What is the difference between clinical and medical oncology? How often have we all heard that question? Rarely from patients, more commonly from trainees looking at career choices or more worryingly from august members of national bodies. I remain surprised that those who are charged with delivering sustainable non-surgical cancer services in the UK are unsure of what service they are shaping. Why are patients less curious? I suspect they mostly assume (hope? believe?) the person in front of them is an expert and are less concerned with titles.
My stock answer mentions radiotherapy in addition to systemic agents as a treatment modality. However, in the increasingly complex world that cancer therapy has become, I wonder if my answer is too simplistic. Am I personally better defined more as a clinical oncologist rather than a specialist in the management of thoracic malignancies? Are we at the tipping point of site specificity versus modality specificity? How do we view ourselves?
The more I speak to colleagues around the country and look at various survey responses, the more I see the practice of clinical oncology as a spectrum. On the one hand there are those who profess to be radiation oncologists. As always, the devil is in the detail. There are indeed some colleagues who deliver absolutely no systemic therapy, but these are rare beasts indeed. As far as I have been able to ascertain they are either recruited from non-UK training schemes (most commonly continental Europe) and support the service delivering mainly breast and/or prostate radiotherapy in centres where radiographer skill mix has been limited or they inhabit large centres with significant national research funding. Interestingly the latter group, when challenged directly, often admit they provide combined modality therapy in the curative setting but no palliative sysstemic anit-cancer therapy (SACT). So there exists the potential to misconstrue the complexity of service delivery in the careless use of shorthand.
At the other end of the spectrum are those who possess an FRCR (which implies a nodding acquaintance with photons) but whose scope of practice almost exclusively ignores their presence (photons that is). There are even centres where the radiotherapy service is delivered by extended role radiographers, with the corresponding SACT delivered by clinical oncologists. Most of us exist somewhere between the two extremes, dictated by clinical preference or service need, usually both. Increasing workforce pressures are often manifest as colleagues trying to maximise the time they spend on the technical aspects of curative radiotherapy (where one can argue they deliver the best bang for the population buck). For many, but by no means all, this results in a shared practice with the majority of palliative SACT delivered by a medical oncology colleague.
From this perspective are medical and clinical oncologists completely different tribes or merely part of the same spectrum? Our defining skills (those which cannot be easily skill mixed away or taken over by artificial intelligence [AI]) are very similar: understanding each cancer as an individual illness, assessing patients’ fitness for therapy, communicating the risk/benefit ratio to each individual patient in an accessible and personalised fashion. What divides us – except ourselves?
Would our patients benefit from closer working between the nonsurgical cancer disciplines? Undoubtedly. There are different staffing problems in each department, but I have yet to talk to a department who feel they could not benefit from more staff. True, staffing ratios vary markedly, so there are myriad possibilities on how to cut the available cloth, but in this current time of spiralling demand, poor outcomes nationally and increasing work force shortages, working together to maximise experience whilst minimising inefficiencies can only benefit patient outcomes.
The General Medical Council (GMC) have tasked all specialties to rewrite their curricula based on high-level outcomes, rather than detailed lists of competencies, as is the current form. An additional charge is to identify commonalities between specialties to facilitate interspecialty transfer for trainees. The final hurdle (at least for now) is to demonstrate consultation and input from stakeholders i.e. those who will utilise the service. For those of us born after 1960, that equates to half of us directly and almost certainly the other half as a spouse, child, sibling. So, I think we are all stakeholders. In the spirit of efficiency and effectiveness, we have opted to conduct this process with our medical oncology colleagues. Have your say as a stakeholder at email@example.com. Suggestions on a better answer to the perennial question on the differences between clinical and medical oncology can be sent direct to me.
Dr Jeanette Dickson
Vice-President, Clinical Oncology