From. The campus of Stanford University people. Are worried about data they're worried about their privacy and their security they should be we need secure, systems, this, is the future of everything but we can't have a system that closes. That data off it is too rich of a source of inspiration, innovation, and discovery for, new things in medicine with your host Russ Altman, today. On the future of everything the, future, of radiation. Therapy. So. Cancer. We all don't, like cancer, and it's, continues, to be a major problem we've. Heard about great advances, but globally, there are still millions of cancer deaths every year so, despite these advances, we still need more and better treatments, when. You think about cancer, therapy, a lot of things come to mind immediately one, thing is chemotherapy, the dreaded word chemotherapy. These, are very. Toxic drugs, that, try to kill the cancer and usually have very big. Toxic. Side effects on the patients you, also think of surgery let's go in and remove that cancer, but, we know that the surgery doesn't always work because there might be little bits. Of cancer that the surgeon doesn't see or that are distant. From the primary, cancer and so surgery also is not always working and. Then the third thing that some people think about and. That we're gonna be talking about today is radiation. Therapy, the idea is that radiation, I'm talking about x-rays, like. Radiation from the atomic bomb or from, linear. Accelerators. That can create these x-rays, are. Harmful, to cells and, they. Cause damage to the DNA and other cellular processes, the. Cells cannot recover and especially, if you're a rapidly, dividing cell that needs to make copies of your DNA in order to divide this, damage, can be lethal and then this cancer, cells die. That's, the theory and we, often use radiation, therapy, in combination. With chemotherapy and, surgery and anybody. Who's who knows a relative, or a friend that has had, cancer knows that we they they might go through a series, of treatments, involving all three of these in. Particular, cancer, of the lung is a very important. Target. For radiation therapy because. Of the difficulty, of doing some of those surgeries the, difficulty, of getting high levels of chemicals into. The lung radiation. Therapy has a really, clear and important role there among others, it. Has its benefits there's, no surgery. No. Extra, surgery, there's no pills you can focus the radiation at least that's what people are trying to do and. You. Can kill, the the cancer in a very very specific way, dr.. Bill Liu is a professor, of radiation oncology radiation. Therapy, at Stanford University, and his research is devoted, to improving the utility, and uses. Of radiation. In cancer therapy and even in other diseases bill. Can, radiation, therapy. Cure. Cancer, or is, it always gonna, be limiting, the disease without completely, removing, it thanks. Russ I'm, really excited to be here I appreciate the invitation. Yeah, so I think your. Introduction, is right on target I think. What many people don't. Realize is. That radiation, is, in fact one of the pillars. Of cancer treatment along. With other treatments like surgery and, drug, therapy and, that includes chemotherapy. And some, of the newer approaches, we have with molecular targeted, drugs and immunotherapy, I didn't mention all of the new systems, that are using the immune system to combat yeah, yeah, and, radiation plays into that as well as it turns out but. Absolutely radiation. Is. Used today, in the United States at. Some point in the course of therapy for about two-thirds, of patients with cancer so it's not rare at all so it's not a rare at all and in fact in the majority, of those cases it, is with the intent, to cure in, other words the goal of the treatment is to try to eliminate, the cancer and. So yes, absolutely radiation, is an important, part of curative, treatment of cancer so what are the what are the frontiers, I mean I've, read stories about in the old days they would literally take a radioactive. Block of like, radium, and. Just stick it near the patient's, chest wall hoping, that those rays would kill the cancer and of course they did huge damage to the skin and to the underlying tissue. Where are we now in terms of being very precise, in the delivery of that radiation yeah. So, with. The, techniques that we have now we are much. Better, targeted. With radiation, in other words we're. Able to create a pretty exquisite, 3d, sculpting, of radiation, doses, and. So so. In that way we're, able to accomplish you know one of the key things that is. Needed, for all cancer therapy, it's.
