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Beddok A, Lim R, Thariat J, Shih HA, El Fakhri G. A Comprehensive Primer on Radiation Oncology for Non-Radiation Oncologists. Cancers (Basel) 2023; 15:4906. [PMID: 37894273 PMCID: PMC10605284 DOI: 10.3390/cancers15204906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Multidisciplinary management is crucial in cancer diagnosis and treatment. Multidisciplinary teams include specialists in surgery, medical therapies, and radiation therapy (RT), each playing unique roles in oncology care. One significant aspect is RT, guided by radiation oncologists (ROs). This paper serves as a detailed primer for non-oncologists, medical students, or non-clinical investigators, educating them on contemporary RT practices. Methods: This report follows the process of RT planning and execution. Starting from the decision-making in multidisciplinary teams to the completion of RT and subsequent patient follow-up, it aims to offer non-oncologists an understanding of the RO's work in a comprehensive manner. Results: The first step in RT is a planning session that includes obtaining a CT scan of the area to be treated, known as the CT simulation. The patients are imaged in the exact position in which they will receive treatment. The second step, which is the primary source of uncertainty, involves the delineation of treatment targets and organs at risk (OAR). The objective is to ensure precise irradiation of the target volume while sparing the OARs as much as possible. Various radiation modalities, such as external beam therapy with electrons, photons, or particles (including protons and carbon ions), as well as brachytherapy, are utilized. Within these modalities, several techniques, such as three-dimensional conformal RT, intensity-modulated RT, volumetric modulated arc therapy, scattering beam proton therapy, and intensity-modulated proton therapy, are employed to achieve optimal treatment outcomes. The RT plan development is an iterative process involving medical physicists, dosimetrists, and ROs. The complexity and time required vary, ranging from an hour to a week. Once approved, RT begins, with image-guided RT being standard practice for patient alignment. The RO manages acute toxicities during treatment and prepares a summary upon completion. There is a considerable variance in practices, with some ROs offering lifelong follow-up and managing potential late effects of treatment. Conclusions: Comprehension of RT clinical effects by non-oncologists providers significantly elevates long-term patient care quality. Hence, educating non-oncologists enhances care for RT patients, underlining this report's importance.
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Affiliation(s)
- Arnaud Beddok
- Department of Radiation Oncology, Institut Godinot, 51100 Reims, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ruth Lim
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François-Baclesse, 14000 Caen, France
| | - Helen A. Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Georges El Fakhri
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Liu J, Shi X, Niu Z, Qian C. Comparative efficacy of intraoperative radiotherapy and external boost irradiation in early-stage breast cancer: a systematic review and meta-analysis. PeerJ 2023; 11:e15949. [PMID: 37744215 PMCID: PMC10512934 DOI: 10.7717/peerj.15949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023] Open
Abstract
External boost radiotherapy (EBRT) and intraoperative radiotherapy (IORT) are shown to be effective in patients with early-stage breast cancer. However, the difference between IORT and EBRT for patients' prognosis remains to be elucidated. The purpose of this meta-analysis is to investigate differences in local recurrence (LR), distant metastases, disease free survival (DFS), and overall survival (OS) between these two therapies. We searched the Cochrane Library, PubMed, Web of Science and Embase, from inception to Jan 10th, 2022. We used The Cochrane risk-of-bias assessment tool to assess the risk of bias of the included studies, and the STATA15.0 tool was used for the meta-analyses. Eight studies were ultimately included. Meta-analysis demonstrated that there was an inconsistent finding in the long-term risk of LR between the two radiotherapies, and there was no significant difference in short-term risk of LR, the metastasis rate, DFS, and OS IORT would be more convenient, less time-consuming, less costly, and more effective at reducing side effects and toxicity. However, these benefits must be balanced against the potential for increased risk of LR in the long term.
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Affiliation(s)
- Jiaxin Liu
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Xiaowei Shi
- Xiamen Hospital, Fudan University Shanghai Cancer Center, Xiamen, China
| | - Zhenbo Niu
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
| | - Cheng Qian
- Affiliated Cancer Hospital of Harbin Medical University, Harbin, China
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Zou W, Zhang R, Schüler E, Taylor PA, Mascia AE, Diffenderfer ES, Zhao T, Ayan AS, Sharma M, Yu SJ, Lu W, Bosch WR, Tsien C, Surucu M, Pollard-Larkin JM, Schuemann J, Moros EG, Bazalova-Carter M, Gladstone DJ, Li H, Simone CB, Petersson K, Kry SF, Maity A, Loo BW, Dong L, Maxim PG, Xiao Y, Buchsbaum JC. Framework for Quality Assurance of Ultrahigh Dose Rate Clinical Trials Investigating FLASH Effects and Current Technology Gaps. Int J Radiat Oncol Biol Phys 2023; 116:1202-1217. [PMID: 37121362 PMCID: PMC10526970 DOI: 10.1016/j.ijrobp.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 03/28/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023]
Abstract
FLASH radiation therapy (FLASH-RT), delivered with ultrahigh dose rate (UHDR), may allow patients to be treated with less normal tissue toxicity for a given tumor dose compared with currently used conventional dose rate. Clinical trials are being carried out and are needed to test whether this improved therapeutic ratio can be achieved clinically. During the clinical trials, quality assurance and credentialing of equipment and participating sites, particularly pertaining to UHDR-specific aspects, will be crucial for the validity of the outcomes of such trials. This report represents an initial framework proposed by the NRG Oncology Center for Innovation in Radiation Oncology FLASH working group on quality assurance of potential UHDR clinical trials and reviews current technology gaps to overcome. An important but separate consideration is the appropriate design of trials to most effectively answer clinical and scientific questions about FLASH. This paper begins with an overview of UHDR RT delivery methods. UHDR beam delivery parameters are then covered, with a focus on electron and proton modalities. The definition and control of safe UHDR beam delivery and current and needed dosimetry technologies are reviewed and discussed. System and site credentialing for large, multi-institution trials are reviewed. Quality assurance is then discussed, and new requirements are presented for treatment system standard analysis, patient positioning, and treatment planning. The tables and figures in this paper are meant to serve as reference points as we move toward FLASH-RT clinical trial performance. Some major questions regarding FLASH-RT are discussed, and next steps in this field are proposed. FLASH-RT has potential but is associated with significant risks and complexities. We need to redefine optimization to focus not only on the dose but also on the dose rate in a manner that is robust and understandable and that can be prescribed, validated, and confirmed in real time. Robust patient safety systems and access to treatment data will be critical as FLASH-RT moves into the clinical trials.
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Affiliation(s)
- Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rongxiao Zhang
- Department of Radiation Oncology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Emil Schüler
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paige A Taylor
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Eric S Diffenderfer
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Tianyu Zhao
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, Ohio State University, Columbus, OH, USA
| | - Manju Sharma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Shu-Jung Yu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Weiguo Lu
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, TX, USA
| | - Walter R Bosch
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Christina Tsien
- Department of Radiation Oncology, McGill University Health Center, Montreal, QC, Canada
| | - Murat Surucu
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Julianne M Pollard-Larkin
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Schuemann
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | | | - David J Gladstone
- Department of Radiation Oncology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Heng Li
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - Kristoffer Petersson
- Department of Radiation Oncology, MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Stephen F Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amit Maity
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Lei Dong
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter G Maxim
- Department of Radiation Oncology, University of California Irvine, Irvine, CA, USA
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey C Buchsbaum
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institute of Health, Bethesda, MD, USA
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