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POSITION PAPER
TECHNIQUES AND TECHNOLOGIES
IN RADIATION ONCOLOGY
2015 HORIZON SCAN
AUSTRALIA AND NEW ZEALAND
FACULTY OF RADIATION ONCOLOGY
THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS®
Name of document and version:
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan
Australia and New Zealand
Approved by:
Faculty of Radiation Oncology Council
Date of approval:
29 April 2016
ABN 37 000 029 863
Copyright for this publication rests with The Royal Australian and New Zealand College of Radiologists®
The Royal Australian and New Zealand College of Radiologists
Level 9, 51 Druitt Street
Sydney NSW 2000
Australia
Email: [email protected]
Website: www.ranzcr.edu.au
Telephone: +61 2 9268 9777
Facsimile: +61 2 9268 9799
Disclaimer: The information provided in this document is of a general nature only and is not intended as a
substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between
a patient and his/her doctor.
CONTENTS
Objectives................................................................................................................ 3
About Radiation Oncology.................................................................................... 3
FRO Horizon Scanning – Why?............................................................................. 3
FRO Definition of Radiation Therapy Techniques .............................................. 4
FRO Definition of Radiation Therapy Technologies............................................ 4
Why Differentiate between Techniques and Technologies?............................... 4
Faculty of Radiation Oncology Position............................................................... 4
Radiation Oncology Techniques........................................................................... 5
Image Guided Radiation Therapy (IGRT)........................................................... 5
Intensity Modulated Radiation Therapy (IMRT)................................................... 5
Stereotactic Radiation Therapy (SRT), Radiosurgery (SRS),
Stereotactic Body Radiation Therapy (SBRT),
and Stereotactic Ablative Body Radiation Therapy (SABR)................................ 6
Advanced Imaging for Treatment Planning ........................................................ 6
Motion Management Techniques for Radiation Therapy Treatment.................... 7
Adaptive Radiation Therapy ............................................................................... 7
Brachytherapy..................................................................................................... 7
Particle Therapy.................................................................................................. 8
Appendix I: Horizon Scan Table............................................................................ 9
Appendix II: Radiation Oncology Delivery Technologies................................. 14
Appendix III: Related Innovations....................................................................... 21
Appendix IV: Glossary.......................................................................................... 24
Acknowledgement................................................................................................ 26
References............................................................................................................ 26
THE FACULTY OF RADIATION ONCOLOGY, RANZCR, is the peak bi-national body advancing patient
care and the specialty of Radiation Oncology through setting of quality standards, producing excellent
Radiation Oncology specialists, and driving research, innovation and collaboration in the treatment of
cancer.
VISION
To have an innovative, world class Radiation Oncology Specialty for Australia and New Zealand focused
on patient needs and quality.
OUR VALUES
In undertaking our activities and in managing the way we interact with our Fellows, trainees, members,
staff, stakeholders, the community and all others with whom we liaise, the Faculty of Radiation Oncology,
RANZCR, will demonstrate the following values:
•
Quality of Care - performing to and upholding high standards
•
Integrity, honesty and propriety - upholding professional and ethical values
•
Patient orientation - understanding and reflecting the views of Fellows and members and working
with them to achieve the best outcomes
•
Fiscal responsibility and efficiency - using the resources of the College prudently.
OUR PROMISE TO THE PATIENTS
We will advocate for the best possible care for individual patients in multidisciplinary meetings and for all
patients with government.
OUR PROMISE TO TRAINEES
We ensure the highest standard of training in radiation oncology by combining a world-class curriculum
with passionate and supportive supervisors. The voice of trainees is valued in Radiation Oncology.
OUR PROMISE TO OUR FELLOWS
We are a member based organisation that utilises its resources effectively and strategically to fulfil our
vision, purpose and core objectives. We strive for best practice and facilitate life-long learning of our
members.
OUR PROMISE TO OUR PARTNERS & STAKEHOLDERS
We are a transparent and collaborative organisation that strives to promote partnerships and
participation of all relevant stakeholders to ensure that patients across Australia and New Zealand
receive a high-quality, timely and appropriate level of care.
CODE OF ETHICS
The Code defines the values and principles that underpin the best practice of clinical radiology and
radiation oncology and makes explicit the standards of ethical conduct the College expects of its
members.
OBJECTIVES
Radiation oncology is a specialty in which highly trained oncologists use their knowledge of
radiation cell biology, and technology to treat cancer with radiation. Radiation therapy can be
used to treat almost all cancers, anywhere in the body. Radiation oncology has a major positive
impact on local cancer control and is a highly effective therapy for control of cancer symptoms
such as pain or bleeding. The safe and accurate delivery of this treatment requires the skills
of a multidisciplinary team of radiation oncologists, radiation oncology medical physicists and
radiation therapists as well as cancer nurses, engineers and allied health staff. The treatment
(radiation) is delivered using various specifically chosen techniques to deliver a prescribed
radiation dose to the target (such as a tumour) while ensuring that the radiation dose to the
surrounding normal tissues is as low as possible.[1]
The overall optimal radiation therapy utilisation rate for all cancer patients, based upon the
best available evidence is 48.3%[2]. This means that one in two people diagnosed with cancer
would benefit from radiation therapy at some point in their cancer journey. Those patients
who miss out on clinically appropriate radiation therapy treatment can be adversely affected.
The consequences can include compromised health outcomes, inadequate symptom control,
reduced quality of life, increased suffering, and premature death.
Utilisation in Australia between 2001 and 2009 has remained at 38%.[3][4] This is despite a
significant investment in radiation therapy infrastructure, which has appeared merely to have
kept pace with increases in the number of patients for whom there is an indication for radiation
therapy.[5] Utilisation in New Zealand is currently at a national intervention rate of 37.4% (with
a range by District Health Board of 27-45%).
FRO HORIZON SCANNING – WHY?
There is confusion regarding the difference between advances in treatment techniques, in the
technologies used to deliver those techniques, and in the implementation priorities for these
techniques and technologies. This information shortfall, along with technology assessment
mechanisms that are unsuitable for radiation therapy, have been contributing factors towards
slow uptake of new radiation therapy techniques and delivery technologies in Australia and
New Zealand compared with other developed and developing countries.
The Faculty of Radiation Oncology is seeking to improve this understanding, via a number of
ongoing initiatives, foremost of which is the radiation oncology horizon scanning project that
was developed in 2011 and which will be updated with new information and evidence on a
biennial basis. This Horizon Scan is to be discussed with key stakeholders that include
policymakers, advocacy groups, consumers and industry. This Position Paper is intended to
accompany the Horizon Scan (included in Appendix II) that was discussed at the Horizon
Scan Industry Roundtable and the Radiation Therapy Innovations Summit in late 2015.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
ABOUT RADIATION ONCOLOGY
Faculty of Radiation Oncology
The aim of the paper is to inform cancer professionals, health professionals, health
administrators, consumers and interested individuals about the techniques and technologies
used for safe delivery of high quality radiation therapy.
3
FRO DEFINITION OF RADIATION THERAPY TECHNIQUES
The term technique is used to describe a concept in radiation therapy planning or treatment.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
FRO DEFINITION OF RADIATION THERAPY TECHNOLOGIES
4
The term technology is used to describe a method utilised to deliver a radiation
therapy technique.
WHY DIFFERENTIATE BETWEEN TECHNIQUES AND TECHNOLOGIES?
As with many other branches of medicine, in radiation oncology there are various vendors and
suppliers that produce and distribute treatment equipment. This equipment often has different
configurations; however the techniques delivered may be the same or similar. An example
of this is Intensity Modulated Radiation Therapy (IMRT). This treatment technique can
be delivered by using a number of different technologies; via static fields with a standard
configuration linear accelerator, via rotational IMRT delivered with a standard configuration
linear accelerator and via helical IMRT that is delivered with a linear accelerator that is
mounted in the style of a CT scanner. All of these technologies deliver IMRT, although the
technology involved is produced by various manufacturers and can be differently configured.
Every attempt has been made in this horizon scan document to use generic terms, rather than
proprietary names to describe techniques and technologies.
