RadOnc Is Still The Best Field in Medicine

[RO2019]

I feel like SDN has become a place for people to vent about things in the our RadOnc world, but I want to use this thread as a place for me, and anyone else who feels similarly, to express what we love about our field. SDN is a place that many many many medical students check out to get their understanding of a field, and it's too bad if people take away too negative of a feeling. Some may have even heard that application numbers across RadOnc programs are down this year (which is a great thing for people applying this year, but not a good thing overall)

1) I have never once regretted my decision to enter this amazing field. Every single day in training I'm reminded of how awesome our field is and what we get to do for our patients. When I go to see inpatient consults, I just realize how glad I am not to have to deal with the grind of babysitting inpatients.

2) If you are interested in oncology at all, Radiation Oncology is still the best field. We have pure oncology training from day 1 of residency, and we leave training with much more experience in dealing with solid tumor oncology cases than our medical oncology colleagues, that's just the facts.

3) Radiation Oncologists still do quite well financially.

4) The job market is not nearly as doom and gloom as people on this thread would have you believe. Just keep your eyes on the ASTRO job center and see for yourself. It is noticeably very very active this year - lots of jobs are being posted DAILY. Maybe its an aberration this year? Or maybe its reflective of the fact that the field continues to grow

5) Yes with hypofractionation, the time 'on beam' for bread and butter breast and prostate patients is decreasing (thankfully, for the better of society tbh). But you know what? People entering training now are going to have a career of treating oligomets in a way that the previous generation did not. There is early data, and soon to be solid randomized data supporting the clear benefit of treating subsets of patients with oligomets in the immune checkpoint inhibition era. Oligomet treatment is here to stay. Not to even mention the cardiac radiosurgery movement which is only going to grow. We are going to be treating patients we've never treated before in the past, even if their actual days on the machine aren't six-nine weeks.

Just to get this started.

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[deleted947887]

Agree that rad onc is great. However, the field needs to reinvent itself. Times and fields are changing while radonc has remained relatively constant. Call me crazy, but I don't think having inpatients is a bad thing. In fact, I think that's where the field got lost. Once we became a referral service, we lost the patients. Oligomets are great, but that's not new. People were doing this off protocol. I think rad oncs need to go back to being doctors and get away from being business executives (this is also what happened to radiology). People see through that (referring docs and patients). If the field is to survive, it is incumbent on the new generation to take the reins (which seems to be happening). Also, we can't just blame the older generation. They don't want to give things up, and are opposed to radical change. Who wouldn't be? It's going to be a team effort. We have to work with them and think outside the box. Ideally a union with medical oncology would reinvigorate the field. How that will happen is yet to be determined.

I feel like SDN has become a place for people to vent about things in the our RadOnc world, but I want to use this thread as a place for me, and anyone else who feels similarly, to express what we love about our field. SDN is a place that many many many medical students check out to get their understanding of a field, and it's too bad if people take away too negative of a feeling. Some may have even heard that application numbers across RadOnc programs are down this year (which is a great thing for people applying this year, but not a good thing overall)

1) I have never once regretted my decision to enter this amazing field. Every single day in training I'm reminded of how awesome our field is and what we get to do for our patients. When I go to see inpatient consults, I just realize how glad I am not to have to deal with the grind of babysitting inpatients.

2) If you are interested in oncology at all, Radiation Oncology is still the best field. We have pure oncology training from day 1 of residency, and we leave training with much more experience in dealing with solid tumor oncology cases than our medical oncology colleagues, that's just the facts.

3) Radiation Oncologists still do quite well financially.

4) The job market is not nearly as doom and gloom as people on this thread would have you believe. Just keep your eyes on the ASTRO job center and see for yourself. It is noticeably very very active this year - lots of jobs are being posted DAILY. Maybe its an aberration this year? Or maybe its reflective of the fact that the field continues to grow

5) Yes with hypofractionation, the time 'on beam' for bread and butter breast and prostate patients is decreasing (thankfully, for the better of society tbh). But you know what? People entering training now are going to have a career of treating oligomets in a way that the previous generation did not. There is early data, and soon to be solid randomized data supporting the clear benefit of treating subsets of patients with oligomets in the immune checkpoint inhibition era. Oligomet treatment is here to stay. Not to even mention the cardiac radiosurgery movement which is only going to grow. We are going to be treating patients we've never treated before in the past, even if their actual days on the machine aren't six-nine weeks.

Just to get this started.

 

[nkmiami]

I am in complete agreement with the post above by sphinx. It is a great field, but it will face quasi existential challenges. I have beaten the job over supply to death, but even scientifically, technologies unimaginable when I was in training are entering medicine: In the last year, Car-T, and now mrna silencing has fda approval, and would have to think that will have an impact in cancer:
Gene-silencing technology gets first drug approval after 20-year wait (and yes, it is 450,000$)

 

[scarbrtj]

OK. Give you a definite maybe. On the other hand, a few less breast and prostate fractions won't offset societal costs for stuff like this. And re: our alleged sui generis lordship over solid tumors, the most common solid tumors are breast, lung, prostate, and colorectal. There's been no survival breakthrough in those things radiation-wise in the last two decades. But off the top of my head: herceptin, durvalumab, abiraterone... and long-term stage IV colorectal cancer survivors (kind of a rarity back in the 90's and before) are not happening because of radiation. The non-radiation oncology oncologists will forever and ever give us the side-eye, and that's OK. Anyways. Rad onc is a great field. And it's the greatest field... for you.

