Expanding global access to radiotherapy

Histological, immunohistochemical and electron-microscopic evaluation of different radiotherapy doses effects on rat's lung

BACKGROUND

Radiation-related complications occur in the lungs during radiotherapy for intrathoracic tumors. Lung damage caused by radiation in the long term varies depending on the radiation dose received. The incidence of pulmonary toxicity has decreased with the advancement of radiotherapy techniques such as intensity-modulated RT (IMRT) and image-guided RT (IGRT). This study aimed to examine the damage caused by different radiation doses applied with the IMRT technique, both histochemically and histopathologically, and to emphasize the effect of a low dose (5 Gy).

METHODS AND MATERIALS

A total of 24 rats were divided into 4 groups: control (Group 1), 5 Gy (Group 2), 10 Gy (Group 3), and 20 Gy (Group 4). Helical IMRT plans were made using tomotherapy to ensure that the thorax received the entire dose designated for each group. The rats in groups 2, 3, and 4 were exposed to radiation doses of 5 Gy, 10 Gy, and 20 Gy, respectively. After 180 days, the morphological and immunohistochemical features and the number of apoptotic cells in the lung tissues were examined using electron microscopy and light microscopy. Morphological, inflammatory (IL-1β, IL-10, and TNF-α), and apoptotic index values were compared statistically.

RESULTS

This study observed that morphological, inflammatory, and apoptotic cell damage in the lungs gradually increased in a dose-dependent manner compared to the control group. However, at the low radiation dose of 5 Gy, the severity of lung damage was relatively less than at the higher doses (10 Gy and 20 Gy).

CONCLUSION

In conclusion, this study found that the severity of lung damage was less at a low radiation dose (5 Gy) compared to higher doses (10 Gy and 20 Gy). This emphasizes the need to limit the maximum dose and the irradiated volume during thoracic radiotherapy.

Decision tree-based machine learning algorithm for prediction of acute radiation esophagitis

Background

Radiation-induced esophagitis remains a significant challenge in thoracic and neck cancer treatment, impacting patient quality of life and potentially limiting therapeutic efficacy. This study aimed to develop and validate a decision tree-based model for predicting acute esophagitis grades in patients undergoing chemoradiotherapy.

Methods

Data from 100 patients receiving thoracic and neck radiotherapy were analyzed. The dataset comprised 33 features, including demographic, clinical, and dosimetric parameters. A decision tree classifier was implemented for both binary (Grade ≥2 vs. <2) and multi-class (Grades 1, 2, and 3) classification. Model performance was evaluated using standard metrics including accuracy, precision, recall, and F1-score.

Results

The binary classification model achieved 97 % accuracy in distinguishing acute esophagitis. The multi-class model demonstrated 98 % accuracy in predicting specific grades. Key predictive features included V40 (volume receiving 40 Gy), V60, and average esophageal dose. The model generated interpretable decision rules, with V60 ≥ 2.3 strongly indicating Grade 3 esophagitis.

Conclusions

The decision tree model demonstrates high accuracy in predicting radiation-induced esophagitis grades while maintaining clinical interpretability. This approach offers potential for treatment optimization and personalized risk assessment in radiotherapy planning. The model's transparency and reliability make it a promising tool for clinical decision support in radiation oncology.

Anticancer Potential of Iron-Based Polyherbal Formulation Against Lung and Colon Cancer Cell Lines

ETHNOPHARMACOLOGICAL RELEVANCE

Evidence-based research could unlock novel, safe drugs from medicinal plants. Ancient herbal formulations remain largely unproven limits their modern use.

MATERIALS AND METHODS

Following a review of extensive ancient literature, "Kantha Chenduram (KC)" was selected. The current investigation involved a comprehensive characterisation utilising Atomic Force Microscopy, X-ray diffraction, Fourier Transform Infrared Spectroscopy, and Scanning Electron Microscopy with Energy Dispersive X-ray spectroscopic Analysis. Subsequently, the formulation's efficacy was evaluated in vitro against two prevalent lethal cancer cells, namely lung (A549) and colon (HT 29) cancer cells, then through a series of cellular assays, including DNA fragmentation, Fluorescence microscopy, cell cycle studies, and Apoptosis studies. Furthermore, cytotoxicity profile of the formulation was assessed using Vero cells, and its anti-inflammatory potential was investigated.

RESULTS

KC showed crystalline particles, ranging from 200 nm-7 μm, with the presence of iron and oxygen. Exhibiting potent anticancer activity, the compound showed statistically significant (P<0.05) IC50 values of 24.75±0.028 μg/mL and 28.8±0.032 μg/mL against lung and colon cancer cell lines, respectively. KC potentially targeted both lung and colon DNA, and fluorescent microscopic studies revealed that apoptotic cells were higher than necrotic cells. Lung cancer cell cycle studies demonstrated G0-G1 phase arrest. Furthermore, Apoptotic studies demonstrated a higher proportion of apoptotic cells in lung (24.33%) and colon (59.73%) cancer cells, suggesting a more aggressive cell death pathway. The formulation exhibited a favourable safety profile in Vero cell assays, indicating its safe potential for in vivo administration (P<0.001). KC evidenced potent anti-inflammatory effects in egg albumin and bovine albumin with IC50 of 73.78 and 81.62 μg/mL, respectively (P<0.05).

CONCLUSION

These scientific data support the claim that the herbal formulation possesses significant anticancer properties, improving human health. Consequently, the formulation is a promising candidate for clinical trials and global application.

Cyclodextrins as non-viral vectors in cancer theranostics: A review

Cancer ranks as the top cause of death following cardiovascular diseases. Identifying cancer patients at early stages presents significant challenges due to the asymptomatic nature of early-stage tumors. Conversely, the advancement of therapy resistance has led to a reduction in cancer treatment efficacy. Consequently, utilizing nanoparticles for the diagnosis and treatment of cancer can greatly enhance the prognosis and results for patients. CDs are recognized entities in the pharmaceutical domain and have been extensively used for therapeutic purposes in disease treatment. These non-viral vectors have shown efficacy in inhibiting both solid tumors and hematological malignancies through targeted drug delivery. CDs can enhance the administration of medications and genes in cancer treatment by ensuring their continuous release. The stimuli-responsive CDs have enhanced the targeted delivery of payloads at the tumor location, responding to the stimuli in TME such as pH, redox and light. CDs can serve as effective carriers that enhance the efficacy of phototherapy by improving the solubility and delivery of phototherapeutic agents, enabling integration with chemotherapy and immunotherapy. The administration of immunomodulators through CDs can enhance cancer immunotherapy and boost the infiltration of immune cells. Ultimately, CDs can aid in cancer diagnosis and the identification of biomarkers.

Impact of mSWI/SNF epigenetic complexes on ionizing radiotherapy resistance in malignant diseases: A comprehensive view in oncology

The mSWI/SNF chromatin remodeling complexes are critical regulators of genomic stability, particularly in their role in orchestrating DNA repair and modulating cellular responses to ionizing radiation therapy. Their involvement has positioned these molecular complexes as key factors in determining radiosensitivity in human malignant diseases. The present review delves into the biomedical contributions of specific mSWI/SNF subunits, including ARID1A, SMARCB1, SMARCA4, PBRM1, and BRD9, highlighting their pivotal roles in influencing tumor responses to radiotherapy. Evidence suggests that the loss of function in these subunits, often due to mutations, disrupts DNA repair pathways, thereby compromising genomic integrity and enhancing susceptibility to radiation-induced damage. Emerging preclinical studies have underscored the potential of exploiting these vulnerabilities through pharmacological targeting of mSWI/SNF complexes. Inhibition of these complexes can impair DNA damage repair mechanisms, creating a synthetic lethality effect by using a combined epigenetic therapy with ionizing radiation protocols. This dual approach not only amplifies the therapeutic efficacy of radiotherapy but also broadens the spectrum of potential strategies for oncological therapy. However, further investigation into the molecular mechanisms underlying these epigenetic interactions is essential for optimizing oncological therapies and paving the way for clinical applications aimed at enhancing radiotherapy outcomes in cancer patients.

Implementation of a proton FLASH platform for pre-clinical studies using a gantry-mounted synchrocyclotron

Objective. External beam radiation therapy (RT) at ultra-high dose rate (FLASH RT) has shown promise for improving the therapeutic ratio; exploiting its full potential, however, requires systematic preclinical studies to unravel the underlying radiobiological mechanisms. We demonstrate a proton irradiation platform for pre-clinical FLASH studies using a gantry-mounted proton therapy system in clinical operation.Approach. An accessory comprising a transmission ionization chamber, a tray accommodating beam modifying elements, including range shifting blocks made of boron carbide (B4C) and poly(methyl methacrylate) (PMMA), and brass apertures to shape the beam's lateral extent was attached to the nozzle. A range modulator composed of arrays of holes drilled in a PMMA slab was used to form a spread-out Bragg peak (SOBP). The integral depth dose (IDD) curves, lateral dose profiles, and dose rate were measured using existing dosimeters for different beam modifying material combinations.Results. The range modulator allowed achieving an SOBP with 14 mm modulation. The proton range was gradually reduced through adding B4C and PMMA blocks in the beamline, while the beam spot's size gradually increased and became more symmetric as protons traveled through more material. The commercial scintillator screen showed a dose-rate-independent response for measuring lateral dose profiles. The representative IDDs of the FLASH beam can be measured with a commercial multilayer ionization chamber device at a low dose rate since the IDD did not depend on the dose rate.Significance. This work demonstrated a platform for delivering ∼70 Gy s-1SOBP proton FLASH beams using a gantry-mounted synchrocyclotron clinical system. We showed the evolution of an asymmetric and small single proton spot to a more symmetric and larger spot after ranging and shaping through different components. Using dosimeters commonly employed for quality assurance purposes, we report an efficient method for the characterization of proton FLASH beams.

