The case for fellowship reform

[radiation]

Right now, much of the energy of this forum is being put into dissuading medical students into joining an amazing and rewarding field due to issues with job placement and geographic restrictions. I understand the sentiment, it is rooted in good intention, but I do think it is really only focusing on the supply side of supply/demand economics (and ignores other fundamental issues in the field).

Fellowships on this board have been lambasted in the past, with good reason. Most do not add anything beyond what a normal training program should be preparing residents to do as they currently only focus on areas that are already commonly used in the general rad onc practice (SRS, SBRT, palliative care). However, to me, it would be much easier to enact fellowship reform vs. coordinated residency contraction, and would be a better long-term investment in the field. This is something the large centers making decisions can more easily acquiesce to, helps them, and doesn’t force a huge amount of restructuring. Like many posters have already pointed out, the job market is distressed NOW, so any residency program adjustments will take 5 years to see changes.

What we really need are fellowships that allow expert utilization of an underutilized radiation modality. This would be beneficial in a number of ways: 1) it would decrease the glut of applicants competing in the same job markets 2) potentially increase overall utilization of radiation therapy services. We should really have bona-fide board-certified fellowships in the following areas:

• Radiopharmaceuticals/Nuc med – this is the big one to me. For the life of me I can’t understand why we basically gave away a huge modality. Y90 and I131 is basically the domain of nuc meds and endocrinologists (and even only IR in some states). We now have 2 new agents that prolong OS for multiple cancers (Radium and Lu). There are more coming. There is basically zero advocacy on trying to keep this a rad onc modality because it reimburses poorly. This is a self-fulfilling prophecy though because the billing is tied to the advocacy behind it. When you are able to really put the weight of lobbying and specialty advocacy around a life-prolonging treatment, the billing can be tremendous (see CART cells, Novocure). Most residents get very poor training in this, and a fellowship is certainly justifiable
• Brachytherapy – brachy use is going down to the detriment of the field. Time and time again we show that you cant replace brachy with external beam A Phase II Trial of Stereotactic Ablative Radiotherapy as a Boost for Locally Advanced Cervical Cancer. - PubMed - NCBI . Brachy is going to become much, much more attractive once bundled payments hits. We should be embracing this and pumping out as many brachytherapists as possible.
• Cardiac SABR – this is a niche field right now with really only a handful places doing it with any real rigor. WashU is really doing a huge favor to the field by making cardiology equal partners in this and doing rigorous prospective trials. This is a potential gamechanger if we can get enough centers doing this.
• Peds – for obvious reasons

Obviously, it doesn’t need to be said but I’ll say it anyway: SRS/SBRT fellowships should be abolished. Palliative fellowships should only be true board-certified ones and not just the inpatient rad onc service (integrated and equivalent to standard palliative care fellowships).

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[Mandelin Rain]

There is plenty of time in 4 years to teach all of this in residency. What rad onc should do, is adequately teach all the clinical aspects of radiation oncology to everyone and do research fellowships for those interested after. Makes much more sense. Get rid of the worthless (for most) 6-12 months of “protected” time and teach the specialty.

If your program isn’t doing enough brachy, it gets cut. No radiopharmacueticals? Cut. Etc, etc, etc...

 

[radiation]

There is plenty of time in 4 years to teach all of this in residency. What rad onc should do, is adequately teach all the clinical aspects of radiation oncology to everyone and do research fellowships for those interested after. Makes much more sense. Get rid of the worthless (for most) 6-12 months of “protected” time and teach the specialty.

I think a lot of these modalities are heavily institution dependent and it would be very hard for most places to train residents to independently practice in these areas. Brachy I agree with, but its just not happening right now. There is basically only a handful of places doing cardiac SABR.

I understand where you are coming from with wanting to cut residency programs and in a perfect world maybe that would be ideal thing. But is it really feasible to do so in this environment? I don't think shutting down more than a handful of places is likely to be realistic. The solution of "just make the all the existing residency programs better" is admirable, but I don't know how actionable that is.

 

[Mandelin Rain]

I’m sorry, but if a place doesn’t have brachy volume to train residents, they shouldn’t train residents. This in no way should be a controversial statement. RRC, your move.

 

[Mandelin Rain]

I’ve never done cardiac SABR, but it strikes me as a one week course you take in Scottsdale during February rather than a year long fellowship.

 

[Mandelin Rain]

General surgery residency: we don’t really do any lap appys or choles but we do put a lot of ports in and remove a lot of lipomas.

ummmm.... no.

 

[RickyScott]

Right now, much of the energy of this forum is being put into dissuading medical students into joining an amazing and rewarding field due to issues with job placement and geographic restrictions. I understand the sentiment, it is rooted in good intention, but I do think it is really only focusing on the supply side of supply/demand economics (and ignores other fundamental issues in the field).

Fellowships on this board have been lambasted in the past, with good reason. Most do not add anything beyond what a normal training program should be preparing residents to do as they currently only focus on areas that are already commonly used in the general rad onc practice (SRS, SBRT, palliative care). However, to me, it would be much easier to enact fellowship reform vs. coordinated residency contraction, and would be a better long-term investment in the field. This is something the large centers making decisions can more easily acquiesce to, helps them, and doesn’t force a huge amount of restructuring. Like many posters have already pointed out, the job market is distressed NOW, so any residency program adjustments will take 5 years to see changes.

