Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

International Conference on Advances in Radiation Oncology (ICARO): Outcomes of an IAEA Meeting

International Conference on Advances in Radiation Oncology (ICARO): Outcomes of an IAEA Meeting The IAEA held the International Conference on Advances in Radiation Oncology (ICARO) in Vienna on 27-29 April 2009. The Conference dealt with the issues and requirements posed by the transition from conventional radiotherapy to advanced modern technologies, including staffing, training, treatment planning and delivery, quality assurance (QA) and the optimal use of available resources. The current role of advanced technologies (defined as 3-dimensional and/or image guided treatment with photons or particles) in current clinical practice and future scenarios were discussed. ICARO was organized by the IAEA at the request of the Member States and co-sponsored and supported by other international organizations to assess advances in technologies in radiation oncology in the face of economic challenges that most countries confront. Participants submitted research contributions, which were reviewed by a scientific committee and presented via 46 lectures and 103 posters. There were 327 participants from 70 Member States as well as participants from industry and government. The ICARO meeting provided an independent forum for the interaction of participants from developed and developing countries on current and developing issues related to radiation oncology. Introduction The ICARO meeting provided an overview of topics ICARO: Advancing Radiation Oncology and issues facing the modern radiation oncologist with All countries are facing an increased demand for health an emphasis on advanced technologies and covering services. In cancer care, there are more expensive topics as shown in Table 1. Invited speakers were pro- demands in diagnosis and treatment, including radiation minent in the field, many with experience in LMI coun- therapy, and systemic therapies. Radiation therapy is a tries. Parallel sessions were held on topics specific for a cost-effective method of treating cancer, yet it is una- subset of the audience (medical physicists and radiation vailable in many low income countries throughout the oncologists) along with side events to discuss very speci- world. In high income countries, the ratio of treatment fic issues such as QA in clinical trials and collaboration machines to population may be as high as six per mil- with commercial companies. Summaries of individual lion individuals, but in many low and middle income sessions are highlighted in the text. (LMI) countries, the ratio may be as low as one per 10- Conclusions based on interaction and discussion 70 million individuals. Twenty IAEA Member States between participants focused on inadequacies of current have no radiotherapy services at all and many low- systems: � There are many low income countries with no or income countries have only basic equipment and often few trained and qualified staff, for which there is a glo- very basic diagnostic and treatment facilities. bal shortage. � Low and middle income (LMI) countries have an increasing number of cancer patients who present with advanced stage disease, with few radiotherapy facilities. Palliative treatment is common, but there are an * Correspondence: eevsal@utu.fi † Contributed equally increasing number of potentially curable patients. STUK, Finnish Radiation and Nuclear Safety Authority and Dept. of Radiation � Demand for radiotherapy services in LMI countries Oncology Turku University Hospital, Finland will increase dramatically over the next 20 years. Full list of author information is available at the end of the article © 2011 Salminen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Salminen et al. Radiation Oncology 2011, 6:11 Page 2 of 9 http://www.ro-journal.com/content/6/1/11 Table 1 Overview of ICARO programme topics Main topic Advanced techniques (*) in teletherapy Clinical sessions/clinical practice Advances in chemo-radiotherapy in cervical and head-and-neck cancer Current trends in brachytherapy Radiotherapy in paediatric oncology Reducing late toxicities Altered fractionation Training sessions/educational How to set up a QA programme? Commissioning and implementing a QA programme for new technologies Transition from 2D to 3 D CRT and IMRT Training, education and staffing: evolving needs/getting ready to transition to the new technologies Cost and economic analysis in radiation oncology Planning new activities PACT meeting with manufacturers of diagnostics and radiotherapy equipment Global quality improvement for clinical trials in radiation oncology Controversial topics and debates Co-60 - no time for retirement? IMRT-are you ready for it? Do we need proton therapy? (*) For the purposes of this report, “advanced technologies” include 3-D conformal radiation therapy (3D-CRT), intensity modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), adaptive radiation therapy (ART), respiratory-gated radiation therapy (RGRT), particle radiation therapy, and image-guided brachytherapy (IGBT) in all aspects; planning, treatment delivery, and quality assurance. Diagnostic Imaging Requirements roughly comparable when combining initial and ongoing Many successes in the treatment of cancer with radia- costs. Cobalt-60 sources must be replaced every 5-6 years, tion therapy are related to earlier diagnosis, a multidisci- requiring disposal of the old sources (an increasingly costly plinary approach to cancer diagnosis and treatment, and and logistically difficult problem) and this expense must be more precise delivery of radiation therapy. Recent weighed against cost, commissioning, training, and mainte- advances in radiation therapy planning and delivery nance of a linac which has a useful lifespan of 10-12 years. allow improved normal tissue sparing and escalation of QA programmes are more complex for linac units. In the tumour dose compared to conventional techniques some LMI countries, the frequent lack of stable electrical (2D RT). These improvements require precise definition power can interfere with the smooth operation of linacs. of the tumour target, especially when three-dimensional Service personnel may have to travel long distances, and conformal radiation therapy (3D-CRT) and intensity- parts may not be readily available. Frustrations were modulated radiation therapy (IMRT) are under consid- expressed with expensive and delicate equipment that was eration. Often this requires the use of dedicated rendered unusable by simple problems, especially when computed tomography (CT) scanning, which can be requirements for infrastructure, staff training and mainte- integrated into treatment planning software. X ray expo- nancewerenot initiallyrecognized. sure associated with extra imaging must be considered. The current and emerging need for teletherapy units There is a general increase of diagnostic X ray exposure in developing countries cannot be met by cobalt worldwide in health care. The risks of radiation expo- machines alone. Selecting the right equipment should be sure in radiation treatment planning may be mitigated mainly based on local radiotherapy experience and case- by requirements for precise treatment delivery, and mix, as well as on financial, technical and human developments in CT equipment may help reduce this resources available. Many LMI countries may benefit exposure. from the use of both cobalt units and linacs with use based on complexity of treatment. Current role of cobalt-60 Conclusion: A debate was held regarding the utility of cobalt-60 tele- therapy in routine practice. Cobalt-60 units have tradition- � There remains a role for cobalt teletherapy in LMI ally been “friendlier” treatment machines to place in new countries. New technical developments may allow low-resource departments with regards to cost, the training the introduction of highly-conformal treatment tech- required, treatment delivery, planning, and maintenance niques with cobalt but this increases the cost to the [1,2]. However, the production cost of cobalt-60 sources is level of medical linear accelerators. increasing and there are heightened security concerns. Modern sophisticated cobalt machines are more costly, reflecting increasing pricing. At the same time, there has Implementation of advanced technologies been a relative decrease in the cost of small, single-energy A series of keynote lectures discussed the underlying linear accelerators (linacs), making the two modalities hypothesis for the use of advanced technologies in Salminen et al. Radiation Oncology 2011, 6:11 Page 3 of 9 http://www.ro-journal.com/content/6/1/11 radiation therapy, discussing the assumption that improved dose distribution [5]. Unexpected toxicities improved dose distribution leads to improvement in and recurrences have been reported in the literature [3]. clinical outcomes. In the USA, where such trials could be done, there is New treatment technologies are evolving at a rate great difficulty recruiting patients to the non-IMRT arm unprecedented in radiation therapy, paralleled by because hospitals promote IMRT in order to stay eco- improvements in computer hardware and software. The nomically competitive. In Europe, IMRT is used some- what less, with figures for Belgium being approximately challenging use of highly precise collimators in the 50% and the UK less than 50%. In India and South IMRT setting, small fields, robotics, stereotactic delivery, Africa, the figure drops to 25%. Comparative case series volumetric arc therapy and image guidance has brought new challenges for commissioning and QA. Existing QA [6,7] and some phase-III trials [8,9] have been com- guidelines are often inadequate for some of these tech- pleted in the USA, Europe and Asia. The overall conclu- nologies. New QA procedures are needed and are under sion from these trials is that there is evidence of development. In the meantime, the existing paradigm of reduced toxicity for various tumour sites by the use of commissioning followed by frequent QA should con- IMRT. The evidence regarding local control and overall tinue, with attention paid to the capabilities offered by survival is generally inconclusive [5]. the new technologies. Risk management tools should be Advanced technologies of radiation treatment such as adapted from other industries to help focus QA proce- IMRT require optimal immobilization and image gui- dures on where they can be most effective. dance techniques. There was debate as to whether These techniques allow assessment of changes in the image guidance was always required with IMRT to tumour volume and its location during the course of ensure accurate delivery. Whether image guidance was therapy (interfraction motion) so that re-planning can necessary daily was also debated and this may be neces- adjust for such changes in an adaptive radiotherapy pro- sary in specific cases, such as when immobilization is cess. Some target volumes move during treatment due not optimal or when hypofractionation is used. Other to respiration (intrafraction motion), especially those in techniques to control organ motion during treatment the lung, liver and pancreas. Advanced techniques for such as respiratory-gating and breath-hold techniques compensating for such motion are already commercially may be necessary when reduced target volumes are available and include respiratory gating, active breathing considered. control and target tracking. A survey on IMRT conducted in the USA [10] deter- mined that the three main motivators for implementing The speakers advised to approach the implementation this modality were normal tissue sparing (88%), allowing of the new technologies with caution. If the identifica- tion of target tissues is uncertain when margins around dose-escalation (85%) and economic competition (the target volumes are tight, the likelihood of geographic desire to remain competitive) (62%). In addition, 91% of misses or under-dosing of the target increases. Move- non-users planned to adopt IMRT in the future. ment of the target with respiration or for any reason Image Guided Radiation Therapy (IGRT) can be during treatment increases the risk of missing or under- defined as increasing the radiotherapy precision, by fre- dosing the