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"Dose-Painting," by Shivani Sud: a resident creates visual narratives within two patients’ dose clouds.

TRANSCRIPT

Narrator: 'Dose Painting' by Shivani Sud, MD. (10.1200/JCO.21.01524)

When asked to describe radiation oncology, my first recollection is watching chart rounds as a medical student. Sitting along the conference room periphery, I observed as dosimetrists projected patients' scans, residents presented histories, and attending physicians reviewed treatment plans. Far from the usual hospital rounds with plans consisting of procedures, consults, and medication changes—here, treatment plans are scans overlaid with intricate colorful lines denoting the amount of radiation traversing internal structures to arrive at the target (ie, tumor) volume. This dose visualization is our primary method of conceptualizing and articulating radiotherapy treatments.

Recent technological advances enable delivery of radiation with immense precision to the extent we dub some techniques as “dose painting.”1 Starting with our planning scan consisting of computed tomography images of the patient in the treatment position, we delineate areas of tumor and likely microscopic disease to compose our target volumes. In collaboration with dosimetrists and physicists, we adjust various parameters including multileaf collimators—movable metal leaves that sculpt the x-ray beam as it departs the linear accelerator to enter the patient—and beam angles such that we cover the intended target with radiation while avoiding delicate neighboring organs. We evaluate and iteratively optimize our radiation plans and the resultant dose distribution. Balancing the correct radiation dose, treatment field size, and shape are critical for preventing recurrence, minimizing toxicity, and improving survival.

At the first glance, our peer review reduces the patient to a spectrum of grayscale pictures a few millimeters thick as we scroll through their bodies searching for tumor and ask whether our colorful delineations will adequately treat the cancer. Controversial plans elicit the most discussion as we glean insights into patients' lives and decision making. Why this shorter course of radiation? His priority is quality of life and maximizing time at home. Why no concurrent systemic therapy? She is too frail for chemotherapy—we are escalating radiation dose as an attempt for more durable local control. Why are you sparing a sliver of the scalp? She fears children will tease her for balding. Answers live within a broader narrative. These rainbow-colored three-dimensional dose clouds represent the complex convergence of patient history, goals of care, humanity, medical judgment, and cautious control of our treatment medium—radiation.

As a resident, I view the dose clouds denoted by the color wash of the computationally optimized radiation distributions through the lens of the patient-physician relationship—literally and figuratively. During late nights and unrushed moments, my mind drifts back to my favorite childhood pastime—spotting shapes in the clouds. This activity is a form of pareidolia—the human tendency to perceive meaningful imagery amid a random or ambiguous pattern. As a child with a sweet tooth, I pictured popcorn and cotton candy in the sky. Now, this manifestation of my imagination was centered on my most salient thoughts—caring for an older woman (Ms V) with lung cancer and a child (Lilly) with Ewing's sarcoma. I grappled with whether our treatment plans were adequate, too little or too much. I turned to painting to articulate my angst as art is part of how I reflect on complex situations. For both Ms V and Lilly, I traced the isodose lines defining the radiation dose distributions to maintain fidelity to the original radiation plan. I then folded those dose distributions into the visual narrative of the paintings to create a reflection of their journeys amid their dose clouds.

Ms V (Figures 1 and 2) had countless admissions for chronic obstructive pulmonary disease, heart failure, valve replacements, and now cancer. Ms V longed for quality time until the sun sets. Her case was complex—she had an early-stage lung cancer, but because of multiple comorbidities, she was not a surgical candidate. She projected courage and resolve in conversations about her goals of care while accepting death as inevitable. We treated her with definitive intent linear accelerator-based stereotactic body radiation therapy. Months later, she died from a heart failure exacerbation. I was heart-broken and humbled. Ms V taught me that prognostication is an elusive art for physicians—I was naively optimistic about curing her early-stage lung cancer. She was pragmatic about embracing the trajectory of her comorbidities. As I scrolled through her treatment plan, the beams enveloped the tumor in warm tones denoting high dose as it floated through a sky of trapped air. I imagined her wishes for quality time expressed as colorful, vibrant brushstrokes of light emanating from a sun setting into a calm, reflective ocean overlaid on my target volume.

