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From ICARO 1 to ICARO 2:The Radiation Oncologist Perspective
Eduardo RosenblattICARO2, Vienna, 20/06/2017
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Radiotherapy in the broader context
• RT is a fundamental component of effective cancer treatment for cure and palliation
• It has been established that at least 50% of cancer patients would benefit from RT
• Virtually absent from global health discourse
• Receives limited domestic and international funding
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Delaney et al. 2005, Barton et al. 2012Rosenblatt et al. 2015Atun et al. LO 2015
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ASR cancer incidence and mortality rates/100.000 between 1975-2012
INCIDENCE (MEN, WOMEN) MORTALITY (MEN, WOMEN)
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Incidence rates tend to increase A substantive decline in ASR mortality
WHO/IARC, World Cancer Report, 2014
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10-year relative survival in adults in England/Wales, 1971-2007
MyelomaStomachOesophagusBrainLungPancreas
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International Conference on Advances in Radiation Oncology
ICARO 1 (April 2009) ICARO 2 (June 2017)
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ICAROApril 2009
ICAROApril 2009
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The historical development of radiotherapy…
has been the search for strategies to enhance the therapeutic ratio of radiation as a cancer treatment:
FRACTIONATIONHYPERTHERMIARADIOSENSITIZERSRADIOPROTECTORSOXYGEN
CHEMO-RADIATIONTARGETED THERAPY3D CONFORMALITYIMRT/IGRTPARTICLE THERAPY…
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Stanford, 1957
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Advances in Radiation Oncology
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Closer approximation of the treatment volume to
the defined target
Biological means to increase the differential
response between tumor and normal tissues/structures
Clinical trials to provide evidence of the
superiority of new strategies
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Significant developments in ROover the past decade:
• Imaging • Computer and information technology• Molecular and clinical radiobiology• Treatment planning• Delivery of RT• Combined modality treatment• Dosimetry of small fields• Multidisciplinary decision-making• Supportive and palliative care
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Debate 1Cobalt-60 – is it time for retirement?
ICARO‐1• There remains a role for
Co‐60 teletherapy in LMICs.
• New technical developments allow the implementation of highly conformal treatment techniques, but this increases the costs to the level of linear accelerators
ICARO‐2
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Linacs 11.444Radionucleide 2.185Total megavoltage 13.629Co‐60 16%
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Debate 2IMRT – are you ready for it?ICARO‐1• Robust clinical trials are
necessary to demonstrate the benefits of new technologies before they are adopted into widespread use
• A new and unproven technology should not be universally adopted as a replacement for established proven technologies
ICARO‐2
Should IMRT be the standard of care?
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YES NO
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Debate 3Do we need proton therapy?ICARO‐1• Physical dose‐distributions
are superior to those of photons
• The cost of establishing and maintaining facilities is significant
• Clinical trials are underway• Whether the clinical gains
from p therapy will outweigh the costs is an unresolved issue …
ICARO‐2
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Operational facilities 73Protons 63Carbon‐ion 11
Facilities under construction 41Facilities in planning 20
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Imaging and functional molecular imaging - IGRT
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CT‐ (green) and PET/CT (red) defined PTVs in the same patient.Mac Manus et al. 2013
MR‐linac(Royal Marsden Hospital, UK)
2004J.F. Dempsey (Univ. of Florida)J.J. Lagendijk, W. Raaymakers(Utrecht, Netherlands)P.J. Krall, M. Barton (Sydney, Australia)G. Fallone (Univ. of Alberta, Canada)
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Volumetric Arc IMRT
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Stereotactic techniques
STEREOTACTIC RADIOTHERAPY
• 3D imaging• Precise positioning and immobilization
• Highly focused beams that converge in a defined volume
• IGRT
SBRT
• Early stage NSCLC• Liver• Spine• Prostate• Radical treatment of
oligometastasis
• ASTRO‐ACR/AAPM/IAEA
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Hypofractionation
ICARO 1
• Patient convenience• Reduced Tx time• Saving resources
• Feasible with highly conformal (precision) RT
ICARO 2
• Prostate• Breast – Whole breast– APBI
• Oligometastasis• Painful bone metastasis• Rectum pre‐op.
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ASTRO Choosing Wisely® (2013)• Don’t initiate whole breast radiotherapy as a part of breast conservation therapy in women age ≥50 with early stage invasive breast cancer without considering shorter treatment schedules.
• Don’t initiate management of low‐risk prostate cancer without discussing active surveillance.
• Don’t routinely use extended fractionation schemes (>10 fractions) for palliation of bone metastases.
• Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry.
• Don’t routinely use IMRT to deliver whole breast radiotherapy as part of breast conservation therapy.
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an inconvenient truth (for radiation oncologists)
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The manual contouring of targets and OAR has become a bottle‐neck in the overall process of radiotherapy
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Automation in contouring and planning
AUTO‐CONTOURING
• Saves time• Reduces inter‐observer
variation
AUTOMATED RT PLANNING
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AUTOMATED QA
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BrachytherapyICARO1• Brachytherapy session• Lunch symposium on Co‐60
BT
ICARO2
• HDR firmly established• Co‐60 HDR also popular• Image‐guided BT planning• New afterloading devices• Hybrid applicators• Electronic BT• Robotic BT (for prostate seed)• Y‐90 microspheres• Improvements in in‐vivo dosim.• GEC‐ESTRO recommendations• ICRU Report 89
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“Radiation offers new cures, and ways to do harm”
Radiotherapy accidents associated with the new technologies …prompted review and strengthening of radiation protection issues• Regulations• Staffing• Training• Incident reporting• Radiation safety
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JAN 23, 2010
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Biology and Radiobiology• Molecular targeted therapy• Angiogenesis and anti-angiogenesis
agents• Paracrine signalling• Stem cell therapeutics• Nanotechnology • Tumour microenvironment• Radiogenomics• Radiobiology of single ablative doses• Radiobiology of particle therapy20.06.2017 Rosenblatt ICARO2 23
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Molecular Targeted Therapy
2‐yr Loco regional control Overall Survival
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45 vs. 55% HR0.74 (0.57 – 0.97) P=0.03
41 vs. 50% HR 0.68 (0.52‐ P=0.005
J. Bonner et al. NEJM 2006
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Radiotherapy and Immunotherapy;a paradigm shift?
• Radiation induces immune modulation
• RT alone does not have the intensity to generate enough immune signals…
• Therefore, a partnership of radiation with targeted immunotherapy agents appears to be important
Formenti S, and Demaria. J Natl Cancer Inst (2013) 105 (4): 256‐265.
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Personalized radiotherapy
PERSONALIZED MEDICINE PERSONALIZED RADIOTHERAPY
• Clinical• Stage• Histopathologic• Tumour shape
• Radiogenomics
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One‐size‐fits‐all vs.Biological adaptation
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Radiation Oncology and Global Cancer Challenges
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UNIATF UN Interagency Task Force for NCDsGTFRTCC Global Task Force for RT in Ca. Control ESTRO‐GIRO Global Impact of Radiation in OncologyPACT‐AGART Advisory Group on Access to RTNCI‐CGH NCI Center for Global HealthICEC International Cancer Expert CorpsICCP International Cancer Control Partnership
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Conclusions:1. The 8 years between ICARO1‐ICARO2 have
accompanied a decade of rapid development in the field of radiation oncology in its technical, clinical, biological and translational research branches
2. There is increased awareness and action to address global disparities in access to radiotherapy services
3. The IAEA‐ICARO meetings represent a step in this direction.
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