S1E23 RadOnc 101 feat. Hefei Liu

Hi all, you're listening to At The Bee. A medical education podcast where we discuss high-yield oncology with a focus in radiation oncology. We are Trudy and Josh and thank you for listening. Alright, hi everyone, welcome to another episode of At The Bee. This is Josh No and there's always I'm accompanied by Trudy Wu. So today we're going to shake things up a little bit. We have a very special medical student episode for you all. So first of all, we wanted to send a congratulations to those of you who have matched this past match day. I know I could speak for both Trudy and myself when we say that we're excited to meet and work with our future colleagues in radiation oncology. And then on that note, we have joined in today a special guest. We're joined by Hefe Lu. He is a fourth year medical student at the medical college of Wisconsin and recently matched at New Penn for a radiation oncology. So you may have seen some tweets about Hefe in the Twitter sphere and watches interviews on Good Morning America last week or read it on ABC News. So Hefe was highlighted as he went through residency match this year with his mother who's going to be pursuing pathology. So first of all, I have a huge congrats to both you and your mother. It's an incredible achievement for both of you and you can't imagine how special it is to go through this with your family. And we wanted to welcome you to @TheBeam and we love it if you could share your story with us. Thank you Trudy and Josh. Yeah, before I start, I just want to thank you guys for bringing me on to this podcast. You know, truly, you're truly honored to be here. So back to the match experience. It was like, it was so surreal that on Monday when we both found out that we matched. So my mom actually started her journey to applying residency back in 2016 when she started for like studying for the US MOE boards, like in her spirit time outside of work. And she even applied to the match last cycle and she actually won a match. So this year for her, she did not have very high expectations going into it, knowing that Trudy odds her stack against her. So finding out that we both matched was quite a surprise, actually. So after we found out, you know, I reached out to our dean and our communications department at my school to help us just get us a shout out during the match day ceremony. But that's actually when the snowball started rolling. So the first tweet about us, you know, on Twitter got close to half a million views within the week. And we got interviewed by like two local news stations at the match day ceremony. And then the days that follow, you know, we had Miss Wisconsin media reached out to us, wanted to do a story, then several national news organization also started reaching out. And that's how we made it to Good Morning America. And I throw all of this, I try to tell people that, you know, my mom is a superstar. Like what I feel like what I achieved is parallel in comparison to what she has done. So. Man, that's amazing. I mean, I can't even imagine like the pressure with match day alone, you know, regardless of everything else that's been going on around you. Man, it's really exciting, seriously, like congrats to you both. It's got to be really good feeling. Thank you. Yeah. Yeah, I mean, I know we both love just following your story and just kind of hearing what's been going on. And we're just so glad to have you on and kind of meet you and talk to you and kind of go through this whole process with you. We do have some questions for you as a medical student and kind of going up through the field. We're just curious because the radiation college is not a very well known field, even in medicine. Just want to get a sense of how you discover the field of radiation and kind of what puts you towards applying to it. Yeah. So this backstory is actually pretty cool. So coming into medical school, I was interested in oncology and was heavily considering medical oncology. So early in my third year, one of my close friends that my medical school was like, hey, why don't you come over to dinner like my friends place. He's an intern here at our hospital. So I was initially hesitant because like most medical students, I wanted to do you world. You know, it was my M3 year, but I went anyways, right? Yeah, I'll have to date with you world that night. So I went and I met this intern guy. He was doing his intern year before like going to Hopkins for IR. So he's like a super smart guy. And we were sipping him some like really expensive like collection of bourbon that he had like he had this one bottle that was like $7,000. So I was like, you're going to let me drink that who doesn't know bourbon at all. You know, and we're just casually talking about our interest in medicine. And I told him I was interested in oncology and he just paused for a second. He asked me, he said, have you ever considered a radiation oncology? And at the time, I didn't know what it was. So I was like, I don't know what that was. So then that's when he got excited. He spent the next two hours like talking into the early morning like it explained to me what radiation oncology is all about. And for me, like I was mesmerized, you know, like I didn't know like such a cool feel of that sort of combines the signs of particle physics and you know, cancer. Like that something like that existed. And I certainly wanted to know more. So he offered to commit connect me with his dad who turned out to be Dr. Minesh Mehta. And for the audience who don't know who Dr. Minesh Mehta is, he's like the aluminum and audio radiation oncology. So that's how I discovered Radon. You know, then I had like really unique experiences that like doing some work for Barian. And some really amazing mentors out there, you know, shout out to Dr. Sushil Berrywall, who knows that I'll be here today. So give him a shout out. That was incredible. That was a wonderful story. A good way to go in sounds like