 

[Radiator20]

I don't think having inpatients is a bad thing

Inpatients aren't a bad thing if you are competent to take care of them well. I don't know a single practicing rad onc who is (including me). No disrespect to them as rad oncs, it's just not what we do. And you aren't good at what you don't do. Parenthetically, the common advice on this forum to do a cush TY (advice I entirely disagree with) only reinforces this issue. Even aside from that, while I agree that innovation is key to our field, trying to take care of inpatients is not innovation--it wouldn't fix any of the issues in our field, and would have a significant negative impact on our QoL.

Union with med onc is a fantasy... or a nightmare, depending on your perspective. Not going to happen, so whatever the solution is, that's not it.

We have multiple paths to innovation in rad onc, including intrinsic technical advances, and figuring out how we interact with improved systemic therapies. 20 yrs ago, doubt many would have predicted how the synergy of better systemic control in lung, melanoma, etc PLUS technical advances in SRS/SBRT would have led to the explosion in stereotactic oligomet treatment we have seen. Paradigm shift made possible by advances in both fields, and has led to dramatic benefit for pts. To me, that's an ideal vision of how a future of comprehensive oncology care could look.

 

[deleted947887]

OK. Give you a definite maybe. On the other hand, a few less breast and prostate fractions won't offset societal costs for stuff like this. And re: our alleged sui generis lordship over solid tumors, the most common solid tumors are breast, lung, prostate, and colorectal. There's been no survival breakthrough in those things radiation-wise in the last two decades. But off the top of my head: herceptin, durvalumab, abiraterone... and long-term stage IV colorectal cancer survivors (kind of a rarity back in the 90's and before) are not happening because of radiation. The non-radiation oncology oncologists will forever and ever give us the side-eye, and that's OK. Anyways. Rad onc is a great field. And it's the greatest field... for you.

Nailed it.

Inpatients aren't a bad thing if you are competent to take care of them well. I don't know a single practicing rad onc who is (including me). No disrespect to them as rad oncs, it's just not what we do. And you aren't good at what you don't do. Parenthetically, the common advice on this forum to do a cush TY (advice I entirely disagree with) only reinforces this issue. Even aside from that, while I agree that innovation is key to our field, trying to take care of inpatients is not innovation--it wouldn't fix any of the issues in our field, and would have a significant negative impact on our QoL.

Union with med onc is a fantasy... or a nightmare, depending on your perspective. Not going to happen, so whatever the solution is, that's not it.

We have multiple paths to innovation in rad onc, including intrinsic technical advances, and figuring out how we interact with improved systemic therapies. 20 yrs ago, doubt many would have predicted how the synergy of better systemic control in lung, melanoma, etc PLUS technical advances in SRS/SBRT would have led to the explosion in stereotactic oligomet treatment we have seen. Paradigm shift made possible by advances in both fields, and has led to dramatic benefit for pts. To me, that's an ideal vision of how a future of comprehensive oncology care could look.

For anyone who did a prelim year, inpatients are not hard to care for (realistically, IM is one more year than a prelim year, because third year is basically a joke). That said, I'm not an ICU doc and I'm not intubating people, but thats ok. I dont need to do that. I disagree that we can't take care of inpatients. Sure we may need some training, but not drastic. Not too sure about technological advances...protons and MRIs have sucked so far. I'd rather take care of inpatients than spend an extra 2 hours recontouring for a theoretical benefit, or to spare some organ with protons-one that doesnt need sparing, or make my dosimetrist's life harder for something that doesnt work. Oligomets is not rad onc innovation. Thats medonc innovation. Priming the immune system wasn't a rad onc. He's married to a medonc.

Our field needs change. We agree on that. We also need to start agreeing on things before we can start changing things.

Also, lets not forget this fiasco:

Physics & Radbio

 

[Radiator20]

inpatients are not hard to care for

Perhaps it depends on your institution. In my experience, onc pts who get admitted are often quite sick indeed--otherwise they wouldn't have gotten admitted in the first place. Moreover, taking care of them is what IM residents, hospitalists, etc. are there to do; they do it every day and are good at it. Rad oncs, not so much.

Oligomets is not rad onc innovation

Without the technical advances that made it possible for us to treat those oligomets, there would not be an oligomet paradigm.

 

[nkmiami]

"Union with med onc is a fantasy... or a nightmare, depending on your perspective. Not going to happen, so whatever the solution is, that's not it."

1) In much of the world, radiation docs give systemic agents. I dont know what game changing technological advantages you envision- mri guided protons: do you think crap like that will have a survival benefit? Also, regarding interface of radiation and the immune system, these pathways can be mimicked with drugs and there are plenty in development. There are multiple agents in the pipeline that focus on the DDR pathway/STING/cGAS etc. Moreover, treating oligomets is not a significant part of our case load, nor is there any level 1 evidence for this- certainly wouldnt call it a "paradigm"

 

[BobbyHeenan]

If I had any say, I would put the focus squarely on pushing randomized trials of XRT up against surgery for two of the most common things we see: prostate cancer and early stage lung cancer. It's a no lose situation for our specialty to enroll these trials. Even if XRT is inferior, I don't think we miss out on treating the poor operative prostate patients or the terrible COPD lung cancer patients. But if the trials accrue well and show equivalence or superiority it could greatly help us.

I know I know - it's hard to do a surgery versus radiation trial but I feel like if we had all hands on deck and even imposed some shaming on our surgical colleagues to enroll, then we could get it done.

