Trends in Radiation Oncology

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The practice of radiation oncology is advancing rapidly, but even as the technology evolves, it is the power of partnership that is key to improving care. Novel collaboration with radiology, payers and the patients themselves are changing the way treatments are delivered.

Bridging the gap: Radiology and radiation oncology

Imagine a patient with early stage lung cancer. The tumor is inoperable because of a risk for pulmonary compromise due to the patient’s long smoking history and underlying emphysema. There are a couple options: The patient could have stereotactic body radiation therapy (SBRT) in multiple sessions over a several week period or the patient could undergo an outpatient thermal ablation. The former strategy costs about three times that of the latter.

All things being equal, the cost-effective strategy would seem to be the way to go, but due to a rift between the specialties of radiology and radiation oncology, the most efficient and cost-effective treatments are not always used, according to Damian E. Dupuy, MD, director of tumor ablation at Rhode Island Hospital and a professor of diagnostic imaging at the Warren Alpert Medical School of Brown University in Providence, R.I.

“It was kind of us versus them, and we were fighting over—people are still fighting over—these patients,” says Dupuy. “That type of siloing mentality is probably not the best patient care.”

The rift grew when the two groups split in the 1970s when people realized the specialties were evolving so rapidly it was becoming too much information for one person to learn. Diagnostic radiology was primarily concerned with imaging and some procedures such as biopsies, while radiation oncology dealt with treatment. Now, however, diagnostic radiology is becoming more involved in cancer care and treatment, specifically with targeted treatments using ablation or embolic agents. These treatments are competing with radiation therapies, says Dupuy.

But they don’t have to. Instead, the treatments offered by the different specialties could be seen as complementary, a point Dupuy underlined when he presented the Annual Oration in Diagnostic Radiology as part of the RSNA 2013 Opening Session. In that lecture, Dupuy referenced the words of Anthony L. Zietman, MD, MBBS, a professor of radiation oncology at Harvard Medical School. Zietman said the strength of radiation oncology is in irradiating the microbes of small volume disease, while most ablative technologies are suited to handle larger tumors but don’t address microscopic disease. It’s possible to combine the strengths of both specialties and utilize embolization or ablation along with radiation.

Dupuy says that even the higher energy hyperfractionated techniques of SBRT can’t effectively treat bigger tumors that are radiation resistant due to a low oxygen environment in their centers. “All of the radiation oncologists know this, but because they tend to be competing with the interventional radiologists for some of these other patients, there’s not this collaborative feel.”

Moreover, it makes sense for the specialties to pool resources such as scanners under one department that works together clinically and administratively, as well as collaborates on research.

As imaging practice and the accountable care movement evolves, it will be important to maintain a focus on collaboration and a search for the most efficient treatments. Dupuy says that in many cases when performing a biopsy for diagnosis, an ablation can be conducted in the same sitting. “So you can actually cut costs even more. You can do a one-stop biopsy and ablate. If you have to put a needle in, why not just ablate it at that time?”

Teaming with patients

Like collaboration between specialties, better coordination between provider and patient can produce benefits for care, even in a specialty like radiation oncology that’s typically very paternalistic. It’s true that radiation oncology is very complex, requiring a multidisciplinary team, extensive technical planning and a tailored approach, but there are still decisions on which patients can provide input, says Neha Vapiwala, MD, associate professor of radiation oncology at the Hospital of the University of Pennsylvania.

For instance, in situations where two doses have been verified to be effective, a patient may prefer to have a higher per-day dose but delivered in fewer treatments. There also are questions about medications to manage treatment side effects. “There are areas lacking clear