Types of Oncologists & the Team Approach

When it comes to cancer treatment, one of the most frequently asked questions is "What kind of Oncologist should I see?"  There are so many kinds of doctors who describe themselves as oncologists: pediatric, medical, radiation, surgical, gynecologic, neuro- &  psycho-... Which types are formally trained to do cancer surgery? drug treatment? radiotherapy?

Are they interchangeable?  In a word, NO!, and this is true on an international scale.  

Hieronymous Bosch  A barber doing Awake Neurosurgery!

Decades ago, before the advent of complex yet significantly better options, cancer was treated by Jacks- & Jills-of-all-trades.  (In fact, centuries ago, barbers did it all.)  These days, however, the management of cancer has become so complex that one can't reasonably expect a single physician to master the intricacies of each pertinent discipline.  It now takes a multi-disciplinary team to optimize treatment planning.  In such a team, each member brings his or her focused expertise to the table, and all considerations of the represented specialties are discussed.  Differences are threshed out to enable a coordinated "best" plan that is specific to each patient.  The beauty of this is that it actually costs a patient much less to consult such an empaneled team than it would to see each specialist separately.  Soon (where not yet applicable), the laws of supply & demand will move institutions to package their teams' services for the consumers' benefit.

Imagine updating oneself in multiple specialties for, say... Breast Cancer:   new surgical techniques with hands-on training, Mammosite brachytherapy and other recent radiation technologies, the 1001 clinical drug trials for invasive and non-invasive breast malignancies, for pre-operative, adjuvant, and metastatic settings.  Then review the status of each modality every 3 months when you haven't even finished going through the standards you'd started out with.  Now do the same for the different soft tissue sarcomas of the breast. Then all the other cancers possible in humans ....Phew! 

For basic information on oncologists, try these links--

1. Define "Oncologist". Check out your doctor's credentials, not a casual description.
2. "Cancer surgeon" on a card does not imply formal subspecialization. General surgeons hereabouts can claim this title without benefit of certification... and in good faith. There is considerable overlap between the jobs of a general "cancer" surgeon and a surgical oncologist, you see, but its the skills learned from experts where they differ. Just what is the advantage of having a formally trained Surgical Oncologist on one's management team? Its important for you to know what this rare bird can offer.
3. What is the extent of a gynecologic oncologist's duties?
4. The tough job of Pediatric Oncologists
5. What is a Medical Oncologist, & what do they do?
6. Radiation Oncologists vs. the UK's Clinical Oncologists
7. Then there are the "Neuro-oncologists", a very confusing term indeed. The surgical neuro-oncologists are neurosurgeons who have had the benefit of regimented clinical training in the surgical management of brain/spine/nerve tumors. Medical neuro-oncologists, on the other hand, may be neurologists or internist-medical oncologists who are proficient in the medical management of such tumors--ie, by treatment with drugs (vs the knife or radiation).

• From the outset, it is certain that the different neuro-oncologists must work as a team, with each member contributing knowledge from his/her area of expertise. But just who best speaks for each specific area? The fact that some  facilties overseas take on both surgeons amd medical people for non-surgical work in clinical (hands-on with patients) or research (hands-off) jobs in their neuro-oncology units contributes significantly to the difficulties in defining the subsequent roles of their products.   For this reason, the practice is not popular at major training centers.  It would take a wise and conscientious hospital credentials committee to define what a program has prepared a doctor for.
   

As for surgeons who administer systemic chemotherapy when a properly trained specialist is easily accessible in the area, let's just say that, outside of gynecologic oncology, I know of no other area where that practice is considered optimal in this, the 21st century.  Even when I was still in training, surgical oncology trainees at chemotherapy units were just "passing through", just as we had to sit through their hair-raising  audit sessions in similar outsiders' roles.  After all, we were already being trained to deal with each other in a proper context even then.

Deciphering an Oncologist's Credentials

An oncologist is a physician  specializing in the treatment of cancer.  By this definition, you can have a basic science PhD who develops drugs for cancer treatment but is not an oncologist (except for his lab rats).  When the drugs or procedures are finally tried in humans, the clinicians are called in.  Why?  Well, I doubt that even Mme. Curie would’ve felt qualified to plan modern brachytherapy for cervical cancer.

There are all sorts of oncologists.  Their qualifications can be checked with the appropriate subspecialty societies that certify them as such.  Competent certification verifies all training credentials, a potentially litigious process, and administers board examinations only to those who pass scrutiny.  Observership ("hands off"), graduate research fellowships (”lab jobs”), and program interruption aren’t quite the same as completed hands-on clinical instruction.  When granted, formal certification implies that the training facilities & program were adequate, that the candidate applies sufficient knowledge to actual cases, & that he is reasonably updated in his field. 