a treat I have to buy more $7,000 bottles of bourbon. And oh, you have big shoes to fill. For sure. And for any upcoming medical students applying this upcoming cycle or future cycles, do you have any advice that you can share with them? Things about, you know, ways, application tips, things along those lines. Yeah. So I think my general advice for medical students applying the cycle is to try to build as many connections as you can with mentors and peers, especially in a small field like Radon. I think it'll help people to get people to know who you are as a person, which not only will help you in an application cycle, but also like further down the road. So for away rotations, I understand that everybody is in a different situation, especially financially. But I would strongly recommend doing one to two ways if you can, you know, at a program that you think you would like to go to. And to succeed at your away rotation is actually not incredibly difficult. I think that, you know, it's not about how much Radon knowledge you know or how early you go in every day or how late you stay every day. I think the most important thing that you can do to convince a program to consider you as their future resident is to be likable, you know, by attendings, by residents, by staff and patients even. I think it's really important to be yourself, you know, be confident, be genuine, be humble, be curious. And if you can keep that same energy, you know, throughout the application cycle, the application season, like writing your personal statements, like doing interviews, I think it really shines through. And, you know, I think programs are going to really appreciate that. Yeah, it's, that's really solid advice. That's, that sounds great. Yeah, exactly. So now that you're all matched up, you're all ready to go getting plans going. What do you look forward to in the next few years? Yeah, for, I feel like for the next few years, I'm most look forward to finally practicing what I've been learning, you know, all my life as a job, you know, it's kind of like training as a basketball player and finally making it to the NBA. Well, actually, no, just, just kidding. It's actually just still trying to do that. I'll be there soon. Just give me a couple more years. Yeah, like, like, like, like, just especially like, it's more like the G-League for now because I'm still a resident, you know, and so not quite there yet. We'll, we'll be there one day. Like, in all seriousness, I think, I think there's three things. Like, relationships I'll build with my patients, like, with colleagues and mentors, you know, the knowledge I'll learn to be the best rat-onk doc that I can be. And, you know, finally going home to Philly, you know, where I grew up and I absolutely love there. And it's incredible. Congratulations again, I feel. It's again, wonderful story. We're really glad to see you joining our field. You know, I'm actually going to turn over to Trudy at this point. We have a special episode in line up that we're glad that you can join in on. Trudy, you want to take it on? Yeah, absolutely. And, you know, congrats again, Haffee. And we were very proud of you and remembering, you know, meeting you during the interview season and so happy that, you know, your future is very bright. So thank you for joining us today. So what we're going to do today is we're going to focus on some more foundational concepts in basics of rat-onk. That's kind of geared towards anyone that's first learning about our field, whether it be a first-year medical student or my brother who still has no idea what I do. So Haffee, you're going to walk us through it all. Is that okay with that? I'll try my best. I'm confident. I'm confident. All right. So, let's start off. What is radiation oncology? Yeah, so radiation oncology or radiation oncologist, like not to be confused with radiologists or radiology oncology. We are physicians who use therapeutic RT or radiotherapy to treat cancers, patients with either curative or palliative intent. So after medical school, we usually complete the intern year in internal medicine or surgery. And then we go on to complete four additional years of training and specialized radiation oncology training. So you know the residency adds up to total five years and in radiation oncology it is not common for residents to pursue a fellowship unlike our friends in internal medicine, surgery or OB. Yeah exactly. So that's actually one of the things I love most about our field is that we generally don't pursue additional training after residency. So even my friends who are you know I met during intern year and who are in radiology residency they will do five years residency and then oftentimes you have to do additional fellowship training. So that's you know extra time right there. Of course there are certain cases where people make standard training periods such as you know complete additional lab work to set up a future lab as a physician scientist or seek extra training and sub-sus specialization like proton therapy or brachy therapy. So have you know what percent of cancer patients or see radiation at some point during their diagnosis and cancer journey? Oh this is a pretty tough question. I think I'm just going to take a while guess that's I don't really know anything. So greater than 60 percent. Great job. You know you know much more than you think you do. Yes but that's correct. Yeah so let's talk a little bit about therapeutic radiation. So what exactly is ionizing radiation? How do we group sources of ionizing radiation? So ionizing radiation in the context of um radio therapy simply means that electrically charged particles induce direct or indirect DNA damage which stops cells from proliferating. They are two common sources of ionizing radiation. One photons and then two particle beams. So let's talk about photons first since this is like the most common type. Photons are most commonly delivered using high energy x-rays which are