Lilly (Figs 3 and 4) was a bald, spunky and vivacious four-year-old girl whom I met after multiple rounds of chemotherapy for a chest wall Ewing sarcoma. As we talked about radiation therapy, Lilly flapped her arms while proclaiming herself a butterfly. Weeks later during a status check, she cried in agony from radiation esophagitis. Her mother solemnly whispered “I wish I could take the pain instead of her.” That evening as I was looking for a picture book for my niece, I came upon the story of a baby giraffe on quest to find his spots until one day while he slept, rays of sun shining through the leaves of a tree tanned his skin with perfect spots. Curiously, I searched for the evolutionary rationale for giraffe spots—they are a trait passed between mother and offspring with size and shape predicting fitness for survival. My mind wandered attempting to create meaning amid these random coincidences as I wrestled with uncertainties about how Lilly would fare after radiation. I sketched Lilly as a baby giraffe—her spots, much like the storybook, sculpted by leaves (of tungsten metal) distilling rays (of photons) to sizes and shapes reddening her skin but designed to improve her chance for survival, spots shared by a mother wishing to take her daughter's suffering upon herself. The painting's striking visual of mutually shared bold, whimsically colorful patterns inspired by the axial, coronal, and sagittal views of the radiation plan set against a stark dark matte background aimed to capture the vibrancy of the love I saw connecting Lilly to her mother and their resilience in the most trying times. Witnessing their journey underscored the permanence of the mother-child bond filled with tenderness and compassion that moved me as I was then caring for my own mother who was receiving radiation therapy.

When my mother's radiation oncologist showed us her treatment plan, I was engulfed by the same questions. Is the dose and field size appropriate for tumor control? Will there be irreparable damage? Will her symptoms improve or get worse? Is this what she wants? I viewed her treatment plan through the lens of a meticulous radiation oncologist in training, but this time, I was sitting in the chair along the wall reserved for family members. Like the patients I care for every day, as we scrolled through the intricate colorful isodose lines, I trusted they were the optimal intersection between science (dose) and art of medicine (painting) we strive for as radiation oncologists.

Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one at podcasts.asco.org.

I'm your host Lidia Schapira, Associate Editor for Art of Oncology, and Professor of Medicine at Stanford. My guest today is Dr. Shivani Sud, a resident in radiation oncology at the University of North Carolina. We'll be discussing her Art of Oncology article, 'Dose Painting'. Our guest today has no disclosures.

Shivani, welcome to our podcast.

Dr. Shivani Sud: Thank you so much for having me. It's a pleasure to be here.

Dr. Lidia Schapira: So, I'd like to start this by asking our authors to tell me what's on their reading list right now, or to recommend a book that has been interesting and inspiring to you that you read in the last year?

Dr. Shivani Sud: That's a good question. I'll be completely honest, I've been a bit boring at the moment with copies of clinical essentials of radiation oncology, and a few of our other handbooks.

Frankly, during the pandemic, and especially with current events, I think I've been more in the nonfiction realm, especially just trying to submerge myself in the news articles and the ground level journalism that's been coming out and so I would actually say that these days kind of a local newspaper and things of that nature have been a bit refreshing.

Dr. Lidia Schapira: Let's turn to your essay and your art. You're very unusual in that you bring to us in your narrative, not only the beautiful narrative and written word, but also visual art. Have you always been a writer and a painter?

Dr. Shivani Sud: I have enjoyed painting for a long time. It was one of those things that started by, I think I was just copying my sister, she once got an acrylic paint set, and she was painting on canvas. And there I was doodling something on paper.

I was always one of those kids who couldn't help but try to fit the whole rainbow into a coloring book page, or any art assignment. And I think that as I went throughout school, and the multiple levels of training that we encounter, as physicians, that painting just became my outlet, whether it was expressing myself, decompressing, feeling like I was channeling my thoughts and my energy into something, while not necessarily kind of sitting idle with those thoughts.

Dr. Lidia Schapira: Your essay helps those of us perhaps, who don't paint as a way of expressing ourselves to understand your process a little bit. And you start by saying that you've always enjoyed looking at shapes and finding connections. Can you talk to us a little bit about the way that you view shapes and find connections? And tell us how you see that in nature, and then in your work as a radiation oncologist?

