to "tame" a very dangerous animal (=high energy radiation). But whats negative about it? Since radiation oncolists tried to find ways to use radiation in the most effective and save way, plenty of hard, objective evidence for its best use exists. These data are out there for everyone to read. So a radiation oncologist copies this data into his/her brain and matches his patients with this data to find the right treatment. Thats the first intellectual performance. When a patient doesn´t precicely fit certain criteria of study xy, the radiation oncologist needs to "improvise" a little by using his experience, basic medical knowledge, logic to find the treatment that gives the most benefit/least harm. Thats the second intellectual performance. However, the more hard evidence there is for every single tiny subgroup of patients, the less need there is for the second intellectual performance. And I feel like this is the case. Even if you "improvise", you improvise in a very narrow safety zone. Correct me if I am very wrong. If the need to improvise (=making decisions based on your unique, subjective knowledge instead of on guidelines) fades away, your only medical value lies in copying guidelines into your brain and matching patients to that. A computer could do this faster and better...
Therefore, I would not feel very valuable in my job. I want to do sth where I know that a pc isnt better at it. Take the skill to build and evaluate a good differential diagnosis as a gp for exemple: Here, my own unique experience and my ability to assess mimic/body language/social status etc withing a fraction of a second, make me very valuable as a human being (also because there is not such a good, close knit net of objective evidence for each decision as there is in radiation oncology).

There's a ton of cases that don't have a straight-forward answer that can be ruled by guidelines or studies. That's why multi-disciplinary tumor boards for all sites are near ubiquitous in all major hospital system. Sure, there are guidelines, but a good radiation oncologist is the one, who at the end of the day, knows when to push RT, and when to say RT is no longer an option. See the discussion on this forums - there are multiple grey zones in Radiation Oncology right now. There are trials that give conflicting recommendations for the same disease process, like MAGIC vs ARTIST vs McDonald (vs CRITICS vs TOPGEAR eventually), and that's just for locally advanced gastric cancer. Pancreas cancer has trials (ESPAC) that say RT kills people, and other trials that say RT absolutely helps.

Older trials don't get quoted as often once the techniques have evolved - 70Gy as definitive RT for prostate cancer is not standard of care now, although all the old trials used that. Hence there are new trials looking at possibility omitting certain areas of treatment (whole pelvis vs prostate only RT, need for ADT) to improve unnecessary toxicities. Possibly treating the primary in metastatic prostate cancer prolongs survival

3. We are not trained for it
95% of the knowledge that I developed in medschool, will not be needed in radiation oncology. I could maybe be a very good radiation oncologist with a 2 year training. I dont need to go to medschool for 6 years for it. I want to put the skills and knowledge that I developed over the years to its best use. And I think this will be in a field like general medicine/pediatrics.

Medical students are not trained for the vast, vast majority of fields outside of the core rotations (given our forced exposure to IM, FM, Peds, Psych, Surgery, and Ob/Gyn as 3rd year students).

Regardless, you're still a doctor as a Radiation Oncologist. H&P is still the most important aspect of our daily activities, even if most of it is from chart review. While the bulk of the day is not spent on diagnosis, there are multiple diagnoses caught by the Rad Oncs I've worked with over my short career - PE, DVT, CHF Exacerbation, Shingles, Cellulitis, Abscess, Open wound infections, etc. If your focus is putting what medical school taught you into practice with the most ease, then I agree that general medicine (IM/FM) is the field that we have most exposure to.

As you can see, all my reasons are based on being valuable to my community. I know this is only a fraction of what can influence my or someone elses decisions (life style, physical disabilities
etc matter as well of course). But at least in Germany, medschool is for free and therefore I feel like I own sth to my community rather than to a bank or to myself.

By the way, I already did 1 1/2 years of research in a lab for radiation biology because I considered this field as my future, but now I am very unsure about it.

I think a radiation oncologist is extremely valuable to a community. In the US, there are huge areas of the country dying for radiation oncologists to come and work full-time to serve the community. May be not as much of a problem in a smaller country like Germany.

tl;dr
If you don't like the field because it's not enough diagnosing, then so be it. Rad onc won't be a winner there.
If you feel that automation and guidelines are too overpowering, I would first work in a Rad Onc department to see the level of customization that most plans have, especially in this day and age of IMRT booming. If it's not enough for you, then so be it.
You still have to know the basics of medical school, because Rad Oncs don't practice in a vaccuum. Having a complete lack of knowledge of basic anatomy, physiology, and procedures that other fields perform will leave you as nothing more than the person who just does what he's told with no spine to push for (or against in some situations) radiation.

 

[scarbrtj]

Everyone's making great points; all great reasons to choose rad onc. But I *do* believe this is where medicine is headed, and if so, rad onc will get there sooner than anyone else because we all have to admit our specialty is more recipe-ish than others and a bit more replete with non-physicians (therapists, dosimetrists, physicists) involved with the delivery of a substantial portion of that care.