target. Since in some instances IMRT uses quent imaging the target and/or healthy tissues just more treatment fields from different directions, its use before treatment and acting on these images to adapt the may increase the volume of normal tissue receiving low treatment [11]. There are several image-guidance options doses which might lead to a higher risk of secondary available: non-integrated CT scan, integrated x-ray (kv) cancers. With the introduction of any advanced technol- imaging, active implanted markers, ultrasound, single- ogy, such as IMRT and IGRT, data should be collected slice CT, conventional CT or integrated cone-beam CT. prospectively, to allow a thorough evaluation of cost- A survey on IGRT in the USA [12] revealed that the effectiveness and cost-benefit [3,4]. proportion of radiation oncologist self-declared users of A debate on IMRT: Are you ready for it? brought IGRT was 93.5%. However, when the use of megavoltage together panel members who represented various views (MV) portal imaging was excluded from the definition from all regions of the world, including high and LMI of IGRT, the proportion using IGRT was 82.3%. Among countries. A modality such as IMRT offers the theoreti- IGRT users, the most common disease sites treated are cal potential to increase radiation dose to tumour target genitourinary (91.1%), head and neck (74.2%), central volumes while sparing normal tissues. Health economics nervous system (71.9%), and lung (66.9%). Conclusions: was identified as a key motivator in the adoption of IMRT. There is still a lack of randomized trials support- � Robust clinical trials are necessary to demonstrate ing robust evidence of clinical benefit of IMRT in many tumour sites. There is little prospective data demon- the benefits of advanced technologies before they are strating that IMRT provides clinical benefit other than adopted into widespread use. Salminen et al. Radiation Oncology 2011, 6:11 Page 4 of 9 http://www.ro-journal.com/content/6/1/11 � A new and unproven technology should not be of these technologies. New QA procedures are needed universally adopted as a replacement for established and are under development. In the meantime, the exist- proven technologies. ing paradigm of commissioning followed by frequent QA � LMI countries should avoid the risk that by hasty should continue, with attention paid to the capabilities implementation of new technologies, patients would offered by the new technologies. Risk management tools no longer have access to established methods of should be adapted from other industries, to help focus treatment. QA procedures on where they can be most effective [13]. It was observed by several speakers that IMRT requires increased attention to physics and dosimetry, more Introduction of advanced technologies: the radiation equipment, training and technical support, and more oncologist perspective time for quality assurance. Specific issues mentioned It was noted that the implementation of advanced radio- included the critical need for accurate calibration of the therapy technologies tends to distance the physician from position of multi-leaf collimator leaves, and the precise the patient, a trend that needs to be consciously counter- modelling of radiation dose distributions especially in the balanced by a more personal and holistic approach. In penumbra region produced by MLC leaves. The veracity addition, it makes it more and more difficult to intuitively of data transfer from the treatment plan to the treatment understand the relationship between the radiation fields machine is critical whether it be by electronic or manual and the patient’s anatomy. Whereas with 3D conformal means, and should be included in QA programmes. radiation therapy, the physician can rely on port films to assess the irradiated volume, with IMRT the physician Fractionation must rely on tools such as computer simulations and Advanced technologies provide an opportunity for the dose-volume histograms (DVH). Users of advanced tech- acceleration of treatment without excessive risk to nor- nologies should be cautioned not to allow themselves to mal tissue [3]. Hypofractionated treatments are more become too dependent upon the technology itself. It was convenient to patients and caregivers. But convenience also recommended that advanced technologies such as is not enough to make hypofractionation a mainstay IMRT and IGRT should not be acquired until physicians treatment. Much of this subject is still surrounded by and hospital staff are fully experienced with advanced ongoing controversy. The avoidance of dreaded late treatment planning techniques in 3D conformal therapy. effects of hypofractionation obviously cannot be con- Modern 3D approaches including IMRT introduce new firmed without long and careful follow-up [14]. requirements in terms of understanding of axial imaging In curative and palliative treatment, several trials of and tumour/organs delineation. Recent literature points hypofractionation in common cancers have shown com- to an uncertainty level at this stage known as “inter- parable clinical outcomes to conventional fractionation. observer variations”. Efforts continue to harmonize the These schedules vary for different diseases with fractions criteria with which tumours, organs and anatomical >2 Gy given daily to once weekly. Common cancers, structures are contoured and how volumes are defined. such as breast cancers, can be successfully treated in three weeks rather than in five weeks [15]. Advanced Introduction of advanced technologies: the medical technology radiation therapy (3D CRT and IMRT) may physics perspective provide an opportunity for the study of tissue tolerance The introduction of IMRT and stereotactic radiation as high doses per fraction can be delivered to small therapy procedures brings special physics problems. For tumour volumes while normal tissues receive conven- example, it is required that calibrations be performed in tional fractionated radiation. small fields, for which the dosimetry is challenging, and Investigators treating common diseases such as pros- no harmonized dosimetry protocol exists. Use of the tate and breast cancer are using non-ablative hypofrac- correct type of dosimeter is critical, and errors in mea- tionation in patients with curable tumours. This strategy surement can be substantial. Several new treatment tends to be well received in environments where the machines provide radiation beams that do not comply cost-savings associated with fewer fractions is important. with the reference field dimensions given in existing In some cases, such hypofractionation has a biological dosimetry protocols complicating the accurate determi- rationale for improving the therapeutic ratio [14]. nation of dose for small and non-standard beams. Conclusions: The introduction of highly precise collimators in the IMRT setting, small fields, robotics, stereotactic delivery, � There is significant published experience with the volumetric arc therapy and image guidance has brought use of hypofractionated regimens in breast, [15,16] new challenges for commissioning and QA. The existing prostate [17,18] brain/body [19] and palliative radiotherapy. QA guidelines are often inadequate for the use of some Salminen et al. Radiation Oncology 2011, 6:11 Page 5 of 9 http://www.ro-journal.com/content/6/1/11 � The use of hypofractionated regimens can be parti- cancer patients should be done preferably within clinical cularly useful in limited-resource centres overloaded studies for collecting data, which allows clear compari- with large number of patients. sonwithconventional photontreatment,therebydefin- ing the role of proton therapy precisely within radiation oncology. Reported biochemical disease-free survival Current role of proton therapy rates after carbon ion radiotherapy appear higher than with modern photon IMRT and proton RT especially The dosimetric advantage of charged-particle beam for patients with high-risk prostate cancer [24]. radiotherapy derived from the Bragg peak was empha- Slater and co-workers [23] report a 5-year NED rate sized. Protons and other particles have been used for decades for ocular melanomas, base of skull tumours, of 57% while a 5-year NED rate of 51% was reported for and brain tumours where radiation dose escalation conventional RT with photons [25]. using photons was not possible due to normal tissue Photon IMRT yields a biochemical DFS rate of 81% at constraints. The first hospital-based proton facility was 3 years, whereas severe toxicity rates to the genitourin- opened in Loma Linda (USA) in 1999 [20]. Since then, ary system and the rectum are higher as compared with over 30 particle-based facilities have opened and another the rates reported by Akakura and co-workers with car- 30 are in the planning stages worldwide, primarily for bon ions (10% vs. 1.4%) [24]. the treatment of cancer patients. Until recently, the sig- Conclusions: nificant capital expenditure required for the establish- ment of a proton facility has limited the availability of � Physical dose distributions of proton beams are this form of radiation therapy in many areas of the superior to those of photons world. This modality is expensive, time consuming, and � The cost of establishing and maintaining proton requires special expertise. The cost of treatment is sig- facilities is significant nificantly higher than conventional 3D-CRT. � Clinical trials are underway and over the next sev- During the ICARO meeting, a debate addressed the eral years an increased amount of clinical data will question: Is there a need for proton therapy? Proponents become available and opponents considered the following three proposi- � The question of whether the clinical gains from tions: (1) Proton dose distributions with currently avail- proton therapy will outweigh the costs is an unre- able equipment are likely to be of real benefit to solved issue. patients; (2) On the basis of clinical evidence, protons should be made available for radical radiotherapy to many more patients; and (3) Further technological Brachytherapy developments will make proton therapy more cost The session on brachytherapy highlighted recent advances effective. in this modality of radiation therapy. In the past, The speakers described the advantages offered by brachytherapy was carried out mostly with Radium ( Ra) proton beams, such as increased conformality of dose sources. Currently, use of artificially produced radionu- 137 192 60 198 125 103 distributions to target volumes and lower doses to non- clides such as Cs, Ir, Co, Au, I, and Pd has target tissues. The speakers provided examples of exqui- rapidly increased. sitely-shaped dose distributions that can be achieved Brachytherapy is an essential component of the cura- with both photon IMRT and with spot-scanned protons. tive treatment of cervical cancer (a very common disease It was mentioned that the improved dose distributions in many LMI countries) and cannot be replaced by with protons might offer significant benefits to paedia- other modalities in this setting. High dose-rate (HDR) tric patients, although the benefits might require some brachytherapy is preferable to low dose-rate (LDR) for years to become detectable and may not yet be readily departments with limited resources that treat a large measureable. No benefit has been demonstrated in the number of patients with cervical cancer. New systems treatment of prostate cancer, including following com- using a miniaturised Co source are becoming very pletion of one randomized trial [21] although proton popular [26-29]. This is due to the fact that Co based therapy appears at least to match the high success rates HDR systems require source replacement approximately and low toxicity available with photon IMRT [22,23]. every 5 years while Ir requires replacement every Future advances in proton therapy equipment and tech- 3-4 months. This represents a significant advantage in nologies are expected to provide even greater benefits terms of resource sparing, import of radioactive sources through improved dose distributions and patient into countries, regulatory requirements and additional throughput, but challenges in standardizing calibrations, workload [30]. treatment parameters, and the relative biological effec- Over the last decade