What we really need are fellowships that allow expert utilization of an underutilized radiation modality. This would be beneficial in a number of ways: 1) it would decrease the glut of applicants competing in the same job markets 2) potentially increase overall utilization of radiation therapy services. We should really have bona-fide board-certified fellowships in the following areas:

• Radiopharmaceuticals/Nuc med – this is the big one to me. For the life of me I can’t understand why we basically gave away a huge modality. Y90 and I131 is basically the domain of nuc meds and endocrinologists (and even only IR in some states). We now have 2 new agents that prolong OS for multiple cancers (Radium and Lu). There are more coming. There is basically zero advocacy on trying to keep this a rad onc modality because it reimburses poorly. This is a self-fulfilling prophecy though because the billing is tied to the advocacy behind it. When you are able to really put the weight of lobbying and specialty advocacy around a life-prolonging treatment, the billing can be tremendous (see CART cells, Novocure). Most residents get very poor training in this, and a fellowship is certainly justifiable
• Brachytherapy – brachy use is going down to the detriment of the field. Time and time again we show that you cant replace brachy with external beam A Phase II Trial of Stereotactic Ablative Radiotherapy as a Boost for Locally Advanced Cervical Cancer. - PubMed - NCBI . Brachy is going to become much, much more attractive once bundled payments hits. We should be embracing this and pumping out as many brachytherapists as possible.
• Cardiac SABR – this is a niche field right now with really only a handful places doing it with any real rigor. WashU is really doing a huge favor to the field by making cardiology equal partners in this and doing rigorous prospective trials. This is a potential gamechanger if we can get enough centers doing this.
• Peds – for obvious reasons

None of this would put dent in job market. Cardiac sbrt is not technically difficult btw I am not sure it would require a one week course. Hahn, wallner , zeitman took up this false argument about fellowships that would train radoncs to put in space oar and other rediculuous Crap that will have less than minimal impact on job supply. Only thing that can expand need substantially is training in medonc , which according to them is just not going to happen despite Hahn being a medonc

I get the feeling zeitman knows we are heading for catastrophw given some of his writing over the past 5 years.

 

[goodkerma]

For those who wouldn't mind a year of fellowship to give concurrent chemo and immunotherapy, this should be an option - this would also lessen the load on medical oncology in many hospital systems. At least at hospitals I staff, there is chronic understaffing of medical oncologists and turn over- which requires us to constantly push for medical oncology to have patient started appropriately with RT.

 

[bluebubbles]

I would personally be willing to do a 1- or even 2-year fellowship if it allowed me to give a significant proportion of systemic therapies (e.g. concurrent chemotherapy and/or immunotherapy, or oral agents for stage IV disease). A medical oncology fellowship is only 1 year for IM graduates, FWIW.

@radiation's argument is well-taken; we should certainly be maximizing our exposure to radiopharmaceuticals, brachytherapy, and cardiac SBRT in residency, and then pushing our involvement with these modalities as attendings. Are separate fellowships required? Probably not. For example, brachytherapy is an integral part of any resident's rotation through GU, gyn, and possibly breast; creating brachytherapy fellowships just tacitly exonerates residency programs from providing proper brachytherapy training.

Fellowships just rearrange the deck chairs on the Titanic. It may reduce the # of trainees looking for jobs one year, only to increase it the next year.

Yes, it's harder to coordinate residency contraction. It's harder to create a systemic therapy fellowship (vs. a zero value-add brachytherapy fellowship). That's what leaders are supposed to do. Hard things.

 

[medgator]

I would personally be willing to do a 1- or even 2-year fellowship if it allowed me to give a significant proportion of systemic therapies (e.g. concurrent chemotherapy and/or immunotherapy, or oral agents for stage IV disease). A medical oncology fellowship is only 1 year for IM graduates, FWIW.

I thought it was 2 years for med onc and 3 years for heme/onc? Granted much of that second year is probably more research oriented

 

[thecarbonionangle]

Ya the most significant thing we can do is work on a systemic agent pathway. If freaking NEUROLOGIST (think about this, the guy who calls things “interesting”) can learn to give PCV/TMZ/TKIs etc we should be able to get a pathway.

 

[PhotonBomb]

Ya the most significant thing we can do is work on a systemic agent pathway. If freaking NEUROLOGIST (think about this, the guy who calls things “interesting”) can learn to give PCV/TMZ/TKIs etc we should be able to get a pathway.

be careful what you wish for.

I for one am thankful I have nothing to do with prescribing chemo or IO and following all the labs, managing the irAEs, admitting patients and having an inpatient service, etc.

Med oncs have entire set-ups of PAs and extenders to allow them to manage this. The infrastructure matters.

 

[medgator]

be careful what you wish for.

I for one am thankful I have nothing to do with prescribing chemo or IO and following all the labs, managing the irAEs, admitting patients and having an inpatient service, etc.

Med oncs have entire set-ups of PAs and extenders to allow them to manage this. The infrastructure matters.

It would work for certain unique situations, otherwise I completely agree with you.

Best approach is to get our own house in order.

I reverse refer a fair amount of concurrent chemo pts out to med onc, mainly h&n and occasional lung.