FACULTY OF RADIATION ONCOLOGY POSITION
It is the Faculty position that timely patient access to appropriate radiation therapy treatment
techniques is of paramount importance. Service planning and reimbursement should be centred
on essential radiation therapy techniques. In 2015, the Faculty views the following techniques
as being essential (i.e. clinically indicated) for some Australian and New Zealand patients:
•
Image Guided Radiation Therapy (IGRT)
•
Intensity Modulated Radiation Therapy (IMRT)
•
Stereotactic Radiation Treatments (including SRS, SRT and SBRT/SABR)
•
Advanced Imaging for Treatment Planning (4DCT, PET-CT, MRI)
•
Brachytherapy
•
Particle Therapy
These radiation therapy techniques are delivered using a variety of technologies. It is the
Faculty position that some techniques must be available in every radiation therapy department
i.e. Linear accelerator with IGRT capability, while other techniques may only be justified at one
facility in Australia and/or New Zealand i.e. particle therapy. In 2015, the Faculty has
reviewed, updated and made public, via its Horizon Scan, its view on implementation priorities
and projected uptake for radiation therapy treatment techniques and technologies.
RADIATION ONCOLOGY TECHNIQUES
Delivery Technologies: Daily Online Correction using 2D (MV or KV) or 3D (KV, CBCT or CT
on rails), pre-treatment ultrasound imaging, MRI guided IGRT in development.
Priority and Projected Uptake: Some form of IGRT should be available in every radiation
oncology facility.
Image guided radiation therapy is currently in use in Australia and New Zealand and it is
the Faculty position that image guided radiation therapy is essential for some patients with
evidence.
Intensity Modulated Radiation Therapy (IMRT)
Intensity modulated radiation therapy (IMRT) is a way of delivering external beam radiation
therapy using high energy megavoltage X-rays that allows the radiation dose to conform more
closely to the shape of the tumour by changing the intensity of the radiation beam. This
technique involves very sharp drop off in effective dose adjacent to both targets and organs
at risk, increasing the consequences of any geometric uncertainty (i.e. missing the target),[8][9]
making daily image guidance an essential component of quality IMRT. It is the tumour location,
size, adjacent organs and dosimetry that define the appropriate role for IMRT, supporting
an approach where the clinical circumstances in addition to specific diagnoses are the most
important determinants for using IMRT.[10] Failure to deliver radiation therapy accurately has
potentially catastrophic consequences for both cancer-control outcomes and normal organ
toxicity.[11]
Delivery Technologies: linac based fixed beam IMRT, linac based rotational IMRT[12], helical
non C-arm based IMRT and hybrid arc IMRT.
Priority and Projected Uptake: Some form of IMRT should be available in every radiation
oncology facility. It is anticipated that the majority of IMRT would be delivered via conventional
linac, with several departments per state offering other methods of IMRT delivery.
Intensity modulated radiation therapy is currently in use in Australia and New Zealand and it is
the Faculty position, with evidence, that intensity modulated radiation therapy is essential for
some patients.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Image-guided radiation therapy (IGRT) is the process of frequent two and three-dimensional
imaging that is captured as close as possible to the time of treatment. Positioning correction
based on these images is done before and sometimes during treatment delivery.[6] Increasing
complexity in planned treatments and individual situations in which setup reproducibility is in
question are indications for IGRT.[7] IGRT is an essential component of intensity modulated
radiation therapy. Indications for IGRT are included in the Faculty of Radiation Oncology
Position Paper on Image Guided Radiation Therapy (IGRT) 2015.
Faculty of Radiation Oncology
Image Guided Radiation Therapy (IGRT)
5
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
Stereotactic Radiation Therapy (SRT), Radiosurgery (SRS), Stereotactic
Body Radiation Therapy (SBRT), and Stereotactic Ablative Body Radiation
Therapy (SABR)
6
Stereotactic radiosurgery allows non-invasive ablative treatment of benign and malignant
tumours. It is used for tumours and other lesions (including arteriovenous malformations) that
would be inaccessible or inappropriate for open surgery. Although stereotactic radiosurgery is
often completed in a one-day session, multiple treatments are sometimes used. The procedure
is usually referred to as fractionated stereotactic radiation therapy, when more than two
treatments are given and stereotactic body radiation therapy and stereotactic ablative radiation
therapy, when treatment is given to areas other than the head. SRS, SRT, SBRT and SABR
are alternatives to invasive surgery, including for tumours and abnormalities that are: hard to
reach, located close to vital organs.[13]
Delivery Technologies: linac based SRS, cobalt based SRS and robotic SRS.
Priority and Projected Uptake: Some form of Stereotactic Radiation Treatment should be
available in several departments per state.
Stereotactic radiation treatment is currently available in Australia and New Zealand and it is
the Faculty position, with evidence, that stereotactic radiation treatment is essential for some
patients.
Advanced Imaging for Treatment Planning
Advanced imaging for treatment planning utilises diagnostic and functional imaging modalities
in addition to the CT scan that is used for radiation therapy planning and dosimetry. These
advanced planning technologies are 4DCT, which provides organ and tumour motion
information, PET, SPECT and hypoxia imaging scans which provides functional information, as
well as MRI and ultrasound which show superior soft tissue definition compared with CT scans.
These images are fused with the planning CT data set and can be used to provide additional
anatomical detail as well as functional and tumour motion information.
Delivery Technologies: 4DCT, PET, SPECT and MRI, with emerging and developing use of
many other structural and functional imaging modalities.[14]
Priority and Projected Uptake: Advanced Imaging for Treatment Planning should be available
to every radiation therapy facility.
Advanced imaging for treatment planning is currently available in Australia and New Zealand
and it is the Faculty position, with evidence, that advanced imaging for treatment planning is
essential for some patients.
Several forms of motion management are currently available in Australia and New Zealand,
however it is the Faculty position that motion management is currently supported by insufficient
evidence to form a view.
Adaptive Radiation Therapy
Adaptive radiation therapy systematically manages changes in the cancer size and shape that
occur during the radiation therapy course due to treatment response. This can be especially
important in cancers that can change in size rapidly over the course of treatment and are
located in close proximity to critical dose-limiting structures. Adaptive radiation therapy
represents a variation of standard radiation therapy, where a “pre-designed adaptive strategy”
replaces the typical single “pre-designed plan”. That is, multiple plans are used as the cancer
responds during the course of treatment. This is an area of significant ongoing research, as
investigators seek to define the patient groups for whom a pre-designed adaptive strategy
would offer the most benefit.[16][17]
Adaptive radiation therapy is currently available in Australia and New Zealand, however it is the
Faculty position that adaptive radiation therapy is currently supported by insufficient evidence to
form a view.
Brachytherapy
Conventional brachytherapy uses a radioactive source and automatic afterloader to deliver
radiation therapy, whereas electronic brachytherapy utilises a miniature low energy X-ray tube.
The source or miniature low energy X-ray tube is inserted into a pre-positioned applicator
within body/tumour cavities or on the skin surface to deliver high doses to target tissues with
the aim of maintaining low doses to non-target tissues.
Delivery Technologies: conventional high dose rate (HDR) and low dose rate (LDR)
radioactive source based brachytherapy, development of electronic brachytherapy and intraoperative brachytherapy.
Priority and Projected Uptake: Brachytherapy should be available in several radiation therapy
departments per state.
Brachytherapy treatment is currently available in Australia and New Zealand and it is the
Faculty position, with evidence, that brachytherapy is essential for some patients.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Motion management techniques in radiation oncology use imaging of anatomy or other
surrogates to track and account for the movement of the tumour during treatment. Gated
radiation therapy is currently available to manage intra-fraction (during treatment) motion in
radiation therapy. In gated radiation therapy treatment, the delivery of radiation is based on the
anatomic location of the tumour throughout the breathing cycle (with this information collected
via 4DCT or other method). Using gating software, a specific window in the breathing cycle
is defined when it is optimal to turn on the radiation beam.[15] Tumour tracking software and
hardware is currently in development for both static field and volumetric arc treatments in
which imaging follows the movement of the tumour during treatment and the MLC leaves move
dynamically to follow this movement.
Faculty of Radiation Oncology
Motion Management Techniques for Radiation Therapy Treatment
7
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
Particle Therapy
8
Particle beam therapy is a form of external beam radiation treatment that uses heavier
charged (typically protons, with developing utilisation of pions, or helium, silicon neon, argon
or carbon ions[18]) or neutral particles (neutrons) rather than electrons or X-rays. The physical
characteristics of the particle therapy beam allow the radiation oncologist to more effectively
treat certain types of cancer[19] and other diseases by reducing the radiation dose to nearby
healthy tissue. In addition, particle therapy is more effective than photon and electron therapy
in causing irreparable cell (both tumour & normal) damage. Particle therapy is used in unique
clinical situations.[20]
Delivery Technologies: conformal proton therapy, intensity modulated proton therapy (IMPT),
and heavy ion therapy.
Priority and Projected Uptake: Australian patients must have access to particle therapy.
Particle beam therapy is not currently available in Australia or New Zealand, however it is the
Faculty position that particle beam therapy is essential for some patients with evidence.
