Instructions for

Use of These Slides

• The purpose of these slides is to serve as a resource that any
radiation oncologist can use when introducing medical students to
a career in radiation oncology.

• It was designed with an extracurricular “oncology interest group” seminar

in mind, though portions could be used in other curricular contexts as well.

• We would encourage tailoring these slides to your audience, and

being flexible in your approach to meet the students’ needs.

• Please encourage students attending your presentation to complete the

following questionnaire afterwards so that we can improve outreach efforts
in the future. It should take less than 5 minutes to complete.
https://redcap.link/radiation

Primary Author: Malcolm Mattes

Peer Reviewers: Thomas Eichler, Neha Vapiwala, Curtiland Deville

Jr, Trevor Royce, Daniel Golden, Shauna Campbell
 A Note on Content Related to the
Future of the Specialty (Slides 46-55)
• This may be the most controversial section. The authors
acknowledge that there are many opinions on the future of the
radiation oncology profession and job market, and it is inherently
challenging to predict the future.

• The goal of these slides is to provide a transparent assessment of

the situation so that students are informed in their decision
making. However, we would encourage any individual who uses
these slides to present the content that they personally feel is
most appropriate.

• We would suggest the following further reading about the

radiation oncology job market if you would like to learn more:
• https://doi.org/10.1016/j.ijrobp.2020.11.056
• https://doi.org/10.1016/j.ijrobp.2020.12.024
• https://doi.org/10.1016/j.ijrobp.2021.02.035
• https://doi.org/10.1016/j.ijrobp.2016.05.029
 Introduction to
Radiation Oncology
 Radiation Oncology Is
A Small Field
Virtually no one envisions
~950,000 themself as a radiation
US doctors ~5,000 US radiation
oncologists (0.5%) oncologist when they
apply to medical school;
most people have never
heard of it!

However, those who do

get some exposure to
the specialty tend to like
it.
 Objectives for Today

• Learn how radiation therapy (RT) is

incorporated into multidisciplinary cancer care

• Understand basic principles of radiation

oncology, applicable to any field you choose to
pursue

• Understand the pros and cons of a career in

radiation oncology, and how to be a
competitive applicant should you choose to
pursue it
 Opportunities to Get More
Exposure to Radiation Oncology
• Online Educational Resources
• ROECSG- https://roecsg.org/introduction-to-radiation-oncology/
• Free ASTRO Membership- https://www.astro.org/Membership

• Mentorship
• ARRO program- https://forms.gle/wjr5iY5E8nQD3Fgy6
• ASTRO program- www.astro.org/mentormatch

• Research Funding
• Your own school’s MS1-2 summer research programs
• ASTRO Minority Summer Fellowship Program
• ACR Pipeline Initiative for the Enrichment of Radiology
• ASCO Diversity Mentoring Program
• RSNA Medical Student Research Grant
 Defining “Oncology”

• What is Oncology?
• The study and treatment of tumors

• What is a Tumor?
• A swelling of a part of the body, generally without
inflammation, caused by an abnormal growth of
tissue, whether benign or malignant (cancer)

Grade 1 Meningioma Grade 4 Glioblastoma

 Defining “Oncologist”

• There are 3 types of Oncologists

Surgical Oncologist Medical Oncologist Radiation Oncologist

“The Army” “The Navy” “The Air Force”

6+ years of training 6 years training 5 years training

- subspecialty dependent - 3yr Int Med residency - 1yr internship
- 3yr Hem/Onc fellowship - 4yr Rad Onc residency

Only treat specific Trained to treat all Trained to treat all

disease site disease sites disease sites

• All are equal partners in cancer care

• All work together to manage patients
Defining the Treatment Modalities
• Surgery is a local/regional therapy

• Radiation is mainly used as a local/regional therapy

• Sometimes it can be is systemic therapy (e.g. TBI/radioisotopes)

• Chemotherapy is a systemic therapy

• Though it can enhance local control when used with radiation

• Chemo is primary treatment for hematologic malignancies

• Since there is nothing local to cut out or irradiate

• Surgery or radiation is primary treatment for solid malignancies

• Unless they become metastatic (primarily a systemic issue)

• Combinations of therapy are common for many cancers

• Approximately 1/2 to 2/3 of patients with cancer receive radiation at
When people hear the word
“radiation” they often think…