The 2024 State of Science report from the European Organisation for Research and Treatment of Cancer's Radiation Oncology Scientific Council

BACKGROUND

Radiotherapy (RT) is a central pillar of a multimodal cancer treatment approach. The ongoing advances in the fields of RT, imaging technologies, cancer biology, and others yield the potential to refine the use of RT. The European Organisation for Research and Treatment of Cancer (EORTC) hosted a dedicated workshop to identify and prioritize key research questions and to define future RT-based treatment strategies to improve the survival and quality of life of cancer patients.

METHODS

An initial call for relevant RT research topics led to the formation of workgroups to develop these into new clinical research proposals and projects. The EORTC Radiation Oncology Scientific Council (ROSC) State of Science workshop was held in Brussels, Belgium, in February 2024, bringing together EORTC members and international stakeholders to connect and work on the proposals.

RESULTS

Four topics of interest were identified: I) De-escalation of RT, minimizing toxicity while maintaining patients' quality of life, II) Technology-driven RT utilizing advances in treatment techniques, such as spatially fractionated RT to improve outcomes in patients with bulky disease and localized high tumor burden, III) Biology-driven RT, integrating the rapid advances in cancer biology and functional imaging to guide and personalize RT, and IV) New indications adding value and expanding the use of RT.

CONCLUSION

The EORTC ROSC State of Science workshop prioritized clinical questions to be addressed in prospective clinical research projects to advance RT care and improve patient outcomes.

An ultra-high dose rate Bragg peak tracking technique provides more affordable proton radiotherapy for cancer patients: From principle to experimental validation

PURPOSE

This work aims to experimentally validate a novel cost-effective solution for achieving both conventional dose-rate and ultra-high dose rate (UHDR) deliveries in pencil beam scanning proton therapy.

METHODS

A proton therapy delivery solution was previously developed by our group using only a single pristine Bragg peak of the highest energy proton beams from a cyclotron. This approach streamlines upstream beam modifiers, including energy degrader, selection and focusing systems, while utilizing of universal range shifters (URS) and range compensators (RCs) to preserve high beam transmission efficiency for UHDR beam delivery. It achieves the Bragg peak tracking and target dose conformity, making it potentially suitable for FLASH radiation therapy. In the current study, we highlighted the realization of the solution by using URS and customized beam-specific RCs via simulation in an in-house treatment planning software (TPS) which is then fabricated by a 3D printer, facilitating precise beam shaping and Bragg peak tracking. Experimental validation of this method was conducted using a clinical proton system to showcase a practical solution that can be translated into realistic operation. Both dose and dose rate were measured and compared to treatment planning results.

RESULTS

The proton convolution superposition (PCS) dose calculation was benchmarked by the Monte Carlo calculation. Matrixx PT measured the delivered dose in the uniform and head-neck (HN) phantom, and the gamma passing rates were > 99 % in the water phantom. The gamma rate was > 98 % for the HN phantom for this distal tracking method. The measured dose difference between the TPS and HN phantom was < 2 %. The implementation of a high temporal resolution strip ion chamber detector array enabled accurate measurement of the spot time structure, facilitating 3D dose rate reconstruction across various beam currents.

CONCLUSION

The experimental validation successfully demonstrated the dosimetric accuracy and robustness of this proposed delivery method. The employment of the Bragg peak tracking method holds great promise for reducing treatment delivery costs for future UHDR and conventional dose rate proton radiation therapy, ultimately benefiting a larger population of patients.

The potentially therapeutic effects of ascorbic acid in different cell line in attempt to reduce the risk of radiation therapy

Leukemia is the most common type of serious, life-threatening cancer that requires the immediate initiation of therapy. Ascorbic acid (AsA), commonly known as Vitamin C, has been gaining attention due to its antioxidant activity as a potential treatment for human malignancies. In this study, the THP-1 monocytic cell line was treated with two doses of AsA: a low dose (L-AsA, 2.5 µg/mL) and a high dose (H-AsA, 5 µg/mL), while the K562 lymphocytic cell line was treated with two doses of AsA: a low dose (L-AsA, 4 µg/mL) and a high dose (H-AsA, 8 µg/mL). After a 24-h incubation period, all cells were exposed to different doses of X-radiation (2, 4, 8 Gy). The viability of THP-1 and K562 treated by AsA was assessed using the MTT assay. Additionally, we evaluated apoptosis, autophagy, proliferation, cell cycle progression, hypoxia-inducible factor (HIF-1), malondialdehyde (MDA), and total antioxidant capacity (TAC). Our study demonstrated that AsA, in combination with X-radiation, induced significant apoptosis and notably reduced Ki67 levels in human leukemia THP-1 cells. Furthermore, X-radiation caused DNA damage, leading to cell cycle arrest at the G0/G1 phase in THP-1 cells. Moreover, AsA significantly reduced HIF-1 levels, which are essential for the survival of tumor cells in hypoxic conditions. We also found that the administration of AsA in combination with X-radiation had a synergistic and dose-dependent effect on THP-1 and K562 cells. Notably, the combination of L-AsA with 2 Gy X-radiation showed a more pronounced effect than 8 Gy X-radiation alone. These results suggest that AsA has promising anti-proliferative, pro-apoptotic, and autophagic effects on leukemic cells. Furthermore, the dose of X-radiation may be reduced when combined with AsA in an effort to minimize its potential side effects.

National Cancer System Characteristics and Global Pan-Cancer Outcomes

Importance

Approximately 29.9 million cancer cases and 15.3 million deaths are anticipated by 2040 globally, necessitating cancer system strengthening. A greater understanding of health system factors that can be leveraged to improve cancer control may guide health system planning.

Objective

To evaluate predictors of improved cancer outcomes globally.

Design, Setting, and Participants

This pan-cancer ecological study used the most recent available national health system metrics and cancer statistics, spanning the breadth of global income levels across 185 countries. Estimates of age-standardized mortality to incidence ratios were derived from GLOBOCAN 2022 for patients with cancer of all ages. The analysis took place on November 27, 2024.

Main Outcomes and Measures

Health spending as a percent of gross domestic product (GDP), physicians per 1000 population, nurses and midwives per 1000 population, surgical workforce per 1000 population, GDP per capita, Universal Health Coverage (UHC) service coverage index, availability of pathology services, human development index, gender inequality index (GII), radiotherapy centers per 1000 population, and out-of-pocket expenditure as percentage of current health expenditure were collected. The association between the mortality to incidence ratio (MIR) and each metric was evaluated using univariable linear regressions (α = .0045), which were used to construct multivariable models (α = .05). Variation inflation factor allowed exclusion of variables with significant multicollinearity. R2 measured goodness of fit.

Results

On univariable analysis, all metrics were significantly associated with MIR of cancer (P < .001 for all), including UHC index (β, -0.0076 [95% CI, -0.0083 to -0.0068]), GDP per capita (β, -5.10 × 10-6 [95% CI, -5.75 × 10-6 to -4.46 × 10-6]), clinical and workforce capacity, radiotherapy capacity (β, -88.25 [95% CI, -100.43 to -76.06]), and gender inequality index (β, 0.63 [95% CI, 0.57-0.70]). After including metrics significant on univariable analysis and correcting for multicollinearity, on multivariable analysis, greater UHC index and GDP per capita were independently associated with lower (improved) MIR for cancer. The multivariable model had R2 of 0.87. On multivariable analysis stratified by sex, greater UHC index and greater GDP per capita were independently associated with improved MIR for all cancers. R2 for the multivariable models was 0.87 for females and 0.85 for males.

Conclusions

This study found that global health system metrics related to progress toward universal health care, greater health care spending and GDP per capita, strengthened clinical workforce and capacity, and increased gender equity were associated with improved pan-cancer outcomes at a population level on univariable analysis. The degree of UHC and GDP per capita were independently associated with improved cancer outcomes in multivariable models with good explanatory power. These exploratory findings merit further validation and may guide health system planning and prioritization.

Impact of Hypofractionated Radiation Protocols on Reducing Travel Burden and Improving Patient Satisfaction: When Less Is More

PURPOSE

Despite rising cancer incidence and mortality in Saudi Arabia, access to radiotherapy (RT) services is limited in some regions. This study aimed to examine the travel burdens of RT patients and assess the benefits of hypofractionated RT (HFRT).

METHODS

This multicenter retrospective study included patients with breast cancer (BC) and prostate cancer (PC) treated with HFRT (26 Gy/5 fractions for BC and 60 Gy/20 fractions for PC) between 2020 and 2024. Patient data were collected from electronic records, and an online questionnaire assessed experiences and financial burdens. Google Maps determined the shortest driving distance from patients' residences to our RT center. Descriptive statistics compared accommodation, transportation costs, and time expenditure for shorter versus longer RT courses.

