pet peeve

[radonc]

just venting, but one of my biggest pet peeves for people applying to radiation oncology is, 'oh im applying to radiation oncology AND radiology, as a backup.'

the pet peeve lies in the fact that those are 2 totally different fields and medical oncology, i believe, is closer to radonc in the fact that both fields actually treat and follow-up patients!

one can only assume that people who apply to radonc and radiology (as a backup) are going into it for the lifestyle, $$$, and all the wrong reasons.

sorry, just my 2 cents at 6 AM on call

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[doctalaughs]

I like rads and rad onc because of the quickly advancing technology in both fields. I was a CS major undergrad and going into academics in either area may be my end goal. I like rad onc better because of the patient interaction, but it seems like both fields have lots of research opportunities and an emphasis on physics/computing.

 

[stephew]

Doctalaughs actually I think makes a good point to radoncs good point. While rad onc and rads iare very different fields, the commonality of physics in med and techology can be links which make them equally appealing to both.

But I do wish I had a dollar for everytime someone has called me a "radiologist".

 

[tinwindow33]

Originally posted by radonc
just venting, but one of my biggest pet peeves for people applying to radiation oncology is, 'oh im applying to radiation oncology AND radiology, as a backup.'

the pet peeve lies in the fact that those are 2 totally different fields and medical oncology, i believe, is closer to radonc in the fact that both fields actually treat and follow-up patients!

one can only assume that people who apply to radonc and radiology (as a backup) are going into it for the lifestyle, $$$, and all the wrong reasons.

sorry, just my 2 cents at 6 AM on call

They do have some things in common in terms of imaging, technology, knowledge of anatomy, some procedures in both, physics involved, both require and allow lots of reading and learning, as well as time to think and cogitate about what you're doing.

You're also not recognizing that a person can have two different interests. I know one person who was interested in heme/onc, cardiothoracic surgery, and pathology. You can like patient care, or you can do without it and like other stuff. If you like patient care, it doesn't necessarily mean that you can't do without it. Or maybe you don't like the fact radiology has no patient care, but you're willing to give that up because the other aspects are so appealing.

 

[tinwindow33]

Originally posted by stephew
But I do wish I had a dollar for everytime someone has called me a "radiologist".

Holy cow, that's so funny. I was confused as heck today, because there were some radiology films that a surgeon wanted and thought my rad onc attending had signed out. The surgeon kept referring to the radiation oncologists as radiologists, which confused me to no end. After running around, it turned out the surgeon didn't actually need the films.

 

[stephew]

well that was a surgeon

Just kiddin'.

 

[radonc]

great points by everyone to my ignorant message BUT being a radiologist means never talking to another patient in depth, never getting to know a patient, their disease, and providing empathy to a patient and their family. the most a radiolgist will do is to talk to the patient while they are on the table.

i respect peoples career choices and i dont mean to flame anyone.

 

[stephew]

And rad onc makes a good point about pt contact; that can be a "make or break" for some. However for some students, they favor less pt contact. But it is certainly a big difference that show weight in as appropriate when making the distinction.

 

[carrigallen]

personally, my pet peeve is when people reply "it's a dying field". i think that these are often the kind of individuals who have a canned remark about every profession.

 

[stephew]

actually, you will get asked "isn't rad onc dying now" -the popular perception is that first came surgery, then rad onc, then chemo which will surplant it all once they perfect it. Farthest thing from the truth. In fact the limitations of chemo have become and are becoming quite evident- this isn't an "anti-med onc" comment in any way whatsoever. But just oncology cant live with chemo as a field, nor can it live without radonc. Rad onc is actually thriving.

I cant fault family or friends out of the field for not knowing, but any oncologist who makes "button pushing " cracks or "dying field cracks" can be reminded that's like calling a med onc a Pharmacist (we push buttons no more than they use mortar and pestle for crusing pills) and if rad onc is such a dying art, stop calling us for so many IP consults and 4.30 friday evening emergencies.

I love med onc too- that was second choice. I dislike willful ignorace from anyone. As Darcy said to Elizabeth (and I paraphrase) "Your fault is in willfully misinterpreting everything".

 

[sobytalz]

are there other reasons why one would say rad onc is a dying field? what does rad onc have in the future that will allow it to thrive? i'm just curious and currently considering the field......

