Beyond the ROI- A Radiation Oncologist’s Personal Insights into the Other Side of the Table

Before we start talking about how SGRT is revolutionizing the field of radiation oncology, I just wanted to take you back in time to the early 2000s when I was a resident in radiation oncology. Back to the times when we were watching Tony Soprano, Carrie Bradshaw, and six friends hanging out in a coffee shop, and back to a time where Britney was still on the radio, and Justin was still in NSYNC. It was during this time that I was using a four-field box to treat prostate. I was putting wires on my breast cancer patients in fluoro to figure out what was the best tangent angle. We were matching photon and electron beams to treat head and neck cancer patients. And as the lowly resident, I was holding a plastic bag open for the therapist to pour foam into so that we could form these alpha cradles.

We were learning alongside with our attendings also at this time about a fancy new technology called IMRT, and this amazingly precise radiation technique allowed us, as you all know, to escalate dose while also sparing nearby normal tissue. And I still remember my very first pelvic IMRT patient. We simmed her on a Friday afternoon, and before my attending left for the weekend, she tasked me with contouring this patient. And she reminded me that it was really important that I do really good contouring because we didn’t want any of the high doses spilling out into the normal tissue. So I went in on a Saturday, sat in a dark room, and just literally contoured every loop of small bowel on every axial CT scan.

Come Monday morning, I was really excited to show my attending what I did. We sat by the treatment planning machine waiting for the plan to come up, and she asked me how long did it take me, and I said, “Oh, about four to five hours.” And she was kind of shocked and had no idea what I was doing for four to five hours. And then when the plan finally came up and she literally saw thousands of contours, she said that was interesting, told me a simple bowel bag would have sufficed, and then also introduced me to this amazing little tool called interpolation. I could hear the dosimetrist snicker as my face turned bright red.

Since my early days, I’m happy to say that my understanding of radiation oncology has come a long way, with a significant amount of my learning actually happening as an attending because of how quickly our technology and treatments are evolving. And while I must admit, sometimes I feel completely overwhelmed as you’re literally learning on the fly, it has been amazing to have this front row seat to all of this progress.

So we often talk about the war on cancer in terms of battles won and lost. But if we look at the landscape of where we are today, the map of that war has completely changed dramatically. And as early as 2025, we have an estimated 18.6 million cancer survivors in the United States alone. To put that into perspective, that is roughly one out of 18 Americans. And this number is projected to exceed 22 million by 2035. This figure is a testament to the fact that our treatments are working, and as more and more patients are walking through the fire and coming out on the other side, we must confront the reality of the aftermath, acknowledging the everlasting effects of side effects and treatment-related complications. For many patients, healing from the cure can be just as demanding as surviving the disease.

As clinicians, our primary focus has always been on prolonging quantity of life, with the patients themselves willing to undergo treatments that would eradicate disease at any cost. In training, I was taught that patients can live with treatment toxicity, but they cannot live with recurrence. So if push came to shove, you do not underdose the tumor. So back in the day of four-field box and matching photon electron beams, it was really common to find patients with significant treatment-related side effects. I still remember treating prostate cancer patients for five weeks, and then we would break them for two weeks because they could never make it through a nine-week course of radiation because of the unrelenting diarrhea and the proctitis. I also remember my head and neck patients who would come in with no teeth because they had such bad xerostomia that their teeth just decayed in their mouths, and they either had to be pulled or they just fell out. And I will never forget the left-sided breast cancer patient that reminded me a lot of myself, who I had developed a relationship with over my four years of residency, and at seven years, she didn’t show up, and it was because a few weeks earlier, she died of a heart attack. These patients are all examples of how clinical success means little if we neglect the long-term side effects and emotional recovery that follow a diagnosis.

Thankfully, over the years, our field has advanced to the point where what we do today is radically different than what we once did, and we are allowed to prolong quality of life without sacrificing quantity. Two years ago, I came to experience the impact of these advancements firsthand when a diagnosis of breast cancer transformed the disease from my profession to my personal reality. What should have been another routine Wednesday morning turned into one of the worst days of my life when I went in for a screening mammogram, which I get every year like clockwork. And honestly, I really expected to be in and out in 30 minutes because I was healthy, I had no risk factors, and I had no symptoms. So when they found calcifications in my right breast, I was surprised, but I wasn’t alarmed because honestly, calcifications like those mean early-stage disease, which is entirely treatable and highly curable.

And then I moved on to the ultrasound, and that’s when everything stopped. They found five masses in my breast, as well as an abnormal lymph node. And then the MRI just kept getting worse. They found small tumors pretty much in every quadrant of my breast, and I do believe the report read something along the lines of tumors that were too numerous to count. The biopsy of two of the biggest tumors and the lymph node were all positive for lobular cancer. As devastating as this all was for me, I kind of thought if I was going to get a cancer, I guess this would be the one to get. After all, I’m considered an expert in the field, I know all the treatment algorithms, all my close friends would be my doctors, and I could pretty much get any test performed within a matter of hours to days.

The first step of my treatment was going to be surgery. And because of how extensive the disease was in my breast, we could not do a lumpectomy. So I figured if I was going to get one off, we would just get both off, and then I got implants. Genomic testing showed that my cancer was low risk, meaning I didn’t need chemo. And as a radiation oncologist reviewing my own plan, I figured if I didn’t have any more lymph nodes, the size of my largest tumor didn’t meet criteria for post-mastectomy radiation. So I didn’t really think I needed radiation, and I just thought I’d go through surgery, be put on a pill, and then I would just kind of move on with life.