RESULTS

A survey of 153 out of 187 patients (average age 57 years for BC, 70 years for PC) revealed significant travel burdens. Notably, 43% traveled from outside Jeddah, averaging 415 km, compared with 17.9 km for those within Jeddah. HFRT offered substantial transportation cost-savings, estimated at $101 in US dollars (USD) for patients with BC (an additional $133 (USD) for those outside Jeddah) and $213 (USD) for patients with PC (an additional $320 (USD) for those outside Jeddah). Median accommodation cost-savings were $733 (USD) for BC and $1,600 (USD) for PC. Median time-savings were 9.25 hours for BC and 30 hours for PC. All patients were satisfied with the treatment duration, with 42% preferring the shorter hospital stay and 8% citing financial reasons.

CONCLUSION

Patients with cancer in Saudi Arabia travel significant distances for RT. HFRT using shorter RT courses reduces patient-related costs, enhances satisfaction, and may improve access by addressing logistical challenges.

Contribution of investment in health and cancer control to economic growth in Commonwealth countries

Background

There are three broad mechanisms through which health investments yield economic benefits. First, health investments in cost-effective innovations help improve health outcomes and reduce healthcare costs in a health system. Second, investments in health can help improve health and wellbeing of individuals. A healthier population is economically more productive, with a longer productive life and reduced absenteeism and presenteeism. Third, an important but often-overlooked mechanism is the benefit of health investments on the broader economy through influences on supply and demand across various other sectors of a country's economy. We examine the third mechanism in selected Commonwealth countries.

Methods

We provide an analysis and estimates of GVA growth and employment effects of the Health Economy for four Commonwealth countries, namely India, Nigeria, Malaysia and the United Kingdom in 2022. Drawing on a conservative 'static estimation approach', whose bases are on the Health Economy Reporting, to provide country-specific assessment of the return on investment in cancer services and cancer prevention in the UK, for which data are available, as an illustrative 'use case'. For cancer prevention, we examine investments in vaccination for Human Papilloma Virus.

Findings

In our analysis, the Gross Value Added (GVA) generated by the Health Economy in the UK amounted to about US$295 billion (8.9% of GDP; the largest sector by size) in 2022, with around US$171 billion of GVA (5.2% of GDP) generated in adjacent sectors, and through these two effects generating additional induced consumption of US$217 billion of GVA (6.6% of GDP). In India, Malaysia, and Nigeria, in 2022, total GVA generated by the Health Economy, adjacent sectors and through induced income accounted for 9.9%, 9.8% and 7.0% of the GDP respectively. In the UK, US$134 million of investment in HPV vaccination generated US$247 million of GVA in total and 2000 jobs. Whereas in India US$756 million of investment in HPV vaccination produced US$ 1149 million in total GVA and generated 155,000 jobs.

Interpretation

The assessment of four Commonwealth countries reveals that the Health Economy contributes substantially to economic growth and generates substantial employment. These contributions extend beyond the health sector itself, reaching adjacent sectors along the health value chain and inducing effects throughout the broader economy. Investment in cancer prevention generates high returns with substantial addictions to GVA and employment.

Funding

No external funding. Self-funded by Harvard University and Wifor Institute.

The socioeconomic burden of cervical cancer and its implications for strategies required to achieve the WHO elimination targets

INTRODUCTION

Cervical cancer is almost entirely preventable by vaccination and screening. Population-based vaccination and screening programs are effective and cost effective, but millions of people do not have access to these programs, causing immense suffering. The WHO Global Strategy for the elimination of cervical cancer as a public health problem calls for countries to meet ambitious vaccination, screening, and treatment targets.

AREAS COVERED

Epidemiological evidence indicates marked socioeconomic gradients in the burden of cervical cancer and vaccination, screening, and treatment coverage. The unacceptable socioeconomic burden of cervical cancer is largely a function of inequitable access to these programs. We discuss these inequities, and highlight strategies enabled by new evidence and technology. Single dose HPV vaccination, HPV-based screening, and the rapidly moving technology landscape have enabled task-shifting, innovation in service delivery and the possibility of scale. Equitable access to optimal care for the treatment of invasive cancers remains a challenge.

EXPERT OPINION

Cervical cancer can be eliminated equitably. It will require global political will, sustained public and private investment, and community leadership to safely and sustainably embed proven tools, technology and infrastructure in local health and knowledge systems.

Oxygen/siRNA-carrying fluoro-nanosensitizers for radio-immunotherapy sensitization

The anti-tumor efficacy of radiotherapy (RT) is limited by the hypoxic and immunosuppressive tumor microenvironment (TME), which leads to RT resistance and failure in eradicating distant metastatic lesions. Herein, we developed a fluorinated nanosensitizer that could deliver both oxygen (O2) and ADAR1 siRNA into tumor cells to reinforce RT by alleviating hypoxia and immunosuppression. Fluorinated poly(β-amino ester) (fPBAE) was designed to complex ADAR1 siRNA (siADAR1) via electrostatic attraction and load O2 due to the O2-dissolving capacity of fluoroalkyls. The formed nanocomplexes (NCs) facilitated robust cytosolic delivery into cancer cells after intratumoral injection, enabling efficient ADAR1 silencing to promote IFN-β release and enhance DC maturation and T cell infiltration. At the meantime, O2 was released to alleviate tumoral hypoxia. As thus, NCs significantly enhanced the anti-tumor efficacy of RT and when further coupled with programmed death ligand-1 antibody, they effectively restrained the growth of both treated primary tumors and untreated distant tumors by eliciting robust systemic immune response. This study therefore reports an enlightened strategy for remodeling the immunosuppressive TME and sensitizing radio-immunotherapy. STATEMENT OF SIGNIFICANCE: The hypoxic and immunosuppressive tumor microenvironment (TME) greatly limits the anti-tumor efficacy of radiotherapy (RT). To address this critical issue, a nano-sensitizer based on fluorinated poly(β-amino ester) (fPBAE) is herein developed to mediate efficient co-delivery of oxygen (O₂) and ADAR1 siRNA into tumor cells. ADAR1 silencing promotes DC maturation and T cell infiltration to reverse immunosuppression while the released O₂ alleviates hypoxia to sensitize RT. Thus, the nano-sensitizer remarkably enhances the anti-tumor efficacy of RT and elicits robust systemic immune response to eradicate primary and distant tumors when further coupled with PD-L1 antibody. This study provides a promising approach for RT sensitization and radio-immunotherapy.

Eliminating Radioresistance With a Magnetic Ion-Generator by Simultaneously Augmenting DNA Damage and Diminishing Immunosuppression

Radiotherapy (RT) hinges on DNA damage-induced cancer cell death and the subsequent anti-tumor immunity. However, the efficacy of RT is curtailed by cell cycle heterogeneity and an immunosuppressive tumor microenvironment, which foster radioresistance. Here an ion generator-based RT enhancement strategy is demonstrated in a mouse model of the radioresistant tumor. The ion generator is degraded in the tumor microenvironment, resulting in iron-triggered ferroptosis that enhanced immunogenic cell death and a manganese-activated stimulator of interferon gene that reversed the immunosuppressive environment. As a result, the proposed strategy promotes dendritic cells maturity, augmentes CD8+ T cell infiltration of tumors, suppresses intratumoral myeloid-derived suppressor cells, and limits the M2 macrophages polarization, indicating the formation of an immunoreactive microenvironment. Significantly, this approach impedes the growth of not just primary, but also distal metastatic tumors. It is thus believed that the current ion generator provides a robust and enduring countermeasure to radioresistant cancer and its metastasis, with potential implications for enhancing the efficacy of RT in clinically resistant tumors.

The Application of Time-Driven Activity-Based Costing in Oncology: A Systematic Review

OBJECTIVES

Time-driven activity-based costing (TD-ABC) holds promise to control costs and enhance value in oncology, but the current landscape of its applications remains uncharted. This study aimed to: (1) document the applications of TD-ABC in oncology and unveil its strengths and limitations, (2) assess the extent to which studies adhere to Kaplan and Porter's method, and (3) appraise study quality.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. To be eligible for inclusion, studies had to provide an empirical application of TD-ABC within oncology. Structured data extraction included key characteristics such as cancer type, perspective, and analysis setting. Quality was assessed using the TD-ABC Healthcare Consortium Consensus Statement checklist.

RESULTS

A total of 59 studies met the inclusion criteria, two-thirds of which were published within the last 5 years. Most studies were conducted in high-income countries and analyzed common cancer types. The provider's perspective (85%) dominated, and studies typically relied on single-institution data (76%). No study assessed costs over a complete cycle of care and most focused on the costs of radiotherapy (56%) or surgery (20%). Articles generally did not adhere to the seven-step method, and average study quality was low (52%), particularly because of inadequate content in methods and results.

CONCLUSIONS

Oncology has emerged as a productive field for TD-ABC analyses, showcasing the effectiveness of TD-ABC in capturing the costs of healthcare processes in which medical devices are integral to care delivery. Nevertheless, concerns arise because of the low overall study quality and the lack of a consistent methodology.

A Pyroptosis Radiosensitizer Facilitates Hypoxic Tumor Necrosis

Hypoxia-related tumor radioresistance markedly impairs the efficacy of radiotherapy. Herein, a targeted radiosensitization strategy is introduced, leveraging the upregulation of gasdermin C (GSDMC) in hypoxic tumor cells, aiming to induce pyroptosis through the application of a cobalt-containing polyoxometalate-based radiosensitizer. This novel radiosensitizer is designed for the precisely controlled release of cobalt ions upon X-ray irradiation, thereby activating caspase-8 and prompting the cleavage of GSDMC. This sequence of events selectively triggers pyroptosis in hypoxic tumor cells, directly addressing radioresistance. The ensuing results highlight the enhanced radiotherapy efficacy and tumor necrosis both in vitro and in vivo models. Overall, the findings confirm the effectiveness of this strategy targeting high GSDMC expression in hypoxic tumors to induce pyroptosis for precise radiotherapy. Such findings encourage further exploration of hypoxia-driven pyroptosis to improve cancer treatment outcomes.