Certifying bodies, such as those of the PSMO (Medical Oncology), PROS (Radiation Oncology), also police their ranks.  Some other societies function more as interest groups and not as certifying bodies, such as the PSO (Philippine Society of Oncologists).  Anyway, these societies are behind all those letters appended to a doc’s name.  So many F's.  What do they mean? 

• Juan de la Cruz, MD, FPSO.  Dr de la Cruz passed the basic Medical Boards & is an F (Fellow) of the Philippine Society of Oncologists.  He is not necessarily a clinical oncologist.   He could even be a pathologist.
• Jose Juan, MD, FACS.  At the very least, Dr Juan is certified by an accredited surgical society in any country.  The American College of Surgeons does not administer examinations.  Better check what he is actually certified for and by whom.
• Crisostomo Ibarra, MD, FPCS, FPSO.  A certified surgeon.  We can’t tell if he trained for any of the surgical subspecialties but, like many general surgeons, he did join the the Philippine Society of Oncologists.
• Maria Clara, MD, FPCP, FPROS, PhD (Radiation Physics).  Dr Clara is clinician-scientist certified for Internal Medicine & Radiation Oncology, with postdoctoral work in radiation physics.  Among many other things she is an oncologist.
• Ida Rizal, MD, FPCP, FPSHBT.  An internist and hematologist, Dr Rizal is competent with blood-related malignancies like the leukemias too.
• Consolacion Damaso, MD, FPSMO.  Dr Damaso is either modest or lazy.  She is both a certified medical oncologist and internist-- unless she’s old enough to have escaped the requirement for PCP certification (”grandfather clause”) imposed years ago.  Strictly speaking, her credentials are MD, FPCP, FPSMO.
• Pediatric oncologists used to belong to the PSMO when there were but a handful of them, so some senior pediatric oncologists are FPSMO.

Confusing, isn't it?

Colorectal Cancer Mabs

Another monoclonal antibody, i.e. "MAb", has been approved by the US Food & Drug guys for the treatment of chemo-resistant metastatic colorectal cancer. This time, its Amgen's panitumumab (Vectibix), a purely human MAb that's priced to give ImClone's cetuximab (Erbitux) a run for the money.  Priced to cost 20% less, its "just" a Filipino-sized US$ 7000 per month for those who may have already failed a gamut of chemo options.

How best to tell folks with the right to know? My patients are well above average in our economic totem pole, yet only 2/3 of them can afford the costs of plain old FOLFOX6 chemo. I wonder what its like to be told that one's disease is back yet again, to know that there's a new fast-tracked targeted therapy for slowing it down, & then to agonize over whether one should sell more stocks or the children's future to avail of it.

To the Powers-that-be… Never mind the MAbs for now. Maybe just a national information & screening program that actually works.

Previous Comments

good day sir!

I’m Nina Bumanglag, a student at UPLB taking up biology. I’ll be having an undergraduate seminar regarding colorectal cancer next year on january 2007.

I was hoping if I could ask for your help about what sort of treatments your patients undertake, the most common and the likely reasons for chooisng it. Your insights would really help with the seminar I am about to undertake.

Thank you Sir and God Bless!

Nina Bumanglag

Posted by nina bumanglag at December 18, 2006, 9:12 am

Hello, Nina. Its a very broad topic. Management would depend upon whether its the colon or rectum that’s affected, the stage, the presenting symptoms, co-morbidities, etc. In fact, even in specialty fora, it helps when discussions are case-based.
Best look at the simplified algorithms for patients. For evidence-based info, look here–> http://www.nccn.org/default.asp
Posted by oncodoc at December 18, 2006, 1:12 pm

hello sir!
I’m a student doing research on colon cancer and its preventive medicines. I was just wondering if you happen to know the rate of colon cancer incidences in the philippines and who are the people commonly “attacked” by this type of cancer.
thank you and god bless!
Posted by ethel at January 16, 2007, 7:46 pm

Online sources for stats include Globocan (2002) at the IARC website. The DOH puts out stats as well. Beware of under-reporting– its a serious consideration hereabouts.
As to risk factors for colon cancer specific to the Philippine population, I’m not aware of any local population-based study in this area. Maybe you can do one. Western medical literature has extensive coverage of risk, however, and you can freely access the information online in both “health professional” and “patient” versions. (See “Links”)
Posted by oncodoc at January 16, 2007, 11:14 pm