The Beam: Proton therapy for sarcomas; radiation oncology residency program

Treating sarcoma with Dr. Stephanie Schaub, radiation oncologist

Sarcomas are tumors that form in the body’s connective tissues such as bone, muscle and fat. They are rare and, because there are more than 150 types, patients benefit from seeing a sarcoma specialist to help determine their treatment options.

At Fred Hutch Cancer Center – Proton Therapy, Stephanie Schaub, MD, is a radiation oncologist who specializes in treating both adults and children with sarcoma. She is part of a sarcoma-focused multidisciplinary team that includes surgeons and medical oncologists.

Schaub and Loggers are looking to test the safety, side effects and best dose of a drug called abemaciclib, and how well it works with radiation therapy before surgery. Abemaciclib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Giving abemaciclib together with radiation therapy may shrink tumors in patients with high-risk disease, Schaub said.

“Depending on the exact location, we evaluate the optimal type of radiation that would result in reduced side effects for patients, which may include the use of protons,” she said.

For any sarcoma treatment, Schaub and her radiation oncology colleagues consider proton therapy on a case-by-case basis and take many factors into consideration, including the location of the tumor. Protons can be helpful when the tumor is located near vital organs because it can be precisely controlled to avoid impacting healthy tissues, or in the pelvis in younger patients to preserve a patient’s fertility.

She also considers protons when she needs to treat with a very high dose if a particular type of sarcoma is radioresistant, meaning it isn’t as easily killed with radiation. This is the case for primary bone tumors of the base of skull, spine and sacrum, such as chordomas and chondrosarcomas.

There are also cases when protons are not indicated.

Sometimes, when patients have titanium hardware in the area to be treated because of previous medical conditions, it casts a “shadow” where radiation cannot reach with protons. Generally, when the tumor is located in an extremity such as an arm or leg, X-rays are better suited because this type of radiation can be more robust to subtle changes in tumor swelling or shrinkage and X-rays cause less skin irritation. There are select times when proton therapy is used for the treatment of an extremity in pediatric patients, such as to reduce radiation dose to the growth plates when feasible. 

“Keeping risks of side effects low while treating the tumor optimally is the goal,” said Schaub. “Sometimes that is achieved with proton therapy and sometimes with X-ray — or photon radiation.”

Schaub recently recorded a webinar titled "Demystifying the Patient Experience” in conjunction with The Northwest Sarcoma Foundation. In the webinar, Schaub and Megan Pittaway, PA-C, with UW Medicine, explain what a patient can expect when being treated with radiation, including side effects.

“I am thankful to be able to provide a resource for the community that will help sarcoma patients find and understand the right treatment and know what they can expect from that treatment,” said Schaub. 

Schaub feels fortunate to be part of a specialized team of radiation oncology providers caring for patients with sarcoma, including Ed Kim, MD, Michael Folkert, MD, PhD, and Megan Pittaway, PA-C, who care for adult patients, and Lisa Ni, MD, Ralph Ermoian, MD, and Layne Chapple, ANRP, who care for pediatric and adolescent and young adult patients.

Residencies: an important part of radiation oncology training

Lia Halasz, MD, is a brain and central nervous system expert at Fred Hutch Cancer Center and leads the Radiation Oncology Residency Program at the University of Washington School of Medicine.

A residency program is post-graduate medical education that new physicians must complete in order to specialize in certain fields. Residencies typically add an additional four years of training and experience.  

The Radiation Oncology Residency Program at the University of Washington School of Medicine is competitive. Of the approximately 120 applicants Halasz receives each year, the program has two to three positions open to be filled via a rank match system that matches applicants to programs. 

“Aside from their medical expertise, we look for people who are caring, work well in a team and want to learn,” said Halasz. “We also look for people we think will push our field forward. What is great about the program here is the collegial culture and how we can provide training in all treatment modalities — including protons and neutrons — and any research area one is interested in.”

As program director, Halasz ensures that the program is properly accredited with the Accreditation Council for Graduate Medical Education, maintains a clinical competency committee that ensures graduates meet all milestones to become a radiation oncologist, and periodically evaluates the program. She meets biweekly with residents and monthly with chief residents to make sure all students are on track to achieve their professional goals.

“Overall, I need to make sure our residents are well taught and mentored,” said Halasz. “A lot of faculty members are involved in this, such as supervisors, committee members and site directors. Residents have access to a lot of expertise to help them.”

When interested providers apply to the program, they do not have to have a lot of training or expertise in radiation oncology. During the four years of residency, Halasz ensures they are trained in all diseases. Over time, residents decide whether to go into community practice (radiation oncologists who treat all disease types) or academic practice (radiation oncologists who specialize in one disease, such as lung cancer).

By the end of the residency, each resident must pass their board exams, which includes written exams in physics and radiation biology, oral exams and clinical exams. Lastly, Halasz will sign off that each resident has competently met all milestones and evaluations in order for them to complete their residency.

“I like to compare best practices and ideas with other residency program directors because there are a lot of regulations in leading such a program,” said Halasz. “It helps us constantly improve our methods to make sure we train the best possible radiation oncologists.”

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