Instrumental to the development of interventional oncology in the USA and globally, William (Bill) Rilling tracks how the discipline has grown over the course of his career from a niche area of medicine for the most challenging cases to a subspecialty with its own society dedicated to revolutionising cancer care.
What initially drew you to interventional radiology (IR), and then specifically to cancer care?
My father was an engineer at GE Medical systems working on MR imaging systems and I had a summer job at GE working on MR spectroscopy experiments. This translated into additional research in MRI at UW Madison in undergrad and medical school so I was exposed to the power of rapidly progressing diagnostic imaging at an early age. In medical school, however, I was drawn to the operating room and the intensity of those experiences. I was torn between diagnostic radiology and surgical subspecialty training such as urology, but then I watched John McDermott drain a paraspinal abscess under CT guidance and the decision was made.
The decision to focus on cancer interventions was much more pragmatic. As a junior faculty member at the Medical College of Wisconsin, we were developing a strong multidisciplinary vascular practice but the turf battles with vascular surgery and cardiology were exploding at academic medical centres across the country. Cancer interventions were a blue ocean, with huge potential. I was also drawn to the cancer patient population—to see people face terrible circumstances with courage and grace is truly inspirational.
Who have been important mentors for you throughout your career?
I was fortunate to have wonderful mentors early in my career. During my fellowship at Northwestern University, both Bob Vogelzang and Al Nemcek influenced me greatly. At that time, Bob was spending many hours per week in meetings helping the Society of Interventional Radiology (SIR) construct the component coding system. Al was also doing work in multiple SIR committees and was starting to build some early quality infrastructure in IR. They both taught me that it was not enough to do the work of patient care every day, but that we should be giving back to this wonderful specialty by volunteering our time and expertise to help IR continue to grow. In my clinical practice, we were developing the foundations of a strong multidisciplinary vascular practice that continues to this day. It was my honour to work for 10 years with Jonathan Towne, who was a national leader in vascular surgery, a superb surgeon, and a fantastic and caring physician.
What challenges did you face in the early years of your interventional oncology (IO) practice, and do these differ to those IO faces now?
Initially, the challenges were to introduce the concept of IO techniques to colleagues in medical and surgical oncology. As with much of IR, we started out by treating the “hopeless cases” that had no other options. Once introduced, the power of these interventions were self evident—to see a patient walk out the door the same day after ablation of liver cancer, now cancer free. The integration of transarterial chemoembolization (TACE), radioembolization, and percutaneous ablation into practice patterns then followed, and so did the higher levels of evidence supporting their use.
Currently, the challenges are different. The rapid development of new targeted cancer drugs, and in particular immunotherapy, is revolutionising cancer care. We now have to discuss how and when to integrate IO therapies and systemic regimens and build the data to support such integration. We still have a very powerful case to make from patient quality of life and cost effectiveness perspectives, but we need to prove these as well.
You were involved in running the first ever meetings dedicated to IO back in 2001. How did this come about?
I joined the education committee for SIR as a junior faculty member to start getting involved in SIR. In the early 2000’s, the role of IR/IO in management of hepatocellular carcinoma (HCC) was beginning to blossom. At this time, I met Jeff Geschwind, and we planned and executed the first three stand-alone meetings focusing on multidisciplinary HCC management, beginning in 2001. To my knowledge, these were the first dedicated IO meetings ever organised, but of course, the term “interventional oncology” did not exist at that time.
As education counsellor on the Executive Council for the SIR, you helped develop the APDIR. How did this help improve IR education?
At that time, the IR programme directors met only once per year, for a couple of hours at the SIR annual meeting. The issues being faced by training programmes were becoming more complex, such as turf battles with other specialties, and it was clear we needed a more organised structure. With the support of SIR, we formed the Association of Program Directors in Interventional Radiology (APDIR). The APDIR had a stand alone meeting once per year with staff support from SIR. We started to tackle some urgent issues such as consistent participation in the National Resident Matching Program process and development of a core IR curriculum. Through APDIR, the programme directors were able to coordinate efforts and best practices to deal with the erosion of vascular cases, attracting medical students and residents to IR, and improving non procedural patient care skills.
You were also instrumental to the implementation of the IR residency task force. How did the existence of an IR-specific residency programme come about, and how has it shaped IR as a specialty?
In the early to mid 2000s, it was clear that IR was evolving into a specialty caring for a complex array of patient populations and that direct patient care was necessary to foster the growth of these new areas of practice. Delegation of the patient care aspects and just “doing procedures” was not an option. The complexity and diversity of interventions performed was expanding rapidly and the one year fellowship training pathway was not sufficient to adequately prepare IR trainees for future practice. Knowing that changing the training pathway was a process that would take many years, we formed the Primary Certificate Task Force in 2006 with an initial goal of a obtaining a stand alone IR certificate. I asked John Kaufman to chair the task force and he graciously accepted. As we went to work, it soon became clear that Diagnostic Radiology chairs and the American Board of Radiology and American College of Radiology would not support a pure IR certificate but would support a combined IR/DR certificate.
The ensuing process of navigating the politics, obtaining American Board of Medical Specialties (ABMS) and Accreditation Council for Graduate Medical Education (ACGME) approval, and implementation into the match was exceedingly complex and took over a decade from start to finish. In addition to John Kaufman, there were so many leaders in IR who pushed this to a successful completion, including Jeanne LaBerge, Gary Becker, Anne Roberts, Matt Mauro, Alan Matsumoto, Vicki Marx, Dan Siragusa, and Jan Durham. There have been countless others including my partner, Parag Patel, who have led the complex process of integration of the IR/DR residency into existing training programmes.
