Why don’t we just start giving our own?

[medgator]

Most rad oncs would have no interest in having an inpatient service which is what this pathway would require. You can't expect to admit to med onc service if you've cut them out of the picture.

Hint: most med oncs don't have a "service" out in the real world. Patients are admitted to the hospitalists and med onc is consulted

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[medgator]

2.5 years of oncology is longer then a medical oncology only fellowship. We need to become the preferred and more relevant oncologist to referring physicians. We need to be a complete clinical oncologist that can curatively treat head and neck, lung, GYN, prostate, etc. patients on our own with both radiation AND systemic therapy. Why can’t we just teach ourselves to administer it in our own without requiring years of training from medical oncologists. Medical oncologists would never agree to this. We all know what needs to be given. Only an NP has to be in the building to deliver it. Any Med onc over the age of 50 never trained with immunotherapies and have learned from the drug reps or meetings what to give. There’s precedent for multiple other specialties giving such therapies. I went to a dermatology convention with a medical school buddy of mine from medical school when he was in town during my residency. I posted about it 10 years ago in here because I was floored at the couple hours of primitive lectures in rad bio and physics that was given to “teach” the dermatologists about giving radiation. Again, I say a lot of this tongue in cheek. Residency closure/contraction is a simpler fix, but doesn’t seem to be happening. Also, I really have no real interest in doing anything that I’m saying. I’m hoping to bank as much as I can in my current gig and have enough to retire before this gig is up. I just firmly believe that a big change is needed to restore us back to the “glory days”. We need a complete different mindset and, obviously, different leadership. If our leadership, embraced an aggressive private practice type mentality, instead of acting like they were above it, we wouldn’t have gone from a top 3 competitive field to the least competitive field in less than 5 years. I could keep babbling, but it’s too depressing.

Could keep it at 2 like a med onc only fellowship. The problem with most med oncs is they do the 3 year route and have to spend it on heme and research too so they end up getting less onc experience and training then they probably should

 

[elementaryschooleconomics]

Could keep it at 2 like a med onc only fellowship. The problem with most med oncs is they do the 3 year route and have to spend it on heme and research too so they end up getting less onc experience and training then they probably should

I was actually surprised at how little clinical Oncology experience the Heme/Onc fellows at my residency institution received. Between the Heme and research blocks, I think it was probably 12 months? Certainly no more than 18.

 

[metallica81788]

Most rad oncs would have no interest in having an inpatient service which is what this pathway would require. You can't expect to admit to med onc service if you've cut them out of the picture.

Most places don't have med onc services anymore, including medium-sized academic centers. Everything is admitted to hospitalists and consulted. Not saying I want any part of this, but that situation would be doable for what has been described.

 

[thesauce]

Most rad oncs would have no interest in having an inpatient service which is what this pathway would require. You can't expect to admit to med onc service if you've cut them out of the picture.

I hear this all the time, but those patients are pretty much all managed by hospitalists or mid-levels at this point

^ the llama beat me to it

 

[theradiator]

Hint: most med oncs don't have a "service" out in the real world. Patients are admitted to the hospitalists and med onc is consulted

Yes, the correct framework is that we would need an active inpatient Clinical Oncology consultation service. Would require restructuring workflow particularly for those not physically attached to a hospital but totally doable.

 

[OTN]

1 year internship
1 year solid tumor medical oncology (that's all medonc fellows do)
3 years radonc
Done

I'd be fine with rounding on patients if necessary, but hospitalist services exist for a reason. I would have MUCH rather learned solid tumor medical oncology for a year than the completely useless research I was forced to do.

 

[TheWallnerus]

1 year internship
1 year solid tumor medical oncology (that's all medonc fellows do)
3 years radonc
Done

I'd be fine with rounding on patients if necessary, but hospitalist services exist for a reason. I would have MUCH rather learned solid tumor medical oncology for a year than the completely useless research I was forced to do.

When radiation therapy was still very inchoate, there was a guy named Franz Buschke who was trying to develop it into a true medical specialty. Other doctors would confuse him for an internist or radiologist. Buschke claimed that other medical specialties were vertical (ie urology, ENT, etc) and could be stacked alongside one another. But oncology he claimed was very horizontal and stretched across the specialties when performed properly. He thus saw a lot of upside to a "radiation therapist" having skill sets outside of radiation therapy... especially skills in internal medicine and in being able to do simple invasive procedures. Even Wallner/Hahn/Zietman argued recently for more rad onc horizontality (albeit into radiology and a return to our roots). Verticality may be only good for NBA centers.

