As a field, radiation oncology is perhaps one of medicine's best kept secrets. Sometimes, even our own colleagues don't know where our department exists in the hospital or exactly what we do.
As two radiation oncologists who are, in fact, the children of radiation oncologists, we will admit that it's possible we are a tiny bit biased. We cannot lie, though: Our field is a hidden gem.
What is well known is that radiation oncologists have a symbiotic relationship with our treatment technology. The evolution of treatment machines and radiation precision allows us to deliver patient-tailored treatment down to the millimeter. What may get lost in the discussions of isodose lines and penumbra, however, is that we've also got cutting-edge research and personalized patient care within a specialized team in the depths of the hospital.
Because the inner workings of what happens to patients as they come in and out of our office remains a mystery, we hope to use this space to clarify the top 5 things most physicians don't know about radiation oncology.
1. Nobody knows what goes on in the basement.
Misconceptions about our subspecialty are common, even among other oncologists. A frequent misconception is that a radiation oncologist's involvement in patient care is limited, and radiation is delivered in a standardized manner. This essentially renders radiation oncologists technicians of expensive machines.
In reality however, radiation oncologists touch every aspect of a patient's care, and customized radiation therapy may be indicated for virtually every cancer site in both curative and palliative settings. We strive to deliver precision medicine and practice truly patient-centered care.
To cure cancer, radiation may be used in the neoadjuvant (prior to local surgical resection), definitive (as the primary local therapy), and adjuvant (postsurgical) setting. In palliative cases, radiation can be used to treat areas of metastatic spread as well as primary unresectable tumors to alleviate obstruction and/or bleeding symptoms. Referral to radiation oncology, therefore, can be appropriate at many different points of time on the continuum of cancer care.
For many treating radiation oncologists, the close personal connections that we form with our patients is one of the primary reasons we went into this field. Not only are we making patient-centered clinical decisions during every step of the treatment plan evaluation and optimization but we also see our patients weekly for clinical visits and then ongoing in visits that may span many years of survivorship.
Our deep commitment to addressing patient needs as they are receiving treatment and responsibility for late radiation effects is absolutely an integral part of our training and lifelong practice.
2. We get down in the details.
The workflow from consultation to radiation delivery can be confusing for anyone outside our specialized field.
Once seen in consult and considered a good candidate for radiation, patients will enter the essential next step: the treatment planning imaging — or "simulation."
The simulation scan — mostly CT, although occasionally fused MRI or PET — involves a separate appointment and another hour or so of arranging and scanning patients in the exact position that they will be treated. Given the precision of modern radiation, the simulation often includes making a customized mold so patients have minimal movement during treatment. These simulation images allow the radiation oncology team to create a treatment plan that is customized to each patient and precisely reproducible during their course of radiation treatments — what's known as fractions.
Creating a treatment plan involves a radiation oncologist literally drawing — or contouring — on pictures of the patient's internal anatomy in 3D. Radiation oncologists contour exactly where the cancer is — or where it was if the treatment is given postoperatively — and identify the surrounding organs so that the doses can be preferentially directed to the cancer target and minimize risk to nearby organs. This precision is within millimeters and accounts for microscopic disease, organ motion, and patient setup. Ultimately, we create colorful heat gradient volumes of the anticipated radiation dose delivery and optimize these to reflect our planning priorities.
We use advanced technologies to shape the beams of radiation to treat the tumor and avoid delivering high doses to the neighboring tissues with techniques such as intensity modulated radiation therapy (IMRT), stereotactic ablative radiation therapy (SABR or SBRT), and stereotactic radiosurgery. We can also take advantage of the unique properties of different modalities, such as proton therapy and electron therapy, to achieve these same goals if indicated. Radiation oncologists live for precision medicine in every aspect of their workflow.
3. We roll deep.
Radiation oncology is exemplary of the "the art of medicine." We fuse anatomy-based treatment design with advanced technology and orchestrate the daily functions of a large medical team.