The IR/DR certificate was the first new primary specialty approved by ABMS in over two decades. Now, medical students can match direcly into a six year IR/DR programme that will prepare them for modern IR practice, including all the patient care skills necessary to succeed. By some measures, it is the most competitive specialty in American medicine. We are attracting the best and brightest to IR.
Would you describe the thought processes behind the decision to create the Society of Interventional Oncology (SIO) in 2017, and the reaction of the IR community at the time?
The decision to form SIO was made after a very long and thoughtful dialogue that occurred over a few years. The World Conference of Interventional Oncology (WCIO) had been in existence since 2005. WCIO was evolving into much broader activities, including research grants, clinical trial development, and advocacy with various cancer organisations. It was becoming much more than a meeting or conference. We also realised that there would be political ramifications to forming a new society. The last thing we wanted to do was damage or undermine IR as a whole, but felt that a small society focused on IO would have a positive impact on the future of patient care and, ultimately, IO as a subspecialty.
The reactions to forming SIO were varied. Certainly, there were some who feared this would weaken IR and might set a precedent for other subspecialties to “break off.” In my view, the development of subspecialty groups and societies is part of the natural evolution of IR. This process has occurred in many other medical specialties over time and is predictable. IR practice development is significantly driven by those who focus on subspecialty areas of practice, such as prostate artery ebmolization (PAE), venous disease, or women’s health. We need to enable subspecialisation and not fear it.
What has been the highlight of your presidency of the SIO?
For me personally, the highlight is to see forward progress on multiple fronts. We have initiated some simple processes which have the potential to make signifianct impacts on IO practice. We have organised expert panels to provide regular comments to disease specific National Comprehensive Cancer Network (NCCN) guidelines with some early evidence that we have initiated positive changes. We have organised committees working with existing cooperative groups such as Eastern Cooperative Oncology Group (ECOG) and the American College of Radiology Imaging Network (ACRIN) to develop IO trials. SIO has also had success in more complex initiatives. Working with our industry partners, SIO has awarded US$1.5 million in translational research grants, some of which have served as a springboard to larger national grants. We are working with SIR to build IO-CORE, a large and disease specific registry platform for IO. We have multiple clinical trials in development which will help raise the level of evidence for IO in meaningful ways.
How do SIO, CIRSE, and SIR work together?
We are working diligently to coordinate efforts with both the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) and SIR. At the end of the day, we all have the same goals: to improve patient care and to advance IR/IO with education and research. SIO leadership is in frequent communication with CIRSE and SIR leaders to try to coordinate our efforts on various fronts, and to hopefully avoid duplicative or competitive activities. As a small society compared to SIR and CIRSE, SIO does not have the resouces for government advocacy, coding and billing initiatives, and some other broad scale IR practice issues that the large societies handle very capably.
As stated above, SIO and SIR are cooperating in building IO-CORE, which will be a registry platform for prospective disease-focused IO data collection with research questions and data elements developed by international expert panels. I believe it is a win for everyone that we do not have parallel or competitive IO registry platforms in development. SIO has had a number of meetings with CIRSE leaders regarding the International Accreditation System for Interventional Oncology Services (IASIOS) initiative, led by Professor Andy Adam. We support the goals of IASIOS to help raise the quality and consistency of IO practice worldwide. We look forward many future cooperative projects with both CIRSE and SIR.
How has SIO adapted during the COVID-19 crisis, and what is the role of medical societies during a pandemic?
SIO has had to change and adapt, similar to all other societies and organisations during this crisis. We now have virtual board meetings, our last in person meeting was in January at the SIO annual meeting. We are planning next year’s annual meeting very aware of uncertainty of future in person meetings—trying to be nimble and have the ability to adjust as circumstances change.
Medical societies provide a very important source of information to members during times like this. I believe that SIO, SIR ,and CIRSE have all done a fantastic job helping to keep members informed of best practices during these rapidly changing circumstances. The webinars regarding patient care during the pandemic hosted by all three societies have been very informative and well attended across the board.
On a personal level, what are the central preoccupations when treating patients with cancer during a global pandemic?
It is a very challenging situation given that cancer patients are vulnerable and have poor outcomes when infected with COVID-19. However, we also know that their cancer needs treatment and that, in most patients, delaying treatment could result in poorer outcomes. So we must balance the risk and benefit and in the majority of cases, we have proceeded with IO treatments as usual. The exceptions have been renal cell cancer ablations and a small number of very small liver tumours that have demonstrated relative stability on imaging. We have worked diligently, as I am certain all IR practices have, to separate inpatient and outpatient flows as much as possible to minimise risk for patients coming in for outpatient treatment.
How do you think this coronavirus pandemic influenced IO, over the short- and long-term?
I think that IR as a specialty has stepped up and shown that we can respond to a public health crisis. Much of our efforts during the pandemic were to support our colleagues in the intensive care unit (ICU), forming teams to perform portable urgent procedures if necessary during the surge of COVID-19 patients in our hospitals.
As stated earlier, much of our IO practice has continued as usual during the pandemic. Globally, I think there has been a shift in some regions toward increased IO treatments, which use fewer hospital resources, PPE, and probably also cause less decrement in the immune system compared to surgery. Over the long term, some of these advantages may result in changes in practice patterns, but it is too early to tell. For example, there has been an increase in overall Y90 treatments in the US during the pandemic—we do not know if this trend will continue.
What are your hobbies and interests outside of medicine?
Outside of medicine, I am blessed to have a wonderful family, including my wife Kate and my three children, Nicholas (24), Gabrielle (20), and Nathaniel (19). Kate has put up with my long hours at the hospital and travel to meetings and my grumpiness at the end of a long day. My children keep me grounded and remind me that there is much to life outside of medicine. I love to spend time with them and to spend time doing just about anything outdoors. I enjoy hiking, skiing, fly fishing, boating, running, and still manage to get up and down the basketball court.