 

[Gfunk6]

Well, since we've obviously steered into futurology allow me to offer a few rationale why "organic" doctors will not be fully replaced:

1. Doctors with their primitive organic brains cannot be hacked

2. When a patient is crying in front of you because you just told them their diagnosis is terminal, organic doctors can actually show empathy, embrace/touch patients, and relate personal experiences from their lives to help patients cope.

3. Break the rules for patient benefit: for instance deliberately down code to avoid out of pocket expenses for poorer patients or give them free samples even when the hospital says not to.

The future lies not in Watson type machines but transhumanism. There will be machine-brain interfaces that combine the best of both worlds.

 

[thecarbonionangle]

1) As systemic therapy becomes better, this will only lead to local therapies being even more important. There is a limit to how aggressive surgery can be unless we have some massive advances in tissue compatible bioengineering. Radiation will continue to play a role as this sytemic therapy becomes better and widely metastatic patients are "downstaged" to oligometastatic disease with resistant clones. Currently things like immunotherapy and targetted agents have many challenges that may or may not ever be worked out. how do you get immune cells to an avascular necrotic tumour? Single targetted agents have the same problem as antibiotics (eventual resistance develops in some people).

2/3) you need to be clinically strong to be a good radiation oncologist. Being clinically competent will earn you respect from you colleagues in other specialties. Many radiation oncologists choose to defer anything "medical" to PCP or medical oncology but this will be truly up to you if you choose to be a doctor and manage other issues. I frequently get asked questions about blood sugars and insulin units weekly (or many other medications), I prescribe antibiotics weekly, I order labs/cultures and follow their results, diagnosed a DVT after I had clinical suspicion and started a patient on therapeutic lovenox, very comfortable with palliative pain control etc etc. This is all based on your comfort level and what type of doctor you choose to be. Many patients essentially stop going to other doctors during treatment because they are overwhelmed and it is up to you to be their doctor. I do "medicine" weekly. I had a very challenging intern year and I feel comfortable doing all these things. We offer plenty of value to the community and to imply otherwise tells me you don't have a full understanding of all we do.

 

[thecarbonionangle]

I'll tell you what worries me about our field. What worries me is that we are falling behind in basic science research. Technology is great but it can only carry you so far. There is a lot of emphasis in making things more conformal and using more powerful forms of radiation to try to improve outcomes. There may be something there, particularly with heavier ions, but I don't think it will be that practice changing in the majority of cancers. There is so much money being invested in billion dollar immunotherapies that maybe improve survival very slightly but little being invested in comparison in research for radiosenstization and radioprotection ( think about all those compounds in the Hall chapter and how many of them are actually used clinically). There is little understanding and research going into understanding the abscopal effect and exploiting it. Everything seems to be about dreaming about a world when we can phase out radiation and just give someone immunotherapy and we are letting med onc control this narrative.

There are also trials that come to mind in radiation that need to be done or repeated and are simply not really being done. All these influx into the field of "bright minds" as the field has become competitive has not necessarily translated to massive advances in the field. I can see how someone may interpret this as going nowhere stagnation.

 

[FindMeOnTheLinks]

I think once someone figures out how to start harnessing/enhancing the abscopal effect for major cancers, the field will explode. That is easier said than done of course. But OP's suggestion that the field has reached its peak of new discoveries and we are now just striving to optimize delivery of treatment, couldn't be further from the truth.


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[OTN]

I'll tell you what worries me about our field. What worries me is that we are falling behind in basic science research. Technology is great but it can only carry you so far. There is a lot of emphasis in making things more conformal and using more powerful forms of radiation to try to improve outcomes. There may be something there, particularly with heavier ions, but I don't think it will be that practice changing in the majority of cancers. There is so much money being invested in billion dollar immunotherapies that maybe improve survival very slightly but little being invested in comparison in research for radiosenstization and radioprotection ( think about all those compounds in the Hall chapter and how many of them are actually used clinically). There is little understanding and research going into understanding the abscopal effect and exploiting it. Everything seems to be about dreaming about a world when we can phase out radiation and just give someone immunotherapy and we are letting med onc control this narrative.

There are also trials that come to mind in radiation that need to be done or repeated and are simply not really being done. All these influx into the field of "bright minds" as the field has become competitive has not necessarily translated to massive advances in the field. I can see how someone may interpret this as going nowhere stagnation.

I strongly, strongly agree with this. Our academic centers should be ashamed of how far they're behind the ball when it comes to harnessing the abscopal effect for our field.

 

[evilbooyaa]

Having done labwork in radioprotectors as a med student, the issue is that NIH funding is reallyyyyyy drying up, and for the most part, pharmaceutical companies would rather sponsor trials with the next big immunotherapy rather than a more focused radioprotector.

 

[TheoLeo]

I appreciate all the thoughtfull contributions!
You are saying that there is a lot of carryover from the medschool knowledge to radiation oncology, you say that you need diagnostic skills, you say that there is potential for future improvements, you say that there is a high level of improvisation/customizing (and a significant impact of that customizing on the patients overall health), you say that a ronc can´t be replaced by a computer (at least not totally) and you say that a ronc is valuable to a community. I agree! But facing a choice, I (and maybe other medical students) try to compare all these aspects to other fields.

