Radiotherapy - the art of the invisible Terry Kehoe

Consultant Clinical ScientistHead of Oncology PhysicsEdinburgh Cancer Centre

“How to crack a walnut”

CRUK - Radio 5 on 10th June 2014 50% survive 5yrs today

CRUK - TI report May 2014Addition of RT – 16% ↑ in 5yr survivalAddition of CT – 2% ↑ in 5yr survival

Why does so much money go into drug development?

30yrs ago – 25% 20yr target – 75%

46.7% -5yr survival in the early 80’s

By the end of the 80’s 5yr survival ↑ 56.3%.

By mid 90’s 5yr survival ↑ to 70%.

Mid ‘00‘s - 5yr survival ↑ to 85.2%

Improved survival from prostate cancer over my career

When I started in 1979

Early Image Guided Radiotherapy IGRT 2004

Fiducial Markers

Inserted trans rectally

Images true prostate position

We increased our doses safely – how?

Diagnostic quality imaging

Modern Image Guided Radiotherapy IGRT 2009

Same Fiducial Markers

Now CT capability

Images true prostate position and software calculates how much to move the field to correct for it

We increased our doses safely – how?

Why we can increase our doses safely

New in 2011 even better IMRT

Will have all LinAcs with this arc therapy by end of 2015

IMRT 5½mins VMAT 1½mins

~ Doubling in 5yr survival in 3½ decades

No it’s been around for a century. Some people call it a “black art” perhaps its “magic”

All from RT? No - 46% of prostate cancer patients receive external beam radiotherapy.

Will the 85.2% 5yr survival rise? Probably.

Image Guided – IMRT is best. Is it new?

How do you know you are doing it right?

I-125 day case permanent implant

Volume Study

2001

Classic 2-stage procedureVolume study to assess prostate size, pubic arch problems and plan treatment

Good for learning curve

Single stop intraoperative prostate Seeds Brachytherapy

ECC late 2009

HDR temporary implant

Meta-analysis of large patient studies Using % PSA progression free as an indication of survival

1 Patients should be separated into Low, Intermediate, and High Risk

2 Success must be determined by PSA analysis

3 All Treatment types considered

4 Article must be in a Peer Reviewed Journal

5. Low & Intermediate Risk articles must have a min of 100 patients

6. High Risk articles, because of fewer patients, need only 50 patients to meet criteria

7. Patients must have been followed for a median of 5 years

Criteria for Inclusion of Article*

* Expert panel consensus

77

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Seeds

Surgery

EBRT

5 5

22 22

← Years from Treatment →

CRYO

11 12 12

24 24

14 14 8 8

22

23 23

HIFU

% P

SA P

rogr

essi

on F

ree

1111

1515

Protons

21 21

4 4

1818

9 9

10 10

EBRT & Seeds

2525

Robot RP 26 26

27 27

HDR

28282929

3030

313132323333

34 34

1919 36 36

37 37

3838

LOW RISK RESULTS Weighted

3 3 3939

35

4040

100100

101101

1313EBRT

Brachy

Surgery

Trea

tmen

t Suc

cess

103103

102 102

66

16 16

104104

105105

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Brachy

Surgery

EBRT

CRYO

HIFU

29 29

2222

2121

5 5 1919

% P

SA

Pro

gres

sion

F

ree

1818

12 12

2828

3 3 17 17

10 10

32 32

99

88 2 2

2525

1 1

13 13

Protons

HDR

← Years from Treatment →

1515

443636

37 37

3838

++

Seeds Alone

Seeds + ADT40 40

Robot RP

4141

42 42

44 44

4343

4545

46 46

INTERMEDIATE RISK RESULTS Weighted

77

11 11

14 14

2020

35 35

34 34

39 39

23232424

1616

66

2626

3333

EBRT & Seeds

EBRT Surgery

Brachy

EBRT & Seeds

Hypo EBRT

EBRT, Seeds + ADT

Tre

atm

ent

Suc

cess 3030

27 27 47 47

66 11 11

3636

25 25

15 15

55

EBRT Seeds +ADT

19 19

3030

16 16 20 20

18 18

2929% P

SA P

rogr

essi

on F

ree

17

21 21

88

99

22 22

24 24

26 26

37 37

4141

1212

Protons

HDR

← Years from Treatment →

4242

43 434444

45 45

4646

47 47

Robot RP

48 48

4949

101101

102102

103103

104 104

105 105

106106

107 107

109 109

HIGH RISK RESULTSWeighted

10 10

2323

3535

108 108 44

22

3131

3939

3232

3333

3434

38

EBRT, Seeds & ADTEBRT, Seeds & ADTBrachy

EBRT Surgery

EBRT & ADT

EBRT & Seeds

Hypo EBRT

Trea

tmen

t Suc

cess

11

77

110110

2727

33

1313

1414

28 28

4040

100100

Thank you for listening

What other radiotherapy improvements will increase 5yr

survival?

• SABR – similar to VMAT but 5 visits only• Better planning including radiobiological systems

•Better knowledge of impact• Physically – transit dosimetry• Biologically – chip on a pill

• Better on-board imaging & faster delivery

• Ability to adapt treatment while on the couch

New imaging

Robotic deliveryProtons

HIFU

CRYO

Photodynamic

“Nanoknife”