Radiation Oncology

What do radiation oncologists do?

Radiation Oncologists use ionizing radiation for the treatment of cancer as well as a few benign medical conditions. The field focuses on prescribing and planning the appropriate treatment, ensuring that the treatment is properly administered each day, managing any complications of treatment, working with medical and surgical oncology colleagues in an interdisciplinary setting, and following the patient after treatment to manage late side effects and monitor the status of disease.

Who do I work with?

Radiation oncology is by its nature a very team-based and multidisciplined specialty. Radiation oncologists work with a team that also includes physicists, dosimetrists, radiation therapists, and nurses. In most academic centers, they also work as part of a multidisciplinary team that includes medical oncologists, surgical oncologists, radiologists, and pathologists. About 50% of patients are treated with curative intent, while the remainder of cases are treated palliatively, (e.g., for pain relief from bone metastases). A small percentage of patients are treated for non-cancerous conditions such as trigeminal neuralgia or keloids.

What are some other things I should know about the day to day?

The specialty is highly academic with a focus on physics, radiobiology, molecular biology, and evidence-based clinical medicine. Imaging and computer treatment planning are also major components. Radiation oncologists divide their time between seeing patients (inpatients and outpatients), participating in tumor boards and multidisciplinary clinics, going over films with radiologiest, performing procedures (such as radioactive implants), and creating/evaluating treatment plans. Physical examinations are also very important in this field (namely the neuro exam, GU/Gyn exams, and lymph node assessments). In the academic setting, radiation oncologists often dedicate a significant portion of their time to research (clinical or basic science).

What about after residency?

Residency graduates may go on to work in academics, satellite facilities associated with academic centers, community hospital-based practices, and private groups.>

Match Statistics

What’s the training like?

Residency is four years (PGY-2 to PGY-5). The PGY1 year can be done as a preliminary year or a transitional year. Most programs do not offer a PGY-1 year, so the applicant needs to apply for and interview at PGY-1 programs separately. However there are some programs that require you to fulfill your PGY-1 year at their hospital (Penn, Emory, Cleveland Clinic). It is important to note that you can have a separate preliminary/transitional program rank list for each Rad Onc program that you rank.

Programs are generally structured so that you have responsibility for patient care and treatment planning from the very beginning of your training. As you progress through the residency, you are expected to function more independently from attending supervision. Most programs have 2 or 3 month rotation blocks where you work with either one or two attendings the entire block. Attendings generally see only a couple of disease sites at most (unless in the community/satellite setting) so you become very competent in those disease sites after your rotations. Additionally, some programs have satellite/community practice rotations in addition to their main academic site so that residents can gain a better appreciation of practicing in different types of environments.

Graduating from residency is dependent upon your completing a certain number of cases for each required site. A number of programs do not have a sufficient caseload in certain areas, usually Pediatrics or Gynecology, for you to complete your cases and you will have to go elsewhere for 4-6 weeks to fulfill these requirements. Most programs where this happens have formal arrangements with a large center, e.g., all Maryland residents go to St. Jude’s for their Pediatric elective.

Do I get time for Research?

Most programs require 3-12 months of research (clinical or laboratory). Some require the resident to publish an abstract or manuscript before graduating. Required or not, the emphasis on research that’s seen in the resident selection process continues throughout residency at most programs. There are a few smaller programs where this may not be as strongly emphasized.Some programs also offer the Holman Pathway which works out to be 27 months of clinical work and 21 months of dedicated research time during your four years of radiation oncology residency. Traditionally, participants in this program have done laboratory research and have extensive basic science experience (ie. PhD) but programs decide this on a case-by-case basis.

How do I learn the physics?

Most residency programs offer formal (i.e., a few hours of lecture per week) protected lectures in physics and radiobiology in addition to hands-on clinical didactics. You are tested in radiobiology and physics on the board exams, so expect to devote some hours each week to learning these subjects.Some programs also have built in physics/dosimetry months into the clinical curriculum where you shadow physicists and dosimetrists and help work on treatment planning.

What is call like?

There is no in-house night call for radiation oncology residents. However, most if not all programs have the residents take beeper call from home, usually for one week at a time. During call you would be expected to address patient problems at night and on weekends as well as consults for radiation oncology emergencies such as spinal cord compression that may require immediate treatment.Most questions can be addressed without coming into the hospital. Also, depending on the situation, it is not imperative that you see the consult immediately.

Other work outside the hospital: Most residents devote a few hours each night to reading, since in addition to physics and biology, residents are also expected to be familiar with important clinical studies for each cancer site and stage. This requires a lot of review and repetition of textbooks and journal articles.

