Internationally-renowned radiation oncologist, Liz Kenny, a longstanding supporter of interventional radiology, shares her views in Interventional News. Kenny, who is senior radiation oncologist at the Royal Brisbane and Women’s Hospital, Queensland, Australia, is also a member of the Oncology Alliance Subcommittee (and a full member) of CIRSE. She is playing a major role in setting the strategic direction for the organisation with regard to interventional oncology.
Kenny was born in Scotland and brought up in Australia. She has held the presidency of the Clinical Oncological Society of Australia, and in 2005 was appointed medical director of the Central Integrated Regional Cancer Service in Queensland.
In 2005, Kenny also became the youngest-ever president of the Royal Australian and New Zealand College of Radiologists (RANZCR). As the College represents both radiologists and radiation oncologists, Kenny is very familiar with the issues facing both of these disciplines. She has promoted the role of interventional radiology in Australia and is a passionate advocate of multidisciplinary care. She is one of the world’s most eminent radiation oncologists and has received the highest possible honours from the largest European and American organisations in radiology, as well as the gold medal of the RANZCR. These include Honorary Fellowship of the Royal College of Radiologists and Honorary Membership of the British Institute of Radiology—a unique double for an Australian, which seems eminently appropriate for someone who started life in the UK.
“I am an interventional oncologist,” she says somewhat tongue-in-cheek to her interventional radiologist colleagues. Yet, she is half-serious about her statement, and does it to stimulate interventional radiologists to think about how to become real oncologists, so that they can go beyond the toolkit and what it can achieve, to doing what is best for their patients.
How did you come to choose medicine as a career? What drew you to radiation oncology?
When I was finishing high school, my interests lay between astrophysics and medicine. Ultimately, I chose medicine because I thought astrophysics was probably a narrower field that might influence where I lived and practised, whereas medicine was broader in this respect.
As a junior intern, I worked for radiation oncologists and I thought that anyone who had such enthusiasm for their specialty and their patients was inspiring. So I went back a second and third time before applying for entry on their training programme.
Who were your mentors in radiation oncology and what do you still remember from their wisdom?
My earliest mentors who inspired me to enter radiation oncology were Bob Smee and Roger Allison. Roger Allison then continued to be a mentor through my entire career. In my mid- to current career, I looked to Chris Atkinson from New Zealand and Lester Peters from Melbourne for inspiration, guidance and a tremendous amount of advice. Of course, in addition to all of that, it has been their personal conduct and their utmost care and respect for patients, that has made a lasting impression on me.
If you could, what three things would you improve on a large-scale in the treatment of cancer?
The first thing is to provide access to care for those who need it, both in developing and in developed countries. Just having the basic infrastructure that allows people who need treatment to receive it would be my first goal. Secondly, I would ensure that multidisciplinary team opinion and consultation be acknowledged universally as the appropriate standard of care. We know that a multidisciplinary team is more likely to recommend standard evidence-based treatment and improve cure rates, and access to trials. I would also look at ways of reducing both the short- and long-term morbidity of cancer treatments. I believe that this can be achieved by choosing treatments wisely and tailoring them individually, and also by substituting some highly morbid procedures with some less morbid ones.
What are the essential things that an interventional radiologist treating a patient with cancer has to bear in mind?
Treat the patient as you yourself would want to be treated, or as you would want a loved one to be treated. Treat them as a person, and not as a cancer. Ask yourself: ‘is this treatment really going to be of overall benefit to the patient?’ Just because we can offer a certain treatment, it does not mean that we should, or that it is necessarily of benefit. The personal cost of treatment may exceed any potential gain. Not offering treatment is sometimes much harder than doing so.
It would be good to ask the question, ‘how does interventional oncology fit into the whole of cancer care in general? How does it fit into the overall management of the individual patient?’ The best way to deal with these issues is for interventional oncologists to be part of a multidisciplinary team and really understand what all the other oncology specialists can bring to that patient’s care. This requires a deep understanding of the natural history of cancer and of the various treatment options. It also requires a seat at the table.
You have been a strong advocate of multidisciplinary teams, and have said in the past that these could be “enablers” for interventional oncology. Please elaborate.
Well-functioning multidisciplinary teams accurately stage a patient’s cancer and make very clear recommendations for appropriate care, taking all factors into account. The majority of multidisciplinary teams do not have interventional radiologists within them. Some of them do not even know that they exist, and they certainly do not know about the benefits and options that interventional radiologists might make available to patients. Having an interventional oncologist at the table can open the eyes of the multidisciplinary team as to what this discipline can offer, and at the same time, it facilitates the interventional radiologist’s understanding of integrated care and of how to base clinical decisions on the overall clinical condition of the patient. Unless interventional oncologists are part of that whole process and have a seat at that table, then what they can bring is just not realised. The participation of interventional radiologists in the joint decision-making process also reduces the risk of bringing interventional oncology into disrepute, by preventing procedures that are of no benefit to the patient from being carried out.
There are pockets of absolute excellence within interventional oncology all over the world, and within the CIRSE community, and many interventional radiologists are utterly committed to delivering what is best for patients. But most of interventional oncology is practised outside of the multidisciplinary team setting, making it hard to appreciate when interventional oncology treatment is appropriate, and how to integrate it into the larger scheme of things. It is extremely difficult for any oncologist, be they surgical, medical, radiation, or interventional to get that perspective outside of practising within a well-functioning multidisciplinary team.
As a radiation oncologist who specialises in head and neck and breast cancer, what are your views on how emotionally involved physicians should get with patients?
