Do you consider these negative aspects of the field?

[medician]

Hey everyone, I'm a third year who just finished my surgery rotation (just started clinics) and although I've been very interested in RadOnc the last two years (still am hopefully), I think I've recently identified some negatives of the field I was wondering I would pose to the forum to see how you all dealt with it, etc.?

#1: In surgery, we came across several patients who had multiple SBOs due to previous radiation to the area. At one point, our chief resident said, I wish "they would just take out and refrigerate the bowels before administering radiation". Do you ever worry that for everyone you treat, you have to sort of harm them with "collateral damage"?

More along that line: In a urology didactic session, when asked about different prostate cancer treatments, I was the first to raise my hand and mention radiation. However, the attending said, "yes definitely an option, but I tend to reserve it only for older patients - 65+ who have other co-morbidities and can't tolerate surgery. The side effects are basically similar in the long run, but this way they don't have to worry as much about living with a secondary cancer 10 years later".

#2 In a breast clinic that I was in, the surgeon offered the patient the choice between mastectomy and lumpectomy plus radiation boost. My question (also incorporating the urologist interaction above): does it bother you that you never really offer the patient the treatments you administer, and they are really "sent" to you for treatment, which seems it is almost always administered (with the advanced technology we have today)?

#3 Jobs, CMS cuts, etc. I hear a lot about this, not just by reading this forum, but also amongst residents in our program, which is probably a top 10 program. How worried should I be that if I go into this field next year, I may not have a good job waiting for me at the end of my training?

Finally, I read this editorial by Zeitman a few months ago: http://www.ncbi.nlm.nih.gov/pubmed/18513631 and now I'm starting to wonder if we're starting to see evidence of what he predicted. The fact that ASTRO is themed: "radiation oncology in 2020" worries me further: it seems everyone is sort of worried about the future even though no one may admit it (being at least subconciously defensive about career choice).

I still like the field overall (tech geek + like oncology patient interaction), but have recently started thinking about another option as well (most likely will pick from these two): cardiac electrophsyiology as a decent lifestyle/high-tech field with a secure future/jobs and more positive treatment options(?) albeit with a much longer and crappier training route.

Sorry about this long post: I'd love to hear candid thoughts from current residents/attendings. I admit its gotta be at least slightly difficult considering possible negatives of the field you practice everyday, but if you could go into the field TODAY and had choice all over again, would you? and Why? What positives would you rely on to help balance the potential negatives above?

Thanks much

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[Palex80]

#1: In surgery, we came across several patients who had multiple SBOs due to previous radiation to the area. At one point, our chief resident said, I wish "they would just take out and refrigerate the bowels before administering radiation". Do you ever worry that for everyone you treat, you have to sort of harm them with "collateral damage"?

Surely this is a major issue.
The bottom line however is that in 90% of the cases we are delivering radiation therapy for one of the two following reasons:

1. The patient has cancer. She/He will benefit in terms of long term survival through radiation therapy. Sometimes this benefit is only 5% or even less, some times it's more. Sometimes radiation therapy is the only therapy available, which has the potential to cure the patient.
If you ask a patient if she would rather not have radiation therapy as an adjuvant treatment for her resected cervival cancer, thus losing about 10-15% in overall survival chances but avoiding perhaps 3% chances of suffering a serious normal tissue late reaction in bowel or bladder, what do you think she would say?

2. The patient has cancer. She/He will die because of this cancer probably within the next year with or without radiation therapy. Radiation therapy is intented to combat symptoms from cancer and enhance quality of life. Surely applying whole brain radiation therapy for multiple brain metastasis can have a negative effect on the patient's neurocognitive functions. However, without radiation therapy he/she has about 6 weeks left to live. With radiation we can bring that up to 4+ months. Late effects after whole brain radiation therapy are generally expected more than half a year after radiation therapy.

In radiation therapy you are constantly confronted with the same decision:"How much dose can I deliver to the normal tissue with "acceptable" rates of sequlae?"
The question: "How much dose do I want to give to the tumour?" generally comes in second place.

More along that line: In a urology didactic session, when asked about different prostate cancer treatments, I was the first to raise my hand and mention radiation. However, the attending said, "yes definitely an option, but I tend to reserve it only for older patients - 65+ who have other co-morbidities and can't tolerate surgery. The side effects are basically similar in the long run, but this way they don't have to worry as much about living with a secondary cancer 10 years later".

Well let's see...
Prostate cancer treatment is a major subject of debate. Personally I feel that surgery does have a place in prostate cancer treatment for selected groups of patients. In the long run however, sequlae of radiation therapy with or without antihormonal therapy are generally better to cope with than potential sequlae of surgery. Furthermore there are a lot of patients out there, that will adjuvant radiation therapy (and is some years antihormonal therapy too maybe) after surgery, because of close margins or higher than expected pT-Stage. This combination certainly yields the maximal possible late sequlae.
Additionaly sequlae of radiation therapy (with or without antihormonal therapy) are different than those of surgery, thus it is in the hands of the patient sometimes to decide, which risk of which side effects he is determined to accept.
There is a fairly good paper published, describing the risk of secondary malignancy after surgery or radiation therapy for prostate cancer.
http://www.ncbi.nlm.nih.gov/pubmed/10640974
"Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery."
Basically the risk is 1,5% at 10 years after radiation therapy, thus not that high. Since this was a retrospective analysis and not a randomized trial, there is potential bias involved here. For example if one looks closely at what kind of cancers developed in the radiation therapy group, it is interesting to see that patients had a lot of lung cancers too. The lungs are not in the vicinity of the prostate, surely you do have some leakage from the LINAC and scattering, but one other explanation may have been this:
Patients not operated, but irradiated, where not only the ones that "chose" radiation therapy. There were many among them, that could not undergo surgery for other reasons. What are the major reasons not being able to undergo surgery?
Arteriosclerosis with coronary heart disease and copd.
How does one get coronary heart disease and copd?
By smoking.
What does smoking induce?
Lung cancer.
Any questions?

