Number of patients potentially eligible for proton therapy

A group of Swedish radiation oncologists and hospital physicists have estimated the number of patients in Sweden suitable for proton beam therapy in a facility where one of the principal aims is to facilitate randomized and other studies in which the advantage of protons can be shown and the magnitude of the differences compared with optimally administered conventional radiation treatment, also including intensity-modulated radiation therapy (IMRT) and brachytherapy, can be shown. The estimations have been based on current statistics of tumour incidence in Sweden, number of patients potentially eligible for radiation treatment, scientific support from clinical trials and model dose planning studies and knowledge of the dose-response relations of different tumours together with information on normal tissue complication rates. In Sweden, it is assessed that between 2200 and 2500 patients annually are eligible for proton beam therapy, and that for these patients the potential therapeutic benefit is so great as to justify the additional expense of proton therapy. This constitutes between 14-15% of all irradiated patients annually.

A prospective survey of radiotherapy practice 2001 in Sweden

A prospective survey of radiotherapy practice in Sweden was conducted during 12 weeks in the autumn of 2001. All hospitals that provided radiotherapy participated, and all patients who started radiotherapy during the study period were included. The final patient sample comprised 5,105 treatments given to 4,171 patients. The results were compared with those of a similar survey conducted in 1992, and the following conclusions were drawn: A substantial increase in the use of radiotherapy was noted; The estimated proportion of cancer cases receiving radiotherapy (compared to the incident number of cases) had increased from 32% in 1992 to 47%; The proportion of cancer patients receiving radiotherapy was estimated at between 37 and 46%; 54% of treatments were given with curative intent, a small increase since 1992; The difference between regional and county departments for proportion of treatments with curative intent had diminished; Treatments with curative intent used a higher proportion of resources measured in terms of fractions; The proportion of palliative treatment was slightly lower than in 1992, but the absolute number of treatments had increased by more than 20%; No improvement in participation in clinical trials was noted; Treatments given with curative intent were more complex with more fields; Hyperfractionation was used, mainly in treatments of cancers of the head and neck, lung, and bladder; The use of brachytherapy for non-gynaecological malignancies had increased dramatically; Treatment of bone metastases with a single or few fractions was used much more frequently; Dose planning and patient set-up showed a high standard but quality control of dosimetry of given treatment did not fully comply with Swedish and European recommendations; The treatment devices seem to be used more efficiently.

"Distributed proton radiation therapy"--a new concept for advanced competence support

The increased interest in high precision radiation therapy is to a large extent driven by the potential of modern imaging technology. The aim of this project was to analyse how an expensive proton facility best could support a multi-centre health care system. We have developed a model for distributed expert collaboration where all clinical experts will work close to their patients in regional centres. Patients who are candidates for proton therapy will be examined and dose-planned at their regional clinic, discussed in a fully information supported video conference and digitally made available at the proton treatment facility. The proton facility itself will be placed near a communication centre easily reached by all patients where they will be treated under full responsibility of their own physician at the home clinic. This concept has been analysed in detail both with respect to the overall functionality and with respect to possible weaknesses. It was found that the concept of distributed radiation therapy, as proposed here, will offer a stable clinical solution for advanced radiation therapy. It will support the spread of knowledge, serve as a fully developed backup system and the concept will further serve as an efficient base for clinical research.

[Oncology forum in urology]

OBJECTIVE

To present to the radiation oncologist the main advances in prostate cancer in the last year

METHODOLOGY

A review of the main congress in uro-oncology (ASCO, ASTRO, AUA, EAU) and international literature

RESULTS

The increase in the incidence of prostate cancer without increasing in mortality must be a signal for oncologist to propose active surveillance to the patients without bad prognostic factors. Use of biomarkers could probably facilitate the selection of patients needing treatment. After prostatectomy, adjuvant radiotherapy could decrease the biochemical relapse rate but also the risk of distant metastasis, particularly for pT3 R1 patients; but the optimal time to deliver this post-operative radiotherapy is discussed: immediately after surgery or delayed in case of PSA relapse (> or = 0,2 ng/ml). For locally advanced disease, combination of radiotherapy and long-term androgen deprivation improved survival over hormonal treatment alone. But duration of androgen deprivation must be adapted to the comorbidities of the patient because of the risk of metabolic syndrome. The value of dose escalation in association with hormonal treatment must be defined.

