Just saw a thoracic surgeon refer a T3N1 to a med onc for neoadj immunotherapy for “tumor downgrading.” I guess we are just skipping right over rads. Patient was not and still not a surgical candidate.
I’m guessing it is Med onc and rad onc that will see the main AI advances rather than surgical?
Of course. But many other fields will see those.
This is ridiculous in every sense. Thoracic surgeons like this should be ashamed of themselves for being "anti-data" and can go to hell. Med oncs who accept and treat those types of referred patients aren't much better at all and are still embarrassments to being called "oncologists".
Good a place as any to drop this:
that is impressive
While the future is both unknown and unknowable, I personally think that Rad Onc will have a major role to play in improving overall survival for patients with stage IV disease in the next 20 years."I know that all oncology fields (medical, surgical, radiation) will all continue to play a large role in cancer treatment and will make advances in their fields," says the OP. However, rad onc's role is diminishing. This is well documented. And the incidences of our major cancers we treat (prostate, lung e.g.) are declining also. Looked at a certain way...
... rad onc doesn't have a very, very large role in "C"ancer therapy (e.g., here's the RT utilization pattern in stage III uterine over time), and has not been innovating in terms of cancer survival that I can recall. The green shading is a bit of a WAG by me right now but it's not off by much I suppose. (Existentially, of course, given how many rad oncs there are... 1 rad onc for every 6 new pancreas ca patients in the US!... and looking at rad onc utilization... )
There was an interesting review article that came out a couple years ago, "Practice-changing radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie?" In it, some of the best minds in the world predicted here's where/how RT would impact cancer therapy in the future:
Improved survival rates are likely to occur through employing/adopting RT in novel situations. There is growing interest in using SBRT to deliver a much higher dose than traditionally given for oligometastatic or oligoprogressive disease; early trials have shown improvements in progression-free survival for this approach. Larger trials aiming to evaluate the role and benefit of ‘radical’ high-dose RT in oligometastatic disease across disease sites are currently underway in the UK (CORE) or in development (ESTRO/EORTC OligoCare studies). SBRT and/or MR-guided RT may also prove beneficial in cancers not traditionally amenable to RT, such as renal and pancreatic cancers, due to the previous inability to irradiate without including large normal tissue margins that precluded the delivery of a tumouricidal dose. Survival may also be improved through dose escalation via improved image guidance (as previously discussed), and novel drug combinations with RT.
IMHO, survival improvements are the "red rose" of cancer therapy. Will treating mets and rare cancers like pancreas be how rad onc innovates in the next decade? It's tough to improve survival with XRT over and above what we already use it for. We are just not going to see curve separations like this or this in XRT, ever. For the last twenty plus years I have been hearing about this unicorny, magical new (non-chemo) drug that will somehow interact with radiation that will make radiation work better. How many hundreds of MD/PhDs have worked on that problem, and how many of these drugs do we use in the clinic daily?
But... keep an eye on FLASH. IF we can offer the same cancer benefit as present-day XRT w/ much less side effects and in a lot fewer fractions, that will be great.
1. Trends in the Utilization of Radiation Therapy (XRT) Among Patients with Non-Hodgkin's Lymphoma (NHL) in the United States (US).
2. What is the optimal radiotherapy utilization rate for lung cancer?—a systematic review.
3. Trends in the use of radiation therapy for stage IIA prostate cancer from 2004 to 2013: a retrospective analysis using the National Cancer Database.
4. Internal mammary and medial supraclavicular lymph node chain irradiation in stage I–III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial.
There are many layers to “stage iv” cancers and although I agree radiation can play a major role in the future, rad oncs would not be credited for any major survival gains. Also the “toxicities” of radiation for stage iv patients are very minimal already.