What are some general things I should know before applying?

Most programs are looking for applicants who show interest in the clinical as well as research aspects of radiation oncology and molecular biology. Positions are very competitive, and good numbers (boards/clinical year grades) and publications within the field of radiation oncology or cancer in general are important in finding a residency position.However, there has been a recent trend in the past couple of years and especially this past application cycle (2020) where the number of applicants has precipitously decreased. This has resulted in a slightly less competitive match with applicants getting significantly more interviews. A large proportion of programs went unmatched last year and actually had to participate in SOAP. This is projected to occur this year as well.

What about Step 1 scores?

Many programs have board score cutoffs in the 230’s and possibly even as high as 240. However, applicants with lower board scores can be competitive if they have other outstanding characteristics, such as research publications, an MD-PhD, or AOA status. Beware that some programs favor MD-PhDs more than others. Grades in Rad Onc electives are particularly important; try to get A’s/Honors in these. Other important rotations are Medicine, Surgery, and Ob-Gyn. There is also data available from the NRMP that is helpful to get an idea of what characteristics make applicants competitive in the Radiation Oncology match.

So should I take step 2 early?What about letters of recommendations?

You can if you want to boost your step 1 score, otherwise you can wait until after your application goes out to programs. In addition to academic abilities, most programs are also looking for applicants who can fit in and work well with the people in their small departments, so personality and letters of recommendation are important as well. As a small field, letters of recommendation from nationally-known faculty members can go a long way towards interview offers. Plan on getting at least 2 letters from someone in radiation oncology. The third (most programs only require up to 3) can be from someone else you worked closely with including a research mentor, a sub-I attending, etc. You should try to get a letter from every away that you do, and preferably get that letter from a famous person there (ie. chair, vice chair, etc).

Do I need research on my app?

Because Rad Onc is a research-intensive field and is competitive, some research in the field is almost an absolute requirement. Publications are impressive, but any research experience which shows your interest and commitment to the field will be helpful. The attendings and residents at Maryland are very supportive and willing to help you set up research experiences.Reach out to them early if you’re interested at all so that you have some time for projects to mature and develop.

Who can I talk to at UMD?

You need to be aggressive about getting such projects though. The residents are a great starting point in setting up research projects and can help direct you to faculty with ongoing projects. In particular, Dr. Vujaskovic has a thriving lab if you are interested in bench research and Drs. Nichols, Mishra, Mohindra, as well as many other faculty members, are very active in clinical research.

Should I take a year off?

A year off is NOT completely necessary. Many applicants each year still match without taking a year off. That having been said, if you have little research experience and/or have less-than-stellar board scores and grades, taking a year off may be beneficial. It is possible to complete research from scratch during the latter half of third year and into fourth year, but requires hard work and no small amount of luck. Case reports are not commonly published in radiation oncology, so getting published isn’t as easy as simply being motivated and willing like in some other fields. It takes time. Getting at the very least a poster presentation under your belt is nearly required. Keep in mind, you are competing against MD/PhDs. Taking a year off may help put you over the edge into gaining interviews at stronger programs.

If I want to take a year, when should I do it?

If planning on taking a year off for research, it would be most helpful for you to do it between third and fourth year. This way, you have a whole year to perform research and generate publications, get LORs, and gain knowledge in the field, before going on to your fourth year radiation oncology electives. Taking a year off after fourth year may not be as useful or productive, as you really only have from May-September to do research before the application cycle begins, which is not that much time to get research and potential publications completed.

How should I plan my fourth year schedule?

Remember that grades from any rotation done after September of your fourth year probably will not make it on your ERAS transcript in time for evaluation by residency programs. However, letters of recommendation and updated transcripts can be sent directly to programs even after ERAS closes.

What about Away Rotations?

There are two major schools of thought regarding away rotations. You can rotate at a big name place and score a big letter, but most of these places do not guarantee an interview to all rotating students. Another option is rotating at a less prestigious institution and potentially impressing the department enough to get an interview and/or even a position. It is important to discuss these options with your advisors and make an informed decision. Geographic location is another consideration. Doing an away rotation in a certain region will often gain you consideration by other schools in that region, as it suggests you would be willing to go to that part of the country for your residency training. You can often find applications for away electives on the different programs websites, but most programs now use VSAS.

How many should I do and when?