About the need to improvise/customize:
Sure, not every trial or guideline is valid enough for your local circumstances and current patients. So you need the knowledge to be able to adjust your treatment accordingly. For exemple, chemo/surgery/staging procedure changes and suddenly there is no good evidence for radiotherapy in this new setting and you need to continue making the right desicisions until there is. Maybe the surgeon tells you that he/she did a complete D2 dissection for his gastric cancer patient..then what? I see the issue. Its just not clear to me, how much of this is really required and what the impact of this is. If this happens a lot, then that truly is challenging. Do you have some more exemples? I checked the forum as well already.

About the potential for improval:
Improving locoregional control biologically (I guess thats where the potential is) by selective sensitizing/protection in a clinically relevant amplitude is very hard. Every new strategy for cancer control will try to have the best therapeutic index possible. To find such a strategy specifically for radiation is way less likely than it is to find a strategy with a high therapeutic index in general. It is as if you were the specialist for aspirin and the big goal is to cure people from migraine. Everyone is free to find whatever treatment might work, but you have to find a drug/strategy that makes aspirin work wonders for migraine. So in radiation biology, one is very restricted (restricted by the need to make radiation work better). Just as the aspirin specialist is restricted by the need to make aspirin work for migraine.

The abscopal effect won´t really be specific to radiation, but it might still show some benefit. I think so too.

 

[seper]

telemedicine is probably going to hit medical physics pretty soon, pretty hard

 

[medgator]

telemedicine is probably going to hit medical physics pretty soon, pretty hard

Can everything they do be done remotely? Machine qa?

 

[thesauce]

*Increased conformality + particle therapy is bull**** in terms of science. It's just that SBRT and proton therapy bills well and a good # of academic rad/onc chairs are all about money and short-term gains.
*A chair of research at a top center was explaining to me why radioprotection/sensitization is hard to get NIH-funded...I forget exactly what he/she said, but it's true.
*If you think the field can be automated, then you should do it. You'll make a ton of money and patients (esp. in rural areas w/o access to radiation oncologists) will benefit.
*RO isn't about "radiation" per se but image-guided therapy. If something like focused ultrasound proves to be better over time (either as a standalone modality or in combo with systemic therapies), the RO workflow doesn't really change...I think. Also, RO isn't limited to "oncology"; think cardiac ablation for arrhythmias for patients that are too sick for the EP lab.

I saw that report on a.fib. treated with RT. Amazing.

 

[thecarbonionangle]

The field is vastly behind in research in radioprotection and radiosensitization. There is very little money going into this compared to other med onc research. Much of this is due to the specialty's failure in educating the public about the value we provide in patient care and allowing the narrative about the miracle systemic therapy to dominate the discussion and nothing about how to make radiation better ( look up any article about Jimmy Carter and all you read is about the miracle drug which "saved" him and nothing about the gamma knife). The "cancer moonshot" has no radiation oncologists in the leadership, and Joe Biden can't be counted to do anything competently. The majority of cancer centers are led by medical oncologists. Surgical oncology and medical oncology departments historically dominate tumor boards and control them. Particularly in the past, radiation oncology was like fight club, the first rule of radiation oncology is that you don't talk about radiation oncology. Most physicians have no clue what we even do. It doesn't surprise me at all most people think radiation will eventually die. Those "miracle" immunotherapies which cost millions that cook people's livers are sure far better than the "big bad radiation" we have to phase out! One of the things that always ends up mattering is perception and I feel like we have ignored this for too long. There is a growing perception that radiation must be phased out and is on the way out.

Chairs all over the country are focused on the same things: expanding programs and having cheaper labour, departments hire chairs who run departments like money making private practices, all paying lipservice to getting protons, an MRI linac, and now multiple departments are openly saying they are getting carbon ions (the next "big" thing).


Looking at this year's google doc disgusts me. More expansions. More new programs. We are already spinning around the toilet bowl.

 

[Krukenberg]

The field is vastly behind in research in radioprotection and radiosensitization. There is very little money going into this compared to other med onc research. Much of this is due to the specialty's failure in educating the public about the value we provide in patient care and allowing the narrative about the miracle systemic therapy to dominate the discussion and nothing about how to make radiation better ( look up any article about Jimmy Carter and all you read is about the miracle drug which "saved" him and nothing about the gamma knife). The "cancer moonshot" has no radiation oncologists in the leadership, and Joe Biden can't be counted to do anything competently. The majority of cancer centers are led by medical oncologists. Surgical oncology and medical oncology departments historically dominate tumor boards and control them. Particularly in the past, radiation oncology was like fight club, the first rule of radiation oncology is that you don't talk about radiation oncology. Most physicians have no clue what we even do. It doesn't surprise me at all most people think radiation will eventually die. Those "miracle" immunotherapies which cost millions that cook people's livers are sure far better than the "big bad radiation" we have to phase out! One of the things that always ends up mattering is perception and I feel like we have ignored this for too long. There is a growing perception that radiation must be phased out and is on the way out.

