An Interview with Deepak Khuntia, MD, FASTRO

By Join Luh, MD, FASTRO, and Scott Silva, MD, PhD

The following interview of Deepak Khuntia, MD, FASTRO, was conducted on October 25, 2023, by Join Luh, MD, FASTRO, and Scott Silva, MD, PhD.

Join Luh:  We're going to compress a lot of your life story into a short period of time, so we wanted to just go and get started and just have you maybe tell us about where you were born, your childhood years, and what influences you had as a child that may have set you up for where you are today? 

Dee Khuntia: Sure, well this could take a bit so I'll try to give you the five-minute spiel on it.  So I was born and raised in a small town in northwest Illinois. The town was Freeport, IL and it was a company town. We had about 25,000 people there and it is the capital of the county. You could walk to Wisconsin and you could ride your bike to Iowa, so that kind of tells you whereabouts it was, and it was a typical company town – one in four people that lived there, worked for Honeywell – my dad being one of them.  He was an engineer there and basically spent about 30 years with Honeywell.  But you know, if you didn’t work for Honeywell, you were probably an agriculturist.  There were many farms there, and it was a very blue-collar town. So that’s where I grew up.

My father, as I mentioned, was an engineer. He was a materials engineer who had trained in India at IIT [Indian Institute of Technology] in Mumbai, where he got his degree, then came to the U.S. and worked on his graduate degrees – an MBA and started a PhD for a while, but then ended up going directly into work and joined Honeywell right away. My mom was an accountant, but then later became a stay-at-home mom and raised me and my younger brother. 

In terms of going beyond my childhood and talking a little bit about the town, as I mentioned, it was a really blue-collar town and about 30% African-American. There were very few Asians. I think in my graduating high school class we had about 400 people in it so it was a large school, but in terms of Asians there were few and there might have been, you know, about ten in the whole school. So that tells you what the makeup was. Most of the kids didn't go into higher education after high school and most stayed in town so we had about 20% that went into four-year universities roughly back then, so you know it sort of tells you the nature of a Midwest town. Then Honeywell pulled out their manufacturing operations in Mexico so they went from 5000 employees down to about 200, so that was pretty devastating to the town. The population actually went down a bit toward the end of my high school years.

After high school, I went on to the University of Illinois. I started in engineering and wanted to do that because that's what my dad did. He's somebody I probably learned the most from more than anyone else. However, I found out I didn't like it, so after my first year I ended up going into a pre-med program as a chemistry major partly because all my chemical engineering credits transferred into that and it allowed me to actually graduate in three years from undergrad. I ended up going to medical school at the University of Illinois as well, and was able, fortunately, to get scholarships so that the state paid for a couple years of my medical school education. I thought for sure I was going to be a small town, family practice doctor in my hometown, and in fact, I had applied through ERAS to family practice residency programs. It was not until late in my third year where I got exposure to oncology.

I was on my medical oncology rotation and followed a young lymphoma patient and I stayed with her through her radiation treatments. In medical school, we don't get much access to radiation oncology and I got to see the technology that was being used, and the engineering side of why I wanted to go into engineering came out. The emphasis on math and physics was attractive to me. So I quickly rearranged my schedule to do an elective rotation in radiation oncology and ironically, I was even able to do a rotation in my hometown where the University of Wisconsin actually ran the cancer center there and I was exposed to radiation oncology there, and then followed this with a rotation at the Cleveland Clinic and really, really fell in love with the field. I ended up withdrawing my ERAS applications and changing them to radiation oncology. So I thought I was going to be a community radiation oncologist, though now I seem to be doing the opposite of that. But that's a longer story we can get to when the time’s right.

Scott Silva:  So tell us a little bit about your career after you finished residency.

John Suh was my program director when I started there. I actually went through three residency program directors in my 5 years as a resident – it was a categorical program. So internship was half oncology, half medicine, and so I was able to stay there for all five years. While I was a resident, I got taken quite a bit by John Suh. He was my first mentor in radiation oncology and his work ethic and just how hard he pushed me – I really liked that. He taught me so much. It was very similar to the mentorship I used to get from my father, and he ended up really shaping a lot of my interest in medical education. I was very fortunate that they let me do a lot of research, even though I wasn't a PhD. I must have given at least 30 presentations at national meetings during my residency, and that inspired me actually to go into academia and also become a residency director myself. 