developments in imaging, com- tiveness must be addressed first. Proton treatment of puter processing and brachytherapy systems and Salminen et al. Radiation Oncology 2011, 6:11 Page 6 of 9 http://www.ro-journal.com/content/6/1/11 applicators have made possible to implement three- times. Therefore, all centres implementing HDR bra- dimensional treatment planning based on cross sectional chytherapy must establish a written policy on QA and imaging with the applicators in place using CT or MRI. pay utmost attention to basic principles of radiation This has been successfully developed for the brachyther- protection. apy of cervical cancer [31-33]. HDR treatments dramatically increase the physician Individual departments in low-middle income coun- and physicist resources that must be allocated to bra- tries should carefully weight the advantages and disad- chytherapy while reducing the needs for inpatient hospi- vantages of adopting this system which implies expenses tal beds. The relative cost and availability of these resources should be compared, and the cost-savings, in terms of applicators and requires readily available MRI services dedicated to the brachytherapy unit or compared with the cost of amortizing the capital invest- department. ment required and the cost of source replacement and In prostate cancer, excellent long-term tumour control machine maintenance [40]. can be achieved with brachytherapy, and this approach is considered a standard treatment intervention asso- Education and training ciated with comparable outcomes to prostatectomy and An important theme echoed by several speakers and the external beam radiotherapy for patients with clinically audience was the global shortage of skilled professionals. localized disease [34]. In low-risk disease patients, seed It was noted that while short-term and local solutions implantation alone (monotherapy) achieves high rates of have been devised, there was a need for a long-term biochemical tumour control and cause-specific survival strategy to produce trainers and educators who could outcomes. For those with intermediate risk and selected increase the supply of adequately trained staff. Training high-risk disease, a combination of brachytherapy and must be adapted to both the working environment and external beam radiotherapy is commonly used. the level of complexity of the available technology; little In the treatment of prostate cancer, the radioactive benefit is derived by a trainee or the trainee’s institution sources can be implanted permanently using I seeds when the education addresses a technology not available [35] or as a fractionated temporary implant using a high in his or her own country. dose-rate stepping source. Although the experience with Thereisclearlyarolefor networking onthenational seed implantation is more extensive and the results and regional levels to support education networks. The mature [36], the use of HDR brachytherapy as monother- role of the IAEA in education and training through apy or combined with external beam therapy is becoming national and regional training courses and development more popular in radiotherapy departments that already of teaching materials and syllabi was recognized. Conclusions: have a HDR brachytherapy device, thus avoiding the costs and procedures of importing I seeds for each individual patient [37,38]. HDR brachytherapy offers sev- � Thereisaworldwideshortageofqualified radio- eral potential advantages over other techniques. Taking therapy professionals advantage of an afterloading approach, the radiation � Specialized education and training must be pro- oncologist and physicist can more easily optimize the vided to meet this demand. delivery of radiation therapy to the prostate and reduce the potential for under-dosage ("cold spots”). Further, this technique reduces radiation exposure to the care Cost considerations providers compared to permanent seed implantation. In the delivery of routine radiotherapy, most expendi- Current approaches are employing HDR monotherapy ture is in personnel costs, followed by equipment costs for intermediate risk patients avoiding the need for sup- and depreciation. Each institution has its own require- plemental external beam radiotherapy [39]. ments for equipment and personnel. These require- Both approaches are time/effort consuming and require ments are based on the type and stages of encountered careful attention to technical detail. An imaging method cancers ("case-mix”), the type of equipment and facilities (commonly trans-rectal ultrasound) has to be used dur- availability, local work practices, and method of finan- ing seed or needle implantation. The procedures require cing, maintenance costs, and down-time and life cycle of attention to accurate dosimetry and normally there is a treatment machines. Many countries have observed the “learning curve” for the whole brachytherapy team. cost of radiation therapy delivery to have increased The introduction of HDR brachytherapy as a treat- annually. ment modality carries with it additional concerns related The IAEA has developed a cost estimator [41] which to QA and radiation protection. The very principle of takes into account potential workload based on cancer HDR brachytherapy is based on working with a very incidence and staging, overhead and indigenous costs of high activity radiation source, and short treatment personnel and facilities, in addition to equipment costs. Salminen et al. Radiation Oncology 2011, 6:11 Page 7 of 9 http://www.ro-journal.com/content/6/1/11 The costs of a cobalt-60 machine when including ulti- � The value of advanced technology must be mate source disposal, has become similar to a low assessed relative to the indigenous needs and struc- energy linear accelerator, but training, personnel, and tures of the country. It is important that radiation maintenance costs are lower and reliability is higher. oncology be part of health planning for a country/ Cost-effectiveness analysis (CEA) is a form of economic community, particularly when there is competition analysis that compares the relative costs and outcomes for health financial resources. � In LMI countries, service and maintenance must (effects) of two or more courses of action [42]. Cost- be considered. Service and spare parts are often not effectiveness analysis is distinct from cost-benefit analysis, readily available and must come from great dis- which assigns a monetary value to the measure of effect [43]. Cost-effectiveness analysis is often used in the field of tances. In the curative treatment of cancer, the health services, where it may be inappropriate to monetize impact of equipment ‘down-time’ may be significant health effect. Typically, CEA is expressed in terms of a and measurably detrimental. ratio where the denominator is a gain in health from a measure (years of life) and the numerator is the cost asso- ciated with the health gain. The most commonly used out- New activities launched at ICARO come measure is quality-adjusted life years (QALYs) [44]. Two sessions focused on completely new activities Cost effectiveness can be measured in gain in quality which are to be facilitated by the IAEA in the future. adjusted life years (QALY), cost per QUALYs, cost per year of life gained or cost per loco-regional failure 1. Quality assurance of international clinical trials avoided. A session was held which reported on the objectives and When assessing the usefulness of newer advanced current status of a working party that is addressing technologies, cost effectiveness can be measured several improvements to the implementation of international ways: clinical trials. Harmonization of QA requirements and Is the number of patients to whom services are deliv- the streamlining of facility questionnaires were dis- ered increased? (Improved access). Are cure-rates cussed, as were the requirements for databases and digi- increased? (improved curability). Is toxicity significantly tal data submission for improved record collection and reduced? (Improved therapeutic index) What is the ulti- analysis. This global working party will meet several mate objective for the introduction of a new technology? times a year to continue the process of analysis and And what are its cost implications? improvement of international clinical trials. Systematic studies of the newer technologies seem required following the methodologies of health technol- 2. PACT and manufacturers ogy assessment and the dissemination of the results in a A side-meeting with manufacturers of diagnostic and form that is accessible to clinicians, mangers and the radiotherapy equipment was hosted by IAEA’sProgramme public. Unfortunately, much of the evidence indicates of Action for Cancer Therapy (PACT) and the Division of that it is difficult to influence practitioners simply by Human Health (NAHU). This meeting was convened due producing and disseminating information. to the IAEA’s unique and leading role in assisting Member Although extremely important, education and training States in the development of cancer therapy, strengthening costs are not usually considered in these formulas. Cost collaboration with manufacturers in providing equipment effectiveness can often be improved by optimal use of that is safe, affordable and technically suitable for develop- conventional technologies and better work practices. For ing country conditions. An advisory group was established instance, hypofractionation can increase patient to continue the process of discussions between the IAEA, throughput while maintaining the same outcome in manufacturers and users [45]. selected indications. Radiotherapy services in LMI countries need high level Conclusions government commitment to mobilize the necessary Demand for radiotherapy services in LMI countries will funds of approximately $5-6 million necessary to estab- increase significantly in the next 20 years. Many Mem- lish a basic cancer centre. Such projects, when com- ber States are still without or with only very basic radio- pleted, take at least 5 years to make a noticeable therapy facilities. There is a shortage of qualified difference in the health care system as a whole. radiation oncologists, medical physicists, dosimetrists, Conclusions: radiation therapists, nurses, and maintenance engineers in the developing world. Education and training must be � ICARO speakers and panellists emphasized that provided to meet this demand and training must be ide- each country should have a comprehensive plan for ally adapted to the available equipment and disease cancer control. profiles. Salminen et al. Radiation Oncology 2011, 6:11 Page 8 of 9 http://www.ro-journal.com/content/6/1/11 Since there is competition for health care resources thereisa paucityofevidence thatIMRTcan and equipment, technical support has to be consistent improve tumour-related outcomes, and clinical trials with the health system infrastructure of each country to are clearly needed. keep radiation treatment affordable, safe and of good � Despite the growing use of protons in various sites quality. In LMI countries, service and maintenance are including prostate cancer, proton therapy must remain often not available and must come from afar. This under scrutiny until it has proven itself cost-effective. needs to be recognized when purchasing any equipment or technology. Theconferencegavedelegates of LMIcountries an Acknowledgements opportunity to assess new technologies relative to their The ICARO meeting was organized by the IAEA and co-sponsored and own situations. Many aspects of advances in radiation supported by ESTRO, ASTRO, ABS, AAPM, IARR, and ICRU, with cooperation from ALATRO, EANM, AFOMP, INCTR, IOMP, TROG, and UICC. Additional oncology were covered and evaluated, ranging from the financial support was received from industries and manufacturers. role of basic technology to how to upgrade and adapt departments to advanced technology. The benefits, Author details STUK, Finnish Radiation and Nuclear Safety Authority and Dept. of Radiation implications, pitfalls, economics, risks, and practicalities Oncology Turku University Hospital, Finland. Department of Nuclear of implementing advances from a variety of viewpoints Sciences and Applications, Division of Human Health, International Atomic were discussed. Energy