A Big word but. The, word the big word is therapeutic, index, ah and. What that means is being able to eliminate, the cancer without. Causing, too much collateral damage, and. That's a key principle you, know regardless, of the treatment you. Know it turns out that what makes cancer. Incurable. In those cases that it is is when. The, what. It takes to eliminate, the cancer is more. Than what the patient can tolerate yeah, and so it doesn't matter if it's a drug or if it's surgery or ray or radiation. Basically. I can give enough, radiation to eliminate, a cancer, that's actually not a fundamental, problem the fundamental problem, is when. The, patient is not able to tolerate that then. Then. We're really limited so tell me a little bit about how we get this precision, you said that you can even do like a 3d. Sculpture and I know in some of your papers you even refer to four-dimensional. So tell, me about 3d, and then maybe we can move to 4d, in terms of what are our capabilities, now and how does it actually work yeah absolutely so there's, different, ways of delivering radiation. But. There's some common principles, to all of them and, the most common, type, of radiation we use is high-energy x-rays, okay, and, the way that we create 3d. Sculpting, of radiation, dose is to create, focusing, of the radiation, is by, coming in from multiple different, directions, and where. Our radiation beams cross the dose adds up and. So you have a bunch, of maybe. Not, so strong x-rays, but there's a lot of them coming into this point, that's right and so they add up so that the, surrounding tissue gets a little bit but, that one point where it's all focused gets, a lot exactly. And we are. Able now to guide that. Precisely with, the better, imaging, that we have so, CT. Scanning PET scanning MRI, all. Of those were able to incorporate to. Get the best picture of, where's, the cancer where are the normal tissues that we want to spare how, do we kind of create that dough sculpting, yes so, now let me ask what, when you when you use these. Images. CTS, MRIs, are you doing it before the treatment or are, you doing it during the treatment in order to watch the effects as it's happening perhaps, I'm just making that up yeah yeah absolutely so it's both so, we use it before the treatment in order to plan it so, we identify, what's, the, area that needs to be treated where's the tumor in relationship.
To The normal organs and, create that plan, of very sculpted, treatment, and then, during, the treatment we, also use imaging, and up, till now the. The. The imaging. That we can use during treatment, is a little bit more limited than what we have you, know for a diagnosis. But, it allows us to see for example whether we're on target and. Is the radiation going where we want it to go so, so yeah this is great this is great and so the 4d, so obviously 3d is the shape of the tumor and you want to match that as well as closely as possible and then is the 4d over time I would presume that's right yeah and is it the time over many weeks and months while the patient is getting the treatments or do you mean the time during the delivery of the x-rays again it's both and, so I think. What. People add, you know may, I realize. If you think about it a little bit right during. The treatment. Every. Part of the body moves all the time some. Parts move more than others so for example, what, I'm treating a lung tumor a patient is you have to breathe yes and so. The people are breathing organs. Move the lungs and other, parts of the body move so, we're always treating moving targets, and. That's where the 4d comes in is understanding what, motion is going on and how do you compensate and then you can adjust so that even if you had an initial plan stuff, happens and you might need to in, midstream, adjust. How you're delivering the x-rays that's right this is the future of everything I'm Russ Altman I'm speaking with dr. bill Liu about frontiers. Of radiation, therapy. And the opportunities, going forward so, so. Many things to ask but let's talk about, timing. We talked about time the fourth dimension, the. Traditional. Story about radiation therapy is often a patient, going in on a regular basis, over weeks or months I'm, staying for quite a long time in, a very rigid position, while you. Guys deliver, the radiation but I understand, that there's been some breakthroughs. Recently, where the treatment, times have, been getting much. Shorter, and and I wanted to ask about what's, the source of those innovations. And is. It having a positive impact on the patient experience, because having, cancer is terrible, as it is but, having to go every day to a clinic and spend two or three hours in a rigid position can't, be fun yeah absolutely, so. There's. A, basically. Developments. Over time that. Have. Given. Us insights, into the. New breakthrough, that you, know I hope, we'll be touching, on which is the phase or technology, that we're working oh my goodness this sounds like Star. Trek absolutely. Phaser so that's a real thing so tell me about phasers, sure well so phaser is, I mean it stands for a mouthful. The. Acronym. Is for blurry, directional, high-energy agile. Scanning, electronic, radio therapy there you go yeah, but. To be honest you, know the motivation, for that comes from the fact that you. Know probably, like you and others of our listeners, I'm a sci-fi nerd right, and those influenced, by Star Trek of course is, that what phaser stands for on Star Trek a good. Question we need to find out yeah but but. You know growing. Up watching Star Trek you know that was you. Know the future of medicine right in, fact the future of everything exactly Star. Trek was filled with medical things you remember the doctor, had that little thing that they put the scanner yeah that figured everything out I would love to have one of my quarters. So. So what is it what is the phaser technology. Right. So we, were talking about time and treating moving targets, right and so a lot, of you. Know the work that I've done together, with my colleagues over the years is implement. Technologies, in the clinic to, compensate. For emotionally, motion, management, all, kinds, of tricks like you. Know turning, on the radiation beam. Synchronized. With the breathing cycle.