Residents and Juniors Onco-radiotherapists' Perceptions of Their Training Programs in Morocco: A Multi-institutional Study

Cancer incidence in Morocco is expected to increase by 17.9% by the year 2030, demanding appropriate training for oncologists radiotherapist (ORs). Radiotherapy, which is required in over 50% of all cancer cases, requires well-trained professionals to provide quality treatment. This study aims to evaluate the perception of radiation oncology residents (RORs) and junior in onco-radiotherapy (JORs) on their training course in Morocco. A cross-sectional descriptive survey was conducted in July and August 2024 in eight Moroccan university hospital centers (UHCs). A standardized online questionnaire was used to assess participants' satisfaction with their training, as well as their perception of the quality of theoretical and practical teaching. Data were analyzed using Chi2 and Fisher's exact tests (p < 0.05). A total of 157 of the 158 radiation oncology residents and 24 ORs of the 100 recent graduates completed the questionnaire. Most participants (90.1%) were satisfied with their choice of specialty. However, only 45.9% of residents were confident in their use of advanced radiotherapy (IMRT/VMAT) and 17.7% in stereotactic radiotherapy. The results revealed disparities between centers in terms of access to technology and supervision, depending on their seniority. Almost half of the participants (44.75%) pointed out the need for a unified national curriculum. Furthermore, the study found overall satisfaction with resident training, but disparities in access to advanced technology and quality of supervision according to center seniority. A unified curriculum and an improvement in available equipment are essential to optimize training in radiotherapy oncology in Morocco.

Dual-pathway tumor radiosensitization strategy based on engineered bacteria capable of targeted delivery of AuNPs and specific hypoxia alleviation

BACKGROUND

Radiotherapy efficacy remains constrained by two key challenges: dose-dependent toxicity to healthy tissues at high radiation doses and hypoxia-mediated tumor radioresistance. While radiosensitizers like gold nanoparticles can enhance tumor-specific radiation deposition, their targeted delivery to tumors presents a significant hurdle. Bacteria have emerged as promising bio-carriers that not only actively target tumors and penetrate complex microenvironments, but can also be genetically engineered as multifunctional platforms for radiosensitizer delivery and hypoxia alleviation.

RESULTS

An integrated nanosystem (PCM@AuNPs), composed of engineered bacteria (PCM) and gold nanoparticles (AuNPs), is used to increase the effectiveness of radiotherapy. PCM can target and colonize tumor sites more effectively, thus improving the delivery efficiency of radiosensitizers. Furthermore, PCM overexpresses catalase (CAT), which decomposes excess H2O2 into O2, helping to mitigate hypoxia in the TME. Under X-ray irradiation, PCM@AuNPs significantly enhance radiosensitization, leading to improved tumor growth inhibition while maintaining good biocompatibility.

CONCLUSIONS

An effective strategy based on an integrated nanosystem (PCM@AuNPs) for radiosensitization through multiple pathways is developed. This novel engineered bacterial strategy holds great promise for enhancing radiosensitization in cancer therapy.

Geometric and dosimetric evaluation of a commercial AI auto-contouring tool on multiple anatomical sites in CT scans

Current radiotherapy practices rely on manual contouring of CT scans, which is time-consuming, prone to variability, and requires highly trained experts. There is a need for more efficient and consistent contouring methods. This study evaluated the performance of the Varian Ethos AI auto-contouring tool to assess its potential integration into clinical workflows. This retrospective study included 223 patients with treatment sites in the pelvis, abdomen, thorax, and head and neck regions. The Ethos AI tool generated auto-contours on each patients' pre-treatment planning CT, and 45 unique structures were included across the study cohort. Multiple measures of geometric similarity were computed, including surface Dice Similarity Coefficient (sDSC) and mean distance to agreement (MDA). Dosimetric concordance was evaluated by comparing mean dose and maximum 2 cm3 dose (D2 cc) between manual and AI contours. Ethos AI demonstrated high geometric accuracy for well-defined structures like the bladder, lungs, and femoral heads. Smaller structures and those with less defined boundaries, such as optic nerves and duodenum, showed lower agreement. Over 70% of auto-contours demonstrated a sDSC > 0.8, and 74% had MDA < 2.5 mm. Geometric accuracy generally correlated with dosimetric concordance, however differences in contour definitions did result in some structures exhibiting dose deviations. The Ethos AI auto-contouring tool offers promising accuracy and reliability for many anatomical structures, supporting its use in planning workflows. Auto-contouring errors, although rare, highlight the importance of ongoing QA and expert manual oversight.

Current availability of radiotherapy devices in Peru and artificial intelligence-based analysis for constructing a nationwide implementation plan

PURPOSE

We provide for the first time a comprehensive situational diagnosis and propose an artificial intelligence (AI)-assisted nationwide plan of implementation, attending the most urgent needs.

METHODS

Baseline information was collected from open-source databases of the Peruvian Government. Data on cancer incidence from the Health Authorities and GLOBOCAN were collected and compared. The existing external-beam radiotherapy (EBRT) devices and brachytherapy (BT) units were identified and information on their obsolescence was additionally collected. The ten most common cancer entities with RT indication were considered for the analysis. Utilizing open-source softwares, population clusters based on density, cancer incidence, geographic distribution, existing facilities able to be implemented with radiotherapy and travel times for patients were defined. A coding for identifying the best possible locations with AI was developed, keeping the allocation of resources to the minimum possible. A projection until 2030 on required resources was additionally elaborated.

RESULTS

As of 2023 eight additional EBRT and seven BT devices were needed to cover the existing demand. The artificial-intelligence algorithm yielded the regions where these resources should be primarily allocated. An increase in demand of approximately 22% is expected until 2030, which translates into additional 23 EBRT and 16 BT devices, considering the replacement of obsolete units until then.

CONCLUSION

Increased investment pace is required to cover the existing RT demand in Peru. This AI-assisted analysis might help prioritize allocation of resources. The code employed in this work will be made publicly available, so this method could be replicated in other developing economies.

Perceived barriers and facilitators affecting utilisation of radiation therapy services: Scoping review findings - Patient and department level influences

Existing evidence supports the benefits of radiation therapy (RT) for cancer patients however, it is underutilised. This scoping review aims to synthesise the current literature investigating patient and department level barriers and facilitators influencing the utilisation trends of RT. A systematic search strategy was developed to identify articles dated from 1993 to 2023. Four online databases (Medline, Embase, Scopus and CINAHL) were searched using key words. Eligible studies needed to report outcomes related to barriers and facilitators influencing utilisation of RT. Data was extracted and categorised into health professional, patient, and department level influences. The review resulted in 340 included studies with 298 (88 %) studies reporting on patient influences. More than half of these studies (n = 164; 55 %) reported accessibility concerns including distance and travel burden. Patient acceptability was reported in 88 (30 %) studies, patient affordability in 138 (46 %) studies, patient knowledge, and education in 92 (31 %) studies and patient health and demographics in 235 (79 %) studies. Of the department level influence papers (n = 242, 71 %), department availability such as infrastructure, staffing and waitlists were reported in 167 (69 %) papers. Department adequacy, including the quality, reputation and technology suitability of departments was reported in 60 (25 %) papers. Clinical pathway use was reported in 107 (44 %) papers. This scoping review identifies the broad range of patient and department level influences and facilitators affecting the global utilisation of RT. Recognition of such influences reducing access to RT will inform proposed interventions or educational strategies to overcome and address such barriers.

A Pilot Study of Computed Tomography Simulator Downtime at an African Cancer Conference: Survey Results From AORTIC 2023

PURPOSE

Computed tomography (CT) simulation is required for centers performing 3-dimensional conformal radiation therapy and intensity modulated radiation therapy. Therefore, CT simulator downtime is likely to lead to delays in patient care. We sought to characterize CT simulator downtime within the African context.

METHODS AND MATERIALS

A pilot clinician survey was developed to evaluate CT simulator downtime frequency, causes, and workflow impact over the last year. It was distributed to African Organization for Research and Training in Cancer Conference attendees in November 2023 and through radiation therapy networks on the African continent. Descriptive statistics were used to summarize data.

RESULTS

Responses were obtained for 22 CT scanners in 16 centers across 9 African countries. Nigeria (n = 6) and South Africa (n = 3) had the most centers represented. Most centers (n = 10, 63%) had a single CT scanner capable of simulation, 5 (31%) had 2, and 1 (6%) had 3 scanners. For the 19 CT simulators with downtime information available, 11 (58%) were down for at least 15 days in the last year. Median downtime per episode was 3.5 days (IQR, 1-9.75 days). Three CT simulators were down all year, 2 of which were the only CT simulator at their respective centers. CT simulators were down because of intrinsic causes for median 8 days (IQR, 3-37.5 days) and extrinsic causes for median 1 day (IQR, 0-7.5 days). Most machines (n = 17, 77%) were under an active maintenance contract. Most centers (n = 11, 69%) lacked access to an alternate CT scanner for simulation during downtime, whereas 3 (19%) maintained normal workflow.

