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Doctors at Work Podcast.

Episode #51

What’s a career in clinical oncology like?

Mat Daniel

20/12/2023

Rachel Cooper tells me that clinical oncology is an exciting and ever changing career. There is much teamwork, varied ways of working, and plenty of research-based advances. Clinical oncologists have multiple treatment options at their disposal, and overall are able to make a difference to many patients and their families. Her top tip for anyone interested is to go and find local consultants working in clinical oncology, and spend some time in their clinics to experience what the specialty is like.

You can find out more here.

Rachel is a consultant clinical oncologist in Leeds Cancer Centre (LCC) specialising in the management of gynaecological and lower GI cancers. Rachel obtained her medical degree from Birmingham University and then completed her clinical oncology training at The Christie Hospital, Manchester and Cookridge Hospital Leeds. She obtained an MD during her training at The Christie, investigating measurement of tumour hypoxia in cervical cancer under the supervision of Professor Catherine West and Dr John Logue. Before taking up her current post she worked in Dokuz Eylul University, Izmir, Turkey as a Visiting Associate Professor where amongst other things she continued her interest in gynaecological brachytherapy. She has a special interest in cervical cancer, in particular image guided brachytherapy and anal cancer.

Rachel has previously held several positions including in LCC training programme director and lead clinician and nationally Medical Director, Education and Training for the UK at the Royal College of Radiologists. Prior to this she was an examiner and then chaired the First FRCR exam board as well as sitting on a number of committees in the RCR and nationally such as the Radiotherapy Reference Group.

She is married to Mehmet, a Professor in Radiation Oncology and clinical oncologist at LCC and has one son, Emre. Outside of medicine she is Chair of Governors for a federation of three primary schools and loves, amongst many things playing tennis, swimming, all arts but especially reading and a good night out with family and friends!

Podcast Transcript

[00:00:00] Mat: Welcome to Doctors at Work. My name is Mat Daniel, and this podcast is about doctors’ careers. Today, I’m having a conversation with Rachel Cooper, And we’re having a discussion about a career in clinical oncology. She tells me that clinical oncology is an exciting and ever changing career. There is much teamwork, varied ways of working, and plenty of research based advances.

Clinical oncologists got multiple treatment options at their disposal and overall are able to make a difference to many patients and their families. Her top tip for anybody interested is to go and find local consultants working in clinical oncology. Spend some time in their clinics to experience what the specialty is like. I hope the podcast is useful. Welcome, Rachel.

Tell me a little bit about yourself.

[00:01:00] Rachel: So my name is Rachel Cooper. I am a clinical oncologist. A clinical oncologist is one of the, I would call them, suite of nonsurgical oncologists, doctors, who manage patients with cancer. I particularly specialize in managing patients with gynaecological cancers, With lower GI cancer, so rectal cancers, colon, and anal cancer in particular is one of my special interests.

And more recently I’ve taken on a specialty called cancer of the unknown primary, which is a little bit different for me, but has been absolutely fascinating. It’s a little bit like being a detective. Yes. I have a very interesting and very varied career, which has changed Very much from when I started training and deciding to become a clinical oncologist to the doctor that I’m now, and that’s what’s made it a very exciting and fascinating career that I’ve had. And no doubt once I’ve retired in a few years’ time, it will change Even more particularly with the introduction of AI and how we can use that in our specialty as well.

[00:02:07] Mat: How did you how did you find that specialty?

[00:02:11] Rachel: When I graduated from medical school, I wasn’t a high flying graduate or anything, But I knew I wanted to do hospital medicine rather than general practice. I was always quite interested in surgery, but at the time, the sort of surgical structure, particularly for women, was a little bit Difficult. Maybe it’s not changed greatly, but it was felt more challenging. So I went into the sort of general medical side of things.

I worked in a hospital in Warsaw General Hospital, which gave me a fantastic grounding in general medicine. And it was in the days where you did very long on calls, and you saw everything. And I gradually ticked off specialties that I didn’t want to do, so cardiology, endocrinology, etcetera. And I did a respiratory job, and it was in the time when respiratory physician physicians used to give chemotherapy themselves, and often the chemotherapy was made up by doctors like myself on the ward. And I started to realize that the group of patients I really identified with and really enjoyed managing, and often these Patients have really quite poor prognosis, in fact with the patients with cancer.