 

[DrAdonis]

=
Instant

1 year internship
1 year solid tumor medical oncology (that's all medonc fellows do)
3 years radonc
Done

I'd be fine with rounding on patients if necessary, but hospitalist services exist for a reason. I would have MUCH rather learned solid tumor medical oncology for a year than the completely useless research I was forced to do.

This should work perfectly. We don’t even need to take medical oncology boards, we just need ABR to update the certification to radiation and clinical oncology (like in other climes) after a resident has fulfilled the requirements of 36 months of rad onc and 12 months of solid tumor med onc training.

 

[IonsAreOurFuture]

The way this is going to work, and work for rad oncs in practice, is for the ACADEMIC RAD ONCS to take on some of these additional responsibilities and to reshape our specialty.

Residency training is cultural training. If residents in other specialties are not "trained" during their residency years that rad oncs do other things besides just radiation, rad oncs will never get additional referrals. Radiation doesn't have a scope of practice problem, really... we have a get-referrals problem (and sure that is to large extent due to our reputation as more technical than physician-y). You have to train 'em young. We would need to train rad onc residents coming in, and the med onc, urology, etc., residents would have to see "Oh ,gee, I can hand some of this stuff off to rad onc, they do a good job with durva/hormones/what have you." Then when those med oncs and urologists get out in practice they will be more willing to yield some work because they were trained and saw it back in residency and it seemed normal.

The moment we have some weird side effect from Arimidex, we will need to refer , probably, to med onc. The only way that spoonful of medicine is going to go down is if it happened a few times during the med onc's fellowship training and he saw such instances as a normal fact of life versus the rad onc being stupid at oncology.

We will never make more money or get more relevance or more "reputation equity", I am afraid, if we all just started, today, in our practices, giving Temodar and Lupron and checking dexa scans etc. No one makes money from that "crap" first of all. (They make some money from infusions, true, and having their own pharmacy.) They make money from the constant spigot of referrals coming into their clinic IMHO. (And med onc has neat tricks whereby they're treating patients over much longer periods of time than rad onc; another story.)

So we all need to think this through and see what it is we are really asking and what we really want. We shouldn't care if we are relevant or not, or what our rep is. We should just care about getting more referrals and how to do more with the referrals we get. Of course, it is all connected: relevance, reputation, and referrals. To that end, academic rad onc will have to lead the way because it is academic RO who defines and shapes the culture of rad onc. This last sentence, though, sucks hope from my soul.

I'm really discouraged to hear that our future could appear so bleak. Another approach, besides simply following in the footsteps of medical Oncology and thus remaining 2 steps behind, would be to lead out in our field of Radiation oncology - radiation first, and Oncology second. Before radiation, there was no radiation Oncology, or medical Oncology for that matter.

We sometimes seem to forget that we are the original targeted therapy. I hope that we can, and i think that we need to, reclaim that title by getting more targeted, more curative, and less toxic than drug therapy, like we used to be.

It's still pretty miraculous to me that we can cure cancer using maths, physics, computers and robots to do our bidding, all without inserting an IV or lifting a scalpel. We should double down and push that envelope.

I now have medical Oncologists walking up to me and asking with hope in their eyes, whether their patient with local-only relapse is a good candidate for proton therapy for reirradiation, because we both know chemo alone isn't going to cut it, and the patient is already progressing through immunotherapy. I used to have that same desperate hope, that all my patients could get on an immunotherapy, and maybe get an abscopal effect, but it's pretty clear now that that ain't gonna happen. I've seen enough patients progressing through immunotherapy now that I realize that PDL1 and CTLA4 are pretty special, but even combined they are not the second coming of the Messiah for cancer patients that I hoped they would be. People are still dying of cancer at an alarming rate, albeit a bit older and more extensively treated than they used to be.

Whatever our future holds, a divergent path is no less risky than a convergent one, unless we should all become Medical Oncologists only, starting now.

In my opinion, I believe it's safer to have a lock on something great that few people know how to do, than to become just one more person in a huge profession who knows how to prescribe tamoxifen or arimidex.

 

[RadOncDoc21]

I'm really discouraged to hear that our future could appear so bleak. Another approach, besides simply following in the footsteps of medical Oncology and thus remaining 2 steps behind, would be to lead out in our field of Radiation oncology - radiation first, and Oncology second. Before radiation, there was no radiation Oncology, or medical Oncology for that matter.