 

[carrigallen]

Originally posted by stephew

I love med onc too- that was second choice. I dislike willful ignorace from anyone. As Darcy said to Elizabeth (and I paraphrase) "Your fault is in willfully misinterpreting everything".

"No'' -- said Darcy the rich rad oncologist, "I have made no such pretension. I have faults enough, but they are not, I hope, of understanding. My temper I dare not vouch for...My good opinion once lost is lost for ever."

"That is a failing indeed!'' -- cried Elizabeth the internist. "Implacable resentment is a shade in a character. But you have chosen your fault well. -- I really cannot laugh at it; you are safe from me.''

"There is, I believe, in every disposition a tendency to some particular evil, a natural defect, which not even the best education can overcome. For example, a propensity to go into internal medicine.''

"And your defect is a propensity to zap every body.''

"And yours,'' he replied with a smile, ``is wilfully to misunderstand them.''

"Do let us have grand rounds,'' -- cried Miss Bingley, tired of a conversation in which she had no share.

 

[stephew]

Carrigellan, you know I happen to be in the middle of rereading P&P and I think I like your verion better- mine must be abridged
BTW- we never say zapped in rad onc, but I'm sure Ms Austen didn't know this; it was a long time ago indeed!

AS for rad onc's future:

As I noted before, the reason people doubt rad oncs future is that they (not willfully) misunderstand oncology as a series of laddered steps: first only sx, then rad, then chemo. Int he future the "magic bullet" will come and replace that etc. In fact, saying rad onc will go the way of the dodo is like suggesting surgery will. So long as people have cancer, surgery will have a place. Chemo asl well. And so too radonc. The modalities can each do things the other can't and often they suppliment each other; chemoradiation for instance is recognized to often be greater than the sum of its parts. We know that while chemo works systemically, radiation tends the majority of the time, to do a better job at local control, often the first site of failuer which may herald in some tumors a poor prognosis, or may just be a symptomatic problem. There are suggestions that superior lcoal control may inprove overall survival.

The only reason people think radiation may go away is a fundemental lack of understanding about oncologic treatment. My prediction is radiation will "ramp up" further in the next few years as the local control issue becomes more fleshed out, and as the technology allows us to increase dose and perhaps cure more tumors. In any event, for better or for worse, it ain't going anywhere.

 

[TheWallnerus]

Carrigellan, you know I happen to be in the middle of rereading P&P and I think I like your verion better- mine must be abridged
BTW- we never say zapped in rad onc, but I'm sure Ms Austen didn't know this; it was a long time ago indeed!

AS for rad onc's future:

As I noted before, the reason people doubt rad oncs future is that they (not willfully) misunderstand oncology as a series of laddered steps: first only sx, then rad, then chemo. Int he future the "magic bullet" will come and replace that etc. In fact, saying rad onc will go the way of the dodo is like suggesting surgery will. So long as people have cancer, surgery will have a place. Chemo asl well. And so too radonc. The modalities can each do things the other can't and often they suppliment each other; chemoradiation for instance is recognized to often be greater than the sum of its parts. We know that while chemo works systemically, radiation tends the majority of the time, to do a better job at local control, often the first site of failuer which may herald in some tumors a poor prognosis, or may just be a symptomatic problem. There are suggestions that superior lcoal control may inprove overall survival.

The only reason people think radiation may go away is a fundemental lack of understanding about oncologic treatment. My prediction is radiation will "ramp up" further in the next few years as the local control issue becomes more fleshed out, and as the technology allows us to increase dose and perhaps cure more tumors. In any event, for better or for worse, it ain't going anywhere.

This sentiment is almost 20 years old; it showed up in my similar thread feed below.

Anyone interested in turning the retrospectoscope on it? I think it’s pretty interesting how things have changed in 20 years. The truth is usually in the middle.

 

[elementaryschooleconomics]

What an interesting post, with all the benefit of hindsight. Gleevec had only been out for ~2 years at this point, and ipilimumab was ~8 years away from FDA approval.

 

[RickyScott]

What an interesting post, with all the benefit of hindsight. Gleevec had only been out for ~2 years at this point, and ipilimumab was ~8 years away from FDA approval.