The UK PACE trial (SBRT/hypo frac XRT vs. prostatectomy) as I understand it is accruing well. The VA is opening up SBRT vs. surgery for early stage lung and I believe maybe even an SBRT vs. IR ablation for HCC.

If these trials show clinical equivalence I have no pipe dreams that it will actually change standard of care over to XRT, but it may at least change standard of consult to every patient should actually see a rad onc to discuss radiation before making a decision. At least at a cancer center/network level a policy change could be enacted if we get stronger randomized data. Best case optimism would be NCCN specifically mentioning radiation consult for these patients (and not just the surgeon "discussing radiation").

IT's a delicate balance because you don't want to piss off your referring surgeons, but at some point if the data is there you can stand upon it and say "every patient with (prostate) or stage 1 lung cancer deserves a radiation consult before moving forward with definitive treatment."

 

[Radiator20]

"Union with med onc is a fantasy... or a nightmare, depending on your perspective. Not going to happen, so whatever the solution is, that's not it."

1) In much of the world, radiation docs give systemic agents. I dont know what game changing technological advantages you envision- mri guided protons: do you think crap like that will have a survival benefit? Also, regarding interface of radiation and the immune system, these pathways can be mimicked with drugs and there are plenty in development. There are multiple agents in the pipeline that focus on the DDR pathway/STING/cGAS etc. Moreover, treating oligomets is not a significant part of our case load, nor is there any level 1 evidence for this- certainly wouldnt call it a "paradigm"

In that part of the world where medicine is organized under the British system, there is one integrated specialty of clinical oncology. Not quite the same as "rad oncs giving systemic agents" (or "med oncs giving RT"). In any case, that is obviously not how the US is organized. By what path, specifically, do you see us moving from our system to theirs? Personally, I do not think ABR and ABIM are at all likely to support, or even permit, that sort of massive reorganization. The rest of your comment is about how you think this would be a good idea. You're certainly entitled to your opinion and I'm not even sure I disagree. But my point was not about whether it's a good idea or not--rather, that it is empirically unlikely to happen.

How significant a part oligomets makes up of your case load at the moment probably depends on your practice context but in any event is likely to continue to increase in the future. I am aware there is no level 1 evidence and never said there was, but the very concept of doing such treatment didn't exist 25 years ago, so yes, I would call it a paradigm.

The idea that DDR perturbogens, etc represent a systemic option that "does the same thing as RT" is... unproven to say the least.

 

[nkmiami]

In that part of the world where medicine is organized under the British system, there is one integrated specialty of clinical oncology. Not quite the same as "rad oncs giving systemic agents" (or "med oncs giving RT"). In any case, that is obviously not how the US is organized. By what path, specifically, do you see us moving from our system to theirs? Personally, I do not think ABR and ABIM are at all likely to support, or even permit, that sort of massive reorganization. The rest of your comment is about how you think this would be a good idea. You're certainly entitled to your opinion and I'm not even sure I disagree. But my point was not about whether it's a good idea or not--rather, that it is empirically unlikely to happen.

How significant a part oligomets makes up of your case load at the moment probably depends on your practice context but in any event is likely to continue to increase in the future. I am aware there is no level 1 evidence and never said there was, but the very concept of doing such treatment didn't exist 25 years ago, so yes, I would call it a paradigm.

The idea that DDR perturbogens, etc represent a systemic option that "does the same thing as RT" is... unproven to say the least.

I thought that at one time the NCI residency program also provided board eligiblity in medonc, so there is precedent here. If I am not mistaken Turrisi and Steve Hahn are technically certified in medonc?

 

[RO2019]

level 1 evidence for oligomets is coming in form of ASTRO plenary later this month. Agree with you radiator20 that this is a new paradigm and we haven't even started to scratch the surface of the growth in this practice yet.

I wonder about people who feel at all doubtful about 'rad oncs being doctors'?? I wonder what kind of training or practice you are in. It''s sad to me for any rad onc to feel that way when there are people in other fields who wonder about that. Never have I not once felt confident that I was a doctor when I'm taking care of my patients. If anything I think we're some of the BEST doctors because we have the luxury of having time to spend with our patients.

i also wonder about the understanding of oncology in people who think CAR-T cells or gene silencing or going to take radiation out of the game soon. Jeez.

 

[nkmiami]

I dont know what type of level I evidence comes from a phase II trial; since oligomets are so common we should be able to quickly accrue pts to a phase III trial? You dont realistically believe oligomets could offset prostate and breast- and we may also get evidence about treating breasts in 5 fractions, which will be a real boon to the future of the field.

Nobody thinks radiation is going to disappear in the next 10 years, its a question of utilization, and its role certainly could be diminished.

10 years from now, our bread and butter prostate and breast- many early case may not get treatment or undergo significant hypofractionation. Maybe this will be slightly offset by the rare oligomets, (and also maybe less patients get mets with better systemic therapy- ex: myleoma, we are treating much less today than 10 years ago) Overall I dont like the trend.

 

[medgator]

Call me crazy, but I don't think having inpatients is a bad thing.

Who said it was? Out in the real world, I see inpatients all the time. And in the clinic, I do all kinds of normal "doctor" things like managing my own complications... I.e..giving narcotics for radiation esophagitis/mucositis, starting high dose steroids for radiation pneumonitis etc. I don't give fluids but my med oncs are happy to help in that regard. One of my retired partners rarely wrote narcotics for xrt issues... a problem with the old timers.

Rounding on inpatients is probably less important than acting like a "doctor" and knowing how to manage your own complications so the med onc/surgeon/referring doesn't have to.