CONCLUSION

Important advances in prostate cancer management have been made during the last months, but inclusion of patients into on-going prospective studies is still important to continue to improve the therapeutic results.

Current status and future potential of advanced technologies in radiation oncology. Part 2. State of the science by anatomic site

In December 2006, the Radiation Research Program of the Division of Cancer Treatment and Diagnosis of the National Cancer Institute hosted a workshop intended to address current issues related to advanced radiation therapy technologies, with an eye toward (1) defining the specific toxicities that have limited the success of "conventional" radiation therapy, (2) examining the evidence from phase III studies for the improvements attributed to the advanced technologies in the treatment of several cancers commonly treated with radiation therapy, and (3) determining the opportunities and priorities for further technologic development and clinical trials. The new technologies offer substantial theoretical advantage in radiation dose distributions that, if realized in clinical practice, may help many cancer patients live longer and/or better. The precision of the advanced technologies may allow us to reduce the volume of normal tissue irradiated in the vicinity of the clinical target volume. Part 1 of this two-part article, which appeared in the March issue of ONCOLOGY, provided a general overview of the workshop discussion, focusing on the challenges posed by the new technologies and resources available or in development for meeting those challenges. This month, part 2 will outline the state of the science for each disease site.

Current status and future potential of advanced technologies in radiation oncology. Part 1. Challenges and resources

In 2006, the Radiation Research Program of the Division of Cancer Treatment and Diagnosis of the National Cancer Institute hosted a workshop intended to address current issues related to advanced radiation therapy technologies, with an eye toward (1) defining the specific toxicities that have limited the success of "conventional" radiation therapy, (2) examining the evidence from phase III studies for the improvements attributed to the advanced technologies in the treatment of several cancers commonly treated with radiation therapy, and (3) determining the opportunities and priorities for further technologic development and clinical trials. The new technologies offer substantial theoretical advantage in radiation dose distributions that, if realized in clinical practice, may help many cancer patients live longer and/or better. The precision of the advanced technologies may allow us to reduce the volume of normal tissue irradiated in the vicinity of the clinical target volume. Part 1 of this two-part article will provide a general overview of the workshop discussion, focusing on the challenges posed by the new technologies and resources available or in development for meeting those challenges. Part 2, which will appear in next month's issue of ONCOLOGY, will address the state of the science for each disease site.

New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology

New technologies such as intensity modulated and image guided radiation therapy, computer controlled linear accelerators, record and verify systems, electronic charts, and digital imaging have revolutionized radiation therapy over the past 10-15 y. Quality assurance (QA) as historically practiced and as recommended in reports such as American Association of Physicists in Medicine Task Groups 40 and 53 needs to be updated to address the increasing complexity and computerization of radiotherapy equipment, and the increased quantity of data defining a treatment plan and treatment delivery. While new technology has reduced the probability of many types of medical events, seeing new types of errors caused by improper use of new technology, communication failures between computers, corrupted or erroneous computer data files, and "software bugs" are now being seen. The increased use of computed tomography, magnetic resonance, and positron emission tomography imaging has become routine for many types of radiotherapy treatment planning, and QA for imaging modalities is beyond the expertise of most radiotherapy physicists. Errors in radiotherapy rarely result solely from hardware failures. More commonly they are a combination of computer and human errors. The increased use of radiosurgery, hypofractionation, more complex intensity modulated treatment plans, image guided radiation therapy, and increasing financial pressures to treat more patients in less time will continue to fuel this reliance on high technology and complex computer software. Clinical practitioners and regulatory agencies are beginning to realize that QA for new technologies is a major challenge and poses dangers different in nature than what are historically familiar.