+1. Just want to point out the great work subatomicdoc is doing on social media to address the fundamental problem you've identified (essentially it boils down to poor advocacy for the specialty). The number of rad oncs on twitter participating actively in the oncology social media world is increasing every day and subatomicdoc is doing the most to lead it.



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[DebtRising]

As much as I criticize aspects of this field, and I agree with the comments about us in general being behind in basic research, I don't blame the field so much for that. And the reason is that there is no funding. Some things seem like obvious opportunities - more research nin dose fractionation schemes in animal models and immune response, assays to predict response, customization of dose based on genetic markers, etc. Obviously some of these are ongoing and some are not.

Let's not pretend medical oncology chairs are uniquely basic research devotees - they have multi-billion dollar behemoths behind drug development, and the system has designated drugs for the biggest potential financial reward. Don't take this as a condemnation of drug companies either, they produce wonderful products. Even if we made a breakthrough in dose fractionation schemes that produce the greatest immunologic response, which financial party benefits from that? No one outside the PI, which experiences a limited gain. It's a societal benefit, but compare it to the financial gain of a single positive new immunotherapy drug - not even the same universe of $$$. Look at how much academia basic research was done in immunology for decades, culminating in some of these drugs. Yes society benefits from this and that is the role of government funding for research - but society only has a tangible financial penalty, first in the tax dollars that funded the research, then in the $15,000 it costs for a dose of Opdivo. The company makes billions, and then correctly plows some of that back to research in search of the next profit source. The same incentive model is absent in our field, and why spend so much effort on an agent that requires radiation for effectiveness?

In reply to the original post, there is a lot of customization in radiation, a depth more than medical oncology in my opinion. Protocols only take you so far in treating an individual patient, but every specialty has the opportunity to make unique decisions in that regard. What's unique is that delivering radiation is not cookie cutter, and has many more variables and degrees of freedom than prescribing a medication. Could it be automated? It probably will be to some extent, but not completely-computers can't advocate for people. Right now auto-contour doesn't even get lung tumors right if they are by a vessel or fissure. The pace is anyone's guess. It certainly will destroy dosimetry first, so watch for that as a true canary in a coal mine sign.

Regarding Radiation Oncology in the US, it is effectively an abusive field for new graduates for the foreseeable future. The interview document suggests more programs this year. Once quick glance leads me to believe there are at least 2 more programs in NY than I remember - because of course that job market is under-served. The existential questions you pose are less relevant in the US market where there is already a predicted labor oversupply and continued new expansions of programs, and continued government funding for slots. This field ate its young in the mid-90s and I guess is happy to do so again as long as it keeps their department workload and finances in order. Hard to advocate strongly for a field that seems so intent on abusing the residency system as a way to pare reimbursement changes.

 

[thecarbonionangle]

New Programs this year:

Stony Brook (NY)
University of Tennessee (Memphis)


New programs over the past few years:

Cedars-Sinai (LA)
North Shore (NY)
University of Mississippi

New programs soon to start (rumored):

University of Arkansas
West Virginia
Insert another program in NYC and LA because they just keep popping up.


--------------

Add this to all the expansions over the past few years and you see where this is heading. If the google doc is to be believed, Yale now takes 5 and Vandy takes 4 a year, UCLA is now 3 a year........list of expansions goes on and on. The rationale for these expansions is the same everwhere, that they have the volume, that they have increasing patient loads, but this is nothing but a cover up for chairs who prefer to have cheap labour over hiring far more expensive PAs, NPs which negotiate their contracts, and ask for things like matching 401ks (most residency programs don't even give you a 401k), and don't take call. I have zero faith in our "leaders". We continue to circle the toilet bowl.

 

[medgator]

Add this to all the expansions over the past few years and you see where this is heading.

We continue to circle the toilet bowl.

Objectively, yes

http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

Honestly, those of us who graduated even a few years ago are in a much better position job wise than the folks graduating now. Literally every job that gets posted at the astro job site is a bogus non-accredited "fellowship" or some place in the rural midwest or rural west coast (along with some northeast jobs where I imagine salaries are lower).

Haven't seen a FL job posted in ages....because FL is pretty saturated, by and large. Ditto for the desirable areas of tx, nc, sc etc. It's like the leadership is pumping out grads like crazy to fill those remaining Wisconsin/kansas/iowa/dakota etc. jobs.

 

[TheoLeo]

Reason Nr.4: Financial pressure to radiate
As with any specialization that makes money by offering procedures, there is a big incentive to treat a patient even though the benefit is at least questionable. And as long as you are not at the top of the food chain, the incentive turns into pressure. I heard a department head asking his resident, who decided against a treatment in a questionable case, if he wants to be a specialist for or against radiotherapy. Funny, but it sums up my concern.