generated by a linach which stands for linear accelerator. The linach is the machine that accelerates electrons that can convert to photons to deliver therapeutic radiation and it is the workhorse of our field. Radiation can also be delivered using gamma rays which are emitted from the nucleus of a radioactive source. This is most commonly used in breaking therapy procedures where radioactive sources are placed near targets and used to deliver RT. But there are some other linach machines that may which may use cobalt to generate gamma rays and the other source of ionizing radiation are particle beams which include protons, neutrons, or electrons. Linachs are able to deliver electron-based treatments and this is most commonly incorporated into clinical practice typically for more superficial treatments. Protons and neutrons however require specialized accelerators and expertise that only a handful of centers across the world can offer currently. Although newer machines are now rising to make proton therapy more commonplace. Great. So generally when we are thinking about therapeutic radiation we can classify broadly as radiation being delivered externally or internally. So breaking therapy as hefe had referenced above is a form of internal radiation where radioactive seeds are implanted permanently into tumor or tumor bad directly or a high-energy radioactive source will travel through a temporarily placed catheter depositing radiation dose along its path. So one question that we often get asked by patients is don't normal healthy cells also get affected by radiation and so if you get asked that question how are you going to reply to that? Yeah so normal healthy cells may also be affected by RT or radiotherapy but the key difference is that normal cells can recover and repair this damage whereas I think of cancer cells that is generally defected and they lack the proper repair mechanism to fix DNA damage thus they die off because of radiation. So also different radiation delivery techniques are used such as intensity modulation and field shaping or fractionation to limit normal tissue exposure to radiation. Great explanation. So we will fractionate radiation for many disease sites as you may remember but can you explain what exactly does fractionation mean? Yeah so the concept of fractionation is a foundational concept of RT and basically means that we're dividing the total prescribed dose into small daily fractions. So like treatments over the course of several weeks. This typically means that the patient is getting 1.8 to 2 grays per fraction and grays is our unit of dose which is which was formerly known as rats and also fractionation acts on the basic radiobiologic principle that allows normal tissues to repair and repopulate during treatment while the malignant tissues are further damaged via redistribution and reoxygenation. Of course there are risk for inter-fractional tumor growth and this is obviously balanced by the over on dose regimen. Great job and nice slip-in of the 4Rs. So the 4Rs for those of you who may not know are the main radiobiological principles thought to impact how tissues respond to fractionated radiation. So again these stand for repair, repopulation, redistribution and reoxygenation. So let's get a little more clinical here. So have a in general what are the two indications/intent for radiation in the treatment of a cancer patient? So when considering radiation we always want to determine whether there's curative or palliative intent with our treatments. If we employed radiation curatively it is often in conjunction with surgery or systemic therapy. If radiation is given after surgery it is termed adjuvant and if given before surgery then we call it neoadjuvant. When radiation is given with systemic therapy we term it concurrent chemo-RT. Some example of disease sites where radiation can be used curatively is in prostate, breast, head and neck cancers and among many others. And furthermore you can hear the term definitive RT which means that the radiotherapy will be the primary mode of treatment often indicating that there will be no surgical interventions involved. And on the flip side radiation can be employed for palliation and to reduce symptoms from tumor burden. One of the most common indications for palliative RT is pain. Yeah great job. Exactly. Many of the reasons why radonks get consulted from inpatient services is for palliation often in advanced cases. So have a while we are on the topic of palliation. What are some common inpatient consults we may get? So as I just mentioned radiation can be an effective and durable treatment for pain control usually in a treatment of bone metastasis and other reasons why we might get consulted are spinal cord, a compression from tumor, vascular compression, brain metastasis, bleeding or bronchioca obstruction. So in patients who get palliative radiation from bone met how effective is radiation? So about two-thirds of the patients will experience some degree of pain relief and a quarter of the patients will experience complete relief. And palliation may not be instant and the median onset to pain relief is actually around three weeks. So we often bridge that with medical pain management. Yeah and then can you explain what a pain flare is because we commonly throw this term around in the clinic and how can we prophylaxically treat for that? Yeah a pain flare is a transient worsening of pain after radiation. More likely the current in patients with more severe pain at the offset. It usually develops one to three days after radiation and is thought to be secondary to the inflammatory effects of radiotherapy. And over the counter end-sets can help with the transient pain flares but a short course of steroids can also be prescribed as well if the patient doesn't respond to end-sets. Great. So let's talk about a typical routine when seeing a new patient. So the patient that comes to CS will typically already have been diagnosed and