Who's Your Doctor? Reflections on Roles, Relationships, and Responsibility

Who's Your Doctor? Reflections on Roles, Relationships, and Responsibility

Miriam Knoll, MD

@MKnoll_MD
Dec 09, 2015

I was fortunate to begin my radiation oncology training on our Chairman’s service, working with lung cancer expert Dr. Ken Rosenzweig (@ken4englewood). At that time, one of my earliest clinical experiences was seeing a woman who had a history of early-stage lung cancer treated with radiation. She was scheduled for a follow-up visit to review her recent surveillance chest CT.

Unfortunately, the CT showed a recurrence. I searched through her electronic medical record to investigate which other physicians she had recently seen. My initial assumption was that she already had heard about the cancer recurrence from another physician. However, I soon realized that Dr. Rosenzweig, her radiation oncologist, was her only oncologist. The only lung cancer treatment that she had received was radiation; she had never undergone surgery or chemotherapy. It dawned on me that it was our responsibility to give her the bad news that her cancer had returned.

Surveillance is an integral part of cancer care

While rotating through different services over the past 3 years, I can recall few other patients with cancer who were monitored solely by a radiation oncologist. In most cases, for example, after completing treatment for her breast cancer, a patient would continue to see her surgical oncologist, medical oncologist, and radiation oncologist for follow-up visits. In addition, she would routinely see a radiologist for mammograms, MRIs, or occasional biopsies.

In fact, even patients who had received definitive radiation alone still followed up with many physicians. For example, a man with prostate cancer who underwent definitive external beam radiation to the prostate continued to see his urologist for surveillance.

Additionally, after a physician sees a patient for a follow-up visit, they often communicate with the other oncologists who also care for that patient. In this way, new findings are discussed and multidisciplinary patient care is retained.

Technology is changing the face of early-stage lung cancer

Now, during my final year of training, I am back on the lung cancer service. Over the past few weeks I've seen many patients with lung cancer for consultation and follow-up visits. Once again, I’ve encountered many patients who remain under Dr. Rosenzweig’s care alone. They don’t have a surgical oncologist because they’ve never had surgery for their lung cancer. They don’t see a medical oncologist because they’ve never received systemic therapy.

During a discussion with Dr. Rosenzweig, he shared with me how his role as an oncologist has changed over the years. He explained, “During the course of my career, there has been a shift in how I interact with some patients. Previously, it was rare for me, as a radiation oncologist, to be the only oncologist a patient would see. I would usually contribute to the care provided by colleagues in surgery and medical oncology. Today, with the enormous success and utilization of stereotactic body radiation therapy [SBRT], we are frequently the only cancer specialist a patient may see, especially for early-stage lung cancer.”

Lung cancer screening is now commonplace

As lung imaging improved, many more early-stage lung cancers were detected. Additionally, the technology of radiation therapy delivery vastly improved over the past 2 decades, allowing SBRT (otherwise known as stereotactic ablative radiation therapy [SABR]) to gain ground as a safe and potentially alternative treatment for early-stage lung cancer. Therefore, many patients with inoperable early-stage lung cancer have received only SBRT for their treatment. A large portion of these patients have excellent survival and continue to remain under the care of their radiation oncologist for many years.

As lung cancer screening programs are implemented nationally, the role of SBRT will likely increase. Most commonly, SBRT is only offered to patients with biopsy-proven early-stage lung cancer who are medically inoperable or who refuse surgery. While some patients are medically inoperable, others with radiographically suspicious lung lesions cannot even undergo biopsy. There are times when a Tumor Board may present a radiation oncologist with the clinical question: Can you take the responsibility of treating this patient without biopsy-proven malignancy? This brings the radiation oncologist's role into a previously undefined era.

As technology and medicine continue to progress, our roles as oncologists evolve. Our relationships with our patients and multidisciplinary team members can transition as well. Our profession is undergoing rapid changes, but our responsibility to treat our patients and #EndCancer remains.

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