Friendly argument w med oncs

[Totem]

Hi everyone,
Quick question: I have spent quite a bit of time with medical oncologists this year as an intern, and they all tell me of the incredible future of molecular targeted and immunologic cancer therapies and have been asking me what promise radiotherapy has for the future and what is coming down the pipeline.
I am a busy prelim medicine intern in a dark place (literally--the MICU--and figuratively) and could use some help. It's been over a year since my last rad onc rotation and spending so much time with med oncs has made me a little nervous about the future. What can I tell them re the future of rad onc? Thanks

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[medgator]

What can I tell them re the future of rad onc? Thanks

Let them know that as sole and combo modality curative treatment, surgery and rad onc will continue to be the workhorses

Chemo has been and will continue to be palliative for the treatment of the vast majority of solid malignancies (except in the adjunct or concurrent setting). The only exceptions I can really think of are certain lymphomas and testicular CA.

 

[OTN]

MedOncs have, since the dawn of oncology, seen their therapeutic instruments through the most rose-colored of glasses. Just tell them you'll be excited once you see good long-term data suggesting chemotherapy is anything but palliative for the vast majority of solid malignancies. In the meantime, you can point to advances in radiation which have already shown benefit: SBRT for early-stage lung ca, for example, or IMRT and IGRT allowing further sparing of normal tissues and decreases in toxicity from XRT. And, keep in mind, if they had a new medicine which demonstrated benefits as large as Ra-223 did recently for osseous metastatic prostate cancer, we'd be hearing about it over and over and over.

While they always have loved to tout what "the future" holds, the vast majority of first-line chemotherapeutic regimens are decades old. Ask them why this is still the case. In reality, a large percentage of medoncs buy into the marketing push from drug companies suggesting a few months' increase in median survival is a huge victory in the fight against cancer.

Bias against radiation from medical oncology drives me crazy. A good friend of mine was recently diagnosed with a Stage IV thymoma and was told by his medical oncologist, an "expert" in thymoma and director of a large academic medical center, that he would not need radiation after surgery. How he could arrive at that conclusion with any reasonable evaluation of the data is beyond me.

 

[thesauce]

Come on guys, they do the best they can with half the training!

 

[medgator]

Come on guys, they do the best they can with half the training!

More like 40%. Half of their 3-year fellowship is heme!

 

[ramsesthenice]

You have to get use to working with people from other specialties and learn how to navigate this situation. In this instance, you just smile and nod. There is almost no chance any chemo or bioligical agents will completely remove radiation from several, let alone one major disease site. It hasn't happened yet and as everyone has said above, the chance of any drug ever being able to wipe out palpable or radiographical tumors to single logs of cells or better without killing the patient just hasn't been done yet and won't be in the near future if ever at all. MultiD is the way of the future despite what some might wish to believe.

But don't think it ends there. Soon you will work with urologists who think raidation is the worst thing you can do to a patient...unless they own the machine. Everyone, including Rad Oncs, is biased towards what they do. They picked their field for a reason. Dont let it get to you. At the same time, don't undervalue the role of med oncs and surgeons either. There isn't that much we do alone ourselves, we are all on the same team.

 

[Sheldor]

More like 40%. Half of their 3-year fellowship is heme!

Also, after speaking with some fellows they told me that sometimes up to half of that 3 years is spent doing research! So that means they'd have 1.5 years for Hematology AND Oncology training. So maybe 9 months of oncology?

 

[medgator]

And, keep in mind, if they had a new medicine which demonstrated benefits as large as Ra-223 did recently for osseous metastatic prostate cancer, we'd be hearing about it over and over and over.

So true.... they get excited about a few months' improvement in DFS/PFS. The RIT (radioimmunotherapy) data is simply compelling and when I sit down with med oncs and talk about, some of them really "get it". Zevalin/Bexxar etc. data was all gathered from patients who'd already seen every chemo regimen under the sun. When it came to Xofigo, the majority of those had already seen taxotere and the trial still managed to show a 4-month OS benefit.