I was being recruited pretty early by a second mentor of mine, Minesh Mehta. Minesh tells the story way better than I do. He goes, “Oh, you know, I saw this kid who used to come to one of our cancer centers in Freeport, Illinois, and there is no way I can get anyone to ever go and staff that clinic so let me go after him as soon as I can so I don’t have to travel to Freeport.” So he started recruiting me as a PGY-2, thinking that I would end up going back to Freeport, which actually was very attractive to me. But what ended up happening is during the rest of my residency he ended up recruiting a really good faculty member who was a pillar of that community, Patrick Fernandez, and instead he said, “Hey, I've got another opportunity for you where you'll split your time between the main campus and during the end of your residency, I want you to build this cancer center halfway between Madison and Milwaukee.” So, as a senior resident, I was actually able to help design a med onc, rad onc freestanding cancer center about 45 minutes from Madison. That was pretty exciting to do that in my free time as a resident and by the time I got to the University of Wisconsin, I was able to actually staff that clinic a couple days a week and for the rest of the time I was at the main campus.

I graduated residency in 2004, so that was the year, that kind of got screwed with the ABR. In the prior year, everyone was board certified before they graduated from residency and then the 2005 class was the class that got to take some of their writtens during residency and then they would do the orals right after. Well, we were in the group where writtens and orals happened after residency, so we were the one year that got penalized. But in some ways it was really good because in addition to practicing medicine, you're also studying all the time. The retention of information was really high. We had three faculty members that started at Wisconsin on the same day, Rakesh Patel, Kristen Gradley and I, and we all graduated at the same time. We had this wealth of knowledge and we were really able to shape the educational curriculum of the program since all the data, the minutia of all the trial details, etc. were so fresh in our heads. And Wisconsin had a good program before, but we saw pretty dramatic changes in the resident education after the three of us started.  The three of us worked and changed the residency structure to be more like the Cleveland Clinic structure. More of a Socratic method teaching as opposed to resident-run teaching. So faculty participation was much more important, and we saw dramatic improvement in the scores of our residents. They were all in the top five percentile of their in-service exams, for example, from being somewhere in the middle of the pack. So that was a nice thing to see, but that got me even more interested in medical education through some of the work happening there. I ended up taking on larger responsibilities within the medical educational side. I ended up running the cancer course in oncology at the med school. All second year med students had to take that class and we had a class of I think it was about 175 kids and we would typically have over five medical students go into radiation oncology every year, which from a percentage standpoint, that's actually quite high, and I think part of the reason is they had early exposure as a second year student as to what radiation oncology was all about, and when students hear about it early, it's hard not to be excited about the field. There's a lot to love. You guys know…we probably couldn't think of going into another specialty after doing this for so many years. So anyway I was pretty active in the medical school from having those students and I also was what was called a “house mentor,” very similar to if you watch Harry Potter how they have the different houses, and so I was in charge of one of the houses, and I was mentor to all of these students, and I ended up running the residency program as well. So education became a really important part of what I enjoy quite a bit about the field. But administration, translational research and academics were also other areas I enjoyed. I like doing everything, to be honest with you, but I ended up at the same time taking on the Vice Chair of Outreach. So I ran all the cancer centers that the state of Wisconsin ran. We had seven centers at the time and it was my responsibility to make sure that they were running appropriately, treating patients appropriately, and then reporting to the COO on a monthly basis as to the success of that program and ensuring consistent quality across the network. The community based practices seemed a little more conservative from what I was seeing at the main campus, and being able to bring the latest and greatest technology and methods to the community practices was pretty exciting.

On the academic side of it, I did run the lung cancer service there and I backed up the brain service for Minesh and the head and neck service for Paul Harari – they were both mentors of mine there. I had one of the heaviest of clinical volumes of any of the staff there and I even remember one day seeing 65 patients in a day which I know in India that's probably not that much. But in Wisconsin, that's actually quite a bit. So clinically, I was really busy and I didn't mind it. It was one of these environments where you know, you just didn't want to go home. It was so much fun. The culture there, the peers, the colleagues... I mean it never felt like work. It was fantastic and I really do miss the faculty there and the department. If I were to ever go back to academics, that probably would be the only place I would consider. I just loved the Midwest ideals and I still go back quite a bit.  Ironically, my son is a sophomore at UW and my daughter is a senior at Case Western, so she goes to Cleveland where we used to live and he goes to Wisconsin where we used to live, and that could have saved us a lot of money staying in California. But hey, I'm happy for them and it just means more visits to the Midwest.

