Is Immunotherapy only the purview of Med Onc?

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M4 here, currently pursuing a path in Radiation Oncology. I have always been keenly interested in cancer since I started medical school, and was drawn specifically to Rad Onc due to its use of technology, treatment success, academic nature, and comprehensive range of malignancies one is able to see in this field. However, there were certainly aspects of Medical Oncology that I was attracted to as well; having a little more "ownership" of the patient being one, and the exciting new developments in immunotherapy and biologics being the other.

I am curious if those of you in the field could tell me if any of the research or headway in immunotherapy is being completed by Radiation Oncologists, or if this is pretty much strictly the purview of Medical Oncologists. I know Rad Onc physicians can and have done basic science research into pathophysiology of cancer, but usually as it pertains to Radiobiology. Does a career in Rad Onc essentially preclude one from this type of work or interest? If not, how much "latitude" does one have in Radiation Oncology to work as an "Oncologist" first and a "Radiation Oncologist" second?

I would also be curious if someone could weigh in on cross-pollination between Rad and Med Onc. It seems to me more likely for a Radiation Oncologist to do research in medical therapies than it does for a Medical Oncologist to do research into Radiation, but then again, I'm an M4 acolyte.

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I'm an ms3 so I don't have firsthand experience, but the rad oncs at my institution are running trials of immunotherapy + xrt. We are also doing translational studies regarding immune environments and how that correlates with clinical outcomes in patients treated with radiotherapy. So, yes, radiation oncologists are definitely working on the front lines of these topics. There is a lot of interaction between xrt and the immune system, and in my opinion rad oncs are better equipped to understand those processes than med oncs. Whether than means rad oncs will be the ones prescribing immunotherapy, hard to say. The thing with immunotherapy is, the risk of bad side effects can be pretty high, and a lot of rad oncs might not want to manage that and thus will leave it to med onc.
 
Research and clinical practice are (of course) different. I'm a private practice rad onc so I won't speak to research.

In private practice, I don't see immunotherapy falling under radiation oncology. The current agents are infusional therapy. Is a radiation clinic going to open an infusion clinic? That seems unlikely for many reasons (cost, upsetting the referring medical oncologists, and comfort with running an infusion clinic). If oral agents become popular those don't generally make money for the physician (unless you own the pharmacy) other than the clinic visits which are not a major source of revenue for most radiation practices. (And medical oncology usually gets the patients first; not likely they are going to send patients to us for a systemic therapy.)

Furthermore, in the clinic, does it really make sense for us to manage immunotherapy? What serves the patients the best? Medical oncologists (and their nurses / NP / PA) are more seasoned in managing the side effects that these medications can have. They have admitting privileges if needed. They have experience in deciding when to switch therapies based on progression or tolerability. Could we learn to do these things? Of course but for what purpose? I understand the need for our field to not be stagnant but I don't think trying to get into the systemic therapy end of things compliments our skill sets.
 
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IT is systemic therapy with possibility for real side effects. That seems solidly in the purview of medical oncologists to me.
 
One interesting phenomenon with immunotherapy is the presence of oligomets. In younger, high KPS patients we used to SBRT the oligomet sites then proceed with definitive CRT to primary. Now with immunotherapy, I tend to just SBRT oligomets and then let immunotherapy take over via (presumed) abscopal effect.


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Research and clinical practice are (of course) different. I'm a private practice rad onc so I won't speak to research.

In private practice, I don't see immunotherapy falling under radiation oncology. The current agents are infusional therapy. Is a radiation clinic going to open an infusion clinic? That seems unlikely for many reasons (cost, upsetting the referring medical oncologists, and comfort with running an infusion clinic). If oral agents become popular those don't generally make money for the physician (unless you own the pharmacy) other than the clinic visits which are not a major source of revenue for most radiation practices. (And medical oncology usually gets the patients first; not likely they are going to send patients to us for a systemic therapy.)

Furthermore, in the clinic, does it really make sense for us to manage immunotherapy? What serves the patients the best? Medical oncologists (and their nurses / NP / PA) are more seasoned in managing the side effects that these medications can have. They have admitting privileges if needed. They have experience in deciding when to switch therapies based on progression or tolerability. Could we learn to do these things? Of course but for what purpose? I understand the need for our field to not be stagnant but I don't think trying to get into the systemic therapy end of things compliments our skill sets.

A melanoma doc at my institution said that his clinic is essentially full of autoimmune patients, happy that their cancer is arrested but really unhappy about the side effects. I don't think rad onc's would want to be responsible for managing IO.


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A melanoma doc at my institution said that his clinic is essentially full of autoimmune patients, happy that their cancer is arrested but really unhappy about the side effects. I don't think rad onc's would want to be responsible for managing IO.


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And it isn't just rashes and hypothyroidism.... try colitis and gi perfs....
 
Well, if it's a tough job market, then I'm sure some junior rad onc's wouldn't mind inpatient responsibilities.

And why do med onc's have admitting privileges? Besides the BMT service, other sick oncology patients are managed by hospitalists or if things get really bad, by critical care doc's. Med onc's either co-manage or follow as consultants. My point is, would it be that hard for rad onc's to get admitting privileges?

No, but why?? :eek: last thing I want to do after a busy 11-12 hour outpatient day between tumor boards/consults/otvs etc is go round on my inpatients at multiple hospitals where I already see consults.
 
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Well, if it's a tough job market, then I'm sure some junior rad onc's wouldn't mind inpatient responsibilities.

And why do med onc's have admitting privileges? Besides the BMT service, other sick oncology patients are managed by hospitalists or if things get really bad, by critical care doc's. Med onc's either co-manage or follow as consultants. My point is, would it be that hard for rad onc's to get admitting privileges?

I don't think there's going to be a nationwide push to have inpatient admitting privileges as a Rad Onc. In certain scenarios, like covering one site with one hospital with multiple rad oncs, without a lot of on-treatment patients, it could be feasible to obtain admitting privileges, especially if you don't have support from surgeons/med-onc to admit your patients when they need admitted.
 
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