My cancer, unfortunately, had other plans. When I was taken to surgery, I had more extensive disease than initially anticipated and was deemed clinically high risk. Therefore, my oncologist recommended I get some chemotherapy. When I reviewed my own pathology, I saw that I had positive margins. I begged my surgeons to take me back to surgery because I did not want radiation. But unfortunately, there wasn’t much more tissue they could resect, nor did they have confidence that they could even find the positive margins. So unfortunately, this also bought me radiation. And to top it all off, a medication called Verzenio was added to my treatment because I was now high risk. And for those of you that don’t know, CDK 4/6 inhibitors can wreak havoc on your GI system. So it is certainly not an easy medication to tolerate. Suddenly, my simple two-step plan to beating cancer became a bit more complicated, and it was clear that there would be no quick recovery.

That being said, I healed well from surgery, and three weeks after the procedure, it didn’t look like anything had happened to me. Then I rolled into chemotherapy, and I was fortunate there too as well. Aside from extreme fatigue and the hair loss, I was able to work through treatment and be there for my kids. For me, the most challenging part was radiation. And I know it’s because I knew too much. Having spent the past 15 years of my life specializing in the treatment of breast cancer, I’ve seen every radiation complication. So radiation pneumonitis, broken ribs, chest wall syndrome, cardiac complications, malignant tumor induction. These were all the visuals that were floating around in my mind as I was getting ready to do radiation. I knew the risks were low, so I understand that. But when you go from being the one prescribing the beam to having to receive the beam, those percentages don’t feel low anymore. They feel like a looming threat where everything is a real possibility. Add to the fact that I am a type A self-diagnosed micromanager who feels comfortable when I’m in control, being on the table was a huge lesson in vulnerability and another reminder of how I wasn’t in control, the cancer was.

I chose to be treated at my center with my therapist that I’d spent years working alongside of. I realized there could be a certain level of awkwardness as I had to lay topless on the table. But I also realized that we were all professionals, and for the 15 minutes I was in the treatment room, I would be the patient, and they would be the therapist. My partner was my treating physician, and she prescribed 16 fractions. Because my chest wall shape is more rectangular rather than oval, we had to use IMRT because 3D just resulted in too much lung in the radiation field. We also utilized deep inspiration breath hold, which at our center is standard regardless of what side the cancer is on. At the time I was undergoing treatment, we were predominantly using RPM for respiratory monitoring. While we did have SGRT, not all the therapists were trained on it. It kind of slowed us down because we weren’t quite sure how to fit it into our workflow, and we really just reserved it for special situations. So it wasn’t considered standard at the time.

RPM, as you all know, is respiratory motion technology that uses infrared cameras and a marker box placed on the patient’s abdomen to track chest wall motion. So RPM is monitoring a surrogate, not the actual target. And in my case, it didn’t work. My abdominal breathing was surprisingly inconsistent, and I was unable to maintain my breath hold in the specified range. While I thought I was breathing like a champ, RPM did not. So that’s a normal one, and that’s what you want, and that was literally me. It just shot straight down. So as I lay on the table waiting for the sim to be over, my therapists were literally drawing straws to see who would come in and tell me the bad news. And they knew I wouldn’t believe them, so they actually took a picture of my waveform and showed it to me as I laid on the table with my arms above my head in the back lock.

I knew what this meant. Under the RPM standard, I would’ve been deemed a failure and treated in free breathing. This was personally devastating, and I was already struggling with the idea of radiation, and now without the ability to do breath hold, I visualized radiation just shooting through a lot of normal lung, my liver, and a little bit of my heart. This is where the power of SGRT became undeniable. My physicist suggested that we use AlignRT to see whether my abdominal movement was the issue or whether my breathing just truly was bad. And do I just hit the button? The instant that we looked at the actual surface being treated, we found I am an excellent breath holder. So by tracking thousands of points across my entire surface, it wasn’t guessing, it was seeing. It accounted for my six degrees of freedom, which RPM does not, and it gave me the submillimeter peace of mind I needed to relinquish control and finally be okay with radiation.

It took me being the patient to realize that SGRT doesn’t just manage motion, it manages human variability. This realization was humbling and quietly transformative because for me, this was the first time I understood that the true value of SGRT wasn’t technical superiority alone, but it’s respect for the reality that patients are not rigid objects, and that the safety and trust emerge when technology adapts to the person, not the other way around. And yet technical precision is only meaningful if it serves what comes after treatment. As our tools become more exact and less destructive, we don’t just control disease, we protect the possibility of survivorship where healing continues long after the last fraction is delivered.

Many people who have never been patients see the cancer journey completing once treatment is done. But what many survivors know and what I know now, is that survivorship is a long winding road that lasts the rest of the patient’s life. It tends to be the most challenging phase of all, despite traditionally receiving the least amount of medical attention. As we push past 18 million survivors in this country, we must continue our commitment to precision care because quality of life needs to be valued just as much as quantity of life. And technological advances are the key for allowing us to do so, as advances allow us to be as precise as possible, buying the patient and the treating team peace of mind.

While in the beginning, SGRT may seem like extra work, it is actually a workflow optimizer providing the therapist with an objective go, no-go signal and removing the subjectivity of looking at a marker or interpreting a waveform. By implementing SGRT, you are building a system that is self-correcting. You are reducing the need for repeat imaging and redos that kill a machine’s schedule, as well as the patient’s trust in the therapist. You aren’t just buying a camera, you are buying time and certainty. And as a patient, I know firsthand how certainty is able to replace anxiety with confidence.

We’ve come a long way since my residency, thanks to systems like Vision RT, which provide the essential technical foundation to push the treatment envelope and redefine successful outcomes. When we invest in this level of certainty, we move beyond simply delivering radiation to providing a higher standard of compassionate, precise care. Ultimately, as our technology advances, our patients’ peace of mind and quality of life can finally advance alongside of it. Thank you.

 

 

This transcript was generated using AI. If you note any issues, please email us at secretary@sgrt.org.