Last thing I am interested in is competing with a referral source

 

[goodkerma]

It really just depends on your practice set up, for example for salaried medoncs at academic institutions, many of them would be happy to not have to overbook their clinic to prescribe my patient xeloda. Also, the medonc group I work with has it well figured out- they each take 2 months of inpatient duty a year. When you cover the hospital you take care of any of the admitted patients for the group and your clinic is covered by someone else, on the flip side outside of those two months- you never step foot on the wards. Again, not suggesting that radiation oncologists should become like clinical oncologists in Europe, but for those that want to prescribe cisplatin for their H&N patients or durva after CRT for their lung patients.. I think it's reasonable.

We have an image problem in our field that we also have to fix, have to get a little dirty for our colleagues to respect us.

Many more interesting words from medical oncology about radonc in this paper... https://www.practicalradonc.org/article/S1879-8500(19)30102-X/fulltext

 

[thecarbonionangle]

I mean it would work just like neuro-onc fellowship. The neurologists who want to do it, do it, the ones that want to continue to consult on a patient and write a 2 hour note with final recommendations stating nothing to do but patient is certainly interesting, do stay away. nobody is going to force people to do it, but I don't see how it would be bad to allow people to expand their spectrum.

 

[PhotonBomb]

Its not bad I just think it’s something most people choosing rad onc aren’t going to want to do. And I don’t think it solves any problems.

 

[FrostyHammer]

be careful what you wish for.

I for one am thankful I have nothing to do with prescribing chemo or IO and following all the labs, managing the irAEs, admitting patients and having an inpatient service, etc.

Med oncs have entire set-ups of PAs and extenders to allow them to manage this. The infrastructure matters.

This. Spot on. Med onc circles don't really focus on the good things about med onc but rather fixate on the bad things (i.e. weekends, evenings/nights, etc). Sound familiar, SDN rad onc?

 

[medgator]

This. Spot on. Med onc circles don't really focus on the good things about med onc but rather fixate on the bad things (i.e. weekends, evenings/nights, etc). Sound familiar, SDN rad onc?

Fwiw, 1/5-6 weekends of call isn't bad, esp when you're finishing the office every Fri at noon. Happens with a larger group I work with.

Not ideal, but I'd do that any day if it meant getting a job in my preferred geographic region

 

[deleted18755]

I've been out of residency for awhile, can somebody clarify:

I thought out of the 4 years of radiation oncology residency a solid 6 months, if not full 12 months, is for "research." Is this true, and if so dies it have to be "research" or can it be "elective" where one uses those extra 6 to 12 months for additional clinical work (either at the home institution or elsewhere)? If so, isn't there a "fellowship" already built into every (or most or many?) residencies?

If I were a resident and had the option of 6-12 months of "research" or elective I'd sure as hell use it as an unofficial fellowship to brush up on whatever it was I felt was lacking clinically or for something like prostate HDR or perhaps even some of the ideas listed above to differentiate me from the pack when looking for a job.

Who do you think is more employable in 4-5 years: I a guy who spent 12 months doing a retrospective review or two that led to a poster at ASTRO (or maybe even 1-2 first author papers) or a guy who spent 12 months perfecting his brachy skills and is more than ready to perform prostate HDR or even open/develop a program right when bundled payments will be taking full effect!?!

 

[elementaryschooleconomics]

I've been out of residency for awhile, can somebody clarify:

I thought out of the 4 years of radiation oncology residency a solid 6 months, if not full 12 months, is for "research." Is this true, and if so dies it have to be "research" or can it be "elective" where one uses those extra 6 to 12 months for additional clinical work (either at the home institution or elsewhere)? If so, isn't there a "fellowship" already built into every (or most or many?) residencies?

If I were a resident and had the option of 6-12 months of "research" or elective I'd sure as hell use it as an unofficial fellowship to brush up on whatever it was I felt was lacking clinically or for something like prostate HDR or perhaps even some of the ideas listed above to differentiate me from the pack when looking for a job.

Who do you think is more employable in 4-5 years: I a guy who spent 12 months doing a retrospective review or two that led to a poster at ASTRO (or maybe even 1-2 first author papers) or a guy who spent 12 months perfecting his brachy skills and is more than ready to perform prostate HDR or even open/develop a program right when bundled payments will be taking full effect!?!

You're correct - it seems like many institutions treat it as true "elective time", and additional clinical training could be done. I've seen this format in surgical residencies. A few issues with the current system, though:

1) If you were to go outside your home institution for any length of time, I imagine there'd be the issue of who's paying the resident and/or who's getting the GME money
2) If you were to stay at your home institution, you're limited by what's available (obviously, can't brush up on prostate brachy if your home program doesn't do it)
3) After the 2018 ABR debacle, I know many residents dedicated 6+ months to studying for radbio/physics. I imagine that will happen again this year and likely for a few years to come. It doesn't matter how much you published or how skilled you are in brachy if you can't pass boards, and the ABR has many people spooked
4) How are you going to sell this on your CV?

I think, in terms of objective training for the resident, it's a great idea. I just don't know if the current system can accommodate the practical issues.

