Future innovation for radiation oncologists

[Seaweed_Man]

Hi all, I'm a US MD student who has been interested in radiation oncology for a long time, but have been receiving mixed advice about continuing to pursue the specialty in the face of all the supply/demand concerns and reimbursement. I've scoured all the threads on SDN in an effort to get more informal information, and it all seems to be mixed (reflecting the advice I got from my mentors across different specialties).

My question is--I know historically a few fields have gone through "crises" the same way rad onc is going through right now (supply/demand concerns with CT surgery when cardiologists started doing procedures, future of diagnostic radiology concerns with AI, etc) but that these fields largely "fixed" themselves by innovating new procedures/technology, discovering a new niche in care, or controlling supply/demand issues by shrinking training programs (CT Surg).

Since we can't seem to control program expansion/shrinkage, I'm wondering what new technology/innovation might keep radiation oncology relevant and maybe cause a rebound of the field in medical care? I.e. will Flash/hypofrac allow us to better compete with surgeons for cancers where surgery vs. radiation have similar outcomes? Will radionuclide therapy become more mainstream for rad onc depts in the future? Will "new types of radiation" (ex. Optune for brain cancer) start popping up that the field can use? Trying to hold on to my reasons to apply into rad onc since i loved the field so much RIP.

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[Bequerel]

None. I envy medical students who have the option to do something else. If you’re an American medical student and have no criminal history and you still choose to go into this field, I have no sympathy for you when you’re either unemployed or making 200k in BFE in 2040.

 

[Gfunk6]

Well, I don't know if I would be as negative as Bequerel, but I think he is fundamentally correct on the issue. There are exiciting developments in treatment like you've cited including: metabolic-guided treatment (Reflexion), FLASH, and use of heavy ions like carbon. All of these actually would DECREASE the number of treatments. Under normal circumstances, this would be a great development for the field, patients, and society. However, since we are pumping out too many residents, decreased treatments = very bad future job market.

There are a lot of things that Rad Onc could do to supplment our practice (again, some of which you cited), like IV radionuclides, SpaceOAR/Barrigel injections, placement of fiducial markers under ultrasound, Optune treatment planning, interstial brachytherapy, elecronic brachytherapy, etc. However, these are all too small IMO to fundamentally change the trajectory of the field.

LIke most people on SDN, I love clinical Rad Onc but I see the writing on the wall and I can't let medical students and residents march like lemmings off a cliff and stay quiet.

 

[Bequerel]

it’s been said for years, but only way to fix it is to drastically cut trainees. If someone can get that done, then the field could be saved. I hope it does because I think it’s an amazing and very rewarding field.

 

[RadRadRad]

Seaweed
You are correct. Many fields have been in crisis mode then fixed themselves. Often this has come by limiting supply (not expanding residency) which fundamentally makes sense for society. Right now we don’t need more people to be radoncs. We need more people to be something else (urology, rads, etc)

It is hard to predict the future especially as it pertains to demand or novel technology. But the overall trend lines for demand and supply are in the wrong direction.

Could things work out. Sure. But would you want to bet your future on it ?

 

[MidwestRadOnc]

To answer the specific question, I don’t think there is a new treatment that is going to save us. Strategic protons may preserve revenue on the technical side for a certain few owners, but it’s a loser for physicians (and patients). FLASH, esp with protons, is not coming to a community clinic near you. Rad oncs giving chemo is an especially perverted isomer of hopium.

Rad oncs are married to the linac. In Ireland. 100 years ago.

The only solution is reducing the supply. Period.

 

[NotMattSpraker]

My question is--I know historically a few fields have gone through "crises" the same way rad onc is going through right now (supply/demand concerns with CT surgery when cardiologists started doing procedures, future of diagnostic radiology concerns with AI, etc) but that these fields largely "fixed" themselves by innovating new procedures/technology, discovering a new niche in care, or controlling supply/demand issues by shrinking training programs (CT Surg).

This is a pretty simplified view of crises and fixes. They are all pretty different except that physicians feel threatened about the future. The healthcare market dynamics play a big role and have changed over time. Etc Etc.

Since we can't seem to control program expansion/shrinkage, I'm wondering what new technology/innovation might keep radiation oncology relevant and maybe cause a rebound of the field in medical care? I.e. will Flash/hypofrac allow us to better compete with surgeons for cancers where surgery vs. radiation have similar outcomes? Will radionuclide therapy become more mainstream for rad onc depts in the future? Will "new types of radiation" (ex. Optune for brain cancer) start popping up that the field can use? Trying to hold on to my reasons to apply into rad onc since i loved the field so much RIP.

Our field can't even have a healthy conversation about the future. Or the present. That is our crisis and would be my biggest concern about this field going forward. Leadership is a huge problem and I think sets Rad Onc apart from how other fields have done "crisis management". In many (but not all) settings, it just doesn't feel like the senior members of the field/department/practice are looking out for the juniors and their future.

If you want a lot of job type/geographic/whatever flexibility, that will probably never be true. All fields could in theory have a job crisis during your career. I agree with others concerns, but its also hard to predict how things will go relative to other fields in the future.

Even if Rad Onc had a med onc style industry research apparatus, I would not place a high priority on the probability of some future breakthrough in my field choice.

 

[MidwestRadOnc]

Our field can't even have a healthy conversation about the future. Or the present. That is our crisis and would be my biggest concern about this field going forward. Leadership is a huge problem and I think sets Rad Onc apart from how other fields have done "crisis management". In many (but not all) settings, it just doesn't feel like the senior members of the field/department/practice are looking out for the juniors and their future.

This.

In a healthy profession the old mentor the young as to how to develop their skills. When is the last time you ever heard of an experienced successful rad onc mentoring someone just out of training on how to start a practice, how to run a business, how to get a loan and bill and collect, how to establish relationships, how to negotiate with payors, etc? Ever? In rad onc it’s taboo to even ask these questions and not just take whatever salary your chairman offers you to stay on board and do what you are told. And those who have been successful are going to keep those cards as close to the chest as possible. That’s not being a professional. That is being a blue collar laborer. You don’t need to go through 13 years of higher level education for that.

Avoid fields that eat their young.

 

[thecarbonionangle]

comparisons to CT surg might seem good but they really are not even close. A CT surgeon can do general surgery, wound care, critical care, etc. Our field broke away from DR and we have nothing to fall back on. Your “mentors” are not telling you the truth if they are telling you anything but proceed with extreme caution.

