My reasons against a career in radiation oncology

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TheoLeo said:
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.
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Did you read carefully what the inclusion criteria for the QUARTZ trial were? Highly ill, poor performance status patients who themselves were fine with omitting RT because of projected limited effect. Most people were not surprised that this trial was negative. What percentage of radiation oncology patients do you think fall under this category?

And let's say a patient does have 60 days to live -- if they have a large, growing and erosive vertebral body metastasis, should we not utilize a treatment that has been shown to be effective (even in a non-RCT way), and instead randomize them to "mock-XRT" with a citation to a paper about patients with osteoarthritis who didn't get benefit from RT 40 years ago?

Besides, back to your whole brain example, how do you reconcile your extrapolation from a gonarthritis study to patients with cancer, when you can't even reconcile the results of the QUARTZ study from data showing that supportive care is inferior to RT in patients with GBM (which was randomized, and published in the NEJM)?

Feel free to edit your post to add back in the disclaimer about not knowing what you're talking about.
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TheoLeo said:
50% of the costs of cancer care are spend on patients in their last 60 days of life. .
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Have you thought to educate yourself on the breakdown of spending in that situation on hospital/icu care vs chemo vs radiation? You don't need to be a rad onc to find out that kind of information.
 
MegaVoltagePhoton said:
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!)
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Hey mates! the stinky strawman called and he wants some of his hay back. NOBODY is arguing that we pour "endless resources". We are arguing that we pour ADEQUATE resources to advance our specialty, just like other specialties like medical oncology are leaving us behind in research money and advocating for their field. Keep sleeping zzzzzzzzzzzzz. Reality may hit you when we no longer have a seat at the table. We are already bottom feeders as it is.
 
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@MegaVoltagePhoton
A patient who has 60 days to live pretty much fits the patients in the quartz trial. So yes, lets take this patient for example. He has multiple large, fastly proliferating metastases in his brain...should we not radiate because some people think there is no point in doing so? Turns out, no, one really shouldn´t. Because overall, looking beyond the brain mets, the patient as a whole had a lot of other problems. I don´t see why it was ok for everyone to not radiate that brain (and thereby risking to shorten this patients life), but it is absolutely unconceivable to even check if radiation is better than just steroids/opiods plus mock-xrt in pain relief for bone metastases (and thereby risking to have a patient only on opiods/steroids for two weeks). You could also choose a site that is not actutely life threatening if left untreated.

You also still didn´t get the point of my references. The point is, that a 60% response rate in pain doesn´t mean much and that pain is much more compex than "cancer not radiated->pain/cancer radiated->no pain". The fact remains, that not everything that is mechanistically plausible and that shows a major pain relief, is much better than a placebo.
 
Is small trial composed of the patients with moderate/severe pain from the bone metastases randomized to opiates and the best and the most supportive care vs the same plus 20/5 that not reasonable? I see a considerable and a very reasonable mad anger directed towards the one that made the original post. He appears to be the internet Troll. But, this is probably the least unreasonable thing that one that has made the original post has suggested. Maybe one of the exclusion criteria can be submitted "large and growing erosive vertebral metastases no allowed". This is quite ferocious and angry responses to fairly reasonable oncologic question.
 
TheoLeo said:
@MegaVoltagePhoton
A patient who has 60 days to live pretty much fits the patients in the quartz trial. So yes, lets take this patient for example. He has multiple large, fastly proliferating metastases in his brain...should we not radiate because some people think there is no point in doing so? Turns out, no, one really shouldn´t. Because overall, looking beyond the brain mets, the patient as a whole had a lot of other problems. I don´t see why it was ok for everyone to not radiate that brain (and thereby risking to shorten this patients life), but it is absolutely unconceivable to even check if radiation is better than just steroids/opiods plus mock-xrt in pain relief for bone metastases (and thereby risking to have a patient only on opiods/steroids for two weeks). You could also choose a site that is not actutely life threatening if left untreated.

You also still didn´t get the point of my references. The point is, that a 60% response rate in pain doesn´t mean much and that pain is much more compex than "cancer not radiated->pain/cancer radiated->no pain". The fact remains, that not everything that is mechanistically plausible and that shows a major pain relief, is much better than a placebo.
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The actual criteria for the QUARTZ trial:
"Clinicians were encouraged to approach potential participants about the trial if there was uncertainty in the clinicians’ or patients’ minds about the potential benefit of WBRT, and a multi disciplinary team that included both neurosurgeons and radiation oncologists had concluded that the patient was unsuitable for either surgery or stereotactic radiotherapy."