The reality of medical use of

radiation therapy is very different
Indications for Radiation Therapy

• Radiation is an important component of curative

treatment either alone or in combination with
surgery, chemotherapy, and immunotherapy

• Radiation is a very effective palliative treatment

of symptoms from advanced cancers that are no
longer curable

• Whether used for curative or palliative indications,

radiation can provide quality-of-life benefits that
may not be possible with the other modalities
 Radiation Therapy as a
Complement to Surgery

• Adjuvant radiation can eradicate microscopic

tumor cells in a post-op tumor bed or nodal region

• Neoadjuvant radiation can downstage a tumor

and make it more amenable to surgical resection

• Examples include:
• Breast cancer, soft tissue sarcoma, malignant
gliomas, uterine cancer, rectal cancer,
esophageal cancer
 Definitive Radiation Therapy
Instead of Surgery
• In some cases, definitive RT is used instead of
surgery with comparable probability of cure

• Potential reasons include:

• Not all tumors are surgically resectable
• Not all patients are medically operable
• Some cancer surgeries are very morbid
• Organ preservation is desirable

• Examples include:
• Prostate, cervix, larynx, pharynx, anus, bladder, lung
Palliative RT for Incurable Patients

• Pain
• bone metastases

• Neurologic Symptoms
• spinal cord compression
• brain metastases

• Bleeding
• bladder, cervix, lung

• Obstruction
• Superior vena cava, airway, esophagus, bile ducts
 How Does Radiation Work?

80% X-rays interact with water

radiolysis

free radicals

bind to and damage DNA

cell death
(by mitotic catastrophe)
20%

Cancer cells are more susceptible to RT

due to impaired DNA repair pathways
 External Beam
Radiation Therapy
 Linear Accelerator (Linac)

• Delivers high energy X-rays (photons) or

electrons
• Non-invasive
• Rapid treatment delivery, in minutes
 Simulation

• Step 1: Position patient and design

immobilization device
• Goals = comfort and reproducibility
• Alpha-cradle:
– Foam ingredients mixed 
exothermic reaction  foam
rises to conform to patient

• Aqua-plast:
– Plastic “mesh” heated until
soft  shaped to conform while
warm  cools to rigid form
 Simulation

• Step 2: CT scan  tattoo/mark patient

Isocenter
 Target-Volume Delineation

• Step 3: Draw the target(s) on PTV

the planning CT (+/- with image CTV
“fusion” with PET or MRI)
GTV

• GTV (Gross Tumor Volume)

• Visible disease
• CTV (Clinical Target Volume)
• GTV + margin for clinical
uncertainty/microscopic spread
• PTV (Planning Target Volume)
• CTV + margin for physical
uncertainties (e.g. positioning,
respiratory motion)
 Generate a Treatment Plan
• Step 4: Use sophisticated computer software to
add RT field(s), and determine “quality” of plan
by calculating dose to tumor and normal organs

Isodose Curve: Dose-Volume Histogram:

A line passing through Relates RT dose to volume of
points of equal dose all contoured structures
 Sometimes a Simple
Treatment Plan is Sufficient

• Adjuvant RT for
right sided breast
cancer

• Palliative treatment
to most bone
metastases
 Sometimes a More Complex
Intensity-Modulated Radiation
Therapy (IMRT) Plan is Necessary
• MLCs can dynamically modulate the
dose intensity around a curved
target volume
o Enables dose escalation or
reduction in toxicity
o Valuable in curative and
reirradiation settings

3DCRT IMRT

Rectal Cancer
 Other Examples of IMRT
Treatment Planning

CNS Gliomas H&N Cancer Lung Cancer

Prostate Cancer
Image-Guided Treatment Delivery
• Accounts for daily shifts in soft tissue anatomy
or patient setup

• Enables reduced margin around tumor  less

risk of toxicity
 Radiation Dosing

• Gray (Gy) is the unit of RT dose

• 1 Gy = 100 centiGray (cGy)

• The dose from 1 cGy roughly equals 1 CT scan

• Dose prescription depends on:

• Goal of treatment (curative > palliative)

• Amount of disease (gross > microscopic)

• RT sensitivity of tumor

• RT sensitivity of surrounding normal tissue

The Total Dose is Delivered in a
Series of Daily Fractions
• Most patients receive multiple fractions during their
treatment course

• RT typically delivered once-daily, 5 days/week (30-

45 min/visit)

• Fractionation decreases risk of toxicity by allowing

for DNA repair in normal tissue

• The potency, or Biologically Effective Dose of a

RT course depends not only on total dose, but how
that dose if fractionated, and the tissue irradiated.
Stereotactic
Radiosurgery
What is Stereotactic Radiosurgery?

