future of radiation therapyfilecache.investorroom.com/mr5ir_varian/635... · beam shaping devices:...

Future of Radiation Therapy

JP Morgan Healthcare Conference

January 12, 2016

Deepak Khuntia, MD,

VP of Medical Affairs

Patrick Kupelian, MD,

VP of Clinical Affairs

Cancer as a cause of death

CANCER TREATMENT MODALITY: RADIOTHERAPY

Localized Treatments:

Surgery

Ablative Treatments: Cryo

HIFU

Laser

Microwave

Systemic Treatments:Drugs: Traditional ChemoRx

Hormonal Therapy

Targeted Drugs

Radiation Therapy (RT):Spectrum of biologic effects

• Ablative: SRS/SBRT

•Biologic therapy

Organ-sparing

DNA changes

Immune modulation

: less invasive?

Very few curative therapies

Minor improvements in subsets of patients

DISEASES TREATED WITH RT

Curable Cancers with RT ALONE:

Prostate Ca

Head & Neck Ca

Lung Ca

Cervical Ca

Skin Ca

Curable Cancers with RT as part of treatment (adjuvant):Breast Ca Brain Tumors Testicular Ca

Adv. Lung Ca Rectal Ca Sarcomas

Adv. Cervical Ca Endometrial Ca Pediatric Ca

Adv. Head & Neck Ca Bladder Ca

Metastatic disease: Bone / Brain / Other…

Improving RT Delivery

1950-60s

Cobalt

Early Linacs

1970-80s

Higher

Energy

Linacs

1990s

Beam Shaping

Devices

2000s

In-room

Image

Guidance

2010s

Integration of

Better Beam

Shaping

and Aiming

Impact Explore new

indications

• Treat deeper

tumors

• Decrease

skin toxicity

• Treat smaller areas

• Individualization

• Decrease toxicity in

deeper organs

• Increase in

tumor doses

• Improve

tumor control

• Higher daily

doses

• Faster, Better,

Safer treatments

Aim: Increase Cure / Decrease Toxicity

Process: Improve RT Shaping and Targeting

Improving RT Techniques and Outcomes1995-2000

Beam shaping devices:

MLCs

2000-2005

In-room image

guidance

2005-2010

Partially integrated

systems

2010-2015

Hypofractionation,

Adaptive RT

2015-Future

Integration of Better

Beam Shaping

and Aiming

Novelty IMRT IGRT • Dedicated devices

• Multivendor

environment

• SRS

• SBRT/SABR

• ART

Need for increased

integration and/or

interoperability

Clinical Impact • Head/Neck: improve

saliva / swallowing

• Pelvis: Less bowel

toxicity

• Allows safer

chemotherapy

administration

• Prostate Ca:

Enable dose

escalation: improve

cure

• Reduce traditional

set-up errors

• Increased

complexity

• Decrease

throughput

• Increase safety

concerns.

• Lung Ca SBRT:

improve cure

• Frameless CNS

radiosurgery

• Partial breast

accelerated

irradiation

• Faster, better, safer

treatments

• Global RT:

• Simpler set-ups

• Education &

training

Andrews DW, Scott CB, Sperduto PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for

patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004 May

22;363(9422):1665-72.

Brain Mets Study: Adding SRS Improves Survival

Treatment Details

• 18 Gy x 1

• 4 non-coplanar arcs

• 1-360, 3-170

• 18 min treatment

• 5 min beam-on

• 708 control points

RapidArc Radiosurgery: Treating 11 Melanoma Mets

SBRT vs. Lobectomy for Operable Stage I NSCLC

Source: Chang JY, Senan S, Paul MA, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung

cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015 Jun;16(6):630-7.

Lung Cancer:

Patients live longer with Radiosurgery than with Surgery

Zelefsky, IJROBP, 84, 125-129, 2012

PROSTATE CANCER

IMAGE GUIDANCE: IMPROVING CURE AND REDUCING TOXICITY

Memorial Sloan Kettering Cancer Center

Prostate Cancer RT: Outcome with and without Image Guidance

Cancer Control Rates Toxicity Rates

Shaping of Radiation Lowers Complications

Reduce Bowel Complications

Cancers impacted:

Prostate Ca

Rectal Ca

Anal Ca

Cervical Ca

Reduce Head & Neck Complications

Complications reduced:

Less dryness of the mouth

Less swallowing problems

Less scarring of joints / muscles

Chopra et al. ASTRO Plenary, San Antonio October 2015.

Gupta et al. Radiotherapy and Oncology. 104:3 (343-348), 2012.