There probably are some patients with large, symptomatic growing brain metastases who don't want WBRT. However, in the majority of cases, these would constitute an urgent consult; most patients would want something done because WBRT has been shown to improve local control/brain control (in a randomized trial, no less, following surgical resection of a met).

Whether you're a troll or just trollish, it doesn't matter -- I've seen people parrot these type of anti-radiation arguments before. It is clear they don't understand the papers that they cite, and are implicitly assuming that radiation oncologists are all about the $$$ and don't care about the patients. Sorry, there are still reasons to do WBRT on patients with lung cancer, because if you want to act like you care about evidence-based medicine, you better make sure you understand the actual inclusion criteria of the trials you cite.
 
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thecarbonionangle said:
Hey mates! the stinky strawman called and he wants some of his hay back. NOBODY is arguing that we pour "endless resources". We are arguing that we pour ADEQUATE resources to advance our specialty, just like other specialties like medical oncology are leaving us behind in research money and advocating for their field. Keep sleeping zzzzzzzzzzzzz. Reality may hit you when we no longer have a seat at the table. We are already bottom feeders as it is.
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The way we get a seat at the table is to work with the medical oncologists and surgical oncologists -- we use our new tools with their new tools. It's called being realistic -- what's the med onc going to care about, how SBRT might be integrated with his immunotherapy drug, or how a drug that causes hypotension (in dehydrated patients getting RT for HNSCC) might make RT more tolerable?
 
Wow this got off track. Leo should get a cookie for being such a good troll. I do like the line about 'financial pressures' as a reason not to go to Rad onc. Was the memo on the rampant EPO over-prescribing or the increasing utilization of prostatectomy for high intermediate and high risk prostate cancer, when the % of EPE and nodal disease is seconds away, not sent overseas? Now, 2 wrongs never make a right, and God forbid me from questioning this smart man's supposed real life example, but when you are differentiating two or more groups then the intelligent path is to use arguments that accurately differentiate said groups. If the new Medicare drug reimbursement changes for med-onc go through, I am sure we will see some changes in prescription volume in the affirmative.

In consideration of the QUARTZ trial, another quick update, it did not show than WBRT was non-inferior to supportive care. Let's repeat that. The QUARTZ trial did not show that WBRT was non-inferior to supportive care. It was a non-inferiority trial that did not meet its endpoint. That's how trials are performed, even in Germany. Even in very sick individuals who were not eligible for surgery or SRS (without a good description of how that was determined), who had even worse than predicted survival by RPA and lesion number, and even with a 5 day regimen that plausibly causes more edema based on radiobiologic principles [Acknowledgment, there are trials examining fractionation for WBRT and edema from the not quite 'gonarthritis' era, but here's another inside tip - those were not heavily enriched for people with high CNS burden of disease (ie, such that they were not SRS or surgery eligible) so we don't have level I evidence that in patients with higher CNS burden hypofractionation leads equivalent cerebral edema]. If you want to argue magnitude of results should override statistical significance then countless interventions can be argued. And no, advocating WBRT for everyone is not a solution, but the fact that you are griping about RCTs and not even understanding a recent one is not a good prognostic sign.

As for bone pain, read the articles from Chow about fractionation, which shows a fairly high degree of pain relief in the setting of pain journals and controlled narcotic dosage, and importantly shows a difference in re-treatment rates in the dose groups. If radiation was a placebo and had no mechanistic pain relief, then most likely single fraction regimens wouldn't consistently be shown to have higher rates of re-treatment. Or maybe it's just some complicated placebo effect that gets abrogated with multiple fractions and is over my head. In general, complaining about this in a field with the highest level of evidence for its use is completely non-sensical - we have decades of evidence, contemporary trials, and suggestion of mechanistic differences relating to dose. On the other hand, we will never have Level I evidence for SBRT versus surgery for early stage lung cancer. Probably should stop offering that right now.

