Rad Onc vs. Med Onc

[echod]

Which specialty do you think has more potential in developing new therapies? I am not very optimistic about radiation oncology because it seems to be limited in treatment modalities--radiation. In contrast, med onc research is constantly coming up with new molecular targets and treatments approaches such as RNAi. As med onc improves in its treatments for cancer, would it be possible to see the end of rad onc as a specialty within our careers? Is that why rad onc is MD/PhD friendly? Because they know they desperately need new treatments or they'll be replaced?

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[Neuronix]

This question comes up a lot at my school--peds onc vs med onc vs surg onc vs rad onc. I'll see if I can get someone currently in this dilemma to comment. My impression is that all of those except rad onc are extremely demanding clinical specialties. It's extremely hard to balance research and clinical in onc specialties besides rad onc, especially if you want to have any life at all outside of the hospital. The students I know who have chosen Rad Onc all came from this Oncology perspective and seemed to choose for that reason. There are some peds and med onc fellows around doing research and they seem to be as beat up and miserable as surgeons.

Fortunately Rad Onc does seem to care about research, so some have pulled it off with subpar grades/Step I scores given things like good PhDs and phone calls.

 

[Doctor&Geek]

There's like ten threads in the Radiation Oncology forum (including the FAQ) which go over this very issue. Use the search forum function.

 

[echod]

There's like ten threads in the Radiation Oncology forum (including the FAQ) which go over this very issue. Use the search forum function.

A multi-modality approach reflects the current state of technology. It is not entirely unreasonable to believe that as one modality (i.e. drugs) become more effective, another would become less frequently used (i.e. radiation). One also has to think about cost: radiation oncology equipment are expensive, but once a drug is off patent, it becomes much more affordable. The CEO of GE recently said that they are going to shift their health care emphasis from creating high end products to those that are more accessible to the masses. I would think that GE is going where the money is instead of being altruistic.

 

[mercaptovizadeh]

Which specialty do you think has more potential in developing new therapies? I am not very optimistic about radiation oncology because it seems to be limited in treatment modalities--radiation. In contrast, med onc research is constantly coming up with new molecular targets and treatments approaches such as RNAi. As med onc improves in its treatments for cancer, would it be possible to see the end of rad onc as a specialty within our careers? Is that why rad onc is MD/PhD friendly? Because they know they desperately need new treatments or they'll be replaced?

I think that's been a worry for a long, long time, since radiation considerably predates chemo. However, clearly it hasn't been phased out and due to the control of residency slots, it's a highly competitive, lucrative, and life-style friendly branch of medicine.

Re: RNAi and approaches such as these, I doubt they will work. The nucleic acid approach - gene therapy, RNAi, etc. - has not been shown to be very effective. Will we ever have a magic bullet? I don't know. I still think it will involve harnessing components of the immune system in some way, since this is the only system with potentially such a high specificity for tumor, but people have been working on it for decades with not that much success.

 

[Gfunk6]

There is so much misinformation in this thread I don't know where to start. To answer the OP's question: Med Onc. If you want to have a laboratory-based career (80% bench) then the ABIM Research Pathway model is optimal. Abbreviated clinical training, guaranteed fellowship and (most importantly) three years of dedicated research with mentorship. Also there are a lot of R01-funded faculty in the Med Onc community who can serve as mentors.

That said, Rad Onc has a pathway for research as well that is about the same length. 5 years of residency + 2 year research fellowship = 7 years (same as for the ABIM research pathway in subspecialites). However, research is not as strongly supported and there are far fewer role models to choose from. That said, Rad Onc has a better lifestlye and (many would argue) superior oncologic training.

OK, now to the old issue of: Is Rad Onc going to become obsolete soon?

The answer is absolutely NO. There has never been and will never be a "magic bullet" coming out of Med Onc labs. Cancer is an extraordinarily heterogeneous disease and to even suggest that all can be treated with one common therapy is the height of ignorance. Chemo is classically given for disseminated disease. Radiation and Surgery are reserved for local disease. As chemo improves (and it will) systemic disease will become less of an issue and local disease will become more important. This may actually increase the use of radiation.

Also, radiation delivery is highly sophisticated nowadays. You don't just toss someone on a table, aim the beam and push a button. There is an incredible level of treatment planning involving highly adaptive software and hardware. Most people (including other oncologists) don't know what our field entails.

Final advice: rotate through both specialites as a med student if you can and make your own decision.

 

[echod]

OK, now to the old issue of: Is Rad Onc going to become obsolete soon?

.[/QUOTE]

I do not think at all that rad onc might be obsolete soon. What I do wonder is whether over the course of 30-40 years the amount of patients treated by rad onc would decrease by 30% to 50%.

 

[NGN47]

I was in a similar position. For many reasons, some that are common, some that are almost unique to me alone, I was drawn to the field of oncology and really never considered anything else. However, after spending some time in medical school I was a little disappointed to find out that there is no such thing as an "oncologist." There is: radonc, heme/onc, ped-heme/onc, gyn-onc, surg-onc, and more.

I eliminated surgery and obgyn during my MS3 year. I still considered ped-onc, but realized I did not want to focus on children. I started MS4 year with a heme-onc rotation (both inpatient and then outpatient). It WAS something that I could see myself doing in the future. Much of the inpatient work- which is very rigorous - involves management of very sick patients made sicker (temporarily or not) from chemotherapy. For example, patients admitted for high dose IV chemo, patients that were neutropenic and became febrile, patients undergoing bone marrow or stem cell transplant. The management of such patients is complex and certainly requires lots of general medicine training. The selection of which drugs to give appeared to me NOT complex, and seemed rather arbitrary (based on published trials of course). I would say that if you know you want to do internal medicine first, and oncology second, heme-onc makes perfect sense, and don't give a second look to radonc. However, if your honest interest is in oncology first, look further and explore radonc, as I did, before making up your mind.