At that point in time, the conventional thinking was that a drug could never theoretically cure stage 4 disease and that the immune system was not involved in cancer. I remember attending a lecture by Paul Turesi as a medstudent where he pointed out how chemo at the time did not extend OS in stage 4 lung cancer.

 

[TheWallnerus]

At that point in time, the conventional thinking was that a drug could never theoretically cure stage 4 disease and that the immune system was not involved in cancer. I remember attending a lecture by Paul Turesi as a medstudent where he pointed out how chemo at the time did not extend OS in stage 4 lung cancer.

Lung cancer survival did not budge the width of an alpha particle for half a century, especially in Stage III/IV disease. Targeted therapy in lung cancer has been a revolution (on top of the Revolution of smoking cessation) there.

2003: "The only reason people think radiation may go away is a fundemental lack of understanding about oncologic treatment. My prediction is radiation will 'ramp up' further in the next few years as the local control issue becomes more fleshed out, and as the technology allows us to increase dose and perhaps cure more tumors. In any event, for better or for worse, it ain't going anywhere."

2023: LungART, de facto raw-number dose de-escalation via hypofx in RO's main disease sites, oncology shying away from LC obesessions (older women w/ breast ca, CRs after chemo in breast ca, etc)... the day-to-day tx technology is essentially the same for ~99% of patients except maybe a cone-beam? I could go on...

 

[RickyScott]

“There is nothing new to be discovered in physics now. All that remains is more and more precise measurement.” Lord Kelvin 1900

 

[elementaryschooleconomics]

“There is nothing new to be discovered in physics now. All that remains is more and more precise measurement.” Lord Kelvin 1900

I literally had the same thought re: this quote and this thread

 

[RickyScott]

I literally had the same thought re: this quote and this thread

When systemic solid disease could almost never (not even theoretically) be cured by a drug, radiation was safe, but now that around 15-25% of stage 4 melanoma, lung etc, are cured, there is a path/possibilty that radiation will be severely curtailed/destroyed within the next 40 years. Crazy that there is not more impetus to follow clinical oncology tract like in the uk.

 

[Mandelin Rain]

What do you mean by "cured"? 5-year OS? Or like gone forever, never to return?

I've definitely seen a growing handful of Stage IV lung cancer patients limp across the 5-year mark, who were decidedly not cured.

 

[IRattending2021]

I debated between radonc and other fields back in college around that time while I was doing some radonc research. I expressed concern to my advisor that one day systemic tx may become good enough to cure on their own. She just laughed at me and said that will never happen.

 

[Mandelin Rain]

I think our bread and butter will always be upfront treatment of malignancies where surgery is not-feasible or too morbid to consider. That, and palliation of refractory disease.

The adjuvant stuff....? Not super safe.

 

[communitydoc13]

“There is nothing new to be discovered in physics now. All that remains is more and more precise measurement.” Lord Kelvin 1900

Interesting quote. While Kelvin was clearly wrong about physics, he was wrong because radical paradigm shifts were on the horizon (quantum mechanics and relativity). Regarding radonc, a radical paradigm shift would mean an intervention unlikely to be in our hands.

Adaptive MRI guided XRT, protons etc. are all attempts to improve conformality "All that remains is more and more precise treatment.". As we've discussed before, reaching the zenith of conformality is unlikely to be a game changer in oncology.

In the short term, the high capital investment in initiatives to marginally improve conformality (and perhaps Grade 1-2 toxicity) do little more than create a rupture between docs at large institutions, who overwhelmingly train our field, and the the docs who tend to the societal need for radiation away from these large institutions. The large institutions have to date overstated the value of these interventions and marketed directly to patients to improve market share.

In the long term, most solid tumors are now largely viewed as systemic diseases, with the outcomes of interest (death and disability) largely driven by systemic progression. Our interventions (and improved conformality) are continuously contextualized to the systemic therapy of the moment and the systemic therapy is improving rapidly. We have seen what 20 years of evidence based medicine can do when supported by pharma and a string of new drugs. We have yet to see what will happen once AI driven drug design really starts impacting the upstream volume of drug candidates.

In the present, the medical oncology machine has probably prematurely bought into the "it's all systemic disease" mantra and diminishes the value of anatomically focused therapeutic interventions (see DLBCL) for their patients. As their drugs get better, they will eventually be more right.