And from there, I was introduced to the visiting, A clinical oncologist who actually worked in Birmingham but used to come up to Walsall to do a clinic, and we met up. And he described clinical oncology as a specialty. And I thought, yeah. That’s the thing for me. It’s got all the elements I want.

It’s mainly outpatient based. It’s got a lot of variety. There’s a lot of continuity of care with patients, so you can look after them for many years. There’s some element of practical. So I’m quite a hands on practical person.

So with radiotherapy planning, And I can talk about my gynae practice as well. There was that element there which really attracted me, so that’s what played to my idea of a little bit being a surgeon. And there was a very excellent training structure, which is still in place and actually has improved over the years for clinical oncology. And therefore, that’s the route I went down.

[00:04:07] Mat: And if I think a patient that has cancer, there are I can imagine there are lots of different ways that as doctors we can help. So can you tell me a little bit about the different modalities that

[00:04:18] Rachel: Yeah. So as I said, we are nonsurgical oncology. So we basically are involved in managing patients with, Radiotherapy, chemotherapy SAT, as we call it now, systemic anticancer therapy because we very much moved on from chemotherapy to target therapies with, very specific drugs to specifically target aspects of cancer metabolism Um, and hormone therapy, as well as moving into palliative care. Why is clinical oncology so attractive?

It’s because clinical oncology embraces all of those aspects of care out outside haematology, although we are involved in the management of patients with lymphoma. So it’s more attractive to me than the other haematology other oncology specialties Because, one, we’ve got such a range of treatments that we can specialize in. And as I mentioned at the beginning, I specialize in three sites, Most consultants will specialize in one or two sites just because of the range and depth of knowledge that you need in order to be to do that and manage those patients with that expertise. But the attraction for me really is around that ability to Manage patients with all aspects outside of surgery. And why is that so attractive is because we know that after surgery, radiotherapy is the most Common way of being able to cure a patient with cancer.

And I’m very fortunate, or I’ve chosen tumour sites where we see very high cure rates. So I treat patients with cervix cancer who are not suitable to have surgery, so more advanced disease, but we see very high cure rates those patients, and the same with anal cancer as well. So for me, that’s what’s really attractive because then, obviously, you’ve cured those patients. You manage them to detect recurrences, but also, you’ve got the option of managing their longer term effects from treatment. So it’s a real whole Package of oncological care.

And we can go on to talk about how radiotherapy alongside, Systemic anti-cancer therapy has changed and developed over the years and has changed my career.

[00:06:25] Mat: Can you tell me a bit more then about systemic anti-cancer

therapies?

[00:06:30] Rachel: Yes. As I mentioned at the beginning, with progress in understanding um, how cancers behave.

And alongside that, understanding genomics so much better as we do now. We’ve been able to develop drugs that actually target specific aspects of different cancers. So instead of seeing a lung cancer as this Sort of big amorphous group of lung cancers that in the past, we would have just treated with a kind of generic chemotherapy. Very variable and generally poor success. We’re now able to look at a lung cancer in an individual patient.

We can do molecular testing on that and genomic testing on that, and we can see if they might respond to a specific Uh, anticancer therapy, which is available to treat that particular patient. And it might be that you actually know because you know that you’ve got other drugs down the line. It might be that you think about Sequencing how you’re going to use those drugs, thinking about what would be best to use first in the knowledge that you might have another drug there in the cover to use. So Whilst in most cases, it’s still a palliative treatment if it’s advanced disease it gives patients a lot longer survival than we had in the past. So from a sort of chemotherapy, anticancer therapy side of things have really changed, and that’s very exciting, obviously, Both for us as clinicians, but, of course, for our patients as well.

From a radiotherapy side, which is most of my practice is more radiotherapy focused Um, the changes have been phenomenal as well. So from when I first trained, when what I when I learned to do radiotherapy Um, we would what we call plan our radiotherapy. So that’s deciding exactly where we want the radiotherapy to go, how we want the radiotherapy beams to be directed at the cancer. And I used to plan on orthogonal films, so just on plain X rays and understand bony anatomy in relation to soft Tissue anatomy. And then we introduced CT scanning you’ve got a more you could target it a little bit better, And then that’s gradually progressed over the years.