You should plan on doing at least two radiation oncology electives before October of the fourth year – one here at Maryland and an away rotation. Many applicants do three or more electives primarily during the summer months and into September and even October. Keep in mind that ERAS applications should be submitted as soon as the system opens in the middle of September. Spend one month at your top program choice whenever possible. It is possible that during July you may get lost in the shuffle since new residents are getting a lot of attention from attendings. However, the opposite also can ensue. Often times you, as the rotating medical student, know significantly more than a starting PGY-2 rad onc resident because you are much more intimately familiar with the field than someone who has just come off a year of preliminary medicine. You should try to start your rad-onc electives as soon as possible so you have time to get LORs. If your schedule dictates that you need to take Step 2 CK/CS in the summer, then try to schedule your aways around them. It is not recommended that you have any other commitments while you are doing away rotations because these rotations are very important and at times function as month-long interviews. You should be on your ‘A’ game. Arrange for away electives early as early as January of the third year because there is associated paperwork including immunization forms that differ from institution to institution. Certain programs are more difficult to get into, and may have step score cutoffs as well (though this information is not readily available online) because they can be difficult to get, especially at top programs.

What about a Sub-I?

Some programs like to see sub-I grades, soif you are able to complete a sub-I before November that is ideal, but this is not crucial. The inpatient Cancer Center month is a great choice, and may provide a chance to get a letter from a prominent medical oncologist, which can be helpful as well. Alternatively, a Medicine Sub-I, would be a good choice. A Surgical Oncology Sub-I may be particularly impressive, but beware that you likely need to do a Medicine Sub-I (Cancer Center counts) early on in the year in order to apply for a preliminary medicine year. Note that you can do a preliminary surgery PGY1year if you wish, but this is uncommon due to the significantly increased workload compared to preliminary medicine or transitional years.

When should I schedule interviews?

You should try to schedule preliminary/transitional year interviews as early as possible (October/November) to get them out of the way. Most radiation oncology interviews are from early November through to the very end of January and even into early February. Some programs even started interviewing at the end of October this year due to the significantly decreased applicant pool. Try to take one of these months off and schedule a flexible elective in the other. DO NOT schedule a sub-I in these months. Technically, you are only allowed to take off 2 days for interviews during a sub-I, 3 during AHEC, and 4 during an elective. Some electives may be stricter with this policy than others.

*** Because of the small number of applicants that are interviewed, each program interviews on only a limited number of dates (typically 1-3). This means that there is very little flexibility when it comes to scheduling interviews and some programs interview on the same date. Because of this, it is important to schedule interviews as soon as you receive an invitation since spots fill up FAST. A matter of twenty minutes can make a difference. Checking your smartphone frequently is an absolute must. There is also a radonc spreadsheet floating around online that is updated in real-time so you can see if certain schools have sent out invites. Replying within minutes of receiving your invitation is ideal. Radiation Oncology tends to send out interview invitations later than most other specialties, though this year, programs started to send them earlier. Most interview invitations will be sent out after the dean’s letter is received, from early November through the end of December. Additionally, you may get off a program’s wait list well into January. Your friends WILL get interviews before you, and this will lead to anxiety. You will likely have interview day conflicts and be forced to choose between programs, which can be very frustrating.

Applications for ERAS should be submitted as close to the date that they are released (typically Sept 15) as possible. Regardless of the deadline, the earlier, the better. Also be advised that some programs might not be accepting applicants in the year that you apply and occasionally the only way to find that out is after you apply.

How many should I apply to?

Plan to apply to 30-60 programs, although it is not uncommon to apply to every program (~80). It is unclear how the match will be moving forward in subsequent years, but it is projected to still be somewhat competitive. Apply broadly and even to programs that you think may be reaches. Some programs may strongly preference M.D./Ph.D applicants, so it is important to know about each program before applying. Apply to a wide range of programs and regions. It is very difficult to predict which programs are likely to interview you or even find a pattern amongst programs that do offer you an interview. It will baffle you. If you have a strong interest in interviewing at a certain program, feel free to e-mail them and express this interest, giving a compelling reason why you want to be there (close family in the area, couples-matching, etc). For example, if you have no apparent ties to (insert state here) on your application, but your significant other’s entire family lives there and you want to relocate, e-mailing the programs nearby can’t hurt.

More about letters please?

Letters from department chairs in Rad Onc and from well-known physicians in the field are extremely helpful. Most programs ask for 3 letters; some only look at letters from radiation oncologists. Get letters from Dr. Regine (Chairman of Radiation Oncology) and/or Dr. Suntha (President and CEO of UMMS) at Maryland. Dr. Vujaskovic is also well known for his research contributions. Additionally, you should plan to get a letter from a well-known attending at each of your away rotations if possible. Be VERY careful with your letter writers. Residents—even at your away rotations—will have a good sense of who would write a good letter. Try to identify who you plan to ask early in your rotation so that you can spend more time in the clinic with them and allow them to write a stronger, more personal letter. Reach out early!

