newer technology-whither blows the wind

Summary:

newer technology-whither blows the wind

newer technology-whither blows the wind

HM 17 Mar 2010 12:39

With the advent of IMRT,suddenly conformal RT has taken a quantum leap.What shape do you think the future of radiation oncology is taking-will it be conformal radiation,biological radiation or the death knell for radiation?
I had a senior colleague from the radiodiagnosis deptt ask me-Have any of these treatment modalities improved survival ?If the jury is still confined for deliberations-the decreased toxicity is what you are actually offering with these-something like enteric coated tablets ( a very expensive variant ).Is varian,Siemens ,Elekta , nucleotron the keepers of the future for the radiation oncology community?Monopolistic !!!!

Re: newer technology-whither blows the wind

Santam Chakraborty 31 Mar 2010 04:38

It stands to reason that with time biologically adaptive radiation mixed with newer targeted agents will come to the fore front. But before that I feel that this decade will be spent on getting major questions regarding conformal radiation answered. The issues of organ motion, deformation and shape change will be of paramount importance as will be dose painting by numbers. We will be getting faster LINACs, dual source tomotherapy and probably be seeing the initial integration of MRI in image guidance and probably greater reliance on particle therapy.
The death knell of radiation can only come if we develop agents to knock out specific cancer cells but that possibility is remote for the simple reason that cancer represents the epitome of evolution and as it develops it "learns" to overcome the barriers that our body has developed to prevent such an occurrence over millions of years of evolution. What targeted agent will be useful if there are no singular target to be hit. I feel the current plethora of targeted agents are a prequel to the up coming era of in vivo genetic modification. Till that date comes the randomness that RT offers will make it the best agent against cancer.
Coming to survival, I personally feel yes properly delivered IMRT can indeed improve the survival as compared to conventional RT as dosimetric uncertainties are reduced. As a case in point I will to point out electron boosts for lateral neck treatment. The dose coverage is certainly inferior to that obtained by IMRT. The quantification of CTV and marginal failures is being done with much greater accuracy as compared to that in the conventional RT era. Another thing I feel important is the time the physician has to spend contouring. All of us who have done conventional planning know what I am talking about. The time spend in target selection and its delineation is necessarily more in IMRT/3DCRT, a fact I feel can only be an improvement. However RT will be RT and the nature of cell survival curve will not change with IMRT. So the additional gain with IMRT in terms of survival is likely to be minuscule. However the gains in terms of toxicity will be important and as we get more patients to survive longer the gains made in toxicity reduction will be more and more important. In that respect I feel from my personal observation that my patients treated with IMRT have a better quality of life as compared to those treated with conventional RT. They swallow better, have better teeth and are able to speak better. The social consequence of this is that unlike several patients of mine treated with conventional parallel opposed treatment they are not shying away from social gatherings and taking their food with their family. So reducing RT toxicity is not like offering enteric coated tablets at all. If you can offer patients pegylated doxorubicin I see no harm in IMRT.
Coming to vendor dependence yes that is a big problem but as you know we in India depend on vendors to innovate. Face it how much of cutting edge research is actually coming from our so called big institutes. Mostly its a reiteration of what has been done elsewhere already. We as a nation are afraid of change and risk else what was stopping us to start image based brachytherapy instead of waiting for ESTRO? Its not like the technology was not available for imaging. What actually stopped us was the fact that we failed to take the mental next step in moving from xray and point based dosimetry to volumetric. And no it is not the consequence of not having the appropriate software or hardware either. Software now peddled by vendors are mostly developed in house in universities in west 5 - 6 years earlier and then sold for a tidy profit. MRI compatible applicators were not developed by Nucletron by themselves but by taking inputs from the University of Vienna. Tomotherapy was developed in university as was Cyberknife and then commercialized. This sort of innovation and commercialization is normal for all industries and RO cannot be an exception. Accelerators are expensive technology and we as a nation should be ashamed that we have not developed our own technology for this. So no its not a monopoly, its the natural consequence of having people who innovate and invent rather than waste time in doing "re-search".

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Last edited on 31 Mar 2010 04:39 by Santam Chakraborty Show more

Re: newer technology-whither blows the wind

AAM 01 Apr 2010 11:25

You should consider that "biologically adaptive" RT (BGRT - biology-guided??) will be predominantly based on IMAGING first at the sub-GTV level. This brings to bear the notion of controlled inhomogeneity. We have started IMRT well, we struggle with rational use of IGRT, we think that MGRT is too difficult and are in love with BGRT.

