Recession proof careers to Flash-RT, does radiotherapy really have a holy grail or should we be careful what we wish for?

My “Exam-Shambles” meant my life fundamentally changed in 1980

The recent “Exam-Shambles” where A level exam results were doctored by an algorithm and then revised back to the marks estimated by the pupil’s teachers took me right back to 1980 when I became a student therapy radiographer. The fact that these pupils didn’t even sit an exam at all merely compounded the hurt. For me I disliked exams, however I did well at my grammar school and achieved three C’s in my mock A levels and was awarded a place at the Turner Dental School in Manchester which was a bit like being presented with an open goal in football parlance!

However, I missed the goal due to a combination of watching too much of the 1978 World Cup finals in Argentina late at night and my inability to put my education and knowledge onto paper. A year of resits and some relevant job experience lead me to the Middlesex Hospital in 1980 to start my vocational training to become a radiographer! It seems a while ago now and so I have used black and white images for extra impact in this blog.

Pic: Argentina win the 1978 World Cup and my career path takes a dramatic turn without me knowing.

I liked the fact that I was training and learning on the job and the DCR course suited me down to the ground as at the end I would have a job and some letters after my name, what could be better than that. I immersed myself, became a valued part of the radiotherapy team, was compassionate to patients, loved the technology (who could imagine how interesting and ethereal radiation physics actually was with its introduction to Quantum theory) and probably only just passed my Hospital and College of Radiographer’s exams while making friends for life.

We had no virtual training software, just operating the largely analogue machines, working in clinics, stints in Medical Physics with their treatment planning systems and dealing with patients and their relatives. It worked for me and I really do hope we see an uptick in applicants to study this amazing subject especially if students are looking at alternative careers based on their exam results and a lack of options with regards to further education.

If you want a recession proof career, become a therapeutic radiographer – a “job for life”

In 1979, and a year prior to me becoming a student the Conservative Party won the General Election and Margaret Thatcher became PM, taking over from James Callaghan.

Pic: Margaret Thatcher was ashamedly a role model for me I believe!

Her first 2 years in office were not easy – unemployment was very high, but the economy gradually showed improvement. She brought more of her supporters into the Cabinet, and added to her reputation by leading the country to war against Argentina in the Falkland Islands.

The Conservatives went on to win the 1983 election by an overwhelming majority, helped by a divided opposition. Her government followed a radical programme of privatisation and deregulation, reform of the trade unions, tax cuts and the introduction of market mechanisms into health and education. The aim was to reduce the role of government and increase individual self-reliance.

During 1980-81, the UK entered a serious recession, with falling output and dramatically rising unemployment making looking for work extremely difficult and on par with today in our post Brexit pandemic era and not pretty.

Unemployment rose to over 3 million and didn’t fall below 3 million until 1986. The 1980 housing act meant people had the right to buy their council homes and John Lennon was murdered in New York that year while Thatcher made her infamous speech to the Conservative Party Conference on 10 October 1980, “You can turn if you want to, the Lady’s not for turning” becoming a defining dictum for her leadership.

Pic: John Lennon died on the 8th December 1980, shot in New York just 40 years old

For those of you who struggle to remember that far back, these are some of the famous songs of 1980 that might jog your memory:

Blondie – Atomic

Dr Hook – Sexy Eyes

Abba – Super Trouper *

David Bowie – Ashes to Ashes

Madness – My Girl

Sheena Easton – 9 to 5

Adam and the Ants – Ant Music

Genesis – Turn it on again

Spandau Ballet – To cut a long story short

Queen – Another one bites the dust

The Jam – Going Underground

The Police – Don’t stand so close to me

Pic: Abba in their 80’s pomp

A very varied list of songs you will agree and a very varied “apprenticeship” in radiotherapy had started!

Conditions in 1980’s were similar to today’s lockdown and coronavirus crisis

The recession of 1980-81 caused a sharp rise in unemployment as mentioned above. Initially, this was demand deficient unemployment, but it also caused structural unemployment with many people who lost their job in manufacturing struggled to find new jobs.