Agency, P.O. Box 100, Vienna, Austria. Department of Radiation Oncology, Northwestern University, 1653 W. Congress Pkwy, Chicago, IL 60612, USA. Radiological Physics Center, UT M.D. Anderson Cancer Center, Recommendations 5 Box 547, 1515 Holcombe Blvd Houston, TX 77030, USA. Dept. of Radiation � Basic radiation therapy services at a minimum Oncology, Wayne State University School of Medicine, Gershenson Radiation Oncology Center, 4100 John R. Detroit, MI 48201-2013. should be made available to all patients with cancer who need them. Authors’ contributions � Education and training programmes to enable EKS was Scientific Secretary of the ICARO Conference and contributed to drafting and review, KK, GSI and MCJ acted as rapporteurs of the meeting good quality radiation therapy services need to be and drafted the initial meeting report, ER, EZ, JW and AM were part of the developed and job opportunities offered with ade- ICARO Organizing Committee and all contributed to the drafting and review quate salary levels to retain staff. of this article. All authors read and approved the final manuscript. � Advanced technologies in radiation therapy should Competing interests not be universally adopted until the following condi- The authors declare that they have no competing interests. tions are met: Received: 27 September 2010 Accepted: 4 February 2011 - A need for advanced technology exists (i.e. Published: 4 February 2011 patients with curative potential) - Experience with 3D conformal radiation ther- References apy and advanced treatment planning exists 1. Adams EJ, Warrington AP: A comparison between cobalt and linear accelerator-based treatment plans for conformal and intensity- before implementation of more advanced modulated radiotherapy. Br J Radiol 2008, 81:304-10. technologies 2. Rachivandran R: Has the time come for doing away with Cobalt-60 - Adequate imaging services are available teletherapy for cancer treatments? J Med P 2009, 34:63-5. 3. Vikram B, Coleman CN, Deye JA: Current status and future potential of - Studies demonstrate a universal advantage to advanced technologies in radiation oncology. Part 1: Challenges and each aspect of advanced technology, either in resources. Oncology 2009, 23:279-83. improving local control or in reducing toxicity 4. Vikram B, Coleman CN, Deye JA: Current status and future potential of advanced technologies in radiation oncology. Part 2: State of the - Personnel have adequate training in planning, science by anatomic site. Oncology 2009, 23:380-5. implementation, and QA in advanced technology 5. Veldeman L, Madani I, Hulstaert F, De Meerleer G, Mareel M, De Neve W: - Continuous medical education system is in Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies. Lancet Oncol 2008, 9:367-375. place. 6. Rothschild S, Studer G, Seifert B, Huguenin P, Glanzmann C, Davis JB, - An adequate QA/QC programme is in place. Lütolf UM, Hany TF, Ciernik IF: PET/CT with intensity modulated radiotherapy (IMRT) improves treatment outcome of locally advanced pharyngeal carcinoma: a matched-pair analysis. Radiation Oncology 2007, � Clinical studies should be undertaken to demon- 2:22. strate clinical and cost-effective benefits to the advanced 7. Zelefsky MJ, Fuks Z, Happersett L, Lee HJ, Ling CC, Burman CM, Hunt M, technologies. Wolfe T, Venkatraman ES, Jackson A, Skwarchuk M, Leibel SA: Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 2000, 55(3):241-249. � Each country must clearly define which cancer 8. Pignol J, Olivotto I, Rakovitch E, Gardner S, Ackerman I, Sixel K, Beckham W, outcomes are expected to be improved by the intro- Vu T, Chow E, Paszat L: Phase III randomized study of intensity modulated radiation therapy versus standard wedging technique for adjuvant breast duction of advanced technologies. radiotherapy. Int J Radiat Oncol Biol Phys 2006, 66(3 Suppl 1):S1. � New technologies such as IMRT offer theoretical 9. Donovan E, Beakley N, Denholm E, Evans P, Gothard L, Hanson J, Peckitt C, advantage in radiation dose distribution. Presently, Reise S, Ross G, Sharp G, Symonds-Tayler R, Tait D, Yarnold J: Randomised Salminen et al. Radiation Oncology 2011, 6:11 Page 9 of 9 http://www.ro-journal.com/content/6/1/11 trial of standard 2D radiotherapy versus intensity modulated radiation with emphasis on MRI assessment of GTV and CTV. Radiother Oncol 2005, therapy (IMRT) in patients prescribed breast radiotherapy. Radiother 74:235-245. Oncol 2007, 82:254-64. 32. Pötter R, Haie-Meder C, Van-Limbergen E, Barillot I, De Brabandere M, 10. Mell LK, Mehrotra AK, Mundt AJ: Intensity-modulated radiation therapy Dimopoulos J, Dumas I, Erickson B, Lang S, Nulens A, Petrow P, Rownd J, use in the U.S. 2004. Cancer 2005, 104:1296-1303. Kirisits C: Recommendations from gynaecological GEC-ESTRO working- 11. Van Herk M: Different styles of Image-Guided Radiotherapy. Semin Radiat group (II): concepts and terms in 3D image-based treatment planning in Oncol 2007, 17(4):258-267. cervix cancer brachytherapy - 3D dose-volume parameters and aspects 12. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK: A survey of of 3D image-based anatomy, radiation physics, radiobiology. Radiother image-guided radiation therapy use in the United States. Cancer 2010, Oncol 2006, 78:67-77. 116(16):3953-60. 33. Viswanathan AN, Erickson BA: Three-dimensional imaging in gynecologic 13. Shortt K, Davidson L, Hendry J, Dondi M, Andreo P: International brachytherapy: a survey of the American Brachytherapy Society. Intl J perspectives on quality assurance and new techniques in radiation Radiat Oncol Biol Phys 2010, 76(1):104-9. medicine: outcome of an IAEA conference. Int J Radiat Oncol Biol Phys 34. Vicini FA, Kini VR, Edmundson G, Gustafson GS, Stromberg J, Martinez AA: A 2008, 71(Suppl 1):S80-S84. comprehensive review of prostate cancer brachytherapy: defining an 14. Timmerman RD: An overview of hypofractionation and introduction to optimal technique. Int J Radiat Oncol Biol Phys 1999, 44:483-491. this issue of Seminars in Radiation Oncology. Semin Radiat Oncol 2008, 35. Rosenthal SA, Bittner NH, Beyer DC, Demanes J, Goldsmith BJ, Horwitz EM, 18:215-222. Ibbott GS, Lee WR, Nag S, Suh WW, Potters L: American Society for 15. Dewar JA, Haviland JS, Agrawal RK, Bliss JM, Hopwood P, Magee B, Radiation Oncology (ASTRO) and American College of Radiology (ACR) Owen JR, Sydenham MA, Venables K, Yarnold JR: Hypofractionation for Practice Guideline for the Transperineal Permanent Brachytherapy of early breast cancer: first results of the UK standardisation of breast Prostate Cancer. Int J Radiat Oncol Biol Phys 2011, 79:335-341. radiotherapy (START) trials [abstract]. J Clin Oncol 2007, 25:LBA518. 36. Battermann JJ, Boon TA, Moerland MA: Results of permanent prostate 16. Whelan TJ, Kim DH, Sussman J: Clinical experience using hypofractionated brachytherapy, 13 years of experience at a single institution. Radiother radiation schedules in breast cancer. Semin Radiat Oncol 2008, 18:257-264. Oncol 2004, 71:23-28. 17. Ritter M: Rationale, conduct and outcome using hypofractionated 37. Galalae RM, Martinez A, Mate T, Mitchell C, Edmunson G, Nuernberg N, radiotherapy in prostate cancer. Semin Radiat Oncol 2008, 18:249-256. Eulau S, Gustafson G, Gribble M, Kovacs G: Long-term outcome by risk 18. Brenner DJ: Hypofractionation for prostate cancer: what are the issues? factors using conformal high dose rate brachytherapy boost with or Int J Radiat Oncol Biol Phys 2003, 57:912-4. without neoadjuvant androgen suppression for localized prostate 19. Nedzi LA: The implementation of ablative hypofractionated radiotherapy cancer. Int J Radiat Oncol Biol Phys 2004, 58:1048-2055. for stereotactic treatments in the brain and body: observations on 38. Pellizzon AC, Fogaroli RC, Gobo Silva ML, Guedes Castro D, Conte Maia M: efficacy and toxicity in clinical practice. Semin Radiat Oncol 2008, Neoadjuvant Androgen Deprivation and Long-Term Results for Patients 18:265-272. with Intermediate- and High-Risk Prostate Cancer Treated with High- 20. Schultz-Ertner D, Jäkel O, Schlegel W: Radiation therapy with charged Dose Rate Brachytherapy and External Beam Radiotherapy. Applied particles. Semin Radiat Oncol 2006, 16:249-259. Cancer Research 2010, 30:306-312. 21. Shipley WU, Verhey LJ, Munzenrider JE, Suit HE, Urie MM, McManus PL, 39. Martinez AA, Pataki I, Edmundson G, Sebastian E, Brabbins D, Gustafson G: Young RH, Shipley JW, Zietman AL, Biggs PJ, Heney NM, Goitein M: Phase II prospective study of the use of conformal high-dose-rate Advanced prostate cancer: the results of a randomized comparative trial brachytherapy as monotherapy for the treatment of favorable stage of high-dose irradiation boosting with conformal protons compared prostate cancer: A feasibility report. Int J Radiat Oncol Biol Phys 2001, with conventional dose irradiation using photons alone. Int J Radiat 49:61-69. Oncol Biol Phys 1995, 32:3-12. 40. Staff requirements for a radiotherapy programme: Setting up a radiotherapy 22. Talcott JA, Rossi C, William UC, Slater JD, Niemirenko A, Zietman AL: programme: clinical, medical physics, radiation protection and safety aspects Patient-reported long-term outcomes after conventional and high-dose International Atomic Energy Agency, Vienna; 2008, 17-31. combined proton and photon radiation for early prostate cancer. JAMA 41. IAEA Human Health: Resources and learning for health professionals. 2010, 303(11):1046-53. [http://nucleus.iaea.org/HHW/RadiationOncology/ 23. Slater JD, Yonemoto LT, Rossi CJ: Conformal proton therapy for prostate Makingthecaseforradiotherapyinyourcountry/ carcinoma. Int J Radiat Oncol Biol Phys 1998, 42:299-304. Roleofradiotherapyincancercare/ 24. Akakura K, Tsujii H, Morita S: Phase I/II clinical trials on carbon ion therapy Radiotherapyisacosteffectivesystemwhichneedsabalance/index.html]. for prostate cancer. Prostate 2004, 58:252-258. 42. Hayman JA, Hillner BE, Harris JR, Weeks JC: Cost-effectiveness of routine 25. Hanks GE, Hanlon AL, Pinover WH: Dose escalation for prostate cancer radiation therapy following conservative surgery for early-stage breast patients based on dose comparison and dose-response studies. Int J cancer. JCO 1998, 16:1022-1029. Radiat Oncol Biol Phys 2000, 46:823-832. 43. Prieto L, Sacristan JA: Problems and solutions in calculating quality- 26. Baltas D, Lymperopoulou G, Zamboglou M: On the use of HDR cobalt-60 adjusted life years (QUALYs). Health and Quality of Life Outcomes 2003, source with the Mammosite radiation therapy system. Med Physics 2008, 1:80 [http://www.hqlo.com/content/1/1/80]. 35:5263-5268. 44. Bleichrodt H, Quiggin J: Life-cycle preferences over consumption and 27. Ballester F, Granero D, Perez-Calatayud J, Casal E, Agramunt S, Cases R: health: when is cost-effectiveness analysis equivalent to cost-benefit Monte Carlo dosimetric study of the BEBI G Co-60 HDR source. Phys Med analysis? J Health Econ 1999, 18(6):681-708. Biol 2005, 50:N309-N316. 45. IAEA Progrramme of Action for Cancer Therapy: cutting cancer treatment 28. Granero D, Perez-Calatayud J, Ballester F: Technical note: dosimetric study costs to save more lives: [http://cancer.iaea.org/newsstory.asp?id=76]. of a new Co-60 source used in brachytherapy. Med Physics 2007, doi:10.1186/1748-717X-6-11 34:3485-3488. Cite this article as: Salminen et al.: International Conference on Advances 29. Richter J, Baier K, Flentje M: The use of Co-60 sources for afterloading in Radiation Oncology (ICARO): Outcomes of an IAEA Meeting. Radiation alternate to Ir-192 sources. IFMBE Proceedings. World Congress on Medical Oncology 2011 6:11. Physics and Biomedical Engineering Seoul Korea; 2006, 1726-1730. 30. Ntekim A, Adenipekun A, Akinlade B, Campbell O: High Dose Rate Brachytherapy in the Treatment of cervical cancer: preliminary experience with cobalt 60 Radionuclide source-A Prospective Study. Clin Med Insights Oncol 2010, 4:89-94. 31. Haie-Meder C, Pötter R, Van Limbergen E, Briot E, De Brabandere M, Dimopoulos J, Dumas I, Helleburst TP, Kirisits C, Lang S, Muschitz S, Nevinson J, Nulens A, Petrow P, Wachster-Gerstner N: Recommendations from gynecologal GEC-ESTRO working-group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Radiation Oncology Springer Journals

International Conference on Advances in Radiation Oncology (ICARO): Outcomes of an IAEA Meeting

Loading next page...
