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Feb 22, 2018

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?

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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 it is pragmatic. You know, you can't have patients following with everyone all the time.

But at the same time, I think not having any continuity of care is also not the answer. And there are pockets of the country in which the radiation oncologist really does the radiation, provides that service, and doesn't see the patient again.

And to me, that's a lost opportunity, both for the radiation oncologist to contribute, for the other oncologists to gain from the radiation knowledge. And then for the patient, it's a loss in my mind. That's at least what posit here, this paper, that it's appropriate in some settings for the rad onc to really lead the followup if that was a primary form of treatment.

Right, in this realm where we're expected to be more and more productive in order to justify our salaries and our jobs, I think there's an aspect to just your own professional satisfaction of being able to follow your patients and take care of them as issues come along, and not just feel that you're there to come up with a plan to deliver a treatment and then pass them back to someone else.

Well, exactly, in a transactional manner, exactly-- and the learning that happens, I say to my trainees all the time. And this is not just for the rad oncs that we train, but also our med onc fellows and our surgical oncology fellows who visit with us.

I think it's really eye opening to see that patient who got radiation five years ago, six years ago, and what he or she is dealing with and how our current treatments might mitigate those side effects because we're doing things differently. If you don't see that, you don't learn from it. So there's a self-serving sort of educational value as well that can ultimately benefit the patients.

And so that example, and then the other was really inspired by, I think, our colleagues in the UK and Canada and elsewhere. They've really sort of taken the lead in terms of having radiation oncologists participate in inpatient care to a greater degree than we might traditionally see here in the United States. And one example of that is certainly palliative care.

Where I practice at the University of Pennsylvania, we have a fellowship trained palliative care specialist who is also a board certified radiation oncologist. And his engagement with the team and what he does for the care of these patients is an absolute resource that we cannot fathom living without now that we have him.

But for the longest time, it was not the case. And we just solely were the consultants and sort of came in and weighed in and signed off. And I think it's not the same as having our own service. But it's certainly a huge step towards taking a much greater role so that the burden does not fall solely on our surgical and medical oncology teams that often admit the patient.

No, I think that's a wonderful start to the discussion here. And obviously, this is something that both ASCO and National Cancer Institute, they care a lot about the true teamwork aspect of multidisciplinary care. And we devoted a whole issue of the JOP in 2016 to this topic. So how can we do better than we're doing right now at incorporating radiation oncologists into the multidisciplinary care team, from the beginning all the way through palliative care?

Yeah, I mean, I think that how we can go about this certainly is going to start with conversations like what we're having, and also through groups like ASCO, NCI, ASTRO. Through our organizations simply making it a priority that when decisions are made, particularly in this area of shared decision making and the informed patients who come into our clinics with reams of papers that they've printed off the internet, and providing that context.

And emphasizing that when there is any discussion of an approach to cancer, that there's a balanced view of it and that all the treatments have an opportunity to be discussed. And if the consultation is needed with the other specialists on the team, that everyone has that opportunity.

I think one of the ways in which radiation oncologists have had a tough time being on the care team is, again, if they're not the primary oncologist seeing the patient, a lot of times the description of the radiation treatment or its role is delivered by others. There's nothing wrong with that. But I think that there are sometimes details or aspects that simply don't get reviewed or discussed.

And how we promote that is, I think, facilitating, making these appointments and facilitating more timely access and standard access. Where groups of oncologists at a given practice from all different specialties decide, here's our pathway or here's our workflow. And here's what we want to do for a stage I lung patient.

We want to ensure that each of those individuals has an appointment with both the thoracic oncologist and the rad onc. And that should just sort of be a commitment that works from something as mundane as the scheduling to the tumor board discussions that allow everyone to speak up.

It sounds like a lot of what we're talking about here requires developing a culture of this teamwork where everybody takes responsibility and wants to share that. And that may be something that might be hard to create out of thin air, but might be a process.

Yes, a process. And there will be plenty of things where the way it's currently done is just right because the individual who ends up leading-- a captain of a ship, if you will, for the patient-- is ensuring that the other members of the oncology care team are being kept in the loop. And sometimes that is plenty, and that suffices.

But I think this might be a disease site per disease site conversation that has to happen from AKSM to ASCO to ASTRO, where you say, you know what? There's no head and neck cancer patient that should go without X, Y, and Z. And I think those kind of things, you're right, it's going to have to be shifts over time.

Well, thanks so much for joining me. This has been a great conversation. And I hope people tune in to your paper and our podcast. And hopefully this will initiate some studies to try to get more of a feel among the radiation oncology field as to how they feel about this topic.

Absolutely, and perceptions from all parties would be very interesting to collect.

Yeah, I agree. And I also want to thank all our listeners out there who joined us for this podcast. The full text of the paper will be available at published online in the February 2018 issue of the JOP. This is Dr. Nate Pennell for the Journal of Oncology Practice signing off.