 

[elementaryschooleconomics]

Our field can't even have a healthy conversation about the future. Or the present. That is our crisis and would be my biggest concern about this field going forward. Leadership is a huge problem and I think sets Rad Onc apart from how other fields have done "crisis management". In many (but not all) settings, it just doesn't feel like the senior members of the field/department/practice are looking out for the juniors and their future.

Ding Ding Ding.

There are a lot of things that Rad Onc could do to supplment our practice (again, some of which you cited), like IV radionuclides, SpaceOAR/Barrigel injections, placement of fiducial markers under ultrasound, Optune treatment planning, interstial brachytherapy, elecronic brachytherapy, etc. However, these are all too small IMO to fundamentally change the trajectory of the field.

This is also key regarding how I personally see the future.

There is a large cohort of early-to-mid career RadOncs settled in (hunkered down) with jobs right now. We have all the required training and certifications, and most importantly, we have experience and...inertia ("the devil you know").

@Gfunk6 didn't mention one thing: AI. I use AI in my clinic daily. I've been doing so since late 2021. It supplements our practice on the other side of the supply/demand equation.

The wolves are coming for me, too. My response has been, and will continue to be, to expand my practice with things like radiopharm, while simultaneously jumping on AI options early to expand my ability to see/treat more and more patients.

At this point, a new grad could call my hospital up and offer to take my place for 1/5th my salary and it wouldn't matter. Unfortunately, the modern RadOnc residency curriculums are disturbingly inadequate in "real world" education.

It would take years for a new grad to build up to the revenue many of the existing RadOnc are generating for their hospital systems, and the lost revenue absolutely dwarfs the money saved on an even wildly lower salary.

Now, I desperately hope we have some new "black swan" event in the next 5-10 years that disrupts the current trend in a positive direction. Because otherwise, I'm extremely worried that the oversupply issue will slam new grads the hardest. Boomers will be retired or clutching to their lazy endowed something-or-other positions. Millennials and Gen X will be borderline cyborgs hitting our 20,000 wRVU/year productivity targets, trying not to take another pay cut.

New grads will be doing 4 unaccredited fellowships, posting on SDN "the attendings at my med school told me everything was fine, the internet was full of stupid misanthropes, but there really doesn't seem to be any jobs, what am I doing wrong?"

 

[NotMattSpraker]

The wolves are coming for me, too. My response has been, and will continue to be, to expand my practice with things like radiopharm, while simultaneously jumping on AI options early to expand my ability to see/treat more and more patients.

At this point, a new grad could call my hospital up and offer to take my place for 1/5th my salary and it wouldn't matter. Unfortunately, the modern RadOnc residency curriculums are disturbingly inadequate in "real world" education.

This is a great point that is really under discussed and also great advice for current early career folks.

We also have advanced practice therapists and virtual supervision.

 

[Palex80]

The only thing that works in our favor is the demographic development. People are dying at an older age and many of them face at least one cancer during their life span.

This is the only development I am aware of that will benefit our field. But pretty much every speciality benefits from that, with the exception of paediatricians.

 

[Gfunk6]

The only thing that works in our favor is the demographic development. People are dying at an older age and many of them face at least one cancer during their life span.

This is the only development I am aware of that will benefit our field. But pretty much every speciality benefits from that, with the exception of paediatricians.

And living in a country where your health system is not a predatory, dystopic ****show also helps

 

[MidwestRadOnc]

The only thing that works in our favor is the demographic development. People are dying at an older age and many of them face at least one cancer during their life span.

This is the only development I am aware of that will benefit our field. But pretty much every speciality benefits from that, with the exception of paediatricians.

See above.

In America life expectancy has gone down and we have accepted sick care of chronic disease as totally normal as that is far more profitable to pharma than prevention. Obesity is ozempic deficiency. Pain is opioid deficiency. Depression is SSRI deficiency, attention problems are amphetamine deficiency, etc.

Except cancer and radiation.
One bone met and it’s IO then hospice at the last second. Or Reflexion I guess. Because that makes about as much sense as anything else.

 

[winstonfoot5]

Medical student comes to rad onc interest group with snacks and questions:

 

[radiation]

Hi all, I'm a US MD student who has been interested in radiation oncology for a long time, but have been receiving mixed advice about continuing to pursue the specialty in the face of all the supply/demand concerns and reimbursement. I've scoured all the threads on SDN in an effort to get more informal information, and it all seems to be mixed (reflecting the advice I got from my mentors across different specialties).

My question is--I know historically a few fields have gone through "crises" the same way rad onc is going through right now (supply/demand concerns with CT surgery when cardiologists started doing procedures, future of diagnostic radiology concerns with AI, etc) but that these fields largely "fixed" themselves by innovating new procedures/technology, discovering a new niche in care, or controlling supply/demand issues by shrinking training programs (CT Surg).

Since we can't seem to control program expansion/shrinkage, I'm wondering what new technology/innovation might keep radiation oncology relevant and maybe cause a rebound of the field in medical care? I.e. will Flash/hypofrac allow us to better compete with surgeons for cancers where surgery vs. radiation have similar outcomes? Will radionuclide therapy become more mainstream for rad onc depts in the future? Will "new types of radiation" (ex. Optune for brain cancer) start popping up that the field can use? Trying to hold on to my reasons to apply into rad onc since i loved the field so much RIP.

Lots of posters here are pessimistic about the future because of current leadership and a very strong attachment to what they consider the golden years of rad onc and how rad onc should be practiced or deserves to be practiced. If you look at current state of the field, it is a very reasonable with a future that can go a number of different ways. If you are an optimist, you can look at the fact that despite all the studies looking to reduce indications for radiation and overall trend of reducing fractions, the incontrovertible fact is that radiation is underused in many situations.

You can make the argument that every stage 4 pt should at least have a consult with a rad onc because they will inevitably get symptomatic mets that may benefit from palliative rt (and maybe more). Organ sparing rt is underutilized (bladder etc) mostly for political/practice pattern reasons, with a similar story for radiopharm. And there is whole untapped field of non malignant uses of RT like arthritis that could open the field in ways nobody even considers

The pessimist would say current leadership and referral culture would make taking advantage of underutilization impossible, and they may be right. You’ll find many more posts on what’s wrong with field but just providing an alternative perspective and some food for thought

 

[Seaweed_Man]

All this input is super helpful^^^ It sounds like the main problem isn't decreasing reimbursement/hypofrac or changing indications (I understand this is complex because indications have decreased in certain situations but expanded in other ways like oligomets), but the expansion of residencies.