 
/lp/springer-journals/international-conference-on-advances-in-radiation-oncology-icaro-QuFENUXucM
Publisher
Springer Journals
Copyright
Copyright © 2011 by Salminen et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Oncology; Radiotherapy
eISSN
1748-717X
DOI
10.1186/1748-717X-6-11
pmid
21294881
Publisher site
See Article on Publisher Site

Abstract

The IAEA held the International Conference on Advances in Radiation Oncology (ICARO) in Vienna on 27-29 April 2009. The Conference dealt with the issues and requirements posed by the transition from conventional radiotherapy to advanced modern technologies, including staffing, training, treatment planning and delivery, quality assurance (QA) and the optimal use of available resources. The current role of advanced technologies (defined as 3-dimensional and/or image guided treatment with photons or particles) in current clinical practice and future scenarios were discussed. ICARO was organized by the IAEA at the request of the Member States and co-sponsored and supported by other international organizations to assess advances in technologies in radiation oncology in the face of economic challenges that most countries confront. Participants submitted research contributions, which were reviewed by a scientific committee and presented via 46 lectures and 103 posters. There were 327 participants from 70 Member States as well as participants from industry and government. The ICARO meeting provided an independent forum for the interaction of participants from developed and developing countries on current and developing issues related to radiation oncology. Introduction The ICARO meeting provided an overview of topics ICARO: Advancing Radiation Oncology and issues facing the modern radiation oncologist with All countries are facing an increased demand for health an emphasis on advanced technologies and covering services. In cancer care, there are more expensive topics as shown in Table 1. Invited speakers were pro- demands in diagnosis and treatment, including radiation minent in the field, many with experience in LMI coun- therapy, and systemic therapies. Radiation therapy is a tries. Parallel sessions were held on topics specific for a cost-effective method of treating cancer, yet it is una- subset of the audience (medical physicists and radiation vailable in many low income countries throughout the oncologists) along with side events to discuss very speci- world. In high income countries, the ratio of treatment fic issues such as QA in clinical trials and collaboration machines to population may be as high as six per mil- with commercial companies. Summaries of individual lion individuals, but in many low and middle income sessions are highlighted in the text. (LMI) countries, the ratio may be as low as one per 10- Conclusions based on interaction and discussion 70 million individuals. Twenty IAEA Member States between participants focused on inadequacies of current have no radiotherapy services at all and many low- systems: � There are many low income countries with no or income countries have only basic equipment and often few trained and qualified staff, for which there is a glo- very basic diagnostic and treatment facilities. bal shortage. � Low and middle income (LMI) countries have an increasing number of cancer patients who present with advanced stage disease, with few radiotherapy facilities. Palliative treatment is common, but there are an * Correspondence: eevsal@utu.fi † Contributed equally increasing number of potentially curable patients. STUK, Finnish Radiation and Nuclear Safety Authority and Dept. of Radiation � Demand for radiotherapy services in LMI countries Oncology Turku University Hospital, Finland will increase dramatically over the next 20 years. Full list of author information is available at the end of the article © 2011 Salminen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Salminen et al. Radiation Oncology 2011, 6:11 Page 2 of 9 http://www.ro-journal.com/content/6/1/11 Table 1 Overview of ICARO programme topics Main topic Advanced techniques (*) in teletherapy Clinical sessions/clinical practice Advances in chemo-radiotherapy in cervical and head-and-neck cancer Current trends in brachytherapy Radiotherapy in paediatric oncology Reducing late toxicities Altered fractionation Training sessions/educational How to set up a QA programme? Commissioning and implementing a QA programme for new technologies Transition from 2D to 3 D CRT and IMRT Training, education and staffing: evolving needs/getting ready to transition to the new technologies Cost and economic analysis in radiation oncology Planning new activities PACT meeting with manufacturers of diagnostics and radiotherapy equipment Global quality improvement for clinical trials in radiation oncology Controversial topics and debates Co-60 - no time for retirement? IMRT-are you ready for it? Do we need proton therapy? (*) For the purposes of this report, “advanced technologies” include 3-D conformal radiation therapy (3D-CRT), intensity modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), adaptive radiation therapy (ART), respiratory-gated radiation therapy (RGRT), particle radiation therapy, and image-guided brachytherapy (IGBT) in all aspects; planning, treatment delivery, and quality assurance. Diagnostic Imaging Requirements roughly comparable when combining initial and ongoing Many successes in the treatment of cancer with radia- costs. Cobalt-60 sources must be replaced every 5-6 years, tion therapy are related to earlier diagnosis, a multidisci- requiring disposal of the old sources (an increasingly costly plinary approach to cancer diagnosis and treatment, and and logistically difficult problem) and this expense must be more precise delivery of radiation therapy. Recent weighed against cost, commissioning, training, and mainte- advances in radiation therapy planning and delivery nance of a linac which has a useful lifespan of 10-12 years. allow improved normal tissue sparing and escalation of QA programmes are more complex for linac units. In the tumour dose compared to conventional techniques some LMI countries, the frequent lack of stable electrical (2D RT). These improvements require precise definition power can interfere with the smooth operation of linacs. of the tumour target, especially when three-dimensional Service personnel may have to travel long distances, and conformal radiation therapy (3D-CRT) and intensity- parts may not be readily available. Frustrations were modulated radiation therapy (IMRT) are under consid- expressed with expensive and delicate equipment that was eration. Often this requires the use of dedicated rendered unusable by simple problems, especially when computed tomography (CT) scanning, which can be requirements for infrastructure, staff training and mainte- integrated into treatment planning software. X ray expo- nancewerenot initiallyrecognized. sure associated with extra imaging must be considered. The current and emerging need for teletherapy units There is a general increase of diagnostic X ray exposure in developing countries cannot be met by cobalt worldwide in health care. The risks of radiation expo- machines alone. Selecting the right equipment should be sure in radiation treatment planning may be mitigated mainly based on local radiotherapy experience and case- by requirements for precise treatment delivery, and mix, as well as on financial, technical and human developments in CT equipment may help reduce this resources available. Many LMI countries may benefit exposure. from the use of both cobalt units and linacs with use based on complexity of treatment. Current role of cobalt-60 Conclusion: A debate was held regarding the utility of cobalt-60 tele- therapy in routine practice. Cobalt-60 units have tradition- � There remains a role for cobalt teletherapy in LMI ally been “friendlier” treatment machines to place in new countries. New technical developments may allow low-resource departments with regards to cost, the training the introduction of highly-conformal treatment tech- required, treatment delivery, planning, and maintenance niques with cobalt but this increases the cost to the [1,2]. However, the production cost of cobalt-60 sources is level of medical linear accelerators. increasing and there are heightened security concerns. Modern sophisticated cobalt machines are more costly, reflecting increasing pricing. At the same time, there has Implementation of advanced technologies been a relative decrease in the cost of small, single-energy A series of keynote lectures discussed the underlying linear accelerators (linacs), making the two modalities hypothesis for the use of advanced technologies in Salminen et al. Radiation Oncology 2011, 6:11 Page 3 of 9 http://www.ro-journal.com/content/6/1/11 radiation therapy, discussing the assumption that improved dose distribution [5]. Unexpected toxicities improved dose distribution leads to improvement in and recurrences have been reported in the literature [3]. clinical outcomes. In the USA, where such trials could be done, there is New treatment technologies are evolving at a rate great difficulty recruiting patients to the non-IMRT arm unprecedented in radiation therapy, paralleled by because hospitals promote IMRT in order to stay eco- improvements in computer hardware and software. The nomically competitive. In Europe, IMRT is used some- what less, with figures for Belgium being approximately challenging use of highly precise collimators in the 50% and the UK less than 50%. In India and South IMRT setting, small fields, robotics, stereotactic delivery, Africa, the figure drops to 25%. Comparative case series volumetric arc therapy and image guidance has brought new challenges for commissioning and QA. Existing QA [6,7] and some phase-III trials [8,9] have been com- guidelines are often inadequate for some of these tech- pleted in the USA, Europe and Asia. The overall conclu- nologies. New QA procedures are needed and are under sion from these trials is that there is evidence of development. In the meantime, the existing paradigm of reduced toxicity for various tumour sites by the use of commissioning followed by frequent QA should con- IMRT. The evidence regarding local control and overall tinue, with attention paid to the capabilities offered by survival is generally inconclusive [5]. the new technologies. Risk management tools should be Advanced technologies of radiation treatment such as adapted from other industries to help focus QA proce- IMRT require optimal immobilization and image gui- dures on where they can be most effective. dance techniques. There was debate as to whether These techniques allow assessment of changes in the image guidance was always required with IMRT to tumour volume and its location during the course of ensure accurate delivery. Whether image guidance was therapy (interfraction motion) so that re-planning can necessary daily was also debated and this may be neces- adjust for such changes in an adaptive radiotherapy pro- sary in specific cases, such as when immobilization is cess. Some target volumes move during treatment due not optimal or when hypofractionation is used. Other to respiration (intrafraction motion), especially those in techniques to control organ motion during treatment the lung, liver and pancreas. Advanced techniques for such as respiratory-gating and breath-hold techniques compensating for such motion are already commercially may be necessary when reduced target volumes are available and include respiratory gating, active breathing considered. control and target tracking. A survey on IMRT conducted in the USA [10] deter- mined that the three main motivators for implementing The speakers advised to approach the implementation this modality were normal tissue sparing (88%), allowing of the new technologies with caution. If the identifica- tion of target tissues is uncertain when margins around dose-escalation (85%) and economic competition (the target volumes are tight, the likelihood of geographic desire to remain competitive) (62%). In addition, 91% of misses or under-dosing of the target increases. Move- non-users planned to adopt IMRT in the future. ment of the target with respiration or for any reason Image Guided Radiation Therapy (IGRT) can be during treatment increases the risk of missing