#2 In a breast clinic that I was in, the surgeon offered the patient the choice between mastectomy and lumpectomy plus radiation boost. My question (also incorporating the urologist interaction above): does it bother you that you never really offer the patient the treatments you administer, and they are really "sent" to you for treatment, which seems it is almost always administered (with the advanced technology we have today)?

I always "offer" treatments.
In Europe you are obliged as a physician to outline to the patient possible treatment alternatives, before advising him what kind of treatment he/she should undergo. I presume this is also the case in the US.
I "offer" mastectomy to all patients that are sent to me after BET for breast cancer as a treatment alternative. In some cases, I do say however, that even if they did undergo mastectomy they would still need radiation therapy after surgery (large pT2 or pT3/4, pN+, etc).
I also discuss Active Surveillance, hormonal therapy, surgery, brachytherapy as alternatives with prostate cancer patients and let them decide what they want to do.

I am not bothered by not having to do all the diagnostic work up before treating the patient. It can be a pain in the ass, takes a lot of time to coordinate and it allows me to focus on treatment.
This week I had a patient referred for treatment of a newly diagnosed extranodal lymphoma. So far it looks like a Stage IAE lymphoma and we have started treatment planning to annihilate the sucker . The diagnosis was established last week and the patients was referred to me by the medical oncologist. When I was confronted by the huge amount of test results he had to perform in order to establish the diagnosis and stage the patient, I was once again reminded why I love being a radiation oncologist.
MRI-scan, CT-scan, Bone marrow aspiration, ORL-consult, blood tests, endoscopy, blablabla... Horrifying...

I admit its gotta be at least slightly difficult considering possible negatives of the field you practice everyday, but if you could go into the field TODAY and had choice all over again, would you? and Why?

Yes.
Because it's fun . It doesn't help you, if you have a decent paid and a secure job, if you don't think it's interesting. I would probably bore myself to death in cardiac electrophysiology. I never did like ECGs for starters...

 

[medgator]

When it comes to worrying about reimbursement, I don't. I love what I do and know that I will make a good income when I get done. I'm sure that over the course of my career my salary will go up and down relative to my colleagues but the way I see it, I get paid to do something that amazes me everyday.

Most people I've met who've met (I'll go out on a limb and say all, pretty much) have gone into this field for the sheer gratification of working with this patient population and the intrigue of the clinical skills involved. The median starting and established salaries are a nice bonus, but at the end of the day, you have to like what you do, day in and day out.

You couldn't pay me enough to do something like derm, path or Dx rads because those fields simply don't interest me.

 

[radonc]

#1
these patients with multiple SBO's...did they ever have surgery?
hernias at presentation - 15% incidence of SBO
appendectomy - 1%
colorectal surgery - 15%

yes, radiation alone can cause SBO's. but so can surgery. and radiation and surgery together, are at least additive in their induction of SBO's. in the NCCTCG (postRT vs postop RT/Chemo in locally advanced rectal ca), the rate of sbo at 7 years was 5%.

w/ respect to the urologists comments. i cant blame him. the data on outcomes after prostatectomies are more mature that that of RT alone; to their advantage, the radiation doses of 15 years ago were lower (66-70Gy) than that of today (78Gy+) and there have been no RCT comparing RP to RT. 10 years is a bit soon for a 2nd malignancy for prostate RT, but im glad he is at least considering sending me patients, and not sending them to a uro-rad. ps: beware of hormones in some patients. the reduction in sexual libido can be long lasting (correlating with length of hormone therapy) while the cardiac effects cannot be ignored.

#2
yes, surgeons 'send' us patients for breast ca on their own. (that is the nature of the field. we play second string to referrers, but its not as bad as the anesthesiology-surgeon relationship; we garner more respect due to our field and our ability to quote studies. at tumor board, if there are any unusual or not-so-straightforward cases, they always turn to radonc.)

but i digress. after a breast cancer patient is 'sent' to me, i discuss options like apbi (balloon vs ebrt vs interstitial), wbrt, hypofractionated wbrt, and even observation. then, i play a large role in determining the fields and their design. in the pmrt setting, i discuss irradiation of regional lymph nodes, and decide whether pwt's, e/shallow tangents, mixed e/p, etc give the best plans. its not as simple as you make it out to be.

#3
dont worry about the future. worry about the present.

 

[medician]

Palex and everyone else: really appreciate your taking the time to respond

Thanks again