April, 2017

Extinct Is Forever

By Michael J. Katin, MD

Consider, if you will, the vaquita. This cetacean may be the mammal most likely to become extinct in the next few years.

Only slightly smaller than the average radiation oncologist, the vaquita is threatened by many of the same factors that place our specialty at risk. It has a limited habitat -- the northern end of the Gulf of California -- and a low reproductive rate. It can be the prey of sharks and killer whales. As if that weren't enough, the worst threat to its survival is being killed as collateral damage from the technique of fishing with gillnets to catch the valuable totoaba fish. In fact, technical advances in fishing in terms of tracking and deployment of gillnets (now usually only two miles long or shorter but previously much longer) have made fishing more successful but also increased bycatch, dooming dozens of other species not intended to be harvested.

It might be somewhat of a leap to compare the fate of the vaquita (Phocoena sinus) to the radiation oncologist (Homo sapiens scintillans) but it appears that our continued existence may be almost equally precarious, and vaquitas are substantially cuter and will generate a lot more sympathy. Parallels abound. Radiation oncologists have a limited habitat, being restricted to relatively large, at least borderline advanced population areas and with mobility restricted by bulky, expensive equipment, and only near sources of electrical power. Generation of new radiation oncologists is not taken for granted considering the relatively long gestation as well as decreased attractiveness of the specialty. A recent report from LinkedIn about the 20 most promising jobs in 2017 listed Hospitalist as #1!!!! Other jobs related to medical science included Pharmacist (#2), Clinical Nurse (#12), Physician Assistant (#13), Anesthetist (#17), and Medical Director (#20). Why go into surgery, medical oncology, or radiation oncology, let alone biomedical research? The other jobs were related to finance, business, and computing, including #10, Scrum Master. If I had a chance to do it over again, I would definitely come back as a Scrum Master.

Unlike the unfortunate vaquitas who need to avoid sharks and killer whales, radiation oncologists are not directly preyed upon, but still have to be very cautious in dealings with medical oncologists, hospital administrators, personal injury attorneys, and CMS (no implications intended).

Finally, as with the vaquita, a significant threat to the continued existence of the radiation oncologist is technology. This affects us in two ways. The first is that, similar to the situation in the Gulf of California, the value of another product is serving to doom our existence. The swim bladder of the totoaba fish is considered in China to have great medicinal value, and is worth up to $100,000/kilogram. The first question, of course, is whether it truly has great medicinal value, in which case we should be studying its properties, but, regardless, at that price it is impossible to restrict fishing since the reward far exceeds any penalties. In our case, the use of expensive treatments such as ipilimumab, pembrolizumab, and atezolizumab, to name but a few, with ever-expanding indications, make the price of cancer care skyrocket, and with the mindset that only a certain amount should be spent on medical care, the difference needs to be made up by cuts in other modalities. Guess which that would be?

But then, technology has the opportunity to eliminate the need for radiation oncologists altogether. As imaging, planning, and treatment equipment become more advanced and are able to communicate with each other, it's a matter of time before everything we are able to do will be automated. IBM Watson Health has developed Watson for Oncology, currently advertised to develop treatment options but, needless to say, communication with treatment units would allow humans to be excluded. It's no coincidence that Genisys was to be activated in 2017.

The salvation for the vaquita appears to be with captive breeding, since the forces leading to its extinction in the wild cannot be adequately controlled. Efforts are underway to capture the remaining vaquitas and contain them in a sanctuary in San Felipe, Mexico. Captive breeding has been successful for other species, such as the giant panda, California condor, and Arabian oryx.

Would similar techniques help to save the specialty of radiation oncology from oblivion? Volunteers?

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including April 1, 2017, this leaves 5,754 days to his goal.