or under- defined as increasing the radiotherapy precision, by fre- dosing the target. Since in some instances IMRT uses quent imaging the target and/or healthy tissues just more treatment fields from different directions, its use before treatment and acting on these images to adapt the may increase the volume of normal tissue receiving low treatment [11]. There are several image-guidance options doses which might lead to a higher risk of secondary available: non-integrated CT scan, integrated x-ray (kv) cancers. With the introduction of any advanced technol- imaging, active implanted markers, ultrasound, single- ogy, such as IMRT and IGRT, data should be collected slice CT, conventional CT or integrated cone-beam CT. prospectively, to allow a thorough evaluation of cost- A survey on IGRT in the USA [12] revealed that the effectiveness and cost-benefit [3,4]. proportion of radiation oncologist self-declared users of A debate on IMRT: Are you ready for it? brought IGRT was 93.5%. However, when the use of megavoltage together panel members who represented various views (MV) portal imaging was excluded from the definition from all regions of the world, including high and LMI of IGRT, the proportion using IGRT was 82.3%. Among countries. A modality such as IMRT offers the theoreti- IGRT users, the most common disease sites treated are cal potential to increase radiation dose to tumour target genitourinary (91.1%), head and neck (74.2%), central volumes while sparing normal tissues. Health economics nervous system (71.9%), and lung (66.9%). Conclusions: was identified as a key motivator in the adoption of IMRT. There is still a lack of randomized trials support- � Robust clinical trials are necessary to demonstrate ing robust evidence of clinical benefit of IMRT in many tumour sites. There is little prospective data demon- the benefits of advanced technologies before they are strating that IMRT provides clinical benefit other than adopted into widespread use. Salminen et al. Radiation Oncology 2011, 6:11 Page 4 of 9 http://www.ro-journal.com/content/6/1/11 � A new and unproven technology should not be of these technologies. New QA procedures are needed universally adopted as a replacement for established and are under development. In the meantime, the exist- proven technologies. ing paradigm of commissioning followed by frequent QA � LMI countries should avoid the risk that by hasty should continue, with attention paid to the capabilities implementation of new technologies, patients would offered by the new technologies. Risk management tools no longer have access to established methods of should be adapted from other industries, to help focus treatment. QA procedures on where they can be most effective [13]. It was observed by several speakers that IMRT requires increased attention to physics and dosimetry, more Introduction of advanced technologies: the radiation equipment, training and technical support, and more oncologist perspective time for quality assurance. Specific issues mentioned It was noted that the implementation of advanced radio- included the critical need for accurate calibration of the therapy technologies tends to distance the physician from position of multi-leaf collimator leaves, and the precise the patient, a trend that needs to be consciously counter- modelling of radiation dose distributions especially in the balanced by a more personal and holistic approach. In penumbra region produced by MLC leaves. The veracity addition, it makes it more and more difficult to intuitively of data transfer from the treatment plan to the treatment understand the relationship between the radiation fields machine is critical whether it be by electronic or manual and the patient’s anatomy. Whereas with 3D conformal means, and should be included in QA programmes. radiation therapy, the physician can rely on port films to assess the irradiated volume, with IMRT the physician Fractionation must rely on tools such as computer simulations and Advanced technologies provide an opportunity for the dose-volume histograms (DVH). Users of advanced tech- acceleration of treatment without excessive risk to nor- nologies should be cautioned not to allow themselves to mal tissue [3]. Hypofractionated treatments are more become too dependent upon the technology itself. It was convenient to patients and caregivers. But convenience also recommended that advanced technologies such as is not enough to make hypofractionation a mainstay IMRT and IGRT should not be acquired until physicians treatment. Much of this subject is still surrounded by and hospital staff are fully experienced with advanced ongoing controversy. The avoidance of dreaded late treatment planning techniques in 3D conformal therapy. effects of hypofractionation obviously cannot be con- Modern 3D approaches including IMRT introduce new firmed without long and careful follow-up [14]. requirements in terms of understanding of axial imaging In curative and palliative treatment, several trials of and tumour/organs delineation. Recent literature points hypofractionation in common cancers have shown com- to an uncertainty level at this stage known as “inter- parable clinical outcomes to conventional fractionation. observer variations”. Efforts continue to harmonize the These schedules vary for different diseases with fractions criteria with which tumours, organs and anatomical >2 Gy given daily to once weekly. Common cancers, structures are contoured and how volumes are defined. such as breast cancers, can be successfully treated in three weeks rather than in five weeks [15]. Advanced Introduction of advanced technologies: the medical technology radiation therapy (3D CRT and IMRT) may physics perspective provide an opportunity for the study of tissue tolerance The introduction of IMRT and stereotactic radiation as high doses per fraction can be delivered to small therapy procedures brings special physics problems. For tumour volumes while normal tissues receive conven- example, it is required that calibrations be performed in tional fractionated radiation. small fields, for which the dosimetry is challenging, and Investigators treating common diseases such as pros- no harmonized dosimetry protocol exists. Use of the tate and breast cancer are using non-ablative hypofrac- correct type of dosimeter is critical, and errors in mea- tionation in patients with curable tumours. This strategy surement can be substantial. Several new treatment tends to be well received in environments where the machines provide radiation beams that do not comply cost-savings associated with fewer fractions is important. with the reference field dimensions given in existing In some cases, such hypofractionation has a biological dosimetry protocols complicating the accurate determi- rationale for improving the therapeutic ratio [14]. nation of dose for small and non-standard beams. Conclusions: The introduction of highly precise collimators in the IMRT setting, small fields, robotics, stereotactic delivery, � There is significant published experience with the volumetric arc therapy and image guidance has brought use of hypofractionated regimens in breast, [15,16] new challenges for commissioning and QA. The existing prostate [17,18] brain/body [19] and palliative radiotherapy. QA guidelines are often inadequate for the use of some Salminen et al. Radiation Oncology 2011, 6:11 Page 5 of 9 http://www.ro-journal.com/content/6/1/11 � The use of hypofractionated regimens can be parti- cancer patients should be done preferably within clinical cularly useful in limited-resource centres overloaded studies for collecting data, which allows clear compari- with large number of patients. sonwithconventional photontreatment,therebydefin- ing the role of proton therapy precisely within radiation oncology. Reported biochemical disease-free survival Current role of proton therapy rates after carbon ion radiotherapy appear higher than with modern photon IMRT and proton RT especially The dosimetric advantage of charged-particle beam for patients with high-risk prostate cancer [24]. radiotherapy derived from the Bragg peak was empha- Slater and co-workers [23] report a 5-year NED rate sized. Protons and other particles have been used for decades for ocular melanomas, base of skull tumours, of 57% while a 5-year NED rate of 51% was reported for and brain tumours where radiation dose escalation conventional RT with photons [25]. using photons was not possible due to normal tissue Photon IMRT yields a biochemical DFS rate of 81% at constraints. The first hospital-based proton facility was 3 years, whereas severe toxicity rates to the genitourin- opened in Loma Linda (USA) in 1999 [20]. Since then, ary system and the rectum are higher as compared with over 30 particle-based facilities have opened and another the rates reported by Akakura and co-workers with car- 30 are in the planning stages worldwide, primarily for bon ions (10% vs. 1.4%) [24]. the treatment of cancer patients. Until recently, the sig- Conclusions: nificant capital expenditure required for the establish- ment of a proton facility has limited the availability of � Physical dose distributions of proton beams are this form of radiation therapy in many areas of the superior to those of photons world. This modality is expensive, time consuming, and � The cost of establishing and maintaining proton requires special expertise. The cost of treatment is sig- facilities is significant nificantly higher than conventional 3D-CRT. � Clinical trials are underway and over the next sev- During the ICARO meeting, a debate addressed the eral years an increased amount of clinical data will question: Is there a need for proton therapy? Proponents become available and opponents considered the following three proposi- � The question of whether the clinical gains from tions: (1) Proton dose distributions with currently avail- proton therapy will outweigh the costs is an unre- able equipment are likely to be of real benefit to solved issue. patients; (2) On the basis of clinical evidence, protons should be made available for radical radiotherapy to many more patients; and (3) Further technological Brachytherapy developments will make proton therapy more cost The session on brachytherapy highlighted recent advances effective. in this modality of radiation therapy. In the past, The speakers described the advantages offered by brachytherapy was carried out mostly with Radium ( Ra) proton beams, such as increased conformality of dose sources. Currently, use of artificially produced radionu- 137 192 60 198 125 103 distributions to target volumes and lower doses to non- clides such as Cs, Ir, Co, Au, I, and Pd has target tissues. The speakers provided examples of exqui- rapidly increased. sitely-shaped dose distributions that can be achieved Brachytherapy is an essential component of the cura- with both photon IMRT and with spot-scanned protons. tive treatment of cervical cancer (a very common disease It was mentioned that the improved dose distributions in many LMI countries) and cannot be replaced by with protons might offer significant benefits to paedia- other modalities in this setting. High dose-rate (HDR) tric patients, although the benefits might require some brachytherapy is preferable to low dose-rate (LDR) for years to become detectable and may not yet be readily departments with limited resources that treat a large measureable. No benefit has been demonstrated in the number of patients with cervical cancer. New systems treatment of prostate cancer, including following com- using a miniaturised Co source are becoming very pletion of one randomized trial [21] although proton popular [26-29]. This is due to the fact that Co based therapy appears at least to match the high success rates HDR systems require source replacement approximately and low toxicity available with photon IMRT [22,23]. every 5 years while Ir requires replacement every Future advances in proton therapy equipment and tech- 3-4 months. This represents a significant advantage in nologies are expected to provide even greater benefits terms of resource sparing, import of radioactive sources through improved dose distributions and patient into countries, regulatory requirements and additional throughput, but challenges in standardizing calibrations, workload [30]. treatment