Posted: December 12, 2016

A recent report in CANCER, a leading oncology journal, has exposed the underbelly of radiation oncology: greed.   The authors queried 1700 radiation oncologists about their practice patterns in treating rectal cancer, and only 11% even bothered to respond.  They favored overwhelmingly a long course of radiation for their patients as part of the preoperative treatment of rectal cancer, given typically along with a chemotherapy drug: either 5FU or Capecitabline.   By way of background, it has been known for over thirty years that if you give radiation and chemo to patients with rectal cancer before surgery, you accomplish several beneficial things: a) you can make a cancer that is not resectable into one that can be; b) you can often avoid a permanent colostomy by shrinking the tumor to the point where is can be removed without removing the entire rectum; c) some elderly and frail patients may be able to avoid surgery altogether; and d) improve overall survival markedly.

So, the next question worth asking is: is all of this radiation necessary or can you accomplish the same ends by a shorter course?  Fortunately this question has been answered in well-done controlled trials and the answer is yes.   So why do a majority of radiation oncologists continue to favor the longer course?  An answer can be found buried in the paper when 20% of them said that when patients have capitated insurance plans they tend to favor the shorter course.  For those of you unfamiliar with the term, a capitated plan typically pays a fixed amount regardless of what treatment is given.

So what do we learn from this?  The decision to give long-course (5-6 weeks) of radiation rather than short course (typically one week of radiation at higher doses) seems to be based in many cases on economics.  And physicians wonder why the public and Congress feel a need to regulate them more closely and admire them less than they used to.  To quote Gordon Gecko: “Greed is good.”  Here, not so much.