CONCLUSIONS

CT simulator downtime is highly variable across the African continent and can cause significant disruptions in radiation therapy treatment at some centers. Intrinsic causes led to most downtime. These results suggest reducing CT simulator downtime frequency and duration or implementing simulation-free workflows may decrease patient delays.

Radiation safety: knowledge, attitudes, practices and perceived socioeconomic impact in a limited-resource radiotherapy setting

Healthcare workers in teaching-hospital settings face numerous occupational hazards, necessitating comprehensive safety protocols to protect both staff and patients. Radiation safety is particularly critical in regions like sub-Saharan Africa, where the sharp rise in radiological procedures and radiation treatments demands stringent protocols to mitigate health risks. The study aimed to assess the knowledge, attitudes and practices related to radiation safety among healthcare workers in a limited-resource setting, as well as evaluate the perceived socioeconomic impact of implementing radiation safety protocols. The research was a quantitative case study of one of the largest radiotherapy centres in Africa. Participants were selected using a stratified random sampling technique. Data were collected using a modified structured questionnaire based on the validated International Atomic Energy Agency radiation safety knowledge, attitudes and practice questionnaire. Data were analysed with the Statistical Package for Social Sciences software. Both descriptive and inferential statistical analyses were performed. Data were summarized using frequencies, percentages, means and standard deviations. The study involved 78 participants, comprising 13 physicians, 40 nurses and 25 other health workers. In all, 53.8% were males, whereas 46.2% were females. The mean age was 24.9 years (SD 4.7) ranging from 23 to 47 years. A significant majority (82%) were knowledgeable about effective ways of reducing radiation exposure. All participants considered radiation safety extremely important, with 55% feeling extremely confident in their ability to practice radiation safety measures. The majority (92%) believed that radiation safety was a shared responsibility within the organization. Only 51% frequently checked radiation safety equipment. There was a strong consensus that these protocols positively affect healthcare worker well-being (a mean score of 4.49) and benefit patient care (a mean score of 4.45). Implementation of workplace safety protocols was perceived to improve worker well-being (B = 0.337 and p = 0.001) and benefit patient care (B = 0.391 and p = 0.014). The study highlights a high level of knowledge and positive attitudes towards radiation safety among healthcare workers in a limited-resource radiotherapy setting. While most participants recognized the importance of radiation safety and its shared responsibility, less than half regularly checked safety equipment. There were significant perceptions of the socioeconomic benefits of implementing safety protocols.

Quantifying radiotherapy beam quality: an analysis using gamma passing rates

Purpose. PDD and profile curves play a crucial role in analyzing the beam quality and energy stability of accelerators. The aim of this study was to assess the efficacy of GPR in machine QA and compare it with traditional methods for analyzing dose outputs.Methods. GPRs were employed to assess the quality of radiation beams by comparing 1D and 2D Profile metrics and PDD data against commissioning data. The data used were obtained from the ASCII data files derived from the water tank. GPRs were calculated for all plots with a lower percentage dose cutoff of 10%. The local GPRs and dose influence for the 2D PDD metrics and dose influence were calculated for an open field 10 × 10 cm2photon beam at SSD = 100 cm. In both 1D and 2D GPRs analyses, criterion of 1%/1 mm was adopted, as this approach allows for the capture of more subtle variations in the data. To substantiate the viability of the study, a comparative analysis was conducted by comparing the outcomes of the gamma analysis with those derived from traditional methods, such as manual machine quality assurance checks.Results. GPRs demonstrated a superior capability for comprehensive data analysis compared to traditional methods. For the 1D curves, the passing rates (γ≤ 1) are 96.19%, 100%, and 93.46%, respectively. With respect to the 2D dose influence, the PDD image passing rate was 99.57%, and significant dose differences were observed at the four corners of the open field, indicating areas that require further investigation.Conclusions. Compared to traditional methods, GPRs are more sensitive to subtle changes in the data, providing valuable insights into the accelerator beam status.

Mayo Clinic Global Oncology Fellowship: Development and Implementation of a Novel 2-Year Multidisciplinary Training Program for Oncologists from Low- and Middle-Income Countries

Cancer is set to become the leading worldwide cause of premature death and mortality will be disproportionately greater in low-and-middle-income countries (LMIC) due to limitations in physical resources and oncology specialists. To address unmet workforce and educational needs, the Department of Radiation Oncology at Mayo Clinic developed the Global Oncology Fellowship, a 2-year multidisciplinary oncology training program for practicing physicians from LMIC. The fellowship was developed through collaboration with multiple institutional departments and external stakeholders. Eligible fellows are graduates of a recognized international medical school who have completed oncology training in a LMIC and confirm intent to practice in a LMIC. During the 2-year program, fellows rotate through Radiation Oncology, Medical Oncology, Palliative Care, Diagnostic Radiology, radiation dosimetry, research, and leadership development. The program design is flexible and can be tailored to fit the trainee's clinical needs and interests and focuses on malignancies and technologies that are common in LMIC. The Global Oncology Fellowship was successfully established and supported by benefactor funds. Recruitment of the first trainee faced challenges related to COVID pandemic, completion of medical licensing exams, and obtaining a United States visa. The first fellow started in February 2023 with training ongoing. With the formal approval of the Global Oncology Fellowship in 2024, the program is recruiting for the 2025-2027 academic years. Short- and-long term assessments of the program are ongoing. The Mayo Clinic Global Oncology Fellowship is a multi-disciplinary training program developed to address the educational needs of oncologists in low-and-middle income countries. We hope to contribute to the number of highly trained oncology specialists in LMIC, who will go on to be leaders in clinical care, education, and research.

A comparison of different machine learning classifiers in predicting xerostomia and sticky saliva due to head and neck radiotherapy using a multi-objective, multimodal radiomics model

Background and Purpose. Although radiotherapy techniques are a primary treatment for head and neck cancer (HNC), they are still associated with substantial toxicity and side effects. Machine learning (ML) based radiomics models for predicting toxicity mostly rely on features extracted from pre-treatment imaging data. This study aims to compare different models in predicting radiation-induced xerostomia and sticky saliva in both early and late stages HNC patients using CT and MRI image features along with demographics and dosimetric information.Materials and Methods.A cohort of 85 HNC patients who underwent radiation treatment was evaluated. We built different ML-based classifiers to build a multi-objective, multimodal radiomics model by extracting 346 different features from patient data. The models were trained and tested for prediction, utilizing Relief feature selection method and eight classifiers consisting eXtreme Gradient Boosting (XGBoost), Multilayer Perceptron (MLP), Support Vector Machines (SVM), Random Forest (RF), K-Nearest Neighbor (KNN), Naive Bayes (NB), Logistic Regression (LR), and Decision Tree (DT). The performance of the models was evaluated using sensitivity, specificity, area under the curve (AUC), and accuracy metrics.Results.Using a combination of demographics, dosimetric, and image features, the SVM model obtained the best performance with AUC of 0.77 and 0.81 for predicting early sticky saliva and xerostomia, respectively. Also, SVM and MLP classifiers achieved a noteworthy AUC of 0.85 and 0.64 for predicting late sticky saliva and xerostomia, respectively.Conclusion. This study highlights the potential of baseline CT and MRI image features, combined with dosimetric data and patient demographics, to predict radiation-induced xerostomia and sticky saliva. The use of ML techniques provides valuable insights for personalized treatment planning to mitigate toxicity effects during radiation therapy for HNC patients.

Global linear accelerator requirements and personalised country recommendations: a cross-sectional, population-based study

BACKGROUND

The Linear Accelerator Shortage Index (LSI) is a practical tool for prioritising the deployment of linear accelerators (LINACs) in various regions within a country. The LSI reflects the ratio of LINAC demand to current availability. The aim of this study was to use the LSI to predict global LINAC needs and classify countries according to the degree of radiotherapy shortage (LINAC shortage grade).

METHODS

In this cross-sectional, population-based study of globally representative, country-level data, we sourced regional LINAC distribution, numbers of radiotherapy centres, and cancer incidence data for 181 countries from the Directory of Radiotherapy Centers and Global Cancer Observatory 2022 databases. Current gross domestic product and gross national income per capita in US dollars were obtained from the World Bank. We calculated an LSI for each country to assess the relative demand and supply of radiotherapy by dividing LINAC use by 450 and multiplying by 100. An LSI of 100 or less indicates no shortage (450 or fewer patients per LINAC), whereas an LSI greater than 100 signals a shortage, with higher values indicating more severe deficits. We categorised countries by LINAC shortage grade: grade 0 (LSI ≤100, no shortage), grade 1 (LSI 101-130, low need), grade 2 (LSI 131-300, high need), grade 3 (LSI >300, excessive need), or grade 4 (no existing LINACs). We estimated LINAC requirements until 2045 using the LSI and Global Cancer Observatory data. We determined future investment costs according to the LSI for each country.