Personally, I firmly believe that you have to give something of yourself. You become a partner with the patient, helping them and guiding them through the entirety of their care and through what is usually a most traumatic period in their lives. To remain completely detached from that situation does not lend itself to building an excellent rapport, yet to get too involved is also very taxing. Therefore, we walk a very delicate line. Patient relationships are not always easy and sometimes can be personally quite burdensome, but in the main they are also one of the most rewarding aspects of oncology. The professional relationship formed with the patient, based on honesty, skill, compassion and kindness, is of critical importance for people affected by cancer. It is very precious. When we are taking patients to the limit of their tolerance, as we often are when treating head and neck cancer, a solid professional relationship, based on a high level of trust and commitment, is critical.
Could you describe a memorable case?
I have no hesitation in saying that in my working life, I see something that amazes me every day. Many of my patients are young men and women who have very difficult and advanced head and neck cancers. There is nothing more rewarding for the entire team involved in the care of a patient than to have someone with a potentially destructive and life-threatening head and neck cancer, get them through highly complex and very difficult treatment, and not only cure them, but have them ultimately leading a completely normal life.
In your own field, what are the technological advances that have really changed the scope of cancer treatment
Radiotherapy has a long and extraordinary history that has been driven by collaboration over many decades. Linear accelerators came into practice in the late 1950s and they have essentially remained the workhorse of the radiation oncology department. However, how we drive them and how we manipulate them, has changed tremendously. There have been three main steps in the advancement of radiotherapy; the advent of multileaf collimators has allowed for the sophisticated shaping of fields; the evolution of computers that help us drive these machines and of course, the advances in imaging, particularly CT, which has allowed us to move from 2D to 3D and 4D treatment. However, it is the understanding of the integration of care and what radiation treatment brings to patient care (either in cure or palliation) that is the critical enabler. The technology enables us to do a great job, particularly in expanding our therapeutic ratio by avoiding organs at risk and allowing us to escalate dose to cancer, but using it wisely is very important.
What strategic approach do you think CIRSE should adopt regarding interventional oncology?
CIRSE should champion the cause of interventional oncology and certainly gather the evidence through large sophisticated databases that are looking at outcomes: patient reported outcomes, cancer outcomes, the morbidity of treatment, and the cost of treatment. Gathering the evidence to support the use of interventional oncology is critical; nobody else is going to do that. When you have rapidly evolving technology, sophisticated databases will allow you to compare interventional radiology techniques with other care, such as radiotherapy, chemotherapy or surgery. By gathering this evidence, can you show that you achieve the same or better outcomes with lower morbidity to the patient and at a lower cost. Patient-recorded outcome measures are a really critical measure—it is not enough to demonstrate that the tumour got smaller (ie. that RECIST criteria have been met). It is very important to show that the treatment actually made a difference to the patient, and gather data on functional outcomes, burden of treatment and the morbidity from treatment. If interventional oncologists can obtain such data through sophisticated databases involving multiple sites, they will be able to amass a lot of information quickly; in turn, that will then provide an excellent base on which to compare their outcomes to those of other treatments. With the cost of care escalating, this is critical.
The second issue on which I would like to see CIRSE lead the way, is the quality of delivery of interventional oncology. We know from trials in radiation oncology that the quality of the actual delivery of the treatment is critical: a high-quality treatment leads to a much better outcome in terms of cure, than lesser-quality treatment. So: have you actually hit your target, i.e. have you achieved what you set out to do? Have you avoided critical, normal tissue? Having a quality assurance programme that actually measures the quality of the delivery of the interventional oncology treatments—I would love to see CIRSE adopt and develop that.
How close do you think radiation oncology and interventional oncology should be?
I think they should be very close, as imaging drives both these disciplines and they are both focused on delivering local cure and local palliation as opposed to having whole body treatment such as with chemotherapy or drugs. There are many synergies; radiation oncologists are well-trained and holistic oncologists; they are real champions for multidisciplinary team care, and so partnering both in training and in practice has a lot of appeal. That partnering is also another way of incorporating interventional oncologists into the multidisciplinary team quickly and effectively. These two disciplines should be working very closely together, both in training and in clinical practice.
What are your interests outside of medicine?
I love to cook for my family and friends, and they love it too—or so they tell me! Our family consists of my husband, Colin, an engineer, our son, William (20), who has just finished studying international relations and political science and is now doing business, and our daughter, Sophie (18), who is studying arts and science. We travel together as a family as often as possible and our children are well-seasoned travellers. We love to ski and do so at least once a year, usually in Japan.
Senior radiation oncologist, Royal Brisbane and Women’s Hospital, Queensland, Australia
Medical director, Central Integrated Regional Cancer Service (CIRCS), Queensland Health
Chair, Queensland Statewide Cancer Clinical Network
Clinical lead for the Queensland Health Imaging Programme
Executive member of the Queensland Clinical Senate
1980 Medical degree from Queensland University, residency at the Royal Brisbane Hospital
1987 Specialty training in Radiation Oncology
Gold Medal of the RANZCR
Honorary fellowship of the American College of Radiology (ACR)
Honorary fellowship of the Royal College of Radiology (RCR)
Honorary fellowship of the British Institute of Radiology (BIR)
Honorary membership of the European Society of Radiology (ESR)
Honorary Membership of the Radiological Society of North America (RSNA)
2005 President of the Royal Australia and New Zealand College of Radiologists (RANZCR)
2002 President of the Clinical Oncological Society of Australia
1998 Dean of the Faculty of Radiation Oncology, RANZCR
Advisory board for Cancer Australia
International Relations Committee European Society of Radiology (ESR)
International Advisory Board Radiological Society of North America (RSNA)
International Affairs Committee American Society of Clinical Oncology (ASCO)
Oncology Alliance Subcommittee, Cardiovascular and Interventional Radiological Society of Europe (CIRSE)