 

[OTN]

I dont know what type of level I evidence comes from a phase II trial; since oligomets are so common we should be able to quickly accrue pts to a phase III trial? You dont realistically believe oligomets could offset prostate and breast- and we may also get evidence about treating breasts in 5 fractions, which will be a real boon to the future of the field.

Nobody thinks radiation is going to disappear in the next 10 years, its a question of utilization, and its role certainly could be diminished.

10 years from now, our bread and butter prostate and breast- many early case may not get treatment or undergo significant hypofractionation. Maybe this will be slightly offset by the rare oligomets, (and also maybe less patients get mets with better systemic therapy- ex: myleoma, we are treating much less today than 10 years ago) Overall I dont like the trend.

In my experience in my practice the improvement in systemic control for diseases like melanoma, renal call ca, NSCLC, etc, has led to a dramatic increase in my treating oligometastatic disease. I have no doubt at least for my practice it's more than made up for any issues with hypofractionation. I don't treat any prostates, really, (thanks urorads), so that hasn't impacted me as much, but I do think that improvements in systemic agents have led to my being busier.

On another positive note, I went to the WashU research symposium on cardiac SBRT for VTach this past weekend...now THAT'S some exciting stuff. I can't give too many details, as their results are still somewhat confidential at this point, but if you read the NEJM article and were excited, you have every right to think that way. Completely non-invasive, works very well. What if it also works for AFib?

 

[scarbrtj]

Without the technical advances that made it possible for us to treat those oligomets, there would not be an oligomet paradigm.

I know this is the party line, but I'm a contrarian.

"[SBRT] techniques are unusual in the high technology realm of radiation treatment in that they require more specialized training of physicians and physicists rather than specialized equipment."

Technical advances: great. Love 'em. Have they truly impacted cancer outcomes by moving the survival needle? A little. There used to be this Fox News show called "Hannity & Colmes." Colmes was the liberal guy. (He was oft relegated to the corner; hey, it was Fox.) Watching the show, it should have been called HANNITY & colmes. For improving cancer outcomes the show used to be Systemics & Radiotherapy. It's becoming SYSTEMICS & radiotherapy. Radiotherapy, like Colmes, still has/had its role to play. FWIW, I liked Colmes. (FWIW, sadly, he's dead.) All that said, I think cardiac SBRT is very exciting.

 

[deleted947887]

Hilarious and on point.

I know this is the party line, but I'm a contrarian.

"[SBRT] techniques are unusual in the high technology realm of radiation treatment in that they require more specialized training of physicians and physicists rather than specialized equipment."

Technical advances: great. Love 'em. Have they truly impacted cancer outcomes by moving the survival needle? A little. There used to be this Fox News show called "Hannity & Colmes." Colmes was the liberal guy. (He was oft relegated to the corner; hey, it was Fox.) Watching the show, it should have been called HANNITY & colmes. For improving cancer outcomes the show used to be Systemics & Radiotherapy. It's becoming SYSTEMICS & radiotherapy. Radiotherapy, like Colmes, still has/had its role to play. FWIW, I liked Colmes. (FWIW, sadly, he's dead.) All that said, I think cardiac SBRT is very exciting.

 

[thaddeus]

I feel like SDN has become a place for people to vent about things in the our RadOnc world, but I want to use this thread as a place for me, and anyone else who feels similarly, to express what we love about our field.

Couldn't agree more, and predictably this thread has been hijacked to discuss our impending doom, all the challenges facing the field, etc. But I love going to work every day, I have a fantastic schedule that allows me to see my family a lot and get compensated more than I think I really deserve. And I'm a relatively new grad, not some dinosaur who got in before the going got tough. So, yes we all know some of the challenges in our field right now, but let's take a step back and just be grateful for what we have.

 

[maruchan]

The issue with this field is that the job market is very limiting, compared to other fields. I don't want to focus on whether the job market is getting better or worse. I don't think the job market has been "good" for 2 decades probably and I don't think it's "good" now.

Some will be fortunate enough to land in the ideal situation for them in terms of work environment, responsibilities, and geography. Those people will be happy and deeply satisfied with their choice of specialty.

Some will not be so fortunate and will have to sacrifice on one or more of these aspects. There are a lot of suboptimal jobs out there. There are a lot of outright bad jobs. The people in those positions will not be happy.

You can go back and forth arguing about how big bucket 1 versus bucket 2 is, and whether landing in one is the function of luck or of ability.

But in my view, it is inarguable that, on average, an individual's control over the job situation is significantly lower than the majority of other specialties. I chose rad onc anyway, but you have to know that if you choose this field, you're taking a gamble on your future job situation.

 

[KHE88]

Since the thread where the complaints about the field was locked down (why? seems like a good idea to direct it all to one spot), no surprise that there will be some of that here. There are a lot of fields in medicine with high quality of life and high pay that don't have the nonsense we have to deal with (optho, rads, IR, derm, EM, anesthesia, GI, urology, even med/onc off the top of my head). A competitive applicant for rad onc would be competitive for any of these.

Perhaps I'm just beat down in my last year from the boards debacle and the nature of residency in general. I have found oncology boring. So much of residency and boards is focused on regurgitating trial data. We like to pretend we're medical oncologists and memorize drugs that we don't prescribe. My med oncs colleagues laughed when I told them we get asked about chemo doses: "we don't even get tested on that!" We lose sight of the forest for the trees. I went to radiation oncology residency to learn how to be a radiation oncologist. Not a medical oncologist. Not a physicist. Not a surgeon. Not a cancer biologist. Part of learning to be a good radiation oncologist involves a basic working knowledge of these other disciplines, but we take it to the extreme. Why do we feel like we need to know as much or more about surgery and chemo than the surgeons and medical oncologists? Do they feel like they need to know more about radiation than us? Why do the academics have this inferiority complex? I am just so over this insecure neverending contest of trying to prove who is the smartest.

