While radiology has devoted considerable effort and expense to devising electronic methods of better meeting the needs of its various constituents in orthopedics, neurology, surgery, and elsewhere, a rather sticky dilemma has been developing in its own backyard-radiation oncology. Considering the shared history of the specialties, this development should not be ignored.
Though well known, the complaints of radiation oncology have been heard with, I suspect, only half an ear in a health care environment that prizes increased throughput. Cancer patients do not fit handily in a 15-minute time slot due to the positioning requirements, and radiation oncologists complain that their patients are frequently bumped off the CT schedule.
This is not a new complaint, but as radiation oncology ascends from the hospital basement and onto the radar screen of hospital administrators with billings rising nationwide, the specialty is gathering the clout it needs to successfully lobby for the acquisition of its own CT and, in some instances, positron emission tomography (PET) technology. One vendor reports that it is selling single-slice helical CT devices to oncology departments faster than it can manufacture them.
It is true that advances in treatment have refined the ability of the radiation oncologist to target a specified volume in three dimensions, though the impact of these advances on outcomes has yet to be scientifically demonstrated, as passionately articulated by Roger M. Macklis, MD, a radiation oncologist at the Cleveland Clinic Foundation, at the recent meeting of the American Society for Therapeutic Radiology and Oncology in San Francisco.
One thing, however, is implicit: the full benefit of improved outcomes is unlikely to be realized without greater cooperation than now exists between radiology and radiation oncology. Beyond the front-end requirements of imaging for diagnosis are the primarily CT images required for calculating clinical tumor volume, gross tumor volume, and planning tumor volume for treatment planning. The armamentarium is widening, however, with the introduction of an MR treatment planning system expected to prove useful for head and neck and prostate cancers and efforts at some institutions to incorporate PET images into the planning process.
Treatment planning systems are automated, but not operator independent. They require the involvement of a physician to draw and describe the treatment area using computer tools. For radiation oncology residents, describing the treatment area must be, to put it delicately, a challenge. It has been many years since the radiation oncology residency was spun off from radiology, so the comfort of a radiation oncologist in the domain of anatomy can be measured, in fact, by the number of gray hairs on his head.
So what is the answer? Radiation oncology reportedly is considering adjusting its residency requirements, but radiology could also devise better ways to meet the specialty’s needs, particularly in helping to calculate gross tumor volume in challenging anatomical regions, such as head and neck. Informatics could play a key role here, and efforts should be made to invite the treatment planning vendors into the Integrating the Healthcare Enterprise initiative, cosponsored by the Radiological Society of North America and the Healthcare Information Management Systems Society.
The specialties of radiology and radiation oncology diverged for reasons beyond anyone’s self-interest. In order to best serve outcomes, the specialties must confer.