Conventional RT IMRT

New Era InnovationKnowledge-Guided Oncology | Intelligent Treatment Delivery

Advanced Data Analytics

IMAGE – Not Yet Complete

RapidPlan™ Ramp Up

300+ Orders

3,800 Potential Installs

Disease Site Models

Prostate

Prostate (+lymph nodes)

Head & Neck

Lung SBRT

Breast

More Models Coming

KNOWLEDGE-GUIDED ONCOLOGY:

University of Michigan: Spine SBRT Study

Manual RapidPlan

Foy J, et al. An analysis of knowledge based planning for stereotactic body radiation

therapy of the spine [abstract]. Poster presentation at: American Association of

Physicists in Medicine (AAPM) 57th Annual Meeting & Exhibition; July 12-16,

2015; Anaheim, CA.

University of Michigan

Equivalent Quality

Manual Rapid Plan

Time 60-90 min 15-20 min

KNOWLEDGE-GUIDED ONCOLOGY:

Royal Surrey County Hospital: Prostate Study

Manual RapidPlan™

Time 114 ± 86 min 21 ± 13 min

Equivalent

or better30% 90%

Better 10% 90%

Courtesy, Royal Surrey County Hospital NHS Foundation, Guilford, UK

Data source on file

0

50

100

150

200

250

300

350

A1A2A3A4B1B2C1D1D2D3E1E2E3F1F2F3F4F5F6

Planning time (min)

conventional RapidPlan

KNOWLEDGE-GUIDED ONCOLOGY:

High Definition Radiotherapy (HDRT)

INTELLIGENT TREATMENT DELIVERY:

Works in Progress

4π Dose Compression for Lung SBRT

INTELLIGENT TREATMENT DELIVERY:

IMRT

PATIENT 1

PATIENT 2

VMAT 4 π HDRT

64 Gy

15 Gy

Dong P et al. IJROBP 86(3):407-13, 2013Works in Progress

High Definition Radiosurgery

Coplanar RapidArc SRS 4π High Definition SRS

Brain Stem Brain Stem

50% Rx Dose50% Rx Dose

INTELLIGENT TREATMENT DELIVERY:

Works in Progress

Promise of Protons

InSightive™ Analytics

Operational Efficiencies

Referral Patterns

Clinical Outcome Analysis

ADVANCED DATA ANALYTICS

ADVANCED DATA ANALYTICS:

VelocityTM

Creates the cancer story from

imaging

Imaging informatics integrated

with our Big Data Analytics

Improve outcomes, quality, and

efficiency

ADVANCED DATA ANALYTICS:

Radio-immunotherapy for Cancer Treatment

Hodge, Guha, Neefjes, Gulley. Oncology, 2008 August, 22(9):1064-1084

Abscopal Responses in Metastatic Non-Small Cell Lung Cancer

(NSCLC) Patients Treated on a Phase 2 Study of Combined Radiation

Therapy and Ipilimumab: Evidence for the In Situ Vaccination

Hypothesis of Radiation

E.B. Golden, A. Chachoua, M.B. Fenton-Kerimian, S. Demaria, and S.C.

Formenti

New York University

ASTRO Annual Meeting

October 2016

The Abscopal Effect:

Radiotherapy in one site can potentially eradicate tumors elsewhere in the body

• Combining radiosurgery with immunotherapy

• Study of NSCLC

• Study shows that SBRT with ipilumimab could

increase tumor control and survival

• 25% remission; 100% control/no progression

Golden et al. ASTRO 2016.

Targeted Therapies and Immunotherapies:

Trend is in Combining Drugs

RT as a combination “drug”

• Available

• Cost-effective

• Reimbursed

Challenges of drug+drug combinations

• Clinical trial design

• Cost

• Commercialization

4. Radiation Medicine

Cardiac Arrhythmia

(Atrial Fibrillation)

Research opportunities in radiation

medicine:

Cardiac arrhythmias

Emphysema

Post-thoracic surgery neuropathy

Plantar fasciitis

Depression

Arthritis

NEW FRONTIERS IN

RADIATION ONCOLOGY

Works in Progress

Cardiac Arrhythmias: A New RT Frontier?

Affordable, Accessible, Quality Care

Cost of Cancer Care in US

30% increase from 2010 to 2020

Average cost for one extra year of life:

1995: $54,100

2005: $139,100

2013: $207,000

Sources: Avalere study, 2015 National Bureau of Economic Research

$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

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RT Surgery Chemo(1 year)

Average Cost per Patient

Technology Decreasing Treatment Cost:

SBRT / SRS

Technology (SBRT) Decreasing Actual Treatment Cost

Time-driven activity-based costing (TDABC), UCLA

SBRT

Utilizing time-driven activity based costing to understand the short- and long-term costs of treating localized, low-risk prostate

cancer. Laviana et al. Cancer. 2015

Conclusion

• Advanced technology is increasing cure rates and

lowering toxicity

• Advanced technology will improve affordability,

accessibility, and quality of radiotherapy

• Radiation therapy utilization could dramatically

increase with new opportunities outside of cancer

Thank You

$3-4M?

IGRT SBRT HDRT

The Key To

Progress:

Better Dose

Delivery

INTELLIGENT TREATMENT DELIVERY:

IMRT

MR LINAC

3D CONFORMAL

Relative Clinical Value

$10M