So would you advise rising M4s to enter this field at this point?

[kristofer]

Don't you think it's just as disparaging to put down family med and ob-gyn and general surgery as it is to put down small cities? Isn't it okay to have different priorities in life?

I want to clarify that in no way did I put down those specialties. I listed the first few specialties that came to my head that are more common and have a higher number of jobs available in large cities. My point concerned how drastically different these professions are from rad-onc, not that they are somehow inferior. Yes, of course I agree it's ok to have different priorities in life. However, I can't wrap my head around this concept of choosing an entirely different career so you can have easy access to certain "ethnic" foods and restaurants, as you brought up below and was brought up in another post. Seems to be a common concern. I mean, I absolutely love fresh seafood, but it's difficult if not outright impossible to get where I am right now. It's not the end of the world. For reference, Bakersfield has 10+ sushi restaurants from a quick google search. My hometown has none. Sounds alright! And they are hiring! Regarding the also commonly discussed worry about the ethnic diversity of the dating pool, I can see that. I suppose that I am lucky that I am not from a family or culture that pressures me to marry someone of the same ethnicity/race/religion/whatever, nor am I of that mindset, and my SO is a different ethnicity. Your question was whether we would advise M4s to enter this field at this point. If you are not open-minded regarding where you live, what type of food you eat, the background of potential life partners, etc then no absolutely not. We're beating a dead horse at this point.

It's frustrating to watch people in medicine constantly trash talk the places I called home growing up and the people in them. There are good people everywhere, and America as a whole is a great place to live. Talk about first world problems. But I get where you're coming from (kind of). I dislike NYC and LA. But I would try to make them work if I had to rather than bail to a different field or industry. My family went where they had to make a living, and it just always seemed to me like that's part of life if you want to do as well as you can. But in this case, it's not like we are comparing NYC to a town in rural Wyoming with no stoplight and dial-up internet. Could you really not even consider the possibility of trying to make a place like San Antonio, Jacksonville, or Phoenix work (all top 5-15 cities in terms of population)? Philadelphia? Boston? What is it about NYC and LA for some people? I'll never get it.

Maybe to put it in perspective, I had a friend who lived in Bakersfield, CA and had to drive four hours to LA every month to get groceries, since Bakersfield doesn't have a grocery store with her home country's ethnic food (FYI, Bakersfield to LA is only 100 miles, much less than the 300 mile radius criterion). For you, this may not be an issue, but I would definitely reconsider the idea that living in a small city comes with no repercussions whatsoever for some people. I can say many of my friends who are ethnic minorities and have lived in mid sized cities (let alone rural areas) say dating is completely different as compared to a big city. I'm not at all trying to say that small cities suck. It's just that there is a huge detriment to my quality of life such that it would be worth it to consider another field. For me personally, if I can find a job living in a top 10 metro area even with a pay cut and worse hours, I would take it in a heartbeat over a job in a rural town making millions working 30 hrs/week. If rad onc can't give me that opportunity, then I definitely will have to think twice, sadly.

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[psy3]

Yes, of course I agree it's ok to have different priorities in life. However, I can't wrap my head around this concept of choosing an entirely different career so you can have easy access to certain "ethnic" foods and restaurants, as you brought up below and was brought up in another post. Seems to be a common concern. I mean, I absolutely love fresh seafood, but it's difficult if not outright impossible to get where I am right now.

Honestly, I don't know IVY's ethnicity as he brought up Bakersfield as his friend's experience. But, as someone who is not Caucasian, I actually find your statement insensitive and ignorant. We are all smart enough to get into medicine, so you should be able to understand being able to find ethnic food and restaurant in a certain city or metro area is a function of what proportion or what absolute number of people in your ethnicity in your city. And that doesn't just affect what you put in your mouth. It affects whether you can find outside-of-work friend in your ethnicity for yourself, for your spouse, and for your kid. It event affects whether your kids can grow up knowing their heritage and speak their mother tongue to their parents and grandparents. And many many more things. You cannot possibly condescend these problems to a same level of whether a random Caucasian person find a decent seafood place in Midwest.

Even outside of ethnicity issue, if you look at Wikipedia like ThrowawayRadonc did for Bakersfield, easily about 1 in 4 or even 1 in 3 of US population liven in top10 metropolitan area (plus some other marquis cities like Seattle, San Diego, and San Jose). That means, out of cohort of medical students or radonc applicants, 25-30% of them came from those big cities. And those people wanting to find their job and grow their family in similar environment, how can you possibly find that unreasonable or irritable? You can be bone dry and tell them "it is hard" to whoever that asks "should I go into radonc if I want to live in NY or LA only?" But, to express in multiple occasions that you cannot wrap your head around those big-city minded people, I find it equally narrow-minded.

And finally, this really is not a dead horse. Because, being able to accommodate anyone's geographical preference was certainly easier, and is getting harder as residency spots continue to expand. And this is just "discouraging medstudent about getting into fields." The whole vein of SDN's existence was sharing reality and trend of what's going on for undergraduates and med students. So why is it wrong to display that good percentages of people in radonc think that the trend in radonc job market is going to wrong direction?