Follow up question from a naive, optimistic med student: since the predominant sentiment of rad oncs (based on sdn, twitter, even some academic leadership I've seen at a few programs) is that we need to decrease residency spots, what is stopping people from doing so? I.e., what does it take to cut 1-2 spots from every program in the country? If ASTRO leadership is a concern, have there been any efforts to "dethrone" people from their ASTRO positions (I'm sure this isn't as simple/straightforward as I'm making it seem, so would appreciate more info )

 

[Chartreuse Wombat]

"have there been any efforts to "dethrone" people from their ASTRO positions"

Catch-22. Many have stopped paying dues and you cannot vote unless you are a member.

Change agents from the inside (Simul, Spraker, etc) are prohibited from participating..

ASTRO is exceptionally opaque and dysfunctional

 

[MidwestRadOnc]

All this input is super helpful^^^ It sounds like the main problem isn't decreasing reimbursement/hypofrac or changing indications (I understand this is complex because indications have decreased in certain situations but expanded in other ways like oligomets), but the expansion of residencies.

Follow up question from a naive, optimistic med student: since the predominant sentiment of rad oncs (based on sdn, twitter, even some academic leadership I've seen at a few programs) is that we need to decrease residency spots, what is stopping people from doing so? I.e., what does it take to cut 1-2 spots from every program in the country? If ASTRO leadership is a concern, have there been any efforts to "dethrone" people from their ASTRO positions (I'm sure this isn't as simple/straightforward as I'm making it seem, so would appreciate more info )

There is an unusually large disconnect between academics and community practice in radiation oncology. This exists to some degree in every field, but I am going to step out on a limb here and say that it's far worse in rad onc than in any other specialty. The interests of academic training programs are not aligned at all with community practice. The academics control the training pipeline. Community rad oncs are disillusioned with ASTRO because they are clearly preferential to the interests of the large academic training programs, and it's in the interest of those programs to have many residency spots without care for market demand in the community.

This was obvious a decade+ ago when you literally had to recite a catechism during your residency interviews that you were only interested in an academic career and explain why you didn't do a combo MD-PHD, and you had to keep this facade up all the way until your last day of PGY-5. It's less obvious now that you can match even by listing your career goals with a thumbs up emoji and extra curricular activities as getting high and playing xbox, but this was unhealthy for a profession on its face.

 

[NotMattSpraker]

"have there been any efforts to "dethrone" people from their ASTRO positions"

Catch-22. Many have stopped paying dues and you cannot vote unless you are a member.

Change agents from the inside (Simul, Spraker, etc) are prohibited from participating..

ASTRO is exceptionally opaque and dysfunctional

Yea I want to be clear that at least I am not trying to dethrone anyone. I am trying to give radiation oncologists perspective and context they deserve. ASTRO has a bad habit of telling half truths and people deserve alternate perspectives or a whole story about a topic.

If that is dethroning, whatever.

They are free to do whatever they like, it's their society. I am a proud non-member. Im not aware I am banned, but if I am, fine with me? I have no plans to ever be a member at this point.

I do think the "leadership problems" spill outside ASTRO. This is an issue in many practices, which has nothing to do with societies.

It's the culture of the field.

My own company has great leadership IMO. It just seems not super common talking to people around the country.

The last person I worked for is the worst leader I have ever known in all of medicine. He might be one of the worst people I know in any setting. Seriously dishonest, toxic, and just mean to people for unclear reasons. Yet, they are an important leader right now.

It's the culture.

 

[CurbYourExpectations]

I think this is the field that I would be the happiest in no matter what, I truly enjoy all aspects of my work. Contrarily, I am very concerned about how leadership is handling things currently.

With those two things in mind you can think of it like a relationship, you may love radiation oncology, but radiation oncology may not love you back, or it may provide you with an unhealthy relationship. If you could only see yourself happy in this field, it might be okay to pursue it still, but if you could be happy doing something else, it may be better for you to do something else.

The job market is arguably one of the worst in medicine currently, but you will likely get a job somewhere and be paid fairly well. If you have no ties to anything and just absolutely love the work, go for it. Even right now it is a "good" market for radiation oncology, but it is still worse than most other specialty choices. I don't personally think the job market will stay strong for an extended period of time.

 

[elementaryschooleconomics]

All this input is super helpful^^^ It sounds like the main problem isn't decreasing reimbursement/hypofrac or changing indications (I understand this is complex because indications have decreased in certain situations but expanded in other ways like oligomets), but the expansion of residencies.

Follow up question from a naive, optimistic med student: since the predominant sentiment of rad oncs (based on sdn, twitter, even some academic leadership I've seen at a few programs) is that we need to decrease residency spots, what is stopping people from doing so? I.e., what does it take to cut 1-2 spots from every program in the country? If ASTRO leadership is a concern, have there been any efforts to "dethrone" people from their ASTRO positions (I'm sure this isn't as simple/straightforward as I'm making it seem, so would appreciate more info )

Oh...make no mistake: reimbursement, hypofrac, and omission are destabilizing problems by themselves.

Residency expansion is just another gun pointed at our head. Granted, it's a plasma cannon from Halo but...one of many.

The main thing stopping anything being done about residency size is "tragedy of the commons". At a local level, each institution is convinced (and may be correct) that they "NEED" their current number of residents. Cutting spots at a local level would cause more work to be distributed over fewer people.

Humanity basically never chooses to create more pain for themselves in a tangible way if the reward is some nebulous "good for society" outcome.

RadOnc residency spots will NEVER be cut in a meaningful way.

 

[NotMattSpraker]

Humanity basically never chooses to create more pain for themselves in a tangible way if the reward is some nebulous "good for society" outcome.

LOL chooses. We've all met small groups of humanity that apparently cant even practice medicine without a resident carrying their service.

 

[Seaweed_Man]

It's a pity that such a wonderful field has become riddled with what seems like political and logistical s***shows that poise rad onc to implode on itself. This is going to be a hard decision to make (whether to apply rad onc, switch to something else, or maybe dual apply to kick the can down the road).

Apart from all of these issues, im wondering---what are some things ya'll enjoy about your day to day work? I.e. do you guys still get up excited for your clinic days or do you regret your decision to pursue to specialty?

 

[MidwestRadOnc]

It’s not a hard decision. Apply to a surgical subspecialty, get a good disability insurance policy, live below your means and invest the rest in the s&p 500, and when you are established look for an opportunity to own part of a surgery center.

Working for a psychopathic rad onc chair is way wayyyy down the list. I have a good set up in rad onc now but there no way I could ever in good faith tell a young trainee to bank on this.

 

[medgator]

. I have a good set up in rad onc now but there no way I could ever in good faith tell a young trainee to bank on this.

