Download Future of Radiation Therapy

Future of Radiation Therapy
JP Morgan Healthcare Conference
January 12, 2016
Deepak Khuntia, MD,
VP of Medical Affairs
Patrick Kupelian, MD,
VP of Clinical Affairs
Cancer as a cause of death
CANCER TREATMENT MODALITY: RADIOTHERAPY
Localized Treatments:
Surgery : less invasive?
Ablative Treatments:
Cryo
HIFU
Laser
Microwave
Systemic Treatments:
Drugs: Traditional ChemoRx
Hormonal Therapy
Targeted Drugs
Very few curative therapies
Minor improvements in subsets of patients
Radiation Therapy (RT):
Spectrum of biologic effects
• Ablative: SRS/SBRT
•Biologic therapy
Organ-sparing
DNA changes
Immune modulation
DISEASES TREATED WITH RT
Curable Cancers with RT ALONE:
Prostate Ca
Head & Neck Ca
Lung Ca
Cervical Ca
Skin Ca
Curable Cancers with RT as part of treatment (adjuvant):
Breast Ca
Adv. Lung Ca
Adv. Cervical Ca
Adv. Head & Neck Ca
Brain Tumors
Rectal Ca
Endometrial Ca
Bladder Ca
Metastatic disease: Bone / Brain / Other…
Testicular Ca
Sarcomas
Pediatric Ca
Improving RT Delivery
Impact
Aim: Increase Cure / Decrease Toxicity
Process: Improve RT Shaping and Targeting
1950-60s
1970-80s
1990s
2000s
2010s
Cobalt
Early Linacs
Higher
Energy
Linacs
Beam Shaping
Devices
In-room
Image
Guidance
Integration of
Better Beam
Shaping
and Aiming
• Treat deeper
tumors
• Treat smaller areas
• Individualization
• Increase in
tumor doses
• Higher daily
doses
• Decrease
skin toxicity
• Decrease toxicity in
deeper organs
• Improve
tumor control
• Faster, Better,
Safer treatments
Explore new
indications
Improving RT Techniques and Outcomes
Novelty
Clinical Impact
1995-2000
2000-2005
2005-2010
2010-2015
2015-Future
Beam shaping devices:
MLCs
In-room image
guidance
Partially integrated
systems
Hypofractionation,
Adaptive RT
Integration of Better
Beam Shaping
and Aiming
IMRT
• Head/Neck: improve
saliva / swallowing
• Pelvis: Less bowel
toxicity
• Allows safer
chemotherapy
administration
IGRT
• Prostate Ca:
Enable dose
escalation: improve
cure
• Reduce traditional
set-up errors
• Dedicated devices
• SRS
• Multivendor
environment
• SBRT/SABR
• Increased
complexity
• Lung Ca SBRT:
improve cure
• Faster, better, safer
treatments
• Decrease
throughput
• Frameless CNS
radiosurgery
• Global RT:
• Increase safety
concerns.
• Partial breast
accelerated
irradiation
Need for increased
integration and/or
interoperability
• ART
• Simpler set-ups
• Education &
training
Brain Mets Study: Adding SRS Improves Survival
Andrews DW, Scott CB, Sperduto PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for
patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004 May
22;363(9422):1665-72.
RapidArc Radiosurgery: Treating 11 Melanoma Mets
Treatment Details
• 18 Gy x 1
• 4 non-coplanar arcs
• 1-360, 3-170
• 18 min treatment
• 5 min beam-on
• 708 control points
Lung Cancer:
Patients live longer with Radiosurgery than with Surgery
SBRT vs. Lobectomy for Operable Stage I NSCLC
Source: Chang JY, Senan S, Paul MA, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung
cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015 Jun;16(6):630-7.
PROSTATE CANCER
IMAGE GUIDANCE: IMPROVING CURE AND REDUCING TOXICITY
Cancer Control Rates
Toxicity Rates
Memorial Sloan Kettering Cancer Center
Prostate Cancer RT: Outcome with and without Image Guidance
Zelefsky, IJROBP, 84, 125-129, 2012
Shaping of Radiation Lowers Complications
Conventional RT
IMRT
Reduce Bowel Complications
Cancers impacted:
Prostate Ca
Rectal Ca
Anal Ca
Cervical Ca
Reduce Head & Neck Complications
Complications reduced:
Less dryness of the mouth
Less swallowing problems
Less scarring of joints / muscles
Chopra et al. ASTRO Plenary, San Antonio October 2015.
Gupta et al. Radiotherapy and Oncology. 104:3 (343-348), 2012.
IMAGE – Not Yet Complete
New Era Innovation
Knowledge-Guided Oncology | Intelligent Treatment Delivery
Advanced Data Analytics
KNOWLEDGE-GUIDED ONCOLOGY:
RapidPlan™ Ramp Up

300+ Orders

3,800 Potential Installs

Disease Site Models

Prostate

Prostate (+lymph nodes)