So now that we can use radiotherapy, a little bit like we were saying about anti-cancer therapy in a much more targeted way. So the way we do treatment is so much more sophisticated. And that means, one we’re less likely to miss the tumour, which I think in the past did happen, um, so we’re targeting the tumour much more accurately. But really importantly for patients, We can maintain very high cure rates, but we can avoid a lot of normal tissues, say bowel or bladder, for example, I treat in the pelvis, Doesn’t need radiotherapy, and the consequence of that is the patient is cured with less longer term side effects. And so Why that’s exciting for me as a clinician is I think you’re in training, and then you get to become a consultant, and you think You’ve made it.

And then after a couple of years, you think, oh, I’m a consultant now. What next? And the lovely thing about clinical oncology Is that then this the what next is the retraining for the next technology that’s come along, the next advance that’s come along. And so what I did as I trained to what I do now is completely different. Keeps you on your toes, keeps you excited, and most importantly, the benefit to patients is amazing.

So to Give you an example. When I train, it was not uncommon to see women have recurrences local recurrences of their service campuses so At this site and that is horrible because it would grow into blood. It would go into bowel. These are young women, often with young families. Very horrible Experience, that is extremely rare.

I can’t remember the last patient of mine in service country who had a local recurrence. The difference is phenomenal, and that’s what’s really exciting for me.

[00:10:17] Mat: It sounds like you’ve got to be on your toes as a consultant because, you don’t just get there and then sit back and relax.

[00:10:23] Rachel: Yeah. No.

I think that’s true. And I think the other exciting thing is trials. So even though I’m not academic, I did do an MD as part of my training. So if you are academic or if you’re interested in research but you don’t want to be an academic, I think the thing about clinical oncology and oncology in general, actually, is the opportunities to be involved in research and development is phenomenal. All of us will be entering patients into trials all of the time.

And again, that’s really exciting as you said because it keeps you on your toes. And, also, that’s the sort of next step on the road to what’s gonna be the next thing for patients. So it really keeps you up to date as well. So it’s not only that kind of developing yourself, um, it’s also for your patients. It’s also about the trials as well.

So I think as a specialty in terms of where you would like to go with your career, I think it’s just so open. It that’s what, for me, makes It’s such an exciting career structure.

[00:11:23] Mat: I hope you’re enjoying the show. If you are, please click subscribe So you will be notified when new episodes come out. This podcast is part of my mission to help doctors create successful and meaningful careers.

You can be part of that mission too by forwarding this show to any one person who you think might benefit from listening. Thank you. Now on with the show. Maybe if I go back to some to the beginning of somebody’s career, how does somebody get started?

[00:11:52] Rachel: Anybody who’s entering into, um, the training program in the UK or out with the UK would need MRCP or at least MRCP equivalent if they’ve not trained in the UK.

So most people in the UK will go now through the IMT route, And most people will do up to IMT two, a co a few people up to IMT three, but IMT three is not necessary. And you will have full membership before you can apply for the specialty. Now why do we do that? It’s because we are a physician specialty even though we don’t sit In the Royal College of Physicians, we sit in the Royal College of Radiologists, but a lot of what we do has a physician basis to it. And in Particular managing some of the effects of both the cancer and the treatment we do has a medical background to it.

So that’s why it’s really important to have that medical the second and so that’s what you would do, and then you would apply s t three level to come into clinical oncology. And the sorts of things that you need to do really or think about doing that would give you that advantage because it is a competitive specialty, is obviously you need to show some interest in oncology. So if you have the opportunity of doing oncology as part of your INT Rotation, definitely do that. The only thing I would say is that INT oncology, so you’re seeing a lot of inpatients, It’s a very skewed view of clinical oncology. As I mentioned at the beginning, most of my work is outpatient, and I have very few inpatients.