Many of us in this boat.

💯💯💯💯

 

[elementaryschooleconomics]

It's a pity that such a wonderful field has become riddled with what seems like political and logistical s***shows that poise rad onc to implode on itself. This is going to be a hard decision to make (whether to apply rad onc, switch to something else, or maybe dual apply to kick the can down the road).

Apart from all of these issues, im wondering---what are some things ya'll enjoy about your day to day work? I.e. do you guys still get up excited for your clinic days or do you regret your decision to pursue to specialty?

I'm not sure anyone is waking up "excited" for work because at the end of the day...this is just a job. Buying into the propaganda otherwise is how you get abused.

But yes, the actual magic of curing cancer/alleviating pain by shooting invisible beams into people is as cool as ever.

Too bad it's like...only 5% of my effort, and the easy part at that.

Obviously, it's not really a secret that American Healthcare is...rocky. Not to say that I think there's a "perfect" system out there - of course there isn't - but 2020 really hit the system with a curveball that continues to evolve.

After training/working in several places, and talking to a lot of people, I think there's really two main flavors of RadOnc: urban vs not-urban (recognizing this exists in all industries and life, haha).

Our job market issues makes this super salient. Urban settings have significantly more resources both in terms of specialties and procedures those specialties offer. Not-urban...does not. Urban is also where you will find the "psychopath Chair" departments.

Most RadOncs, at least 80%, want to be in urban environments - so it has been, and always will be, the most difficult place to get a job. Non-urban jobs are "easier" to get, but you won't be practicing medicine the way you see in med school/residency.

This might seem totally tangential to your question, but what you're asking about job satisfaction. And med students always ask it like that - I know, because I was one, and me and all my friends did the same thing.

What you really need to ask is what you, as an individual, want for the rest of your life. What would make YOU personally satisfied. Sure, the day-to-day mechanics of the job are important. They're necessary...just not sufficient.

So for me, I practice in a non-urban environment. I have zero concerns about losing my job, unless they cure cancer tomorrow...but even then, I suspect I'll still be fine.

The price I pay for this is a hospital without several specialists that are important for cancer and that I was used to in residency or at other jobs. Neurosurgery, for example. This is more common than you'd think - you need to be a hospital of a certain size to be able to attract and retain a Neurosurgeon. So I always have to have a patient transferred at least an hour away to a hospital with Neurosurgery. Coordination is...hard. Harder than aiming my linac to cure cancer.

And the kicker: if I want to leave this job, I have to move. I have a family, and we've moved a lot to even get to this point. I don't want to move again.

Not being able to switch jobs without moving isn't exclusive to RadOnc, of course, but it's not the case for most specialties.

Anyway, my long-winded point is that rather than focusing so much on the day-to-day mechanics, it's important to think about your life for the next 30 or 40 years, what you value, and what can bring you in alignment with those values.

Because if you value freedom and flexibility...RadOnc ain't it.

 

[MidwestRadOnc]

Many of us in this boat.

💯💯💯💯

It’s also probably worth clarifying what I consider a “good setup” for me personally would probably represent catastrophic career failure and be accompanied with crushing depression, familial distress, and shattered self-worth for a majority of mid career rad oncs. It also required running through a gauntlet of numerous objectively awful to anybody positions to get to this point.

 

[NotMattSpraker]

It's a pity that such a wonderful field has become riddled with what seems like political and logistical s***shows that poise rad onc to implode on itself. This is going to be a hard decision to make (whether to apply rad onc, switch to something else, or maybe dual apply to kick the can down the road).

Apart from all of these issues, im wondering---what are some things ya'll enjoy about your day to day work? I.e. do you guys still get up excited for your clinic days or do you regret your decision to pursue to specialty?

I love my day to day, the department I work in, and the city I live in. That was not true in my first job. It seems super lucky to have all that as a rad onc, so I can't recommend the field.

 

[evilbooyaa]

I'll start by saying I agree with most posters here. If you are on the fence between something and Rad Onc, I would recommend picking that other thing. The current wave of med students becoming attendings are very likely to have a very poor job market in 2030 (when MS4s would graduate residency).

That being said, in terms of things that MAY increase utilization of Rad Onc services in the future (this does not account for the multiple scenarios where radiation is actively 'losing out' on indications):
Evidence based benefit of treating patients with metastatic disease - we do a fair bit of this with palliative doses and even then this is still horribly underutilized. Evidence about treating oligometastatic, then polymetastatic disease. Treating high-risk mets that may fracture, even before there are symptoms. Oligoprogressive disease management. Looking BEYOND OS or LR as the only factor of interest that RT helps with (chemo-free intervals in ovarian cancer, ADT-free survival in prostate cancer, etc.)

Increased non-operative management, replaced by radiation as the local therapy:
We've already taken over anal cancer from colorectal surgery and locally advanced cervical cancer from GynOnc. Rare cancers though.
In rectal cancer, omitting surgery, thus cementing role of radiation. Perhaps brachytherapy boost as well in rectal cancer.
Lung cancer - potential for increase in SBRT of early stage disease. Screening people that are not operative candidates so they can get SBRT.
Liver primary/mets - potentially taking non-op management from IR?
Prostate - some sort of national guideline that EVERY pCA patient should meet with a RO prior to making a decision about definitive management would go a long way to increasing people's radiation volumes.
Renal cell - potentially taking non-op management from IR?
Bladder - some sort of national guideline that EVERY bladder cancer patient should meet with a RO prior to making a decision about definitive management would go a long way to increasing people's radiation volumes.
Radiopharmaceuticals - If become standard of care for a non-metastatic patient with good reimbursement, will increase volume
H&N cancer - if we can safely treat with 30Gy (instead of 50-60) to elective nodal volumes (but still treat primary to 70) then what's the advantage of adding in surgery? Separate from the fact that, what's the advantage of surgery even now??

Benign disease - Osteoarthritis is a huge potential indication, very low toxicity therapy. If we can make this routine, then we can start branching out into other inflammatory conditions (rheumatoid diagnoses).
People researching SRS for things like OCD, depression. Educating about potential of it for things like tremor, trigeminal neuralgia.
Maybe MR-Linac - maybe some toxicity benefit in prostate SBRT. Making treating abdominal targets with SBRT more feasible than historical, to higher doses, so maybe RT gets well established again in say prostate cancer.
Maybe FLASH (likely not), maybe Protons, lol - there is that one trial of protons for LMD I guess.
But, all of this will be for naught, without decreasing the amount of residents from the doubling of graduating residents on a per-year basis. The ACGME RO RRC does not have the teeth to cause programs to contract. I would support them having the teeth to do so.