We sometimes seem to forget that we are the original targeted therapy. I hope that we can, and i think that we need to, reclaim that title by getting more targeted, more curative, and less toxic than drug therapy, like we used to be.

It's still pretty miraculous to me that we can cure cancer using maths, physics, computers and robots to do our bidding, all without inserting an IV or lifting a scalpel. We should double down and push that envelope.

I now have medical Oncologists walking up to me and asking with hope in their eyes, whether their patient with local-only relapse is a good candidate for proton therapy for reirradiation, because we both know chemo alone isn't going to cut it, and the patient is already progressing through immunotherapy. I used to have that same desperate hope, that all my patients could get on an immunotherapy, and maybe get an abscopal effect, but it's pretty clear now that that ain't gonna happen. I've seen enough patients progressing through immunotherapy now that I realize that PDL1 and CTLA4 are pretty special, but even combined they are not the second coming of the Messiah for cancer patients that I hoped they would be. People are still dying of cancer at an alarming rate, albeit a bit older and more extensively treated than they used to be.

Whatever our future holds, a divergent path is no less risky than a convergent one, unless we should all become Medical Oncologists only, starting now.

In my opinion, I believe it's safer to have a lock on something great that few people know how to do, than to become just one more person in a huge profession who knows how to prescribe tamoxifen or arimidex.

At first I assumed this was a plug for protons, but realized that there is still an appropriate use for them. I do agree with your message and personally feel doing what others are doing isn’t necessarily the way, especially in regards to enhancing our field.

I believe we need to see the patients, discuss their cases sooner and stop trying to find reasons to not give radiation and to find more reasons to give it. One disease site we are failing is in regards to most GI malignancies where there are still high death rates, yet we rely on systemic therapy and don’t even consider radiation in most gastric/pancreatic cancers. I applaud the SBRT/MRI Linac folks because they are at least trying to keep our field alive in those areas. In addition, we all know the other areas such as breast where we are decreasing our role willingly and last but not least we should be seeing more early stage prostates, lungs and definitive skin cancers but can’t get the referrals from the PCP’s.

So in summary, I believe we should be doing more radiation and seeing patients sooner. If we are to go down the path of prescribing systemic meds, maybe we should also start looking into alternative medicine, the use of medical marijuana, Ivermectin (sorry had to do it), or opening up health spas.

We can always improve our “business” but are we really improving our field?

 

[deleted941485]

Most rad oncs would have no interest in having an inpatient service which is what this pathway would require. You can't expect to admit to med onc service if you've cut them out of the picture.

I think ROs are gonna have to get over that if they want to remain relevant.

 

[thesauce]

Has anyone ever given Tamoxifen or an Aromatase Inhibitor for breast cancer? Can you see an issue with this (outside of the "political" side of things?) Seems like a relatively simple way to get into the systemic therapy arena.

 

[CaesarRO]

Has anyone ever given Tamoxifen or an Aromatase Inhibitor for breast cancer? Can you see an issue with this (outside of the "political" side of things?) Seems like a relatively simple way to get into the systemic therapy arena.

Seems like I've seen more Rad Onc Rxing ADT than anti-estrogens for some reason

 

[elementaryschooleconomics]

Has anyone ever given Tamoxifen or an Aromatase Inhibitor for breast cancer? Can you see an issue with this (outside of the "political" side of things?) Seems like a relatively simple way to get into the systemic therapy arena.

I couple of my breast patients have told me they have a better rapport with me/my staff than the MedOnc they were referred to, and have asked if I'd do this for them. I've talked it over with my group and was given the greenlight to do it if I wanted.

I haven't pulled the trigger yet. I have a few other irons in the fire that I'd rather focus on first.

Seems like I've seen more Rad Onc Rxing ADT than anti-estrogens for some reason

Yeah, I do all the ADT for all of my prostate patients. It feels paradoxical to me, too.

Honestly, it's just because while I know a lot of RadOncs who do ADT, I haven't heard of anyone doing anti-estrogens. I'm SURE they exist in America though, they have to.

 

[TheWallnerus]

Seems like I've seen more Rad Onc Rxing ADT than anti-estrogens for some reason

Yeah, I do all the ADT for all of my prostate patients. It feels paradoxical to me, too.

I prescribe anti-estrogens all the time. But only to men. Who are on ADT.

 

[dieABRdie]

Has anyone ever given Tamoxifen or an Aromatase Inhibitor for breast cancer? Can you see an issue with this (outside of the "political" side of things?) Seems like a relatively simple way to get into the systemic therapy arena.