 

[deleted18755]

I want to clarify that in no way did I put down those specialties. I listed the first few specialties that came to my head that are more common and have a higher number of jobs available in large cities. My point concerned how drastically different these professions are from rad-onc, not that they are somehow inferior. Yes, of course I agree it's ok to have different priorities in life. However, I can't wrap my head around this concept of choosing an entirely different career so you can have easy access to certain "ethnic" foods and restaurants, as you brought up below and was brought up in another post. Seems to be a common concern. I mean, I absolutely love fresh seafood, but it's difficult if not outright impossible to get where I am right now. It's not the end of the world. For reference, Bakersfield has 10+ sushi restaurants from a quick google search. My hometown has none. Sounds alright! And they are hiring! Regarding the also commonly discussed worry about the ethnic diversity of the dating pool, I can see that. I suppose that I am lucky that I am not from a family or culture that pressures me to marry someone of the same ethnicity/race/religion/whatever, nor am I of that mindset, and my SO is a different ethnicity. Your question was whether we would advise M4s to enter this field at this point. If you are not open-minded regarding where you live, what type of food you eat, the background of potential life partners, etc then no absolutely not. We're beating a dead horse at this point.

It's frustrating to watch people in medicine constantly trash talk the places I called home growing up and the people in them. There are good people everywhere, and America as a whole is a great place to live. Talk about first world problems. But I get where you're coming from (kind of). I dislike NYC and LA. But I would try to make them work if I had to rather than bail to a different field or industry. My family went where they had to make a living, and it just always seemed to me like that's part of life if you want to do as well as you can. But in this case, it's not like we are comparing NYC to a town in rural Wyoming with no stoplight and dial-up internet. Could you really not even consider the possibility of trying to make a place like San Antonio, Jacksonville, or Phoenix work (all top 5-15 cities in terms of population)? Philadelphia? Boston? What is it about NYC and LA for some people? I'll never get it.

Yeah that was definitely a weird example. I’m honestly curious where in the world that person is from that their food can’t be found in a city that size. I’ve lived in towns that are well under 100,000 (maybe even 50,000) that have more than one Indian grocery store and Asian grocery stores divided by country. My current town has a few people from freakin’ Bhutan who cook the most delicious goat dish from their home country.

The internet exists outside of major metropolitan cities and Amazon prime deliveries may take (gasp) 3 days instead of 2 in small towns (and many if not most consider a place with the population cited for Bakersfield as a full blown city).

The examples given previously with regards to job opportunities for your spouse and being stuck in a terrible job vs moving away from your kids if you get a divorce are extremely valid and the job market is deteriorating to the point that I don’t recommend this field to medical students but that example was silly.

PS: my wife and I are 1st/2nd generation Indians but we aren’t religious (and I’ll readily admit that I made my parents get Christmas trees every year so I could fit in), can understand and to varying degrees speak Hindi but our children don’t know a word, and when I read the post in the other thread about types of Indian restrauants I had to look them up so maybe we apparently aren’t as “ethnic” as many others but for what it’s worth we have been treated with nothing but respect by the small town white Christian people whom we have lived amongst our entire lives (again maybe we just assimilated well by choice or perhaps even necessity).

 

[kristofer]

Honestly, I don't know IVY's ethnicity as he brought up Bakersfield as his friend's experience. But, as someone who is not Caucasian, I actually find your statement insensitive and ignorant. We are all smart enough to get into medicine, so you should be able to understand being able to find ethnic food and restaurant in a certain city or metro area is a function of what proportion or what absolute number of people in your ethnicity in your city. And that doesn't just affect what you put in your mouth. It affects whether you can find outside-of-work friend in your ethnicity for yourself, for your spouse, and for your kid. It event affects whether your kids can grow up knowing their heritage and speak their mother tongue to their parents and grandparents. And many many more things. You cannot possibly condescend these problems to a same level of whether a randomCaucasian person find a decent seafood place in Midwest.

It's food for crying out loud. Are we on the same planet? This concept of not going into rad onc because you might not be able to order out your favorite food is totally asinine. And for what it's worth Bakersfield apparently has multiple "ethnic" grocery stores: Specialty Asian stores, pan-Asian stores, African stores, Mexican stores, Indian stores, and more.

It is absolutely hilarious that you are essentially calling me a racist when you are ranting about how important it is to make sure you aren't in an area where you are around too many white people and telling me that I'm narrow-minded. Would my kids even be allowed to be friends with your kids?

Edit: I'm dipping out of this thread because I don't see it going anywhere good at this point. But I just can't stop reading this line over and over: "It affects whether you can find outside-of-work friend in your ethnicity for yourself, for your spouse, and for your kid." I don't know what's more troublesome. That you actually wrote it, or that a lot of people who claim they only want to be in a big city also may agree with it. The previous comments about hyperbole are spot on. People like you made the wrong choice to go into rad onc, sure. It is unfortunate that you are so unwilling to give "random Caucasian people" like me a chance.

 

[DebtRising]

This will be my last post on this subject for some time.

Stop the anecdotes. Stop the incidental bashing of people, on both sides. You only give fuel to the fire to the people who are abusing this field.

Here are the facts
1. The published model to project supply and demand projects an oversupply at 2016 levels. It has been posted on her ad nausea. Since then, MORE residencies have expanded and opened.

2. No one has rebutted the voracity of this model. Further, when a similar model was constructed with some of the same people involved in its creation and was published ~5 years earlier, Rad Onc Chairs, ASTRO, etc trumpeted this as a bastion of fact.
In other words, the leadership of this field endorsed the methodology and veracity of the model when it suited their goals. Now that the same model shows a result they don't like, they bury it.