 

[Seaweed_Man]

@evilbooyaa this is awesome information. I know the field is spiraling rn and maybe to the point of no return if leaders in the field don't make appropriate changes. But this is exactly the info I was looking for--I know as you said all of these are hypothetical changes, but nevertheless, things to consider.

A few questions about what you posted:
--What are you referring to when you say "non-op management" of liver/renal cell? I unfortunately don't know too much about IR and their involvement in cancer management.
--What do you think it would take to implement national guidelines that require every prostate/bladder pt to meet with an RO in addition to a urologist? I've seen this at a couple of institutions I've shadowed at and I feel like it's a great move that improves patient-focused care (in addition to increasing RO volumes too).

As a side note, about H&N cancer--> I go to a med school where the ENTs openly brag during tumor board about wanting to "surgerize" regardless of what pts want in terms of options with radiation, etc. which seemed like a pretty toxic mentality imo. Does this happen at a lot of places or is rad onc given an equal seat at the table?

 

[medgator]

.

As a side note, about H&N cancer--> I go to a med school where the ENTs openly brag during tumor board about wanting to "surgerize" regardless of what pts want in terms of options with radiation, etc. which seemed like a pretty toxic mentality imo. Does this happen at a lot of places or is rad onc given an equal seat at the table?

Yes and it's sad. Not a whole lot different than overly aggressive GUs

At least CT surgery has to worry about pulmonary functions and having pulmonary involved upfront in most if not all cases

 

[evilbooyaa]

@evilbooyaa this is awesome information. I know the field is spiraling rn and maybe to the point of no return if leaders in the field don't make appropriate changes. But this is exactly the info I was looking for--I know as you said all of these are hypothetical changes, but nevertheless, things to consider.

A few questions about what you posted:
--What are you referring to when you say "non-op management" of liver/renal cell? I unfortunately don't know too much about IR and their involvement in cancer management.
--What do you think it would take to implement national guidelines that require every prostate/bladder pt to meet with an RO in addition to a urologist? I've seen this at a couple of institutions I've shadowed at and I feel like it's a great move that improves patient-focused care (in addition to increasing RO volumes too).

As a side note, about H&N cancer--> I go to a med school where the ENTs openly brag during tumor board about wanting to "surgerize" regardless of what pts want in terms of options with radiation, etc. which seemed like a pretty toxic mentality imo. Does this happen at a lot of places or is rad onc given an equal seat at the table?

So, tumors in the liver (either primary tumors like hepatocellular cancer, or liver metastases) and tumors in the kidney (primary renal cell cancers), the 'gold standard' is surgical resection. However, a ton of patients are NOT surgical candidates. Historically, the answer has been for IR to do something for the tumor. For RCCs, the answer is focused thermal ablation. For liver, they can do focal ablation, TACE, or now TARE (Y-90).

SBRT is challenging paradigms in both of those diagnoses as to whether radiation may be better than some of the IR offered options in certain clinical scenarios. As a RO, I'm biased and think SBRT should be the preferred option for many of those patients who can't have surgical resection.

National guidelines is a pipe dream. It will take a grass roots movement at each institution to cause any effective change.

Surgerizing H&N cancer in general is reasonable. Oral cavity cancers do better after upfront surgical resection than definitive chemoRT. T4 larynx cancers may have better survival than chemoRT approach. But, Total laryngectomy for T3 or less larynx cancers? No benefit. Vocal cord stripping, half-assed surgery instead of definitive RT for larynx cancers? Stupid.

The biggest culprit of 'unnecessary surgery' is what is the most burgeoning increasing of incidence, TORS for P16+ oropharyngeal cancer, is mostly, completely unnecessary. There are trials in this space like ORATOR and ORATOR-2 specifically defining that early stage patients do better with just RT alone compared to TORS alone. Those trials are summarily ignored by all TORS zealots.

There are are a number of high-volume places that do it inappropriately, where they are doing surgery to pad their wallets or publish research, not benefit the patient infront of them. Everywhere the TORS research comes from is probably doing it inappropriately. E3311 showed that 90% of patients ended up getting additional therapy afterwards.

If someone is getting TORS they should have a very realistic shot of requiring NO adjuvant therapy afterwards - it should be a surprise after TORS that the patient needs adjuvant RT. If a patient gets TORS and requires adjuvant radiation therapy AND chemotherapy, it should be a tracked metric for surgeons for adequacy of case selection. Because, that surgeon has now taken a patient who was going to be very well curable with 90%+ local control with just radiation and chemotherapy, and made them undergo trimodality therapy with zero oncologic benefit, and only additional toxicities.

*EDIT* - I'll say that I consider myself fortunate that I work at a place where the H&N surgeons are extremely thoughtful about who they will TORS, and it seems like every case they are at all considering for TORS gets presented in H&N tumor board to ensure that there is group consensus versus just proceeding with the STANDARD OF CARE, RT +/- chemotherapy. Thus, the amount of TORS we do as an institution seems incredibly low compared to other institutions, although it's hard to compare numerators of patients getting TORS without knowing the denominator of total P16+ Orophx patients.

Same concept of doing prostatectomy on high-risk or VHR prostate cancer. They're gonna develop biochemical recurrence and be recommended salvage RT > 60-80% of the time, why even bother with the RALP in the first place when you could just do RT + ADT?

 

[Mandelin Rain]

Normalizing radiation therapy for benign conditions is likely the best we can hope for absent some fantastical black swan like FLASH curing all cancers.

Tobacco smoking rates are WAYYYY down in America over past 20 years. Relying on things like lung or bladder or head and neck to grow volume is not wise. HPV vaccines broadly available, though still underutilized. We will be losing other head and necks, anal, and cervix as time goes on. All this is good for patients, BTW.

I do think SBRT is underutilized in liver and kidney. Potential there.

The larger issue is omission and improving precision medicine in common malignancies/bread and butter sites like; Lymphoma (radiation is pretty much gone), Breast (radiation quickly minimizing and/or omitting role), Rectal (obviously MMR+ radiation role almost gone most places, for the rest... I think XRT minimization will be MUCH more likely than non-op management), Gastric (limited role for XRT, GE Junction may follow suit), Pancreatic (again, radiation pretty much gone), and Prostate (increased surveillance, genomic testing, other "ablative" techniques being pushed on urologists).


Strong headwinds for Rad Onc. If the ASTRO/ACRO/ARS alphabet soup wanted to increase volumes for docs, we'd re-tool as Radiation Medicine and place coordinated national direct to patient advertisements regarding their nagging aches and pains and faciitites. We could help a lot of people in pain and keep a lot of lights on.