Btw, that is one of the biggest drawbacks of the ongoing specialization and subspecialization. Sure, medicine becomes more efficient and less mistakes are done, but it turns the patient into a market place to compete in. Maybe the overall health benefit would be greater, if less specialization would be required (a ronc could be a radiologist again who doesn´t need to radiate because his job doesn´t depend on it).

 

[Dare2Dream]

Objectively, yes

http://www.redjournal.org/article/S0360-3016(16)30289-9/abstract

Honestly, those of us who graduated even a few years ago are in a much better position job wise than the folks graduating now. Literally every job that gets posted at the astro job site is a bogus non-accredited "fellowship" or some place in the rural midwest or rural west coast (along with some northeast jobs where I imagine salaries are lower).

Haven't seen a FL job posted in ages....because FL is pretty saturated, by and large. Ditto for the desirable areas of tx, nc, sc etc. It's like the leadership is pumping out grads like crazy to fill those remaining Wisconsin/kansas/iowa/dakota etc. jobs.

There is rightfully quite a bit of concern about the number of RO residency spots and the discussed shortage of jobs for residents. With 160 or so residents finishing up each year, we're not seeing large number of members posting here each year about their personal struggles finding a job. That makes me wonder whether it is because those struggling to find jobs, who've always been high achievers, don't want to discuss their struggles with this issue or if the vast majority are still finding decent jobs in less desirable location but mainly through networking. Has anyone looked at how many of these dubious "fellowship" positions there are that are actually getting filled each year and whether there is enough of them to mask the unemployed count?

 

[bluebubbles]

I heard a department head asking his resident, who decided against a treatment in a questionable case, if he wants to be a specialist for or against radiotherapy.

That's really sad. Yet it pervades the field. Just look at the maniacal responses to the WBRT trial.

I don't think that rad onc has to be so bound to radiation, or to push it so much. I'm sure med onc's thought that they'd be bound to cytotoxic chemotherapy forever once upon a time, and just spend their lives tweaking doses, formulations, adding chemosensitizers...

Being a used car salesman is not my cup of tea.

 

[Sheldor]

New Programs this year:

Stony Brook (NY)
University of Tennessee (Memphis)


New programs over the past few years:

Cedars-Sinai (LA)
North Shore (NY)
University of Mississippi

New programs soon to start (rumored):

University of Arkansas
West Virginia
Insert another program in NYC and LA because they just keep popping up.


--------------

Add this to all the expansions over the past few years and you see where this is heading. If the google doc is to be believed, Yale now takes 5 and Vandy takes 4 a year, UCLA is now 3 a year........list of expansions goes on and on. The rationale for these expansions is the same everwhere, that they have the volume, that they have increasing patient loads, but this is nothing but a cover up for chairs who prefer to have cheap labour over hiring far more expensive PAs, NPs which negotiate their contracts, and ask for things like matching 401ks (most residency programs don't even give you a 401k), and don't take call. I have zero faith in our "leaders". We continue to circle the toilet bowl.

Just slight clarifications: University of Arkansas is still years away from existing, if it ever does. I was told they were "starting a residency soon" back in 2008. Also, vanderbilt and yale haven't increased their numbers in 4-5 years, but they each have lopsided classes from when they last added a spot.

Still, your point stands and we need far fewer programs!

 

[medgator]

There is rightfully quite a bit of concern about the number of RO residency spots and the discussed shortage of jobs for residents. With 160 or so residents finishing up each year, we're not seeing large number of members posting here each year about their personal struggles finding a job. That makes me wonder whether it is because those struggling to find jobs, who've always been high achievers, don't want to discuss their struggles with this issue or if the vast majority are still finding decent jobs in less desirable location but mainly through networking. Has anyone looked at how many of these dubious "fellowship" positions there are that are actually getting filled each year and whether there is enough of them to mask the unemployed count?

I guarantee the job market hasn't increased 60% over the last decade the way the number of residency positions has in RO.

Guarantee

 

[Kazaki]

OP is a perfect example of how useless the German medical system is.
Goodluck in whatever field you go into.

 

[Krukenberg]

*If you think the field can be automated, then you should do it. You'll make a ton of money and patients (esp. in rural areas w/o access to radiation oncologists) will benefit.

Google's DeepMind project to auto-contour head and neck

https://www.google.com/amp/s/www.te...-to-streamline-targeted-cancer-treatment/amp/


Sent from my iPhone using SDN mobile app

 

[seper]

.

 

[seper]

Can everything they do be done remotely? Machine qa?

You're right, currently monthly LINAC QA cannot be done remotely.

 

[TheoLeo]

OP is a perfect example of how useless the German medical system is.
Goodluck in whatever field you go into.

Could you be more specific, please? Useless in what regard? And how am I an example of this uselessness? Maybe it even relates to the topic.
Thanks.

 

[Kazaki]

Could you be more specific, please? Useless in what regard? And how am I an example of this uselessness? Maybe it even relates to the topic.
Thanks.

95% of the knowledge that I developed in medschool, will not be needed in radiation oncology.