 

[deleted18755]

You're correct - it seems like many institutions treat it as true "elective time", and additional clinical training could be done. I've seen this format in surgical residencies. A few issues with the current system, though:

1) If you were to go outside your home institution for any length of time, I imagine there'd be the issue of who's paying the resident and/or who's getting the GME money
2) If you were to stay at your home institution, you're limited by what's available (obviously, can't brush up on prostate brachy if your home program doesn't do it)
3) After the 2018 ABR debacle, I know many residents dedicated 6+ months to studying for radbio/physics. I imagine that will happen again this year and likely for a few years to come. It doesn't matter how much you published or how skilled you are in brachy if you can't pass boards, and the ABR has many people spooked
4) How are you going to sell this on your CV?

I think, in terms of objective training for the resident, it's a great idea. I just don't know if the current system can accommodate the practical issues.

I just threw the prostate HDR brachytherapy out there since not too long ago I had a friend who had to compete with a urorads and so was recruiting somebody with interest and skills in prostate cancer, which clinically at least of course includes brachytherapy and especially HDR now. He advertised the position as general with emphasis on prostate and was first surprised that so many residents, even the ones applying for a prostate heavy job and had interest in GU, were not totally comfortable with LDR let alone HDR brachytherapy, but then was shocked that graduating residents seemed to think that anybody in the "real world" gave a crap about the retrospective reviews and other low level prostate research the residents were so proud of on their CV as if that is more important and marketable than actual clinical skills, especially a newer modality that is highly sought after.

Now that the payment reform/bundled payments are on the horizon I can really see a graduate with excellent skills in prostate brachytherapy (of course LDR but especially HDR since most who have been out of residency for awhile never learned it) being highly sought after, or at least more so than a graduate did prostate cancer "research."

If I were a resident I would definitely spend 6-12 months focusing on being highly proficient in something that has a clinical need vs a retrospective review or two (or maybe even higher quality research since it seems like the funding just isn't there to take it to the next level or even the true academic jobs).

 

[PleaseRemainCalm]

I just threw the prostate HDR brachytherapy out there since not too long ago I had a friend who had to compete with a urorads and so was recruiting somebody with interest and skills in prostate cancer, which clinically at least of course includes brachytherapy and especially HDR now. He advertised the position as general with emphasis on prostate and was first surprised that so many residents, even the ones applying for a prostate heavy job and had interest in GU, were not totally comfortable with LDR let alone HDR brachytherapy, but then was shocked that graduating residents seemed to think that anybody in the "real world" gave a crap about the retrospective reviews and other low level prostate research the residents were so proud of on their CV as if that is more important and marketable than actual clinical skills, especially a newer modality that is highly sought after.

Now that the payment reform/bundled payments are on the horizon I can really see a graduate with excellent skills in prostate brachytherapy (of course LDR but especially HDR since most who have been out of residency for awhile never learned it) being highly sought after, or at least more so than a graduate did prostate cancer "research."

If I were a resident I would definitely spend 6-12 months focusing on being highly proficient in something that has a clinical need vs a retrospective review or two (or maybe even higher quality research since it seems like the funding just isn't there to take it to the next level or even the true academic jobs).

Not every residency is going to make it easy to go somewhere else during this 6 to 12 months. In some places this resident still has clinic, call, or other responsibilities.

 

[deleted18755]

Not every residency is going to make it easy to go somewhere else during this 6 to 12 months. In some places this resident still has clinic, call, or other responsibilities.

Maybe now that the ball is in your court you guys can push for things like this?

 

[Mandelin Rain]

If those 6-12 months are actually “protected” who really cares where they’re at or what they’re doing as long as it’s productive for their career goals?

 

[RadOncMegatron]

I just threw the prostate HDR brachytherapy out there since not too long ago I had a friend who had to compete with a urorads and so was recruiting somebody with interest and skills in prostate cancer, which clinically at least of course includes brachytherapy and especially HDR now. He advertised the position as general with emphasis on prostate and was first surprised that so many residents, even the ones applying for a prostate heavy job and had interest in GU, were not totally comfortable with LDR let alone HDR brachytherapy, but then was shocked that graduating residents seemed to think that anybody in the "real world" gave a crap about the retrospective reviews and other low level prostate research the residents were so proud of on their CV as if that is more important and marketable than actual clinical skills, especially a newer modality that is highly sought after.

Now that the payment reform/bundled payments are on the horizon I can really see a graduate with excellent skills in prostate brachytherapy (of course LDR but especially HDR since most who have been out of residency for awhile never learned it) being highly sought after, or at least more so than a graduate did prostate cancer "research."

If I were a resident I would definitely spend 6-12 months focusing on being highly proficient in something that has a clinical need vs a retrospective review or two (or maybe even higher quality research since it seems like the funding just isn't there to take it to the next level or even the true academic jobs).

If there ever was a scheme from the pits of academic hell it would be that retrospective reviews are given so much time and effort. The bottom level of hell is reserved for NCDB and SEER analyses. [Caveat: Rare diseases are an exception where data could not otherwise be had].

I myself am trying to purge myself from the need to publish or perish and the need to accumulate "expertise" with retrospective publications. It is so hard. From a game theory prospective, it is not a successful strategy to be the first or only one who does not publish this crap at least once a year or so. I digress... but I am still considered an expert right?

