Stephen T. Lutz: Palliative Radiotherapy, a growing subspecialty
Dr. Stephen Lutz (Figure 1) is a physician at the Armes Cancer Center in Findlay, Ohio, who is board certified in Radiation Oncology as well as Hospice and Palliative Medicine. He practices full time as a Radiation Oncologist, while he has published extensively about end-of-life oncology care. In October of 2014, Dr. Lutz and Professor Edward Chow began co-authoring a regular column entitled “Palliative Radiotherapy” for Annals of Palliative Medicine (APM). Owing to his contributions to the field, the editor of APM seized the opportunity to interview Dr. Lutz after the 2014 meeting of the American Society for Radiation Oncology (ASTRO) which was held in San Francisco, California. The interview delves into Dr. Lutz’ personal experiences in getting involved with palliative radiotherapy as well as his opinions regarding the potential benefits to patient care by more closely aligning the radiotherapy and palliative care specialties. At the end of the interview Dr. Lutz also shares the history of the International Consensus Conference on Palliative Radiotherapy and the formation of the new Society for Palliative Radiation Oncology (SPRO).
APM: What triggered your interest in palliative care and what keeps you active in the field?
Dr. Lutz: I first became interested in palliative care because I had older parents for whom I helped provide care for several years. I became intrigued by the disparity between my parents symptom and emotional concerns and the focus of their healthcare providers. During my radiation oncology residency I found the provision of end-of-life oncology to be both the most challenging and rewarding part of my position. When I decided to pursue an additional board certification in Hospice and Palliative Medicine, I was disappointed to realize how little my medical school and residency training had taught me about this subject, especially given that a large number of our patients face these issues. My decision to participate in palliative oncology research, education, and advocacy was fostered by three of the most accomplished palliative oncologists ever, Thomas Smith, Nora Janjan, and Edward Chow. Their guidance and kindness allowed me to work with colleagues from all over the world, many of whom are now my good friends. Still, it is the benefit to patients’ quality of life that continues to inspire me to focus my efforts on palliative care.
APM: What was the role of radiotherapy in palliative care when you first step in and what does it look like now?
Dr. Lutz: Radiotherapy has played a key role in symptom management in advanced cancer since shortly after its discovery in the late 1800s. Still, radiation oncology as a specialty has only intermittently and incompletely embraced its importance in this setting. While academic radiation oncology training centers subdivide patient care by anatomic site of origin or tumor histology, the only palliative radiotherapy service in existence when I trained in radiation oncology was led by Nora Janjan at the MD Anderson Cancer Center. The number of radiation oncologists interested in palliative care issues then was small, and we were greeted with more enthusiasm by Hospice and Palliative Medicine professionals than we were by colleagues in our own specialty. Now, the number of palliative radiotherapy services within academic programs has begun to grow, and the number of young interested, energetic palliative radiation oncologists has increased by a factor of ten.
APM: What is the best way to integrate the radiotherapy and palliative care specialties in your opinion?
Dr. Lutz: Some of my colleagues who direct palliative radiotherapy academic services, such as Tracy Balboni and Josh Jones, would probably be better able to answer this question. Still, it is clear that educational cross pollination between trainees in these two specialties early in the curriculum would aid our combined efforts. Also, since the reimbursement constructs differ greatly between Radiation Oncology and Hospice and Palliative Medicine, one could predict that a greater concordance between those two models would improve collaborative care.
APM: With different progresses being achieved in developed and developing countries, what are your suggestions in collaborating the two specialties in developing countries?
Dr. Lutz: The problems associated with the delivery in developing countries seem to be much more tied to resource inadequacies that exist in addition to palliative radiotherapy educational deficiencies. I have had no experience with the delivery of radiation oncology in developing countries, but my colleagues have described circumstances that would be considered very foreign to our practitioners in developed countries. The need for effective, short course palliative radiotherapy regimens is even greater in these countries where patients may have limited access to radiation oncology dose planning and delivery equipment.
APM: What are the challenges and opportunities of palliative radiotherapy in its current stage?
Dr. Lutz: The number of patients faced with life-threatening cancers is predicted to increase dramatically in the coming years due to aging in developed countries and a decrease in other causes of death in developing countries. These increased demands exist upon a backdrop of limited resources, requiring that treatment be delivered more effectively, efficiently, and affordably. The great promise associated with highly conformal therapy techniques require better survival predictions and research directed at the best niches for an ever-growing number of interventions. All of these factors contribute to an increased focus on palliative radiotherapy that will likely lead to marked improvements.