My second rotation was in Radonc. It was something I could also see myself doing in the future. It is nearly all outpatient. It is wedded to technology - both in imaging, in radiation delivery, and the merging of the two. The actual work you do in Radonc is diverse: examination and consultation with patients, careful examination of multiple imaging modalities, the physics of treatment planning, and then finally the treatment itself (which could be via a linear accelerator or sealed, implanted radioactive sources at the tumor site, or free radioactive molecules). You might also give additional, non-radiation treatments as well (for example, hormonal therapy in prostate cancer to name one). I felt that, on average, the overall fund of knowledge about cancer as a disease was greater among the physicians in the radiation oncology department than those in the heme-onc department - though there were some exceptions of course. Perhaps this is because Radoncs spend 4 years training in cancer rather than 3. Its worth noting that training in Radonc takes 5 years including internship, compared with 6 for heme-onc (3 for IM plus 3 for fellowship).

I may be going out on a limb here to my own peril, but I think the future of cancer treatment will not involve administering lots of new systemic cytotoxic drugs that put you in the hospital. As you have stated, it may involve siRNA. I would say, more generally, that it will involve increasingly targeted therapy - molecularly targeted as well as anatomically targeted. Radiation therapy is already and will be increasingly anatomically targeted as technical advances in imaging and delivery come to the clinic. Chemoembolization is another example of an (anatomically) targeted therapy. To be complete, surgery is obviously anatomically targeted, just not always practical. Kinase inhibitors and monoclonal antibodies are examples of (molecularly) targeted therapy. Perhaps we may even see cellularly targeted therapy making use of "smart" T-cells. Research in the previously mentioned treatments are fair game for anyone in any oncology specialty. I would add that either medonc or radonc residency training can be done on a research track - sanctioned by the ABIM or ABR (called the "Holman pathway"). And, at most programs that I considered, you can choose a research mentor from any department provided the research is relevant. This was true for heme-onc fellows as well.

So, the decision is up to you. Both can take you where you want to be.

 

[echod]

I was in a similar position. For many reasons, some that are common, some that are almost unique to me alone, I was drawn to the field of oncology and really never considered anything else. However, after spending some time in medical school I was a little disappointed to find out that there is no such thing as an "oncologist." There is: radonc, heme/onc, ped-heme/onc, gyn-onc, surg-onc, and more.

I eliminated surgery and obgyn during my MS3 year. I still considered ped-onc, but realized I did not want to focus on children. I started MS4 year with a heme-onc rotation (both inpatient and then outpatient). It WAS something that I could see myself doing in the future. Much of the inpatient work- which is very rigorous - involves management of very sick patients made sicker (temporarily or not) from chemotherapy. For example, patients admitted for high dose IV chemo, patients that were neutropenic and became febrile, patients undergoing bone marrow or stem cell transplant. The management of such patients is complex and certainly requires lots of general medicine training. The selection of which drugs to give appeared to me NOT complex, and seemed rather arbitrary (based on published trials of course). I would say that if you know you want to do internal medicine first, and oncology second, heme-onc makes perfect sense, and don't give a second look to radonc. However, if your honest interest is in oncology first, look further and explore radonc, as I did, before making up your mind.

My second rotation was in Radonc. It was something I could also see myself doing in the future. It is nearly all outpatient. It is wedded to technology - both in imaging, in radiation delivery, and the merging of the two. The actual work you do in Radonc is diverse: examination and consultation with patients, careful examination of multiple imaging modalities, the physics of treatment planning, and then finally the treatment itself (which could be via a linear accelerator or sealed, implanted radioactive sources at the tumor site, or free radioactive molecules). You might also give additional, non-radiation treatments as well (for example, hormonal therapy in prostate cancer to name one). I felt that, on average, the overall fund of knowledge about cancer as a disease was greater among the physicians in the radiation oncology department than those in the heme-onc department - though there were some exceptions of course. Perhaps this is because Radoncs spend 4 years training in cancer rather than 3. Its worth noting that training in Radonc takes 5 years including internship, compared with 6 for heme-onc (3 for IM plus 3 for fellowship).

I may be going out on a limb here to my own peril, but I think the future of cancer treatment will not involve administering lots of new systemic cytotoxic drugs that put you in the hospital. As you have stated, it may involve siRNA. I would say, more generally, that it will involve increasingly targeted therapy - molecularly targeted as well as anatomically targeted. Radiation therapy is already and will be increasingly anatomically targeted as technical advances in imaging and delivery come to the clinic. Chemoembolization is another example of an (anatomically) targeted therapy. To be complete, surgery is obviously anatomically targeted, just not always practical. Kinase inhibitors and monoclonal antibodies are examples of (molecularly) targeted therapy. Perhaps we may even see cellularly targeted therapy making use of "smart" T-cells. Research in the previously mentioned treatments are fair game for anyone in any oncology specialty. I would add that either medonc or radonc residency training can be done on a research track - sanctioned by the ABIM or ABR (called the "Holman pathway"). And, at most programs that I considered, you can choose a research mentor from any department provided the research is relevant. This was true for heme-onc fellows as well.

So, the decision is up to you. Both can take you where you want to be.

Is chemoembolization done by the hemo oncs or the surgeons?

 

[NGN47]

Is chemoembolization done by the hemo oncs or the surgeons?

Interventional radiologists - and now we can add them to the "oncologist" list, too.