And obviously, those patients who do come in are the sicker patients or the patients with more advanced disease. So it’s really important that you try and get To outpatients, you try and get to some radiotherapy clinics to get a really good feeling of what being in a clinical oncologist is. So some interest there. If you don’t get that to the rotation or you do get to do on a rotation, Try and go down to the radiotherapy department. Try and get some taste of days.

Most clinical oncologists, or all of them I know, are very friendly, very open, and they really want you to join our specialty. So they’re very willing to come and show you, show your radiotherapy machine, show you, some aspect of what you would be doing, so contouring and planning and that sort of aspect of it. So that would be good. If you get the opportunity to do an audit or a quality improvement project based around oncology, that would be great. And if you get the opportunity to do some research, maybe some retrospective review or something like that then again, that will help your portfolio in terms of applying.

So then you come in at s t three. At the moment well, not at the moment, but the curriculum and the structure of the curriculum Is that clinical oncologists and medical oncologists do this first year jointly, and it’s exactly the same training. Medical oncologists Our nonsurgical oncologists like myself, but they’re not trained to deliver radiotherapy. They are trained specifically in chemotherapy, anticancer therapy. So we have a joint training for one year.

At the end of that first year, clinical oncologists would be expected to be ready to sit and hopefully pass Their FRCR part one exam. And I would I’m not gonna say this is not a problem. It’s not a problem, but it’s just Something that you have to do at the clinical oncology is there are more postgraduate exams. But one of them I’ve always been interested in education. I’ve worked very much in the college.

So I think and we can talk about the exams in a minute, but the exams are much more focused now on what you need to become a clinical oncologist. And then you would work through it’s a five year training program by s t four five. We’d well, s t five, we’d expect you to set your final FRCR. And then in that last year of training, it would be looking towards, thinking about what you specialize in as a consultant.

[00:15:42] Mat: So a medical oncologist would deliver chemotherapy, whereas a clinical oncologist would deliver chemotherapy and radiotherapy.

[00:15:50] Rachel: Exactly. So that’s the main difference. We have that those skills and training to do all aspects of radiotherapy as well which is, I personally think whilst you have those extra exams to do, that’s a relatively short period of your Career. Yeah. And uh, very high percent.

It’s very rare for trainees to drop out Not being able to pass those exams. But what that does, it then opens up a much bigger door of things that you can do in your career. But we need medical oncologists as well. So even if people don’t want to be clinical oncologists, if they choose to be a medical oncologist, I’m very happy because they’re still staying in oncology.

[00:16:31] Mat: And earlier, you talked about higher degrees.

Is it normal? Is everybody doing the doctor?

[00:16:36] Rachel: Not everybody, but some people will do as I said, I did an MD, which is, is two years. They’re less fashionable now so not so many people do that. In some ways, I think it’s a little bit of a shame because that two years is quite a nice time to take actually research.

But if you’re interested in doing, say, PhD, even if you’ve not come down the academic route, there’s often options to do that. But I would also emphasize that we also like to give opportunities to do other aspects. If you might perhaps want to go down more of an educational route, is what I did. Or if you’re more interested in management and leadership we like to open up those opportunities. So certainly here in Leeds, where I am Now we’ve got lots of trainees who are doing lots of different things during their training, either as time out or As sort of part time alongside their training in leadership or in education or as I said in research.

So I think it is a specialty that opens lots of doors, not only clinically, but out with that sort of clinical experience in whatever way you want to go.

[00:17:42] Mat: And you talked about sub specialization then. So the does everybody Specializing sort of one, two, three sites. Is that

[00:17:51] Rachel: Yeah. Yeah.

So most people will have a maximum of two sites, which is what is recommended by our The Royal College of Radiologists and a few people, it will just be one site. There’s a few people like myself who might do three sites. In the UK, clinical oncology of most places is organized as a hub and spoke type, Specialty. So because radiotherapy is so specialized, they will mostly most cities outside of London, and I think it is only London, will have one Radiotherapy centre. There are some bigger centres such as the Christie Manchester will have some satellite centres, but you’ll you will have one main centre, which will serve a population around the city.