The bottom line for patients is to get all this together using IMRT + IGRT + MGRT + BGRT well.

I can see the death of RT, it's about as far away as Galaxy JKCS041. The almost infinite variability of tumour cells will keep us bound to blunderbuss therapies of slash, burn and poison for a long time. Our major challenge today is in the MGRT and BGRT areas.

We have to get this morphology thing right, because the inhomogeneous boost requires that we know our morphology constraints (otherwise we will drop high doses into normal tissues). We have to be involved in the development of the biology stuff. Us or our colleagues need to be in there pushing for the development of biologicals that alter radiation cell survival allowing us to wind back dose without loss of cure.

The contouring/voluming issue I think requires us to alter our mindset - its not a waste of time. It is akin to the surgeons changing from a fast open cholecystectomy to a slow laparoscopic cholecystectomy - why? Its better for the patient, and that's the only reason we need. In our centres we need to be flagging this increasing requirement by undertaking morphology research to show it works and then implementing this in our practices. The notion of taking a week in another centre to undergo voluming/contouring QA for colleagues has to come into our thinking. We need to develop an assessment model that can provide us with the notion of internationally approved excellence in voluming/contouring.

There are some things that we each can do well, depending on what we have. India has to play to its strengths, Australia has to play to its strengths (as we do in cricket when we consistently beat you! …. sorry, momentary lapse there!). So perhaps we should discuss real strengths.

I'll start the bidding - you have patients ++++. You have IT ++++. You can't build linacs yet. You have difficulty delivering anything technically intricate. You have developed the ability to devise and plan the technically intricate. What can be done with that?

Re: newer technology-whither blows the wind

HM 02 Apr 2010 09:28

Often it is suggested that the western data cannot be extrapolated for the Asian /Indian population-Even though the reports from this country have never revealed any difference,except in prevalence/incidence?And India is the IT capital of the world.Would the open architexture of the internet provide opportunities for interactive CMEs with contouring and imaging online?Maybe isocentre in collaboration with AROI could itself start the revolution in the standardisation of contouring volumes!if nothing else you could probably write an erudite paper on common contouring errors among an online radiation oncology community.
Again I come to the question of biologicals and newer chemotherapy agents used for chemosensitization?I wonder how these agents affect the radiation per se? Does hypoxia mapping or even radiosensitization make more sense instead of receptor antagonism???However it is the market for the pharmaceuticals which drives our treatment modalities.
I do not believe that just b'cos australia managed to beat India in the Border -Ponting era ,it will last.the newer players will learn and will consistently beat Australia at their own game.but this implies the willingness to learn and imbibe the spirit of the Aussies.India's strength today is in educated youth with ambition,we just need to curb the Argumentative Indian in all of us and we could be right up there.
And forums like these could lead the way.
I bid for the empowerment of the youth and dissemination of expertise along with an open forum to question and form thoughts and ideas!maybe even a paradigm shift in our management of patients to tailor the treatment for the lowest common denominator rather than the best the west has to offer.After all our strengths are derived from fields where we have not followed the west.
P.S:- Some of the above is the Argumentative Indian in me just being contrite!

Re: newer technology-whither blows the wind

RAJESH R NAIR 02 Apr 2010 10:34

suggestion that western data cannot be extrapolated for asian/indian population is right.but data generation in asia/india is difficult.
technology is not solution although it may help.here problem is time/money.Time is required to observe and think.Money is required to implement the thought.What is happening is when money is there time is not there and time is there money may not be there.

If technology can ease time factor for eg a technology help u to evaluate tumor response result in first fraction of radiation looking some molecular change in first fraction it self with out any invasive test and techonogy is made available cheaply and the change predict survival then quality data generation will come.other wise doing tumor response after a month of treatment then evaluate time to survival of patient where patient drop the fact is difficult to generate.

Good care of patient by western generated data is what is hapening now a days in asia /india.Following a data is only one level of growth that is what now happening in asia(except japan) because of technology.

So in these place if a physcian vary treatment according to his perspective is quiet common and it has helped patients .