 

[thecarbonionangle]

If there ever was a scheme from the pits of academic hell it would be that retrospective reviews are given so much time and effort. The bottom level of hell is reserved for NCDB and SEER analyses. [Caveat: Rare diseases are an exception where data could not otherwise be had].

I myself am trying to purge myself from the need to publish or perish and the need to accumulate "expertise" with retrospective publications. It is so hard. From a game theory prospective, it is not a successful strategy to be the first or only one who does not publish this crap at least once a year or so. I digress... but I am still considered an expert right?

Dante’s rad onc inferno basically. I like the thought exercise. The entrance would still read “abandon all hope, all ye who enter here”

 

[evilbooyaa]

If there ever was a scheme from the pits of academic hell it would be that retrospective reviews are given so much time and effort. The bottom level of hell is reserved for NCDB and SEER analyses. [Caveat: Rare diseases are an exception where data could not otherwise be had].

I myself am trying to purge myself from the need to publish or perish and the need to accumulate "expertise" with retrospective publications. It is so hard. From a game theory prospective, it is not a successful strategy to be the first or only one who does not publish this crap at least once a year or so. I digress... but I am still considered an expert right?

Phew! That's all my research is!

And yes, it's tough to do something more than retrospective research as a resident unless you go to a place that has great infrastructure for clinical trials, or you can write up your attendings' clinical trial results.

Academic attendings - be doing clinical trials, for your benefit and that of your residents!

 

[RickyScott]

Many years at astro, one of physicists from Wisconsin presented data on accuracy of retrospective research predicting later phase 3 trials,and they were not anymore accurate than chance.

 

[evilbooyaa]

Many years at astro, one of physicists from Wisconsin presented data on accuracy of retrospective research predicting later phase 3 trials,and they were not anymore accurate than chance.

Recent paper in JCO saying NCDB/SEER analyses concordance with clinical trial data is similar to a coinflip: https://ascopubs.org/doi/10.1200/JCO.18.01074 This has mostly soured me from doing additional database analyses in the future, although I was never one who challenged clinical trial results with NCDB/SEER.

I think the people that attempt to refute clinical trials with database analyses are some of the biggest fools out there, and doubly so if anybody is still trying it (I'm sure somebody is given the easy access) after this JCO paper.

 

[RadOncMegatron]

Recent paper in JCO saying NCDB/SEER analyses concordance with clinical trial data is similar to a coinflip: https://ascopubs.org/doi/10.1200/JCO.18.01074 This has mostly soured me from doing additional database analyses in the future, although I was never one who challenged clinical trial results with NCDB/SEER.

I think the people that attempt to refute clinical trials with database analyses are some of the biggest fools out there, and doubly so if anybody is still trying it (I'm sure somebody is given the easy access) after this JCO paper.

That is a mighty fine paper, but it really points us to the rot of the state of science in medicine. It really is a no brainer that these database studies are so flawed that of course they don't correspond with RCT data (important paper nonetheless). This is published in JCO who will hopefully no longer accept any more NCDB and SEER analyses (except for rare diseases or things of that nature).

 

[Aphtalyfe]

I've been out of residency for awhile, can somebody clarify:

I thought out of the 4 years of radiation oncology residency a solid 6 months, if not full 12 months, is for "research." Is this true, and if so dies it have to be "research" or can it be "elective" where one uses those extra 6 to 12 months for additional clinical work (either at the home institution or elsewhere)? If so, isn't there a "fellowship" already built into every (or most or many?) residencies?

If I were a resident and had the option of 6-12 months of "research" or elective I'd sure as hell use it as an unofficial fellowship to brush up on whatever it was I felt was lacking clinically or for something like prostate HDR or perhaps even some of the ideas listed above to differentiate me from the pack when looking for a job.

Who do you think is more employable in 4-5 years: I a guy who spent 12 months doing a retrospective review or two that led to a poster at ASTRO (or maybe even 1-2 first author papers) or a guy who spent 12 months perfecting his brachy skills and is more than ready to perform prostate HDR or even open/develop a program right when bundled payments will be taking full effect!?!

You're correct - it seems like many institutions treat it as true "elective time", and additional clinical training could be done. I've seen this format in surgical residencies. A few issues with the current system, though:

1) If you were to go outside your home institution for any length of time, I imagine there'd be the issue of who's paying the resident and/or who's getting the GME money
2) If you were to stay at your home institution, you're limited by what's available (obviously, can't brush up on prostate brachy if your home program doesn't do it)
3) After the 2018 ABR debacle, I know many residents dedicated 6+ months to studying for radbio/physics. I imagine that will happen again this year and likely for a few years to come. It doesn't matter how much you published or how skilled you are in brachy if you can't pass boards, and the ABR has many people spooked
4) How are you going to sell this on your CV?

I think, in terms of objective training for the resident, it's a great idea. I just don't know if the current system can accommodate the practical issues.

Not every residency is going to make it easy to go somewhere else during this 6 to 12 months. In some places this resident still has clinic, call, or other responsibilities.

If those 6-12 months are actually “protected” who really cares where they’re at or what they’re doing as long as it’s productive for their career goals?

We're definitely going to have a residency spot contraction in the coming years... that makes residents even less likely to be able to go outside their institution for "fellowship" training.