So Leeds, we serve West Yorkshire going up As far as Lee as York going down to Wakefield and out towards Huddersfield um, and then there’s another centre saying Hull, another in Sheffield, another in Newcastle. So you’ve got these hubs. And then quite often what happens is you’ll have a clinical oncologist who then might go out to a district general hospital to deliver a clinic at once or twice a week, where they may administer chemotherapy, which may be given locally, so that’s very, better than the patient. But the patients would come in to have their radiotherapy. So That is the most common model.

As I said, there are other models such as satellite centres. And also here in Leeds, we have a different model where we have a centre, But we also have units that have their own medical oncologist generally who deliver the chemotherapy. It’s a little bit varied, but That’s there’s something to think about in your career that you’ll mostly be in a larger urban centre as part of you where you’ll be Working because of the way radiotherapy is delivered.

[00:19:38] Mat: Maybe if I stick with that idea about how Career fits into the rest of somebody’s life.

Yeah. Chances are that if you’re gonna go down the route of this, you probably gonna do a fair bit of traveling, and you’re gonna be based in a large centre from what you’re saying. Yeah. What else do people need to think about in relation to how the career fits into their whole life?

[00:19:57] Rachel: I think the first thing as you said is you may have to travel, but it won’t it’ll usually be one day week.

And it will be it’ll be a reasonable distance. You won’t be traveling huge distances. So that is mostly it. However I don’t actually do that anymore, but I haven’t done it a lot in my career. I used to love going out to the district hospital because you’re the visiting oncologist.

Generally, everybody loves you because you’re coming out. You’re delivering this service for them. So I and I always enjoyed and you’re out of the centre in a different environment, and so I always enjoyed doing that anyway. So I think that is actually a positive rather than a negative. But, obviously, with family life, particularly with young children, that would be something to take into consideration.

I Think, though, it’s important to remember that The on call generally is not too onerous. It’s not like a surgical or a general medical on call. I think most people would say that. As I said, for most tumour sites, you are mostly, uh, outpatient based specialty, so you’ll have less inpatients Compared to, say, perhaps many of our med my medical oncology colleagues um, it’s it fits very nicely, I think, into a less than full time career because of that reason of not having too many, really sick inpatients, And job sharing as well, it fits very nicely into that sort of pattern. Other things To think about as I said, it’s a career which because you get that really good Basis of treating of oncology in your training.

If you want, say, at age Fifty two, I’d got bored of gynaecological cancer, which if you knew me, you never know what happened. But say I had done, it’s very, Not easy, but it’s very possible to start treating learning how to treat another cancer site. And so I’ve got quite a few colleagues who Sort of refashion their career during their careers. It’s that flexibility as well. So there are lots of Positives from that point of view.

Negatives, I think the training, the exams, everybody sees it as negatives. I think it’s something that It’s built up too much, really, and I think the structured training supports trainees to get their exam. We’ve just I’ve just demitted from being the so I probably would say this, the director of medical education and training for the UK for clinical oncology, but we have just restructured the final exam, Which I think most people felt was a hurdle and made that into a very I believe, a really fair exam now. A lot of consistency, See a lot of quality assurance around it, so it’s a good exam now, I think. So I think that is something to think about, it’s a relatively short period of your career.

I think other downsides is if you are You know, if you’re in a relationship, you need to think that you would be potentially safe. So it’s often it’s two doctors, isn’t it? Or to professionals, you’re much more limited as to where you can work. So you need to think about that in terms of who’s going to be the dominant person I think I’m trying to think of other negatives. As you can tell, I really like my job, So they’re difficult.

Obviously, there’s an emotional toll. I don’t I think that’s For medicine in general, really, isn’t it? But, yes, there is you know, you are dealing with people who, obviously, when you’re diagnosed with cancer, that has Obviously, major implications for the patient and their family. And so you are dealing with people, one of the major Traumatic times of their lives as well. But, again, you’re very much trained in how to communicate.

That’s a major part of our training. And again, for me, although it can be seen as a negative, it’s I think it’s a positive as well because, that aspect of communication is something that I’ve always, really valued that interaction with patients. But I don’t I think it’s something that should be thought about. And I suppose the other thing to think about is, the incidence of cancer is increasing because of an aging population. So we are busy.