FINDINGS

As of the data cutoff on Sept 15, 2024, the global median LSI was 130 (IQR 96-319), suggesting a shortage of 30% in radiotherapy capacity. Significant disparities in median LSI were observed across income levels: low-income countries had a median LSI of 1523 (528-2247), lower-middle-income countries 399 (183-685), upper-middle-income countries 133 (104-198), and high-income countries 96 (83-127; p<0·0001). The distribution of countries across LINAC shortage grades was 40 (22%) of 181 as grade 0, 32 (18%) as grade 1, 35 (19%) as grade 2, 38 (21%) as grade 3, and 36 (20%) as grade 4 (no LINACs). Most LINAC shortage grade 4 countries were low income (12 [33%]) or lower-middle income (16 [44%]). The median number of new LINACs needed per country by 2045 was estimated at 6 (1-13) for grade 0, 21 (4-102) for grade 1, 22 (8-80) for grade 2, 52 (26-113) for grade 3, and three (2-14) for grade 4. To meet these demands, also including the replacement of obsolete devices, an estimated 30 470 LINACs will be needed by 2045. The median total investment required for new and replacement machines and radiotherapy centres to meet the 2045 demand is projected at US$162 million (49-369) for grade 0, $216 million (54-772) for grade 1, $143 million (64-580) for grade 2, $238 million (126-561) for grade 3, and $16 million (9-59) for grade 4. A significant change in LINAC shortage grade composition between 2020 and 2045 is predicted, with distribution of 40 (22%) versus seven (4%) for grade 0, 32 (18%) versus 23 (13%) for grade 1, 35 (19%) versus 63 (35%) for grade 2, 38 (21%) versus 52 (29%) for grade 3, and 38 (20%) versus 38 (20%) for grade 4 (p<0·0001).

INTERPRETATION

The LSI and LINAC shortage grade systems are effective for evaluating, monitoring, and forecasting global LINAC needs. The LSI and LINAC shortage grade highlight the substantial disparities in radiotherapy availability and underscore the urgent need for investment in radiotherapy capacity building, particularly in many low-income and middle-income countries.

FUNDING

None.

The Burden of Insurance Prior Authorization on Cancer Care: A Review of Evidence From Radiation Oncology

Purpose

Despite its high cost-effectiveness, radiation oncology faces the greatest prior authorization (PA) burden of any medical specialty. Insurance denials and resulting treatment delays have been documented across several treatment modalities, including stereotactic body radiation, intensity modulated radiation, and proton therapy. Although insurance companies suggest that PA is intended to control health care spending and ensure the implementation of evidence-based practice, the number of radiation treatment plans reviewed by the PA process that result in changes is quite low. Yet, the cost to patients, providers, and the health care system is rising.The increased administrative work required to address the appeal process, including the development of radiation plan comparisons, results in lost productivity of radiation staff and increased clinic costs that are not currently reimbursed. Treatment delays from PA may elevate patient anxiety and affect their ability to enroll in clinical trials, resulting in decreased quality of care. As a result of possible harm to patients, the Centers for Medicare and Medicaid Services developed a ruling that mandates increased transparency of insurers' requirements, decreased allowable time for arriving at PA decisions, and a more efficient electronic communication system to address the time and resource burden of PA.

Methods and Materials

This article summarizes key discussions from the literature and provides recommendations to help mitigate insurance PA strain.

Results

These recommendations broadly address the following key areas: (1) omission of PA for routine care and clinical trials, (2) implementation of efficient, streamlined electronic peer-to-peer communication, (3) increased transparency of insurance requirements and rationale for denials, and (4) decreased time allowances for PA decisions.

Conclusions

Policy reform focused on evidence-driven treatment coverage, reduction of the proportion of cases requiring PA, and a simplified, timely insurance appeal process is necessary to ensure optimal cancer care for patients requiring radiation therapy as part of their cancer journey.

Multidisciplinary Collaboration and Novel Technological Advances in Hadron Therapy

The battle against cancer remains a top priority for society, with an urgent need to develop therapies capable of targeting challenging tumours while preserving patient's quality of life. Hadron Therapy (HT), which employs accelerated beams of protons, carbon ions, and other charged particles, represents a significant frontier in cancer treatment. This modality offers superior precision and efficacy compared to conventional methods, delivering therapeutic the dose directly to tumours while sparing healthy tissue. Even though 350,000 patients have already been treated worldwide with protons and 50,000 with carbon ions, HT is still a relatively young field and more research as well as novel, cost-effective and compact accelerator technologies are needed to make this treatment more readily available globally. Interestingly the very first patient was irradiated with protons in September 1954, the same month and year CERN was founded. Both of these endeavours are embedded in cutting edge technologies and multidisciplinary collaboration. HT is finally gaining ground and, even after 70 years, the particle therapy field continues innovating and improving for the benefits of patients globally. Developing technologies that are both affordable and easy to use is key and would allow access to more patients. Advances in accelerator-driven Boron Neutron Capture Therapy (BNCT), image-guided hadron beams delivery, clinical trials and immunotherapy, together with the recent interest and advances in FLASH therapy, which is currently an experimental treatment modality that involves ultrahigh-dose rate delivery, are just a few examples of innovation that may eventually help to provide access to a larger number of patients.

Ultra-fast, one-click radiotherapy treatment planning outside a treatment planning system

We present an automated radiation oncology treatment planning pipeline that operates between segmentation and plan review, minimizing manual interaction and reliance on traditional planning systems. Two AI models work in sequence: the first generates a dose distribution, and the second creates a deliverable DICOM-RT plan. Trained and validated on 276 plans, and tested on 151 datasets, the system produced clinically deliverable plans-complete with all VMAT parameters-in about 38 s. These plans met target coverage and most organ-at-risk constraints. This proof-of-concept demonstrates the feasibility of generating high-quality, deliverable DICOM plans within seconds.

Genomic and transcriptomic profiling of radioresistant prostate and head and neck cancers implicate a BAHD1-dependent modification of DNA damage at the heterochromatin

Radiotherapy is an integral modality in treating human cancers, but radioresistance remains a clinical challenge due to the involvement of multiple intrinsic cellular and extrinsic tumour microenvironment factors that govern radiosensitivity. To study the intrinsic factors that are associated with cancer radioresistance, we established 4 radioresistant prostate (22Rv1 and DU145) and head and neck cancer (FaDu and HK1) models by irradiating their wild-type parentals to 90 Gy, mimicking the fractionated radiotherapy schema that is often using in the clinic, and performed whole exome and transcriptome sequencing of the radioresistant and wild-type models. Comparative genomic analyses detected the enrichment of mismatch repair mutational signatures (SBS6, 14, 15, 20) across all the cell lines and several non-synonymous single nucleotide variants involved in pro-survival pathways. Despite significant inter-cell type heterogeneity of their transcriptomic profiles, 18 common dysregulated genes (5 upregulated and 13 downregulated) were identified across the 4 models, including the overexpression of bromo-adjacent homology domain containing 1 (BAHD1) gene, which is involved in heterochromatin formation. Interestingly, this coincided with our observation of increased histone 3 lysine 9 trimethylation (H3K9me3) and histone 3 lysine 27 trimethylation (H3K27me3) expression post-irradiation in our radioresistant cells. The dependency between BAHD1 and heterochromatin formation was confirmed by siRNA knockdown of BAHD1, indicating preferential reduction of H3K9me3 and H3K27me3 expression in the radioresistant cells, but not the wild-type parentals, and confirmed by clonogenic assays showing reversal of radioresistance post-siBAHD1 treatment. We further showed that inhibition of the BAHD1-heterochromatin formation axis led to reduced DNA double-strand break repair. Finally, analyses of treatment outcomes in 4 prostate and head and neck cancer radiotherapy cohorts suggested an increased risk of failures in tumours of high heterochromatin activity. Taken together, our results support a new model implicating BAHD1-dependent modulation of the heterochromatin in acquired radioresistance of prostate and head and neck cancers.

Artificial Intelligence-Empowered Multistep Integrated Radiation Therapy Workflow for Nasopharyngeal Carcinoma

PURPOSE

To establish an artificial intelligence (AI)-empowered multistep integrated (MSI) radiation therapy (RT) workflow for patients with nasopharyngeal carcinoma (NPC) and evaluate its feasibility and clinical performance.

METHODS AND MATERIALS

Patients with NPC scheduled for MSI RT workflow were prospectively enrolled. This workflow integrates RT procedures from computed tomography (CT) scan to beam delivery, all performed with the patient on the treatment couch. Workflow performance, tumor response, patient-reported acute toxicities, and quality of life were evaluated.

RESULTS

From March 2022 to October 2023, 120 newly diagnosed, nonmetastatic patients with NPC were enrolled. Of these, 117 completed the workflow with a median duration of 23.2 minutes (range, 16.3-45.8). Median translation errors were 0.2 mm (from CT scan to planning approval) and 0.1 mm (during beam delivery). AI-generated contours required minimal revision for the high-risk clinical target volume and organs at risk, minor revision for the involved cervical lymph nodes and low-risk clinical target volume (median Dice similarity coefficients (DSC), 0.98 and 0.94), and more revision for the gross tumor at the primary site and the involved retropharyngeal lymph nodes (median DSC, 0.84). Of 117 AI-generated plans, 108 (92.3%) passed after the first optimization, with ≥97.8% of target volumes receiving ≥100% of the prescribed dose. Dosimetric constraints were met for most organs at risk, except the thyroid and submandibular glands. One hundred and fifteen patients achieved a complete response at week 12 post-RT, while 14 patients reported any acute toxicity as "very severe" from the start of RT to week 12 post-RT.

CONCLUSIONS

AI-empowered MSI RT workflow for patients with NPC is clinically feasible in a single institutional setting compared with standard, human-based RT workflow.