I also specialized in brain tumors and did a lot of work with the RTOG and now NRG, chairing many trials, particularly related to neurocognition, and I continue to help support the NRG. I was examining for the oral boards for well over a decade. I think last year was the last time I'll probably do it for a while unless they really need somebody; but for almost 15 years I've been involved with the ABR, either writing questions or examining for over a decade, so it's a lot of fun. I love that part of the job and I love giving back. 

But then what happened is one of my partners and best friends, Rakesh Patel, had left Wisconsin for a private practice in the Bay Area – and he ended up recruiting me to join a private practice in the Bay Area too. We resisted for a few years and finally, one thing led to another where I talked to my wife and I said, “Hey, I know we're both from the Midwest, we love it here, our family’s here, but if we're going to try something different, now is the right time. The kids are young enough where we can make that move.” So in the end of 2010, we ended up moving to the Bay Area, joining a 10 radiation oncologists in the group, and I continued to examine for the boards. I also continued to run these trials through the NRG, and I maintained sort of an academic presence despite being in community, very similar to what you do, Join. However, our practice ended up splitting in half and I ended up staying with Dr. Patel's half of it. 

So we were down to four docs at the time and it was a med onc/rad onc practice and it was becoming a little bit harder to maintain my academic relevance because if I'm gone, nobody else can take time off. And as you know when you're in academia, you have to be gone a lot for meetings, and this was before COVID where people didn't do Teams meetings or Zoom meetings regularly. So I was going to go back to academics and we had narrowed it down to be a Vice chair over at Stanford or Vice chair at the Cleveland Clinic. Then Bill Regine asked me to come in and take over that position and at the time, Minesh was at Maryland too, so I’d be able to work with him again as well and so we were deciding between these three really competitive offers and can’t tell you where we were leaning toward because I might make the other two departments upset. 

But what ended up happening is at the very last minute, Varian approached me and said, “Hey we heard that you might be potentially leaving the area, but don’t do that. We want you to come and work for us. We’ve never had a radiation oncologist and we like what you’re about,” because I got to know them through our practice. I was about to build a West Coast Training Center for Tomotherapy and I was very familiar with Tomo-technology being from Wisconsin, and at one time I probably had the most patients under treatment on Tomo than anyone else in the country and I was training people all over the world on how to use that. So I said, “Great, we’ll build the training center on the West Coast” as they only had an East Coast training facility at the time. So this would have been a nice mix as I was heading to Asia quite a bit to train. Well, now Asia could come to the Bay Area.  Comparatively, it's a pretty easy trip and we’re about five miles from SFO, the location of our cancer center. But ironically what happened was Accuray acquired Tomo and whenever an acquisition happens, a lot of things were paused for a while just so they can figure out the new organizations and so our training center was put on hold, which actually opened up the door for us to think about other options. That’s when I got to meet the Varian team and I came to Palo Alto and I presented my vision of the future of oncology, and Chris Toth, Corey Zankowski and Kolleen Kennedy were there. We were each pitching our visions of the future and they overlapped really, really well. We ended up putting in one of the very first Truebeam STX systems, certainly the first in California, and we were building a program around it and teaching people on how to actually build the program.  So I was getting my education fix, while still maintaining a community practice. But ultimately when the changes happen to our clinical practice they approached me and I said, “Wow, this doesn’t happen every day, right?” This would be the first time for hiring a radiation oncologist, and this would be to run medical affairs. They did have John Adler, a neurosurgeon, at the time, that worked for Varian, he was more sort of a special advisor to the CEO, Dow Wilson, and so I was really the first radiation oncologist and the fact that they said, “We encourage you to keep seeing patients if you're willing,” which was really important to me. A lot of device companies don't let their employees continue to practice medicine. 

At Varian, we have a different philosophy where it makes you more relevant in your Varian work when you really understand what our customers are going through on a day-to-day basis. So anyway, I ended up taking the job and that's a story in itself, is how that's evolved over the last decade. But I'd like to say I've made a pretty big impact on Varian, as well as the specialty, because of the work that I do here.

Join Luh:  That's quite a story.  So when you made this transition, you were able to still see patients in clinic and still fulfill your duties at Varian, as well?

Dee Khuntia:  Yep.  Well, I think it's one of these things where – you guys know this, we're doctors – a 40-hour work week is a vacation, right?

Join Luh:  Yeah.