Burden of cancer and projections for 2016, Indian scenario: gaps in the availability of radiotherapy treatment facilities

Plausible projections of future burden of cancer in terms of incident cases and requirement of radiotherapy treatment facilities at the national and state level are useful aids in planning of cancer control activities. The present communication attempts to provide a scenario for cancer in India during the year 2001 and its likely change by 2016 for all sites of cancer as well for selected leading sites. Further, a study was made of: (i) the state-wise distribution of radiotherapy treatment facilities and short falls; and (ii) pattern of investment of finances through central assistance by Government of India for cancer control activities during the various plan periods. The age, sex and site-wise cancer incidence data along with populations covered by 12 Indian population based cancer registries were obtained from the eighth volume of Cancer Incidence in Five Continents (CIV-VIII) and other published reports. Pooled age sex, site specific cancer incidence rates for twelve registries were estimated by taking weighted average of these registries with respective registry population as weight. Population of the country and states according to age and sex for different calendar years viz. 2001, 2006, 2011 and 2016 were obtained from the report of Registrar General of India. Population forecasts were combined with the pooled incidence rates of cancer to estimate the number of cancer cases by age, sex and site of cancer for the above 5-yearly periods. The existing radiotherapy facilities available in the country for cancer treatment during the year 2006 was based on the published reports and updated through personal communication from the Ministry of Health of India. During the year 2001, nearly 0.80 million new cancer cases were estimated in the country and this can be expected to increase to 1.22 million by 2016 as a result of change in size and composition of population. The estimated numbers were greater for females (0.406 millions, 2001) than males (0.392 millions, 2001). Lung, esophagus, stomach, oral and pharyngeal cancers are much higher in men while in women, cancers of cervix and breast are predominant forms followed by those of oral cavity, stomach and esophagus. Considering all the sources, it was noted that during the year 2006, there were 347 teletherapy units in the country as against a requirement of 1059. The state-wise analysis of the distribution of RCCs, and radio-therapy units shows wide gaps in the availability of facilities. The existing treatment facilities for cancer control in-terms of radiotherapy and financial allocation are woefully inadequate to take care of even the present load. The only way to fight this scourge under such circumstances is to have pragmatic programmes and policies based on currently available scientific information and sound public health principles.

Processes for quality improvements in radiation oncology clinical trials

Quality assurance in radiotherapy (RT) has been an integral aspect of cooperative group clinical trials since 1970. In early clinical trials, data acquisition was nonuniform and inconsistent and computational models for radiation dose calculation varied significantly. Process improvements developed for data acquisition, credentialing, and data management have provided the necessary infrastructure for uniform data. With continued improvement in the technology and delivery of RT, evaluation processes for target definition, RT planning, and execution undergo constant review. As we move to multimodality image-based definitions of target volumes for protocols, future clinical trials will require near real-time image analysis and feedback to field investigators. The ability of quality assurance centers to meet these real-time challenges with robust electronic interaction platforms for imaging acquisition, review, archiving, and quantitative review of volumetric RT plans will be the primary challenge for future successful clinical trials.

Innovations in image-guided radiotherapy

The limited ability to control for the location of a tumour compromises the accuracy with which radiation can be delivered to tumour-bearing tissue. The resultant requirement for larger treatment volumes to accommodate target uncertainty restricts the radiation dose because more surrounding normal tissue is exposed. With image-guided radiotherapy (IGRT) these volumes can be optimized and tumoricidal doses can be delivered, achieving maximal tumour control with minimal complications. Moreover, with the ability of high-precision dose delivery and real-time knowledge of the target volume location, IGRT has initiated the exploration of new indications for radiotherapy, some of which were previously considered infeasible.