What Is Pediatric Radiation Oncology? (It’s Not Radiology)

Session 49

Dr. Victor Mangona is a private practice Radiation Oncologist specializing in Pediatrics and Proton Therapy. If you’re interested in Rad Onc, listen to this!

The Specialty Stories podcast was actually posted by somebody at the University of Colorado School of Medicine. He posted this in the group for the first years and he didn’t know that I actually teach at the medical school. So as I showed up to teach today (the day I’m recording this) and two of the students thought my voice I was familiar. And that’s because they listened to my podcast. So thank you for sharing that, whoever you are.

If you’re at a medical school and you have a private Facebook group, I would love for you to share this podcast with your fellow classmates. Also, kindly check out all our other podcasts on MedEd Media.

Back to today’s episode, Victor is a pediatric Radiation Oncologist who specializes in Proton Therapy, which is pretty rare here in the United States. And Victor talks about the number of Proton Therapy Centers here in the country. Listen to the struggles they encounter with proton therapy and with radiation oncology. And whether or not the viability of radiation oncology with proton therapy is something that will be here in the future.

[02:10] An Interest in Pediatric Radiation Oncology

At the end of his third year of medical school, he didn’t really know much about the specialty. He heard a little bit about the specialty from some friends he met one night. And that’s when he learned about the specialty. He later on realized that was actually hanging out with half of the residency program.

He didn’t in the rotation until July of his fourth year and that was the point he knew that’s what he wanted to go into. Initially, he thought about doing interventional radiology for a long time. But having rotated in that, he realized they didn’t have the continuity of care he was looking for. And Radiation Oncology was a good balance between continuity of care and being able to have a procedure-oriented, technologically advanced type of specialty in medicine.

Knowing he wanted to do something technologically oriented, he wanted something that could continue to change with technology. He doesn’t want to be in a specialty that would be phased out with newer technology. He also enjoyed pediatrics and pediatric specialization. So with radiation oncology, he could do both adult and pediatrics at the same time.

He then ended up doing a pediatric fellowship in radiation oncology to gain expertise in treating children and treat adults equally.

[04:03] Traits that Lead to Becoming a Good Rad Onc Doc

Victor explains that considering the number of board exams, you have to be aware of this before heading down this path. Radiation oncology has a board exam in Physics and a board exam in Radiation Biology. This is in addition to the board exams for Radiation Oncology itself, which are oral and written. So there are four board exams all in all.

[Tweet “”If you really are averse to physics, I would advise people not to pursue the path because the radiation oncology-physics boards can be challenging and a core portion of our training.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

Victor also explains that there aren’t any other specialties that have additional boards like physics anymore. So it keeps their specialty somewhat separate from others which he thinks is important for anyone interested to know.

This being said, you need to be comfortable with doing further physics studying during training and taking those boards. It is important to understand that you’re taking potentially long term care of patients. A lot of times, you see patients and treat them for two or three months. But you’ll see them again for follow up every two months for a year. And you’ll still see patients after years of follow up and if they have recurrences, you’re treating them again. Hence, you do build relationship with your patients.

You certainly get to know the people you’re treating in this specialty and this is something that drew him to it compared to other specialties.

[06:20] Radiation Oncology Is Not Radiology!

It’s a very common confusion, Victor says, and that most doctors don’t really know what radiation oncology is in the first place.

In medical school, there’s generally no requirement for having any experience in radiation oncology. Hence, people are not familiar with it.

People think that the term ‘radiation’ is related to radiology. And even practicing doctors think that and people in the insurance industry. They think he’s a radiologist. He explains that historically, diagnostic radiology used to be one specialty. And radiation oncology was just a fellowship training afterwards. So it initially became this branch called Therapeutic Radiology.

Their association, the American Study for Therapeutic Radiation Oncology (ASTRO) which has changed its name to American Society of Radiation Oncology, used to be a branch of that specialty. But now, they’re completely independent. Their training is completely separate from theirs.

[08:03] How Radiation Oncology Fits In with Oncology

[Tweet “”We treat cancer patients, that’s what we do.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

Cancer is basically the pathology of the cell. Cancer is oncology and radiation oncology is just a subset of cancer care that deals with using radiation. Energy can be delivered with internal or external radiation. So they are part of the integral portion of treating cancer patients.

Different cancers are treated with different treatments. But in general Victor illustrates this triangle of therapeutic arms. One is surgical intervention. Second is chemotherapy which is systemic management. And the last one is radiation, which is another local treatment.

