prospectives on neuro-oncology field. need advice

[Temodar]

Good evening

I'm considering neuro-oncology as a fellowship and I do have a couple of questions about it

- I heard from a neurooncologist in my institution that the field is currently unstable as no treatments are emerging and most of the therapies will be challenged in the future by insurance companies because they don't add much to neuro-oncology patients. So my question is, what is the future of this field and is it going to be fade away because it is solely a diagnostic field?
- Can you do neurooncology in private practice ? what will be the limitations ? I did try to look for oncology jobs and they are all academic and couldn't find private practice opportunities
- What are the other neurology fellowships that can be done with oncology and help in practice ?

Thank you everyone

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[Giovanotto]

Also interested.

 

[Alpetragius]

Interested

 

[deathmerchant]

Good evening

I'm considering neuro-oncology as a fellowship and I do have a couple of questions about it

- I heard from a neurooncologist in my institution that the field is currently unstable as no treatments are emerging and most of the therapies will be challenged in the future by insurance companies because they don't add much to neuro-oncology patients. So my question is, what is the future of this field and is it going to be fade away because it is solely a diagnostic field?
- Can you do neurooncology in private practice ? what will be the limitations ? I did try to look for oncology jobs and they are all academic and couldn't find private practice opportunities
- What are the other neurology fellowships that can be done with oncology and help in practice ?

Thank you everyone

Its partly true, but the number of neurooncologists' is so small that I think there will always be need for someone interested in it. There is always research going on and new things are in the pipeline.
Every moderate-big academic Neuro program and big private/cancer hospitals will need at least 1-2 neurooncologists.

I don't think you can survive with only neuro-onc in pp. May be employed at a large private hospital or large cancer center.

You can practice gen neuro on the side and/or take stroke call; which I think most neuro-onc have to do. I can't think of another fellowship that would be complimentary to Neuro-Onc.

 

[deleted102545]

Good evening

I'm considering neuro-oncology as a fellowship and I do have a couple of questions about it

- I heard from a neurooncologist in my institution that the field is currently unstable as no treatments are emerging and most of the therapies will be challenged in the future by insurance companies because they don't add much to neuro-oncology patients. So my question is, what is the future of this field and is it going to be fade away because it is solely a diagnostic field?
- Can you do neurooncology in private practice ? what will be the limitations ? I did try to look for oncology jobs and they are all academic and couldn't find private practice opportunities
- What are the other neurology fellowships that can be done with oncology and help in practice ?

Thank you everyone

1) That sounds wrong. There is always need for someone who knows good neurology for cancer patients. The field is growing as evidenced by the increasing size of SNO and the conferences each year. Yes, it is true that progress has been slow. Not sure where insurance companies come into that though. But if you're are at smaller instutition without lots of research then perhaps it may seem the other way.

HOWEVER, I think there are too many neuro-oncology fellowship spots. It is a small, niche field so there are not many patients to go around. Certain markets (Boston, NYC, east coast area) can handle a lot of neuro-oncologists per volume but the rest of country is not like that.

2) Neuro-oncology in a large community non-academic setting is feasible. Given consolidation in large healthcare groups there are some jobs here and there but overall it is academic in nature. I remember when I was looking for jobs a few years ago there some opporuntinties in the midwest and South at large community health systems. Neuro-oncology is a very multidisciplinary field so if you're not working with good neurosurgeons, radiation oncologists, or heme-oncs your practice won't succeed. One issue is that heme-oncs think they can do the neuro part of neuro-oncology - this is not true.

3) Neuroimmunology possibly. They are increasingly using more and more biologics and immunomodulatory drugs. A few years ago I would see patients here and there from older neurologists just to give rituximab but now with the newly trained neuroimmunologists those patients aren't being sent over.
A good neurophys background could be helpful.

 

[Epic786]

In my two cents, neuro oncology is the most depressing field in which most of your patients don't survive. Neurosurgeons are also leading the show in some of the area.

 

[Hank Rearden]

To the original poster - your neurooncologist must live in a cave because there are exciting treatments for GBM just around the corner. Look at some of the viral therapies being offered in clinical trials at MD Anderson and Duke. Around 5% of these patients achieve longstanding complete remission from refractory disease, something that was unheard of when I was in training. Those numbers are sure to improve over time.

 

[deathmerchant]

How about epilepsy/EEG? 70% of patients with LGG have epilepsy. Also, epilepsy is not a multidisciplinary field. Epilepsy patients don't need as much time/planning.

that's a reasonable thought. Probably most useful of all other fellowships.

 

[Thama]

that's a reasonable thought. Probably most useful of all other fellowships.

Since most of what neuroonc actually does is manage the epilepsy and headache caused by the tumor that is otherwise being managed by neurosurgeons and radonc, you might as well just skip the neuroonc fellowship and do epilepsy.