Yes, I enjoy contouring a complicated target volume and building a sophisticated plan. Yes, I enjoy going back to the machine for a clinical setup or doing an emergent sim and treat. Yes, I enjoy doing gyn brachy and other procedural rad onc. Yes I enjoy managing patients on treatment and seeing them in follow-up. No, I don't enjoy sifting through volumes of worthless retrospective and SEER publications, being forced to generate said publications, memorizing p-values and response rates to the tenth of a decimal point from randomized trials, getting relentlessly pimped by site-specific attendings on obscure chemo and surgery trials, and studying cancer biology at the molecular level. Residency wasn't about teaching you how to be a good radiation oncologist - managing patients, building good plans, you know the day-to-day work we actually do. Residency was about serving as scribes primarily and secondarily memorizing all this ancillary stuff for these silly exams that have nothing to do with clinical competency and tip-toeing around the dogma and sensitive feelings of the site specific attendings. The important apprenticeship stuff we just kind of pick up along the way by osmosis (hopefully). I had no idea how to tell if a DVH was acceptable until after my first year because I was too busy writing notes and trying to memorize historical trial data so I didnt't get humiliated in peer review conference. I didn't know how the machines worked - check a light field, set up an electron treatment, even check port images. I didn't know what the therapists were doing in SIM. I didn't know what the dosimetrists did. I picked all this up on my own later. Because we are too focused on being academics. Oh, the horror if someone calls us a technician! You want to go into private practice? Better keep it a secret. Why?

ALL that said... Yes, I was at home 90% of weekends and worked on average 50 hours/week during residency. Not many residencies can say that. BUT, I had to move far away from my family for residency due to the competitive and small size of the field and there are no jobs back home, so I'll be working very far away (and admittedly getting paid very well) until the day a partner retires and a spot opens up.

Hopefully my feelings will change when I start independent practice as most of my complaints are about residency and boards, but right now, I'm not sure I would do this again.
It's no surprise numbers are down this year. They should be. Med students aren't dumb. Rad onc is not the only path to a comfortable life in medicine.

 

[UndecidedM3]

SDN is a place that many many many medical students check out to get their understanding of a field, and it's too bad if people take away too negative of a feeling. Some may have even heard that application numbers across RadOnc programs are down this year (which is a great thing for people applying this year, but not a good thing overall)

Just curious, how down are application numbers this year? What are your sources for this?



Sent from my iPhone using SDN mobile

 

[deleted947887]

There are a lot of fields in medicine with high quality of life and high pay that don't have the nonsense we have to deal with (optho, rads, IR, derm, EM, anesthesia, GI, urology, even med/onc off the top of my head). A competitive applicant for rad onc would be competitive for any of these.

Bingo. People aren't happy when real issues concerning our field are discussed on this forum. This is a "student doctors network." Med students should make an educated informed decision. If you love this field and are willing to put up with the prospects of not being geographically where you want to be, not passing your boards (I'm not being facetious here, a 50% pass rate means it can go either way... to me anyway), and being a scribe for 4 years then it's for you. Emphasis on love the field. I love what we do. Its fun, patients are awesome and we make what doctors make. Would I do it again? Thats a big "maybe." There are many other things that I find awesome, that pay well, are less geographically restrictive and have greater potential. Ablating the heart and oligomets are great, but not where our ceiling should be. That's my opinion anyway. Will that change? Another big "maybe." For that to happen the rad onc community needs to agree on some things. Rad oncs have inferiority problems so thats not going to happen anytime soon. Do what you love and hope for the best.

 

[Radiator20]

I hope we can acknowledge that:

A) there is a spectrum of how satisfied people are with their choice of field;

B) Being all rad oncs, we are not in a position to evaluate objectively whether the grass really is greener in derm, ophtho, etc. We do know how the rad onc sausage is made and we don’t know the same for other fields;

C) The almost uniquely small size of our field does pose particular challenges;

D) This thread was created to provide a space to say that there are some people who are very satisfied with their choice of rad onc, and we can allow that opinion to exist—even if not everyone agrees.

 

[Mandelin Rain]

Hopefully my feelings will change when I start independent practice as most of my complaints are about residency and boards, but right now, I'm not sure I would do this again.
It's no surprise numbers are down this year. They should be. Med students aren't dumb. Rad onc is not the only path to a comfortable life in medicine.

Most residencies suck for a multitude of reasons, and rad onc is certainly no different. I had the same feelings as you during my senior year of residency. Scut. Scribe. No teaching. Learn by brute force volume.

But, take heart, things are about to get much better. Life as an attending rad onc (at least in my experience as a private practitioner) is pretty great. Treat 20-25 patients. Make a lot of money. Get home in time for dinner with family. No boss. Full autonomy. Build programs the way you see fit. Staff helps you rather than hinders you. Spend as much time as you want with patients. Discuss their diabetes management/diet/depression/dependence on narcotics for benign back pain/etc... that the PCPs just don't do. Change their lives for the better. Also, treat their cancer.

It's an awesome gig.