We are busy, and there aren’t Probably enough of us, and that’s some of the work that the clinical oncologists have done around increasing training numbers. So for people who are coming into training now, As they come out, there will be an increase. It’s not just replacing people like me retiring. There’s actually gonna be increase in clinical oncologists to Take account for that increase in the incidence of cancer. So we hope that will make that Work balance better in terms of the number of new patients and patients that people are seeing.

[00:24:44] Mat: And what’s your typical week

like?

[00:24:48] Rachel: So my typical week is great. It’s really varied. I do a mixture Of for the tumour sites I do on Monday morning, I would start with an MDT. It’s eight thirty and that’s for the colorectal cancer.

I think I might be I don’t know whether I’m different for the people, but I love MDTs mostly. I like working with different Groups of people. I like the opportunity to learn. So I’ve learned huge amount from my radiology, pathology, Surgical colleagues, so that’s who I mainly work with. as doctors have a lot of black humour, so some of the MDTs can be, quite I don’t wanna say fun, but they were in they are interactive, and you get good discussions going as well about how Treat patients.

So I find MDTs really stimulating. And then I’ll have a ward round, maybe See two maximum three patients. As I said, we have very few. I’ll do that ward round with one of our clinical nurse specialists. So that’s another group of people who we work really closely We were very supportive of us and the patients, so very well developed in oncology skill mix across the board.

So I work with ACPs. I work with consultant radiographers. So that’s really nice aspect of oncology. In the afternoon, on a Monday, I have a radiotherapy new clinic, I see patients to consent them to start treatment. I see patients on treatment.

Sometimes they’re seen by me. Sometimes they’re seen by other people. Tuesday is my favourite day of the week. So Tuesdays, I do theatre. So for cervix cancer or gynaecologic Answers, we do a type of radiotherapy called brachytherapy, which means closed treatment from the Greek.

And, essentially, we put radioactive sources into tumours that allows us to give really high doses. So that’s practical in my surgical bit of it. And it’s an area that I’ve really specialized in and tried to develop for our centre and also hopefully across the UK. And then I get to radiotherapy planning on a Tuesday as well, which I love. So that’s basically using a computer program to decide where the patient’s going to have radiotherapy.

And that’s again something that, It’s changing, and I’m learning all the time. Wednesdays is more MTT. Wednesday afternoon is a sort of SPA time, so time to develop, have meetings, think about, Do quite the research sort of thing. And then Thursdays, I have outpatients. And Fridays, I don’t work.

I have a long, uh, four days busy four days, and then I don’t work Fridays. And I think in quite a few places, but certainly here in Leeds when I was I no longer am, but when I was medical director for our specialty, I encourage a lot of uh, it’s, I think, flexible, but thinking about people’s job plans so that they can have, an early finish or a day a week when they don’t work, male and female To take that kind of pressure off that we were talking about and to do that, to facilitate that, we very much work in teams. And I think team working It’s another major aspect of clinical oncology that I absolutely love as I’ve said. So and I think it’s not only about that supportive environment, but it’s that stimulating environment so that you can have those discussions about how to best manage patients.

[00:28:04] Mat: And then maybe my final question, what would be your top tips for somebody who’s considering clinical oncology as a career?

[00:28:12] Rachel: So my top tip would be to come and is to find your local centre, maybe find who’s the training program director or somebody Just find somebody you know, a consultant there, contact them, and ask them if you can come and spend a couple of days with them. If you’re on an oncology rotation, Come and spend some time doing what we really do rather than just being on the wards. I think that’s really important so you don’t get that kind of skewed. This is a really sad specialty.

Everybody’s sick or they’re near the end of life, which is not the case. So you really get to see that variety and Feel I think it’s a really exciting specialty, and you really make a massive difference to people and families’ lives. So I think it’s to actually come and experience that is what I would say is a top tip. And that will give you a much better idea of whether you want to do this specialty or not. And if you decide not to, that’s great.

But at least you’ve got a realistic oh, what it’s really like rather than looking at a lot To seek patients on the wall.

[00:29:16] Mat: Wonderful. Thank you very much.

[00:29:18] Rachel: Thank you.

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