APPENDIX I: HORIZON SCAN TABLE
The focus of the Horizon Scan is on clinical relevance. Cost implications of different technologies
are outside the scope of this Horizon Scan.
The information contained in this Horizon Scan was initially divided into three tables, showing
radiation therapy techniques, technologies and related innovations. As the tables have been
revised on an annual basis, the increasing volume of information has required an update to the
format. From 2015 onwards, the horizon scan format consists of one table, showing radiation
therapy techniques, included in this position paper as Appendix I. Descriptions of the associated
radiation oncology technologies are included in Appendix II of this position paper and related
innovations are included as Appendix III.
Priority and Projected Uptake
The ‘Priority and Projected Uptake’ described in the ‘Radiation Oncology Techniques’ section of
this paper describes the Faculty of Radiation Oncology position relating to the projected uptake
of the described technology that may be appropriate for Australia and New Zealand.
The projected uptakes noted may change over time as further research is undertaken.
Technique Categories
The horizon scan table shows a ‘traffic light’ system to describe the priority category that the
Faculty of Radiation Oncology has assigned to the various treatment techniques. The four
categories are as follows:
Essential for some patients with evidence
Available alternative
Evidence gathering underway
Not yet commercially available for treatment
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
The purpose of the Horizon Scan is to assist in building expert consensus and to inform
policy makers and consumers about the relevance of emerging and evolving techniques and
technologies to patient outcomes.
Faculty of Radiation Oncology
Radiation therapy is a proven, safe, effective and economical cancer treatment, however the
radiation oncology sector has not been systematic or strategic in implementing new and evolving
technologies in Australia and New Zealand. There is confusion and limited understanding
regarding implementation priorities and the difference between advances in treatment techniques
and in the technologies used to deliver those techniques.
9
EXPLANATION
SUPPORTIVE STATEMENTS
FIRST CLINICAL USE
WORLDWIDE
CURRENT UPTAKE IN AUS/NZ
Image Guided radiation
therapy (IGRT)
Daily online correction using 2D
(MV or KV) or 3D (CBCT or CT on
rails) imaging. Ultrasound guidance.
MRI guided IGRT and 4D-CBCT in
development
Image-guided radiation therapy (IGRT) is the process of frequent two and three-dimensional
imaging that is captured as close as possible to the time of treatment. Positioning correction
based on these images is done prior to treatment delivery. Increasing complexity in planned
treatments and individual situations in which set up reproducibility is in question are
indications for IGRT. Gold Standard IGRT is the ability to confirm that the target is within the
treatment portal during the entire ‘beam-on’.
FRO Position Statement: “IGRT represents and has represented
standard of care radiation oncology practice for many years.
Technologies that encourage image guidance are to be
supported as a self-evident quality imperative”.
Electronic portal imaging
(first generation of image
guidance) first commercialised
in the early 1990s
99.5% of linear accelerators in
Australia and 100% in New Zealand
are equipped with electronic portal
imaging (2D) and 76.4% of linear
accelerators in Australia and 83.9%
in New Zealand are equipped with
kV Imaging (2D and 3D).
Intensity Modulated
radiation therapy (IMRT)
Linac based IMRT, Linac based
Rotational IMRT, Helical IMRT,
HybridArc IMRT
Intensity Modulated Radiation Therapy (IMRT) is a form of external beam radiation therapy
that allows the radiation dose to conform more closely to the shape of the tumour by
changing the intensity of the radiation beam. This technique involves very sharp dose
gradients adjacent to both targets and organs at risk increasing the consequences of any
geometric uncertainty, making daily IGRT is an essential component of quality IMRT.
ASTRO (American Society for Radiation Oncology) believes that
tumour location, size, adjacent organs and dosimetry define the
appropriate role for IMRT, and support an approach where the
clinical circumstances in addition to specific diagnoses are the
most important determinants for using IMRT.
1995
99.5% of linear accelerators in
Australia and 96.8% in New Zealand
are capable of delivering fixed beam
IMRT. 72% of linear accelerators in
Australia and 74.2% in New Zealand
are capable of delivering rotational
IMRT. There are 5 non c-arm based
linear accelerators delivering helical
IMRT in Australia and none in New
Zealand.
Stereotactic
Radiosurgery (SRS),
Stereotactic Radiation
Therapy (SRT), and
Stereotactic Body
Radiation Therapy
(SBRT), Stereotactic
Ablative Body
Linac based stereotactic radiation
treatment, Robotic stereotactic
radiation treatment, Cobalt based
stereotactic radiation treatment,
Helical IMRT based stereotactic
radiation treatment
Stereotactic radiosurgery (SRS) allows non-invasive ablative treatment of benign and
malignant tumours. It is used for tumours and other lesions that would be inaccessible or
inappropriate for open surgery. Although SRS is often completed in a one-day session,
multiple treatments are sometimes used. The procedure is usually referred to as
fractionated stereotactic radiation therapy (SRT) when more than one treatment is given.
SRS, SRT, Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Ablative Body
Radiation Therapy (SABR)are alternatives to invasive surgery, especially for patients who
are unable to undergo surgery, and for tumors and abnormalities that are: hard to reach,
located close to vital organs and/or subject to movement within the body.
Stereotactic radiosurgery (SRS) and stereotactic radiation therapy
(SRT) has a well-established role for the treatment of benign and
malignant intracranial disease and the efficacy of SRS for the
treatment of brain metastases has been demonstrated in several
randomised trials. Stereotactic body radiation therapy is
increasing in use for sites such as the spine and lung (stage 1
non-small cell lung cancer).
Late 1960s
In Australia, 17 facilities deliver SRS,
20 deliver SBRT and 7 deliver both.
In New Zealand, 2 facilities deliver
both SRS and SBRT.
Radiotherapy (SABR)
Advanced Imaging for
Treatment Planning
4DCT, PET-CT, MRI, UIltrasound,
SPECT-CT, PET Hypoxia Imaging
and PET-MRI with MRI fibertracking
in development
Computed tomography (CT) scans acquired in the radiation therapy treatment position
before the start of radiation therapy remain the basic imaging modality for contouring
tumour target volumes and healthy tissues as well as for dose calculation in radiation
therapy planning. Standard CT has limitations however, as it only provides anatomical
information at one point in time and does not provide functional information. The ability to
fuse additional images with the planning CT allows the addition of additional information to
the planning process that is not available with conventional CT Scans. PET scans show
functional information, 4DCT shows the motion of tumours and/or organs at risk, MRI
provides superior soft tissue imaging and MRI fiber tracking show additional anatomical
detail that cannot be visualised on conventional CT or standard MRI.
Advanced imaging for use in radiation therapy treatment planning
is essential for some patients. Although a planning CT scan is still
required at this time for treatment calculations, there are some
treatment sites in which other (advanced) imaging techniques
provide superior anatomic or functional information. This
information can show the location and extent of the tumour with
increased clarity, the metabolic activity of the tumour as well as the
motion of the tumour and/or adjacent healthy organs.
MRI from early 1980s, PET-CT
from late 1990s, 4DCT from
2003
Yes
Motion Management
Techniques for Radiation
Therapy Treatment
Gated radiation therapy, Motion
managed radiation therapy
Motion management techniques for radiation therapy treatment attempt to account for
tumour motion during treatment delivery. In gated radiation therapy, the delivery of radiation
is based on the anatomic location of the tumour throughout the breathing cycle (with this
information collected via 4DCT or other method). Delivery of gated radiotherapy can be
done via several means. Using gating software, a specific window in the breathing cycle
is defined when it is optimal to turn on the radiation beam. In motion adaptive radiation
therapy, the multileaf collimators are moved dynamically to track the movement of a moving
tumour (e.g. lung). In addition to motion adaptive treatment of fixed beam radiation therapy,
studies are also underway of motion adaptive treatment in volumetric arc treatment. Another
method is to move the entire linac (the current system allowing this has the linac attached
to a robotic arm) to follow tumour movements.
Gated radiation therapy
from 2003. Motion adaptive
radiation therapy in
development
Yes
Adaptive Radiation
Therapy
Target tracking treatment tool.
Various strategies are implemented
to manage changes in cancer size/
shape over the course of treatment
Adaptive radiation therapy systematically manages changes in the cancer size that occur
during the radiation therapy course. Adaptive radiation therapy represents a variation of
standard radiation therapy, where a “pre-designed adaptive strategy” replaces the typical
single “pre-designed plan”. That is, multiple plans are used as the cancer responds during
the course of treatment.