 

[OTN]

I like that we have a space to talk about what we like about the field- it's only natural for us to complain between each other, but you are correct in that med students, etc use this space to figure out what fields may interest them. In that vein, I always like to emphasize that I really enjoy, at least in private practice, the variety of MDs with whom I interact on a daily basis on a fairly involved level. This morning I've already gone to neuro-oncology tumor board, talked with a pulmonologist about EBUS results, talked with a medonc about a tx plan, and talked with a pathologist about bx results. If you like to learn about many different types of medicine but don't want to go into primary care or emergency care and still want to see patients, this specialty fills a nice little niche.

 

[RickyScott]

There is no question that this is an awesome field, especially for those of us, mid career. My wife reminds me every week how I seem to have the best job in the world. The issue is the viability of the field 10 years from now with residency expansion, hypofractionation, and changes in cancer management. Sure, I will join the chorus and say yes I have a great salary, and yes I have a great job. In fact, I dont plan to ever retire- I would rather be practicing radonc than golfing etc. But would I tell a medstudent to enter this field? They almost certainly wont get my job. Geographic restriction is already a given. Salaries will match demand. You have to be willing to possibly work as a satellite babysitter for a large instituition with strict protocols on everything from contour colors to doses, etc

Echoing points above: I have classmates from med school in optho, anesthesia, derm, and a variety of specialties that have similar lifestyles and pay, but whose fields dont have such an uncertain future, and they all seem to love their careers.

 

[emt409]

I feel like SDN has become a place for people to vent about things in the our RadOnc world, but I want to use this thread as a place for me, and anyone else who feels similarly, to express what we love about our field. SDN is a place that many many many medical students check out to get their understanding of a field, and it's too bad if people take away too negative of a feeling. Some may have even heard that application numbers across RadOnc programs are down this year (which is a great thing for people applying this year, but not a good thing overall)

1) I have never once regretted my decision to enter this amazing field. Every single day in training I'm reminded of how awesome our field is and what we get to do for our patients. When I go to see inpatient consults, I just realize how glad I am not to have to deal with the grind of babysitting inpatients.

2) If you are interested in oncology at all, Radiation Oncology is still the best field. We have pure oncology training from day 1 of residency, and we leave training with much more experience in dealing with solid tumor oncology cases than our medical oncology colleagues, that's just the facts.

3) Radiation Oncologists still do quite well financially.

4) The job market is not nearly as doom and gloom as people on this thread would have you believe. Just keep your eyes on the ASTRO job center and see for yourself. It is noticeably very very active this year - lots of jobs are being posted DAILY. Maybe its an aberration this year? Or maybe its reflective of the fact that the field continues to grow

5) Yes with hypofractionation, the time 'on beam' for bread and butter breast and prostate patients is decreasing (thankfully, for the better of society tbh). But you know what? People entering training now are going to have a career of treating oligomets in a way that the previous generation did not. There is early data, and soon to be solid randomized data supporting the clear benefit of treating subsets of patients with oligomets in the immune checkpoint inhibition era. Oligomet treatment is here to stay. Not to even mention the cardiac radiosurgery movement which is only going to grow. We are going to be treating patients we've never treated before in the past, even if their actual days on the machine aren't six-nine weeks.

Just to get this started.

I have heard through the grapevine that there is very exciting news coming when COMET results are presented.

 

[OTN]

I have heard through the grapevine that there is very exciting news coming when COMET results are presented.

If the results are good enough this could be huge for radiation oncology, and a true paradigm shift in our field.

 

[medgator]

If the results are good enough this could be huge for radiation oncology, and a true paradigm shift in our field.

Let's see what evicore says

 

[scarbrtj]

Let's see what evicore says

Discussions with Evicore--always fun. NOT. Today, I'm trying to do IMRT for bladder cancer. Evicore doc: "I talked to Anthony Zeitman... he says he doesn't do IMRT for bladder." Well, you don't say.

 

[RickyScott]

"i also wonder about the understanding of oncology in people who think CAR-T cells or gene silencing or going to take radiation out of the game soon. Jeez."
When I entered this field, there was maybe one (herceptin) or 2 antibodies in oncology, and one targeted drug- gleevec. Eli Glatstein was telling anyone who would listen that IMRT is horrible and that the immune system had almost nothing to do with cancer . Meanwhile, around this time, Allison could not find a major drug company to develop/ pick up his CTLA4 antibody and apparently had to settle for Medarex. Medstudents would be foolish to discount disruptive changes over what you hope to be a 40-50 year career.

 

[Palex80]

I fully agree that technological advances in radiation oncology are not going to provide survival benefit for many patients. Some patients may profit, but most will not. Therapy will become better tolerable and bear less side effects, but that's not the "breakthrough" we are after.

On the other hand, hundreds of agents which interact with cell proliferation are in development and there are even some technologies which can interact with it as well. Think of TTF for GBM. What if we combined that with RT? Keeping the cell cycle going for hours and the cells in a very radiosensitive phase will enhance the effect of radiation. Will that cure GBM? Nope. But it may lead to a PFS improvement.

I expect new agents will pop up in the future that will interact with radiation damage repair in cancer cells (more or less radiosensitizers the other way around) or may alter cell cycle (CDK4/6 inhibition does that, however not in a "radiation-friendly" way) or may decrease side effects.


15 year from now we will still be treating stage IIIA NSCLC with radiotherapy. The med oncs will still probably give chemo + immunotherapy for it. But we may be able to give
a) one agent during RT to prolong the G2 phase and cause more damage with RT
b) one agent during RT that will limit dysphagia (perhaps something like this small molecule that was shown in ASCO for H&N: Small Molecule GC4419 Reduces Duration of Severe Oral Mucositis in Patients Receiving Radiation for Head and Neck Cancers)

 

[RadOncDoc21]

I think advancements in technology is very important in our field. Although, it may not be appreciated as much from the outside world, it can allow us to do things such as re-treat an area or get patients through treatment easier.