Challenges in assessing national radiotherapy costs: application of the ESTRO-HERO model in Spain

Background and purpose

The aim was to estimate the cost of the external beam radiotherapy (EBRT) in public health care centers in Catalonia (Spain), according to the ESTRO-HERO costing model for 2018.

Materials and methods

Personnel, equipment, and activity data from 2018 from the 11 RT centers were used, incorporating European mean values adapted to the Catalan context. Secondly, EBRT costs were estimated, incorporating 2023 fractionation technique and scheme usage percentages. Finally, complementary estimates were included: complementary planning examinations, stereotactic body radiation therapy (SBRT) fiducial markers, and hospital overhead costs.

Results

In 2018, EBRT cost was estimated at EUR 42.2 M for all patients in the region. Directly related treatment activities represented 69.0% of the total cost, while support and non-directly related EBRT activities accounted for 20.2 and 10.8%, respectively. Mean radical treatment cost varied from €1714 (leukemia) to €4,645 (pancreas), and for palliative intent, from €938 (bone metastases) to €1753 (brain metastases). According to the technique used, costs ranged from €1,475 (3D conformal) to €3,608 (rotational IMRT), and by fractionation scheme, from €1,308 (extreme hypofractionation) to €4,094 (standard fractionation). Accounting for 2023 complexity levels, mean treatment cost rose by 0.9%, but varied widely by tumor site, with a 13% increase for stomach cancer, and decreases of -15.0, -24.4, and - 17.2% in myeloma, pancreas, and lung cancer, respectively. Including complementary examinations and hospital overhead costs, mean cost increased by 15.6%.

Conclusion

This study provides a first approximation to EBRT cost using time-driven activity-based costing (TD-ABC) in Catalonia showing the feasibility of the assessment. For each indication, average treatment cost increases with the associated complexity. Additionally, costs decrease with hypofractionation schemes, largely due to lower equipment weight in treatment cost. Consequently, the adoption of stereotactic techniques is driving cost decreases. Overall, this model represents a robust tool for analyzing different possible scenarios, including changes in fractionation and complexity.

Genotype-Directed Synthetic Cytotoxicity of ATR Inhibition with Radiotherapy

PURPOSE

The importance of the DNA damage response in mediating effects of radiotherapy (RT) has galvanized efforts to target this pathway with radiosensitizers. Yet early clinical trials of this approach have failed to yield a benefit in unselected populations. We hypothesized that ataxia-telangiectasia mutated (Atm)-null tumors would demonstrate genotype-specific synergy between RT and an inhibitor of the DNA damage response protein ataxia-telangiectasia and Rad3-related (ATR) kinase.

EXPERIMENTAL DESIGN

We investigated the synergistic potential of the ATR inhibitor (ATRi) RP-3500 and RT in two Atm-null and isogenic murine models, both in vitro and in vivo. Staining of γ-H2AX foci, characterization of the immune response via flow cytometry, and tumor rechallenge experiments were performed to elucidate the mechanism of interaction. To examine genotype specificity, we tested the interaction of ATRi and RT in a Brca1-null model. Finally, patients with advanced cancer with ATM alterations were enrolled in a phase I/II clinical trial to validate preclinical findings.

RESULTS

Synergy between RP-3500 and RT was confirmed in Atm-null lines in vitro, characterized by an accumulation of DNA double-strand breaks. In vivo, Atm-null tumor models had higher rates of durable control with RT and ATRi than controls. In contrast, there was no synergy in tumors lacking Brca1. Analysis of the immunologic response indicated that efficacy is largely mediated by cell-intrinsic mechanisms. Lastly, early results from our clinical trial showed complete responses in patients.

CONCLUSIONS

Genotype-directed radiosensitization with ATRi and RT can unleash significant therapeutic benefit and could represent a novel approach to develop more effective combinatorial synthetic cytotoxic RT-based treatments. See related commentary by Schrank and Colbert, p. 5505.

Sister partnership to overcome the global burden of cancer

Emerging countries are currently facing an increasing burden of cancer while they do not have adequate prevention, monitoring, and research capabilities to tackle the disease. Cancer outcomes are influenced by several factors, including different cancer patterns, national cancer screening guidelines, current stage of disease, and access to quality care and treatments. Discrepancies in cancer care between emerging and developed countries require actions to achieve global health equity. The process of pioneering a sister relationship in the oncology field can thwart the global burden of cancer. The objective of such cooperation programs should include research and training programs, evidence-based oncology practice, and quality cancer. Building global connections will therefore be the novel approach to addressing the global burden of cancer.

Cancer education and training within the South Asian Association for Regional Cooperation (SAARC) countries

The education and training of the oncological health-care workforce is vital for building effective health-care systems that deliver optimal care to patients with cancer. In the South Asian Association for Regional Cooperation (SAARC) nations, there is a notable shortage of both physician and non-physician oncology professionals, including oncologists, medical physicists, radiotherapy technologists, and oncology nurses. This shortage is primarily caused by inadequate education and training programmes. Oncology professionals across SAARC countries face several challenges, including a scarcity of trained personnel, poor health-care infrastructure (including resources and equipment), and insufficient educational opportunities. This Series paper examines the current state of oncology education and training programmes within the SAARC region, identifies the challenges faced by oncology professionals, and offers recommendations for improvement. Short-term strategies focus on developing a skilled, multidisciplinary oncology workforce and enhancing existing training programmes. In the long term, the goals are to establish self-sufficient cancer care systems, promote regional collaboration, and strengthen research infrastructure. Achieving these objectives will require comprehensive approaches, increased financial resources, advanced cancer care infrastructure, and innovative educational models. Regional and international collaborations are essential to raise awareness of cancer as a major public health concern, advance prevention and early detection efforts, and bolster research initiatives.

Okonkwo E, Moore E, Streatfield K, Elit L. Developing a modern radiotherapy department in a rural hospital in Cameroon: The Mbingo experience

Although radiotherapy is critical for cancer cure and palliation, access to such expensive and sophisticated technology is very limited in low- and middle-income countries (LMIC). Cancer incidence in Africa is currently 1.5 million case per year, thus urgent and innovative solutions are required to build necessary infrastructure needed to address this global health challenge. We describe our approach and challenges as a faith based non-government organization in setting up a modern radiotherapy department in a rural hospital in Cameroon to mitigate this unmet need. We highlite our engagement with international bodies and individuals for fund raising and volunteerism, local radiotherapy workforce development and training (radiation oncology, dosimetrists, radiation therapist and medical physicists) and the expertise required for construction of the bunker and installation of the Linac machine.

The status quo of global geriatric radiation oncology education: A scoping review

Purpose

To identify potential gaps in geriatric radiation oncology (RO) education worldwide, as measured by geriatric oncology (GO) content within postgraduate RO training program (TP) curricula across 8 focus countries.

Methods and materials

The need for improved education around GO is internationally recognized and is a key strategic priority of the International Society of Geriatric Oncology (SIOG).Two reviewers undertook a systematic scoping review from March to September 2023. Focus countries were selected using predefined selection criteria based on national radiation therapy (RT) service provision, RT access and post-graduate specialty training standards. This review is in accordance with evidence-based curriculum design methodology and represents the initial phase i.e., problem identification and needs assessment.

Results

Overall RO TP and curriculum elements varied by jurisdiction. Common elements included length of training, summative assessments and prerequisite requirements. Considerable variability exists across TPs around identified learning outcomes, content, TP organization, training networks and accreditation.Across 6 TPs, only 2 had any documented GO curriculum content. Of these, only one contained geriatric RO content scoring moderate to high based on accepted quality benchmarks. Outside official RO TPs, there is considerable GO online education content, including face to face courses, peer-reviewed articles, learning materials and resources relevant to RO postgraduate training worldwide. However accessibility to these learning interventions may be region specific and content is not standardized.

Conclusions

As expected, this systematic scoping review has identified significant gaps in GO education within RO TPs worldwide. These findings represent an essential step in the development of evidence-based recommendations for updating standards for GO training within RO training programs and establishing a globally accepted, standardized benchmarks for minimal geriatric RO education. In turn, this will ensure future radiation oncologists are able to deliver a high standard of care to and improve outcomes for older people with cancer.

Role of universal health coverage in improving quality of breast cancer care: an international comparison study

Introduction

Breast cancer is the most common and lethal cancer among women worldwide. Good quality cancer care is a key pillar in improving the survival rate and reducing the burden of this cancer. This study aimed to evaluate the current status and temporal trends in global breast cancer care and to identify the association between universal health coverage and quality of breast cancer care.

Methods

A quality of care index for breast cancer was constructed using disease burden data from the Global Burden of Disease 2019 database. This index was evaluated and compared at global, regional and national level. The association between universal health coverage index and breast cancer quality of care index at national level was also explored.

Results

The quality of breast cancer care improved from 1990 to 2019, and the disparity narrowed between countries at different development levels over the same period. The universal healthcare coverage index was positively associated with national breast cancer care quality. This finding was robust across countries at low and middle levels of development, as well as more developed countries.

Conclusions

The identified association between universal health coverage and breast cancer care highlight the key role of developing a high-quality and resilient healthcare system for improving breast cancer care. Then expanding the universal health coverage with inclusion of breast cancer care may help improving the breast cancer care quality and reduce the disproportionate mortality due to breast cancer in low social development countries.