Early 2000s
Yes
Brachytherapy
Conventional high dose rate (HDR)
and low dose rate (LDR) radioactive
source based brachytherapy, low
energy and high dose rate electronic
brachytherapy, intra-operative
brachytherapy
Conventional brachytherapy uses a radioactive source and automatic afterloader whereas
electronic brachytherapy utilises a miniature low energy X-ray tube.The source or miniature
low energy X-ray tube is inserted into a pre-positioned applicator within body/tumour
cavities or on the skin surface to deliver high doses to target tissues while maintaining low
doses to non-target tissues.
Experience has shown brachytherapy to be a valid treatment
option for many types of cancer, however there are few
randomised trials directly comparing brachytherapy with external
beam radiation therapy.
1901
Yes
Particle Therapy
3D conformal proton therapy,
intensity modulated proton therapy
(IMPT), heavy Ion therapy
Particle beam therapy is a form of external beam radiation treatment that uses heavier
particles (such as protons or carbon ions) instead of electrons or X-rays. The physical
characteristics of particle therapy beam allow the radiation oncologist to more effectively to
treat certain types of cancer and other diseases by reducing the radiation dose to nearby
healthy tissue. Particle therapy is used in unique clinical situations.
ASTRO Emerging Technologies Committee Evaluation of Proton
Beam Therapy: “There is reason to be optimistic about the potential
developments in proton therapy and the prospective research
that is ongoing at centres worldwide. In all fields, however, further
clinical research is needed and should be encouraged. The
paediatric solid tumour population potentially has the most to
gain from more widespread use of PBT because of the potentially
devastating side effects of impaired growth and function, the
increased risk of second malignancies, and the high likelihood of
cure.”
First patient treated with
protons in 1961, first hospital
based cyclotron late 1980s
No
TECHNIQUE
CATEGORY
Faculty of Radiation Oncology
TECHNOLOGY USED
TO DELIVER THIS TECHNIQUE
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
TECHNIQUE
Disclaimer: The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal
advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor.
10
11
APPENDIX II: RADIATION ONCOLOGY DELIVERY TECHNOLOGIES
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
Image Guided Radiation Therapy (IGRT)
12
Image-guided radiation therapy (IGRT) is the process of frequent two, three and fourdimensional imaging that is captured as close as possible to the time of treatment. The gold
standard is image-guidance during treatment beam-on but there is no technology currently
commercially available. Positioning correction based on images is done before treatment
delivery. It is used in many treatment sites and should be available in every radiation therapy
department. Greater use of imaging is required to safely deliver increasingly complex
treatments.
2D Megavoltage and Kilovoltage IGRT
In Australia, IGRT has been recognised for the Medicare Benefits Schedule (MBS) funding.
Megavoltage (MV) image guidance is achieved by capturing an image using an electronic
portal imaging panel mounted to the linear accelerator using the treatment beam. 99.5% of
linear accelerators in Australia and 100% in New Zealand are equipped with Electronic Portal
Imaging (EPI). To utilise EPI for IGRT, the linear accelerator must have an on board imaging
system. This consists of a retractable megavoltage detector array that can be placed directly
opposite gantry (source of the X-rays) when the patient is in the treatment position on the
linear accelerator. Immediately prior to delivery of the fraction of radiotherapy, a 2D image is
obtained with the passage of an X-ray beam from the gantry that passes through the intended
treatment area of the patient. The beam that exits the patient is then captured on the detector
placed on the other side of the patient. The information obtained allows the correct placement
and delivery of the treatment for that day. EPI IGRT can be utilised daily but only provides
information in 2D format. The quality of the image is also less defined compared to
kilovoltage IGRT.
2D Kilovoltage IGRT requires the linear accelerator to have a kilovoltage X-ray tube (attached
at 900 to the linear accelerator gantry) and corresponding kilovoltage detector panel (attached
at 2700 to the linear accelerator gantry) to capture images. Similar to 2D Megavoltage IGRT,
immediately prior to delivery of the fraction of radiotherapy, a 2D image is obtained with the
passage of an X-ray beam from the kilovoltage X-ray tube that passes through the intended
treatment area of the patient and the beam is captured on the detector placed on the other side
of the patient.
The 2D kilovoltage images obtained provide much better definition of bony and some soft tissue
structures compared to 2D megavoltage EPI. This can lead to better targeting of the intended
treatment volume. The absorbed dose of 2D kilovoltage IGRT is also less than 2D megavoltage
EPI. The cost of kilovoltage is higher than 2D megavoltage EPI as it requires additional more
modern equipment. 77.2% of linear accelerators in Australia and 80.6% in New Zealand are
equipped with Kilovoltage imaging.
3D Kilovoltage IGRT (Cone-beam IGRT) and 4D IGRT
Similar to 2D Kilovoltage IGRT, 3D Kilovoltage IGRT requires the linear accelerator to have
a kilovoltage X-ray tube (attached at 900 to the linear accelerator gantry) and corresponding
kilovoltage detector panel (attached at 2700 to the linear accelerator gantry) to capture images.
To obtain 3D or volumetric images, the equipment is rotated 360 degrees with the patient in
the treatment position on the linear accelerator. This format of images is often referred to as
Cone-beam CT images. As this provides good 3D images of the organs and structures, the
treatment is more accurately guided to the intended target while helping to minimise the dose to
the organs and structures at risk. This is particularly useful where there are deformable target
volumes and deformable hollow organs due to variable filling of those structures (e.g. bladder
and bowel filling).
MRI guided IGRT
The advantage of MRI as the image guidance tool is that it does not use ionising radiation and
as such, reduces the overall radiation dose received by the patient while still allowing for daily
on-line 3D imaging. A number of groups are working on this technology, combining a linear
accelerator and MRI image guidance in Canada[21], the Netherlands[22] and Australia[23]. A cobalt
based radiation treatment system with MRI based image guidance is currently commercially
available via Viewray[24] although this system does make some compromises with both the
strength of the magnet used for imaging and the use of cobalt-60 rather than linear accelerator
based radiation. MRI guided IGRT would be of most benefit in the treatment of lung, abdomen
and mobile soft tissue tumours with uptake in Australia and New Zealand depending on further
development, research and the production of more advanced MRI-Linac models. MRI for image
guided radiation therapy is not currently in use in Australia or New Zealand.
Intensity Modulated Radiation Therapy (IMRT)
Fixed beam IMRT with conventional C-arm linac
IMRT is a way of delivering radiation therapy that allows the radiation dose to conform more
closely to the shape of the tumour by changing the intensity of the radiation beam. The sharp
dose gradients adjacent to both targets and organs at risk involved in this technique increase
the consequences of any geometric uncertainty, making daily image guidance an essential
component of quality IMRT. IMRT is used in many treatment sites and should be available in
every radiation therapy department. 94% of linear accelerators in Australia and 83.9% in
New Zealand are commissioned to deliver IMRT. In Australia, IMRT has been reconigsed for
the Medicare Benefits Schedule (MBS) funding.
Rotational IMRT - C-Arm linac based
Rotational IMRT delivers radiation by rotating the linac gantry through one or more arcs with the
radiation continuously on. As it does this, beam parameters can be varied. These include: i) the
MLC aperture shape, ii) the dose rate, iii) the gantry rotation speed and iv) the MLC orientation.
This method of delivering radiation therapy can increase dose conformity to tumours located
centrally within the body although it can result in a ‘wash’ of low dose in the healthy tissue
surrounding the target. Indications for rotational IMRT are the same as for fixed beam IMRT
with evidence of dosimetric advantage of rotational IMRT in head and neck, prostate, brain and
SBRT treatment. Rotational IMRT is largely considered to be the natural progression and more
efficient use of IMRT. It is superior to fixed beam IMRT for treatment of some cancers but is not
anticipated to completely replace this technique. 50.5% of Linear Accelerators in Australia and
74.2% in New Zealand are commissioned to deliver VMAT.
Faculty of Radiation Oncology
Ultrasound
There are ultrasound systems available for image guidance of radiation therapy that allows
automated ultrasound scanning from outside of the treatment room. In the case of prostate
cancer, a probe positioned at the patient’s perineum is used to visualise the prostate.