Radonc does remind me of physics. In post atom bomb, post Sputnik, cold war era USA, there was a push for physics in terms of national security, renewable energy etc. It's where the really smart kids went. Good programs were available in many universities. Of course the jobs dried up and many really smart physicists minted in 70s going forward had to change fields. Some of them changed to biology (the power of molecular bio and genetics becoming much more apparent in the 70s) and have had remarkable academic careers.

It's a shame. Cause physics just so much prettier than bio IMO.

 

[RickyScott]

Interesting quote. While Kelvin was clearly wrong about physics, he was wrong because radical paradigm shifts were on the horizon (quantum mechanics and relativity). Regarding radonc, a radical paradigm shift would mean an intervention unlikely to be in our hands.

Adaptive MRI guided XRT, protons etc. are all attempts to improve conformality "All that remains is more and more precise treatment.". As we've discussed before, reaching the zenith of conformality is unlikely to be a game changer in oncology.

In the short term, the high capital investment in initiatives to marginally improve conformality (and perhaps Grade 1-2 toxicity) do little more than create a rupture between docs at large institutions, who overwhelmingly train our field, and the the docs who tend to the societal need for radiation away from these large institutions. The large institutions have to date overstated the value of these interventions and marketed directly to patients to improve market share.

In the long term, most solid tumors are now largely viewed as systemic diseases, with the outcomes of interest (death and disability) largely driven by systemic progression. Our interventions (and improved conformality) are continuously contextualized to the systemic therapy of the moment and the systemic therapy is improving rapidly. We have seen what 20 years of evidence based medicine can do when supported by pharma and a string of new drugs. We have yet to see what will happen once AI driven drug design really starts impacting the upstream volume of drug candidates.

In the present, the medical oncology machine has probably prematurely bought into the "it's all systemic disease" mantra and diminishes the value of anatomically focused therapeutic interventions (see DLBCL) for their patients. As their drugs get better, they will eventually be more right.

Radonc does remind me of physics. In post atom bomb, post Sputnik, cold war era USA, there was a push for physics in terms of national security, renewable energy etc. It's where the really smart kids went. Good programs were available in many universities. Of course the jobs dried up and many really smart physicists minted in 70s going forward had to change fields. Some of them changed to biology (the power of molecular bio and genetics becoming much more apparent in the 70s) and have had remarkable academic careers.

It's a shame. Cause physics just so much prettier than bio IMO.

Exactly. Medical oncology is the paradigm shift. When I was a medical student the paradigm was that systemic therapy could not cure stage 4 solid malignancies. At conferences a lot of researchers feel that with further refinements/drugs IO will ultimately cure 40-50% of cancers. It used to be a mantra that targeted therapies were cytostatix and could not cure systemtic disease, but I think we have data of 20-30% cure rate of Mek/braf in mutated melanoma?

 

[seper]

All smart nuclear physicists are doing second checks for IMRT plans now

 

[TheWallnerus]

Interesting quote. While Kelvin was clearly wrong about physics, he was wrong because radical paradigm shifts were on the horizon (quantum mechanics and relativity). Regarding radonc, a radical paradigm shift would mean an intervention unlikely to be in our hands.

Adaptive MRI guided XRT, protons etc. are all attempts to improve conformality "All that remains is more and more precise treatment.". As we've discussed before, reaching the zenith of conformality is unlikely to be a game changer in oncology.

/philosophy
Further using your analogy, one of the basic ideas of quantum mechanics is: precision is not not infinitely achievable. There is a level of precision which is... quantum. We continue to wage our technological arms race of protons, MRgRT, etc, but perhaps this means the less we know of biology. (This is entropy too: the more intellectual energy we spend on technology, the less energy we have for biology.) I saw on Twitter recently re: a "precision radiation oncology" fellowship. "Precision" plus "radiation therapy" can actually make for an oxymoron. As we are all taught in residency, the X-rays (and protons, and neutron beams, and brachytherapy sources) have one cellular target: DNA. And the interaction is always random. The interaction follows a probability curve, but at the "quantum level" (and it really is quantum!) it's random. X-rays will never, ever be able to be aimed at just one gene or part of the DNA molecule. This is not a limitation for chemico-molecular agents obviously. Radiation therapy, like quantum mechanics, is stochastic. This is both its best feature (no cancer is immune to death from ionozing radiotherapy) and its worst feature!
/philosophy