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Jonathan Feddock, MD University of Kentucky Department of Radiation Medicine

Improving Access and Decreasing Side Effects Radiation Oncology Advances for Breast and Gynecologic Cancers. Jonathan Feddock, MD University of Kentucky Department of Radiation Medicine 2017 Kentucky Cancer Registry Annual Meeting September 21, 2017. Markey Cancer Center.

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Jonathan Feddock, MD University of Kentucky Department of Radiation Medicine

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  1. Improving Access and Decreasing Side EffectsRadiation Oncology Advances for Breast and Gynecologic Cancers Jonathan Feddock, MD University of Kentucky Department of Radiation Medicine 2017 Kentucky Cancer Registry Annual Meeting September 21, 2017

  2. Markey Cancer Center

  3. The Radiation Medicine Department

  4. Objectives • Review of Radiation Oncology Services and Innovative Treatment Options • Stereotactic Body Radiation Therapy • Helical Tomotherapy • Gamma KnifeRadiosurgery • Advanced Brachytherapy • SIRS Spheres • Discuss recent advances in Breast and Gynecologic Cancers • Improve Access to Care and Referrals

  5. Radiation Oncology Services at UK Marc Randall William StClair Mahesh Kudrimoti Jonathan Feddock Ronald McGarry Mark Bernard

  6. Radiation Oncology Services at UK 5 Full time Physicians 5 Full time Medical Physicists Radiation Oncology Residency program (6) Medical Physics Residency Program (4) Medical Physics Masters Program (6) Medical Physics PhD Program (1) - pending 4 Full time dosimetrists 10 full time Radiation Therapists

  7. What is radiation? Ionizing Radiation refers to a type of radiation with sufficient energy to cause the ionization of cells

  8. How does radiation work? Radiation relies primarily on the cellular content of water Cells with condensed chromatin are susceptible to damage Only cells actively dividing tend to be injured Cancer cells are affected at a much faster rate than normal cells

  9. Linear Accelerator(Working Horse of Radiation Oncology)

  10. Radiation Oncology Services at UK Treatment Units: Varian Platinum ix Linear Accelerator Varian Truebeam SX Linear Accelerator Tomotherapy Gamma Knife Perfexion Varian High Dose Rate Brachytherapy Afterloader

  11. Varian Truebeam SX

  12. Varian Truebeam SX • UK has the first slim-line True Beam installed in the US (2/2014) • Enhanced linear accelerator with: • Microleaf collimator • On-board Cone Beam CT – kV and MV capabilites • Variable Dose Rate • Advanced treatment options: • 3-Dimensional conformal radiation therapy (3D-CRT) • Stereotactic body radiotherapy (SBRT) • Intensity Modulated Radiation Therapy (IMRT) • Volumetric Modulated Arc Therapy (VMAT)

  13. Varian Truebeam SX - VMAT VMAT generally uses either 1 or 2 treatment arcs Goal is to generate the most conformal treatment plan capable

  14. Tomotherapy

  15. Tomotherapy • Linear Accelerator on a CT frame • Daily CT image guidance for confirmation of setup • Enables the treatment of circular structures or sparing of relatively nearby organs at risk

  16. Gamma Knife Radiosurgery

  17. Advanced Brachytherapy Suite Coming (2020???) • CT on Rails image-guided brachytherapy suite: • Gynecological • Biliary • Skin • Head & Neck • Prostate

  18. How do we use Radiation clinically? Definitive treatment – ie Head and Neck Cancer, Cervical Cancer Adjuvant treatment (extra) – ie after surgery for a Breast Cancer Neo-adjuvant treatment (extra and before) – ie before surgery in Breast, Esophageal, Rectal cancers, etc. Palliative (to help with symptoms) – ie bone metastases, bleeding, etc.

  19. Debunking Myths Regarding Radiation Facts: Side effects of treatment are limited to where radiation is directed Linear accelerators do not have flashing lights, bells, whistles, etc. Radiation delivered by a linear accelerator is not contagious Everyone is not going to have sunburns… depends on where we are treating

  20. Radiation Causes Heart Disease! Darby et al. NEJM. 2013. This is TRUE… but not necessarily the reality Several studies published in the past 10 years have identified that women treated for breast cancer with radiation therapy can have as much as a 6X increase risk for a major heart attack1

  21. Role of Radiation in Breast Cancer – Early Stage • Mastectomy vs Breast Conservation Therapy (BCT) • Very frequently women decide this up front • Based on historic NSABP B-06 trial (Fisher et al. JAMA) • 25 yr recurrence rate for invasive breast cancer • Mastectomy: 10% • Lumpectomy + Radiation: 14% • Lumpectomy alone: 40% • Mastectomyis considered = Lumpectomy + Radiation • The only women that we believe can avoid Radiation are age >70

  22. Role of Radiation in Breast Cancer – Advanced Stage • If a woman presents with more advanced cancer in the breast or multiple positive lymph nodes, a mastectomy frequently becomes the standard treatment • There are 2 strong indications for radiation proven to improve survival • Any primary tumor >5cm (T3 or greater) • Any patient with 4 or more positive lymph nodes (N2 or greater)

  23. Back to the Risk for Heart Disease • The Heart is on the LEFT (most of the time) • We don’t really do radiation the way that we used to in the 80s and the 90s • The risk for heart disease after radiation treatment is a 20+ year process • Major change in the early to mid-2000s to using CT scans regularly

  24. Reducing Risk for Heart Disease

  25. How do we plan breast cancer treatments now? Supine Prone Breath-holding techniques Prone (stomach down) treatments Advanced radiation treatments when needed