Ultrasound can also be used for replanning between brachytherapy fractions to account for
movement of the implant. The use of ultrasound may allow localisation of soft tissue targets
without the use of ionising radiation. Ultrasound based IGRT is used in treatment of the breast
and prostate and further uptake will depend on the results of ongoing studies and development.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
An extension of 3D kilovoltage IGRT is to obtain a series of Cone-beam CT images over a
period of time (minutes) during a fraction of treatment to demonstrate the movement of a target
within the body due to respiration where the expansion and contraction of the lung cavity
causes displacement of a target. Using this information, the treatment beam can be turned on
or off depending on the position of the target in relation to its ideal placement. The concept of
4D IGRT is not confined to using kilovoltage on-board imaging equipment attached to the
linear accelerators as technological advances from multiple problem-solving programmes
have resulted in various vendors developing many advanced systems. (see also the section
on “Advanced Imaging for Treatment Planning” and “Motion Management Techniques for
Radiation Therapy Treatment” on pages 6&7)
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Faculty of Radiation Oncology
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
14
Helical IMRT - non C-Arm based linac
Helical IMRT combines a CT scanner with a radiation therapy delivery system (linac), enabling
daily 3D megavoltage imaging with radiation treatment as well as volumetric IMRT. Indications
for helical IMRT are similar to rotational IMRT with potential advantages in highly complex
and large treatment volumes. It is anticipated that helical IMRT will be available in multiple
departments in Australia and New Zealand as an alternative to rotational IMRT using a C-arm
linac. Helical IMRT is available via the Tomotherapy system. There are five non C-Arm based
linear accelerators delivering helical IMRT in Australia and none in New Zealand.
Hybrid Arc IMRT
Hybrid Arc is a novel treatment planning approach that combines optimised dynamic arcs
with intensity-modulated radiation therapy (IMRT) beams. Hybrid Arc IMRT has the potential
to incorporate the benefits of rotational IMRT (reduced treatment time) with fixed beam IMRT
(reduced low dose ‘wash’ over healthy tissue) and could be used for many treatment sites
depending on the results of further research and development.
Stereotactic Radiation Therapy (SRT), Radiosurgery (SRS) and Stereotactic
Body Radiation Therapy (SBRT)/Stereotactic Ablative Radiation Therapy (SABR)
SRT/SRS/SBRT/SABR - linac based
Radiosurgery allows non-invasive ablative treatment of benign and malignant tumours. It is
used for tumours and lesions as an alternative to surgery including for those in patients that
are not surgical candidates due to comorbidities. SRS is used in the treatment of brain, spine,
lung and liver tumours as well benign tumours and conditions. Frameless treatment is an option
with linac based cranial SRS, meaning that invasive headframes are not required. Stereotactic
body radiation therapy/stereotactic ablative radiation therapy use stereotactic principles to treat
lesions throughout the body[25]. In Australia, the current MBS item reflects single treatment SRS
rather than fractionated SRT. Linac based stereotactic treatment is available in 20 radiation
therapy facilities in Australia and 2 in New Zealand.
SRT/SRS - cobalt based
Cobalt based radiosurgery uses approximately 200 Cobalt-60 sources to stereotactically treat
brain cancers and benign brain conditions. Cobalt based stereotactic treatment is available via
the Gamma Knife system in one facility in Australia and none in New Zealand.
SRT/SRS/SBRT/SABR - Helical IMRT
Helical IMRT can also be used to deliver stereotactic treatment and could be especially useful
in the case of larger treatment volumes (in stereotactic body radiation therapy) and multiple
treatment targets. Stereotactic helical IMRT gives the ability to treat multiple targets in a single
delivery sequence with a single setup and no isocenter shifts. Patient positioning occurs via
IGRT using mega-voltage CT scans. Helical IMRT stereotactic treatment is available via the
Tomotherapy system. There are five non C-Arm based linear accelerators that are capable of
delivering stereotactic treatment in Australia and none in New Zealand.
SRT/SRS/SBRT/SABR - Robotic Radiosurgery
Robotic radiosurgery is designed to treat tumours throughout the body with high precision
and continuous image guidance. Robotic radiosurgery can be used in intra– and extra-cranial
stereotactic radiation therapy/radiosurgery. Robotic radiosurgery is available via the Cyber
Knife system at one facility in Australia and none in New Zealand.
PET-CT for fusion with planning CT
In PET-CT, a Positron Emission Tomography (PET) and an X-ray Computed Tomography
are combined in a single system, so that images acquired from both devices can be taken
sequentially, in the same session and combined into a single co-registered image. Thus,
functional imaging (which has poor spatial anatomy) obtained by PET, can be precisely aligned
or correlated with CT anatomic imaging. Functional imaging via PET increases the ability of the
clinician to both visualise and therefore treat the entire tumour, and also to choose appropriate
patients for radiation therapy treatment [27] (it is more sensitive than CT alone in picking up
small volume disease). The International Atomic Energy Agency states “At present there is no
compelling data to prove that patient outcomes are superior as a result of the use of PET in RT
planning. Proving that PET-planning is superior would require a randomized trial in which some
patients were randomized to a less accurate staging workup, thereby presenting significant
ethical challenges. Nevertheless, in the opinion of the IAEA expert group, radiation therapy
planning should be based on the most accurate available assessment of tumour extent. PET/
CT may provide the best assessment for cancer patients at this time.” [28] PET-CT scans can
be acquired in the radiation therapy facility if this equipment is available, otherwise external
diagnostic images can be imported into the treatment planning system.
Magnetic Resonance Imaging (MRI) for fusion with planning CT
Magnetic Resonance Imaging (MRI) often plays an important role in defining the location
and local extent of disease. It provides a primary imaging role in CNS disease and in some
other diseases (e.g. prostate and head and neck cancer). It defines organ or disease extent as
well as spinal cord compression more accurately than other modalities. MRI has been shown
to be superior to CT in the staging of some tumours and provides superior soft tissue definition
compared with CT scans.[29] MRI for fusion with planning CT is indicated for tumours within soft
tissue where delineation between target and healthy tissue is difficult to accurately define using
CT alone.[30] MRI scans can be acquired in the radiation therapy facility if this equipment is
available, otherwise external diagnostic images can be imported into the radiation therapy
treatment planning system (it is, however preferable for images to be acquired in the treatment
position). The ‘Imaging in Radiation Oncology – A RANZCR Consensus White Paper’
publication describes the tumour sites for which MRI is an appropriate tool for diagnosis and
staging as well as for treatment and planning. It should also be noted that for some tumour
sites there are limits or restrictions regarding MBS reimbursement in Australia. An example
of this is the limit of one MRI for gynaecological and rectal cancers and no reimbursement
is available for MRI of prostate cancer. Currently there is significant work being undertaken
looking at defining optimal MRI sequences (software involved with image acquisition and
manipulation) and functional imaging in radiation therapy, both in treatment planning and
treatment responses. All this is aimed at better targeting the target, regions of the target and
adjacent normal organs.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
CT scanner with 4D CT software and hardware
Four-dimensional (4D) CT is an imaging technique that provides information regarding organ
motion during respiration (the 4th dimension being time). By using this information at the time of
planning, we have a more accurate assessment of target shape and trajectory than traditional
3D (static) planning CT scans.[26] The clinical use of 4DCT data is important for optimal IGRT
of tumours in the thorax and upper abdomen and should be available to all radiation therapy
facilities. 80.8% of radiation therapy facilities in Australia and 90% in New Zealand have inhouse access to 4DCT for treatment planning.
Faculty of Radiation Oncology
Advanced Imaging for Treatment Planning
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Faculty of Radiation Oncology
SPECT-CT
SPECT-CT is a nuclear medicine tomographic imaging technique that uses gamma rays. It is
similar to conventional nuclear medicine planar imaging using a gamma camera, however it
is able to provide true 3D information. Whereas PET imaging shows a 2D representation of a
3D structure (in the same way that a plain X-ray does), SPECT shows a true 3D image and
allows accurate localisation in space. SPECT-CT provides information about localised function
in internal organs and future uptake will depend on the results of ongoing development and
studies.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Ultrasound
With ultrasound, the contour of the patient as well as the location and depth of tumours and
normal structures can be visualized and recorded. 3D ultrasound imaging is non invasive
and does not require any radiation for generation of images. Ultrasound information can be
incorporated into treatment planning, either as a primary or secondary imaging modality.
Utilising 3D ultrasound for brachytherapy planning can allow plans to be prepared in real-time [31]
(while the ultrasound images are being acquired).
PET hypoxia imaging
Tumour hypoxia is an important contributor to radioresistance, and increasing the radiation
dose to hypoxic areas may result in improved locoregional control.[32] Tracers are being refined
that allow accurate detection of hypoxic tumour subvolumes using PET imaging. Current
tracers that are used to identify hypoxic cells are characterised by slow tracer retention and
clearance, resulting in low inter-tissue contrast. Refinement of tracers will allow increased
uptake of this technology.