As the “dinosaurs” in other fields start to retire with the belief that radiation can only be given once or the ones who remember how a patient had “radiation burns” 30 yrs ago and recommend mastectomies for DCIS to all of their patients.

I also believe that we need to hit the PCP’s more and become a secondary specialty vs. a tertiary one. Why can’t we see an early stage lung cancer or prostate cancer patient in the upfront setting?

I know “personalized medicine and “targeted therapy” are the buzzwords in today’s world, but technology and successful marketing are still key cornerstones in our field.

 

[Mandelin Rain]

Regarding the future of our specialty; my crystal ball is cloudy.

I do know that there will always be times when everything goes to hell, and they will need a rad onc there to pick up the pieces and interject some common sense into the equation.

 

[RadOncMegatron]

I still think radiation oncology is the best field in medicine. We are in a field that is immensely intellectually and emotionally satisfying. I don't think there is any other field that spends as much time with the patients. When I counsel them, esp. in difficult situations (ie H&N re-irradiation) being able to talk about surgical options vs systemic therapy options. vs radiation options and the need to show true compassion brings together all the best parts of medicine so perfectly. We also work with computers and with very advanced medical technology, are compensated very well, and have a great lifestyle. I am currently very happy and so is my family. So there is still a lot to love.

I would note that the other issues noted here decline in payments, inability to locate easily, rise of AI, the looming danger of bundled payments, lack of research clout, and being at the mercy of the referring doctors are real concerns and should not be discounted. These do play a significant factor, but I am sure they do in other fields as well. I also recognize my current position is a very good one, not everyone has it so good. The biggest complaint is the lack of power vs administration and referring colleagues.

It is important to note that I see our compensation and lifestyle as trade offs for "so called power." Good trade for now...

 

[bluebubbles]

As for paradigm shift, one thing that could move the needle is early detection. Much of the gains in population-wide survival over the last few decades has been because of early detection (mammograms, pap smears, colonoscopies, etc.). And, across many major disease sites (lung, breast, prostate), radiation has a much bigger role in early-stage disease than late-stage disease. I'd much rather be doing SBRT for stage I/II NSCLC than for oligomets in some poor chap who's flipping a coin to see if he gets a good response to immunotherapy. All the med onc agents that rad onc's both fear will overtake their roles or love to throw shade at (targeted therapy, immunotherapy), will never make major in-roads for early-stage disease. Early detection is good for radiation oncology and good for society.

However, the field needs to reinvent itself.

Reinvention requires young talent. Always has. The cardiac SBRT radiation oncologist was junior faculty when he started his ablation work. An earlier post mentioned that an esteemed rad onc elder poo poo-ed IMRT and immunotherapy once upon a time (though to be fair, everyone was skeptical of immunotherapy less than a decade ago).

Compared to med onc or surg onc, rad onc could do a better job of supporting its trainees and junior faculty.

Doh! I was supposed to end on a high note.

 

[Fpg1245]

Please...for the young trainees you probably should worry more about the future than anything else. You need to think more about what you bring to the table because honestly with all the fervor around immuno and targeted agents nobody really cares about RT. The most disturbing development is the fact that ROs at the top 5 institutions are more excited about eliminating RT than anything else. I literally had a 1hr discussion with a Rad Onc talking about how great it is the with nivo+ipi he can “spare” them the horrible side effects of one time SRS. He actually said he hates SRS

 

[deleted947887]

Agree with this 100%

As for paradigm shift, one thing that could move the needle is early detection. Much of the gains in population-wide survival over the last few decades has been because of early detection (mammograms, pap smears, colonoscopies, etc.). And, across many major disease sites (lung, breast, prostate), radiation has a much bigger role in early-stage disease than late-stage disease. I'd much rather be doing SBRT for stage I/II NSCLC than for oligomets in some poor chap who's flipping a coin to see if he gets a good response to immunotherapy. All the med onc agents that rad onc's both fear will overtake their roles or love to throw shade at (targeted therapy, immunotherapy), will never make major in-roads for early-stage disease. Early detection is good for radiation oncology and good for society.



Reinvention requires young talent. Always has. The cardiac SBRT radiation oncologist was junior faculty when he started his ablation work. An earlier post mentioned that an esteemed rad onc elder poo poo-ed IMRT and immunotherapy once upon a time (though to be fair, everyone was skeptical of immunotherapy less than a decade ago).

Compared to med onc or surg onc, rad onc could do a better job of supporting its trainees and junior faculty.

Doh! I was supposed to end on a high note.

 

[Fpg1245]

Agree with this 100%

And while all that is going on Med students should probably look elsewhere.

 

[RadOncDoc21]

Am I still the “fear-mongerer” here?

I spoke about a bad experience I had with an oral board examiner and there are like 3 threads with the same people posting the same thing everyday about the end of radiation oncology, but yet I don’t see that word thrown around.

 

[nkmiami]

Am I still the “fear-mongerer” here?

I spoke about a bad experience I had with an oral board examiner and there are like 3 threads with the same people posting the same thing everyday about the end of radiation oncology, but yet I don’t see that word thrown around.

For a med student with choices- do you think the future of radiation oncology in lets say 2035 is as secure as optho, derm cardiology etc?

 

[medgator]

For a med student with choices- do you think the future of radiation oncology in lets say 2035 is as secure as optho, derm cardiology etc?