There’s also other treatments. Interventional radiology has things like radiofrequency ablation, also used for cancer management. This is a separate branch of diagnostic radiology or interventional radiology. And Victor believes that in the future, this could be its own separate specialty called Interventional Oncology. There are people whose entire practice involves things like radiofrequency ablation or liver directed therapies that interventional radiologists do. So this is another extra branch.

Ultimately, Victor clarifies that radiation is another local therapy which is often done instead of surgery or in concert with surgery as after-treatment. This depends on the type of cancer, stage, and other factors.

[10:02] Types of Patients

In Victor’s practice, he considers himself though to be an exception to almost all radiation oncologists. He has a very busy pediatric practice. He estimates that he treats 70 new kids per year, which is one of the busiest pediatric practices in the country. This comprises about half of his practice. He treats different kinds of pediatric tumors. Most often, they’re brain tumors but he’s also treating other solid tumors in the body.

The other half of his practice consists of adult tumors, mostly CNS or brain and spinal cord tumors. This is because Brain and Pediatric Tumor was his area of specialty during fellowship.

Victor also gives us a look of how it’s like in the community setting. A lot of cases could be things like prostate cancer, breast cancer, lung cancer. This could make the bulk of a community physician’s practice.

[11:10] Typical Day as a Pediatric Radiation Oncologist

Victor’s typical day would start at 7 am going to the tumor board. This is a discussion among radiation oncologists, surgeons, medical oncologists, radiologists, and pathologists. They discuss new cases for about an hour at a hospital. Then he goes to his clinic. One day of the week, he will see all the patients currently receiving radiation. People who receive radiation usually receive it once a day, Monday through Friday for about six weeks or so.

Other days, he will see new patients or patients he’s calling up from previous treatments. He would also do a radiation treatment planning. So if it’s a new patient and a new treatment, he will do a CT scan with them. In their facility, they will make a special mobilization device so they’re in the same position everyday for treatment. He would do the plan on the computer. He also works with a team of other people to help design the treatment.

[Tweet “”I’m kind of like the architect of a building. I’d come up with a plan and then I have other people help design and execute the plan.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

Victor would liken it to a surgeon that does their surgery in the operating room. In their case, they do their procedure virtually on a computer. He adds that you can do your decision-making not in the real-time. So you can do all this in advance and go back and forth to modify things until you have the plan exactly the way you want to.

Mostly, it’s a clinic-based specialty. Some people will do some procedures and do internal radiation. But that’s also often done in a radiation facility. Moreover, Victor is often at work from 8am until 5-6pm. One day a week, he would be done a little later since he’s treating patients until 8 pm. This being said, their practice can be varied depending on what kind of practice you’re working at as well as patient size.

[14:02] Taking Call as a Pediatric Radiation Oncologist

Victors mentions that one of the biggest perks of their specialty is they won’t have to work on weekends. There are very few emergencies in radiation oncology. So they only treat patients on weekdays. In his practice, they don’t do calls. If you’re hospital-based, there will be more inpatient calls. But in general,

[Tweet “”Most people know that there aren’t really radiation emergencies that require treatment after hours. Everything can be treated at 7 o’clock the following morning.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

However, they’re composed of a large team of people, not just one person going in and do everything themselves. In fact, Victor admits he can’t do anything himself. He’s dependent on a whole team of other people who help drive the machines.

And unless it’s a very rare emergency, general radiation can wait another twelve hours. It’s very rare that that little amount of time will make a difference in somebody’s diagnosis. You can usually use steroids and other things that can buy some time in the meantime.

[15:22] Pediatric Radiation Oncology Lifestyle

Victor thinks he has enough time for family. He works at a private practice. Describing the lifestyle in pediatric radiation oncology, he says sometimes he’s very busy and sometimes he’s not that busy. He mentions that one of the difficulties in their field is that because you have ownership of your patients, a lot of your work is attached to you.

[Tweet “”It’s not a shift work specialty where when you’re not there, everything else just goes along.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

You pretty much have your own patients so he has to take care of his own patients. When his practice gets really busy one week, there will be some days that he’d come home very late. Other weeks, he’d come home at very reasonable hours. But in general, he always has his weekends off. So it’s a pretty good lifestyle, all in all.

They have been trying to make four-day weeks for the most part. And two weeks out of the month, he can do that. There’s always one Friday when he has to go in and cover the clinic from morning until night. He works at a place with three physicians and they rotate this. They try to make sure they protect each other’s time off and they work together, this being one of the benefits being in a group practice—it can help with these lifestyle factors.