Great example is centre are there preop radiotherapy to breast tumor before surgery is done .they think it is better than post op although there thinking cannot be substantiated.

where technology and biology progress there will come a time when good quality dats are generated from these places.

border pointing era,ganguly -dhoni era ,there are super player all along in both team ,means it is all there in humans.

Re: newer technology-whither blows the wind

AAM 06 Apr 2010 13:29

if you can't extrapolate data from East to West and vice versa, can you tell me where the divide lines are? Can you translate from India to England, India to China, India to South East Asia, England to Australia? Should our data be ethnically related?

If you can't extrapolate E>W or W<E then why are drug companies pushing their randomised trials into E away from W? Because you know that the justification for use in the W (think big bucks) will be this data.

What you have there is the opportunity to pick simple questions that prove that new technology is better.

• randomised trials that look at acute effects as their primary end point (when patient follow up is difficult). Is this relevant to your very poor patients?
  • Perhaps rapid voluming techniques that minimise skin toxicity and oral toxicity compared to POP setups.
  • Perhaps even use some IT solutions to undertake this voluming
  • Perhaps investigating methods of great conformality but rapid delivery time with point and shoot IMRT (which is going to be the mainstay in a lot of places for another 10 years)
• randomised trials that look at cure and late effects as their primary end point (when patient follow up is expected)
• prospective trials looking at organ changes in relation to dose during treatment (parotid/submand)
• prospective trials looking at muscle and fat content changes in relation to dose during treatment
• FOSS healthcare IT solutions which focus on diagnosis, delivered treatment and biological data (e.g., genomics) can provide a lot of synergy. India provides the IT backbone and you then ask for donations to process genomics or even send genomics off shore for analysis.

Anyone got any other thoughts? I'll keep cogitating.

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Not wanting to start a cricket war, but the psyche of teams is fascinating. Many of the recent troubles of the subcontinental cricket teams reveal a culture of privilege and arrogance, which has not been evidenced in the Australian or NZ teams. NZ is just too small to be anything more than the occasional nuisance, but India et al should be unstoppable given the population and popularity of the game there. A bit like the Australian soccer team playing & beating South Americans and Europeans at World Cup level.

The Australian leaders - Border, Waugh, McGrath, Warne, Taylor, Ponting - have all been exceptional cricketers, but we here never felt that any thought that they deserved a place in the side because they were good. They all projected the belief that their place required that they perform. Favouritism got some tolerance when you had a bad run, but you had to show that you were working to get out of the slump otherwise you were gone. That ethic of work and the meritocracy of performance is what seems lacking in many of the teams competing with these Australian teams. Even now I would call the present Australian team mediocre by their previous standards, yet not matched by many still.

Last edited on 06 Apr 2010 13:41 by AAM Show more

Re: newer technology-whither blows the wind

RAJESH R NAIR 06 Apr 2010 15:06

Cell culture data to animal studies to western to eastern ,one individual to other there is difference since genetic make up of cell and its enviornment is different.So what level we discuss the issue is where the difference is.
When we extraplolate and convince ourself that data is same is what we do now since presently that is what is workable.When personalised medicine get it real colour what it means is this extraplolation idea goes.
Blocking each pathway which is activated or inactivated ,mechanism in which each individual get ressistance to medicine is circumvented may be different .so treatment vary individually.Not to beleive this is not the future is difficult.
This is future and yet to come.
As far as radiotherapy is concerned most of technology even imrt /3dcrt/2d all comes and apply without any trial data.reason being there is no need to tell toxicity is less with imrt and 3d crt.whether we need to know any other effect related to integral dose and all both eastern and western world ignore in same way.
IT solutions can come from place where research activity can be funded and these can be done all over world where money is and now all come from US than any other place although it is done individual of different country.

Pharma company comes due to many cancer patients in India/asia and many new molecules from different company which they need to prove one is better than other.

It is not doing things matter it is the whole process .i still think when whole process is taken there is much difficulty and those who are generating few data are doing it but quality of data is comprimised/squeezed to get positive result to publish since negative result is never published when both have same significance..

I have seen many trial started with good intention but end up no where.And majority in these countries are so.Instead of wasting time and resource giving care to patient with what ever standarded is logical.Or otherwise good funding gone through uncorrupt channel to good people with intention to prove truth should be there.it is difficult to get.