3. In the only published response to this model by ASTRO, there is a vague editorial whose only argument counter to this model is that 'well, the previous one was different'.
That is basically saying - well, I don't believe the 2016 census because it has different results than the 2012 census. IT is not a valid argument

4. Fellowships, as tracked by ARRO, and again posted on this forum, have increased by either 15-25 spots in the last 5-6 years. Fellowships in this field are not regulated, do not allow you to do anything new procedures, get new privileges, or further your practice of radiation.
https://www.astro.org/uploadedFiles...ources/Content_Pieces/FellowshipDirectory.pdf

There are now 24 Rad onc programs offering somewhere between 35-45 fellowship positions, depending on the number per institution and with the knowledge there are last 4 other fellowships not posted on that site.

5. Utilization of radiation oncology for many disease sites, and the fractions used, is decreasing. Again the labor paper shows how much the utilization rate of RT has changed for disease states.
The ASTO consensus statements unequivocally state to hypofractionate everything in breast, and the prostate one was shaping up the same. I have strong personal feelings that the prostate hypofractionation data is very underwhelming and I have made that known - but do not let that cloud the point that this is happening, and we are being forced to treat least. This is very good where appropriate, but means there is less need for physicians to manage patients on treatment, and effects income.

6. The change in ABR certification, whether good or bad or for altruistic or business purposes, allows older physicians an easier time to stay certified. A bunch where grandfathered in, a bunch more will never have to take a serious exam to prove competence.

7. There is an annual workforce survey by ASTRO every 4 years. Google it. The last one in 2017 was presented at ASTRO but not yet published
53% of respondents listed the job market and oversupply as their top concern. Over half the current radiation oncology practicing physician workforce thinks this is a significant problem. They don't all need to live in a Manhattan penthouse to be happy, and they do not deserve to have their feedback invalidated by the culture warriors of both sides on SDN. Be quiet.


Every single objective piece of evidence and the only coordinated, anonymous feedback by practicing Rad Oncs is that we are being training more physicians than are needed. And as I posted before, per the CMS statements on driving of healthcare costs, increasing physician supply typically leads to increased utilization increased costs, and there is a legitimate argument that ACGME / SCAROP / ASTRO are misusing Medicare funds when pushing from for residency slots in a specialty already over training. Training physicians who are needed for society is good. Training more than is needed is bad.

As a rising MS4 you have 0% chance of predicting what will happen at the time of your graduation in years, but know that the angst and anger on this board is born of legitimate concerns, unheeded by leadership, and supported by the evidence. IF you want to roll the dice on over coming those factors, be my guest. But don't do it based on anecdotal accounts, and have your eyes wide open.

 

[DrfluffyMD]

I just want to chime in about the spouse thing.

Here are some people I dated in NYC
- leader in prominent NGO (think UN and the like)
- heiress to a minor business empire
- up and coming artist
- fashion modes

Once I got to a moderately large midwest town, the only elligible women I see are sadly, other coresidents. I literally trolled dating site each july for new trainees.

How come? Because there are no major industry here where young people join in besides health care. I am not going to find heiress, semi wellknown artist or fashion models here....I am not talking about the attractivenes of spouses. There are hot people everywhere, but it’s difficult to find high achieving young people outside of major metros like NYC, LA, Boston, Chicago, etc.

 

[DrfluffyMD]

It's food for crying out loud. Are we on the same planet? This concept of not going into rad onc because you might not be able to order out your favorite food is totally asinine. And for what it's worth Bakersfield apparently has multiple "ethnic" grocery stores: Specialty Asian stores, pan-Asian stores, African stores, Mexican stores, Indian stores, and more.

It is absolutely hilarious that you are essentially calling me a racist when you are ranting about how important it is to make sure you aren't in an area where you are around too many white people and telling me that I'm narrow-minded. Would my kids even be allowed to be friends with your kids?

Edit: I'm dipping out of this thread because I don't see it going anywhere good at this point. But I just can't stop reading this line over and over: "It affects whether you can find outside-of-work friend in your ethnicity for yourself, for your spouse, and for your kid." I don't know what's more troublesome. That you actually wrote it, or that a lot of people who claim they only want to be in a big city also may agree with it. The previous comments about hyperbole are spot on. People like you made the wrong choice to go into rad onc, sure. It is unfortunate that you are so unwilling to give "random Caucasian people" like me a chance.

Wanting to have people of one’s ethncitiy around and being friends with white people are not mutually exclusive...

 

[RickyScott]

Thank you Debt Rising. I grew up in a small town, and they really can offer a great quality of life. The point I keep trying to make over and over again is not so much about the location, but the fact that a tight job market gives your employer/job a lot of leverage over you, wherever you are, and it will be used at some point, sometimes subtlely, sometimes not. As neuronix said, if he leaves, people will be lining up to take his position.
Whether this translates into delayed/negated promotion/raise, coverage of a satellite 50 miles a way, tolerating malignant staff, favoritism ... Dont think this cant affect job satisfaction. When you know that you cant easily leave a job, everything changes.

Residents are so focused on that fist job, earning several hundred thousand (they think their happiness will forever take a big jump forward when they get their first paycheck), they lose track that are going to be employed for the next 40 years...