[16:50] Radiation Oncology Schooling: The Path to Residency and Fellowship

Victor calculates it’s five years in total for radiation oncology schooling—after medical school itself. You do a transitional year, usually as your intern year. You could also do a preliminary year. Other specialties call it two transitional years. This is nice if you’re working at a place that allows you to rotate in medical oncology or pediatric oncology or ENT and Neurology. You get to see those other specialties and spend more time in them.

Then you do four years of radiation oncology residency. Most programs have one to three residents per year. A big program has like three per year and a small program would have about one per year. Some programs have six per year, but those would be the rare exception.

[Tweet “”The great thing about being in a big program is the call is split up among the bigger pool. That’s always really important to look out for when you’re picking a program.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

After your fifth year of residency, you find a job. You either go to academics or private practice. Victor did a fellowship focused on pediatric radiation, brain tumors, and effectively using proton radiation. He works at a facility that only offers proton radiation. There are about 20-25 facilities that open around the country so there’s not many of them.

So if you count the four years of premed, four years of medical school, plus five years of residency, that’s 13 total years of schooling to get to be a pediatric radiation oncologist.

This is part of the reason he got his specialized training as he wanted to work with children and with protons. He further says there are only a handful of people a year who do fellowships in radiation oncology in terms of people who train in the United States. There are people who train in other countries who do fellowships in the United States to have some opportunity to get some clinical training.

[18:55] Radiation Oncology Residency Competitiveness

If Victor had to scale the competitiveness in radiation oncology from one to five with five as the highest, he would give it a 5. Although it’s up and down. Some years, it can get very competitive, other years could be less. But generally, it’s very competitive to match into radiation oncology.

He went to a school with 300 students and there were three of them. It’s the biggest class to go into radiation oncology for a number of years. Most medical schools will have one person doing radiation oncology. Sometimes, none. When he was in training, there were about 160 going in per year and now there’s around 200 or so per year. But compared to medical schools, you can get about 1-2 per medical school across the board.

To be a competitive applicant for radiation oncology, you need to have good grades and good board scores. But this is just to get your foot in the door for the most part.

[Tweet “”A large percentage of their field are people who have MD/PhD’s. So if you have that, in general, that puts you in a whole different category.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

When he applied, about half of the trainees across the country were MD/PhDs. But now that the number has expanded, the number has gone down. Still, it’s a higher percentage. He also mentions research, publications in medical school are very important.

Strategy to Deal with the Competitiveness of Radiation Oncology

And the most important thing he says is if you can find somebody who can take you into their training program. It only takes one residency spot, one person to convince to let you train there.

Especially if people are not the strongest applicants, Victor would advise against applying broadly and everywhere to try to get into one place. Although he recommends applying to a wide net, if you’re not a good applicant, try to focus on one to a few places. Get to know people from radiation oncology departments very well.

Victor would prefer people who are not the strongest applicants but they worked really hard at one particular place. They did it over a number of years. For instance, after your first year of med school, you did research for the radiation oncology department. Then you continued working with them for the next three years. And if you’re able to show you’re going to continue to work hard and help publish.

[Tweet “”The radiation oncology residency program is much more willing to take a candidate they know well who can produce even if your grades might not be the top.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

Victor adds that paper is just one thing. He also advises not to go on a forum like SDN. The things that people post online can be very demoralizing to most candidates because of the publication bias.

So if this is one thing you’re really passionate about, just work hard at establishing a very good relationship with one person or one place where you think you can ultimately get yourself in. Especially if they take multiple residents per year, it’s easier for them to take one internal candidate even if your numbers may not be the best.

[23:50] Negative Bias Towards DO’s

Victor actually knows multiple DO physicians who are radiation oncologists. He believes that more than anything, the most important thing is to establish that relationship with a program that you feel like you could get into. Then work hard at getting into that one place. It could take years of creating that relationship.

If you don’t get into a program right out of medical school, you could take a year off. Find a place where you could do a research fellowship for a year at a place that has a track record for taking on their own fellows. If you could publish a lot and get a lot of work done during that research year, more places would be willing to take you.

[24:55] Subspecialization Opportunities

Pediatrics is one of the options and this is what Victor did. If you want to do procedures, there’s brachytherapy which is internal radiation. Internal radiation could be used to treat the prostate or breast or GYN. You could be a radiation oncologist and spend a lot of time just doing procedures.