Dee Khuntia:  At the time, Varian was not used to having people with these types of work ethics where we're still getting our 40 hours or more in at Varian, even if we're seeing patients one day a week. This is what we do and it's sort of ingrained in us and I think the company sees the value in it.  In fact, most of the physicians at Varian now – we have quite a few of them – they still practice medicine. They don't have to, but they choose to, and it does help with our customer interactions because yes, we are Varian, but I think we're looked at a little differently when we talk to customers.

Join Luh:  Yeah, definitely adds to the credibility of what you bring to the table for Varian and I just want to add that John Adler is actually a neurosurgeon, so it's definitely a huge thing for a radiation oncologist physician to be a part of Varian. You know, with all your involvement in so many things, when you were in academics, you did a lot of more than what the typical academic physician gets involved with, including being involved with ASTRO, the NRG, and the leadership within your own department, cancer center and university.  Tell us about other national or international organizations that you're active in and belong to?

Dee Khuntia: That's a very good question, Join, and I think you know that I'm part of ACR, as I said, on the educational committee there, and I've been doing that for quite some time. I’m also heavily involved in the RSS, in fact, bringing John Adler back up again, I was in community practice here in the Bay Area and you know John is one of the people that started the previously known CyberKnife Society that's what it was called. And so he and I were the ones that work together to change the name from the CyberKnife Society to the Radiosurgery Society and this whole "bridging the gap" theme that they have, that was something that I had put together with their executive team and it's sort of carried all that way. This happened before I joined Varian, but realizing that, the LINAC-based world needs to have a society where they can lean on, just like ISRS was pretty heavily dominated by Gamma Knife and so I felt RSS was an organization that was small enough where you can have a huge impact on the direction of it. ASTRO is such a large organization, you can have an impact, but it's probably in just one small area to have a big impact on it. You really probably have to be at the top levels of that society, as opposed to in the RSS, where we've done a great job of dramatically increasing the membership of that society. I'm involved in ESTRO, the European group for radiation oncology heavily involved there, and also with ACRO.

I think one of the things that ACRO does really, really well is focusing on the here and now of what we can do to make practice more successful, whether it's clinical education or dealing with reimbursement or improving operating efficiently. As a brachytherapist myself, The American Brachytherapy Society, is another society I am passionate about. In the past, I ran the prostate program back at Wisconsin, and I also did quite a bit of lung brachy. I did the first Davinci-assisted brachytherapy procedure for lung cancer, which was before the randomized trial came out with wedge resection plus or minus brachytherapy where we would add the mesh directly onto the staple line. The exposure levels associated with building these handmade meshes are not trivial.  And so, to be able to implant it using a robot where you are far enough away from the iodine or the cesium that was on there, we thought it was a promising idea and so we did a few cases here with one of the Stanford thoracic surgeons. But none of these are probably anything unexpected for most radiation oncologists.

I would say the ones that I get involved in that you may not be aware of is MAPS, which is the Medical Affairs Professional Society. So having Medtech involved in medical affairs is, I would say, a relatively new in the big scheme amount affairs. Pharma has been doing it for decades, whereas Medtech or Biotech is probably something that's become more and more important over the last ten to fifteen years. And so I do have leadership roles within MAPS. AdvaMed, which is the technical society that supports radiation oncology. I am actively involved with the Society for Interventional Radiology and the Society of Interventional Oncology, and partner with them on a variety of different research projects. Because Varian also has a whole portfolio in interventional radiology from cryotherapy and embolics, including – drug eluting beads, radiofrequency ablation, microwave, and those sorts of technologies – so that's something that I spend a lot of my time and effort on building in regards to that specialty. There are all kinds of opportunities, especially now that they’ve become a categorical program right out of residency and you no longer have to do your radiology residency first and then do a fellowship. So we're expecting to see a big increase in the number of people that go into that specialty. So those are some of the societies. I'm sure I'm forgetting one or two, but those are the larger ones.

Scott Silva:  So Dr. Khuntia, you're basically like the Jack of all trades with significant experience in academia and private practice and industry. I'm curious, what advice would you give to residents and young faculty today?