I cannot come close to justifying a statement like that from a medical doctor.
The medical education you received is BS, or you do not have a good understanding of what exactly a radiation oncologist does.
Whichever one it is, it reflects a poor system.

 

[evilbooyaa]

I saw that report on a.fib. treated with RT. Amazing.

Link?

 

[TheoLeo]

@Kazaki: I see. You don´t like the rhetoric in my statement. Fair enough. What I mean with that is, that I think that in other specialties, I will, on average, need more of my already acquired knowledge and skillset on a day-to-day basis than in radiation oncology. Think of a radiation oncologist and a general internist doing the usmle steps again after 20 years of practise. I could imagine, that the general internist, on average, does better.
It doesn´t mean a radiation oncologist does not need to know anything. No need to be condescending.

 

[OTN]

@Kazaki: I see. You don´t like the rhetoric in my statement. Fair enough. What I mean with that is, that I think that in other specialties, I will, on average, need more of my already acquired knowledge and skillset on a day-to-day basis than in radiation oncology. Think of a radiation oncologist and a general internist doing the usmle steps again after 20 years of practise. I could imagine, that the general internist, on average, does better.
It doesn´t mean a radiation oncologist does not need to know anything. No need to be condescending.

Sure, a general internist would be better than a radonc on that test, but I'd be willing to bet we'd do better than most orthopedic surgeons, neurosurgeons, radiologists, pathologists, etc, etc, etc. You're significantly undervaluing your general medical education, to be honest.

 

[RadOncDoc21]

Sure, a general internist would be better than a radonc on that test, but I'd be willing to bet we'd do better than most orthopedic surgeons, neurosurgeons, radiologists, pathologists, etc, etc, etc. You're significantly undervaluing your general medical education, to be honest.

:troll:

 

[medgator]

Sure, a general internist would be better than a radonc on that test, but I'd be willing to bet we'd do better than most orthopedic surgeons, neurosurgeons, radiologists, pathologists, etc, etc, etc. You're significantly undervaluing your general medical education, to be honest.

Not to knock psych, but I think that's a specialty more along the lines of what TheoLeo was thinking of.

 

[kimplera]

Whatever the reasons we went into radiation oncology in the past, i think it is critical that we remember (and tell others) that the treatment we use has the ability to both CURE patients of their cancers and palliate them as they approach the end of life. This puts us in a very powerful position and should be something we are proud of every day. Clearly we can do better, but what other oncologist routinely does both of those in the same day?

 

[TheoLeo]

Whatever the reasons we went into radiation oncology in the past, i think it is critical that we remember (and tell others) that the treatment we use has the ability to both CURE patients of their cancers and palliate them as they approach the end of life. This puts us in a very powerful position and should be something we are proud of every day. Clearly we can do better, but what other oncologist routinely does both of those in the same day?

The ability to provide cure or relieve is very attractive. But I, at least in my surely incomplete understanding, have the impression, that the workload in radiation oncology (and medical oncology) is substantially inflated by treatment practises that are driven by financial reasons (or tradition). I might be very wrong about this too, I understand. But this is my impression and that´s why I am trying to hear your opinions about it.

Take the palliative treatment for bone metastases for example. I thought there surely is level one evidence to support this widely used practise. But to my knowledge, there isn´t a single large RCT comparing XRT to a mock-XRT in this setting. The astro guidelines just state that it is widely used and effective (they don´t cite anything, because there is nothing to cite, I assume) and then continue explaining how different fractionation schedules are equally effective/ineffective (citing a lot of great RCTs on this question).
All you find are evaulations of response rates to XRT without a placebo control. Response rates are about 60%, which is great (https://www.ncbi.nlm.nih.gov/pubmed/17416863).

But treatment of gonarthritis with XRT (mostly 1Gy 2-3x/week for two weeks) seems to have a comparable response rate (50-70%). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582586/
Unfortunately, there also isn´t a single modern RCT (to my knowledge) comparing XRT to placebo-XRT for osteoarthritis. There is however one study from the 70s, that examined the pain relieve of a mock-XRT in several benign painfull conditions of the locomotor system (OA etc). The overall response rate for improvement of pain was again about 60-70%. http://www.tandfonline.com/doi/abs/10.3109/02841867009129108.

This makes the use of XRT for pain relieve from bone metastases at least questionable. And since it is an expensive treatment, I think there should be better evidence to support its wide use in this setting.

Without a doubt, there are patients that truly benefit from XRT and even get cured because of it. But this doesn´t exclude that it might be an overinflated field that might pop in the rising concerns about cost effectiveness around the world.

 

[medgator]

This makes the use of XRT for pain relieve from bone metastases at least questionable. And since it is an expensive treatment, I think there should be better evidence to support its wide use in this setting.

Really? What about compared to any other intervention? Where are the randomized kyphoplasty trials?

Heck, what about narcotics vs nsaids? The narcotic epidemic in this country is significant in terms of morbidity and mortality, shouldn't we be treating patients with NSAIDS until an rct is available?