(Lastly, after, about 125,000$ studies have shown that salary does not affect happiness- there is whole body of literature on this)

 

[Fpg1245]

Even if someone doesn’t care where they end up practicing, the caliber of the people they meet, quality of the schools, housing, culture, etc. Wouldn’t it be better if they had more options available to them? Even if someone ends up where they want to, if things don’t work out for whatever reason they are screwed. Their next job maybe thousands of miles away and not even remotely resemble what they would have wanted. When someone in Rad Onc says you have to be flexible, it just means you have to be prepared to accept anything. I don’t believe in the whole salary, lifestyle, location pick 1,2 etc because the reality is you won’t have a choice in any of them. Adding children and a spouse into the mix and you probably will be lucky if you can mentally contort yourself into believing you ended up with one of those three.

 

[medgator]

I just want to chime in about the spouse thing.

Here are some people I dated in NYC
- leader in prominent NGO (think UN and the like)
- heiress to a minor business empire
- up and coming artist
- fashion modes

Once I got to a moderately large midwest town, the only elligible women I see are sadly, other coresidents. I literally trolled dating site each july for new trainees.

How come? Because there are no major industry here where young people join in besides health care. I am not going to find heiress, semi wellknown artist or fashion models here....I am not talking about the attractivenes of spouses. There are hot people everywhere, but it’s difficult to find high achieving young people outside of major metros like NYC, LA, Boston, Chicago, etc.

Yes, clearly all of the professional non-medical women (of which there are plenty) in Kansas City*, Cincinnati, Cleveland and Pittsburgh etc are all undateable hags.

Thank God for the coasts (on second thought, maybe not) to keep some on this forum in the gene pool long term.

And I say this having met my spouse away from the coast and living on the south east coast now










*-just for kicks, you should look up the number of F500 companies HQ in KC and whether they are medical or non medical

Also, I find it humorous you bring up dating fashion models while saying it is not about looks in the same paragraph too. Nice touch

 

[nkmiami]

Thank you Debt Rising. I grew up in a small town, and they really can offer a great quality of life. The point I keep trying to make over and over again is not so much about the location, but the fact that a tight job market gives your employer/job a lot of leverage over you, wherever you are, and it will be used, sometimes subtlely, sometimes not. As neuronix said, if he leaves, people will be lining up to take his position.
Whether this translates into delayed/negated promotion/raise, coverage of a satellite 50 miles a way, tolerating malignant staff, favoritism ... Dont think this cant affect job satisfaction. When you know that you cant easily leave a job, everything changes.

Residents are so focused on that fist job, earning several hundred thousand (they think their happiness will take a big jump forward when they get their first paycheck), they lose track that are going to be employed for the next 40 years...

(Lastly, after, about 125,000$ studies have shown that salary does not affect happiness- there is whole body of literature on this)

Ten years at ago, at the ASTRO resident job session, they had this mantra about "your first job wont be your last." This whole dynamic has changed.

 

[DrfluffyMD]

Yes, clearly all of the professional non-medical women (of which there are plenty) in Kansas City*, Cincinnati, Cleveland and Pittsburgh etc are all undateable hags.

Thank God for the coasts (on second thought, maybe not) to keep some on this forum in the gene pool long term.

And I say this having met my spouse away from the coast and living on the south east coast now










*-just for kicks, you should look up the number of F500 companies HQ in KC and whether they are medical or non medical

Also, I find it humorous you bring up dating fashion models while saying it is not about looks in the same paragraph too. Nice touch

I am sure there are fine young people out there, but many of those people in the midwest are also family oriented and the great ones are mostly married. Have you ever tried to date in KC or Cleveland vs NYC?

 

[mheat3]

Finally, one area where there's space to improve is getting referrals from urologists for patients with adverse features following prostatectomy. This is known to be beneficial, has little room to be hypofractionated (due to bowel constraints),

NRG-GU003: A Randomized Phase III Trial Of Hypofractionated Post-Prostatectomy Radiation Therapy (HYPORT) Versus Conventional Post-Prostatectomy Radiation Therapy (COPORT)

 

[medgator]

I am sure there are fine young people out there, but many of those people in the midwest are also family oriented and the great ones are mostly married. Have you ever tried to date in KC or Cleveland vs NYC?

That's kinda the point if you're looking for a spouse, now isn't it? Who do you think it is more looking to settle down, the fashion model from Manhattan/artist from Greenwich village, or the engineer from Kansas City or Cincinnati?

 

[soulcity]

Thank you everyone for the great conversation. All posts were very valuable for me.

I was surprised to learn that some of you were able to nail the fact that yes, I am a visible minority. I didn't always have restrictions on geographic locations. In fact, I have been fluid about geographic locations before I came to med school and that is how I ended up in a small city in one of the flyover states for med school. Seeing some folks around my current med school town however got me thinking about a lot of things. I have neighbors that fly a confederate flag. I have taken care of patients that have swastika tattooed all over them. I have been called racial slurs just walking down the street around my apartment (young teenage kiddos mostly, but still very hurtful). Perhaps the current political climate empowers certain individuals to act out this way. Regardless of the cause, there have been many moments where I felt very uncomfortable. This is the biggest motivating factor for me to be on the coast, where there is greater diversity. I have nothing against small cities, but I just desire to blend-in better in my day to day life.

I have yet to figure out definitively whether this comfort factor should trump my career. At this point it seems like I have an option to settle for an okay job (doing something I am not crazy about) vs live out of my comfort zone for an extended period of time.