Dee Khuntia:  Yeah, thanks Scott for the question. I would say the reason Varian hired me is because I did all these different things. Radiation and cancer care delivery is done in all practices, big and small. Challenges are different for each. So, whether you're the head of ASTRO, or you're in a small community practice where the next closest cancer center is eight hours away, I understand what the different users have to go through, and so if I were a resident or if I was giving advice to a resident, I would say the number one thing you can do is be a good clinician. So study hard, work hard, learn as much as you can, be the best clinician you can possibly be, and get the volume early. This is the best time to hone your skills and you know, practice makes perfect and focus on that as a resident and then take advantage of the opportunities that are given to you, even if you're not quite sure the type of practice that you want to be or what your career is going to look like. I was going to be a family practice doctor in a really small community delivering babies every day. That is the opposite of what I'm doing now and so having options is important and you just don't know what you don't know. So being exposed to as many different things, whether it's translational research, clinical research, whether it's being in an administrative role as a resident, being a leader in ARRO for example, or being the AMA representative for your area as a resident, I would say try to do as many different things as possible. Though you will have more responsibilities, they are often going to end after your five years, and so this is a great time to take chances, to experiment, to figure out what resonates with you, and you may end up being like me, where you like doing a lot of different things. And you never know where that's going to.

Join Luh: Yeah, that's a great message.  You know, just the importance of having radiation oncologists in different areas that you may not expect, such as organizations like the AMA or even your own county medical society. You know, it's important to have our voices as radiation oncology clinicians there. Also, you had mentioned how you had reshaped the training at University of Wisconsin and how it improved the board performance of the residents. What are your thoughts about training, you know, nationwide for residents – the challenges and opportunities, and as well as the workforce issues that we're seeing, and maybe the role of AI?

Dee Khuntia: Yeah, all good questions.  In terms of resident education, I'm a huge, huge fan of active learning. Passive learning is not effective for most folks though there are exceptions. One of the doctors on my team, Sushil Beriwal, you may know him, he's got a photographic memory. I remember studying with him for the boards and he was sitting there reading the New York Times while we're all cramming. Back when the test was done in Louisville, we’d have this bet going that if we ever knew something about radiation oncology that he didn't know, he would have to buy us lunch. Well, it's been over 20 years and he still has not bought us lunch. But most people aren't like that, you know? And so whenever you are being put on the hot seat you tend to remember things, right? You particularly will remember the things you don't get right. And so this is the way my residency was at CCF was and this was brough to CCF by the chair then, Roger Macklis who brought it from Mass General. Bringing this to Cleveland Clinic was then socialized to Wisconsin and many other programs across the country from ex-CCF residents and faculty. A lot of the residents that were at the University of Wisconsin or at Cleveland Clinic became residency directors at other institutions and did the same thing, and we saw the same sort of results where, Socratic method teaching actually works. You have to be able to do it in a way where you can ask one resident 1000 questions in an hour, but at the end of the day you buy them a beer and they know it's just to make them better and not to make them feel bad.  But there's a right way to do it, which you know inspires them and doesn't intimidate them.

That's, I think, something I did really well or I'd like to say I did well, and these residents have become my best friends and many of them were older than me too, because I was a little bit younger when I had graduated residency and several of my residents had actually done PhDs and so forth. So half of the residents that I trained, I was their residency director. I was younger then, and so I would say from an education standpoint, I think doing active learning is great and whenever you see a patient, reading up on that disease helps because that's active learning as opposed to just reading a textbook from cover to cover. 

Now in terms of the future, I know ASTRO tends to be more of a U.S.-focused society, but I tend to look at things globally. My role is global and I have to help patients everywhere in the world for what I do. In fact – that's one of my highest priorities is how to bring access to care, whether it's in Zambia or whether it's in the north side of St. Louis, how do we ensure that there's equity and access to cancer care everywhere? There are not enough clinicians that will meet that gap to address the global burden.

Now we all know there is a recent ASTRO paper that even came out about staffing and radiation oncology and the number of residency slots and I think the general thinking is to not open up any new residency spots right now and I totally get it but globally, that's not the problem, we have the opposite problem. Even if we added double the number of residency slots globally, we're not going to be able to address the cancer burden. The cancer burden is increasing faster than we can train clinicians and there are lots of reasons for it: people are living longer, we're getting better at addressing disease, survival has been improving on these diseases, so patients are getting recurrences, we're focusing less on communicable diseases and now noncommunicable diseases like HIV or better managed. Developing nations are now investing a lot more into oncology, and so the only way to bridge that gap is to use technology to allow people to do a lot more with less and to democratize care so somebody in the south side of St. Louis gets the same care as someone on the north side of Saint Louis. There is actually a line in St. Louis if you live on one side of the street, your survival is dramatically lower than if you're on the other side of the street and we have to do a better job of eliminating that. So software and technology are going to bridge that gap.