But, the treatment plan and delivery would not be possible without the input and care given within a large multi- and intradisciplinary team of oncologists, medical physicists, dosimetrists, radiation therapists, nurses, social workers, and other support staff. Radiation oncologists participate in regular tumor boards with surgeons, medical oncologists, pathologists, and radiologists to optimize interdisciplinary management of complex patients, providing a thoughtful tumor localization and treatment plan, as well as to better understand an individual's ongoing symptoms and well-being as a whole. Considering all aspects of what a patient may need involves communication with fellow physicians, nurse navigators, and social workers.
Within our own department, treatment plan creation and quality checking or verification can sometimes take over 2 weeks, with detailed input from dosimetrists and medical physicists. The actual treatment delivery involves daily communication with the radiation therapists who are dedicated to each treatment machine — like the linear accelerator — and symptom management with clinic nurses and supportive staff, such as physical therapists and registered dieticians.
This massive team effort is required to get each patient through daily radiation treatments that can last 7 weeks and may require rapid replanning if the tumor shrinks or the patient loses weight.
As part of this team, radiation oncologists are uniquely positioned to quarterback each play and guide the entire game strategy.
4. Radiation therapy takes a lot of heat.
Other than fatigue, associated side effects are localized and related to the total radiation dose and fraction size — how much and how fast — that reaches the surrounding tissues.
Our colleagues often swap stories of the bizarre things radiation therapy has been blamed for, including dental problems in someone receiving vaginal cylinder treatment, heart dysfunction in someone treated for rectal cancer, and hip fracture in someone treated for breast cancer because the radiation "destroyed" their bones. At best, these are humorous stories, but at worst, they can delay diagnosis and treatment of what is truly causing someone's symptoms.
5. We truly believe that less is more.
One of the most fundamental aspects of radiation oncology is our drive to optimize treatment delivery and continually improve patient care — sometimes at our own field's economic detriment. We're dedicated to showing that patients may get the same benefit from less and less radiation.
In the past two decades, the evolution and adoption of photon IMRT and proton therapy has allowed radiation plans to successfully spare surrounding tissue while improving our targeting. This evolution is coupled with technological and imaging advances that allow us to delivery of doses to certain tumors via SABR/SBRT in one to five total fractions.
A prime example: Treatment to eradicate lung or gastrointestinal tumors, which used to span up to 6 weeks, can now potentially be delivered in as little as 1 week.
For other common cancers, hypofractionation — slightly higher radiation doses per fraction at fewer total fractions overall — has revolutionized patient care, providing less radiation without impacting survival or increasing treatment toxicity.
Take breast cancer care: Fifty years ago, virtually all patients with breast cancer received a mastectomy and lymph node dissections. Today, surgical techniques for lumpectomy paired with radiation therapy to the whole breast now allows us to preserve disease-free survival for those who elected to keep their breasts.
Over the past 20 years, the standards of care have shifted from 6-7 weeks of treatment to 3-4 weeks using a hypofractionated model that involves daily whole-breast radiation. The most recent clinical trials have shown that whole-breast radiation can be delivered safely and effectively for select women in as few as five fractions with either whole or partial breast targeting. Additional research driven by the idea of "right sizing" radiation treatment has even shown that certain women may not need radiation at all.
This evolution in radiation therapy illustrates how our subspecialty is constantly working to improve survival and patient well-being, form deep connections with our patients, and push the boundaries of medical innovations.
We are proud to be radiation oncologists and happy to share more. Want to know more about what goes on in the basement? Come on down, we're happy to show you around.
Lead image: DigitalVision/Getty Images
Image 1: UF Health Creative Services
Image 2: Memorial Sloan Kettering Cancer Center
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Fantine Giap, Fumiko Chino. 5 Things Most Physicians Don't Know About Radiation Oncology - Medscape - Jun 24, 2022.