• Use of a high dose/fraction

of RT in a very focused way

• High probability of
local control (>90%)

• Can be done safely for well

defined, small-medium
sized targets, using our
most advanced treatment
technologies to deliver this
very potent dose safely
Special Stereotactic Radiosurgery
Treatment Platforms
• Gamma Knife
• Head frame immobilization
• 192 Co-60 sources
• Used to treat brain tumors with high precision
Special Stereotactic Radiosurgery
Treatment Platforms

• Cyber Knife
• Robotic arm can treat tumors throughout body
• High precision, but very long treatment times
Proton Beam Therapy
 Proton Beam Therapy
• Advantage over photon IMRT in dose distribution;
less low-intermediate dose to surrounding tissues.

Reduces risk of long-term Benefits under investigation

side effects in pediatric in adult malignancies
malignancies (where low dose may have
less impact on toxicity)
Brachytherapy
 What is Brachytherapy?
• “Short distance” therapy using radioactive implant
• >100 years old, since radioactivity was discovered

• Radioactive sources placed on or inside a tumor

• Can be temporary or permanent implant

• Allows ↑ dose escalation by sparing normal tissue

Prostate IMRT Prostate Brachytherapy

 Example of a
Prostate Seed Implant
 Other Examples of
Interstitial Brachytherapy
 Examples of
Intracavitary Brachytherapy
Choosing a Career in
Radiation Oncology
Primary Care vs. Subspecializing
• Cancer requires complex care by many
physicians
• PCPs are critical to prevention, screening, and
initial symptom assessment

• Specialists like gastroenterologists,

pulmonologists, urologists, pathologists and
radiologists are critical to diagnostic workup

• Surgical, medical, & radiation oncologists are

critical to treatment

• There are pros and cons of all paths; we

need diverse representation in all areas of
medicine
 Why Radiation Oncology?
• The treatment modality itself is
rewarding
• You get to cure cancer every day!
• When used for cure, RT is often oriented towards
preserving normal function. When used for
palliation, the risk:benefit ratio is often favorable
• No radiation exposure for us

• The patient interactions are rewarding

• Although often confused with radiology, radiation
oncologists see patients every day
• Variety of patients; short & long-term relationships
• Have plenty of time with each patient  meaningful
& educational interactions
 Why Radiation Oncology?
• Cancer is intellectually stimulating
• Treatment approaches evolve with time
• There is much more to learn about cancer (lots of
research funding and opportunity)
• A somewhat “science-oriented” specialty
• Lots of new, evolving technology
• And exercising social responsibility to use it in a
patient-centered way
• Lots of procedure opportunities
• If desired
• Lifestyle
• Outpatient hours, home call, few emergencies
• Plenty of time to do research, teach, or enjoy life
 Concerns With Radiation
Oncology
• Usually not first Oncologist a patient sees
• Depend on referrals from surgical and medical oncology
• Need to develop relationships with referring physicians,
and educate them on the value of RT

• Disadvantages of being in a smaller field

• Minimal curricular attention in med school  RT is a
relative unknown for most doctors
• Risk for less political influence locally and nationally
• Sacrifice some geographic flexibility in residency match
and job market

• Suboptimal Workforce Diversity

• 27% women, 9% under-represented minorities
• This is a need, but also an opportunity if you want to help
make a difference in addressing cancer health disparities
through patient care and/or health policy.
 Examples of Radiation Oncologists
Addressing Health Disparities Locally

• Develop departmental initiatives to create a more

inclusive workplace or more patient-centered
treatment approaches

• Work with community partners and population

scientists to improve cancer screening, education,
survivorship care, etc

• Join medical school or GME committees to teach

about health equity, holistic review processes, or
how race impacts patient care

• Organize workshops or mentorship program for high

school students
Examples of Radiation Oncologists
Addressing Health Disparities
Nationally/Internationally

• Join a cooperative group health equity committee

to ensure equitable clinical trial design and access

• Work with national specialty societies to develop

relevant education and advocacy initiatives
related to DEI

• Work with International Atomic Energy Agency

(IAEA) to build treatment facilities in countries
with fewer resources
 What About
Job Security?

How Does Radiation Therapy Fit Into the

Future of Oncology?