The fact that I would have a job to go into with over 3m unemployed was comforting but it wasn’t a given that you would work where you wanted to. I was lucky in that out of the 4 people on my DCR course, I was given the only basic grade radiographer post available on my home patch at the Middlesex so I must have made an impact somewhere down the line! I was only the second male therapy radiographer ever to qualify at the Middlesex and so we need to find innovative ways to get more men into our profession, I think.

It is common knowledge that any generation that enters the job market during a recession suffers long lasting disadvantages and with circa 800k students have recently left full time education this year, many are now floundering in a damaged job market largely due to lockdown and Covid-19.

The number of graduate jobs on offer presently is down by around 60% due to business uncertainties, social distancing or travel restrictions for instance. Non graduate jobs have fallen off a cliff, in part due to lack of opportunities in the damaged hospitality sector.

Post Brexit and now during the pandemic, opportunities for young people are as tough as they were in the 1980s where there was a larger than normal swell of people looking for employment, a recession and where unemployment stayed above 3m for many years as I’ve discussed.

Rishi Sunak, the chancellor has just announced a “Plan for Jobs” and the “Kick Start” program whereby businesses will be paid to create jobs for 16 to 24-year olds who will be adversely hit by this abnormal sequence of health and economic events.

It is now the time for our sector in radiotherapy to restart vocational training for therapeutic radiographers and create further recession proof careers for suitable students, it’s been done before and the current crisis makes it paradoxically, far easier to justify. I see no reason why this should not start now with our own radiotherapy focused “Kick Start”.

With therapeutic radiographer student attrition rates dangerously high around 1 in 4 and a circa 7% vacancy rate for qualified staff in the UK and a further expansion of the provision of radiotherapy delivery equipment planned, something needs to be done. I love the fact that we now have consultant radiographers and staff with doctorates but this must not be to the detriment of the various entry levels of our profession for students and staff.

I’ve spent 40 very happy years working in radiotherapy, it is a very rewarding and varied career both clinically and the corporate sector. If I was given the chance to change what I did, I wouldn’t hesitate to do it all over again!

Is the continued focus on hypofractionation and by extension Flash-RT ultimately our holy grail?

Radiotherapy reimbursement is a historic anomaly in that we get paid for delivering fractions, the amount of staff and number of treatment machines we need is loosely based on the number of fractions that centres deliver and not individual patients treated. In 1982 when I qualified the bread and butter treatments making up to 70% of our cases involved a minimum of 25 fractions for breast tumours and at least 30 for prostate/bladder cancer and radiotherapy tariffs have not changed that dramatically since then.

Today in our attempt to provide a Covid-19 secure environment breast fractionation has come down to just 5 with the Fast Forward technique and novel Prostate regimens in some cases down to 7, bowel cancer treated in just one week with a longer delay to surgery and SABR fractionation regimens even shorter, with 3 high dose fractions for small cell lung cancer for instance. IORT reduces fractionation even further down to one for some breast, pancreas and colorectal patients, the ultimate in hypofractionation until the advent of Flash Radiotherapy.

But this new technology may well lead to us needing less radiographers and we are already having to negotiate new tariffs to cover shorter treatments when arguing that the added complexity and increased management negates the reduced fractionation. I hope the NHS don’t try to manipulate this argument. Achieving a reasonable tariff for treating patients with IORT has proven to be almost impossible when compared to external beam radiotherapy payment codes although the private sector have moved on this recently in that IORT saves on the cost of the standard of care of 15 fractions for early stage breast cancer. This can be a preferable treatment of choice for busy women who meet the treatment criteria and want their surgery and radiotherapy completed in one day and a further Covid-safe treatment option.

While on the subject of the NHS and Covid-19, in our last blog we explored the UK’s cancer crisis in some detail. The NHS mandated the severe reduction in cancer services and radiotherapy in March that have led to this huge problem and potentially far worse health crisis based on protecting the NHS and patients from the novel coronavirus. However, while the spotlight continues to focus on the Health Secretary, I have heard little from NHS CEO Simon Stevens who seems not to be held to account for this mess we find ourselves in and have not heard him articulate his and the NHS’s resolutions to move forward. Hands on solutions to the cancer crisis have largely come from prominent oncologists, MP’s and Action Radiotherapy among others who make the arms-length approach from the NHS questionable at the very least and his silence is deafening. This is not acceptable in my opinion as he has not protected cancer patients at all. Where has he gone?