parameters, and the relative biological effec- Over the last decade developments in imaging, com- tiveness must be addressed first. Proton treatment of puter processing and brachytherapy systems and Salminen et al. Radiation Oncology 2011, 6:11 Page 6 of 9 http://www.ro-journal.com/content/6/1/11 applicators have made possible to implement three- times. Therefore, all centres implementing HDR bra- dimensional treatment planning based on cross sectional chytherapy must establish a written policy on QA and imaging with the applicators in place using CT or MRI. pay utmost attention to basic principles of radiation This has been successfully developed for the brachyther- protection. apy of cervical cancer [31-33]. HDR treatments dramatically increase the physician Individual departments in low-middle income coun- and physicist resources that must be allocated to bra- tries should carefully weight the advantages and disad- chytherapy while reducing the needs for inpatient hospi- vantages of adopting this system which implies expenses tal beds. The relative cost and availability of these resources should be compared, and the cost-savings, in terms of applicators and requires readily available MRI services dedicated to the brachytherapy unit or compared with the cost of amortizing the capital invest- department. ment required and the cost of source replacement and In prostate cancer, excellent long-term tumour control machine maintenance [40]. can be achieved with brachytherapy, and this approach is considered a standard treatment intervention asso- Education and training ciated with comparable outcomes to prostatectomy and An important theme echoed by several speakers and the external beam radiotherapy for patients with clinically audience was the global shortage of skilled professionals. localized disease [34]. In low-risk disease patients, seed It was noted that while short-term and local solutions implantation alone (monotherapy) achieves high rates of have been devised, there was a need for a long-term biochemical tumour control and cause-specific survival strategy to produce trainers and educators who could outcomes. For those with intermediate risk and selected increase the supply of adequately trained staff. Training high-risk disease, a combination of brachytherapy and must be adapted to both the working environment and external beam radiotherapy is commonly used. the level of complexity of the available technology; little In the treatment of prostate cancer, the radioactive benefit is derived by a trainee or the trainee’s institution sources can be implanted permanently using I seeds when the education addresses a technology not available [35] or as a fractionated temporary implant using a high in his or her own country. dose-rate stepping source. Although the experience with Thereisclearlyarolefor networking onthenational seed implantation is more extensive and the results and regional levels to support education networks. The mature [36], the use of HDR brachytherapy as monother- role of the IAEA in education and training through apy or combined with external beam therapy is becoming national and regional training courses and development more popular in radiotherapy departments that already of teaching materials and syllabi was recognized. Conclusions: have a HDR brachytherapy device, thus avoiding the costs and procedures of importing I seeds for each individual patient [37,38]. HDR brachytherapy offers sev- � Thereisaworldwideshortageofqualified radio- eral potential advantages over other techniques. Taking therapy professionals advantage of an afterloading approach, the radiation � Specialized education and training must be pro- oncologist and physicist can more easily optimize the vided to meet this demand. delivery of radiation therapy to the prostate and reduce the potential for under-dosage ("cold spots”). Further, this technique reduces radiation exposure to the care Cost considerations providers compared to permanent seed implantation. In the delivery of routine radiotherapy, most expendi- Current approaches are employing HDR monotherapy ture is in personnel costs, followed by equipment costs for intermediate risk patients avoiding the need for sup- and depreciation. Each institution has its own require- plemental external beam radiotherapy [39]. ments for equipment and personnel. These require- Both approaches are time/effort consuming and require ments are based on the type and stages of encountered careful attention to technical detail. An imaging method cancers ("case-mix”), the type of equipment and facilities (commonly trans-rectal ultrasound) has to be used dur- availability, local work practices, and method of finan- ing seed or needle implantation. The procedures require cing, maintenance costs, and down-time and life cycle of attention to accurate dosimetry and normally there is a treatment machines. Many countries have observed the “learning curve” for the whole brachytherapy team. cost of radiation therapy delivery to have increased The introduction of HDR brachytherapy as a treat- annually. ment modality carries with it additional concerns related The IAEA has developed a cost estimator [41] which to QA and radiation protection. The very principle of takes into account potential workload based on cancer HDR brachytherapy is based on working with a very incidence and staging, overhead and indigenous costs of high activity radiation source, and short treatment personnel and facilities, in addition to equipment costs. Salminen et al. Radiation Oncology 2011, 6:11 Page 7 of 9 http://www.ro-journal.com/content/6/1/11 The costs of a cobalt-60 machine when including ulti- � The value of advanced technology must be mate source disposal, has become similar to a low assessed relative to the indigenous needs and struc- energy linear accelerator, but training, personnel, and tures of the country. It is important that radiation maintenance costs are lower and reliability is higher. oncology be part of health planning for a country/ Cost-effectiveness analysis (CEA) is a form of economic community, particularly when there is competition analysis that compares the relative costs and outcomes for health financial resources. � In LMI countries, service and maintenance must (effects) of two or more courses of action [42]. Cost- be considered. Service and spare parts are often not effectiveness analysis is distinct from cost-benefit analysis, readily available and must come from great dis- which assigns a monetary value to the measure of effect [43]. Cost-effectiveness analysis is often used in the field of tances. In the curative treatment of cancer, the health services, where it may be inappropriate to monetize impact of equipment ‘down-time’ may be significant health effect. Typically, CEA is expressed in terms of a and measurably detrimental. ratio where the denominator is a gain in health from a measure (years of life) and the numerator is the cost asso- ciated with the health gain. The most commonly used out- New activities launched at ICARO come measure is quality-adjusted life years (QALYs) [44]. Two sessions focused on completely new activities Cost effectiveness can be measured in gain in quality which are to be facilitated by the IAEA in the future. adjusted life years (QALY), cost per QUALYs, cost per year of life gained or cost per loco-regional failure 1. Quality assurance of international clinical trials avoided. A session was held which reported on the objectives and When assessing the usefulness of newer advanced current status of a working party that is addressing technologies, cost effectiveness can be measured several improvements to the implementation of international ways: clinical trials. Harmonization of QA requirements and Is the number of patients to whom services are deliv- the streamlining of facility questionnaires were dis- ered increased? (Improved access). Are cure-rates cussed, as were the requirements for databases and digi- increased? (improved curability). Is toxicity significantly tal data submission for improved record collection and reduced? (Improved therapeutic index) What is the ulti- analysis. This global working party will meet several mate objective for the introduction of a new technology? times a year to continue the process of analysis and And what are its cost implications? improvement of international clinical trials. Systematic studies of the newer technologies seem required following the methodologies of health technol- 2. PACT and manufacturers ogy assessment and the dissemination of the results in a A side-meeting with manufacturers of diagnostic and form that is accessible to clinicians, mangers and the radiotherapy equipment was hosted by IAEA’sProgramme public. Unfortunately, much of the evidence indicates of Action for Cancer Therapy (PACT) and the Division of that it is difficult to influence practitioners simply by Human Health (NAHU). This meeting was convened due producing and disseminating information. to the IAEA’s unique and leading role in assisting Member Although extremely important, education and training States in the development of cancer therapy, strengthening costs are not usually considered in these formulas. Cost collaboration with manufacturers in providing equipment effectiveness can often be improved by optimal use of that is safe, affordable and technically suitable for develop- conventional technologies and better work practices. For ing country conditions. An advisory group was established instance, hypofractionation can increase patient to continue the process of discussions between the IAEA, throughput while maintaining the same outcome in manufacturers and users [45]. selected indications. Radiotherapy services in LMI countries need high level Conclusions government commitment to mobilize the necessary Demand for radiotherapy services in LMI countries will funds of approximately $5-6 million necessary to estab- increase significantly in the next 20 years. Many Mem- lish a basic cancer centre. Such projects, when com- ber States are still without or with only very basic radio- pleted, take at least 5 years to make a noticeable therapy facilities. There is a shortage of qualified difference in the health care system as a whole. radiation oncologists, medical physicists, dosimetrists, Conclusions: radiation therapists, nurses, and maintenance engineers in the developing world. Education and training must be � ICARO speakers and panellists emphasized that provided to meet this demand and training must be ide- each country should have a comprehensive plan for ally adapted to the available equipment and disease cancer control. profiles. Salminen et al. Radiation Oncology 2011, 6:11 Page 8 of 9 http://www.ro-journal.com/content/6/1/11 Since there is competition for health care resources thereisa paucityofevidence thatIMRTcan and equipment, technical support has to be consistent improve tumour-related outcomes, and clinical trials with the health system infrastructure of each country to are clearly needed. keep radiation treatment affordable, safe and of good � Despite the growing use of protons in various sites quality. In LMI countries, service and maintenance are including prostate cancer, proton therapy must remain often not available and must come from afar. This under scrutiny until it has proven itself cost-effective. needs to be recognized when purchasing any equipment or technology. Theconferencegavedelegates of LMIcountries an Acknowledgements opportunity to assess new technologies relative to their The ICARO meeting was organized by the IAEA and co-sponsored and own situations. Many aspects of advances in radiation supported by ESTRO, ASTRO, ABS, AAPM, IARR, and ICRU, with cooperation from ALATRO, EANM, AFOMP, INCTR, IOMP, TROG, and UICC. Additional oncology were covered and evaluated, ranging from the financial support was received from industries and manufacturers. role of basic technology to how to upgrade and adapt departments to advanced technology. The benefits, Author details STUK, Finnish Radiation and Nuclear Safety Authority and Dept. of Radiation implications, pitfalls, economics, risks, and practicalities Oncology Turku University Hospital, Finland. Department of Nuclear of implementing advances from a variety of viewpoints Sciences and Applications, Division of Human