In generally any academic center, people tend to specialize in one or two different organ sites. There’s so many people in the academic specialty that are specialized to do research in an area. They treat one or two diseases depending on how big the program is. This then becomes where you end up working on what kind of research you do.

But outside of the academia, brachytherapy and pediatrics are two of the areas you can subspecialize in. 98% of radiation oncologists treat almost zero pediatrics a year. So for all of those that don’t do it, they basically can go the rest of their lives never treating a single child. Meanwhile, all those who treat kids get all the kids so they end up having potentially a busier practice if they’re at a place with high pediatric volume.

[Tweet “”98% of radiation oncologists treat almost zero pediatrics a year. So for all of those that don’t do it, they basically can go the rest of their lives never treating a single child.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

[26:43] Working with Primary Care and Other Specialties

He wishes to let primary care physicians know that they’re not diagnostic radiologists. They are a completely separate specialty. Second, is that radiation is a part of cancer care. Sometimes he feels that doctors think radiation is a backup option.

Rather, radiation is just a different modality of treatment. So it is not necessarily better than any other form but just different. Different types of diseases require different treatments. And often, there are different treatments that are equivalent. One of which is for prostate cancer: radiation and surgery have equivalent outcomes in general.

Radiation oncology is the least known treatment arm among physicians. And the reason for this is that they’re a very small specialty. So they’re not as feasible as other specialties. Often, there’s only one radiation oncologist in an area and will show up in the tumor board along with 50 other doctors. So he stresses how they’re an integral portion of a patient’s cancer care.

[Tweet “”In general, we need to be involved early in the management of somebody’s care so we can help with the decision-making process at the outset.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

Other specialties he works the closest with include medical oncology, pediatric oncology, surgeons, neurosurgeons (particularly because he treats brain tumors mostly).

[29:06] Most and Least Liked Things

What he likes the most about his specialty is being able to play a very important role in people’s lives. A lot of people think his job is really sad. But he also feels very lucky to be able to be there to help people for something that’s so important. Not all kids get better obviously. But when you have the opportunity to help the quality of life in some of them and save the lives of many others, that’s more rewarding than anything else.

What he likes the least is insurance. Also, in his specialty using protons. it gets its own special categorization. And they have to fight for approval for every single one of their patients. They can have a contract with an insurance but that doesn’t indicate they would accept the pay for the treatment. So he ends up having to write letters and appeal for basically every single patient he treats. This process takes weeks. Unfortunately, in a lot of patients, their disease could progress in the waiting period. It’s frustrating how they end up having to go back and get treatment which could have started weeks earlier had they not been waiting for proton approval. They get a lot of push back from the payers so it makes it very hard to provide medical care.

Part of the problem is that there are only five proton centers up until five years ago. Although some of them have been around for a long time, there is not a bunch of data. There is not enough data for certain things where there should be no question. However, it’s much more expensive than the alternative X-ray radiation. So patient will hold because of the significant variant in price.

[31:26] The Benefits of Proton Therapy and the Challenges They Face

But Victor stresses the long term value in protons, especially for children’s cancer and brain tumors. There are long term toxicities of X-ray radiation for somebody who needs radiation to the whole brain and spine. X-rays go through their heart, lungs, intestines, stomach, pancreas, and even the ovaries. But with protons, there’s no radiation delivered to the thorax, abdomen, and pelvis. So it’s remarkably safer. Clearly, there’s a long lifetime value.

[Tweet “”You can use protons and there’s no radiation delivered to the thorax, abdomen, and pelvis. It’s just remarkable how much safer it is.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

In England for instance, they’re building two or three proton centers right now because they’re aware of the value of saving patients from long term morbidity. Sadly, here in the states, the payor system is different. The private payors are the most difficult to get approval of. While for Medicaid patients it’s also a challenging process to get approval with so many different policies. Whereas there are other things in medicine that can be very expensive but have a lot of people behind it. They show a very small difference in studies and become considered standard of care and insurances pay for it.

For example, Avastin is a very expensive medication used for several cancers and it’s often an additional agent to other chemotherapeutic agents. Its cumulative cost in the country can blow away the cost of all proton radiation facilities combined. But Avastin in general, is an anti-angiogenic agent which prevents or slows down growth of tumors. So it’s an adjunctive treatment. Whereas, proton radiation is a definitive curative management with decreased long term morbidity.

[Tweet “”Ultimately, it’s a very small portion of medicine and it gets pigeonholed and blackballed.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

But they don’t have a strong force behind them and they’re a very small group of people. Things in medical oncology are standing behind thousands of medical oncologists that all have access to medication.