 

[medgator]

. This is the biggest motivating factor for me to be on the coast, where there is greater diversity. I have nothing against small cities, but I just desire to blend-in better in my day to day life.

This issue I have with that idea is that it ignores many diverse and decently "big" cities away from the coasts like: kansas City, Cincinnati, Denver, Atlanta, Charlotte, Pittsburgh, Orlando, Chicago, Minneapolis, Phoenix, San Antonio, Austin, Dallas/Irving/Arlington, Houston etc. There are many more I am probably not remembering off the top of my head.

2017’s Most Diverse Cities in America

 

[laserbeams]

NRG-GU003: A Randomized Phase III Trial Of Hypofractionated Post-Prostatectomy Radiation Therapy (HYPORT) Versus Conventional Post-Prostatectomy Radiation Therapy (COPORT)

I stand corrected.

Another potential way to think about this is that many men who would benefit from adjuvant treatment are not receiving any radiotherapy following prostatectomy, which is the difference not of 37 vs 25, but something vs nothing.

 

[mheat3]

I stand corrected.

Another potential way to think about this is that many men who would benefit from adjuvant treatment are not receiving any radiotherapy following prostatectomy, which is the difference not of 37 vs 25, but something vs nothing.

Totally agree, I was just pointing out the the hypofract movement is ever expanding.

 

[scarbrtj]

That is an interesting point. I am reaching back here, but I believe the cost of machine in the early 2000s was 600-900,000, and they were often in use for 15-20 years. (with blocks, not mlcs). Also, systemic therapy improvements may lessen the need for dose escalation/hyper precision as they will undoubtedly have local control benefits. (pacific trial benefitd lung pts, not 74 Gy, and some of this benefit has to be local)

With hypofract, and little in the way of linac game changing technology on the horizon (like cone beam), the vendors will have profitability issues. Varian seems like it is trying to sell more software services. A truebeam with 6 degree couch, is probably going to be over 3 mill, making the number on treatment for roi higher than it was in the past? It certainly is making hospitals/centers think twice about getting a new linac in this environment.

For me, and maybe I'm just kidding myself (however when Paula Abdul first came on the scene I remember thinking "she's gonna be famous" and I was right!), it's a when not an if question as to radiation's diminishing importance in cancer therapy. It's an antediluvian approach to cancer cell DNA manipulation. Other approaches will be "smarter" and better. It's amazing that Siemens (former makers of radiation therapy equipment, if no one knew that) is participating in this type research and Varian is not. Well, maybe not that amazing.

 

[nkmiami]

For me, and maybe I'm just kidding myself (however when Paula Abdul first came on the scene I remember thinking "she's gonna be famous" and I was right!), it's a when not an if question as to radiation's diminishing importance in cancer therapy. It's an antediluvian approach to cancer cell DNA manipulation. Other approaches will be "smarter" and better. It's amazing that Siemens (former makers of radiation therapy equipment, if no one knew that) is participating in this type research and Varian is not. Well, maybe not that amazing.

.. It is still surprising that there is not a movement to create fellowships that offer useful training in systemic therapy for us to stay relevant (like in much of the rest of the world).

 

[DrfluffyMD]

.. It is still surprising that there is not a movement to create fellowships that offer useful training in systemic therapy for us to stay relevant (like in much of the rest of the world).

Isn’t there already a fellowship in systemic therapy called heme onc?

 

[nkmiami]

Isn’t there already a fellowship in systemic therapy called heme onc?

Last I checked, you needed 3 years of IM to apply..This field started in France and England, It was not uncommon to go over there for training/fellowships up until 70s and 80s. They do know what there are doing over there. Or, alternatively we can simply become less and less relevant...while churning out "fellows" in core areas like "palliation" and SBRT and excess residents.

 

[DrfluffyMD]

When I was a med student, I gained some exposure to radonc and decided against it. My issue with it is that we are ultimately fighting poison with poison. At the crux of it, I don’t see radiation therapy as an elegant approach. As you know, you ultimately just cannot control the strand breaks / the underlying mechanism of therapy.

I can see surgery being there 100 years from now. I can see angio/IR techniques being there 100 years from now, but I am not sure that radiation therapy will be there 100 years from now.

 

[medgator]

I can see surgery being there 100 years from now. I can see angio/IR techniques being there 100 years from now, but I am not sure that radiation therapy will be there 100 years from now.

Famous last words over the last several decades.

Just look at the terrible control rates with rfa in lung, for example. Sbrt is the clear winner there and is much closer to what you see with surgical outcomes. The sbrt data is looking good in liver and starting to encroach on IR turf there as well

 

[DrfluffyMD]

Famous last words over the last several decades.

Just look at the terrible control rates with rfa in lung, for example. Sbrt is the clear winner there and is much closer to what you see with surgical outcomes. The sbrt data is looking good in liver and starting to encroach on IR turf there as well

I am not specifically talking about IR and surgery. I am talking about common sense. I am sure that using a highly focused beam of energetic particle can destroy cells very well, but why would you use such an indiscriminate method of destruction when more precise options are available? Especially when you cannot avoid delivery of those beams through tissues?

I have done treatment planning before. I have seen what radiation do to people. I hope for a better future where we have a more elegant solution. We are getting close to that.

People favor radiation because the price you pay isn’t one where you tend to see immediately after the procedure, and the nature of scientific research means poor outcomes over a long time is under-reported (such as cardiac issues from mantle radiation) and don’t come to be recognized years later.