Understanding Concerns About the

Radiation Oncology Job Market
 Surgery: The “Historical
Standard”
Surgery has evolved and improved over time...

but by nature it is limited by its invasiveness.

In all areas of medicine, there is a trend toward

developing less invasive techniques and being
more judicious with their application
 Systemic Therapy and
Radiation Have Great Potential
Both modalities have become more targeted in
their approach. They are largely non-invasive,
complimentary and synergistic.
Radiation and Systemic Therapy
Will Continue to Improve
• We will learn more about what drives tumor
formation and growth
• Systemic therapy has become increasingly targeted
• More precisely tailor/individualize treatment to a
patient’s specific tumor

• Radiation physics will continue to develop

• Delivery of RT more precisely with less side effects

• Radiation biology will continue to develop

• Better drugs to sensitize cancer cells to RT
synergistically, or protect normal tissue from RT,
optimize tumor kill
Will the Drugs Get So Effective
That Radiation is Unnecessary?
• Unlikely (at least not in the foreseeable
future)

• Targeted/biologic/systemic therapies are

typically not curative

• Tumors may temporarily stop growing,

but the cancer cells eventually evolve
and develop new mechanisms of growth
and survival
 What About
Job Security?

How Does Radiation Therapy Fit Into the

Future of Oncology?

Understanding Concerns About the

Radiation Oncology Job Market
Is Securing a Rad Onc Residency
Position Currently Competitive?
• Yes, for the best residency programs
• No, to match into any residency program

• Mainly due to more available positions at

present, and concern about job opportunities in
certain geographic regions
Bates J et al, Pract Radiat Oncol, 2020
 How is the Job Market
Currently?
• 94% of graduating Rad Onc residents in 2020
participated in a job market survey

• 1 out of 179 residents did not report having a job

offer at the time of the survey (May 2020)
• No other information was provided by that individual, and their
circumstances post-residency were not assessed.

Please rate your overall satisfaction with the position you

have accepted or your plans for next year.
4% 5% 65%

2% 24%
Very Dissatisfied Dissatisfied Neutral
Satisfied Very Satisfied
Campbell S et al, ASTRO Annual Meeting, 2020
What Does the Future Hold?

• A variety of changing market forces impact

supply and demand, for all medical fields

• Demand for RT may be reduced by:

• Technologic advances allowing for more efficient RT
delivery in shorter courses
• New systemic therapies or surgical techniques

• Demand for RT may be increased by:

• An aging population leads to more cancer
• Expanding indications for RT to complement systemic
therapy for metastatic disease
• Expanding indications for definitive RT in the curative
 Take-Home Points
• Choose the field of medicine that intrinsically
motivates you, and will provide you satisfaction

• Radiation oncology remains a rewarding specialty

despite concerns about the future job market

• If living in a specific geographic area is very

important to you, then small specialties like
radiation oncology may be a more challenging
choice to meet your goals

• If you are flexible in where you live and work, the

current Rad Onc job market is likely to support you
 So Now You’re
Potentially Interested in
Radiation Oncology

How Do You Do It?

Know the Data: NRMP 2020

Becoming P/F to
limit bias in its
utilization

Skewed by % with
a PhD. For MD’s, 1-
2 publications is
usually enough to
match

Likely related to
heavy weighting
of research
experiences
General Strategies to Be a
More Competitive Applicant
• Study Hard and Be Responsible
• Grades and USMLE exams matter
• Avoid disciplinary actions for academics or professionalism

• Research
• Clinical vs. basic science vs. health systems vs. health policy vs. cost
effectiveness vs. education, etc
• Think about what type of research you would realistically want to incorporate into
your career.
• Pick a good mentor that publishes frequently
• Try to get a realistic sense for how long the project will take to complete and publish
and your role in it (including authorship)
• Start early

• Letters of Recommendation
• Be enthusiastic and proactive
• Take on as many clinical responsibilities as possible
• Be honest and humble when you don’t know something

• Leadership/Volunteering & Networking

 Thank You!

• Post-Presentation Questionnaire:
• https://redcap.link/radiation

• Online Educational Resources:

• ROECSG-
https://roecsg.org/introduction-to-radiation-oncology/
• Free ASTRO Membership-
https://www.astro.org/Membership

• Mentorship:
• ARRO program- https://forms.gle/wjr5iY5E8nQD3Fgy6
• ASTRO program- www.astro.org/mentormatch