 

[TheoLeo]

Really? What about compared to any other intervention? Where are the randomized kyphoplasty trials?

Heck, what about narcotics vs nsaids? The narcotic epidemic in this country is significant in terms of morbidity and mortality, shouldn't we be treating patients with NSAIDS until an rct is available?

You are absolutely right, I think. They need to be done. It has been done for arthroscopic debridement in OA (which is also a treatment that had response rates of about 50%). As it turned out, it wasn´t better than a fake-arthroscopy. http://www.nejm.org/doi/full/10.1056/NEJMoa013259#t=article. Same was shown and done for partial meniscectomy: http://www.nejm.org/doi/full/10.1056/nejmoa1305189#t=article

Edit: I am sure that these RCTs will come for XRT as well. For the patients and the specialty, I hope that they show a clear benefit for XRT over a mock-XRT. But I would not bet on it.

 

[OTN]

The problem with XRT vs. mock-XRT for bone mets is that we DO have good non-randomized data showing what very much does appear to be a significant benefit to XRT. As a result, from a clinician's standpoint, the trial you propose would not have equipoise, and I do not believe it would be ethical to enroll people on the trial.

Not every decision you will make as a physician will have Level I, RCT-based evidence. This is one of those situations. However, just because you don't have that data doesn't mean people are treating bone mets only for the financial impact. Overall, I'd say you're very pessimistic about the reasons behind the decisions we make as radoncs every day. I'm not sure if it's your home institution or to whom you've been exposed, but I think you're overestimating the impact financial decisions have on our practice. For example, I treat nearly all my breast cancer patients with hypofractionation, even though it hurts my bottom line. Sure, lots of places aren't hypofractionating for that reason, but I think you're making too many assumptions about our motivations.

 

[evilbooyaa]

You can't have level 1 Evidence for everything. RT for bone mets works, and no IRB is going to think it is ethical to randomize patients with painful bony metastases to RT vs mock-RT. Your studies looking at benign conditions and response to RT do not really apply in this setting. The reason those trials you are quoting were done decades ago was because there was not as much thought about the ethical concerns of withholding treatment for patients, regardless of their results.

There's no level 1 evidence to suggest jumping out of an airplane with a parachute, but we all do it. Needs a RCT!

 

[TheoLeo]

@OTN : I am sure that the decisions that radoncs make are based on a mixture of medical and financial reasons (as always) and I don´t think that anyone radiates their patients without at least hoping that it does more good than harm or that it is at least neutral from a health standpoint.
I was being too negative.
Oncology takes place in a triangle between benefits for the patient, disadvantages/risks for the patient and the financial cost for society/patient/family. Every decision in oncology is influenced by these three corners. Even as a clinician, one has to consider all these aspects.
So the question is, if the evidence for and the degree of a benefit from this treatment is big enough for 8000 dollars a patient. I dont say this out of cold financial thinking. I think that this is so much money, that it could make a persons life a lot better in so many ways and therefore, the treatment has to show that its really worth as much as a trip around the world for a couple, or a car for the single-mom grand daughter etc.
But I have to admit, that I don´t know all the evidence there is for the radiotherapy of bone mets and it might very well be clear as daylight to every radonc and so profound, that patients are truely relieved.

@evilbooyaa : It is also unethical to perform a potentially harmfull treatment without solid (but what is solid...) proof for its benefits.
One could give a single dose of 8Gy to group A and a single dose of nothing to group B. Afterwards, pain is assessed and patients have the option to get a real reirradiation if they want to. This way, one could assess pain and the need for a second irradiation in both groups. One could also exclude patients who are in very severe pain.
I think the studies about the radiation of benign conditions (especially the one from the 70s) apply, because they give a nice estimate of how big the placebo-effect of XRT on pain might be. The studies of the surgical interventions apply, because they also had a plausible explanation for their mechanism of action (removing irritating debris), yet turned out to be a placebo in most cases.

Thanks for your responses. They help me to get a better perspective of things. I am so critical about radonc, because I like a lot about it and I am trying to figure out how valid my concerns are. If I wouldnt like it, I wouldnt even care.

 

[evilbooyaa]

@evilbooyaa : It is also unethical to perform a potentially harmfull treatment without solid (but what is solid...) proof for its benefits.
One could give a single dose of 8Gy to group A and a single dose of nothing to group B. Afterwards, pain is assessed and patients have the option to get a real reirradiation if they want to. This way, one could assess pain and the need for a second irradiation in both groups. One could also exclude patients who are in very severe pain.
I think the studies about the radiation of benign conditions (especially the one from the 70s) apply, because they give a nice estimate of how big the placebo-effect of XRT on pain might be. The studies of the surgical interventions apply, because they also had a plausible explanation for their mechanism of action (removing irritating debris), yet turned out to be a placebo in most cases.

Thanks for your responses. They help me to get a better perspective of things. I am so critical about radonc, because I like a lot about it and I am trying to figure out how valid my concerns are. If I wouldnt like it, I wouldnt even care.