With your question around generative AI, we're going to have to get used to it. So if you're a resident, immerse yourself in understanding how these things work. Treatment planning is the low-hanging fruit here. Segmentation is another area of low-hanging fruit. Whether you like what you're seeing, there's a lot that's not clear yet that just takes time to get through the regulatory process that will dramatically improve the efficiency and quality of segmenting even complicated structures like the hippocampus. We have tools now just within Varian and Healthineers. We were acquired as many of you know by Siemens Healthineers about two years ago, and so now we're one big company. Though I'm the chief medical officer for Varian, I do lead the broader global company strategy on oncology. As a combined company, we can do things like segment out the hippocampus in under a second and we can do it very accurately. For those of you that were at ASTRO, you know how much evidence now is emerging about the value of the hippocampal sparing and whether it's, you know, small cell lung cancer or other brain mets that you're treating. We also know how complicated radiosurgery planning can be, especially in countries where you're not used to delivering such a high dose where automation is here and we can democratize the treatment for some of these radiosurgery procedures like brain metastases. So this is probably the most important big step in radiation oncology in terms of improving the quality of care. 

I would say the next thing that we should expect in the next decade is more work happening where we can actually learn more about how a tumor responds to therapy and help predict what the best therapy should be in the future when a new patient comes in. Something that many people don't know is that as Varian, we actually own 16 cancer centers in India, we treat about 70,000 cancer patients a year in our own centers. We’re the second largest provider of cancer care in India and India is now the largest population country in the world. Dr. Beriwal from my team leads the medical affairs initiatives there. Being able to actually understand the phenotype of the patient, the genotype of the tumor, how the patient was treated, what the outcomes were for those patients, that does give you the possibility of building a learning system from beginning to end that will then allow you to make better decisions in the future. So that's something that was always a pipe dream before, but now I think we have the possibility of building tools like that because we will save a lot more lives. Getting that part right, treating patients the right way, then we will be going from a 2 1/2 millimeter MLC to a 1 millimeter MLC, for example, on our LINAC and so I’m pretty excited about what AI can do for the specialty in that regard.

Scott Silva: I find it interesting that you think about radiation oncology on a more global scale, and I think most radiation oncologists think of it more on a local or even national scale. So how would you say we get more radiation oncologists interested in global radiation oncology?

Dee Khuntia: Yeah, good question. I think there are certain people that gravitate toward wanting to help underserved folks, and there are several NGOs there that actually, whether it's Radiating Hope partnering with large societies like ASTRO and ESTRO that actually have programs directed at low and middle income countries getting involved there. It all depends on your time commitment. Some countries recognize your medical license from the US and you don't have to reexamine for their country to practice medicine, and other countries you do, so you have to figure that part out. But for those that are actually interested in practicing medicine overseas, it is a great experience and it's something that I think allows you to sort of “train the trainers”, so to speak. We run programs that are shorter since it is easier for us to be at a site for a few weeks vs a few years. We run these train the trainers program for both interventional radiology and for radiation oncology. I think going to ASTRO and going to the international section of the meeting, you'll build those relationships and you'll find out that there are more opportunities than there are people that can staff it. So if you're interested, that's probably a really good first step. 

Now, I think if you're interested in more on the technology side, like how can we use technology to increase the throughput, which is a big issue. We have one Halcyon system, for example, in India, that had scheduled over 200 patients a day on one machine. Every single patient was IGRT IMRT  and now only 186 patients were treated that day because 14 didn't show up. But the point of the matter is, that's doing the work of three to four Linacs. You know, these are the real problems that we don't have to face in most of the US, but you'll have an entire country with a single Linac. It’s unbelievable and there is a tremendous opportunity that's there. So it's really easy if you're interested in this, go to the ASTRO sessions, talk to me, you know, talk to other thought leaders that are in the space. There's plenty of work that can be done.

Join Luh:  Yeah, great advice, and definitely helps us think outside the box in terms of traditional career trajectories for radiation oncologists. I'm thrilled that we covered so much ground during this interview, so I guess I'll just ask any closing thoughts or things that we didn't cover that you'd like to bring up?