Protons is a form of radiation only available to a very small percentage of radiation oncologists. And Victor admits there’s even a lot of internal politics within their own specialty of other physicians in radiation oncology who don’t support proton radiation primarily because they don’t have access to it.

[34:15] What He Wished He Knew that He Knows Now

The one thing he wished he knew better is how reliant your practice can be on you as a physician. If you take a week of vacation, in his place being a small practice of three physicians and him being the only one who treats the kids, it’s more challenging.

If he were at a solo practice all by himself, it can even be more challenging. And if your’e at a big academic center, it’s a lot easier to treat the patients since there are other people there where they could cover.

[Tweet “”But in general, in radiation oncology, there’s a strong requirement for the physician to actually be around.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

There are also certain requirements by Medicare that there’s a radiation oncologist who is in the facility any time a patient is treated. So if you’re working in a small town, and there’s two small towns 45 minutes away, a lot of physicians will go to one practice in the morning and another practice in the afternoon.

Nowadays, you need a physician at both places all day long. And this limits your ability to run a practice since you can’t be at two places at one time, even if the volume at one of them is not very much.

Victor says another challenge in their specialty is that they are dependent on them being physically available any time patients are being treated. So it’s a lot harder to walk away from. Hence, they can’t even consider taking a week off in their specialty, at least not easily.

Unlike for shift work, you have more control over your life and over how much you want to work. So this would have been something he would have taken into consideration. Where he could be in a specialty that he can just do shift work and just one day a week if he felt like it.

Moreover, he had to do it all over again, he isn’t really sure. He likes his job overall. But he thinks that if he had known everything he knows now about everything, he would probably favor a specialty that would give him more freedom to not work. It could be something like diagnostic radiology.

His wife is a diagnostic radiologist and she has a very sustainable lifestyle. She works 8 am-4:30pm everyday and never has to worry about working late. She works evening shifts every couple of weeks from 4pm to 10pm. She works one weekend every six weeks. She could back to 60% at any time. And as a radiologist, you have a computer-based specialty so you could work from home and as an independent contractor.

Victor’s specialty requires a machine so he really doesn’t have that flexibility. So there is a cost of losing some of that freedom. But overall, he feels he gets compensated for it especially in private practice. But in academia, he’s not sure if they’re compensated as well.

[39:10] New Changes in the Future of Radiation

In the medical oncology world, targeted therapies and immunotherapy are really the big thing these days. They are taking over cancer. They’re finding more and more indications for different immunotherapies.

Victor thinks the future of radiation is finding how radiation and these immunotherapies work well in concept with each other. Proton radiation is the biggest question mark. There are a lot more places opening because of the reducing cost. But they’ve haven’t gone to the volume of proton facilities where it would become ubiquitously available.

He finds it in a tipping point where eventually it could go the way where they aren’t getting approved for treatments even more than they are now. And this could cause proton therapy to shut down because it’s not financially viable. Or they could become cheap enough and become more financially viable.

That said, they’re very expensive. There’s one proton center that shut down within the past couple of years and another one just declared bankruptcy earlier this year. So it’s so hard if you’re treatments are not getting approved for coverage.

[41:21] Final Words of Wisdom

Victor says that if you’re interested in radiation oncology, the most important thing is to meet people in the specialty. Start working with them in any way you can during your time as a medical student. Find a way to do research with them in the Summer of your first year, for instance, or if you could rotate with them in your third year. Or try to work on doing research on the weekends just to get in the door at a facility.

And Victor notes that probably the most valuable thing you can do is do research in medical school with your radiation oncology department that gets presented at ASTRO or just published. So develop and foster relationships.

Try to keep those relationships as positive as possible. Try to groom that into them wanting to keep you on there for another four or five years. So take that opportunity and really leverage that to the best you can. That’s an opportunity that you can’t let go to waste.

[Tweet “”If you are ever spending time with somebody that you could be working with in the future, you should be considering that as an interview or an audition.” https://medicalschoolhq.net/ss-49-what-is-pediatric-radiation-oncology-its-not-radiology/”]

[42:50] Last Thoughts from a Pediatric Radiation Oncologist

If you’re interested in pediatric radiation oncology or radiation oncology, apparently you have to love Physics. Do well at physics to pass the Physics boards.

It’s pretty crazy that there’s a math test to be a doctor. But that’s radiation oncology and you’re like firing laser beams at people. But check it out if you’re interested in it. But if you’re going to primary care, Victor sent out a great message for you as well.