The thing is a good Radiation Oncologist knows the evidence for interventions better than any other member of the team, and being a tertiary referral specialist can impart a great deal of impartiality [more difficult in private settings]. Some are correct to point out that we need a bigger seat at the table, but without performing biopsies or without pharmaceutical company money behind us, it's difficult. Biopsy gives control of a patient. The drug companies are the most powerful lobby, research funding source, and professional aid in health care. For instance, the proposed Medicare changes lower reimbursement % given for drug purchases to medical oncology, as a way to dis-incentive ordering costly drugs (along with a few other carrots). Who loses? The medical oncologist. In reality he or she, especially in a community setting, will just find ways to prescribe more. And who wins? Well, the drug company of course, it's not as if the drug price has changed. Contemporary medicine can make a fairly compelling case that medical oncology today is more of a stop in line to order a drug from a company with very structured guidelines already in place, particularly as mid-levels and hospitalists take over in-patient care. In my facility it is rare for a medical oncologist to see clinic patients more than 2 days per week.
 
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I understood the inclusion criteria of the QUARTZ trial just fine. The authors identified a subgroup of patients that does not benefit from wbrt. A subgroup that was not always spared from radiation. Otherwise, they would not have done this study. Because it would have been so very unethical to give wbrt to these people, even though everyone knew that they wouldn´t benefit (or did they just do this study to trash radonc to capitalize on it because they, unlike you, have bad morals?).)... And just because the trial didn´t meet its endpoint doesn´t mean that it didn´t show a total lack of any clinically relevant benefit of wbrt for this heterogenous subgroup of patients as a whole .

The whole point of me bringing up this trial is, that a widely used practise since the 50s was questioned and then they successfully identified a subgroup of patients which doesn´t benefit from the healing XRT despite of growing metastases in their brain. If you are now thinking that it was clear that they wouldn´t benefit, please read again what I wrote in the first paragraph.
So there might just be a subgroup of patients with bone mets, that don´t benefit from the radiotherapy. Not every bone met hurts for the same reasons or is biologically identical. To not even consider that xrt might not help in some patients and that these patients might just report a placebo effect in these cases, is very dogmatic.

That the reirradiation rate is substantially higher after a single session of 8Gy than after 5 sessions of 4Gy can have lots of reasons that are not related to the actual effectiveness in pain reduction or the potential difference in the BED. Especially if they failed to actually show a difference in pain reduction. Apart from that, the response rate seems very similar in different fractionation schedules in various entities. Which is also suspicious, because again, not every bone metastasis is identical (same alpha/beta, same absolute alpha and beta values, same interactions with the ecm, same immunogenicity...).

I am being polite here and explicitly appreciate your input. I mention my lack of experience in this field to give any reader an idea of the foundation of my writings. The reactions that I get and the hybris of some, are quite appalling. The references to my nationality in this context are also very inappropriate.
 
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Krukenberg said:
Several innovative sbrt vs. surgery trials have opened recently. The patient flow has the pulmonologist explaining treatments and randomizing rather than waiting until the patient sees the surgeon. They're basically getting around the fact that when surgeons explain treatments they clearly favor their own.


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Unlike urologists wrt prostate ca, thoracic surgeons usually don't diagnose lung CA first. Makes the process more sound
 
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MegaVoltagePhoton said:
Highly ill, poor performance status patients who themselves were fine with omitting RT because of projected limited effect. Most people were not surprised that this trial was negative.
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Not exactly true. You quoted a snippet from the trial; I'll quote this:

"Although overall the patients recruited in this study had a poorer prognosis than those in previous case series, which had provided the evidence base for the use of WBRT in this setting, the trial population reflects the typical clinical experience, in which very few patients meet the criteria for the best prognostic classes... In routine clinical practice, only 3·5–7·5% of patients with brain metastases fall into RPA class 1 and conversely, 40–50% fall into RPA class 3. Although the RPA class 3 patients have been excluded from clinical studies, clinicians continue to consider and frequently offer WBRT to this group because of the absence of alternative treatment options. The QUARTZ trial was the first opportunity to assess all these prognostic classes in a randomised setting, both in terms of their prognostic effect and their ability to predict WBRT benefit. In line with everyday clinical experience, our data included only 30 (6%) of 533 RPA class 1 patients, and so we are unable to make any definitive statements about the benefit of WBRT in this group. We saw a non-significant association between RPA and treatment group, which suggested a potential benefit with WBRT with better RPA class, but further evidence is needed to firmly establish the size of any effect for patients who fell within RPA class 1. Importantly, patients who fell within RPA class 2 (301 [56%] of the 533 patients in the QUARTZ cohort), who have previously been thought to require and potentially benefit from WBRT, seemed to derive no clinically significant benefit from this treatment. In addition, QUARTZ has now provided data to back up the belief that WBRT should not be seen as a beneficial palliative treatment for patients falling within RPA class 3."
 