 

[drowsy12]

The increase in employed rad onc where people have less on beam by standard - while it has many issues and things to be concerned about - does help
The job market

That’s the hard part of deriding high hospital charges (in comparison to true freestanding) too much - reality is it carries the field and won’t change anytime soon

 

[NotMattSpraker]

Strong headwinds for Rad Onc.

The increase in employed rad onc where people have less on beam by standard

All we have to do is stop training like crazy in order to support the interests of a small group of academic rad onc chairs.

 

[MidwestRadOnc]

Tobacco smoking rates are WAYYYY down in America over past 20 years.

We’ve replaced it with vaping and marijuana, which is, and I’m gonna take a totally wild guess here… probably not going to turn out well. But this is another perk (if you want to call it that) of being a Midwest (or even better southeast) rad onc. Still lots of tobacco use to give us work for the foreseeable future.

That’s the hard part of deriding high hospital charges (in comparison to true freestanding) too much - reality is it carries the field and won’t change anytime soon

It’s really amazing to see centers with 5-8 on treatment consistently, and the hospital can afford to pay the rad onc 700k, guaranteed because they have to. Not anywhere you want to live but it happens.

 

[DoctwoB]

.

Same concept of doing prostatectomy on high-risk or VHR prostate cancer. They're gonna develop biochemical recurrence and be recommended salvage RT > 60-80% of the time, why even bother with the RALP in the first place when you could just do RT + ADT?

A few reasons: usually less ADT exposure (none or six months with salvage vs 2 years). Retrospective data (yes I know, not restarting the whole debate) of improved CSS/OS compared to xrt alone, and the absolute misery that is local failure after XRT, which occurs more then many of you realize. Never seen local failure after RALP with appropriate salvage prn. Very rarely see local failure with XRT with brachy and ADT. XRT alone with ADT is unfortunately common.

Edit: Adding some data. 10% local failure rate in intermediate and high risk disease with XRT. Trust me when I say this is misery to manage, though usually not fatal.

 

[drowsy12]

Retrospective data (yes I know, not restarting the whole debate) of improved CSS/OS compared to xrt alone

okay but why would you even cite this when it's absolutely mind-bogglingly ridiculous?

 

[DoctwoB]

okay but why would you even cite this when it's absolutely mind-bogglingly ridiculous?

Because the alternative is to say nothing (when patients ask directly) or rely purely on clinical acumen or "eminence based medicine." Trust me when I say you guys don't want all the surgeons just going with their gut.

A measured response in which I explain to the patient studies are mixed, but there may be a signal favoring surgery, with the caveats of selection bias (which I then explain to the patient) is the best you're going to get from a surgeon.

Conversely, I also always discuss bladder sparing options tor MIBC, also based on highly selected mostly retrospective data. Sometimes non randomized data is better then no data so long as one understands the limitations and caveats.

 

[ramsesthenice]

A few reasons: usually less ADT exposure (none or six months with salvage vs 2 years). Retrospective data (yes I know, not restarting the whole debate) of improved CSS/OS compared to xrt alone, and the absolute misery that is local failure after XRT, which occurs more then many of you realize. Never seen local failure after RALP with appropriate salvage prn. Very rarely see local failure with XRT with brachy and ADT. XRT alone with ADT is unfortunately common.

Edit: Adding some data. 10% local failure rate in intermediate and high risk disease with XRT. Trust me when I say this is misery to manage, though usually not fatal.

I don’t think surgery for high risk is crazy. But I have 2 patients under beam as we speak for sidewall failures (obturatorish) after surgery and salvage radiation. I treat a few per year so don’t kid yourself, it definitely happens. Just like in-gland failures after RT alone. Fortunately, the salvage Brachy and SBRT data (and cryo for that matter) with modern techniques looks pretty good. I do maybe 4-5 of these cases a year. As long as they don’t have crippling LUTS at baseline, they by and large do fine.

The other thing I would say is that the less ADT argument is drying up for a lot of the VHR subjects thanks to PYL scans picking up pelvic sub clinical pelvic nodes. I think the more compelling reason to do surgery in a lot of these guys is just plane ol’ obstructive symptoms. Sure, a lot will need to get salvage RT but they may still be better off in the long run from a symptom perspective doing both.

My opinion, we can all point to this case or that but by-and-large, if you start with curative therapy, they are unlikely to die of prostate cancer and usually have pretty good QOL. Ethically, it’s just best to make sure they know their options first.

 

[radiation123]

A few reasons: usually less ADT exposure (none or six months with salvage vs 2 years). Retrospective data (yes I know, not restarting the whole debate) of improved CSS/OS compared to xrt alone, and the absolute misery that is local failure after XRT, which occurs more then many of you realize. Never seen local failure after RALP with appropriate salvage prn. Very rarely see local failure with XRT with brachy and ADT. XRT alone with ADT is unfortunately common.

Edit: Adding some data. 10% local failure rate in intermediate and high risk disease with XRT. Trust me when I say this is misery to manage, though usually not fatal.

I would argue if the rad onc is using modern techniques and doses the local failure should not be anywhere near 10%. In the boosted arm of the Flame trial (the vast majority of patients were high risk) the local failure was 2.7 %. In PACE B (the vast majority of patients were intermediate risk) less than 5% of paitents in the SBRT arm had a biochemical failure at 5 years.

https://www.redjournal.org/article/S0360-3016(23)07822-7/abstract

CORE - Standard of care +/- stereotactic body radiotherapy for oligometastases - primary results

www.estro.org

 

[evilbooyaa]

A few reasons: usually less ADT exposure (none or six months with salvage vs 2 years). Retrospective data (yes I know, not restarting the whole debate) of improved CSS/OS compared to xrt alone, and the absolute misery that is local failure after XRT, which occurs more then many of you realize. Never seen local failure after RALP with appropriate salvage prn. Very rarely see local failure with XRT with brachy and ADT. XRT alone with ADT is unfortunately common.

Edit: Adding some data. 10% local failure rate in intermediate and high risk disease with XRT. Trust me when I say this is misery to manage, though usually not fatal.

I think saying surgery + RT +/- ADT is better than RT + ADT is a big non-evidence based outlook. Decent number of HR/VHR patients get surgery and pop up with N+ disease. Now they need years of ADT + salvage RT anyways. What has surgery added for this patient population? Increased toxicity without improvements in oncologic outcomes. HR doesn't need automatically need 2 years of ADT.