PET-MRI
Integrated PET/MRI scanners combine anatomic with functional imaging and may have a
specific impact on the staging and treatment of head and neck cancer. Advantages of the PETMRI system over current MRI and PET-CT systems include simultaneous imaging, reduced
radiation dose, and increased soft tissue contrast. In tumour sites such as oropharyngeal and
oral cavity tumours, integrated PET/MRI scanners may further improve the accuracy of GTV
delineation. In addition, dynamic MRI studies such as dynamic contrast-enhanced MRI and
blood oxygen level–dependent MRI, as well as MR spectroscopy, may add complementary
functional information. PET-MRI combines the superior anatomical definition of MRI with the
functional information of PET and uptake will depend on the results of ongoing development
and studies.
Motion Management Techniques for Radiation Therapy Treatment
Gated radiation therapy - planning, treatment and respiration monitoring system with
gating capability
In gated radiation therapy treatment, the delivery of radiation is based on the anatomic
location of the tumour throughout the breathing cycle (with this information collected via Four
Dimensional Computed Tomography (4DCT) or other method). Using gating software, a specific
window in the breathing cycle is defined when it is optimal to turn on the radiation beam.
Gated radiation therapy can be used in treatment of lung, breast and liver, with further uptake
depending on the results of development and studies [33] [34].
Motion adaptive radiation therapy
In motion adaptive radiation therapy, the multileaf collimators are moved dynamically to track
the movement of a moving tumour (e.g. lung). Studies are also underway of motion adaptive
treatment in both fixed beam and volumetric arc treatment. Motion adaptive radiation therapy
is in development for fixed beam and volumetric arc radiation therapy [35] and is intended for
use in the treatment of lung, breast and liver, with further uptake depending on the results of
development and studies.
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Brachytherapy
Permanent Low Dose Rate (LDR) Implant Brachytherapy
Uses low dose rate radioactive seeds that are implanted into the treatment target. This method
can be used to treat an intact structure (e.g. Prostate) or surgical cavity (e.g. Breast). This
method of treatment is an accepted treatment option for men with low risk prostate cancer. [37]
LDR permanent implant brachytherapy requires further clinical trials to show that this is
equivalent to other breast cancer treatments. This method of treatment could be very beneficial
to those patients that do not live in close proximity to a radiation therapy facility. There are
18 radiation therapy facilities offering low dose rate brachytherapy in Australia and 2 private
centres in New Zealand also offer the LDR brachytherapy.
Electronic Brachytherapy (EBT)
Electronic brachytherapy (EBT) uses a miniature low energy X-ray tube instead of traditional
brachytherapy sources made of radioactive substances. This is inserted into a pre-positioned
applicator within body/tumour cavities or positioned on the skin surface to deliver high doses
to target tissues while maintaining low doses to non-target tissues.
5-year results of the TARGIT-A trial using the INTRABEAM® device have shown that
TARGIT concurrent with lumpectomy could be considered an equivalent alternative to
postoperative EBRT in patients selected per the TARGIT-A protocol,[38] however longer term
follow-up is required before this can be considered a standard treatment option. Patient
preference studies[39] and feedback from consumergroups show that there are patients that
would opt for this treatment, given its convenience, even if there was an increased risk of
recurrence when compared with postoperative EBRT.
This treatment has been approved by MSAC for reimbursement. One facility in Australia
and one in New Zealand currently deliver electronic brachytherapy using the INTRABEAM®
device.
It is the Faculty position that this technology is not supported by sufficient evidence to form
a definitive view. If this device is to be used patients need to be informed that the TARGIT-A
trial follow-up data is short and that with longer follow-up there may be an increased risk of
recurrence, late side effects and worse cosmesis.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Adaptive radiation therapy systematically manages changes in the cancer size that occur
during the radiation therapy course. Adaptive radiation therapy represents a variation of
standard radiation therapy, where a “pre-designed adaptive strategy” replaces the typical
single “pre-designed plan”. That is, multiple plans are used as the cancer responds during the
course of treatment. Currently, adaptive radiation therapy (ART) remains labour and resource
intensive. As ART clinical outcomes mature and the incorporation of volumetric imaging into
ART becomes increasingly sophisticated, it is possible that ART will evolve and become a
commonplace approach for head and neck and a variety of other radiation treatments.[36] The
optimal frequency of assessment of treatment response and the ultimate clinical impact of ART
remains to be defined. Adaptive radiation therapy is optimally used in either treatments in
which the target size and shape can change on a daily basis, such as bladder radiation
therapy, or in treatments in which the tumour is located in close proximity to critical structures
that may move into the high dose region over the course of treatment due to tumour shrinkage
such as head and neck radiation therapy.
Faculty of Radiation Oncology
Adaptive Radiation Therapy
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Faculty of Radiation Oncology
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
18
Directional Brachytherapy
Directional brachytherapy uses 125I, a low-energy source that delivers a low dose to adjacent
tissue. One consequence of using a low-energy radionuclide is that it can be shielded with
a thin layer of high-Z material (such as lead or gold), a feature that enables the integration
of an internal radiation shield within the source itself. The resulting directional source offers
reduced radiation intensity in the shielded direction, while maintaining a similar dose distribution
as a conventional brachytherapy seed on the unshielded side. The shielded source used in
directional LDR brachytherapy may also enable treatment of breast tumours closer to the
surface or chest wall, for example, as well as larger lesions and tumours in smaller breasts than
is possible for conventional LDR seed brachytherapy. This is an investigational treatment and
uptake will depend on further development and the results of clinical trials.
Particle Therapy
Proton Therapy - 3D Conformal and scanning beam
Proton beam therapy is a form of external beam radiation treatment that uses protons rather
than electrons or X-rays. Another term for particle beam therapy is hadron therapy. The
physical characteristics of the proton therapy beam allow the radiation oncologist to more
effectively treat certain types of cancer and other diseases by reducing the radiation dose to
nearby healthy tissue. Proton therapy is used in unique clinical situations. Very high intensity
laser proton therapy units are in development [40] as well as new small proton machines that
have become clinically available requiring significantly reduced capital expense and space
considerations than current conventional proton therapy equipment [41]. Pencil-beam scanning
is a dynamic beam-delivery system in which a proton beam is actively scanned throughout the
target tumour volume providing improved three-dimensional conformity to the target. During
a treatment, the transverse beam position, longitudinal beam position (range) and dose are
controlled and adjusted to deliver the prescribed dose in the target. A further benefit of pencil
beam scanning proton therapy is its use in patients with recurrent disease, who have already
received full doses of radiation. In this case, pencil beam limits or eliminates radiation to these
already treated areas.[42] This technology continues to build on the patient benefits already
offered with proton therapy – more targeted, higher tumour dose, shorter treatment times,
reduced side effects and increased treatment options. Proton therapy is indicated for in the
treatment of paediatrics, sarcomas and tumours of eye and base of skull [43] with current and
future indications included in the “Faculty of Radiation Oncology Proton Therapy Position
Paper.” As of 2014 there were over 50 proton and heavy ion therapy centres around the
world, with as many as 40 additional facilities being either proposed or under construction.[44] A
number of patients are sent each year from Australia and New Zealand to international proton
therapy facilities in cases where this treatment is proven to be beneficial.
Proton Therapy - Intensity Modulated Proton Therapy (IMPT)
Intensity Modulated Proton Therapy (IMPT) modulates the intensity of the proton beam in a
similar way to an IMRT photon beam. This technological advancement makes proton therapy
applicable to more disease sites and overcomes some of the limitations of conformal proton
therapy [45]. IMPT technology is especially beneficial for larger and complex tumour shapes,
such as head-and-neck tumours, tumours of the lower abdomen that have a curved shape and
tumours wrapped around the spinal cord or brain stem. IMPT can shape complex fields with
a limited number of radiation angles, which keeps the treatment time as short as possible and
helps to spare healthy tissue.
Faculty of Radiation Oncology
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Heavy Ion Therapy
Heavy ion therapy utilises particles more massive than protons or neutrons, such as carbon
ions. The biological advantages of carbon compared to protons means that the efficiency of
the dose is increased by a factor between 1.5 and 3. Heavy ions are preferable to photons for
both physical and biological characteristics: the Bragg peak and limited lateral diffusion ensure
conformal dose distribution, while the high relative biological effectiveness and low oxygen
enhancement ratio in the Bragg peak region make the beam very effective in treating radioresistant and hypoxic tumours. Results coming from Japan [46] and Germany [47] provide strong
clinical evidence that heavy ions are an extremely effective weapon against cancer. However,
more research is needed, especially on optimisation of treatment planning and risk of late
effects in normal tissue, including secondary cancers.