Dr. Shivani Sud: Certainly, I think a lot of this goes back to that word we mentioned, pareidolia, and this human tendency to want to find meaning in randomness. And so, that was that childhood memory where you're on the playground with your friends, and you're lying on a grassy hill, and you're looking up at the clouds, and somebody sees a bunny, and somebody sees popcorn. And then someone says, 'Well, it reminds me of cotton candy.'

And so, I think as I then look forward to these late nights, these unrushed moments when frankly, you're maybe a little bit tired, maybe a little bit delirious, who knows, but you're looking at your work, you're seeing these shapes, you're looking at the plan, those memories of what the patient said was important, your abilities and limitations to control radiation dose, and seeing them merge together.

And I think it was really that immersion of, here are these dose lines, they're not random. They reflect meaning, they reflect what I am trying to accomplish and what we as a team are trying to accomplish for this patient. And so that was really what gave rise to these visual narratives in trying to take the dose lines, take the patient's narrative, and essentially create that visual narrative within their dose clouds.

Dr. Lidia Schapira: I found your essay so moving and so clear in helping somebody who is not a radiation oncologist think through all of the steps of the treatment planning and the delivery of the treatment, but what I appreciate so much about your writing is the humanity you brought into this.

One of the lines I found so beautiful was when you're describing the scene of this older woman who has so many comorbidities and now is facing lung cancer, and you're trying to palliate and treat with your treatment. And you say, you imagine and I'm quoting you now, 'her wishes overlaid on my target volume'. Can you tell us a little bit about how you imagine the patient's wishes and aspirations as you are crafting a treatment plan and delivering that plan?

Dr. Shivani Sud: It all starts with the consultation. I think oftentimes, even myself before I became a trainee in radiation oncology, I thought it would be a very impersonal field. I imagined just plans and computers and scans, and that it wasn't a field where you necessarily interfaced with patients as much as I learned that we do.

And so, the consultation is an amazing opportunity to get to know the patient. You have reviewed their medical record, you've scrolled through their scans, and you started to think about how you want to treat things. And all of that comes into reality when you actually meet someone.

You actually talk about what is important to them. Who did they come with? What does the person who was with them say about them? And what's important to them? How do they advocate for them?

And so, a lot of it is that merger of this is what I've trained to know. This is what the guidelines say. This is what the studies say. And now I'm meeting you, and I have an opportunity to learn about you. So, how can I take this information? And how can we embrace it in what you want to come up with the best plan?

Dr. Lidia Schapira: That's beautifully stated. You tell us in the narrative that this patient told you that she longed for a quality time until the sun sets, and then you drew or you painted this oil painting, right? It's an oil on canvas, that you titled 'Until the Sun Sets', and you said that you then use the art as a way of expressing yourself, but then also sharing it with others, perhaps gifting it to a loved one. Talk a little bit about how this art helps you to reflect, process, express, and then share?

Dr. Shivani Sud: I think, for me, a lot of the expression has to do with both the patient's journey, as well as my journey here. I started out as an outsider. I didn't understand what these plans meant. How they came together. And then as a trainee, working with Ms. V, I was able to understand, how do we actually use radiation to give her a short course of treatment, so she can get back to that vibrant life that she was enjoying, that quality life that she wanted, until the sun sets?

And in her case, especially, beyond just the radiation, she taught me so much about what we strive to do as providers and where our limitations are. So, I found myself very enthusiastic about treating this early-stage tumor. I had all the statistics about what the control rates were, and everything of that nature.

I remember her being very pragmatic about her multiple comorbidities and whether or not she felt she would derive a lot of benefit from treatment. And indeed, in the end, she was right. You could argue there might not have been a lot of benefit from treatment, because she passed away, a few months after we treated her, from those other comorbidities. But I remember after she passed away, and I saw that chart notification, it made me rethink all of our conversations, and that was one of those moments where you pause and you say, 'What did she want? And what was I trying to achieve? And where is the overlap between the two of them?'

And so, my target in the moment was that gross tumor volume. It was that nodule in the lung that I had circled, it was the hot spot in that dose cloud. And what I was trying to achieve for her was short treatment so she can get back to her day-to-day life. That meant I needed a hot dose in the center. I needed things to be cool and calm around the periphery. So, I didn't damage too much lung. And then I thought about this sunset, and there was this target volume. There was light because she was so light, so bright, so vibrant. And I had that sun setting into a calm ocean, not a turbulent one, to reflect her pragmatism, her ability to stay calm, cool, collected in the face of not only lung cancer but all of these other comorbidities. And so, really, it was meant to be 'What does she want? What is she stating? How do we accomplish it for her? And how do we put that forward in a visual narrative that someone else can understand and appreciate aside from, here are some colorful isodose lines that happened to look nice?'