Re: "shockingly" good survival in SABR-COMET. One of these days we're all gonna have to get together and be honest about the limits and abilities of radiotherapy to affect survivals. Irradiation of micrometastatic lymphatic disease won't improve survival in breast, but irradiating macrometastatic hematogenously spread disease will? (Most the patients in SABR COMET were breast patients I believe), What's the mechanism for demonstrated failure to affect survival in thousands of patients in the former and the "shockingly" good survival effect in tens of patients in the latter? Immune system? Magic? Statistical noise? I think SABR can improve survival. Can. But it's got a long row to hoe.
Stature? I am at the median in height (slightly over in weight).
You are out of line Mr. This thread is devoted to predicting the demise of our field. Take your educational tidbits elsewhere
Um sorry. Pessimism? You want pessimism? I have a Master's Degree in negativity bias...You are out of line Mr. This thread is devoted to predicting the demise of our field. Take your educational tidbits elsewhere
My first year of practice I reached (for a week or two, here or there) 70 under beam by myself and worked 7 AM to 7PM most days and had to do all my dictations on Saturday and Sunday. Not kidding. I have no tales about walking to work in the snow tho.
Once "they" allowed, or unintentionally allowed to happen, the commoditization of rad oncs themselves (oversupplied), that at least allows scenarios like this to possibly happen. It can be reversed though. How? Simply uncommoditize rad oncs. But a "radical" de-commoditization is the only possibility I'm afraid. (I.e., produce no new rad oncs for ~5 years.) The sweet spot was ~2000-2010 time frame. Lots of new demand, lots of new tech, residents could command high salary prices out of residency because they were in demand. Because they were rare. Places struggled to find people, new grads or not, in ~2005.
Agree. 15-25 out in the real world is very doable and certainly not close to a max for an industrious rad Onc
In hospital based practice 35-40 is really the max before you start dropping the ball. A freestanding center, max much higher if a lot of breast and prostate.
Two sites we hypofx and ultra-hypofx to not even offer treatment at all in some.
You win. Lets go back to talking about bandwagons.
Your people? This is my hometown parade
Thanks RadOncDoc21. You bring up 3 excellent points: 1. drug therapy alone is seldom curative for solid tumors, at least historically. I think this is beginning to change in the immune era, at least for melanoma, as there were 10% of patients alive after 10 years in the trial that got Ipilimumab approved as monotherapy. 2 and 3 drug combos look even better.
I respect the COMET data but please keep in mind the small number of patients in the arms and the G5 toxicities compared to other trials. For instance in the Rosel-Stars pooled data there were no G5 toxicities associated with SBRT and 5% G5 in the surgery arm. Although very low number of patients in each arm.
For #3, this is why importance of risk-adapted dosing is so important. >= 50Gy in 5 fractions for stage I NSCLC? Yes, critical importance. An oligomet or oligoprogressive patient with disease close to esophagus? OK to give something gentler in terms of dosing - goal should be make sure OARs are respected FIRST, then worry about dose to tumor.
How do you use “disruptive” to describe something that has 30% more cell kill (in cell culture!) for isoctoxicty? Something promising would have at least several orders of magnitude benefit and even then would unlikely to translate into the clinic.
What?
Hyperbaric, hyperthermia give similar benefit in this ball park and never amounted to much. At least most drugs totally cure cancer in mice before failing in the clinic.
Not messin' around Jim, we like FLASH here. I think it's going to work. But as I understand it today, its approach will actually lessen the "intellectual rigor" and effort of RT. No (or little) inverse optimization, OARs, etc. And it'll make treatment courses smaller, thus there'll be workforce ramifications. (Always are.) Machine prices may go up, but will CMS pay more for FLASH which they will see as shortened RT courses with less side effects and less physician effort being expended? If FLASH is kind of like a standard dosing recipe, what does that mean for rad onc residencies? So you gotta look at it both ways. GREAT, possibly, for patients; but perhaps/probably bad for a way oversupplied workforce. A fons et origo for improvement or worsening; TBD. The good 'ol 2-sided p-value at work.