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TheoLeo said:
I understood the inclusion criteria of the QUARTZ trial just fine. The authors identified a subgroup of patients that does not benefit from wbrt. A subgroup that was not always spared from radiation. Otherwise, they would not have done this study. Because it would have been so very unethical to give wbrt to these people, even though everyone knew that they wouldn´t benefit (or did they just do this study to trash radonc to capitalize on it because they, unlike you, have bad morals?).)... And just because the trial didn´t meet its endpoint doesn´t mean that it didn´t show a total lack of any clinically relevant benefit of wbrt for this heterogenous subgroup of patients as a whole .

The whole point of me bringing up this trial is, that a widely used practise since the 50s was questioned and then they successfully identified a subgroup of patients which doesn´t benefit from the healing XRT despite of growing metastases in their brain. If you are now thinking that it was clear that they wouldn´t benefit, please read again what I wrote in the first paragraph.
So there might just be a subgroup of patients with bone mets, that don´t benefit from the radiotherapy. Not every bone met hurts for the same reasons or is biologically identical. To not even consider that xrt might not help in some patients and that these patients might just report a placebo effect in these cases, is very dogmatic.

That the reirradiation rate is substantially higher after a single session of 8Gy than after 5 sessions of 4Gy can have lots of reasons that are not related to the actual effectiveness in pain reduction or the potential difference in the BED. Especially if they failed to actually show a difference in pain reduction. Apart from that, the response rate seems very similar in different fractionation schedules in various entities. Which is also suspicious, because again, not every bone metastasis is identical (same alpha/beta, same absolute alpha and beta values, same interactions with the ecm, same immunogenicity...).

I am being polite here and explicitly appreciate your input. I mention my lack of experience in this field to give any reader an idea of the foundation of my writings. The reactions that I get and the hybris of some, are quite appalling. The references to my nationality in this context are also very inappropriate.
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Don't be deterred. You're intelligent and logical, and this should be a judgment-free zone for you. Some people are turds. That's the English word for a German word I don't know but wish I did.
 
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that mock arthroscopy study was great
 
scarbrtj said:
Not exactly true. You quoted a snippet from the trial; I'll quote this:

"Although overall the patients recruited in this study had a poorer prognosis than those in previous case series, which had provided the evidence base for the use of WBRT in this setting, the trial population reflects the typical clinical experience, in which very few patients meet the criteria for the best prognostic classes... In routine clinical practice, only 3·5–7·5% of patients with brain metastases fall into RPA class 1 and conversely, 40–50% fall into RPA class 3. Although the RPA class 3 patients have been excluded from clinical studies, clinicians continue to consider and frequently offer WBRT to this group because of the absence of alternative treatment options. The QUARTZ trial was the first opportunity to assess all these prognostic classes in a randomised setting, both in terms of their prognostic effect and their ability to predict WBRT benefit. In line with everyday clinical experience, our data included only 30 (6%) of 533 RPA class 1 patients, and so we are unable to make any definitive statements about the benefit of WBRT in this group. We saw a non-significant association between RPA and treatment group, which suggested a potential benefit with WBRT with better RPA class, but further evidence is needed to firmly establish the size of any effect for patients who fell within RPA class 1. Importantly, patients who fell within RPA class 2 (301 [56%] of the 533 patients in the QUARTZ cohort), who have previously been thought to require and potentially benefit from WBRT, seemed to derive no clinically significant benefit from this treatment. In addition, QUARTZ has now provided data to back up the belief that WBRT should not be seen as a beneficial palliative treatment for patients falling within RPA class 3."
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Yes...a little snippet called the inclusion criteria. The point being, the folks on the QUARTZ trial were people who were essentially universally considered a priori to have uncertain benefit from WBRT. To broaden that to palliative RT in general is asinine.
 
