What Should the Role of Radiation Oncologists Be in the Future?

Dr. Pennell and Dr. Neha Vapiwala discuss the role of radiation oncologists be in the future.
Related Article: Care Provider or Service Provider: What Should the Role of Radiation Oncologists Be in the Future?
Support for JCO Oncology Practice podcast is provided in part by AstraZeneca, dedicated to advancing options and providing hope for people living with cancer. More information at astrazeneca-us.com.
Hello, and welcome back to the ASCO Journal of Oncology Practice podcast. This is Dr. Nate Pennell, medical oncologist at the Cleveland Clinic and consulting editor for the JOP. The treatment of patients with cancer is increasingly multidisciplinary, with medical oncologists working very closely with their colleagues in surgery and, of course, radiation oncology, among other disciplines, to deliver the best care possible.
However, should all of the members of the multidisciplinary team share equal responsibility for patient care? Or is it OK if some of them operate more as consultants who perform services on request and then hand the patients back to their team? I think this is a very important discussion to have, both from a patient care perspective but also from the standpoint of professional satisfaction from the physicians who are participating in these care teams.
Joining me today to talk about this fascinating topic is Dr. Neha Vapiwala, Associate Professor and Vice Chair of Education as well as the Radiation Oncology Assistant Dean of Students at the University of Pennsylvania. She's going to discuss her paper titled "Care Provider or Service Provider, What Should the Role of Radiation Oncologists Be in the Future?" Neha, thank you for joining me today.
Absolutely, thank you for inviting me.
So I really like this. And it really struck me as an important topic that not many people are talking about today. So why did you feel this was something you needed to address?
Well, first, again, I'd like to thank you for bringing attention to this and to JOP for acknowledging our work. It is an uncomfortable conversation to have, in the sense that it's shining a spotlight on ourselves, something that we don't often necessarily think to do, as we are so focused in our various arenas of patient care and groundbreaking research and teaching.
But at the same time, it's something that, at least in speaking to my colleagues who helped co-author this, it was clear. Having this multidisciplinary world in which cancer care clearly has not just evolved but thrived and not addressing the fact that different members of the team may have differing stakes and differing roles. And are they the right roles, and is everyone contributing maximally based on their training and their interests?
It just sort of raised the question of re-evaluating radiation oncologists and the ways in which their role has evolved over time, which is part of what we try to talk about in this piece. And then not just on the history, but then focus on also where we are headed or where we could be heading. And in particular, all of these conversations have to happen with everybody at the table, not just amongst radiation oncologists in isolation.
I don't know if you can actually answer this question, but is there any data out there of how radiation oncologists see themselves in this particular discussion? Do they see themselves more as service providers, perhaps more like a radiologist? Or do they consider themselves to be longitudinal caregivers who want to follow their patients and manage their issues?
No, I wish I did have data that I could call upon to give you cross-sectional view of 2018, where we're at as a profession. But absent to that kind of collected data, I can tell you that, in terms of anecdotally and also in speaking to many colleagues, I think how radiation oncologists view themselves and the pride that they take in working on teams and contributing, from tumor boards to palliative care services and everything in between, certainly in the research realm, I think there's how we view ourselves and then there's how others view us.
And I do think there is a realization amongst many radiation oncologists that, because we don't often have inpatient services, because we haven't necessarily the schedule or perceived schedule that others may have, particularly in the surgical and inpatient medical oncology side, that that could be construed as not being as engaged, and perhaps rightly so.
And so those perceptions and sort of the PR of it, if you will, the way the aesthetics of it look, can work against us. Particularly those of us that are inclined to be more involved and to contribute more, there is almost these limitations that are placed by the nature of some of what we do and what we are allowed to do from a credentialing standpoint.
OK, well there's that aspect. And, of course, there's also a financial aspect. You know, radiation oncology is extremely profitable for most centers that include that among their practitioners. And whether those centers would want you guys to have time blocked off to manage medical issues is a question some centers may want to ask.
Absolutely, it's a brilliant point that we didn't elaborate on other than to say that institutions, the cancer centers, and the other providers would all need to, of course, have buy in to such a change in the scope of practice.
But you are correct that the nature of the reimbursement, at least as it has been historically-- who knows what the future holds-- but, yes, the nature of the reimbursement within the technical work we do is such that it's been what everyone's happy for us to focus on. And so, therefore, perhaps the impetus and the drive to do more beyond that could be seen more as caring for the patient has been limited because we're able to meet the bar just through the technical work. Yeah, that's exactly right.
But I would say, in your paper, you made some compelling arguments about why it might be important for radiation oncologists to be involved from the very beginning and longitudinally. So give me some examples that you mentioned in your paper?
Sure, yes, absolutely. So one way to look at this would be just if you simply look through the research lens. Obviously, right now it happens to be very topical, the role of immunotherapy and systemic therapy combination with radiation and how the two can be synergistic, if not at least compatible, and take advantage of the therapeutic window.
And that's not a new concept, but certainly burgeoning now with the advent of newer and newer systemic therapy agents. And so I feel that the role of local treatment with radiation is, in a way, from a research angle, become more exciting, more than ever before.
And so just as it's critical for the radiation oncologist to be at the table in the design of the clinical trials and the protocols and the grant proposals that go in, similarly, the care of those patients-- and in this case, I guess, study patients-- but the care of those patients and the toxicities and the adverse events that have to be monitored, there's a need for radiation oncologists to be able to own every piece of that and, of course, to work with the study team to be equal contributors in that realm. And so that's sort of an easy example.
When you start to try to translate it to clinical care, there is a lot about radiation therapy and the cancer survivor that is, for very obvious reasons, not something that your average primary care physician is necessarily going to be familiar with or know to look out for. And frankly, I don't expect that folks that are oncologists that aren't practicing or familiar with radiation would necessarily know some of the stigmata to expect or not expect depending on the radiation the patient did or didn't have.
And that alone, in terms of the service or disservice we would do to our patients if we don't follow them, is just one example that we cite here, in that we have given up sometimes that follow-up care to others. And part of …