A few issues I've seen with people trying to go outside of their institution for brachy training:
1. Residents on research typically still do some clinical work (like PleaseRemainCalm mentioned)
2. Who is paying the "fellowship" institution for training the resident? Or are they expected to do it for free?
3. Many places with high volume brachytherapy practices already have residents (or fellows) on service... are there enough cases to go around?

Also wanted to mention that ABS is trying to train more brachytherapists via 3 month mini-fellowships. The first one just opened (LDR though) and probably more to come.

 

[theradiator]

I've been out of residency for awhile, can somebody clarify:

I thought out of the 4 years of radiation oncology residency a solid 6 months, if not full 12 months, is for "research." Is this true, and if so dies it have to be "research" or can it be "elective" where one uses those extra 6 to 12 months for additional clinical work (either at the home institution or elsewhere)? If so, isn't there a "fellowship" already built into every (or most or many?) residencies?

If I were a resident and had the option of 6-12 months of "research" or elective I'd sure as hell use it as an unofficial fellowship to brush up on whatever it was I felt was lacking clinically or for something like prostate HDR or perhaps even some of the ideas listed above to differentiate me from the pack when looking for a job.

Who do you think is more employable in 4-5 years: I a guy who spent 12 months doing a retrospective review or two that led to a poster at ASTRO (or maybe even 1-2 first author papers) or a guy who spent 12 months perfecting his brachy skills and is more than ready to perform prostate HDR or even open/develop a program right when bundled payments will be taking full effect!?!

Sadly the real answer is both will end up on the proverbial bread line.

 

[RickyScott]

Sadly the real answer is both will end up on the proverbial bread line.

Just an opinion, but this what my gut tells me. Brachy outside of gyn is likely to be dead. Seen enough stereo prostate that small fistula risks of brachy just aren’t worth it and stereo prostate is technically very simple. I would not advise residents to focus on brachy.

 

[OTN]

Just an opinion, but this what my gut tells me. Brachy outside of gyn is likely to be dead. Seen enough stereo prostate that small fistula risks of brachy just aren’t worth it and stereo prostate is technically very simple. I would not advise residents to focus on brachy.

I do a decent amount of HDR brachy for skin and breast, but agree that without an OS benefit (and with a massive urorads group taking most of the prostate ca in town), I’m not going to run out and start an HDR prostate program.

 

[tomhobbes]

Dear colleagues,

Columbia PGY5 here. I completed the new ABS 3-month LDR prostate program at the Chicago Prostate Cancer Center with Dr. Brian Moran during my home program’s elective/research time this Fall. My PD and program coordinator graciously coordinated the logistics with GME so that I could work with Dr. Moran as a resident.

The ABS 3-month fellowship is a phenomenal program for anybody interested in the procedural aspect of GU. In my 10.5 weeks there (I missed over a week between ASTRO in September and job interviews) I did 130 procedures. Dr. Moran made sure that I got my hands on every OR case and every outpatient pre-plan volume study. The vast majority of OR cases were LDR implants for all prostate cancer risk stages, with ~dozen transperineal biopsies as well for initial diagnosis or evaluation for recurrent disease. The volume is high and the training hands-on. Typical OR days, usually 3 days a week, included three to five one-hour cases in the mornings from 7 or 8 AM till noon. This was concurrent with a full outpatient clinic of consults, volume studies and follow ups, with everything wrapping up daily by 3-4 PM. Regular outpatient clinic on non-OR days.

I estimate that I saw a similar number of consults as I did implants, as well as over 500 follow ups. I mention the number of follow ups because I felt that it was an important part of my training – I wanted to see the full-spectrum of sequelae from months to years after treatment. Not once did I see GI issues in any brachytherapy monotherapy follow-up (no spacer used). GI toxicity following beam and brachy was no different from what I had seen in conventionally fractionated external beam courses. GU toxicities by and large limited to G1-2 frequency returning to baseline within 2-8 weeks. No retention requiring cath. It was a highly educational training experience at a high-volume center of excellence.

WRT to an earlier thread “Prostate biopsy and Rad Onc”, I think it’s feasible and fairly straightforward to do our own transperineal mapping or MRI guided biopsies with the template grid to delineate target for boost or focal therapy. Each core from each coordinate goes to path in a marked container. The benefit of good path mapping and low risk of infection comes at the cost of sedation (although I think many men would prefer the general anesthesia to the typical conscious transrectal biopsy approach).

OTN and RickyScott – I can’t predict where brachy is going. We do have good early ultra-hypofractionated results in HYPO-RT and PACE, along with a large body of non-randomized data. A lot of our patients opt for prostate SBRT. That being said (in my limited experience), the potential for dose-escalation with brachytherapy is bar none. It’s possible to contour a DIL or partial hemigland and easily cover that volume with 150% prescription dose, with low toxicity risk, with an implant. I’m not sure we can achieve that level of escalation with an external beam approach. Now whether this is clinical necessary is unclear and a separate issue.

Another benefit to brachy is the potential for reduced time on ADT in UIR and HR compared to an external beam only approach. Most men have less of a problem with EBRT, brachy or even surgery, than they do with ADT. This potential advantage is not often discussed.