MegaVoltagePhoton said:
Yes...a little snippet called the inclusion criteria. The point being, the folks on the QUARTZ trial were people who were essentially universally considered a priori to have uncertain benefit from WBRT. To broaden that to palliative RT in general is asinine.
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The only inclusion criteria I know of for QUARTZ is that 1) had to have brain met(s), 2) had to have NSCLC, and 3) considered not a candidate for SRS or surgery. I do not immediately recall turning a single patient away from treatment who matched these criteria during my residency circa 1999-2003. Not sure that there is or was consensus in our field that these "were people who were essentially universally considered to have uncertain benefit from WBRT." In fact, if you put what you're saying another way: everyone knew that no one knew whether WBRT was beneficial. Yet the practice seems widespread. So there was a trial. The trial suggests there's no benefit. (I think the young man was trying to say that he senses other clinical scenarios wherein if there were performed more trials rad oncs might be surprised at counter-intuitive findings further challenging many widely accepted practices, reasonably influencing his choice of rad onc as a career... someone mentioned the folly of a randomized trial for parachute-less jumping out of airplanes... upon testing, a parachute is not beneficial, either.)
 
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MegaVoltagePhoton said:
To broaden that to palliative RT in general is asinine.
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The value (=putative average amplitutde of additional benefits above a placebo effect for 8000 dollar per patient or above an alternative pain treatment) of radiation therapy for pain relief in patients with bone metastases seems to be a no-brainer that is not to be questioned. If you would rate all the indications for ratiotherapy according to its putative value, this one would propably be in the top 10.
Questioning the value of xrt for bone mets, out of all things, might irritate people. I get that. But getting a better idea about the value of a top10 indication (by openly questioning the amplitute of the average additional benefit above a placebo) helps me to get a better estimate of the value of the indications that didn´t make it into the top10.

Side note: I think that the value (and the reputation) of radiation oncologists correlates with the value of the treatments that they offer. One way to increase and ensure this value (and reputation) is to be VERY critical about the indications.
One of the reasons why doctors have or had such a good reputation in society is because they are willing to sacrifice their own benefits for the greater good of their patients. A good trauma surgeon sacrifices his/her social life and sometimes even his/her health for the patients. A good radiation oncologist is very critical about the use of his/her modality and thereby is willing to sacrifice some of his/her salary. A good radiation oncologist doesn´t look for any reason to radiate, but looks for any reasons not to radiate. Being open to critique, to actively seek the truth in it, is one of the uniue characteristics of a good radiation oncologist (especially in comparison to other specialties). If you, as a radiation oncologist, lose this, then you are just someone with a great salary and a great lifestyle and nothing else. Not a doctor.
 
Alright, that's enough. You've played this crap out for long enough. You want Radiation Oncologists to find "any reason" NOT to radiate? Med-oncs and surgeons do more than enough of that for us on a daily basis.

You have NO idea what encompasses a good clinical radiation oncologist. A good radiation oncologist knows when TO radiate to help the patient, either in the short or long-term. Why should only Radiation Oncologists neuter themselves by finding "any reason" not to provide their services? Why don't surgeons find a reason not to operate? Why don't med-oncs find a reason not to offer chemo?

I just can't anymore. You were somewhat reasonable at first, asking about the limitations of the field, then you made some outlandish claims wanting RCTs looking at RT for pain response in painful bone mets compared to mock-RT (this is what I would expect for something like Reiki), and now you want to judge the entire field as a whole, because you, as a German medical student, know EXACTLY what makes a good radiation oncologist? You ignore the thoughts of 5-10+ people that are actually within the field and want to tell us how to our jobs? Again, we have more than enough people in this world telling us how to do our jobs.

You're focused on Rad Oncs "making the big bucks" offering palliative RT for bone mets. Here's the skinny: what Rad Oncs make is not primarily due to bone mets, especially in this day and age of hypofractionation becoming more common.
What about urologists who will RP anyone and everyone with prostate cancer, indications be damned, the same ones who gave Lupron to everybody until reimbursement dropped? Where's the outrage against 'greedy urologists'?
What about 'palliative chemo' that costs 100k to the tax payer? Where's the outrage about greedy med-oncs? (I know med-oncs aren't making a ton of money anymore, but the pharm companies and their shareholders instead)

I'm just disappointed I even participated in this thread. Disappointed I even wrote the post above.

You've officially jumped the shark, OP.
 
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@evilbooyaa : I don´t know why you get upset if you think that you are open to critique and critical about the indications. Then I have described you in my post.