Our recent blog on the cancer crisis is here:

CRUK RadNet Research fund starts to make an impact.

Cancer Research UK (CRUK) recently announced a £56 million research network to transform the UK into a global hub for radiotherapy research by pioneering the use of the latest technologies including artificial intelligence and FLASH radiotherapy.

The new network called ‘RadNet’ is CRUK’s biggest investment in radiotherapy research set up to assist in the development of advanced radiotherapy techniques and to challenge the boundaries of this treatment.

Exploring FLASH radiotherapy, where high doses of radiation are delivered in short, rapid pulses of less than a second is a crucial area. Ultra-fast dose rates now increasing up to 33 Gy/s allow normal tissue tolerance levels to be exceeded, at least in animal models, with a greater probability of tumour control and little or no normal tissue damage.

Funding has been allocated to teams in Oxford and Manchester and research so far suggests that FLASH has the potential to cause less damage to the healthy tissue surrounding the tumour than traditional radiotherapy, where tissues are exposed to lower doses of radiation over a longer period, often resulting in long-term side effects.

Investigating ways to overcome hypoxia and why some cancers come back after treatment by studying the role of cancer stem cells added to using radiotherapy in combination with other treatments, including immunotherapy and lastly harnessing the power of artificial intelligence are also being looked at.

How does Flash radiotherapy work?

One mechanism is the prevention of cytokine activation while FLASH radiotherapy seems more effective in killing hypoxic cancerous cells than standard dose rate radiotherapy with the added advantage of sparing normal tissue.

Flash radiotherapy can be administered away from the research environment by adapted, high-end conventional linear accelerators, proton beam therapy systems and even mobile electron accelerators that deliver IORT presently.

“The FLASH effect may lead to one of the greatest breakthroughs in radiotherapy in decades. There is still much we hope to learn and understand about this phenomenon. We know that the next logical step is to begin human trials and are excited to be working with IntraOp on this initiative.”

The Lausanne University Hospital (CHUV) and IntraOp Medical Corporation have recently announced a research and development collaboration to accelerate the development of Flash radiotherapy toward first human trials.

IntraOp’s mobile electron beam linear accelerator has been equipped with an ultra-high dose rate mode, as an integral part of ongoing research and developments in Flash radiotherapy. The new technology leverages the company’s core technology and demonstrated 20-year track record in manufacturing compact medical-grade linear accelerators. The prospect of adding Flash capability to their portfolio of image-guided electron IORT and electrons for dermatology applications is a compelling pathway for these modalities to advance into the future.

You can read more on the Intra-Op solution for Flash RT here and their move towards patient treatments in combination with Laussane University.

But we should be careful what we wish for!

With human trials of Flash RT now starting and the ability to treat one patient in less than a second added to our well-trodden path towards further hypofractionation regimens, the ability of AI to automate treatment with robotic machines and couches and patients identification systems that are able to ID and position the patient remotely, will our previously recession proof career hit the buffers?

Pic: Vintage robot from well before 1980!

We need more trained staff and students to fill the void of attrition and retention and to run the increased levels of planned new equipment but what may look to some like a panacea of reducing fractionation may in fact be the start of a slippery slope with therapeutic radiographers one of the first to suffer from further forms of automation.

In my May 2019 Blog we explored the impact of AI on radiotherapy and asked “How will AI affect us as workers” as questioned by Max Tegmark in his new book “Life 3.0 being Human in the age of artificial intelligence”.

In the book he looked at what career advice we should give to our children now focusing especially on ones where machines are presently bad at performing the roles and may not get automated any time soon.

If you answer yes to these questions below more than once you are on the right track:

Do you have to interact with people using social intelligence?

Are you creative and come up with clever solutions?

Do you work in an unpredictable environment?

You can read more here if you wish:

Will robots take my job?

Finally, there is a website that allows you to enter your job to see how future proof it is.

I typed in Radiation Therapist, the US title of our profession and it seems it is 42% likely that we will be replaced by robots in the next 20 years. Something to mull over until my next blog. You can have a go here if you like!

Duncan Hynd – Sept 2020

* I apologise if you are having Abba’s Super Trouper playing in your head now and stuck there, it has that effect and this is called an “earworm” it seems, I have!