Download Mine - Edinburgh & Lothian Prostate Cancer Support Group

Radiotherapy - the art of the
invisible
Terry Kehoe
Consultant Clinical Scientist
Head of Oncology Physics
Edinburgh Cancer Centre
“How to crack a walnut”
CRUK - Radio 5 on 10th June 2014
50% survive 5yrs today
30yrs ago – 25%
20yr target – 75%
CRUK - TI report May 2014
Addition of RT – 16% ↑ in 5yr survival
Addition of CT – 2% ↑ in 5yr survival
Why does so much money go into drug
development?
Improved survival from prostate
cancer over my career
46.7% -5yr survival in the early 80’s
By the end of the 80’s 5yr survival ↑ 56.3%.
By mid 90’s 5yr survival ↑ to 70%.
Mid ‘00‘s - 5yr survival ↑ to 85.2%
When I started in 1979
We increased our doses safely – how?
Early Image Guided
Radiotherapy IGRT 2004
Fiducial Markers
Inserted trans rectally
Images true prostate position
We increased our doses safely – how?
Diagnostic
quality imaging
Modern Image Guided
Radiotherapy IGRT 2009
Same Fiducial Markers
Now CT capability
Images true prostate position
and software calculates how
much to move the field to
correct for it
Why we can increase our doses safely
New in 2011 even better IMRT
Will have all LinAcs with this arc
therapy by end of 2015
IMRT 5½mins
VMAT 1½mins
~ Doubling in 5yr survival in 3½ decades
All from RT? No - 46% of prostate cancer
patients receive external beam radiotherapy.
Will the 85.2% 5yr survival rise? Probably.
How do you
know you are
doing it right?
Image Guided – IMRT is best. Is it new?
No it’s been around for a century. Some people
call it a “black art” perhaps its “magic”
I-125 day case permanent
implant
Volume Study
2001
Classic 2-stage procedure
Volume study to assess prostate
size, pubic arch problems
and plan treatment
Good for learning curve
Single stop
intraoperative prostate
Seeds Brachytherapy
ECC late 2009
HDR temporary implant
Meta-analysis of large patient studies
Using % PSA progression free as an
indication of survival
Criteria for Inclusion of Article*
1
Patients should be separated into Low, Intermediate, and High Risk
2
Success must be determined by PSA analysis
3
All Treatment types considered
4
Article must be in a Peer Reviewed Journal
5.
Low & Intermediate Risk articles must have a min of 100 patients
6.
High Risk articles, because of fewer patients, need only 50 patients to
meet criteria
7.
Patients must have been followed for a median of 5 years
* Expert panel consensus
LOW RISK RESULTS
Weighted
Brachy
% PSA Progression Free
Treatment Success
100
23
25
4
22
30 6
EBRT
37
31
90
19 105 24
14 21
13 8
35
3
33
29 101
39103
18
102
38
40
1 100
27
32
10
28
36
2 26
EBRT & Seeds
5 16
12
7
104
9
80
15
Surgery
70
34
← Years from Treatment →
60
11
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Robot RP
Seeds
Surgery
EBRT
CRYO
HIFU
Protons
HDR
INTERMEDIATE RISK RESULTS
% PSA Progression Free
Treatment Success
Weighted
EBRT & Seeds
Brachy
100
33
14
90
24 2313
35
16 4
30 36 45
40
38
32
43
18 47
19 5
7
42
3
28
9 26
25
29
41
1
8
10 11
60
EBRT
20
Hypo EBRT
17 27
2
46
Surgery
50
← Years from Treatment
→
40
2
3
4
5
6
21
7
8
Brachy
Seeds Alone
Surgery
EBRT
CRYO
HIFU
HDR
EBRT, Seeds +
ADT
22
1
Seeds + ADT
EBRT & Seeds
39
6 12
70
+
34
15 44
80
Robot RP
37
9 10 11 12 13 14 15
Protons
HIGH RISK RESULTS
Weighted
% PSA Progression Free
Treatment Success
EBRT, Seeds & ADT
20
Brachy
16
109
45
19 18
4
38 22
100
108
EBRT & ADT
17
EBRT & Seeds
40
3 34
9 41
13 36
25
101
106
EBRT
44
48
1
33 21
43 32
2
10
12
14
46
42
8
110
31
28
104
24
5
Surgery
30 27
107
102 15
105
Protons
HDR
23 29
← Years from Treatment →
Hypo EBRT
39
11
7 6 26
103
35
37
47
49
EBRT Seeds +
ADT
Robot RP
Thank you for listening
What other radiotherapy
improvements will increase 5yr
survival?
• SABR – similar to VMAT but 5 visits only
• Better planning including radiobiological systems
• Better on-board imaging & faster delivery
• Ability to adapt treatment while on the couch
•Better knowledge of impact
• Physically – transit dosimetry
• Biologically – chip on a pill
New imaging
Robotic delivery
Protons
HIFU
CRYO
Photodynamic
“Nanoknife”