1."A good radiation oncologist doesn´t look for any reason to radiate, but looks for any reasons not to radiate"...this statement is not an absolute truth but serves to underline the direction of focus that is necessary to increase the value of treatments.
2."A good radiation oncologist knows when TO radiate to help the patient, either in the short or long-term"...this statement underlines the direction of focus that is necessary to help the most amount of patients by using XRT.

Both directions of focus are necessary for different aspects of radiation oncology. However, if you think that the value of xrt can not/should not be increased or if you think that financial pressure is and will be irrelevant to the field, then of course my statement is unbearable.
But usually, unspecific statements are not mathematics and can not be judged in a binary fashion. They can be complemented. Therefore, two unspecific statements usually don´t exclude eachother.

Looking for a suitable specialty, the increasing use of xrt by other specialties (neurosurgery, urology), an increasing focus on cost effectiveness in health care, the increasing use of non-xrt for local ablation, the high potential of systemic therapies (especially immnotherapies) and the increasing use of hypofractionation, the rise of autocontouring and the need for high long term investments in a fastly evolving field do not make radonc look like a field that can afford not to care about the value of their treatments (ups, rather: that will not face finfancial pressure which might lead to a less selective use of the modality).
 
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TheoLeo said:
Looking for a suitable specialty, the increasing use of xrt by other specialties (neurosurgery, urology), an increasing focus on cost effectiveness in health care, the increasing use of non-xrt for local ablation, the high potential of systemic therapies (especially immnotherapies) and the increasing use of hypofractionation, the rise of autocontouring and the need for high long term investments in a fastly evolving field do not make radonc look like a field that can afford not to care about the value of their treatments.
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Won't respond to the rest b/c you've passed that point for me. However, I do want to address these other concerns (which have some validity) for others who may read this thread in the future.

-XRT by NSG/Urology? Has to be prescribed by a board-certified radiation oncologist. GammaKnife requires both NSG and Rad Onc involvement. In linac-based SRS, the Rad Onc is the critical one, but we will include Neurosurg on all patients out of courtesy, and especially those that were operated on (or will be operated on) to discuss areas of concern.
-Increasing focus on cost effectiveness - Yes, I agree. That's why 8Gy x 1 or 30/10 will be deemed more cost-effective for painful bone mets than lifelong Xgeva.
-Increased use of non-XRT for local ablation - Besides RFA (which isn't durable and can generally be salvaged by RT), there's HIFU/cryo/whatever else urology is doing in those they can't RP, but that's for a different thread. With the increase in lung cancer screening and a lot of sicker patients coming for SBRT for their early stage lung cancers, I don't think local ablative therapy is going anywhere.
-I was very skeptical of immunotherapy when I first heard about it, but I'm really starting to see people with good, sustained responses to Pembro/Nivolumab/etc. There are multiple studies looking at combining immunotherapy with RT to utilize the abscopal effect. If that takes off, we could be on the immunotherapy train along with med-onc. Think of how Xeloda or 5-FU is given to sensitize patients to RT, now have that as well as the reverse effect (RT making immunotherapy work better) for metastatic disease.
-Increasing use of hypofrac comes into the cost effectiveness, but yes, there is a push towards this across the country. This will hurt Rad Oncs' wallet now. However, a lot of us hypofrac quite routinely. Still need to decide when hypofrac is appropriate at the current time, FWIW. Maybe if/when capitation system comes, hypofrac won't be seen as the enemy (although that's its own question given how Med Oncs are likely to be the oncological gatekeepers, per se)
-Rise of autocontouring? Have you actually tried to use any autocontour software? It's really not fully there yet.
 
I thank you all for your responses (which do influence my view on the field). I know I´ve dropped some bricks that are easy to get offended by. But they weren´t meant to offend and if they did, I am sorry. All the best.
 
We all are "agree to disagree" with Troll Guy I think so. To prove to ACO and to gates keepers, value based trials will be the very helping. SBRT to lung will soon be more valuable than surgery, some small trial, but maybe china or Japan do big one. Beam to prostate will be the equal of surgery effectively and less of the bad toxic. Brain met trial somewhat confusing but looking like a bad value for many that we thought it was good value for. Maybe we not be so mad jumping up down for bone metastases trial to preserve very important part of our practice. We know works. I saw yesterday. It's a nice trial maybe small and having crossover to avoid ignoring questions of the equipoise conundrum. Comparing Effective research will be too important when stupid medonc is even more charge of all things. I like we stop being geeky guy who get sand kicked on beach by German students by having good study for good thing we do. Radiation very hard to get into usa. Need to happy to be practice but also happy to make the trial.
 
