Rad Onc and IR: Should we get married?

[Member223232]

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I know this topic has been discussed before but I thought it warrants a re-visit. The background is that in 2008, Dr. Zietman, the famous GU radiation oncologist at Harvard published an op-ed piece discussing some of the threats to radiation oncology as an independent specialty. These threats include: 1. relying on a single treatment modality that may someday (not soon) become obsolete, 2. being on the downstream of the patient "referral chain" such that one becomes dependent on the whims of the upstream referring docs. 3. over-focus on technology rather than patient care. In the paper, he articulates several possible solutions for this problem including combining rad onc with IR and med onc.

It is interesting to see that Dr. Zietman's proposal gaining some traction such that he was given the podium at this year's RSNA plenary session to broadcast his ideas. Having worked at both a community hospital during intern year and doing a rad onc rotation there and now at an academic center for residency, I can say that a lot of Dr. Zietman's concerns are very real. I wonder if current residents can somehow get in this dual RO-IR training track that Dr.Zietman is proposing and if SDN members have heard of anything similar.

 

[Gfunk6]

In my opinion, it is a pipe dream. Medicine has become more specialized over time and I just don't see it going in the other direction unless there is a fundamental paradigm shift.

Also, the path to becoming a Radiation Oncologist and an Interventional Radiologist is fundamentally different except for the year of internship. The most expedient path to dual certification would be to do a regular Rad Onc residency (5 years) followed by the DIRECT pathway (4 years) for a total of NINE years.

Who in their right mind would be willing to do this?? A lot of what you learn in those nine years would probably be irrelevant to a practicing brachytherapist/interventional oncologist. Therefore, it would essentially be up to the American Board of Radiology to design a specific pathway for efficient training. Honestly though, if I were a patient I would prefer to be treated by a dedicated Rad Onc or IR depending on my need. A similar argument could be made for Rad Oncs delivering any form of chemotherapy, even oral agents.

Keep in mind that two things will happen in the future to defray the ever-inflating costs of medical care:

1. More use of mid-levels; these are folks who have SIGNIFICANTLY less clinical training than MDs yet can practice independently
2. Eventual bundling of payments through ACOs; therefore Medicare/private insurance will give a lump sum for any cancer treatment to be divided among all specialist providers

Both of these factors are strong financial disincentives to increase residency training even further.

 

[Brim]

If you do, be sure to get a prenup.

 

[badasshairday]

No, it is very unlikely.

More likely to see a marriage between vascular surgery, interventional cardiology, and interventional radiology producing the interventionalist of the future. Even this is somewhat unlikely.

 

[Taurus]

Very different skillets and if you don't do a lot of either your skills get dull quickly. Plus, IR wouldn't go for this based on turf. I do agree though that relying on one modality like the way radonc does is very risky especially if some new treatments like targeted chemo comes along. That's one thing that turned me off to radonc.

 

[thesauce]

Very different skillets and if you don't do a lot of either your skills get dull quickly. Plus, IR wouldn't go for this based on turf. I do agree though that relying on one modality like the way radonc does is very risky especially if some new treatments like targeted chemo comes along. That's one thing that turned me off to radonc.

.

Actually the opposite is true. As systemic agents improve, the need for local control (i.e. radiation) becomes even more important. Think about it: right now, we have situations where the disease has spread to the point that local therapy does little good. If you come up with targeted agents that can better address the distant disease, you may be able to consolidate the disease to a few sites where local therapy can knock it out. Every radonc hopes for better targeted agents and many are helping to develop them.

 

[medgator]

Very different skillets and if you don't do a lot of either your skills get dull quickly. Plus, IR wouldn't go for this based on turf. I do agree though that relying on one modality like the way radonc does is very risky especially if some new treatments like targeted chemo comes along. That's one thing that turned me off to radonc.

.

Actually the opposite is true. As systemic agents improve, the need for local control (i.e. radiation) becomes even more important. Think about it: right now, we have situations where the disease has spread to the point that local therapy does little good. If you come up with targeted agents that can better address the distant disease, you may be able to consolidate the disease to a few sites where local therapy can knock it out. Every radonc hopes for better targeted agents and many are helping to develop them.