 

[xenotype]

Clearly you have no idea how a neuro-oncology clinic looks like. A neurosurgeon does not open without a neuro-oncologist gives the green light. In fact, in most cases, the role of surgery is to obtain tissue for diagnosis except for cases like meningioma where surgery can be the mainstay in treatment. Still, the patient will need to follow with neuro-oncology afterward. Good luck with neurosurgery giving chemo. Similarly, radonc once they're done with the RT, it is adios! Please spend a week in any neuro-onc clinic before you attempt to reply.

Surgeons are going to operate or not operate regardless of what a neuro-oncologist thinks. For new masses outside of obviously low risk lesions they do not wait for the opinion of a neuro-oncologist- they just take the patient to the OR the following day even if in a community hospital with no neuro-oncologist (which is most community hospitals). The chemotherapy given by neuro-oncologists can easily be done by the local heme/onc. What you are left with is giving second opinions, writing for temodar and CBCs, and managing headaches/seizures. Most neuro-oncologists get stuck after depakote and keppra and end up needing an epileptologist anyways. Thama is a very experienced academic neurologist who is not clueless. In residency I had extensive exposure to a large neuro-onc clinic regional referral center. He is correct. The options for aggressive tumors are really limited right now, and easily managed by a heme-onc with no neuro-onc involvement. That doesn't mean one can't have a great research career to try to change that, but most of the actual patients mainly need a good neurologist more than someone to write standard chemotherapy. Glioblastoma will be the majority of your work, and the treatment is completely palliative for everyone. As for viral treatments- don't get too excited.

 

[Thama]

Clearly you have no idea how a neuro-oncology clinic looks like. A neurosurgeon does not open without a neuro-oncologist gives the green light. In fact, in most cases, the role of surgery is to obtain tissue for diagnosis except for cases like meningioma where surgery can be the mainstay in treatment. Still, the patient will need to follow with neuro-oncology afterward. Good luck with neurosurgery giving chemo. Similarly, radonc once they're done with the RT, it is adios! Please spend a week in any neuro-onc clinic before you attempt to reply.

This may be the case in a handful of centers with large, robust neuroonc groups. However, it's not the case in most places. Hell, in my top 10-15ish center it's not the case - medonc is primary on brain tumor patients with neurosurgery calling the shots on steroids, etc. There are far too many brain tumor patients for neuroonc to be involved with all of them, and I've rarely seen them involved with chemo in any capacity other than agreeing with the Temodar or whatever else medonc was planning to give anyway.

When trainees are asking for insight on this forum regarding career paths, they are generally asking what the real world is like, not what it's like to be senior faculty at Dana Farber.

edit to add: Looking at your posting history, it looks like you came here 3 years ago asking this very forum for education on the basics of what neurooncology is and does. Congratulations on your extremely accelerated learning curve.

 

[Thama]

To you and "xenotype".
Again you are clueless. If you have second-hand info, recheck it.
GBM, HGG astro, LGG astro, HGG oligo, LGG oligo, pilocytic astro, meningioma all grades, PCNSL, systemic lymphoma with CNS involvement, NF1, NF2, ependymoma, medulloblastoma, LMD, PND and many others to name the cases you get to see in a neuro-oncology clinic. Yes, if you are located in a remote area, you should not expect to see much aside from the common cases. To correct you, neuro-onc get consults from the hemo-onc people themselves on cases with cancer involving CNS/PNS. If the burden of the disease involves the CNS is high, the neuro-onc actually is the leading team in the beginning then hands over the patient later to the oncology team. I lost count on how many times neurosurgery called it off based on the rec's of the neuro-oncologist simply because first they are not sure whether to proceed or not and also they know once surgery is done, the patient should see a neuro-onc whom they do want to be on the same page with the treatment. Also, we like neuroradiology people, but they are not as good in interpreting brain masses/lesion. Neurosurgeon wants to hear from onc to proceed. to give you an example, it is totally different the way you do surgery on CNS lymphoma than on glioma. Read to learn! Not speaking about emergency mass effect which even a started PGY2 should know what to do to manage them! In a tertiary center you can see as much CNS lymphoma as you will see DM cases in your internship. Are you a med student? what grade?

I'm faculty at a major (Doximity top-10) academic neurology department, and am speaking from direct experience. You came to this forum less than 3 years ago basically asking what neuro-oncology did. There isn't really much use attempting to remediate someone with your attitude, other than to note that were you my resident, you would get a fun note sent to your PD. I'll have you on ignore from now on.

 

[Spinothalamic]

What is the premise that you are debating? Is it the statement that one should consider skipping neuro-oncology fellowship to do epilepsy if the goal is private practice? Is it that neuro-oncologists don’t provide added benefit for patients with brain tumors? It is not clear to me.

I think we can all agree that there is major variability among practice culture at many institutions. In some institutions it seems that neuro-onc doesn’t call many of the shots, and in a some institutions (like mine) they are seeing all patients with primary brain tumors as well as many patients with intracranial metastases from active primary malignancies.