TheoLeo said:
I thank you all for your responses (which do influence my view on the field). I know I´ve dropped some bricks that are easy to get offended by. But they weren´t meant to offend and if they did, I am sorry. All the best.
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I have been in the field for 25 years and have some familiarity with German medicine. Your comments for the most part have not offended me except for repeated suggestions that we are only in the field for a good lifestyle, money, that the treatments are not that important or effective and you are glad you will not be apart of its future.

Part of the attacks you have endured, and graciously I might add, is because for the last 20 years in the US, the best and brightest have gone into this great specialty. We care for many hopeful, anxious, frightened, and eternally grateful patients. We are Oncologists in the end, and many patients with cancer are steered in the right direction by a smart and intelligent Rad Oncs. We don't just treat, we manage side effects from chemo and surgery and I know we learn and practice the art of medicine with pain, radiation physics and biology, elderly patients, and yes psychological aspects of death, families in much greater detail than any med school will teach.

Germans worry about money and lifestyle, (like we do)and happens to be the biggest source of alternative science such as strength testing with meds , etc. In Rad Onc in Germany and I'm sure other fields, many doctors practice in private as well as public to make money.

In summary, it is a great field with lots of incredible science and caring for complicated cases of which no 2 are the same. XRT for bone mets improves pain by 70-80% and takes it away in 50-60 %. It is used much less because not all med once know its value.

Lastly, I'm getting close to the end of my career but I have only done IMRT when I see a clear indication or benefit so that has been 25 %. I shorten treatments for the elderly and tell patients no treatment when it is not necessary. My pocket book will survive but my conscience is not for sale.

Good luck in your field you chose. You did not choose ours for the right reasons but we still wish you luck. A good doctor in any field is worth his weight in gold. Half of what you learned in med school is also BS.

No other profession demands and grinds, as an oncologist. I've gotten hugs from theGBM patient in year 8 of FU. You cry when one of your favorite patients die or see a young patient with little kids. But the thought required in each case and the joy of helping people and working with people I like and respect including many patients will be what I will miss most. So be happy.... you missed one of the great fields in medicine but hopefully you found one.....
 
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TheoLeo said:
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.
Click to expand...



This highlights again why med students are terrible decision makers on the whole; I also was terrible at that stage. I don't disagree with you, you're allowed to have an opinion on this though many of us in the field disagree, and your claims about evidence base are very med student level. But as it turns out every field will have good and bad, and if you focus on the good every single field will have awesome parts of it. So the only tiebreaker is to focus on what you want for your life then choose the field to fit it. That is it, really. Yes, some people are meant to be surgeons or think they are, fine. But for anyone even considering RT then you're not differentiated along any lines. So you can rule out every field in that case. But you probably will pick one and you should consider your life factors above everything else. For most people that will rule out radiation actually. I personally have little doubt in my mind this is the best field in medicine but the life factors should rule it out for most.
 
Haybrant said:
This highlights again why med students are terrible decision makers on the whole; I also was terrible at that stage. I don't disagree with you, you're allowed to have an opinion on this though many of us in the field disagree, and your claims about evidence base are very med student level. But as it turns out every field will have good and bad, and if you focus on the good every single field will have awesome parts of it. So the only tiebreaker is to focus on what you want for your life then choose the field to fit it. That is it, really. Yes, some people are meant to be surgeons or think they are, fine. But for anyone even considering RT then you're not differentiated along any lines. So you can rule out every field in that case. But you probably will pick one and you should consider your life factors above everything else. For most people that will rule out radiation actually. I personally have little doubt in my mind this is the best field in medicine but the life factors should rule it out for most.
Click to expand...


Haybrant, dude, I love your respectful and measured tone; your advice is sage and sound. Thus, I feel bad following you up, but here goes:


I totally agree w OP: OP should defs avoid rad onc.

I think OP is correct that 1) there is low potential for improvement (since apparently everyone in Germay is cured with RT effectively sans side effects); 2) we are so evidence based that it is all cookie cutter (just ask all the other head and neck rad oncs how easy it is for us to contour and treat- child's play!), and 3) OP not trained in in Rad Onc, and thus, fully aware of our fields potential.