19
APPENDIX III: RELATED INNOVATIONS
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
Part A – Used in Radiation Therapy
20
Fiducial Markers
To ensure improved accuracy of delivery of radiation therapy, fiducial markers can be implanted
into the target (tumour or tumour bed), and their position is checked via imaging immediately
prior to treatment each day. Any deviation from the desired set-up is corrected. Fiducial markers
can be passive, such as metal seeds identified by X-ray, or active, containing radiotransmitters
that broadcast their location to an external receiver. This ensures that the target is treated with
the correct dose each day but importantly, also minimises radiation dose to the adjacent normal
tissues. Newer generation fiducials made from carbon coated ceramic and stainless steel are
being introduced [48] that are intended to reduce dosimetric effects of the implanted fiducials.
Image guided radiation therapy (IGRT) utilising daily on-line verification of tumour position
or surrogate such as fiducial markers has been shown to reduce systematic and random
treatment errors, decreases the risk of geographic miss (for a given margin), and may allow for
some reduction in PTV margins. Fiducial Markers are used in the treatment of mobile tumour
sites, for example, prostate, lung, liver, and breast. Fiducial Markers are currently used as a
standard practice in many facilities in Australia and New Zealand.
Hyperthermia: local, regional or whole body
Hyperthermia used in the treatment of cancer used as an adjunct to treatments such as
radiation therapy and chemotherapy. It involves raising the temperature of tumour-loaded tissue
to 40-43oC.[49] Hyperthermia may make some cancer cells more sensitive to radiation or harm
other cancer cells that radiation cannot damage. When hyperthermia and radiation therapy are
combined, they are often given within an hour of each other. Hyperthermia can also enhance
the effects of certain anti-cancer drugs. Although many clinical trials have been conducted
to evaluate the effectiveness of hyperthermia, this treatment has not been widely adopted [50].
Hyperthermia is used in a small number of facilities in Australia in combination with other
therapies for cancer of the cervix, neck and head, lungs, stomach, oesophagus, breast and
liver. Further uptake will depend on the results of ongoing studies.
Target/OAR separation (Inert gel or rectal device)
Target/OAR separation is used in treatment of the prostate, to increase the space between the
prostate and rectum. The separation of target and organ at risk is achieved by the insertion
of various inert substances injected between the rectum and prostate or by a rectal device
inserted for each treatment to reduce overall dose to rectal tissue during prostate radiation
therapy. Both rectal devices and insertion of inert substance are used in Australia. Further
uptake will depend on the results of ongoing studies.
Fluorescent Tumour Imaging
Fluorescent tumour imaging is an investigational imaging method that uses proteins that allow
visualisation, in real time, of tumour cell mobility, invasion, metastasis and angiogenesis.
These multi-coloured proteins have allowed distinction of healthy tissue from tumour with
single-cell resolution. Visualisation of many aspects of cancer initiation and progression in vivo
should be possible with fluorescent proteins. Research is ongoing in animal studies [51] and
this method of tumour visualisation is starting to be used in human trials [52]. This is potentially
of great interest. Uptake of fluorescent tumour imaging for staging, surgery, radiation therapy
treatment planning and follow-up will depend on the results of ongoing studies.
Part B – Associated Treatments
Radium 223 Chloride
Radium-223 (Alpharadin) is a first-in-class alpha-pharmaceutical. It targets bone metastases
with high-energy alpha-radiation of extremely short range that spares bone marrow. Radium
is similar to calcium in that it sticks to bone, and particularly to where new bone is being
formed, so it is a highly effective way of delivering radiation to a bony target.[54] This procedure
is undertaken in the Radiology department, by Interventional Radiologists in the treatment of
castration resistant prostate cancer and associated bony metastases.
Radiofrequency Ablation
In radiofrequency ablation, a needle-like RFA probe is placed inside the tumour. The
radiofrequency waves passing through the probe increase the temperature within tumour
tissue, destroying the tumour. This procedure is performed under image guidance. RFA is
considered mainstream in selected liver patients with hepatocellular carcinoma and liver
metastasis with evidence in phase II and III studies. There is also emerging use of RFA in the
treatment of spinal metastases, with a device (STAR Tumour Ablation System) currently under
assessment by HealthPACT in Australia. Ablative treatments using heat are susceptible to what
is known as the “heat sink phenomenon” whereby major blood vessels draw heat away from
the treatment area. As a result, tumour cells that are next to the blood vessel cannot get hot or
cold enough to achieve cell death. It is likely that liver SBRT will ultimately need to be trialled
against this technology. This procedure is undertaken in multiple facilities in Australia and
New Zealand in the Radiology department, by Interventional Radiologists in the treatment of
hepatocellular (liver) carcinoma and liver metastasis.
Microwave Ablation
Microwave ablation is a procedure that uses heat from microwave energy to destroy cancer
cells. It is mainly used to treat cancer that has spread to the liver from other parts of the body,
usually from the colon or rectum. Ablative treatments using heat are susceptible to what is
known as the “heat sink phenomenon” whereby major blood vessels draw heat away from
the treatment area. As a result, tumour cells that are next to the blood vessel cannot get hot
or cold enough to achieve cell death. The heat-sink phenomenon is less of a problem with
Microwave ablation compared to Radiofrequency ablation. This procedure is undertaken in
multiple facilities in Australia and New Zealand in the Radiology department, by Interventional
Radiologists in the treatment of liver, lung, kidney, breast, bone, pancreas and adrenal glands.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Completed trials have demonstrated the efficacy and safety of SIRT [53] in treating secondary
liver tumours from various primary tumours including bowel cancer and neuroendocrine. In
addition, an increasing number of publications have demonstrated reductions in tumour sizes
with SIRT in primary liver cancer. This procedure is undertaken in multiple facilities in Australia
and New Zealand in the Radiology department, by Interventional Radiologists in the treatment
of hepatocellular (liver) carcinoma and liver metastasis. There is also increasing use in primary
and metastatic renal cancers as well as osteoid osteomas and some lung cancers.
Faculty of Radiation Oncology
Selective Internal Radiation Therapy (SIRT)
In Selective Internal Radiation Therapy (SIRT), microscopic resin microspheres (SIR-Spheres)
that are impregnated with a beta radiating isotope yttrium 90 are injected into the hepatic artery
supplying blood to the liver tumours. The SIR-Spheres are then trapped in the vascular bed of
the tumours where the beta radiation is released.
21
Faculty of Radiation Oncology
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
22
MR Guided focused ultrasound surgery (MRgFUS)
MR-guided focused ultrasound surgery (MRgFUS) is an emerging technology with the
potential to disrupt traditional treatment techniques across a wide variety of surgical and
medical disciplines. Proposed applications for MRgFUS are increasing and include indications
as diverse as tumour ablation [55], thrombolysis, haemostasis, reversible blood-brain barrier
disruption, targeted drug delivery, gene therapy, and neuromodulation. Based on the low-level,
preliminary evidence currently available it would appear that MRgFUS might be a useful tool for
the treatment of patients with tumours who may have limited treatment alternatives available
to them. HealthPACT assessed this technology in 2011 and an update to this assessment
was published in November 2013. This updated assessment found that the technology is still
immature and that further research should be published before any recommendation can be
made.[56] This procedure is undertaken in a small number of radiology departments in
Australia and none in New Zealand, by Interventional Radiologists in the treatment of the
brain, liver, bone, breast and prostate.
Nanoparticles
Nanoparticle-aided therapy is currently being investigated and considered for a number of
therapeutic approaches in oncology for drug delivery, photodynamic therapy, hyperthermic
therapy and radiation therapy. As a targeted contrast agent, drug delivery system or
radiosensitizer, nanoparticles could be applicable to many facets of cancer diagnosis, staging
and treatment. This is currently an area of significant research worldwide and has the potential
to be of great interest. Future uptake will depend on the results of ongoing studies.
Auger Electron Therapy
Auger electron emitters (such as 99mTc, 111In, 123I and 125I) decay and emit extremely low energy
electrons. This very low energy means that the radiation travels only nanometres and using
tumour-seeking nanoparticles bound to Auger electron emitters would enable treatment of
tumours at the cellular level. Research is ongoing in both animal and human studies. The great
advantage of this treatment would be low normal tissue complications due to the very low
penetrating power of this treatment. This is an area of worldwide investigation, and uptake will
depend on the results of ongoing studies.
Microbeam
Microbeam radiation therapy (MRT), is a form of experimental radiosurgery of tumours
using multiple parallel, planar, micrometres-wide, synchrotron-generated X-ray beams
(‘microbeams’), and has been show to safely deliver radiation doses to contiguous normal
animal tissues that are much higher than the maximum doses tolerated by the same normal
tissues of animals or patients from any standard millimetres-wide radiosurgical beam. Animal
studies [57] have shown that this form of radiation is remarkably well tolerated by normal tissue,
but can destroy entire tumours. However, the fundamental biology of MRT remains a mystery
and is the focus of research in Australia and internationally. Microbeam treatment would
theoretically be appropriate for small tumours currently treated steretoctically and is an area of
worldwide investigation. Uptake would depend on the results of ongoing studies.