  26. Improving Access to Care CDC – Age-adjusted Mortality for Cancer

  27. Breast Cancer Treatments(More Radiation options…) • Standard Radiation • Whole Breast Treatment • 30 Treatments (Monday thru Friday) • 6 weeks • Accelerated Partial Breast* • Only treat where tumor was removed • 10 treatments (2 per day Monday thru Friday) • 1 week *Only suitable for women age >50, small, favorable tumors • Short-Course Radiation • Whole Breast Treatment • 15-18 treatments (Monday thru Friday) • 3 weeks • Standard course with Breaks • Whole Breast Treatment • 6 treatments (one day per week) *Best suited for women with inability to travel or of poor health

  28. What should our risk for Heart Disease be now? • Unfortunately, there are competing risks: • Chemotherapy – Herceptin, Adriamycin • Hormonal Therapy – blocking estrogen can be detrimental • The dose from radiation can never be zero… • With what we can do now though… risks should be minimal

  29. Expanding Treatment Options beyond Breast Cancer • In contrast to Breast Cancer, outcomes for Gynecologic Cancers are significantly lower • Screening is much less effective and/or performed • Gynecologic cancers tend to present at much more advanced stages • Not as accessible surgically

  30. Radiation Options for Gynecologic Cancers External Beam Radiation Interstitial Radiation Radioactive sources are placed directly into a tumor “Round-Up Weed Killer” • Machine delivers radiation from outside of the body • “Whole Yard Weed Killer”

  31. Recurrent Gynecologic Cancers • A local recurrence of gynecologic cancer can be common despite initial treatment • 15% of uterine corpus cancers • 40-50% of uterine cervix cancers • 50% of vulvar cancers • Regardless of primary site – salvage options are limited • Most are offered radical or exenterative surgery • Psychological, medical, and physical complications • Five-year survival rates of 20-73%

  32. Current Train of Thought • Once someone has received radiation therapy to their pelvis, they cannot receive radiation again • This is not really true! • We just can’t do it again the same way…

  33. Permanent Interstitial Brachytherapy

  34. What’s Unique about Interstitial Implants? • Permanent • Slowest form of radiation delivery available • “Ultra-low dose rate” • Radiobiologically, the lowest risk for long-term side effects • Outpatient procedure with minimal sedation requirements • Able to treat small volumes

  35. What’s Unique about Interstitial Implants? • Dose of radiation is dependent on the placement of individual radiation seeds • Able to create three-dimensional shapes of radiation treatment • Relatively low treatment cost • Minimal requirements for procedural space / equipment

  36. Sample Case Most Common Method(s) for Re-Irradiation: Daily Radiation for 2-3 weeks Internal Radiation Cylinders • Using a combination of over- and under-treating the actual tumor. • Treatments are not very successful – high toxicity and low cure rates.

  37. Sample Case Treatment Using Interstitial Re-Irradiation: Manual Placement of Radioactive Seeds Directly into the Tumor • Benefits: • One treatment • Full dose of radiation can be delivered • Dose is delivered over the lifetime of radiation sources (~ 1 month) • Less side effects • High cure rate (80%)

  38. Sample Case Recurrent Cancer at Vaginal Apex Radiation Seeds at Time of Implant

  39. Sample Case Recurrent Tumor (9/2015) No Evidence of Disease (7/2017)

  40. Where Are We Going in Oncology?

  41. Necessity to Approach Treatment From All Perspectives • Multidisciplinary Cancer Team • Surgical Oncologist • Medical Oncologist • Radiation Oncologist • Pathologist • Diagnostic Radiologist • Social Workers • Research Personel • Physical Therapists • Nurses • Pharmacist

  42. Cancer Care Teams at Markey • Breast Cancer • Carcinoid & Neuroendocrine • Endocrine • Gastrointestinal • Genitourinary • Gynecologic • Head and Neck Cancers • Hematalogic • Melanoma & Sarcoma • Musculoskeletal • Neuro-Oncology • Pediatric Hematology & Oncology • Thoracic Oncology • Molecular Tumor Board

  43. Molecular Profiling of Cancer • Newer tests are available that can search for the genetic profile of a cancer • What genes are telling a cancer to grow or spread • Several of these tests are commercially available and covered by insurance in specific situations • E.g. Foundation One Test

  44. Precision Medicine MATCH: Molecular Analysis for Therapy Choice Trial Available at Markey Recurrent cancers that have failed standard treatments

  45. How is Precision Medicine Different?

  46. Potential Benefits of Precision Medicine Improved efficacy of treatment Higher chances for a cure Reduced side effects Reduced cost of care

  47. Immunotherapy • Our immune systems have the ability to fight cancer • Abscopal responses in Melanoma, Renal Cell Carcinoma, Neuroblastoma • Kaposi Sarcoma in patients with HIV • Patients with solid-organ transplants on immunosuppression

  48. Immunotherapy cont.

  49. Cancers With Clinical Trial Results Supporting use of Immunotherapy • Clinical Trial Data Available • Melanoma • Renal Cell Carcinoma • Neuroblastoma • Non-small Cell Lung Cancer • Colon Cancer • Neuro-endocrine Tumors • Accounts for perhaps the highest number of new clinical trials currently • Current Trials Enrolling Patients: • Endometrial • Ovarian • Breast • Pancreatic • Small Cell Lung Cancer • Melanoma • Many more…

  50. Communication with UK Radiation Medicine Clinic main telephone line: 859-323-6487 Clinic nurses telephone line: 859-257-7618 Best method to reach physicians: UK MDs 859-257-5522

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