Dr. Lidia Schapira: I must say I find it very inspiring to hear you talk because you talk about radiation oncology, being a technical field and I hear in your voice, everything about connection and mission-driven work.

So, I think it's beautiful. The idea is that you're sort of translating and applying what you hear from the human being who is bringing you this disease into your thinking and crafting your dose and your delivery. That's really very beautiful. I wonder if you can share with us a little bit about your comment about the importance of the caregiver story. And in the essay, you say that perhaps some of your response to your patients was also impacted by your experience as a caregiver for your mom when she was undergoing radiation. Can you share a little with the readers and listeners?

Dr. Shivani Sud: I think this is part of the reason why Lily's situation and her journey resonated so closely with me. She and her mother were an inspirational duo, regardless, but I think there was this extra level of connection, as we took care of Lilly because my mother was about to start her radiation treatments herself.

This is another one of those examples, where, as a trainee especially, it feels like you start off as an outsider, and then you're part of the system. And then here, I was, not necessarily, you know, I wasn't part of my mother's radiation treatment delivery team, but I was still a radiation oncologist in training. And here I was sitting there by her side, trusting the system that I was once an outsider to, and then was once part of, but from a different vantage point. And so that's kind of those shifts in where the chair is located. And in chart rounds, it was along the periphery for the medical students, and then you're sitting in the main seat as the radiation oncologist. And now you're sitting in the chair along the wall reserved for family members.

I think the role of a caregiver is tremendously important in terms of caring for patients. First, of course, for the patient's well-being for them to have someone to speak with, at least that was the case with my mother. We would often talk about her symptoms, and what she was afraid of, what she wanted out of treatment, the parts of radiation that were scary and nerve-wracking to her.

And it was interesting to now be on this cusp and, had her tumor arisen five years before, I wouldn't be able to speak both languages of daughter and radiation oncologist. But given the point in time, there were many moments where I could reassure her. And there were also many moments where, after I reassured her, I would then sit there and say, 'Oh, dear, is this actually going to work?'

You have all this training, but then you kind of pause and you say, 'Well, do I believe it?' And you think about things a little bit differently, again, when you're not necessarily in the system, but you understand the system, but you're sitting in a different position.

Dr. Lidia Schapira: You're clearly inside the system. Now, my final couple of questions are these, one is what motivated you to write and publish the story?

Dr. Shivani Sud: The paintings themselves arose from seeing these visual narratives. And essentially the same way that a writer likes to put thoughts to paper, I wanted to put paint to canvas, because that was the way that I was going to remember this connection that I had made. And this was the best way that I would be able to share the connections that I had made with others.

In terms of wanting to pen the story, part of it was giving light and continuity to these experiences of taking care of these two patients who had taught me so much and clearly struck a chord with me in terms of wanting to craft these paintings and to also share with others that there is humanity in our field, there is such a deeper connection that we make. And even though these computer-generated lines might seem so impersonal, and you see us scrolling through scans and things of that nature, there is very much a human connection, a human cause, and purpose behind all of that, and everything we do is centered around the patient. And this for me was just my way of showing a way in which I bring my mind, body, and soul to the work that I do. And take home this work and say, 'This is where it's a part of me.'

Dr. Lidia Schapira: Have you shown your artwork?

Dr. Shivani Sud: I have shown my artwork to a few of my co-residents. A few of my attendings have seen it as well, I haven't widely circulated it at this point in time.

Dr. Lidia Schapira: Shivani, thank you so much for sending us your work, and please remember to keep your humanity about your work. It is inspiring. It is inspiring to hear you. It was really moving to read your essay and to appreciate your artwork. Thank you so much.

Dr. Shivani Sud: Well, thank you so much for having me. Thank you for accepting the piece, for encouraging us to embrace our humanity in the work that we do, and for having the Art of Oncology section. It's a pleasure to be able to join. I really appreciate your taking the time to include me.

Dr. Lidia Schapira: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen.

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