As is not uncommon in our discussions together, you see a 'numerator' of an event (we've previously discussed this in regards to RT related toxicity), but the denominator is higher than you can truly imagine. This similarly applies to chances of local recurrence. 10-15% risk of local recurrence at 10-15 years is the standard. Kishan analysis suggests it may be as high as 25% local only failure in HR patients. But both of those pale in comparison to RALP in HR/VHR patients where vast majority of those patients are going to end up getting RT too.

The absolute misery that is local failure after XRT? Can you expound on this? They get re-irradiation with HDR or SBRT or Cryo, it works 50-60% of the time (similar to salvage RT after RALP in unselected patients, similar to salvage RP per MASTER meta-analysis, etc.), vast majority don't have catastrophic toxicity, if they recur locally you do the other salvage option, and they kick the can sufficiently down the road or they develop mets (as they were going to anyways) and ideally the patient dies with prostate cancer rather than of prostate cancer...

 

[DoctwoB]

I think saying surgery + RT +/- ADT is better than RT + ADT is a big non-evidence based outlook. Decent number of HR/VHR patients get surgery and pop up with N+ disease. Now they need years of ADT + salvage RT anyways. What has surgery added for this patient population? Increased toxicity without improvements in oncologic outcomes. HR doesn't need automatically need 2 years of ADT.

As is not uncommon in our discussions together, you see a 'numerator' of an event (we've previously discussed this in regards to RT related toxicity), but the denominator is higher than you can truly imagine. This similarly applies to chances of local recurrence. 10-15% risk of local recurrence at 10-15 years is the standard. Kishan analysis suggests it may be as high as 25% local only failure in HR patients. But both of those pale in comparison to RALP in HR/VHR patients where vast majority of those patients are going to end up getting RT too.

The absolute misery that is local failure after XRT? Can you expound on this? They get re-irradiation with HDR or SBRT or Cryo, it works 50-60% of the time (similar to salvage RT after RALP in unselected patients, similar to salvage RP per MASTER meta-analysis, etc.), vast majority don't have catastrophic toxicity, if they recur locally you do the other salvage option, and they kick the can sufficiently down the road or they develop mets (as they were going to anyways) and ideally the patient dies with prostate cancer rather than of prostate cancer...

I would argue that using and interpreting studies in light of their quality and risk of bias is evidence based, while throwing out all retrospective data we don't like due to unmeasured cofounders is a non-evidence based outlook. We don't do that for bladder or renal XRT, why do it for prostate?

Arguments about the numerator/denominator are all valid, but do have some data to guide them. I don't have the data in front of me, but if i recall rates of radiation vs. surgery for prostate cancer were close enough to 50/50. Obviously locally practice patterns may vary, but if 95% of treatment related complications I see in inpatient/ER consultation are related to radiation, that still tells you there is disparate incidence.

Local failure after XRT is a big problem. I have yet to come across a salvage modality that offers both acceptable cancer related outcomes and AEs.. Salvage prostatectomy is high risk and carries significant risk of long term severe incontinence in a patient population that is high risk for measures that improve it such as an AUS due to prior XRT. I have seen good cancer control from salvage brachytherapy, but have seen poor functional outcomes. The "good" outcomes are long term significant frequency/urgency/nocturia that is often medication refractory. The "bad" outcomes are men who are urethral cripples requiring either catheters or complex reconstruction with often suboptimal outcomes. This is, btw, in the setting of some of the highest brachy volumes in the country. Cryo outcomes i have seen have been very poor both cancer and functionally, though admittedly I haven't done it personally and have mostly inherited patients from people who I suspect were doing a poor job. I wouldn't be shocked if a high volume centers could do better. I admittedly have less familiarity with salvage HIFU/IRE and have some hope these could be good options moving forward in the right patient. All this is in the population of men that are potentially salvageable (local only disease with relatively low burden).

Having local failure in the setting of men with metastatic disease/extensive disease burden is very problematic. Men who are progressing locally despite their ADT/ARSI will retain urine requiring catheters, often with urethral issues requiring dilations/difficulty getting in said catheters, bleed (leading to retention leading to CBI/catheters), or require surgical intervention with Channel TURP which isn't always effective, can lead to fistula or severe incontinence, etc. These guys are frequent flyers and often miserable.

 

[evilbooyaa]

I would argue that using and interpreting studies in light of their quality and risk of bias is evidence based, while throwing out all retrospective data we don't like due to unmeasured cofounders is a non-evidence based outlook. We don't do that for bladder or renal XRT, why do it for prostate?

Making judgments that one treatment is better than another when we all know there are unmeasured confounders (and are an attempt to REFUTE randomized trial data such as ProtecT) in terms of folks who or are not surgical candidates is not evidence based, IMO. I feel similarly about retrospective analyses saying adding brachy boost improves OS compared to EBRT alone, when ASCENDE-RT did not show that. Hypothesis generating at best, and again, ignore unmeasured confounders at worst.

I'm not sure what you mean by bladder. Most retrospective data suggests bladder preservation is just as effective as RC. Are you suggesting that bladder preservation patients are MORE likely to have factors that would improve their survival compared to those who underwent surgery?

What do you mean by renal RT? FAST-TRACK is a ph II prospective trial. I'm not advocating for renal SBRT to replace surgery (yet). But it should be an equal player to IR Ablation for non-op candidates, and for lesions > 2cm in size or near heat sinks, should probably be preferred. I personally think SBRT is a better option for patients than IR Ablation regardless of disease size, but that is currently unproven.

Arguments about the numerator/denominator are all valid, but do have some data to guide them. I don't have the data in front of me, but if i recall rates of radiation vs. surgery for prostate cancer were close enough to 50/50. Obviously locally practice patterns may vary, but if 95% of treatment related complications I see in inpatient/ER consultation are related to radiation, that still tells you there is disparate incidence.

I agree that late side effects of RT do infact happen late, while surgery toxicities are unlikely to 'worsen' over time (unless patient gets radiation). Incontinence and erectile function are not reasons for ED visits. Bleeding can be. Disparate incidence of them needing to come to the hospital. I do try to follow all my prostate cancer patients but I know many a RO who don't and have no interest in managing post-RT toxicities. A patient will come to the hospital with one episode of BRBPR if they do not 1) know it can happen as a result of RT and 2) are no longer seeing their RO at whatever time point they are at post-RT.