Check out The Association of Residents in Radiation Oncology website (www.arro.org) for a list of all the Radiation Oncology residency programs in the U.S., the number of residents in each program, the program director’s name, and the contact information for each program. This website is more accurate than FRIEDA.

The match is competitive. Most programs receive 150-200 applications and interview 10-30+ for an average of two positions. Statistically, if you can rank 10 programs by the end of the interview season, you have an approximate 95% chance of matching. That having been said, there are anomalies every year, and even very strong candidates on paper may go unmatched if they don’t interview well. Rotating at a department and putting on a good performance is truly a way to increase your chances of matching there. But by no means does this ever guarantee you a spot, even if they give you praise and positive feedback on your rotation. In the past, thank you notes were standard and post-interview communications (including informing your #1 program), however, there has been a movement to “take the game out of the match” that is now embraced by most well-respected academic program. Prior to interviewing, you should read these articles (https://www.ncbi.nlm.nih.gov/pubmed/26581129 and https://www.ncbi.nlm.nih.gov/pubmed/26972659) that lay out the guidelines that most programs have pledged to follow (pay special attention to programs listed on the original publication and the response so you know what is acceptable for each program on your interview list). Second looks can usually be arranged, if you wish. Most programs will tell you second looks do not affect how they rank a candidate.

Few residency graduates pursue fellowship, but the most common one is pediatrics. Proton therapy fellowships are also available. Graduating residents in the past typically did not struggle to secure job offers. Procuring a job in a competitive market, however, is not as easy. Academic positions at the main campus of a university hospital in a desirable city are extremely difficult to come by. In addition, there has been much discussion especially this year about the job market and prospects for residents just entering the field. It is unclear how the market will shape out in the next 5-10 years, but for those in the field and those still heavily interested in the field, there is still optimism. Consult with faculty mentors and residents if you have any further questions. Positions with satellite facilities of academic programs and private groups easier to find, but still are limited. There are typically job openings in rural areas and less coveted areas.

Interviews also play a vital role in the selection process. Interview days are very long; often you are interviewed by 6-12 attendings for 15-30 minutes each. Most places will also have you interview with faculty from the Physics and Radiobiology division and some places (e.g. Florida, Wisconsin, MD Anderson) have panel interviews. Make sure you are very familiar with your research and read up on the program a little bit (from information packets or web sites) prior to your interview. Other popular topics of discussion include how you got interested in Rad Onc, why you are interested in Rad Onc as opposed to Medical or Surgical Oncology, your strengths/weaknesses, and your career goals. A dreaded yet common question: why do you want to come HERE versus other places you have interviewed/rotated?

What to Look for in a Program: Questions to Ask Your Interviewers

• How are physics and biology taught?
• What updates/changes in the program are expected during your residency?
• What kind of jobs have recent graduates gotten? Have any had to pursue fellowship?
• Did your program not match? Did it SOAP? Why was this the case?
• What types of research have residents recently published?
• Do Residents have the opportunity to present their research at national conferences? How much research support do residents have in terms of funding, statistical support, etc?
• How supportive is the Chair and other faculty in helping residents with the job search?
• What is the board pass rate?

Although, it is important to note that these differences can be subtle and not immediately evident from the information presented during the interview day. Make sure you have stock questions in your head to ask during your interviews so that you do not come off looking disinterested in the program. You will be hearing the phrase “what questions do you have for me?” in your nightmares for years to come.

How much scutwork (e.g., tracking down medical records, pulling films) do the residents do?
What is the attendings’ attitude towards teaching (malignant/supportive/indifferent)?
What is the atmosphere of the department (formal vs. informal)?
Does the department perform a sufficiently wide range of procedures to equip you for your future practice?
Strengths of the department. Some departments are particularly known for certain disease sites (University of Florida: head and neck, and pediatrics; Thomas Jefferson: CNS. Etc.)
How old/new are the treatment machines and planning equipment?
Cost of living in the surrounding area.
Workload. At some programs, residents legitimately work most days from about 8am-4:30pm.
At other programs they will work consistently from 7:30-6:30pm+, or even later especially for new residents getting into the swing of things.
***Are the residents satisfied with their learning and clinical experience?***

Good Luck!!

Last Revision: February 5, 2020