worked up. Usually these are sometimes referrals from like tumor board. So the first thing we usually do is see the patient in consultation as an outpatient. At that appointment we will make the recommendation for our against radiation and discuss logistics and side effects. So if the patient will receive radiation usually the next step is to get a CT simulation scan and which is often called CT sim for short. So have they what's a CT sim? So a CT sim is a treatment planning scan that we usually obtain before each radiation course. These scans are typically performed in a radunk department as special tables and devices and localization tools are needed. These appointments generally last no longer than an hour. And our patients are usually immobilized using a VAC lock, a mask, depending on our treatment sites to ensure reproducibility and positioning before each fraction. So for example if a VAC lock which is essentially like an air type beam back mold is created at the time of CT sim then the patient will lay in the same mold for each of their treatments to reproduce that same position. So after the scan is obtained we'll sometimes fuse the CT sim with other imaging such as PET scans or MRI which may offer better visualization of our targets and that helps delineate the treatment volumes. Exactly. Yeah so a CT sim is usually the first step in starting the radiation process and you may ask why not playing with an MRI or PET CT and the reason is that CT scans offered density information on how ready will travel through different media in the body, such as air, bone, fat, muscle, and so on. So we can use that personalized data for customized treatment planning. After the SIM, a good rule of thumb is that the first fraction of radiation will start about a week after to allow for treatment planning and quality assurance. So what's the general workflow after a CTC? So the radiation oncologist will counter the treatment volumes and noting the areas that we would like to treat with radiation and the different dose levels to each target that they might need. After the contours are finalized, a dose of mattress or medical physicists helps create the radiation plan. And the treatment planning is careful and is often a very time-consuming process. And this often is why it takes several days to come up with a radiation plan. And we, and because we want to be thoughtful in designing the best radiation plan that achieves the excellent coverage of the target while minimizing dose to the nearby organs at risk, after the plan is approved by the radiation oncologist, plan must be QAID or quality assured, which can be anything from double checking the dose calculations to running a phantom plan on the machines itself. So you're sure that our plans treatment will play out the way we intended to play out. And this typically occurs the night before the patient starts a treatment or ideally be a few days before that. Yeah, that's a great overview. QA and the many safety checks our departments have in place are very important and ensure that the treatment is delivered correctly, effectively and safely. So radiation plans they can range in complexity, often depending on the intent. So for example, a palliative treatment versus definitive, and also the dose and fractionation. So let's say the patient has started treatment. We often throw around the term OTV, so, "hafe, what does that mean?" Yeah, so OTV stands for on treatment visits. These are usually quick visits that occur once a week between the radiation oncologist and the patient, while the patient's actively getting treatment. And the purpose of these visits is to mainly assess for any acute side effects, but also we can use that time to check in with patients to see how they're doing or answer any questions that may come along the way. Exactly. And so when you're checking for toxicity, we usually divide radiation early a toxicity into a acute or chronic. So chronic toxicity is usually defined of as at least three months after the patient finishes radiation. And the toxicity profile is often different from acute toxicity. Yeah, so radiation toxicity is typically related to where we are pointing our radiation beam. And it's sometimes a common misconception by patients and even some practitioners that our patient side effects may be related to radiation when the affected organ is not in the field of treatment. Awesome. And to wrap things up, let's close with a shout out to all the team players in radiation oncology who help us take care of our patients. So one thing that I never realized, even as a medical student, is how many people are involved in treating a patient with radiation. So have they, do you want to quickly name off some members of the team who make all this effort possible? Absolutely. Yeah, so we have the physicians who, which include the radiation oncologists and often the resident as well. There are mid-level providers, nurses, texts that help in the clinic. We also have the cemeterists and medical physicists who help create the radiation plan and ensure radiation delivery is safe. And radiation therapists who actually manages the radiation delivery process, which and are by law the only ones who are able to press go on the machine. Also, there are support staff, like social workers, administration, front office staff that help ensure that our patients are cared for. And of course, medical students like me who come in just ruin everything. That's not true. We love you guys. Excellent job. Happy. That was so great. Thanks for joining us today. And again, congratulations on your match, such a big achievement. I really hope you get to spend the next few months on before you start entering your doing some fun things. And we would like to thank Astros Resources on radiation for healthcare professionals for serving as a guide for creating this episode. And we'll link the PowerPoint in our show notes. Be well and remember to trust, but always verify. Oh, thank you.