I don't think there's any true legal barriers to it. You would have to be ready to deal with the side effects as well as keep on top of other monitoring exams (GYN for tamox; bone density for AI)

Our med oncs would hate it because they make their money by seeing 60 patients a day with an army of NPs. We are busy enough.... so I think I would only do it if a patient for some reason didn't have someone else doing it for them.

 

[elementaryschooleconomics]

I don't think there's any true legal barriers to it. You would have to be ready to deal with the side effects as well as keep on top of other monitoring exams (GYN for tamox; bone density for AI)

Our med oncs would hate it because they make their money by seeing 60 patients a day with an army of NPs. We are busy enough.... so I think I would only do it if a patient for some reason didn't have someone else doing it for them.

Definitely no legal barriers (if you're licensed to practice medicine in a state, everything is on the table - but if you start doing plastic surgery without a residency or board certification, you're not going to get insurance reimbursement and you'll lose any malpractice suit brought against you).

The three main barriers I've envisioned:

1) Political. Don't ruffle the MedOnc or Breast Surgeon feathers. If they've bought in, great.

2) Insurance. I don't think there's a problem with reimbursement for this, because you're just seeing them in follow-up, and really the only charge you're submitting is the E&M.

3) Medical Staff privileges. I can't imagine a scenario where you wouldn't have privileges to prescribe tamoxifen, but I've seen stranger things. At one of the hospitals I'm on staff at, it's explicitly written that I can give immunotherapy. Will I? Well, let's see how much APM hurts first (kidding...kind of).

 

[theradiator]

3) Medical Staff privileges. I can't imagine a scenario where you wouldn't have privileges to prescribe tamoxifen, but I've seen stranger things. At one of the hospitals I'm on staff at, it's explicitly written that I can give immunotherapy. Will I? Well, let's see how much APM hurts first (kidding...kind of).

Ha! Perhaps you will be Anthony Zeitman's second "canary in the coal mine"

 

[elementaryschooleconomics]

Ha! Perhaps you will be Anthony Zeitman's second "canary in the coal mine"

My lawyer has instructions to "send my regards to SDN" if I end up in prison.

 

[taserlaser]

I prescribed adjuvant exemestane last week. It‘s uncommon that I prescribe ET, but up in Canada where I practice the low risk adjuvant breast patients just see RO, higher risk get RO and MO consults. The GU docs do ADT, some of them do abi and things too.

 

[bobow98]

I stumbled upon your thread accidentally while doing a google search on med onc stuff.
Would people in your field honestly be willing to take call as a group to cover all the complications and such? Inpatient rounding on weekdays and weekends?
What I am hearing is a lot of "we can do infusion and make dough" without much discussion about how time and effort intensive it is to manage patients on systemic therapy.

Urologists have definitely been getting into the systemic therapy game. And let me tell you - by the time a prostate patient reaches our door it's a hot mess and dumpster fire most of the time if it's only been the urologist involved in their care to that point.

Someone said a 2-3 year fellowship in IM and Med Onc which is probably the closest thing to reasonable I have heard on here. The most valuable part of residency was PGY2 year when you learn to run a team and troubleshoot/triage a list of 20+ sick patients.

Perhaps advocating for the training to be 2+3+1 (prelim, IM PGY2, Rad Onc x3, Med Onc) for a total of 6 years you could create an integrated pathway for the ideal solid tumor oncologist who can do their own systemic therapy and radiation. Can you imagine the amount of buy in you would need from every department to get this off the ground? I think it would be pretty interesting to see how the training turns out.

 

[fiji128]

I stumbled upon your thread accidentally while doing a google search on med onc stuff.
Would people in your field honestly be willing to take call as a group to cover all the complications and such? Inpatient rounding on weekdays and weekends?
What I am hearing is a lot of "we can do infusion and make dough" without much discussion about how time and effort intensive it is to manage patients on systemic therapy.

Urologists have definitely been getting into the systemic therapy game. And let me tell you - by the time a prostate patient reaches our door it's a hot mess and dumpster fire most of the time if it's only been the urologist involved in their care to that point.

Someone said a 2-3 year fellowship in IM and Med Onc which is probably the closest thing to reasonable I have heard on here. The most valuable part of residency was PGY2 year when you learn to run a team and troubleshoot/triage a list of 20+ sick patients.

Perhaps advocating for the training to be 2+3+1 (prelim, IM PGY2, Rad Onc x3, Med Onc) for a total of 6 years you could create an integrated pathway for the ideal solid tumor oncologist who can do their own systemic therapy and radiation. Can you imagine the amount of buy in you would need from every department to get this off the ground? I think it would be pretty interesting to see how the training turns out.

