Julius Chapiro and Lynn Savic claim there is “no need for scepticism” about the recent emergence and growth of immuno-oncology from an interventional oncologists’ perspective. Indeed, they write that interventional oncology (IO) will thrive in this new research environment, and say that combinations of loco-regional therapies and immunotherapies are just now being trialled that may yet transform cancer care whilst centring the skills and clinical expertise of interventional oncologists.
Interventional Oncology (IO) brands itself as the fourth pillar of cancer care alongside medical, surgical, and radiation oncology. Across the board, IO is now the fastest growing sub-specialty in interventional radiology (IR) and certainly understands itself as the flag bearer of our entire field. The vast majority of National Institute of Health (NIH) funding for IR research supports IO science. The presence of an interventional oncologist at interdisciplinary tumour boards in every tertiary care centre has become the new normal. In fact, the rapidly growing IO culture—enhanced by our own society, the Society of Interventional Oncology (SIO)—can be seen as an organising principle among interventional radiologists that strive to abide by Charles Dotter’s everlasting legacy calling upon us to “provide clinical care” rather than practicing as “high-priced plumbers”.
Our dedication to curing cancer minimally invasively—one tumour at a time—and our involvement in patient care as clinicians rather than service providers was reinforced and invigorated during the COVID-19 pandemic. Precisely because of this level of maturity of our profession, there is no need for skepticism or concerns in light of the recent emergence of the “other IO”, immuno-oncology.
Without a doubt, novel immunotherapies transformed the way we approach cancer care. As such, five novel molecular targeted agents and their combinations have become available and US Food and Drug Administration (FDA)-approved for the use in advanced stage primary liver cancer within just roughly three years. While some in our community are overwhelmed and anxious in light of this rapid development, fearing replacement by the “other IO” in our key domain of liver-directed cancer therapies, the overall message remains reassuring: “our IO” will thrive in this new environment.
As the clinical trial data on immunotherapies in liver cancer continues to trickle in, we begin to realise that therapeutic outcomes in immunotherapy have not yet delivered upon the initial promise to make a substantial difference or even provide a cure. In fact, many in our community began to explore combinations of loco-regional and immunotherapy, and, meanwhile, numerous trials have been initiated to study this exciting new option.
While we eagerly await the first results from such prospective clinical trials, we must continue to do our homework in science and education. Historically, basic and translational research has been the Achilles’ heel of IR and this is especially true for the ethos of our professional training. The fellowship training model in IR was naturally focused on rapidly building up procedural hands-on skill in just 12 months of training by means of volume, frequently leaving no room to learn the “language of oncology”. Aware of its shortcomings, the generation before us wisely paved the way for a dedicated IR residency as the new training model. As such, we are now able to recruit trainees from a pool of medical students that have six years to make IR their professional identity, and interventional oncology their sub-specialty.
Therefore, and in order to succeed in this increasingly complex environment of advanced cancer care, we must substantially expand upon interventional oncology education and expect engagement in basic, translational, and clinical research from day one of training. Our interdisciplinary partners in tumour boards should sit across specialised peers with knowledge and profound understanding of tumour biology, disease staging, and clinical trial design when requesting our advice. We must therefore step up in those disciplines and offer more than just technical expertise on whether or not a tumour can be safely reached and targeted under image guidance. Formal oncologic training, increased participation in non-procedural patient care, shared therapeutic decision making, advice on expected outcome, and key opinion leadership in cutting edge research and guidelines must be the new hallmarks of our identity.
Consequently, we must leave behind our anxious heritage as proceduralists and no longer engage in meaningless conversations about “takeover” of our procedures by “competing” specialties. The future of cancer care lies in teamwork and it is time for us to recognise our qualitative edge and expand upon our expertise beyond a set of hands-on skills that can be easily learned by anyone with interest and access to equipment. Thus, we should define new role models in this rapidly evolving field and shift away from reverence and idolisation of procedural prowess as the final endpoint of career development.
Ultimately, the central task of our generation will be to establish formal interventional oncology training as part of the IR residency curriculum, and possibly even offer a formal IO fellowship for sub-specialisation. With that in mind, we will continue to strengthen our role as the fourth pillar of cancer care with content and substance to ensure a bright future of our specialty for the next generation of interventional oncologists.
Julius Chapiro is an assistant professor of Radiology and Biomedical Imaging, co-director of the Yale Interventional Oncology Research Lab, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, USA. Chapiro declares grants and research support from the Society of Interventional Oncology, Philips Healthcare, Boston Scientific, Guerbet, and the National Institutes of Health.
Lynn Savic is a diagnostic and interventional radiology resident and co-director of the Minimally Invasive Tumor Therapy Research Laboratory at the Charité University Hospital, Berlin, Germany. Savic has no disclosures.