Local failure after XRT is a big problem. I have yet to come across a salvage modality that offers both acceptable cancer related outcomes and AEs.. Salvage prostatectomy is high risk and carries significant risk of long term severe incontinence in a patient population that is high risk for measures that improve it such as an AUS due to prior XRT. I have seen good cancer control from salvage brachytherapy, but have seen poor functional outcomes. The "good" outcomes are long term significant frequency/urgency/nocturia that is often medication refractory. The "bad" outcomes are men who are urethral cripples requiring either catheters or complex reconstruction with often suboptimal outcomes. This is, btw, in the setting of some of the highest brachy volumes in the country. Cryo outcomes i have seen have been very poor both cancer and functionally, though admittedly I haven't done it personally and have mostly inherited patients from people who I suspect were doing a poor job. I wouldn't be shocked if a high volume centers could do better. I admittedly have less familiarity with salvage HIFU/IRE and have some hope these could be good options moving forward in the right patient. All this is in the population of men that are potentially salvageable (local only disease with relatively low burden).

Having local failure in the setting of men with metastatic disease/extensive disease burden is very problematic. Men who are progressing locally despite their ADT/ARSI will retain urine requiring catheters, often with urethral issues requiring dilations/difficulty getting in said catheters, bleed (leading to retention leading to CBI/catheters), or require surgical intervention with Channel TURP which isn't always effective, can lead to fistula or severe incontinence, etc. These guys are frequent flyers and often miserable.

I would say that, again, you are seeing the numerator, not the denominator. In regards to localized failure post RT - vast majority of patients don't have G3 toxicity as per MASTER meta-analysis who undergo salvage SBRT, brachy (would prefer HDR in this scenario rather than LDR), or Cryo. Doesn't mean they won't be at risk of some toxicity.

Yes, it is unfortunate that you, as a Urologist, have to manage Rad Onc related toxicity beyond the clinic. And patients are (or should be) counseled extensively on risks of urethral stricture, rectal irritation, chronic bladder and rectum bleeding, all on things that are Gr 3 or less in the setting of re-RT. ADT alone is reasonable as well in a local failure patient who doesn't want to be at risk of those other things and would control most tumor related symptoms (until they became castrate resistant). Unfortunately these men live so long that their symptomatic stage can be quite long, so I feel you that it seems like an inordinate burden there. I do see where you're coming from.

 

[RSAOaky]

Hi all, I'm a US MD student who has been interested in radiation oncology for a long time, but have been receiving mixed advice about continuing to pursue the specialty in the face of all the supply/demand concerns and reimbursement. I've scoured all the threads on SDN in an effort to get more informal information, and it all seems to be mixed (reflecting the advice I got from my mentors across different specialties).

My question is--I know historically a few fields have gone through "crises" the same way rad onc is going through right now (supply/demand concerns with CT surgery when cardiologists started doing procedures, future of diagnostic radiology concerns with AI, etc) but that these fields largely "fixed" themselves by innovating new procedures/technology, discovering a new niche in care, or controlling supply/demand issues by shrinking training programs (CT Surg).

Since we can't seem to control program expansion/shrinkage, I'm wondering what new technology/innovation might keep radiation oncology relevant and maybe cause a rebound of the field in medical care? I.e. will Flash/hypofrac allow us to better compete with surgeons for cancers where surgery vs. radiation have similar outcomes? Will radionuclide therapy become more mainstream for rad onc depts in the future? Will "new types of radiation" (ex. Optune for brain cancer) start popping up that the field can use? Trying to hold on to my reasons to apply into rad onc since i loved the field so much RIP.

No one can predict the future. Medicine ebbs and flows. The thing that makes radonc different to other fields is that we are the only specialty actively trying to research ourselves out of a job. We've tried nothing and we're all out of ideas. There is no innovation, just hundreds of academic physicians trying to figure out if we can do in 9 treatments what we used to do in 10, or if we can do zero treatment for things that used to be 40.

 

[MidwestRadOnc]

No one can predict the future. Medicine ebbs and flows. The thing that makes radonc different to other fields is that we are the only specialty actively trying to research ourselves out of a job. We've tried nothing and we're all out of ideas. There is no innovation, just hundreds of academic physicians trying to figure out if we can do in 9 treatments what we used to do in 10, or if we can do zero treatment for things that used to be 40.

Agree. If you want to experiment with dosing, there are so many other interesting questions that could be answered other than number of fractions. Dose rate, time between fractions, homogeneity, etc. testing x vs y fractions is intellectually lazy. Maybe giving 100 cgy and 300 cgy on alternating days works. Maybe there is an optimal time of 19 hours between fractions in certain cancers. Nobody knows because nobody cares to find out. So that’s what’s done.

 

[drowsy12]

Hypofrac has been a worldwide active area of investigation for nearing two full decades now.

It’s such a boring topic at this point to continue to rehash here.

I will say that the idea that this is US academic led is silly at best and ignorant at worst. Look around the world. This was always going to happen.

At some point we can stop talking about it over and over again IMO.

 

[drowsy12]

I don’t think urologists are well versed in reading or interpreting oncologic literature in my experience. It can be very frustrating.

Again - the idea that you actually can with a straight face suggest that surgery can improve OS in this disease is wild.

WILD!

 

[RSAOaky]

Hypofrac has been a worldwide active area of investigation for nearing two full decades now.

It’s such a boring topic at this point to continue to rehash here.

I will say that the idea that this is US academic led is silly at best and ignorant at worst. Look around the world. This was always going to happen.

At some point we can stop talking about it over and over again IMO.

Nowhere in my post did I suggest that this was "US academic led." However, it does overwhelmingly affect a US medical student deciding what career to pursue and all of my points are still germane to the original questions.

Regardless, it's irrelevant whether it's Europe or the US leading the charge. The bottom line is that if there was enough meaningful innovation left to be done in radonc we would be occupying our time doing that instead of fellating one another over our practice altering hypofractionation studies. Just this week I had our academic mothership poach a post-op H&N patient to enroll them on a phase 1 trial of 4 weeks instead of 6 weeks PORT. They now drive an hour into a busy city, past our center 5 minutes from their house, for the sake of "science." These are solved disease sites that we continue to devote resources to trying to solve differently, to the detriment of ourselves and oftentimes our patients. I would love this to be a boring topic, but it continues to go on and it continues to be relevant to a medical student asking if they should join our field.

The treatment we do today is almost identical to the treatment we did a decade ago when I started residency except we do less of it. Even when we do come out with expensive new technologies (MRI-L, Protons, Ethos), we simply use them to offer the exact same treatments we could do on a conventional LINAC but we charge more money for them. The only reason we haven't hit rock bottom yet is that our palliative treatments have gotten more expensive a la SRS/SBRT and patients are living longer due to systemic therapies, allowing us to do more of them.