I do. Assuming one is location agnostic as to where they end up practicing

 

[Fpg1245]

For a med student with choices- do you think the future of radiation oncology in lets say 2035 is as secure as optho, derm cardiology etc?

The question is not weather it will be around the question is weather it will be thriving. You need your field to thrive in order to Secure your future. Cards, Derm, and ophtho all have their threats but their futures still are very good. They have decent organizations that look out for their people unlike ours which is especially bad. And before you try all the mental gymnastics of saying “oh I’ll do Rad Onc anyway because I’ll just match to an awesome place because I’m so awesome and everything will be fine” consider the fact that it’s still a sinking ship. It’s like the titanic, the first class passengers may not feel anything for a while but eventually everything and everyone goes underwater. Seriously...Med students shouldn’t waste their cognition on this question because it’s simple...they need to look elsewhere. Their intellect and efforts are best used elsewhere.

 

[RadOncDoc21]

For a med student with choices- do you think the future of radiation oncology in lets say 2035 is as secure as optho, derm cardiology etc?

I think we're starting to see a shift of practicing rad oncs from the 3D era to the SBRT era with the majority of those practicing today well trained in the IMRT era. The IMRT era rad oncs benefited the most and experienced the "golden era" of radiation oncology. Most of these docs were well compensated with a great quality of life. I do believe the glory days are gone and we are now at a critical stage in our field.

New grads will need to adapt to the change on how we are compensated. The old way was based on the number of fractions and keeping the machine going. I've seen justification for expensive treatments without any benefit to the patient, however I do not believe in the insurance company regulating our treatment decisions. I also do not believe academia has our best interest in mind at this time as it has become a dog eat dog world in our field.

In my opinion, the future of rad onc will depend on the referral patterns. I've mentioned before in other posts that we need to be in the minds of the PCP's. Ultimately, we will need to see more patients in order to make up for the loss in compensation.

 

[nkmiami]

The question is not weather it will be around the question is weather it will be thriving. You need your field to thrive in order to Secure your future. Cards, Derm, and ophtho all have their threats but their futures still are very good. They have decent organizations that look out for their people unlike ours which is especially bad. And before you try all the mental gymnastics of saying “oh I’ll do Rad Onc anyway because I’ll just match to an awesome place because I’m so awesome and everything will be fine” consider the fact that it’s still a sinking ship. It’s like the titanic, the first class passengers may not feel anything for a while but eventually everything and everyone goes underwater. Seriously...Med students shouldn’t waste their cognition on this question because it’s simple...they need to look elsewhere. Their intellect and efforts are best used elsewhere.

that is really what I meant. Clearly, radiation is not going to disappear, but how confidant can we be that its role wont substantially diminish in 15 yrs, something that is not as much a concern in other specialties.

 

[Fpg1245]

that is really what I meant. Clearly, radiation is not going to disappear, but how confidant can we be that its role wont substantially diminish in 15 yrs, something that is not as much a concern in other specialties.

And I hope my point came across clearly because you wouldn’t believe the utter cognitive dissonance some people are truly capable of performing.

 

[evilbooyaa]

Please...for the young trainees you probably should worry more about the future than anything else. You need to think more about what you bring to the table because honestly with all the fervor around immuno and targeted agents nobody really cares about RT. The most disturbing development is the fact that ROs at the top 5 institutions are more excited about eliminating RT than anything else. I literally had a 1hr discussion with a Rad Onc talking about how great it is the with nivo+ipi he can “spare” them the horrible side effects of one time SRS. He actually said he hates SRS

I hate the fact that IT for melanoma can show a ~50% ORR in the brain and it gets into NEJM. Forget the fact that SRS has a 90%+ response rate and has rates of toxicity < 5-10%. That NEJM paper is now leading to some melanoma patients are our institution being treated with first line IT and then sent for RT at progression..... at which point they've progressed massively and end up getting whole brain and dying shortly thereafter. Maybe that one met was better off served with SRS rather than immunotherapy.

 

[Neuronix]

Indeed, and the responses with targeted agents or immunotherapy alone tend to be transient--typically one year or less. Therefore, the trials that have used immunotherapy or targeted agents for first line treatment in patients with brain mets have mandated MRI brain every 6 weeks.

This seems reasonable enough, but does not seem to be happening off protocol. This could be one of the factors that led to a survival benefit for patients receiving upfront RT in this paper: http://ascopubs.org/doi/abs/10.1200/JCO.2016.69.7144

 

[evilbooyaa]

Indeed, and the responses with targeted agents or immunotherapy alone tend to be transient--typically one year or less. Therefore, the trials that have used immunotherapy or targeted agents for first line treatment in patients with brain mets have mandated MRI brain every 6 weeks.

This seems reasonable enough, but does not seem to be happening off protocol. This could be one of the factors that led to a survival benefit for patients receiving upfront RT in this paper: http://ascopubs.org/doi/abs/10.1200/JCO.2016.69.7144

I'm glad that the Magnuson paper was published - finally pushed some of our med-oncs to stop TKI'ing and waiting for progression (q3 month MRIs if that) on all the people with any volume of brain mets (even 1-3 mets).

Unfortunately now we're going to need something similar in Melanoma given that people are going to do the exact same thing with melanoma brain mets with IT instead of SRS.

 

[Neuronix]

Seems silly to treat with immunotherapy alone in melanoma with brain metastases considering the responses to immunotherapy alone in melanoma brain metastases are much worse than the responses to EGFR inhibitors in mutant NSCLC.