This conversation was had 30 years ago. It's being had now, and will likely occur 30 years from now while all of us are busily-employed radiation oncologists 😉

thesauce is correct.

 

[Taurus]

.

Actually the opposite is true. As systemic agents improve, the need for local control (i.e. radiation) becomes even more important. Think about it: right now, we have situations where the disease has spread to the point that local therapy does little good. If you come up with targeted agents that can better address the distant disease, you may be able to consolidate the disease to a few sites where local therapy can knock it out. Every radonc hopes for better targeted agents and many are helping to develop them.

I have no doubt what you're saying. IR docs are more than happy to help you out. But for them to train you so you don't need them? Good luck with that. As I said, IR skills are very different and you can't pick them up or maintain them unless you do a lot of IR.

 

[Member223232]

Yeah, I agree more with Zietman's preposition that we need to "own" our patients rather than to merge with IR. I think he's trying to get help re-vitalize the speciality and IR is probably the lowest hanging fruit. It's much harder for us to merge with med onc or any surgical speciality. I do think there are some advantages to merging with IR beyond ablation. For example chemo/radio embolization is great for liver mets and it's essentially owned by IR now. If we could get in that (maybe start with radioemboloization with Y-90 for example) that would add to our portfolio.

Also, a lot of biopsies are done by IR now to establish the diagnosis. If we did that, then we could move ourselves much earlier on the referral chain. For example, we would be at the initial discussion of a lot of early stage lung cancers which are currently owned by thoracic surgery. We'd be able to offer SBRT without having to beg the surgeons for referrals.

I definitely think we should be more involved in giving systemic therapy especially for combined chemo/rads. For example for rectal cancer, we can give Xeloda or Temodar for GBM's. They are oral pills for God's sake, you don't even need infusion center privileges. And it would be one less doctor the patient has to see.
One area we could definitely improve on is for met prostate CA. Since pt's usually do not see med onc initially, we essentially own these patients jointly with urology. Why do we need to refer to med onc to give lupron shots? We do it for definitive therapy in conjunction with RT, why can't we do it for metastatic disease? Also, there are a lot of oral pills now like Zytiga etc that we can also give. Plus we can treat them for bone mets with RT when necessary.

It's kind of frustrating because at my program , we don't do any of the above. We just refer to med onc as soon as the patient gets met. prostate CA. I don't know if its because we don't want to manage them due to poor reimbursement for non-procedural visits or because we're scared we would piss off the med oncs and they will stop referring patients to us.

 

[Gfunk6]

Giving someone temozolomide or capecitabine is not the same as prescribing Lipitor. When side effects happen, you had better be able to manage them. We are NOT trained to handle cytopenias and opportunistic infections. Are you prepared to also admit patients and manage them in house?

 

[deleted4401]

The job is hard enough.
If we also had to manage the toxicity of systemic therapy (checking bloodwork, giving Neulasta, admitting them when neutropenic), we would never get home at night.
And, I'm not about to do biopsies. There is technique that takes a while to learn and side effects I don't want to deal with (pneumothorax, infections, bleeding)
Ownership of the patient is important. It would be great to convince PCPs to consult urology and rad onc when a patient has an elevated PSA to force a multidisciplinary discussion. The biggest threat is self referral and we gotta quit being pansies. There needs to be stigmatization for partnering with urologists but at the same time, although there are good reasons to own Linacs, we may have to take a good look at ourselves and our habits.
The discussion is good, but need to be more realistic.
S

 

[Taurus]

Lol. Before you guys start daydreaming about doing procedures, maybe you should spend some time in the IR suite. Even biopsies are not always as straightforward as you guys think. I've seen lots of complications. I've heard of patients dying from a liver biopsy. I know of one case where a patient lost a kidney transplant after a biopsy.

 

[medgator]

For example, we would be at the initial discussion of a lot of early stage lung cancers which are currently owned by thoracic surgery. We'd be able to offer SBRT without having to beg the surgeons for referrals.