APPENDIX IV: GLOSSARY
Brachytherapy is commonly used as an effective treatment for cervical,
prostate, breast, and skin cancer and can also be used to treat tumours
in many other body sites
External Beam Radiation
Therapy
The most common form of radiation therapy, which directs the radiation
at the tumour from outside the body. With external beam radiation
therapy, the dose is usually delivered by a linear accelerator, which
can produce radiation beams from different angles by rotating the
accelerator “arm” (the gantry).
Helical Intensity Modulated
Radiation Therapy (IMRT)
An external radiation therapy technique to deliver therapeutic doses of
radiation to a tumour or cancer inside the body.
The term ‘helical’ is used to indicate the fact that both the gantry and the
couch move during helical tomotherapy, while standard external beam
radiation therapy from a linear accelerator involves only the movement
of the gantry, not the couch during treatment.
Intensity Modulated
Radiation Therapy (IMRT)
Intensity modulated radiation therapy is a radiation therapy technique
that allows radiation to be more closely shaped to fit the tumour and
spare nearby critical normal tissue.
High Dose Rate (HDR)
Brachytherapy
High-dose-rate (HDR) brachytherapy is a technique using a relatively
intense source of radiation therapy to deliver a therapeutic dose of
radiation therapy through temporarily placed needles, catheters, or other
applicators.
HDR brachytherapy is when the rate of dose delivery exceeds 12 Gray
per hour (Gray is the radiation unit of measurement used in radiation
oncology). The most common applications of HDR brachytherapy are in
tumours of the cervix, oesophagus, lungs, breasts and prostate.
Horizon Scan
In this context, a specialised and distinct activity which reviews current,
evolving and emerging techniques and technologies in the radiation
oncology sector.
HybridArc Intensity
Modulated Radiation
Therapy (IMRT)
A radiation therapy technique that allows radiation to be more closely
shaped to fit the tumour and spare nearby critical normal tissue. This
technique combines the benefits of fixed beam and rotational IMRT.
kV Imaging
Kilovoltage X-rays used to take films closer to diagnostic quality and
for fluoroscopy.
Linear Accelerator (Linac)
The device most commonly used for external beam radiation treatments
for patients with cancer.
The Linac is used to treat all parts/organs of the body. It delivers
high-energy X-rays to the region of the patient’s tumor. These xray treatments are designed in such a way that they deliver radiation to
cancer cells while sparing the surrounding normal tissue.
Faculty of Radiation Oncology
A type of radiation therapy where radioactive substances are positioned
adjacent to, or surgically implanted into the tumour to deliver radiation;
also called internal radiation therapy.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Brachytherapy
The Linac is used to treat all body sites, using conventional techniques,
Intensity-Modulated Radiation Therapy (IMRT), Image Guided
Radiation Therapy (IGRT), Stereotactic Radiosurgery (SRS) and
Stereotactic Body Radiation therapy (SBRT).
23
Low Dose Rate (LDR)
Brachytherapy
LDR brachytherapy treatment involves permanently or temporarily
implanting radioactive seeds into or adjacent to the tumour, killing the
cancer cells by damaging their ability to divide and grow.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
LDR brachytherapy involves radiation sources that emit radiation at a
rate of up to 2 Gray per hour. LDR brachytherapy is commonly used for
cancers of the prostate, cervix, oral cavity, oropharynx, and sarcomas.
24
Margin
Although patient set-up and stabilisation are used to minimise set-up
variations and organ motion, there will always be some uncertainty left.
Therefore, safety margins must be applied around the tumour during
treatment planning.
MV Images
Megavoltage images (images taken on the Linac)
Organs at Risk (OAR)
Organs at Risk. Normal tissue close to and/or along the treatment
pathway. Minimising radiation dose to these structures improves the
toxicity profile and maximises organ function and therefore quality of life
following radiation therapy.
Palliative Treatment
Treatment for symptom control, not with a curative intent
Radiation Oncologist (RO)
A radiation oncologist is a medical specialist who has specific
postgraduate training in radiation cell biology and management of
patients with cancer, in particular involving the use of radiation therapy
(also called radiotherapy) as one aspect of their cancer treatment. They
also have expertise in the treatment of non-malignant conditions with
radiation therapy.
Radiation oncologists work closely with other medical specialists,
especially surgeons, medical oncologists, pathologists, radiologists
(diagnostics) and palliative care physicians, as part of a multidisciplinary
team caring for patients with cancer.
Radiation Oncology Medical
Physicist (ROMP)
A Medical Physicist has substantial tertiary qualifications in physics
and applies their knowledge of the principles of physics to the care of
patients.
Radiation oncology medical physics is the application and development
of the principles and techniques of physics for the therapeutic use of
ionising radiation. Radiation Therapist (RT)
The Radiation Therapist is an allied health professional who works in
the field of radiation oncology. Radiation therapists plan and administer
radiation treatments to cancer patients.
Radical Treatment
Treatment with a curative intent
Radiation Therapy
A treatment for cancer and a number of non-malignant conditions,
which uses highly precise doses of radiation to kill abnormal cells while
minimising doses to the surrounding healthy tissue. It has a major
positive impact on local cancer control and is a highly effective therapy
for control of cancer symptoms such as pain.
Stereotactic Body Radiation
Therapy (SBRT)/Stereotactic
Ablative Body Radiation
Therapy (SABR)
SBRT/SABR (both interchangeable) is a technique designed to deliver
radiation therapy very precisely to tumours anywhere in the body. The
word stereotactic pertains to the precise positioning of a tumour in
relationship to the body. The technology used in SBRT/SABR allows
external beam radiation to be delivered with pinpoint accuracy. Stereotactic Radio-Surgery
(SRS)
SRS is a special form of radiation therapy – it is not surgery. SRS allows
precisely focused, high dose X-ray beams to be delivered to a small,
localized area of the brain.
Stereotactic Radiation
Therapy (SRT)
SRT is a form of external radiation treatment used to eradicate
cancerous growths. With SRT, a series of precise radiation beams are
aimed at a tumour from many different directions.
Stereotactic Radiation Therapy (SRT) utilises the principles of
Stereotactic Radiosurgery for localisation, and fractionation regimes
that are based on conventional external beam radiation therapy.
SRT often is used to treat cancers in the radiation-sensitive areas of
the brain, head and neck — but it can often be used in other locations
where radiation is effective.
Target
Area where the radiation beams are aimed; usually a tumour,
malformation, or other abnormality of the body.
Three Dimensional (3D)
Imaging
Three-dimensional (3D) Imaging in radiation therapy treatment is
localisation of the target by comparing a cone-beam computed
tomography (CBCT) dataset with the planning computed tomography
(CT) dataset from planning.
Treatment Planning
The process in which a team consisting of radiation oncologists,
radiation therapist and medical physicists plan the appropriate external
beam radiation therapy or internal brachytherapy treatment technique
for a patient with cancer.
Two Dimensional (2D)
Imaging
Two-dimensional (2D) Imaging in radiation therapy treatment is
localisation of the target by matching planar kilovoltage (kV)
radiographs fluoroscopy or megavoltage (MV) images with digital
reconstructed radiographs (DRRs) from the planning CT.
Volumetric Modulated Arc
Therapy (VMAT)
VMAT is a new type of intensity-modulated radiation therapy (IMRT)
treatment technique that uses the same hardware (i.e. a digital linear
accelerator) as used for IMRT or conformal treatment, but delivers the
radiation therapy treatment using rotational or arc geometry rather than
several static beams.
ACKNOWLEDGEMENT
To Michael Bailey for introducing the concept of Radiation Oncology Techniques vs.
Technologies.
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
It is used to treat small brain and spinal cord tumours as well as blood
vessel abnormalities in the brain and neurologic problems such as
movement disorders. SRS principles are also utilised to treat certain
small tumours in the liver, spine and lungs with Stereotactic Body
Radiation Therapy (SBRT).
Faculty of Radiation Oncology
The radiation dose per treatment is usually higher (hence more
damaging) and much more precise, resulting in fewer treatments
necessary than traditional radiation therapy.
To Aimee Lovett for researching and writing much of this report.
To Natalia Vukolova, A/Prof Chris Milross, Dr Dion Forstner and Dr Carol Johnson who have
been invaluable in writing and editing the document.
25
Position Paper Techniques and Technologies in Radiation Oncology 2015 Horizon Scan, Australia and New Zealand
Faculty of Radiation Oncology
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