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,
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 three dimensions. 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.