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Advances in radiation oncology:Cancer care

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Advances in radiation oncology:Cancer care

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Radiation therapy has tremendous capacity for cancer cure. Advancement in last few decades have further enhanced its outcome. Global access would save many lives

Radiation therapy has tremendous capacity for cancer cure. Advancement in last few decades have further enhanced its outcome. Global access would save many lives

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Advances in radiation oncology:Cancer care

  1. 1. Advances in Radiation Oncology: Improvement and Outcome Dr Ajeet Kumar Gandhi MD (AIIMS), DNB (Gold Medalist) UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  2. 2. Treatment modalities • Surgery • Radiotherapy • Chemotherapy • Hormone therapy • Biological therapy/Immunotherapy • Pain and palliative care therapy • Alternative and Complimentary therapies
  3. 3. Radiation Therapy • Ionizing Radiation: X-rays, Gamma rays, electrons, protons
  4. 4. Dose (Gy) Control Complications Goal of radiation therapy
  5. 5. Radiation therapy cures: Saves lives • 40-50% of cancers are eliminated by radiotherapy either alone or in combination with other treatments: – Head & Neck Cancers – Lung Cancer – Cancer of Uterine Cervix – Prostate Cancer – Others: Urinary bladder, Vagina, Penis, brain tumour
  6. 6. Radiation therapy cures: Saves lives • Radiotherapy is given in combination with surgery/systemic therapy: – Brain tumors – Head & Neck Cancers – Breast Cancers – Lung Cancer – Gastrointestinal Cancer – Genito-urinary Cancers – Soft-tissue sarcoma – Lymphoma, Myeloma, Leukemia
  7. 7. Radiation therapy cures: Saves lives Benign Tumors – Acoustic Neuromas – Arteriovenous Malformations – Pituitary Adenomas – Trigeminal Neuralgia – Craniopharyngioma – Fibromatosis – Chordomas
  8. 8. Radiation therapy: Alleviates pain and Improves QOL • Neurological: Brain metastasis, Compressions • Pain: Tumor, bone metastasis, Nodes • Bleeding from tumor • Respiratory and obstructive symptoms
  9. 9. Advances in Radiation Oncology: Improving outcomes • IMRT/ IGRT/VMAT • RGRT • SBRT • Adaptive RT • 4DRT • Proton Beams and heavy ions • Image based Brachytherapy • IPSA • Real time image guided brachytherapy-SWIFT • Integrated Brachytherapy Unit
  10. 10. Intensity Modulated Radiotherapy is the key Complex and Irregular Anatomy for the tumor Different Nodal Volumes with different prescription Carcinoma Nasopharynx: c T4 N2c M0
  11. 11. Temporal Lobes Parotids Submandibular Glands larynx Brachial Plexus Constrictor Muscles Brain Stem Optic Chaisma Spinal Cord OARs for Head and Neck Radiotherapy
  12. 12. Dose sculpting/painting
  13. 13. Advances in RO: Improving outcomes
  14. 14. Advances in RO: Improving outcomes
  15. 15. Advances in RO: Improving outcomes Cyberknife Tomotherapy
  16. 16. Advances in RO: Improving outcomes MRI-Guided Radiation therapy
  17. 17. Advances in RO: Improving outcomes Proton therapy
  18. 18. Technology transcends to practice Advances in RO: Improving outcomes
  19. 19. Metabolism: 18F-FDG 11C-Met Proliferation: 76Br-BFU (Bromo Fluro-deoxyuridine) Hypoxia:18F-EF3 (2-Nitro Imidazole marker) Advances in RO: Improving outcomes Biological targeting
  20. 20. Advances in RO: Brachytherapy
  21. 21. Advances in RO: Brachytherapy different sites Ca Prostate Ca Cervix: ISBT Soft Tissue Sarcoma Ca Breast
  22. 22. Advances in RO: Intra-operative radiotherapy
  23. 23. Advances in RO: Surface Mold Brachytherapy
  24. 24. Randomized Trials documenting superiority Reference Design Site of Disease Primary Endpoint Results P Value JCO,2007;2 5 (31), Nov 1 Prospective Randomize d [2D vs. IMRT] T1-2b N0- 1 M0 Nsophary nx cancer Severe xerostomia @ 1 Year @ 1 year, Severe xerostomia: 39.3% vs. 82.1% 0.001 JCO,2008;2 6 (13), May 1 Multicentric ,double blinded RCT [IMRT vs. CRT] Breast Moist desquamati on Moist Desquamation: 31.2% vs. 47.8% 0.003 Lancet Oncology, 2011;12:12 7-36 Phase III, Multi- centric, RCTs [IMRT vs. CRT] Head & Neck Cancers Parotid Sparing [Grade 2 or worse xerostomia] @ 12 Months- Grade 2 Xerostomia: 38% vs. 74% @24 Months- 29% vs. 83% 0.0027 0.0001
  25. 25. Randomized Trials documenting superiority Reference Design Site of Disease Primary Endpoint Results P Value Lancet 1999;353:267- 72 Randomized Trial [Conformal vs. Conventional] Prostate Radiation induced proctitis and bleeding RTOG ≥ 1: 37% vs. 56% RTOG ≥ 2 : 5% vs. 15% 0.004 0.01 JCO 2013; 31 (36): 4488-95 Randomized controlled trial [IMRT vs. CRT] Breast Overall cosmesis & Skin Telengectas ia Overall cosmesis better with IMRT [OR 0.68] & Telengectasia [OR 0.58] 0.027 Radiotherapy and Oncology; 2012;103:305- 313 Prospective Multicentric Study [ 2D vs. 3D] Carcinoma Cervix [PDR Brachyther apy] 3D Brachytherapy has improved local control and half the toxicity with 2D Dosimetry
  26. 26. prostate specific antigen relapse-free survival Survival benefit: IGRT vs. Non-IGRT in Prostate Cance
  27. 27. Beadle BM, MDACC. Cancer, 2013 [Ahead of Print]  SEER Medicare analysis [1999-2007]  A total of 3172 patients were identified. Median follow-up of 40 months.  CSS of IMRT vs. Non- IMRT (84.1% versus 66.0%; P <.001) both overall and subset wise.  Difference persisted on multivariable analysis
  28. 28.  India is sorely under equipped, having just 1machine per 21 lakh people and would need 1215 teletherapy machines by 2020  2756 radiation oncologists, 1533 medical physicists, and 4737 radiation therapists must join the work force by 2020 to meet India’s needs.
  29. 29. Radiation Oncology India: Challenges & Opportunities • Patients can wait up to 2months after diagnosis before treatment is initiated in public hospitals. These delays adversely affect patient outcomes • More than 70% of India's population resides in rural settings but only 40/640 districts have LINAC • Wide regional disparity and public/private access to radiotherapy
  30. 30. Cost Amount of Use Health Policy Decision Indigenous Production and Design Acceptance
  31. 31. Indigenous Design: Panacea • Bhabhatron-II with MLC • Integrated IGRT unit: G Ray [Co-60 with 70 cm SSD] • Karknidon: Ir-192 afterloader [20 Channels] 33
  32. 32. Inform Govt and policy makers make radiotherapy a central component of cancer care in policies, planning and budget Plan Patient group and media: Improve general awareness about radiotherapy and it`s need Harmonize Multidisciplinary cancer care: Fully integrate radiotherapy in treatment planning Integrate Professional Societies: Education of radiotherapy professionals Invest Investment in research and use of data for Innovation
  33. 33. THANK YOU ajeetgandhi23@gmail.com 9560703223

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