The logistics of LDR implant, compared with 5 fx SBRT, may be a toss-up. A fair proportion of men who went to the Chicago Prostate Cancer Center for LDR brachytherapy did not want to make multiple visits (if brachytherapy monotherapy was an option). Those men went to the center twice: once for consult and volume study, and then a second visit ~2 weeks later for the implant. The implant visit was typically 3.5-4 hours from when they walked in to when they walked out (without a foley). ~40 min under anesthesia, 20 minute implant. The rest was pre-op prep and post-op recovery. It was a very streamlined process. Right now HDR monotherapy for prostate cancer is at minimum a two-fraction affair.

In sum, would strongly recommend the ABS 3-month LDR program to residents who are interested in the skillset and can work it into their training. Happy to answer any questions about my experience there.

Mark

 

[theradiator]

Beautiful post. It does sound like an excellent education experience and you clearly have passion and motivation but...

Doesn't this vignette prove the main premise of this thread? You train at one of the most famous hospitals in the world that is located in a 20+ million population metropolitan area. Columbia is one of the top ranked US News and World Report hospitals, NCI designated comprehensive cancer center and proudly runs an Advanced Radiation Oncology Clinical Fellowship. Yet you had to make special arrangements to receive prostate brachytherapy training in suburban Chicago.

 

[evilbooyaa]

I would strongly consider the 3-month experience if it was offered as an elective during residency. I do not have any interest in delaying attending salary for 3 months to go to it. Also, I personally believe HDR prostate is the future rather than LDR.

While it's obviously a great educational experience, the concern in the post immediately above mine is well taken. That being said, I imagine there's not a ton of places doing 130 prostate seeds over a 3 month period, and this would be a valuable educational experience for a resident from most (if not all) programs looking for focused LDR brachytherapy experience.

 

[thecarbonionangle]

Beautiful post. It does sound like an excellent education experience and you clearly have passion and motivation but...

Doesn't this vignette prove the main premise of this thread? You train at one of the most famous hospitals in the world that is located in a 20+ million population metropolitan area. Columbia is one of the top ranked US News and World Report hospitals, NCI designated comprehensive cancer center and proudly runs an Advanced Radiation Oncology Clinical Fellowship. Yet you had to make special arrangements to receive prostate brachytherapy training in suburban Chicago.

we all just get a pee break because my brotha just hit BINGO.

 

[thecarbonionangle]

I would strongly consider the 3-month experience if it was offered as an elective during residency. I do not have any interest in delaying attending salary for 3 months to go to it. Also, I personally believe HDR prostate is the future rather than LDR.

While it's obviously a great educational experience, the concern in the post immediately above mine is well taken. That being said, I imagine there's not a ton of places doing 130 prostate seeds over a 3 month period, and this would be a valuable educational experience for a resident from most (if not all) programs looking for focused LDR brachytherapy experience.

also a lot of departments would never support their warm body leaving for 3 months to get an education. CRAZY IDEA folks.

 

[fiji128]

Dr. Moran probably does more prostate brachy then anyone else in the world (or at least close to it). I've observed him performing brachy at his place in the Chicago suburbs while I was a resident. The difference between his skill level and that of the place where I trained was like watching a junior high school student in wood shop versus a master craftsman.

 

[PhotonBomb]

Dr. Moran probably does more prostate brachy then anyone else in the world (or at least close to it). I've observed him performing brachy at his place in the Chicago suburbs while I was a resident. The difference between his skill level and that of the place where I trained was like watching a junior high school student in wood shop versus a master craftsman.

yep, no doubt about it. especially for prostate brachy, expertise matters.

SBRT is nice for prostate because expertise really doesn't matter that much, most people can do it.

 

[RadOncDoc21]

yep, no doubt about it. especially for prostate brachy, expertise matters.

SBRT is nice for prostate because expertise really doesn't matter that much, most people can do it.

And more convenient for both the doc and patient. I’m not saying I want prostate cancer but if I had it, this would be my treatment preference based on my experience.

 

[goodkerma]

HDR prostate is very forgiving and a good option for those who may only treat a few patients a month rather than on a weekly basis and already have an afterloader. 19Gy x 1 obviously wasn't enough for monotherapy - but I am sure the hype will be back when the correct dose is used. Data is good for 1fx HDR when used as a boost. SBRT is getting very good- but what you see is not always what you get... when your catheters are physically in the prostate you can be confident the dose is going where it should be- and there is something to be said about brachy heterogeneity- those 200% IDLs right around the catheters are probably doing something on a biological level.

 

[scarbrtj]

Dear colleagues,

Columbia PGY5 here. I completed the new ABS 3-month LDR prostate program at the Chicago Prostate Cancer Center with Dr. Brian Moran during my home program’s elective/research time this Fall. My PD and program coordinator graciously coordinated the logistics with GME so that I could work with Dr. Moran as a resident.

The ABS 3-month fellowship is a phenomenal program for anybody interested in the procedural aspect of GU. In my 10.5 weeks there (I missed over a week between ASTRO in September and job interviews) I did 130 procedures. Dr. Moran made sure that I got my hands on every OR case and every outpatient pre-plan volume study. The vast majority of OR cases were LDR implants for all prostate cancer risk stages, with ~dozen transperineal biopsies as well for initial diagnosis or evaluation for recurrent disease. The volume is high and the training hands-on. Typical OR days, usually 3 days a week, included three to five one-hour cases in the mornings from 7 or 8 AM till noon. This was concurrent with a full outpatient clinic of consults, volume studies and follow ups, with everything wrapping up daily by 3-4 PM. Regular outpatient clinic on non-OR days.