Head & Neck

Lung SBRT

Breast

More Models Coming
KNOWLEDGE-GUIDED ONCOLOGY:
University of Michigan: Spine SBRT Study
Manual
Time
Manual
Rapid Plan
60-90 min
15-20 min
Equivalent Quality
Foy J, et al. An analysis of knowledge based planning for stereotactic body radiation
therapy of the spine [abstract]. Poster presentation at: American Association of
Physicists in Medicine (AAPM) 57th Annual Meeting & Exhibition; July 12-16,
2015; Anaheim, CA.
University of Michigan
RapidPlan
KNOWLEDGE-GUIDED ONCOLOGY:
Royal Surrey County Hospital: Prostate Study
350
Manual
Time
Equivalent
or better
RapidPlan™
114 ± 86 min
21 ± 13 min
30%
90%
Planning time (min)
300
250
200
150
100
Better
10%
90%
50
0
Courtesy, Royal Surrey County Hospital NHS Foundation, Guilford, UK
Data source on file
A1A2A3A4B1B2C1D1D2D3E1E2E3F1 F2 F3 F4 F5 F6
conventional
RapidPlan
INTELLIGENT TREATMENT DELIVERY:
High Definition Radiotherapy (HDRT)
Works in Progress
INTELLIGENT TREATMENT DELIVERY:
4π Dose Compression for Lung SBRT
64 Gy
PATIENT 1
PATIENT 2
15 Gy
IMRT
Works in Progress
VMAT
Dong P et al. IJROBP 86(3):407-13, 2013
4 π HDRT
INTELLIGENT TREATMENT DELIVERY:
High Definition Radiosurgery
Brain Stem
Brain Stem
50% Rx Dose
Coplanar RapidArc SRS
Works in Progress
50% Rx Dose
4π High Definition SRS
Promise of Protons
ADVANCED DATA ANALYTICS:
InSightive™ Analytics
ADVANCED DATA ANALYTICS

Operational Efficiencies

Referral Patterns

Clinical Outcome Analysis
ADVANCED DATA ANALYTICS:
Velocity
TM

Creates the cancer story from
imaging

Imaging informatics integrated
with our Big Data Analytics

Improve outcomes, quality, and
efficiency
Radio-immunotherapy for Cancer Treatment
Hodge, Guha, Neefjes, Gulley. Oncology, 2008 August, 22(9):1064-1084
Abscopal Responses in Metastatic Non-Small Cell Lung Cancer
(NSCLC) Patients Treated on a Phase 2 Study of Combined Radiation
Therapy and Ipilimumab: Evidence for the In Situ Vaccination
Hypothesis of Radiation
E.B. Golden, A. Chachoua, M.B. Fenton-Kerimian, S. Demaria, and S.C.
Formenti
New York University
ASTRO Annual Meeting
October 2016
The Abscopal Effect:
Radiotherapy in one site can potentially eradicate tumors elsewhere in the body
• Combining radiosurgery with immunotherapy
• Study of NSCLC
• Study shows that SBRT with ipilumimab could
increase tumor control and survival
• 25% remission; 100% control/no progression
Golden et al. ASTRO 2016.
Targeted Therapies and Immunotherapies:
Trend is in Combining Drugs
Challenges of drug+drug combinations
• Clinical trial design
• Cost
• Commercialization
RT as a combination “drug”
• Available
• Cost-effective
• Reimbursed
4. Radiation Medicine
NEW FRONTIERS IN
RADIATION ONCOLOGY
Research opportunities in radiation
medicine:
 Cardiac arrhythmias
 Emphysema
 Post-thoracic surgery neuropathy
 Plantar fasciitis
 Depression
 Arthritis
Works in Progress
Cardiac Arrhythmia
(Atrial Fibrillation)
Cardiac Arrhythmias: A New RT Frontier?
Affordable, Accessible, Quality Care
Cost of Cancer Care in US
30% increase from 2010 to 2020
Average Cost per Patient
$120,000
$100,000
$60,000
$40,000
$20,000
RT
Sources: Avalere study, 2015 National Bureau of Economic Research
Surgery
Hospital
Office
Pancreatectomy
Lobectomy
Cystectomy
Colectomy
Long course
$0
Short course
1995: $54,100
2005: $139,100
2013: $207,000
$80,000
Intermediate
Average cost for one extra year of life:
Chemo
(1 year)
Technology Decreasing Treatment Cost:
SBRT / SRS
Technology (SBRT) Decreasing Actual Treatment Cost
Time-driven activity-based costing (TDABC), UCLA
SBRT
Utilizing time-driven activity based costing to understand the short- and long-term costs of treating localized, low-risk prostate
cancer. Laviana et al. Cancer. 2015
Conclusion
• Advanced technology is increasing cure rates and
lowering toxicity
• Advanced technology will improve affordability,
accessibility, and quality of radiotherapy
• Radiation therapy utilization could dramatically
increase with new opportunities outside of cancer
Thank You
INTELLIGENT TREATMENT DELIVERY:
Relative Clinical Value
$10M
The Key To
Progress:
Better Dose
Delivery
$3-4M?
MR LINAC
3D CONFORMAL
IMRT
IGRT
SBRT
HDRT