I think most rad oncs who advocate for administrating their own systemic therapy don’t fully acknowledge the issues that come from our lack of training in medical management as pointed out in your post.

 

[elementaryschooleconomics]

I think most rad oncs who advocate for administrating their own systemic therapy don’t fully acknowledge the issues that come from our lack of training in medical management as pointed out in your post.

I guess it depends on which "systemic therapy" you're talking about. ADT or tamoxifen/Arimidex is one thing. 5-FU and MMC is something else. The TKIs or Keytruda, perhaps somewhere in the middle.

@bobow98, what are your Urologists giving?

 

[seper]

Everywhere I've seen, MedOnc and Uro have an army of physicians extenders. MD is just taking heavy-hitting decisions.
Radoncs, they do all the work

 

[Mandelin Rain]

Everywhere I've seen, MedOnc and Uro have an army of physicians extenders. MD is just taking heavy-hitting decisions.
Radoncs, they do all the work

Except set the patient up, or actually treat them, the therapists do that. Nor perform the CT mapping, the sim guy does that. Nor draw the OARs, the dosimetrist. Nor treatment plan, dosimetrist/computer software. Nor take care of machine, physics.

We do draw mean circles, fill out meaningless notes for billing, and hand out samples of skin cream (though. usually the RN or MA).

EDIT: Not a self-hating post. Just an acknowledgement that we do not "do all the work" in the least. We QB the team so we get the credit/blame. But there's a lot of other players.

 

[communitydoc13]

Perhaps advocating for the training to be 2+3+1 (prelim, IM PGY2, Rad Onc x3, Med Onc)

I think this is a reasonable prospect. This would strictly be a clinical pathway and only the most dedicated would turn this sort of training into a research career with a subsequent research fellowship.

What I am hearing is a lot of "we can do infusion and make dough" without much discussion about how time and effort intensive it is to manage patients on systemic therapy.

I don't know how many of us are looking at infusions as a dough making prospect. What we are is clear eyed about our futures and the future of the field. We have over trained radiation oncologists coincident with the "cambrian explosion" like advances in systemic therapy over the past 11-12 years. In addition, the best research in our field over the same time has focused on reduction or elimination of XRT and going forward will likely focus on automation.

Our roles as oncologists are clearly diminishing, yet many of us are well trained in many aspects of outpatient oncology, including performative things like discussing prognosis and technical things like reviewing restaging imaging personally and guiding best approaches for biopsy. It makes sense that we would be interested in a more holistic job.

One more year of IM and an additional year of medonc seems reasonable for comprehensive solid tumor oncology. But what about softer stuff like endocrine therapy for breast or Abiraterone/Xtandi for prostate or even supportive medications like densumab?

It is very hard to recruit a medical oncologist away from favorable locations nowadays.

 

[metallica81788]

Except set the patient up, or actually treat them, the therapists do that. Nor perform the CT mapping, the sim guy does that. Nor draw the OARs, the dosimetrist. Nor treatment plan, dosimetrist/computer software. Nor take care of machine, physics.

We do draw mean circles, fill out meaningless notes for billing, and hand out samples of skin cream (though. usually the RN or MA).

EDIT: Not a self-hating post. Just an acknowledgement that we do not "do all the work" in the least. We QB the team so we get the credit/blame. But there's a lot of other players.

Agreed.

However, the others (medonc notably) have other players that can intercept problems before it reaches the MD. We generally don't have that, unless you work at a large academic place.

Patients have problems on treat? Follow ups with issues or questions? Inpatient consult while you're in clinic? That generally goes straight to you whereas the medoncs have NP/PAs to potentially handle the more common less urgent occurrences and not waste your time. That I think is where we lose. Not all of us, but most of us. Good radonc nurses are hard to find.

 

[TheWallnerus]

Except set the patient up, or actually treat them, the therapists do that. Nor perform the CT mapping, the sim guy does that. Nor draw the OARs, the dosimetrist. Nor treatment plan, dosimetrist/computer software. Nor take care of machine, physics.

We do draw mean circles, fill out meaningless notes for billing, and hand out samples of skin cream (though. usually the RN or MA).

EDIT: Not a self-hating post. Just an acknowledgement that we do not "do all the work" in the least. We QB the team so we get the credit/blame. But there's a lot of other players.

A bit of an aside but I am reading a fascinating book right now "Cancer, Radiation Therapy, and the Market."