I estimate that I saw a similar number of consults as I did implants, as well as over 500 follow ups. I mention the number of follow ups because I felt that it was an important part of my training – I wanted to see the full-spectrum of sequelae from months to years after treatment. Not once did I see GI issues in any brachytherapy monotherapy follow-up (no spacer used). GI toxicity following beam and brachy was no different from what I had seen in conventionally fractionated external beam courses. GU toxicities by and large limited to G1-2 frequency returning to baseline within 2-8 weeks. No retention requiring cath. It was a highly educational training experience at a high-volume center of excellence.

WRT to an earlier thread “Prostate biopsy and Rad Onc”, I think it’s feasible and fairly straightforward to do our own transperineal mapping or MRI guided biopsies with the template grid to delineate target for boost or focal therapy. Each core from each coordinate goes to path in a marked container. The benefit of good path mapping and low risk of infection comes at the cost of sedation (although I think many men would prefer the general anesthesia to the typical conscious transrectal biopsy approach).

OTN and RickyScott – I can’t predict where brachy is going. We do have good early ultra-hypofractionated results in HYPO-RT and PACE, along with a large body of non-randomized data. A lot of our patients opt for prostate SBRT. That being said (in my limited experience), the potential for dose-escalation with brachytherapy is bar none. It’s possible to contour a DIL or partial hemigland and easily cover that volume with 150% prescription dose, with low toxicity risk, with an implant. I’m not sure we can achieve that level of escalation with an external beam approach. Now whether this is clinical necessary is unclear and a separate issue.

Another benefit to brachy is the potential for reduced time on ADT in UIR and HR compared to an external beam only approach. Most men have less of a problem with EBRT, brachy or even surgery, than they do with ADT. This potential advantage is not often discussed.

The logistics of LDR implant, compared with 5 fx SBRT, may be a toss-up. A fair proportion of men who went to the Chicago Prostate Cancer Center for LDR brachytherapy did not want to make multiple visits (if brachytherapy monotherapy was an option). Those men went to the center twice: once for consult and volume study, and then a second visit ~2 weeks later for the implant. The implant visit was typically 3.5-4 hours from when they walked in to when they walked out (without a foley). ~40 min under anesthesia, 20 minute implant. The rest was pre-op prep and post-op recovery. It was a very streamlined process. Right now HDR monotherapy for prostate cancer is at minimum a two-fraction affair.

In sum, would strongly recommend the ABS 3-month LDR program to residents who are interested in the skillset and can work it into their training. Happy to answer any questions about my experience there.

Mark

You have to give Moran credit; sounds like he's optimized/streamlined LDR in a way few have (one key I'm sure is his urologist connections which many of us struggle with). I felt similarly excited about LDR on completing training, although I hadn't had the breadth/depth of LDR you have. But, still, I had done a fair amount of LDR. Suffice it to say life comes at you hard. Evidently it comes at us all hard, everywhere (Australian data showing rapid decline in #brachytherapy for #ProstateCancer, mimics other international data suggesting a very niche future role). Whether it's urologist shenanigans, seed delivery delay, reimbursement, having a seed stuck in a catheter, ~one out of ~twenty "weird" post-implant studies, urinary bother months after the procedure in one or two guys... it weighs on you. Perhaps you and other people may un-niche it. But at the end of the day, *I* was a less frustrated radiation oncologist when I finally let LDR go. A solipsistic outlook, but that's the only one I've got.

SBRT can (should?) be done in a single fraction for prostate (hence the rationale for single fx HDR; this wasn't a convenience play as much as a cancer-killing, normal-sparing play). When the alpha/beta of a tumor is lower than the surrounding normal tissue, single fx is the best radiobiological approach to manipulate in a maximum fashion the therapeutic ratio. I would be surprised if 1) LDR and SBRT offered much different cancer outcomes, and 2) such a trial requiring ~1000 patients minimum can even be done on this planet.

 

[medgator]

Happy to refer brachy out when patients are interested. It just isn't cost effective in a busy external practice imo

 

[RickyScott]

You do enough brachy, you will eventually get a couple really unhappy pts that you just wont see with a large Ebrt experience.

 

[seper]

I would love to see a randomized study SBRT vs. HDR (in a right population, i.e. not low risk PSA-detected).

 

[radiation]

I would love to see a randomized study SBRT vs. HDR (in a right population, i.e. not low risk PSA-detected).

 

[Chartreuse Wombat]

I would love to see a randomized study SBRT vs. HDR (in a right population, i.e. not low risk PSA-detected).

Good scientific question but not feasible.

Sample size needs to be gigantic and the number of people with equipoise AND HDR/SBRT familiarity is very small.

Always difficult to randomize to brachy or not.

 

[seper]

Well, primary endpoints could be made modest - PSA decrease by 12 months, freedom from catheter or rectal bleed, etc. Kind of like Canadians did with robotic surgery vs. XRT for oropharynx on 100-odd patients.

Good scientific question but not feasible.

Sample size needs to be gigantic and the number of people with equipoise AND HDR/SBRT familiarity is very small.

Always difficult to randomize to brachy or not.