radiotherapy - the art of the invisible terry kehoe consultant clinical scientist head of oncology...
TRANSCRIPT
Radiotherapy - the art of the invisible Terry Kehoe
Consultant Clinical ScientistHead of Oncology PhysicsEdinburgh Cancer Centre
“How to crack a walnut”
CRUK - Radio 5 on 10th June 2014 50% survive 5yrs today
CRUK - TI report May 2014Addition of RT – 16% ↑ in 5yr survivalAddition of CT – 2% ↑ in 5yr survival
Why does so much money go into drug development?
30yrs ago – 25% 20yr target – 75%
46.7% -5yr survival in the early 80’s
By the end of the 80’s 5yr survival ↑ 56.3%.
By mid 90’s 5yr survival ↑ to 70%.
Mid ‘00‘s - 5yr survival ↑ to 85.2%
Improved survival from prostate cancer over my career
When I started in 1979
Early Image Guided Radiotherapy IGRT 2004
Fiducial Markers
Inserted trans rectally
Images true prostate position
We increased our doses safely – how?
Diagnostic quality imaging
Modern Image Guided Radiotherapy IGRT 2009
Same Fiducial Markers
Now CT capability
Images true prostate position and software calculates how much to move the field to correct for it
We increased our doses safely – how?
Why we can increase our doses safely
New in 2011 even better IMRT
Will have all LinAcs with this arc therapy by end of 2015
IMRT 5½mins VMAT 1½mins
~ Doubling in 5yr survival in 3½ decades
No it’s been around for a century. Some people call it a “black art” perhaps its “magic”
All from RT? No - 46% of prostate cancer patients receive external beam radiotherapy.
Will the 85.2% 5yr survival rise? Probably.
Image Guided – IMRT is best. Is it new?
How do you know you are doing it right?
I-125 day case permanent implant
Volume Study
2001
Classic 2-stage procedureVolume study to assess prostate size, pubic arch problems and plan treatment
Good for learning curve
Single stop intraoperative prostate Seeds Brachytherapy
ECC late 2009
HDR temporary implant
Meta-analysis of large patient studies Using % PSA progression free as an indication of survival
1 Patients should be separated into Low, Intermediate, and High Risk
2 Success must be determined by PSA analysis
3 All Treatment types considered
4 Article must be in a Peer Reviewed Journal
5. Low & Intermediate Risk articles must have a min of 100 patients
6. High Risk articles, because of fewer patients, need only 50 patients to meet criteria
7. Patients must have been followed for a median of 5 years
Criteria for Inclusion of Article*
* Expert panel consensus
77
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Seeds
Surgery
EBRT
5 5
22 22
← Years from Treatment →
CRYO
11 12 12
24 24
14 14 8 8
22
23 23
HIFU
% P
SA P
rogr
essi
on F
ree
1111
1515
Protons
21 21
4 4
1818
9 9
10 10
EBRT & Seeds
2525
Robot RP 26 26
27 27
HDR
28282929
3030
313132323333
34 34
1919 36 36
37 37
3838
LOW RISK RESULTS Weighted
3 3 3939
35
4040
100100
101101
1313EBRT
Brachy
Surgery
Trea
tmen
t Suc
cess
103103
102 102
66
16 16
104104
105105
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Brachy
Surgery
EBRT
CRYO
HIFU
29 29
2222
2121
5 5 1919
% P
SA
Pro
gres
sion
F
ree
1818
12 12
2828
3 3 17 17
10 10
32 32
99
88 2 2
2525
1 1
13 13
Protons
HDR
← Years from Treatment →
1515
443636
37 37
3838
++
Seeds Alone
Seeds + ADT40 40
Robot RP
4141
42 42
44 44
4343
4545
46 46
INTERMEDIATE RISK RESULTS Weighted
77
11 11
14 14
2020
35 35
34 34
39 39
23232424
1616
66
2626
3333
EBRT & Seeds
EBRT Surgery
Brachy
EBRT & Seeds
Hypo EBRT
EBRT, Seeds + ADT
Tre
atm
ent
Suc
cess 3030
27 27 47 47
66 11 11
3636
25 25
15 15
55
EBRT Seeds +ADT
19 19
3030
16 16 20 20
18 18
2929% P
SA P
rogr
essi
on F
ree
17
21 21
88
99
22 22
24 24
26 26
37 37
4141
1212
Protons
HDR
← Years from Treatment →
4242
43 434444
45 45
4646
47 47
Robot RP
48 48
4949
101101
102102
103103
104 104
105 105
106106
107 107
109 109
HIGH RISK RESULTSWeighted
10 10
2323
3535
108 108 44
22
3131
3939
3232
3333
3434
38
EBRT, Seeds & ADTEBRT, Seeds & ADTBrachy
EBRT Surgery
EBRT & ADT
EBRT & Seeds
Hypo EBRT
Trea
tmen
t Suc
cess
11
77
110110
2727
33
1313
1414
28 28
4040
100100
Thank you for listening
What other radiotherapy improvements will increase 5yr
survival?
• SABR – similar to VMAT but 5 visits only• Better planning including radiobiological systems
•Better knowledge of impact• Physically – transit dosimetry• Biologically – chip on a pill
• Better on-board imaging & faster delivery
• Ability to adapt treatment while on the couch
New imaging
Robotic deliveryProtons
HIFU
CRYO
Photodynamic
“Nanoknife”