Another way (at least in the private world) to swing it is to be on good terms with PCPs and pulmonologists so they know to knee-jerk consult you when the diagnosis of a pulmonary malignancy is made. Remember, thoracic surgeons have to get those referrals from somewhere too

I definitely think we should be more involved in giving systemic therapy especially for combined chemo/rads. For example for rectal cancer, we can give Xeloda or Temodar for GBM's. They are oral pills for God's sake, you don't even need infusion center privileges. And it would be one less doctor the patient has to see.

Giving someone temozolomide or capecitabine is not the same as prescribing Lipitor. When side effects happen, you had better be able to manage them. We are NOT trained to handle cytopenias and opportunistic infections. Are you prepared to also admit patients and manage them in house?

Gfunk nailed it. Do you know when to give neulasta? I know I don't

One area we could definitely improve on is for met prostate CA. Since pt's usually do not see med onc initially, we essentially own these patients jointly with urology. Why do we need to refer to med onc to give lupron shots? We do it for definitive therapy in conjunction with RT, why can't we do it for metastatic disease? Also, there are a lot of oral pills now like Zytiga etc that we can also give. Plus we can treat them for bone mets with RT when necessary.

Have you been out much in the real world of private practice? I know it was a wakeup call for me. I sometimes order lupron and often insert my own fiducials for prostate IMRT/IGRT because the urologists just aren't interested in doing either. I feel comfortable telling pts to start Vitamin D/Calcium while on it and talk about getting a DEXA scan/controlling their DM/HTN with their PCP.

If you asked around, you'd find other rad oncs out in practice who prescribe lupron and place their own fiducials For urologists, Lupron these days doesn't the pay the way it used to in the 90s..... but I digress.

It's kind of frustrating because at my program , we don't do any of the above. We just refer to med onc as soon as the patient gets met. prostate CA. I don't know if its because we don't want to manage them due to poor reimbursement for non-procedural visits or because we're scared we would piss off the med oncs and they will stop referring patients to us.

It's not your fault. Where I trained was often a similar situation. I think it's the Ivory tower syndrome where everyone has their specific niche and really doesn't want (or feel comfortable) to step out of that.

Lol. Before you guys start daydreaming about doing procedures, maybe you should spend some time in the IR suite. Even biopsies are not always as straightforward as you guys think. I've seen lots of complications. I've heard of patients dying from a liver biopsy. I know of one case where a patient lost a kidney transplant after a biopsy.

Yup. Not interested in that can of worms.

 

[fizzle]

.

 

[Gfunk6]

Honestly, I think the most positive thing we can do is to take ownership of patients. When you see them on-treatment be sure to manage all of their side effects yourself. It is certainly appropriate to discuss with a surgeon or medical oncologist but in the end you should not "dump" your patients on them when you are the one who caused the side effects.

Also, it is important to follow-up with your patients long-term for years. If you just treat the patient and dump them to someone else for follow-up that makes you look like a technician rather than an oncologist. In addition, long-term follow-up is important for understanding how/if your treatments cause long-term side effects.

Finally, be part of a multi-disciplinary group either through your practice or hospital. Show up to tumor boards and, ideally, start/join multi-disciplinary clinics. That way, everyone is on the same page and the patients really appreciate it.

 

[medgator]

Honestly, I think the most positive thing we can do is to take ownership of patients. When you see them on-treatment be sure to manage all of their side effects yourself. It is certainly appropriate to discuss with a surgeon or medical oncologist but in the end you should not "dump" your patients on them when you are the one who caused the side effects.

Also, it is important to follow-up with your patients long-term for years. If you just treat the patient and dump them to someone else for follow-up that makes you look like a technician rather than an oncologist. In addition, long-term follow-up is important for understanding how/if your treatments cause long-term side effects.

Finally, be part of a multi-disciplinary group either through your practice or hospital. Show up to tumor boards and, ideally, start/join multi-disciplinary clinics. That way, everyone is on the same page and the patients really appreciate it.

It's sad that some of this needs to be summarized but all of it is completely true, whether in academics or private practice.