On-site Radiologist Could Be New Model of Care in Radiation Oncology

The presence of a dedicated in-house radiologist improves patient care in the radiation oncology department and is on track to become the way of the future.

The presence of a dedicated in-house radiologist improves patient care in the radiation oncology department and is on track to become the way of the future, according to research presented at RSNA 2012.

Radiation oncologists are using increasingly complex cross-sectional imaging techniques to improve the accuracy of their radiation therapy planning contours, despite little formal training in diagnostic imaging, said Noel Young, M.D., a radiologist at the University of Western Sydney in Sydney and co-author of the paper, “Incorporating a Radiologist in a Radiation Oncology Department: A New Model of Care?”

“Contour accuracy is essential in conformal techniques like intensity-modulated radiation therapy,” Dr. Young said. “There is need for a more reliable imaging review.”

Dr. Young and colleagues studied the impact of having a radiology fellow in the radiation oncology department over a nine-month period. The fellow provided radiological advice on diagnostic and treatment planning images for two sessions per week and reviewed the accuracy of the patient’s tumor contours for the weekly quality assurance audit meetings.

“The oncology staff was able to book time slots with the radiologist and complete a feedback questionnaire afterward,” Dr. Young said.

There were 49 consultation sessions during the study period, including a review of 56 diagnostic imaging or treatment planning scans. The radiologist’s advice resulted in a change of patient management in 25 percent of cases and recommendations for further evaluation in another 20 percent. Changes to target volume and normal tissue volume were among the radiologist’s recommendations.

“A good percentage of patients benefitted from this interaction and the oncologists were open-minded about having changes made to their target planning,” Dr. Young said.

In one case, the planning CT revealed a vertebral lesion in a patient with potentially metastatic prostate cancer. The radiologist confirmed the finding as a benign tumor on an earlier diagnostic CT, avoiding unnecessary further imaging or biopsy.

“A radiologist who is located within the department has access to the patient’s clinical notes and other multimodality diagnostic imaging and time to review the planning scans in detail prior to the meeting,” said study co-author Marion Dimigen, M.D., from Liverpool Hospital in Sydney. “This results in a qualified interpretation of imaging leading to better radiation oncology care.”

The radiologist also reviewed 94 CT scans for the quality assurance audit meetings. Queries over the accuracy of the contours resulted in a significant change of management in six patients. Dr. Young displayed images from one case where the radiologist had added a nearby lymph node group to the target area in a patient with Merkel cell carcinoma, a rare form of skin cancer.

Drs. Young and Dimigen suggested that access to an on-site radiologist may become the new model of care as radiation therapy planning imaging becomes more complex.

“The rationale behind this being a fellowship position is to conduct collaborative research between the two specialties,” Dr. Dimigen said. “However an alternative model of care may be funding a radiologist for sessions within the radiation oncology department to review diagnostic and radiotherapy planning images for direct clinical care.”

“Having more clinical interaction between radiology and clinical medicine—in this case, cancer care—is the way of the future,” Dr. Young added.

Radiology and Radiation Oncology Need Closer Alliance

Zietman

After a long separation, it may be time for radiation oncology and radiology to get back together, according to a leading expert.

Anthony L. Zietman, M.D., M.B.B.S., a professor of radiation oncology at Harvard Medical School and director of the radiation oncology program at Massachusetts General Hospital—both in Boston—traced the long separation to the early days of radiology, when the therapeutic side of the practice existed in the shadows of the diagnostic side.

“Radiologists spent nine months training in therapy,” said Dr. Zietman, delivering the Annual Oration in Radiation Oncology at RSNA 2012. “During the 40s and 50s, small groups of radiologists began concentrating more on therapy and less on diagnosis. These physicians argued that therapy was a separate area, and that nine months of training was woefully inadequate.”

RSNA annual meetings in the 1950s became occasions for unofficial gatherings of fledgling radiation oncologists at Chicago restaurants—Dr. Zietman showed an invitation to one such meeting at Barney’s Steakhouse—and in 1958, the radiation oncologists ended up forming the American Club of Radiation Oncologists, precursor to the American Society for Radiation Oncology (ASTRO). The development of specialized radiation oncology residency training programs followed and, by the late 1960s, two completely separate specialties had been established.

“The amicable divorce between therapy and diagnosis was complete,” Dr. Zietman said.

The ensuing decades saw both specialties prosper. Diagnostic radiology spun off its own therapeutic branch—interventional radiology—with many subspecializing in cancer therapy using ablative techniques, while radiation oncology became the most sought after residency in the U.S., according to Dr. Zietman. But trouble looms on the horizon for both specialties, he warned, due to an increasing reliance on technology.

“The problem is that as you become more and more technological, you make yourself less and less necessary,” he said. “The art of radiotherapy has progressively been lost as we’ve taken a technological focus.”

Dr. Zietman believes it is time to consider rebuilding the union between the professions. He pointed out that radiation oncologists and interventional radiologists have complementary strengths that would serve cancer patients well.

“Radiation oncologists are good at treating small lesions, and less good at treating bulk tumor, while interventional radiologists handle bulk tumor much better with their ablative techniques,” Dr. Zietman said. “Think how powerful it would be if we could put them together.”

Pilot programs that offer a hybrid specialty to interested medical residents would be a good way to bring the erstwhile partners back together, Dr. Zietman suggested.

Obstacles to a union remain, including tradition, self-interest and training concerns, but Dr. Zietman said that strengthening the bond between radiology and radiation oncology is essential to protect each specialty from becoming irrelevant.