Health, International Atomic were discussed. Energy Agency, P.O. Box 100, Vienna, Austria. Department of Radiation Oncology, Northwestern University, 1653 W. Congress Pkwy, Chicago, IL 60612, USA. Radiological Physics Center, UT M.D. Anderson Cancer Center, Recommendations 5 Box 547, 1515 Holcombe Blvd Houston, TX 77030, USA. Dept. of Radiation � Basic radiation therapy services at a minimum Oncology, Wayne State University School of Medicine, Gershenson Radiation Oncology Center, 4100 John R. Detroit, MI 48201-2013. should be made available to all patients with cancer who need them. Authors’ contributions � Education and training programmes to enable EKS was Scientific Secretary of the ICARO Conference and contributed to drafting and review, KK, GSI and MCJ acted as rapporteurs of the meeting good quality radiation therapy services need to be and drafted the initial meeting report, ER, EZ, JW and AM were part of the developed and job opportunities offered with ade- ICARO Organizing Committee and all contributed to the drafting and review quate salary levels to retain staff. of this article. All authors read and approved the final manuscript. � Advanced technologies in radiation therapy should Competing interests not be universally adopted until the following condi- The authors declare that they have no competing interests. tions are met: Received: 27 September 2010 Accepted: 4 February 2011 - A need for advanced technology exists (i.e. Published: 4 February 2011 patients with curative potential) - Experience with 3D conformal radiation ther- References apy and advanced treatment planning exists 1. Adams EJ, Warrington AP: A comparison between cobalt and linear accelerator-based treatment plans for conformal and intensity- before implementation of more advanced modulated radiotherapy. Br J Radiol 2008, 81:304-10. technologies 2. Rachivandran R: Has the time come for doing away with Cobalt-60 - Adequate imaging services are available teletherapy for cancer treatments? J Med P 2009, 34:63-5. 3. Vikram B, Coleman CN, Deye JA: Current status and future potential of - Studies demonstrate a universal advantage to advanced technologies in radiation oncology. Part 1: Challenges and each aspect of advanced technology, either in resources. Oncology 2009, 23:279-83. improving local control or in reducing toxicity 4. Vikram B, Coleman CN, Deye JA: Current status and future potential of advanced technologies in radiation oncology. Part 2: State of the - Personnel have adequate training in planning, science by anatomic site. Oncology 2009, 23:380-5. implementation, and QA in advanced technology 5. Veldeman L, Madani I, Hulstaert F, De Meerleer G, Mareel M, De Neve W: - Continuous medical education system is in Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies. Lancet Oncol 2008, 9:367-375. place. 6. Rothschild S, Studer G, Seifert B, Huguenin P, Glanzmann C, Davis JB, - An adequate QA/QC programme is in place. Lütolf UM, Hany TF, Ciernik IF: PET/CT with intensity modulated radiotherapy (IMRT) improves treatment outcome of locally advanced pharyngeal carcinoma: a matched-pair analysis. Radiation Oncology 2007, � Clinical studies should be undertaken to demon- 2:22. strate clinical and cost-effective benefits to the advanced 7. Zelefsky MJ, Fuks Z, Happersett L, Lee HJ, Ling CC, Burman CM, Hunt M, technologies. Wolfe T, Venkatraman ES, Jackson A, Skwarchuk M, Leibel SA: Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 2000, 55(3):241-249. � Each country must clearly define which cancer 8. Pignol J, Olivotto I, Rakovitch E, Gardner S, Ackerman I, Sixel K, Beckham W, outcomes are expected to be improved by the intro- Vu T, Chow E, Paszat L: Phase III randomized study of intensity modulated radiation therapy versus standard wedging technique for adjuvant breast duction of advanced technologies. radiotherapy. Int J Radiat Oncol Biol Phys 2006, 66(3 Suppl 1):S1. � New technologies such as IMRT offer theoretical 9. Donovan E, Beakley N, Denholm E, Evans P, Gothard L, Hanson J, Peckitt C, advantage in radiation dose distribution. Presently, Reise S, Ross G, Sharp G, Symonds-Tayler R, Tait D, Yarnold J: Randomised Salminen et al. Radiation Oncology 2011, 6:11 Page 9 of 9 http://www.ro-journal.com/content/6/1/11 trial of standard 2D radiotherapy versus intensity modulated radiation with emphasis on MRI assessment of GTV and CTV. Radiother Oncol 2005, therapy (IMRT) in patients prescribed breast radiotherapy. Radiother 74:235-245. Oncol 2007, 82:254-64. 32. Pötter R, Haie-Meder C, Van-Limbergen E, Barillot I, De Brabandere M, 10. Mell LK, Mehrotra AK, Mundt AJ: Intensity-modulated radiation therapy Dimopoulos J, Dumas I, Erickson B, Lang S, Nulens A, Petrow P, Rownd J, use in the U.S. 2004. Cancer 2005, 104:1296-1303. Kirisits C: Recommendations from gynaecological GEC-ESTRO working- 11. Van Herk M: Different styles of Image-Guided Radiotherapy. Semin Radiat group (II): concepts and terms in 3D image-based treatment planning in Oncol 2007, 17(4):258-267. cervix cancer brachytherapy - 3D dose-volume parameters and aspects 12. Simpson DR, Lawson JD, Nath SK, Rose BS, Mundt AJ, Mell LK: A survey of of 3D image-based anatomy, radiation physics, radiobiology. Radiother image-guided radiation therapy use in the United States. Cancer 2010, Oncol 2006, 78:67-77. 116(16):3953-60. 33. Viswanathan AN, Erickson BA: Three-dimensional imaging in gynecologic 13. Shortt K, Davidson L, Hendry J, Dondi M, Andreo P: International brachytherapy: a survey of the American Brachytherapy Society. Intl J perspectives on quality assurance and new techniques in radiation Radiat Oncol Biol Phys 2010, 76(1):104-9. medicine: outcome of an IAEA conference. Int J Radiat Oncol Biol Phys 34. Vicini FA, Kini VR, Edmundson G, Gustafson GS, Stromberg J, Martinez AA: A 2008, 71(Suppl 1):S80-S84. comprehensive review of prostate cancer brachytherapy: defining an 14. Timmerman RD: An overview of hypofractionation and introduction to optimal technique. Int J Radiat Oncol Biol Phys 1999, 44:483-491. this issue of Seminars in Radiation Oncology. Semin Radiat Oncol 2008, 35. Rosenthal SA, Bittner NH, Beyer DC, Demanes J, Goldsmith BJ, Horwitz EM, 18:215-222. Ibbott GS, Lee WR, Nag S, Suh WW, Potters L: American Society for 15. Dewar JA, Haviland JS, Agrawal RK, Bliss JM, Hopwood P, Magee B, Radiation Oncology (ASTRO) and American College of Radiology (ACR) Owen JR, Sydenham MA, Venables K, Yarnold JR: Hypofractionation for Practice Guideline for the Transperineal Permanent Brachytherapy of early breast cancer: first results of the UK standardisation of breast Prostate Cancer. Int J Radiat Oncol Biol Phys 2011, 79:335-341. radiotherapy (START) trials [abstract]. J Clin Oncol 2007, 25:LBA518. 36. Battermann JJ, Boon TA, Moerland MA: Results of permanent prostate 16. Whelan TJ, Kim DH, Sussman J: Clinical experience using hypofractionated brachytherapy, 13 years of experience at a single institution. Radiother radiation schedules in breast cancer. Semin Radiat Oncol 2008, 18:257-264. Oncol 2004, 71:23-28. 17. Ritter M: Rationale, conduct and outcome using hypofractionated 37. Galalae RM, Martinez A, Mate T, Mitchell C, Edmunson G, Nuernberg N, radiotherapy in prostate cancer. Semin Radiat Oncol 2008, 18:249-256. Eulau S, Gustafson G, Gribble M, Kovacs G: Long-term outcome by risk 18. Brenner DJ: Hypofractionation for prostate cancer: what are the issues? factors using conformal high dose rate brachytherapy boost with or Int J Radiat Oncol Biol Phys 2003, 57:912-4. without neoadjuvant androgen suppression for localized prostate 19. Nedzi LA: The implementation of ablative hypofractionated radiotherapy cancer. Int J Radiat Oncol Biol Phys 2004, 58:1048-2055. for stereotactic treatments in the brain and body: observations on 38. Pellizzon AC, Fogaroli RC, Gobo Silva ML, Guedes Castro D, Conte Maia M: efficacy and toxicity in clinical practice. Semin Radiat Oncol 2008, Neoadjuvant Androgen Deprivation and Long-Term Results for Patients 18:265-272. with Intermediate- and High-Risk Prostate Cancer Treated with High- 20. Schultz-Ertner D, Jäkel O, Schlegel W: Radiation therapy with charged Dose Rate Brachytherapy and External Beam Radiotherapy. Applied particles. Semin Radiat Oncol 2006, 16:249-259. Cancer Research 2010, 30:306-312. 21. Shipley WU, Verhey LJ, Munzenrider JE, Suit HE, Urie MM, McManus PL, 39. Martinez AA, Pataki I, Edmundson G, Sebastian E, Brabbins D, Gustafson G: Young RH, Shipley JW, Zietman AL, Biggs PJ, Heney NM, Goitein M: Phase II prospective study of the use of conformal high-dose-rate Advanced prostate cancer: the results of a randomized comparative trial brachytherapy as monotherapy for the treatment of favorable stage of high-dose irradiation boosting with conformal protons compared prostate cancer: A feasibility report. Int J Radiat Oncol Biol Phys 2001, with conventional dose irradiation using photons alone. Int J Radiat 49:61-69. Oncol Biol Phys 1995, 32:3-12. 40. Staff requirements for a radiotherapy programme: Setting up a radiotherapy 22. Talcott JA, Rossi C, William UC, Slater JD, Niemirenko A, Zietman AL: programme: clinical, medical physics, radiation protection and safety aspects Patient-reported long-term outcomes after conventional and high-dose International Atomic Energy Agency, Vienna; 2008, 17-31. combined proton and photon radiation for early prostate cancer. JAMA 41. IAEA Human Health: Resources and learning for health professionals. 2010, 303(11):1046-53. [http://nucleus.iaea.org/HHW/RadiationOncology/ 23. Slater JD, Yonemoto LT, Rossi CJ: Conformal proton therapy for prostate Makingthecaseforradiotherapyinyourcountry/ carcinoma. Int J Radiat Oncol Biol Phys 1998, 42:299-304. Roleofradiotherapyincancercare/ 24. Akakura K, Tsujii H, Morita S: Phase I/II clinical trials on carbon ion therapy Radiotherapyisacosteffectivesystemwhichneedsabalance/index.html]. for prostate cancer. Prostate 2004, 58:252-258. 42. Hayman JA, Hillner BE, Harris JR, Weeks JC: Cost-effectiveness of routine 25. Hanks GE, Hanlon AL, Pinover WH: Dose escalation for prostate cancer radiation therapy following conservative surgery for early-stage breast patients based on dose comparison and dose-response studies. Int J cancer. JCO 1998, 16:1022-1029. Radiat Oncol Biol Phys 2000, 46:823-832. 43. Prieto L, Sacristan JA: Problems and solutions in calculating quality- 26. Baltas D, Lymperopoulou G, Zamboglou M: On the use of HDR cobalt-60 adjusted life years (QUALYs). Health and Quality of Life Outcomes 2003, source with the Mammosite radiation therapy system. Med Physics 2008, 1:80 [http://www.hqlo.com/content/1/1/80]. 35:5263-5268. 44. Bleichrodt H, Quiggin J: Life-cycle preferences over consumption and 27. Ballester F, Granero D, Perez-Calatayud J, Casal E, Agramunt S, Cases R: health: when is cost-effectiveness analysis equivalent to cost-benefit Monte Carlo dosimetric study of the BEBI G Co-60 HDR source. Phys Med analysis? J Health Econ 1999, 18(6):681-708. Biol 2005, 50:N309-N316. 45. IAEA Progrramme of Action for Cancer Therapy: cutting cancer treatment 28. Granero D, Perez-Calatayud J, Ballester F: Technical note: dosimetric study costs to save more lives: [http://cancer.iaea.org/newsstory.asp?id=76]. of a new Co-60 source used in brachytherapy. Med Physics 2007, doi:10.1186/1748-717X-6-11 34:3485-3488. Cite this article as: Salminen et al.: International Conference on Advances 29. Richter J, Baier K, Flentje M: The use of Co-60 sources for afterloading in Radiation Oncology (ICARO): Outcomes of an IAEA Meeting. Radiation alternate to Ir-192 sources. IFMBE Proceedings. World Congress on Medical Oncology 2011 6:11. Physics and Biomedical Engineering Seoul Korea; 2006, 1726-1730. 30. Ntekim A, Adenipekun A, Akinlade B, Campbell O: High Dose Rate Brachytherapy in the Treatment of cervical cancer: preliminary experience with cobalt 60 Radionuclide source-A Prospective Study. Clin Med Insights Oncol 2010, 4:89-94. 31. Haie-Meder C, Pötter R, Van Limbergen E, Briot E, De Brabandere M, Dimopoulos J, Dumas I, Helleburst TP, Kirisits C, Lang S, Muschitz S, Nevinson J, Nulens A, Petrow P, Wachster-Gerstner N: Recommendations from gynecologal GEC-ESTRO working-group (I): concepts and terms in 3D image based 3D treatment planning in cervix cancer brachytherapy

Journal

Radiation OncologySpringer Journals

Published: Feb 4, 2011

References