I have no issue with radonc as a field. I just had extensive experience in it during med school and decided that despite the money and lifestyle, it isn’t for me because I ultimately think this is a form of therapy that will be viewed as crude in the far distant future (along with things like cisplatin).

 

[medgator]

I have done treatment planning before. I have seen what radiation do to people. I hope for a better future where we have a more elegant solution. We are getting close to that.

Really? Please feel free to share your experiences with modern imrt/vmat/igrt/srs/sbrt techniques and the outcomes you saw in real patients

 

[DrfluffyMD]

Really? Please feel free to share your experiences with modern imrt/igrt/srs/sbrt techniques and the outcomes you saw in real patients

To elaborate further would out myself because I imagine not many IRs have those type of research in med school. But yes, I have worked with those.

It doesn’t matter how you rotate the beam or play around with the MLCs, actual radiation still enter through tissue overlying the tumor. As you know that there are effects of radiation that aren’t dose dependent but can present with any dose.

 

[deleted18755]

I am not specifically talking about IR and surgery. I am talking about common sense. I am sure that using a highly focused beam of energetic particle can destroy cells very well, but why would you use such an indiscriminate method of destruction when more precise options are available? Especially when you cannot avoid delivery of those beams through tissues?

I have done treatment planning before. I have seen what radiation do to people. I hope for a better future where we have a more elegant solution. We are getting close to that.

People favor radiation because the price you pay isn’t one where you tend to see immediately after the procedure, and the nature of scientific research means poor outcomes over a long time is under-reported (such as cardiac issues from mantle radiation) and don’t come to be recognized years later.

I have no issue with radonc as a field. I just had extensive experience in it during med school and decided that despite the money and lifestyle, it isn’t for me because I ultimately think this is a form of therapy that will be viewed as crude in the far distant future (along with things like cisplatin).

In post #74 you say "When I was a med student, I gained some exposure to radonc and decided against it."

Then a few minutes later in post #76 you claim "extensive experience in it"

On top of that there is another post a few minutes later. . .

Are you posting out of your mother's basement? If not, I'm honestly curious in what field of medicine one has time to post multiple random things on a forum that isn't even one's specialty!

I'll be the first to say the future of radiation oncology is not looking good, but it's a fascinating and highly refined field.

 

[nkmiami]

I dont see radiation disappearing as a field in the next 20 years, but it certainly will be scaled back, just a question of how much.

 

[Haybrant]

To elaborate further would out myself because I imagine not many IRs have those type of research in med school. But yes, I have worked with those.

It doesn’t matter how you rotate the beam or play around with the MLCs, actual radiation still enter through tissue overlying the tumor. As you know that there are effects of radiation that aren’t dose dependent but can present with any dose.

Haha, are you IR? I love IR the most. They are the most idealistic of idealistic. Zero training in oncology but love speaking about oncology and how IR will change the oncology world. Look around you at tumor boards next time, who isn’t there? Oh right, IR. That’s beciase you don’t know or understand oncology. When you guys decide to target lymph nodes and lymph node basins and spend some time reading about cancer come back and have a discussion with us.

 

[evilbooyaa]

To elaborate further would out myself because I imagine not many IRs have those type of research in med school. But yes, I have worked with those.

It doesn’t matter how you rotate the beam or play around with the MLCs, actual radiation still enter through tissue overlying the tumor. As you know that there are effects of radiation that aren’t dose dependent but can present with any dose.

Then we should clearly all not go outside because of all that radiation we'll receive.

The stuff that people actually worry about is dose dependent, or dose-volume dependent. Kind of like those DVHs that we all obsess over in practice. Lol @ the entire field is going to die.

Do you think that sticking a needle into tumor and heating up to a million degrees roasting that plus the a 1-2cm margin of normal tissue is 'more precise' method than what we can do non-invasively, without needles?

 

[DrfluffyMD]

Then we should clearly all not go outside because of all that radiation we'll receive.

The stuff that people actually worry about is dose dependent, or dose-volume dependent. Kind of like those DVHs that we all obsess over in practice. Lol @ the entire field is going to die.

Do you think that sticking a needle into tumor and heating up to a million degrees roasting that plus the a 1-2cm margin of normal tissue is 'more precise' method than what we can do non-invasively, without needles?

That is also a barbaric method. I am hoping for the future with things like targeted therapy.

Although I do believe in the future of ablation. At least thermal ablation doesn’t tend to lead to DNA strand breaks and incidental future tumors, which can be an emerging issue with people living longer.

 

[DrfluffyMD]

In post #74 you say "When I was a med student, I gained some exposure to radonc and decided against it."

Then a few minutes later in post #76 you claim "extensive experience in it"

On top of that there is another post a few minutes later. . .

Are you posting out of your mother's basement? If not, I'm honestly curious in what field of medicine one has time to post multiple random things on a forum that isn't even one's specialty!

I'll be the first to say the future of radiation oncology is not looking good, but it's a fascinating and highly refined field.

Sure, I have done a research year in it with publications. To some it’s an exposure, to others it’s extensive experience, depends on your prospective.

 

[deleted18755]

Then we should clearly all not go outside because of all that radiation we'll receive.

The stuff that people actually worry about is dose dependent, or dose-volume dependent. Kind of like those DVHs that we all obsess over in practice. Lol @ the entire field is going to die.