Impact of Gold Nanoparticles and Ionizing Radiation on Whole Chromatin Organization as Detected by Single-Molecule Localization Microscopy

In radiation tumor therapy, irradiation, on one hand, should cause cell death to the tumor. On the other hand, the surrounding non-tumor tissue should be maintained unaffected. Therefore, methods of local dose enhancements are highly interesting. Gold nanoparticles, which are preferentially uptaken by very-fast-proliferating tumor cells, may enhance damaging. However, the results in the literature obtained from cell culture and animal tissue experiments are very contradictory, i.e., only some experiments reveal increased cell killing but others do not. Thus, a better understanding of cellular mechanisms is required. Using the breast cancer cell model SkBr3, the effects of gold nanoparticles in combination with ionizing radiation on chromatin network organization were investigated by Single-Molecule Localization Microscopy (SMLM) and applications of mathematical topology calculations (e.g., Persistent Homology, Principal Component Analysis, etc.). The data reveal a dose and nanoparticle dependent re-organization of chromatin, although colony forming assays do not show a significant reduction of cell survival after the application of gold nanoparticles to the cells. In addition, the spatial organization of γH2AX clusters was elucidated, and characteristic changes were obtained depending on dose and gold nanoparticle application. The results indicate a complex response of ALU-related chromatin and heterochromatin organization correlating to ionizing radiation and gold nanoparticle incorporation. Such complex whole chromatin re-organization is usually associated with changes in genome function and supports the hypothesis that, with the application of gold nanoparticles, not only is DNA damage increasing but also the efficiency of DNA repair may be increased. The understanding of complex chromatin responses might help to improve the gold nanoparticle efficiency in radiation treatment.

The 'Liaisons dangereuses' Between Lung Cancer and Interstitial Lung Diseases: A Focus on Acute Exacerbation

Patients with interstitial lung disease (ILD) are about five times more likely to develop lung cancer than those without ILD. The presence of ILD in lung cancer patients complicates diagnosis and management, resulting in lower survival rates. Diagnostic and treatment procedures needed for cancer can increase the risk of acute exacerbation (AE), one of the most severe complications for these patients. Bronchoscopic techniques are generally considered safe, but they can trigger AE-ILD, particularly after cryoprobe biopsies. Surgical procedures for lung cancer, including lung biopsies and resections, carry an elevated risk of AE-ILD. Postoperative complications and mortality rates highlight the importance of meticulous surgical planning and postoperative care. Furthermore, cancer treatments, such as chemotherapy, are all burdened by a risk of AE-ILD occurrence. Radiotherapy is important for managing both early-stage and advanced lung cancer, but it also poses risks. Stereotactic body radiation and particle beam therapies have varying degrees of safety, with the latter potentially offering a lower risk of AE. Percutaneous ablation techniques can help patients who are not eligible for surgery. However, these procedures may complicate ILD, and their associated risks still need to be fully understood, necessitating further research for improved safety. Overall, while advancements in lung cancer treatment have improved outcomes for many patients, the complexity of managing patients with concomitant ILD needs careful consideration and multidisciplinary assessment. This review provides a detailed evaluation of these risks, emphasizing the need for personalized treatment approaches and monitoring to improve patient outcomes in this challenging population.

Access to diagnostic imaging and radiotherapy technologies for patients with cancer in the Baltic countries, eastern Europe, central Asia, and the Caucasus: a comprehensive analysis

BACKGROUND

Only 10-40% of patients with cancer in low-income and middle-income countries were able to access curative or palliative radiotherapy in 2015. We aimed to assess the current status of diagnostic imaging and radiotherapy services in the Baltic countries, eastern Europe, central Asia, and the Caucasus by collecting and analysing local data.

METHODS

This Access to Radiotherapy (ART) comprehensive analysis used data from 12 countries: the three Baltic countries (Estonia, Latvia, and Lithuania), two countries in eastern Europe (Moldova and Ukraine), four countries in central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan), and three countries in the Caucasus (Armenia, Azerbaijan, and Georgia), referred to here as the ART countries. We were not able to obtain engagement from Turkmenistan. The primary outcome was to update the extent of shortfalls in the availability of diagnostic imaging and radiotherapy technologies and radiotherapy human resources for patients with cancer in former Soviet Union countries. Following the methods of previous similar studies, we developed three questionnaires-targeted towards radiation oncologists, regulatory authorities, and researchers-requesting detailed information on the availability of these resources. Authors from participating countries sent two copies of the appropriate questionnaire to each of 107 identified institutions and coordinated data collection at the national level. Questionnaires were distributed in English and Russian and responses in both languages were accepted. Two virtual meetings held on May 30 and June 1, 2022, were followed by an in-person workshop held in Almaty, Kazakhstan, in September, 2022, attended by representatives from all participating countries, to discuss and further validate the data submitted up to this point. The data were collected on a dedicated web page, developed by the International Cancer Expert Corps, and were then extracted and analysed.

FINDINGS

Data were collected between May 10 and Nov 30, 2022. 81 (76%) of the 107 institutions contacted, representing all 12 ART countries, submitted 167 completed questionnaires. The Baltic countries, which are defined as high-income countries, had more diagnostic imaging equipment and radiotherapy human resources (eg, Latvia [1·74] and Lithuania [1·47] have a much higher number of radiation oncologists per 100 000 population than the other ART countries, all of which had <1 radiation oncologist per 100 000 population) and greater radiotherapy technological capacities (higher numbers of linear accelerators and, similar to Georgia, high total external beam radiotherapy capacity) than the other ART countries, as well as high cancer detection rates (Latvia 311 cases per 100 000 population, Lithuania 292, and Estonia 288 vs, for example, 178 in Armenia, 144 in Ukraine, and 72 in Kazakhstan) and low cancer mortality-to-cancer incidence ratios (Estonia 0·43, Latvia 0·49, and Lithuania 0·48; lower than all but Kazakhstan [0·41]). The highest cancer mortality-to-cancer incidence ratios were reported by Moldova (0·71) and Georgia (0·74).

INTERPRETATION

Our findings show that the number of cancer cases, availability of diagnostic imaging equipment, radiation oncologists and radiotherapy capacity, and cancer mortality-to-cancer incidence ratios all vary substantially across the countries studied, with the three high-income, well resourced Baltic countries performing better in all metrics than the included countries in eastern Europe, central Asia, and the Caucasus. These data highlight the challenges faced by many countries in this study, and might help to justify increased investment of financial, human, and technological resources, with the aim to improve cancer treatment outcomes.

FUNDING

US Department of Energy's National Nuclear Security Administration's Office of Radiological Security.

Radiotherapy and theranostics: a Lancet Oncology Commission

Following on from the 2015 Lancet Oncology Commission on expanding global access to radiotherapy, Radiotherapy and theranostics: a Lancet Oncology Commission was created to assess the access and availability of radiotherapy to date and to address the important issue of access to the promising field of theranostics at a global level. A marked disparity in the availability of radiotherapy machines between high-income countries and low-income and middle-income countries (LMICs) has been identified previously and remains a major problem. The availability of a suitably trained and credentialled workforce has also been highlighted as a major limiting factor to effective implementation of radiotherapy, particularly in LMICs. We investigated initiatives that could mitigate these issues in radiotherapy, such as extended treatment hours, hypofractionation protocols, and new technologies. The broad implementation of hypofractionation techniques compared with conventional radiotherapy in prostate cancer and breast cancer was projected to provide radiotherapy for an additional 2·2 million patients (0·8 million patients with prostate cancer and 1·4 million patients with breast cancer) with existing resources, highlighting the importance of implementing new technologies in LMICs. A global survey undertaken for this Commission revealed that use of radiopharmaceutical therapy-other than 131I-was highly variable in high-income countries and LMICs, with supply chains, workforces, and regulatory issues affecting access and availability. The capacity for radioisotope production was highlighted as a key issue, and training and credentialling of health professionals involved in theranostics is required to ensure equitable access and availability for patient treatment. New initiatives-such as the International Atomic Energy Agency's Rays of Hope programme-and interest by international development banks in investing in radiotherapy should be supported by health-care systems and governments, and extended to accelerate the momentum generated by recognising global disparities in access to radiotherapy. In this Commission, we propose actions and investments that could enhance access to radiotherapy and theranostics worldwide, particularly in LMICs, to realise health and economic benefits and reduce the burden of cancer by accessing these treatments.

Gas immnuo-nanomedicines fight cancers

Certain gas molecules, including hydrogen (H2), nitric oxide (NO), carbon monoxide (CO), hydrogen sulfide (H2S), oxygen (O2) and sulfur dioxide (SO2) exhibit significant biological functionalities that can modulate the immune response. Strategies pertaining to gas-based immune therapy have garnered considerable attention in recent years. Nevertheless, delivering various gas molecules precisely into tumors, which leads to enhanced anti-tumor immunotherapeutic effect, is still a main challenge. The advent of gas treatment modality with desirable immunotherapeutic efficiency has been made possible by the rapid development of nanotechnology, which even derives the concept of the gas immnuo-nanomedicines (GINMs). In light of the fact, we herein aim to furnish a cutting-edge review on the latest progress of GINMs. The underlying mechanisms of action for several gases utilized in cancer immunotherapy are initially outlined. Additionally, it provides a succinct overview of the current clinical landscape of gas therapy, and introduces GINMs specifically designed for cancer treatment based on immunotherapeutic principles across multiple strategies. Last but not least, we address the challenges and opportunities associated with GINMs, exploring the potential future developments and clinical applications of this innovative approach.