Dee Khuntia:  I think we're looking at sort of the history of radiation oncology and ASTRO’s history. I think that my message to members of ASTRO is that you cannot underestimate what ASTRO could do, or what ASTRO does do for the specialty. Being able to be a voice with the government and doing things with the PAC I think is something that we can probably move the needle more on, you know, we know in the U.S. anyway, which is just about half of Varian’s businesses in the U.S., and same with most companies is the dollars are what drives how we treat whether it's right or wrong.  You know that that can be debated, but until the system changes and you know, working with these PACs, I would say is pretty critical and making sure that the leaders that sit on the AMA CPT panel meeting understand what's happening on the technology side because technology is ahead of clinical practice. For example, had we had five product launches, there's just at this ASTRO alone, and I mean, we're innovating faster than people can consume things and which also means that reimbursement is lagging almost a decade behind where the technology is. So I think there's opportunities for us to impact more patients if we can, you know, ensure that the reimbursement happens at the right pace as well – not an easy task, but if ASTRO can't do it, nobody can do it. So, you know, that's something that I think there's opportunities for now.

Another welcome thought here is that with the health equity missions of ASTRO, these are important, and we have it as the largest society for radiation oncology. We must take this very seriously so we can put a dent in the access problem, which is just going to get worse. So we can't just hold the line and incrementally improve what we do in terms of access, it has to scale up faster, and then I would say the last thing is that we have to be you know, so you could see it on the back of my head poster here at the sustainability side of what we do. There is a lot of innovation that should happen to help reduce our carbon footprint in everything that we do. You know, we're seeing the environmental impact and so things like going from 43 fractions of external beam radiation for prostate cancer down to five, just the carbon footprint impact from transportation, from energy consumption, etc. You know that is tremendous for the environment. Now, sometimes the reimbursement does not pan out and we get underutilization, but we have great data now that came out at ASTRO with the PACE study, with five fractions for low and intermediate just as good as the forty-three fractions. So let's look at how we can get alignment where reimbursement, sustainability, and outcomes are all prioritized and ASTRO, I think, is the best venue to make these things happen.

Scott Silva: No, I think this is excellent. I appreciate all of your insight, Dr. Khuntia.  You have a wealth of experience, and this is good for me. It makes me think outside of the box, so I appreciate this interview.

Dee Khuntia: Well, speaking of outside the box, Join, you reminded me of another society that I'm a member of that I didn't talk about. This is one of my most enjoyable ones.  It’s the American Wagyu Association.  We raise cattle, hogs, chickens, turkeys, pheasants and board horses.

Join Luh:  Wow, and you also belong to a krewe for the Mardi Gras in New Orleans.

Dee Khuntia:  Oh yeah, that’s Endymion. I am a member of the Endymion Krewe as well. This is one of the largest Super Krewes of Mardi Gras (I think the largest). I’ve been riding in that large parade for over a decade now.

Join Luh:  So that reminds me – one final question – we forgot to ask you about your hobbies.

Dee Khuntia:& Yeah, you know my hobbies are diverse. I’m a bad guitar player. I keep picking it up and letting it go. I started when I was a resident. I wish I could get better at it. I do play tennis though. I ruptured my Achilles playing it in April and now just got cleared to go back to full strength tennis again. I hunt and fish. Being from the Midwest and being in a rural town, fishing was something I did every weekend the weather allowed. I love the whole regenerative agriculture side of what I do on our ranch. There's five of us that own the place, so trying to find ways of improving carbon sequestration with rotating crops, rotating livestock, trying to, you know make the earth healthier than when we found it, these are all things that I really like to do.

Join Luh:  Well, what a wonderful, balanced life and career, and so many accomplishments!

Dee Khuntia: I could say the same about you, Join.  Scott, I don't know you very well, but hey, I'd love to learn more about you too.

Scott Silva: Well, we'll have to chat sometime, but this has been great.  I think you’re an excellent mentor, I really appreciated hearing all your words of wisdom and you know, perhaps next year at ASTRO we can meet up.

Dee Khuntia: Let's plan on it.

Join Luh:  Absolutely. Dee you’ve been a great person to know, and I'm glad you and Scott have made the connection because I think there's a lot of information to be shared. 

Dee Khuntia:  Yeah, and before I forget, I am also on the ROI Board and Join is on there with me, and I lead the Corporate Research forum of that. So we want to make sure that you know people are aware of how important that organization is for funding education for our junior faculty and residents.

Join Luh:  Right.  We certainly appreciate yours and Varian’s support on that as well.  Well, thanks again for all your time.

Dee Khuntia:  Yep.