Do you think that sticking a needle into tumor and heating up to a million degrees roasting that plus the a 1-2cm margin of normal tissue is 'more precise' method than what we can do non-invasively, without needles?

I rarely actually pay attention to who is posting what but I'm pretty sure this is the guy who a few days ago claimed to have dated a super model, Paris Hilton, and others while a medical student (and also having time to gain extensive exposure to radiation oncology!!!)

 

[DrfluffyMD]

Haha, are you IR? I love IR the most. They are the most idealistic of idealistic. Zero training in oncology but love speaking about oncology and how IR will change the oncology world. Look around you at tumor boards next time, who isn’t there? Oh right, IR. That’s beciase you don’t know or understand oncology. When you guys decide to target lymph nodes and lymph node basins and spend some time reading about cancer come back and have a discussion with us.

Nice insult on another profession. I don’t have an issue with radoncs. I respect them as colleagues and mentors with incredible amount of knowledge and clinical skills. Not to mention the highly scientific attitude.

My issue lies with using ionizing radiation as a theraputic modality. We have to not, but I hope we won’t need to in the future.

With that being said, some IRs definitely have understanding of oncology and participate in tumor boards. Not all IRs are the same.

 

[DrfluffyMD]

I rarely actually pay attention to who is posting what but I'm pretty sure this is the guy who a few days ago claimed to have dated a super model, Paris Hilton, and others while a medical student (and also having time to gain extensive exposure to radiation oncology!!!)

Research year in NYC helps. I never claimed I have dated a super model also.

 

[MDACCRules]

Not sure why getting so defensive towards the radiologist.

RT *is* inelegant. It *is* a lot of collateral damage. There are lots of side effects. We have a more and more precise and accurate bludgeon. It's still a bludgeon. We used to measure dose by skin redness. Now we have diodes. Better, but clearly not that accurate as people seems to react differently to similarly measured doses. It's interesting enough work. "Cerebal-ish" (using hand air quotes). Some nice patient care. Both curative and palliative care. But fascinating? Hmm... not the word I'd describe for what is still 'work'. It's not like designing a new app or learning molecular gastronomy techniques or writing the next great American novel. But, I can't really get paid all that much to those things, since I don't have the skill or talent.

And, all of the same can be said about surgery, currently. Lots of pain, side effects, need for anesthesia, loss of function, removal of non-disease tissue, risk of surgical complications and death. I cannot envision a coherent argument about why surgery is more elegant.

And so we come to medical oncology. Targeted treatments. Immunotherapy. Vaccine. THE CURE FOR CANCER!!! (Every couple years Newsweek or Time or some garbage publication puffs some other expensive but basically ineffective treatment). Yet, barely any of it works. Well, some of it does. Like cisplatin. R-CHOP. Adriamycin and Cytoxan. But those aren't really elegant are they? These DFS improvements in metastatic and advanced cancers with whatever inhibitor or mutation dependent blah blah blah are great. But, they gotta actually cure something one of these days. And can't just sputter, "BUT .. BUT .. GLEEVEC". That's one bullet for one disease.

I'm pleased with my trusty and ever more precise and accurate bludgeon, for now.

 

[radiaterMike]

FWIW the radiation exposure from IR procedures (where radiation enters the skin and exits out the body) can be astronomical- essentially poisoning the body to get a real time image.

 

[DrfluffyMD]

Not sure why getting so defensive towards the radiologist.

RT *is* inelegant. It *is* a lot of collateral damage. There are lots of side effects. We have a more and more precise and accurate bludgeon. It's still a bludgeon. We used to measure dose by skin redness. Now we have diodes. Better, but clearly not that accurate as people seems to react differently to similarly measured doses. It's interesting enough work. "Cerebal-ish" (using hand air quotes). Some nice patient care. Both curative and palliative care. But fascinating? Hmm... not the word I'd describe for what is still 'work'. It's not like designing a new app or learning molecular gastronomy techniques or writing the next great American novel. But, I can't really get paid all that much to those things, since I don't have the skill or talent.

And, all of the same can be said about surgery, currently. Lots of pain, side effects, need for anesthesia, loss of function, removal of non-disease tissue, risk of surgical complications and death. I cannot envision a coherent argument about why surgery is more elegant.

And so we come to medical oncology. Targeted treatments. Immunotherapy. Vaccine. THE CURE FOR CANCER!!! (Every couple years Newsweek or Time or some garbage publication puffs some other expensive but basically ineffective treatment). Yet, barely any of it works. Well, some of it does. Like cisplatin. R-CHOP. Adriamycin and Cytoxan. But those aren't really elegant are they? These DFS improvements in metastatic and advanced cancers with whatever inhibitor or mutation dependent blah blah blah are great. But, they gotta actually cure something one of these days. And can't just sputter, "BUT .. BUT .. GLEEVEC". That's one bullet for one disease.

I'm pleased with my trusty and ever more precise and accurate bludgeon, for now.

I absolutely do not mean to disparage the field of radonc and I have no doubt that it will be there during my career.

I just wonder that perhaps when I need it, we will have a whole bunch of bullet like gleevec.

And like you say, thermal ablation, surgery, loco regional chemo are all bludgeons. Radiation does have its issue but it’s the least invasive we got.

 

[DrfluffyMD]

FWIW the radiation exposure from IR procedures (where radiation enters the skin and exits out the body) can be astronomical- essentially poisoning the body to get a real time image.