Everything you wrote above? It didn't HAVE to be that way. "Radiation oncologists" could have been much more hands-on. But, bascially, blame General Electric Corporation. Excerpt from the chapter "The General Electric Company Dominates X-Ray":

​

The Company Promotes Business Strategies in Medicine (and Beyond)​

​

GE reinforced medical specialization’s functional division of labor. Like the work organization that made factory work more efficient, academic medical centers had developed a hierarchy of staff and trainees to perform a hierarchy of patient care tasks.44 Victor News suggested that the machines’ easy adjustability was particularly suitable for operation by nurses, and its photographs showed nurses aiming machines at patients and operating control panels.​

​

The radiology profession codified functional division of labor in Practical Radiation Therapy. “Properly organized” departments, the textbook instructed, assigned a managerial role to physicians and the actual treatment of patients to interns and technicians.45 This organization required a full range of medical staff, from the senior resident who managed the treatment process down through the ranks to the junior intern, who should perform routine preparations and take patients’ histories. Fully trained radiologists should read films and plan treatments in the privacy of their offices. Such a division of labor, in which radiologists never have to lay eyes—let alone hands—on patients, eventually led to outsourcing radio-diagnosis to computer monitors across the globe.​

​

New York’s Memorial Hospital took the factory division of labor too far, MIT engineer John Trump would later charge, by “excessively routiniz[ing] its radiation procedure to handle mass numbers of patients.” “The diagnostician marks the suggested treatment on a chart and usually does not see the patient again,” Trump claimed, and “the treatment is administered by technicians on the basis of the chart.”46 Although such an organization may enhance institutional productivity, it misses opportunities for doctors to learn how the machines actually functioned and malfunctioned—not to mention patient response to treatment. A radiation oncologist noted in 2011 that many of his colleagues continued to practice without examining their patients receiving radiation therapy.47​

​

General Electric actively encouraged a managerial approach to medical care, holding that medical care had much to learn from industry. Victor News called on the burgeoning field of business management to teach doctors and hospital administrators how to think and act like businessmen. One editorial advised that high-cost assets boosted financial gains.48 Higher-powered machines, the company instructed potential customers in the late 1930s, could treat more patients per day at lower unit costs and thus generate higher revenues per patient.49 Of course, this required treating higher total numbers of (paying) patients.​

​

The returns on investment could be professional as well as monetary.50 “He who serves best profits best,” GE was fond of intoning. It was advisable (and possible) to apply “good business principles to the practice of medicine,” the company advised in a mantra that the medical profession would make more overt 50 years later, “without detracting in the least from established standards.”51 Neither the company nor the physicians who worked with it seemed to consider the reciprocal: that business principles might shape medical standards themselves.​

 

[communitydoc13]

I am reading a fascinating book

I need to get this.

MIT engineer John Trump would later charge,

Effing Jungian synchronicity at its finest here. We're definitely in a sim(ulation).

 

[elementaryschooleconomics]

Everything you wrote above? It didn't HAVE to be that way. "Radiation oncologists" could have been much more hands-on. But, bascially, blame General Electric Corporation. Excerpt from the chapter "The General Electric Company Dominates X-Ray":

 

[deleted1111261]

I cannot believe I’ve never heard of this book. Thanks @TheWallnerus !

 

[theradiator]

I think this is a reasonable prospect. This would strictly be a clinical pathway and only the most dedicated would turn this sort of training into a research career with a subsequent research fellowship.


I don't know how many of us are looking at infusions as a dough making prospect. What we are is clear eyed about our futures and the future of the field. We have over trained radiation oncologists coincident with the "cambrian explosion" like advances in systemic therapy over the past 11-12 years. In addition, the best research in our field over the same time has focused on reduction or elimination of XRT and going forward will likely focus on automation.

Our roles as oncologists are clearly diminishing, yet many of us are well trained in many aspects of outpatient oncology, including performative things like discussing prognosis and technical things like reviewing restaging imaging personally and guiding best approaches for biopsy. It makes sense that we would be interested in a more holistic job.

One more year of IM and an additional year of medonc seems reasonable for comprehensive solid tumor oncology. But what about softer stuff like endocrine therapy for breast or Abiraterone/Xtandi for prostate or even supportive medications like densumab?

It is very hard to recruit a medical oncologist away from favorable locations nowadays.

It seems like there has to be some type of opportunity here. If the medical oncologists are so busy and in short supply, then a well run, patient focused radiation oncology office with an effective patient navigator and nursing could absolutely fill the clinical oncology space in some communities.

DEFINE_ME