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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
Faithfull, S.1
Emerging Questions
Slide One
• Which patients benefit most from
radiotherapy?
• What is the optimal dose and
fractionation schedule?
• What impact does multi-modality
radiotherapy have on patients?
• What is the balance between new
developments and the support
required?
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Aims of radiotherapy
• To achieve tumour control by
Slide Two
delivering a homogeneous
radiation dose to tumour-bearing
tissues
• To avoid radiation-induced
complications by minimising dose
to normal tissue structures
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Three
Developments in
radiotherapy
Royal Marsden NHS Foundation Trust
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Causes of failure of
radiotherapy treatment
(1)
Slide Four
Biological response to radiotherapy
• Tumour physiology
• Repopulation: accelerated cell
proliferation
• Redistribution
• Re-oxygenation of hypoxic areas
within the tumour
• Intrinsic sensitivity of the tumour
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Causes of failure of
radiotherapy treatment
(2)
Slide Five
New developments impact clinically
in:
• determining the underlying
molecular basis for differences in
radio-sensitivity
• making possible the ability to
individualise radiotherapy
through biological understanding
of damage mechanisms
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Tissue effects
Slide Six
RADIATION
Blood
Barrier
P a re nc hym a l
c e ll lo s s
R e c o v e ry
E xt ra v a s a t io n
o e de m a
D ys re gula t e d
int e ra c t io ns
Inf la m m a t o ry
c yt o k ine ,
gro wt h f a c t o r
m ile u
Inf la m m a t io n
E ndo t he lia l c e ll
f unc t io n c e ll lo s s
S t ro m a l c e ll
inf ilt ra t io n
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Seven
Understanding the
optimal dose and
fractionation schedule
• Adjusting fractionation regimes
– hyperfractionation
• Individualised radiotherapy
regimes and dosages
• Combined modality treatment
chemo-radiation (CMT)
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Chemo radiotherapy
and combined modality
treatment
Slide Eight
•
Increasing oxygenation
– Perflurochemical emulsions:
improving oxygen delivery to the
tumour
•
Agents that selectively sensitise tumour
cells to irradiation
– Misonidazole: substitutes for O2 in
fixing radiotherapy DNA damage
– Fludarabine, Gemcitabine: prodrug
inhibits various enzymes involved
in DNA synthesis and repair
•
Radioprotectors: Amifostine
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Improving radiotherapy
delivery (physical
optimization)
Slide Nine
•
Define target volume and normal
tissues in 3D
– Higher doses
– Improved tumour control
– Increased toxicity
•
Accurately determine doses to
tumour and normal tissues
(prognostication)
– Lower volumes of structures
irradiated
– Lower late toxicity
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Ten
Technological advances
•
Portal imaging
•
Intensity Modulated therapy (IMRT)
•
Image-guided radiation therapy (IGRT)
•
Conformal therapy (CFRT)
•
Multileaf collimation
•
Stereotactic radiotherapy
•
Gated treatment (pulsed according to
the phase of the respiratory cycle)
•
Therapy with portable photon sources
(Intraoperative)
•
Prostate brachytherapy
•
Intraoperative brachytherapy using Flab
(flexible tissue-equivalent material)
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Eleven
Developments in
supportive care with
radiotherapy
• Improved patient information ,
patient education and written
consent
• Nurse-led follow up
• Extended therapy radiographer
roles
• Patient education
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
The challenges
Slide Twelve
• Lack of assessment in
radiotherapy
• Large proportion of patients are
palliative; may have different
needs
• Lack of knowledge
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Thirteen
Comparison of
technology and
supportive care
publications
300
250
200
IMRT
150
S/E intervention
100
R/T nursing
50
0
1999/2000
2001/02
2003/4
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slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Fourteen
How will high tech
treatments impact on
patients?