If rad onc has too little room for improvement for you, please drop by my follow-up clinic, OP; door's open for survivorship clinic, homes, where its all smiles and toxicity free high fives. If your PC is so smart that you are are afraid of getting smoked by a comupter algorithm, let me feed your model my recurrent re-irradiation post-op head and neck cases, Watson. Oh, and "I could maybe be a very good radiation oncologist with a 2 year training"? I am still on the learning curve 5-years into faculty *and I only treat one organ site all day long*; dollars to donuts you don't even get the nuances of what some of these old cats rocking 20+ years experience are doing, because I still get amazed by my multi-MD QA clinics with my team weekly. Competence for prostate EBRT in 2 years? Maybe. But you think you can treat Pedi/CNS cases, hardcore head and neck IMRT, and brachy, "with a 2 year training"? #colormetrolled You must be smarter than most of us in rad onc, so yeah, you'll really be daily challenged by the mental minefield "in a field like general medicine/pediatrics", Osler.

Also, TBH, as a guy funded by NSF and NIH to do Big Data analysis for rad onc, the idea that GoogleMind is going to round up a ton of head and enck plans and replace rad oncs is laughable--but I pray they can cut my scut time contouring everyday, and I'd love more, not less interest from Apple/Google/SageBionetworks. As several posters allude, if you think rad onc is only contouring and cookbook dose prescription, I've got a dosimetry job with your name on it.

My 2 cents: antibiotics did not eliminate infectious disease doctors, DaVinci did not replace surgeons, and CAD software hasn't replaced radiologists. Why? Because providing care to humans is not widget building or search engine optimization *because if you screw up [antiobiotics/surgerydiagnosis/radiation], people die or are injured horribly*, so a human will always take responsibiltiy. Plus, have you ever heard Siri tell a patient they are going to die because of recurrence? Didn't think so, Steve Jobs.

BTW, the next med student who tells me "chemo/targeted agents/immunotherapy/nanoparticles/genomics/unicorns are going to replace rad onc" can then tell me how "SBRT and CT screening will replace thoracic surgeons" (I actually heard this BS from an MS3) while I laugh heartlily.
 
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Bearstronaut said:
Did medicine go from evidence-based to evidence-required while I wasn't looking?
Click to expand...

Unfortunately, many medical students can't tell the difference.

"There's no evidence for that!" ≠ "It's the wrong thing to do!"
 
Came across this trial:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112926/

So they did a placebo controlled RCT for painfull bone metastases to test the efficacy of MRgFUS. The response rate for the placebo group was about 40% 10 days after treatment and then it dropped to 20% during the following 3 months. The response rate for MRgFUS was stable at about 60-70% over three months. I mention it because it shows that the placebo response rate here is clearly not as high as it is after XRT. But it also shows the course of the pain level after a sham treatment with big machines (but only in 35 patients).
 
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TheoLeo said:
Came across this trial:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112926/

So they did a placebo controlled RCT for painfull bone metastases to test the efficacy of MRgFUS. The response rate for the placebo group was about 40% 10 days after treatment and then it dropped to 20% during the following 3 months. The response rate for MRgFUS was stable at about 60-70% over three months. I mention it because it shows that the placebo response rate here is clearly not as high as it is after XRT. But it also shows the course of the pain level after a sham treatment with big machines (but only in 35 patients).
Click to expand...

So a placebo effect had 20% pain control after 3 months. 3:1 true MRgFUS: sham MRgFUS randomisation due to the ethical concerns of performing placebo-level treatment to this patient population.
Are you in agreement that pain responses to radiation have a much higher success rate than 20% at 3 months? Is this sufficient evidence to show that radiation helps with pain due to metastases?

Despite my previous posts, I'm not annoyed (anymore) given that the thread cooled off a bit. Legit question to you in the line above.
 
evilbooyaa said:
Is this sufficient evidence to show that radiation helps with pain due to metastases?
Click to expand...

To me it was important to see how many patients would report an improvement of pain after a sham treatment in the setting of bone metastases and radiation (or sth similar). Just to have something to compare the reported response rates after XRT to. So even though it was only a small patient sample and even though the patient population differs from the patient populations in the XRT trials (patients who didn´t respond to xrt for example), it adds an important dimension to the existing evidence for me and makes the evidence sufficient in my eyes.
 
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