I re-iterate that it will be (near) impossible to convince an IRB to randomize people to withholding something that is generally understood to have a very significant palliative effect on symptoms. We don't radiate people's spines for the fun of it. As much as I love randomized trials, I don't personally need (or want) the one that you are describing. I'm not sure why this is a stand you are choosing to make; I think it highlights your inexperience with the field of clinical radiation oncology. If you want, I'm sure you could talk to the NHS or any other cost-cutting entity in Europe to see if they would fund a study comparing real RT to sham-RT for painful bone mets. It would certainly help their bottom line if they were true believers in it.

And if you think the benign conditions of having a placebo effect with 'mock-RT' would be equal to a placebo effect of RT on actual invasive cancer that is clinically and radiographically eating through bone, then I think you need to re-evaluate your understanding of both cancer and radiation biology.

 

[Kahreek]

3. We are not trained for it
95% of the knowledge that I developed in medschool, will not be needed in radiation oncology. I could maybe be a very good radiation oncologist with a 2 year training. I dont need to go to medschool for 6 years for it. I want to put the skills and knowledge that I developed over the years to its best use. And I think this will be in a field like general medicine/pediatrics.

Mathematical integration for total safe dosage is calculated by physicists/techs with doctor's input on what will be a suitable projection and area of effect given the disease. Radiation is a tool, a rad onc doctor treats patients who may benefit from radiation therapy. The focus of a rad onc doctor is not to turn on and off the accelerator.

 

[MegaVoltagePhoton]

I know it's fashionable these days to trash radiation oncology, even if you're a radiation oncology, but this is getting out of hand. I'm very sorry that some of you feel like we're all glorified technicians with no clinical knowledge and/or we need to pour endless resources into investigating amifostine (that turned out great guys, let's try a trial of R-amifostine next and see if it works even better!). And people love to undercut the advances in technology because hey, usually a physicist or a non-radonc came up with those. But actually, SBRT and other technical advancements have changed the face of oncology significantly.

As for this "mock-XRT" BS, this is a just a joke. TheoLeo, spouting out nonsense is not suddenly excused by a "but maybe I don't know what I'm talking about" line in every post. Here's a tip, if, everytime you speak you need to give the caveat that you might not be informed -- take the hint. You're not informed. It is beyond idiotic to even consider the trials you are considering, especially given the fact that excellent evidence already supports that RT is beneficial. Yes, you found a negative study of "gonarthritis" from the 70s, well done. Perhaps you can do a further literature search and enlighten us with your studies of how RT is ineffective for "plagueis bubonicus" (not to be confused with darth plagueis)?

Get a clue. RCTs cost time and money, too -- and no one would ever consider a trial of "palliative RT" vs. "no palliative RT" for a willing patient to have equipoise.

 

[TheoLeo]

I know it's fashionable these days to trash radiation oncology, even if you're a radiation oncology, but this is getting out of hand. I'm very sorry that some of you feel like we're all glorified technicians with no clinical knowledge and/or we need to pour endless resources into investigating amifostine (that turned out great guys, let's try a trial of R-amifostine next and see if it works even better!). And people love to undercut the advances in technology because hey, usually a physicist or a non-radonc came up with those. But actually, SBRT and other technical advancements have changed the face of oncology significantly.

As for this "mock-XRT" BS, this is a just a joke. TheoLeo, spouting out nonsense is not suddenly excused by a "but maybe I don't know what I'm talking about" line in every post. Here's a tip, if, everytime you speak you need to give the caveat that you might not be informed -- take the hint. You're not informed. It is beyond idiotic to even consider the trials you are considering, especially given the fact that excellent evidence already supports that RT is beneficial. Yes, you found a negative study of "gonarthritis" from the 70s, well done. Perhaps you can do a further literature search and enlighten us with your studies of how RT is ineffective for "plagueis bubonicus" (not to be confused with darth plagueis)?

Get a clue. RCTs cost time and money, too -- and no one would ever consider a trial of "palliative RT" vs. "no palliative RT" for a willing patient to have equipoise.

50% of the costs of cancer care are spend on patients in their last 60 days of life. People will check for treatments that might not help. From the literature, the benefit is far from obvious (because there is nothing to compare it to). Where is the excellent evidence? Any herbalist will tell you how great his stuff works because he has seen it so many times and he doesn´t need any placebo controled trials to know this... Why did zoledronic acid or methyprednisolone have to prove its effectiveness in placebo controlles RCTs in the palliative setting but XRT didn´t (even though XRT seems to have a big placebo effect). If you think that placebo effects on pain can´t be observed in severe medical conditions, then you should reevaluate your medical understanding as well.

And if people were brave enough to try to omit radiotherapy for brain mets in the quartz trial (even though everyone knew how effective it is since the 1950s... and even though brain mets surely are life threatening... and even though radiation can kill cancer cells...), then I could imagine that they could think of a trial that delays radiotherapy for a week or two in patients who are willing to contribute to improve cancer care.