APM: What is your contribution to the field so far and what are you going to do in pushing forward the progress?
Dr. Lutz: My contribution to the field is limited in comparison to many of our international colleagues such as Peter Hoskin, Yvette van der Linden, Edward Chow, and Daniel Roos, all of whom have guided meaningful palliative radiotherapy research which shapes daily practice. My main contribution has been to persist in an era when the US has not afforded a great number of academic positions to radiation oncologists with palliative care interest. I had to decide early on whether to join an academic practice and leave my focus on palliative radiotherapy, or whether I should follow my passion outside of the normal academic pathways. I have only been able to serve the specialty in any capacity due to the kindness and guidance of our international colleagues plus the opportunities offered by ASTRO.
APM: Are there any other professors or groups along the way that you have been working with for the same goal?
Dr. Lutz: The radiation oncology team at Toronto Sunnybrook Hospital has served as my source of guidance and support since I first became interested in this topic. Edward Chow, his Sunnybrook colleagues, and a seemingly never-ending stream of fellows and trainees have provided energy to the palliative radiotherapy subspecialty that is almost too great to measure. Their expertise is renowned, and they have kindly treated me like one of their own, throughout.
APM: What do you think is most difficult to deal with during your practice?
Dr. Lutz: The most difficult problem I’ve had to deal with recently in my practice has been a lesser acceptance by patients of those natural forces which are out of our control. When I began this specialty, many of the patients we cared for had been through the Great Depression and World War II. A great number of them had suffered personal experiences that resulted from trying times or negative experiences. By contrast, many in my generation, the so called Baby Boomers, have enjoyed unencumbered success that has led to heightened expectations about what we can control. The upside of these shared expectations is that members of our generation who face a life-threatening cancer diagnosis do eventually find strength and inner peace beyond that which they knew they had.
APM: Could you share with us any particular challenges, setbacks or success that you’ve encountered along the way?
Dr. Lutz: The greatest challenge I have faced to this point has been the lack of familiarity between professionals in the Radiation Oncology and Hospice and Palliative Medicine communities. Even though providers from each of these specialties share a great number of patients, that commonality usually occurs serially over time rather than concurrently. Furthermore, given that trainees in one specialty are not routinely educated about the benefits of the other, there is limited conversation and common ground from which to work. Nearly all of the conflict I have witnessed between the two specialties has been due to simple lack of familiarity. However, within this lack of understanding resides great promise. Virtually all of the Radiation Oncologists and Hospice and Palliative Medicine professionals I have worked with are tireless patient advocates and humanitarians, so all of our combined projects over the years have progressed easily and have been received well.
APM: What among your achievements that you are most proud of?
Dr. Lutz: I’m most proud that we were able to create a palliative radiotherapy textbook for trainees in radiation oncology as well as in Hospice and Palliative Medicine. For several years our Hospice counterparts asked for a resource that they could use to understand the nomenclature of radiation oncology as well as those clinical situations when it would possibly benefit their patients. Also, it is gratifying to know that medical students and radiation oncology trainees now have access to a text that can hopefully fill in some of the missing pieces of their medical education.
APM: I see that the palliative radiotherapy working group gathers a group of enthusiastic and renowned experts with passion on palliative radiotherapy. Could you introduce the history of the working group and what does it achieve?
Dr. Lutz: The International Consensus Conference on Palliative Radiotherapy was begun in 1990 and has convened every 10 years since. Many of the projects which have shaped the goals and outcomes of palliative radiotherapy research have been forged at one of these previous consensus conferences. The success of past meetings, coupled with increasing calls for palliative radiotherapy research, has led the group to shorten the time between conferences. The next International Consensus Conference on Palliative Radiotherapy will take place in April 2015 in conjunction with the European Society for Radiation Oncology meeting in Barcelona, Spain. The Europeans have excelled in palliative radiotherapy research, and so it is appropriate that they will be carrying the torch for this iteration of the consensus conference.
Beyond these intermittent consensus conferences, we have now formed the SPRO. This international group currently has invited participants from 18 countries and will address palliative radiotherapy through three subgroups: research, education, and advocacy. The group will hopefully empower those who are interested in end-of-life oncology and will also help palliative radiotherapy ascend to its proper place as a dedicated subspecialty.
APM: Thank you very much!
Disclosure: The author declares no conflict of interest.
(Senior Editor: Nancy Q. Zhong, APM, firstname.lastname@example.org)