• Combined modality acute side
effects are more severe
• Improve flexibility and individuality
of treatment regimes
• Lag time from treatment to
development of late side effects
• Need to balance of length of time
of new treatments against resource
implications need cost benefit
evaluation
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FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Conclusion
Slide Fifteen
• Sustained radiotherapy
technological development is likely
to improve treatment efficacy
• Essential to assess the clinical and
biological nature of cancer and the
patient to patient variability to
optimise new developments
• Ongoing multi-professional
assessment of toxicity is essential
to aid decision making
• Optimal multi-modality
management approaches and
evaluation
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slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
References and further
reading
Slide Sixteen
• Adamson, D. (2003). The radiobiological basis of
radiation side effects. In Supportive care in radiotherapy,
Faithfull, S. & Wells, M. (eds). Churchill Livingstone:
Edinburgh.
• Bentzen, S. (1998). Towards evidence based radiation
oncology: improving the design, analysis, and reporting
of clinical outcome studies in radiotherapy.
Radiotherapy and Oncology, 46, 5-18.
• Bentzen, S. (2004). High-tech in radiation oncology:
should there be a ceiling? Int. J Radiation Oncology Biol.
Phys., 58, 320-330.
• Burnet, N., Benson, R. & Williams, M. (2000). Improving
cancer outcomes through radiotherapy. BMJ, 320,
198-199.
• Colyer, H. & Hlahla, T. (1999). Information and support
radiographers: a critical review of the role and its
significance for the provision of cancer services.
Journal of Radiotherapy in Practice, 1, 117-124.
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
References and further
reading (continued)
Slide Seventeen
• Dische, S., Joslin, C., Miller, S., Bell, N. & Holmes, J.
(1998). The breast radiation litigation and the clinical
oncologist. Clin Oncol, 10, 367-71.
• Dixon, P. & Mackillop, W. (2001). Could changes in
clinical practice reduce waiting lists for radiotherapy?
Journal of Health Services Research, 6, 70-77.
• Fulop, N., Allen, P., Clarke, A. & Black, N. (2003). From
health technology assessment to research on the
organisation and delivery of health services: addressing
the balance. Health Policy, 63, 115-165.
• Goldberg, Z. & Lehnert, B. (2002). radiation induced
effects in unirradiated cells: A review and implications
in cancer. International Journal of Oncology, 21, 337-349.
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
Slide Eighteen
References and further
reading (continued)
• Green, J., Kirwan, J., Tierney, J., Symonds, P., Fresco, L. &
Collingwood, M. (2001). Systematic review and metaanalysis of randomised trials of concomitant
chemotherapy and radiotherapy for cancer of the
uterine, cervix: better survival and improved distant
recurrence rates. Lancet, 358, 781-6.
• Hill, R., Rodemann, H., Hendry, J., Roberts, S. & Anscher,
M. (2001). Normal tissue radiobiology: from the
laboratory to the clinic. Int.J.Radiation Oncology Biol.
Phys., 49, 353-365.
• Lewanski, C. & Gullick, W. (2001). Radiotherapy and
cellular signalling. The Lancet Oncology, 2, 366-370.
• Murthy, V. & Horwich, A. (2004). Intensity modulated
radiation therapy. European Journal of Cancer, 40, 23492351.
• Sikora, K. & Bosanquet, N. (2003). Cancer care in the
United Kingdom: new solutions are needed. British
Medical Journal, 327, 1044-1046.
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2005
Developments in radiotherapy treatment
for cancer: implications for practice
(continued)
References and further
reading (continued)
Slide Nineteen
• Stone, H., Coleman, C., Ansher, M. & McBride, W.
(2003). Effects of radiation on normal tissue:
consequences and mechanisms. The Lancet Oncology, 4,
529-36.
• Symonds, R. (2001). Recent advances in Radiotherapy.
BMJ, 323, 1107-10.
• Tobias, J. (2000). Risk management and radiotherapy
for cancer. Clinical Risk, 6, 13-16.
• Wells, M. (1998). What's so special about radiotherapy
nursing? European Journal of Oncology Nursing, 2, 162168.
• Wells, M. (2003). The treatment trajectory. In
Supportive care in radiotherapy, Faithfull, S. & Wells, M.
(eds). Churchill Livingstone: Edinburgh.
*Click on “View”; “Notes Page” for explanatory notes
slides available at: www.blackwellpublishing.com/journals/ecc