Indeed. Some IR procedure is essentially one fraction of RT.

 

[Haybrant]

It is true, we should not get defensive about or put down other specialties. But as Rad Oncs we know the detriment it causes to patients to make hypothetical assumptions not grounded in the reality of clinical oncology. Please tell me how you suppose lymphnode basins can be treated to 45+Gy without “poisoning” the nearby tissue (think using heat won’t?). You can’t. There is nothing physically more elegant for this and there will never be which makes RT incredible elegant and beautiful. It’s like saying quantum mechanics won’t work in the future. It’s not true. So we live with “poisoning” and causing diarrhea or esophagitis which isn’t that big a deal in the face of potential cure. Yes I’d love a therapy that targets cancer stem cells. That’s a far far way off, it may well not be possible.


I also used to think RT may be gone in the future. Now that I’ve been using it I see how that is simply not possible. If anything IR will be gone in the future when people see all the recurrences that occur from poor mans Therapy of IR. I mean look at liver - why does that **** keep coming back. It’s bc IR does a terrible job at cancer. IR should look for a different home bc oncology is not the right space for IR and IR specialists are simply not versed it. Yes even the ones that go to asco to claim IR will be the hub of oncology in the future. It won’t. If you believe it will I know you’re well meaning but you’ve been duped by your superiors

 

[medgator]

At least thermal ablation doesn’t tend to lead to DNA strand breaks and incidental future tumors, which can be an emerging issue with people living longer.

Coincidentally, thermal ablation often doesn't lead to cure in tumors as they get larger, either. Strange coincidence, huh?

 

[DrfluffyMD]

Coincidentally, thermal ablation often doesn't lead to cure in tumors as they get larger, either. Strange coincidence, huh?

This is why we shouldn’t use ablation for lesions over a certain size. I am not sure why there is so much sneering toward my field. IO is only a part of our practice and more data remains to be seen.

I can also quote the study where SBRT shows less complete response and pathological response compared to Y90, etc, but that’s not the crux of my issue. My issue is radiation vs targetted therapy and the elegance of one versus lack of in the other.

 

[Haybrant]

“My issue is radiation vs targetted therapy and the elegance of one versus lack of in the other.”


Our point is that Radiation is the most elegant targeted curative therapy. The issue at play is that you see 1% of cancer maybe 2% so you assume the same issues apply to the other 98% and it doesn’t. Tumor board would be a good place to go and get more exposure. Start with Head and Neck and see what you can offer from IR there.

 

[DrfluffyMD]

“My issue is radiation vs targetted therapy and the elegance of one versus lack of in the other.”


Our point is that Radiation is the most elegant targeted therapy. The issue at play is that you see 1% of cancer maybe 2% so you assume the same issues apply to the other 98% and it doesn’t. Tumor board would be a good place to go and get more exposure. Start with Head and Neck and see what you can offer from IR there.

We can offer a plenty. SK and China are ablating thyroid CAs with good safety profile and outcomes.

Unfortunately in the US there seem to be a lot of political forces driving utilization, referal pattern and care. I am sure you are famililar with urorads. For us the issue comes from turf wars. China also has Y90 permeated SVC stents for SVC syndrome but introduction of it in the US is difficult. Is it brachytherapy? Is it an endovascular device? Turf wars like this get into the way for patient care.

 

[Haybrant]

We can offer a plenty. SK and China are ablating thyroid CAs with good safety profile and outcomes.

Unfortunately in the US there seem to be a lot of political forces driving utilization, referal pattern and care. I am sure you are famililar with urorads. For us the issue comes from turf wars. China also has Y90 permeated SVC stents for SVC syndrome but introduction of it in the US is difficult. Is it brachytherapy? Is it an endovascular device? Turf wars like this get into the way for patient care.

Yes turf war is the only thing holding IR back. IR is ready for the prime time. Come over to head and neck tumor board I’m happy to refer you anyone you think you can do something for

 

[DrfluffyMD]

Yes turf war is the only thing holding IR back. IR is ready for the prime time. Come over to head and neck tumor board I’m happy to refer you anyone you think you can do something for

Why the sarcasm and hostility? You and I both know that in the US there aren’t many things IR can do for head and neck, which is fine. Just because we can’t do much now doesn’t mean we can’t do much in the future.

Meanwhile, why don’t you tell me some significant revolutionary changes for radonc on the horizon after proton and heavy particles or coadministration of targetted therapy?

 

[Mandelin Rain]

What are the revolutionary changes coming for IR? Smaller needles?

 

[Mandelin Rain]

Every IR guy I've ever met is extraordinarily good at treating a picture on a screen. Put the needle in the round thing. Done. Treating a cancer patient is an ever so slightly different skill set, at least in my humble opinion.

Sometimes the round things are big, or irregularly shaped, or stuck to the aorta, or has spread into many other round things. My concern of RadOnc losing all ground to IR = 0.

 

[Gfunk6]

Since we are all piling on IR, my pet peeve is that they take absolutely no ownership of patients. They do their job and leave you to deal with the crap. Prime case is IR PEG-tube insertion for H&N cancer patients undergoing definitive radiation.

Me: "What happened? The patient was discharged from the hospital without a nutrition consult and without any means to get cans for tube feeding!"

IR: "What do you want from me? You asked me to put a hole in the patient with a connecting tube and I did that. You deal with that ****."