Or, Following, tumors around with the radiation, beam very. Complicated, things that we're, at now able to do on a routine basis, but it's hard. To do hard to do right easy to do wrong very. Hard to translate out, into you know the rest of the world yeah I imagine this involves, maybe robotics, and artificial intelligence type technologies. And yeah not, you don't have to just get it to work at your clinic and in your lab but you have to figure out how do I export, this so that everybody can benefit from it exactly, so that so the phaser is the phaser technology, this a very intelligent tracking. Of the tumor and, deciding. When to send the beam. Is it also more intense beams, is, that how we get a time shortening, for the treatments right so all, of those strategies that, we've developed in, the past have, been based on the fundamental assumption, that it takes longer to give the radiation, treatment than it does for the body to move but. Over time as we've implemented, these various technologies, we've. Sort of realized, that. The. Treatment, times you know we've successfully, decreased. Gradually, so. When we first started doing this in the early 2000s. To give a big you, know focused, dose of radiation using. The new technologies, at the time maybe. Three, hours two to three hours that the patient would be on, the table getting treated now. We do those similar treatments, in about, three, minutes. Feet. Up but, still a long time compared, to the motion in the body but. The insight, that came from that is what have we flipped the problem around what, if the treatment, was done so fast like in a flash like flash photography that, all the motion is frozen then, that's a fundamental, solution to this. Motion, problem, that, gives us the ultimate precision yes and that we Arup utak index because. If. We're able to treat more precisely, with, less slop less, spillage of radiation, dose into normal tissues. That. Gives us that that. Benefit, of being able to kill the cancer and cause, less collateral damage, this, is the future everything I'm Russ Altman speaking, with dr. bill Liu about the advances. In radiation therapy. We're now talking about phasers, and a flash treatments. So when. I think so flash sounds like a great analogy to just imagine what it's like and we all know that the thing about flash photography is, it's extremely. Bright so yes it captures our motion but, for that you, know several, milliseconds. We're almost rendered, incapable. Of, doing anything else because of the overwhelming, light so is there an analogy, and the treatment so first, of all it must be very stressful for you to turn on such a bright beam even, it's for even if it's for a short period of time that, the first time you do that it must be very stressful I would imagine, because. If. You've, overexposed. So to speak the patient or if you've missed the target you might be doing a lot of damage to the wrong part of the body so how, do you even begin. To do to, test these technologies, to the point where you're comfortable using them in patients, right well, so one key part is, integrating. Something that we've been doing for a good, period of time now which is that image guidance, aspect, of it right so it's very important, to, have a clear picture of what's going on in the patient's body so, that the beam is turned on at exactly the right place in the right time like your remarks and yeah exactly, when is the when, we have it in the crosshairs press, the button that's right yeah and so, you, know so. Some of those imaging, technologies, we already, used some extent, in. Fact you. Know the. Way it works right now is that even. Though, our. Radiation. Treatments aren't so fast right, you. Know we line everything up perfectly, you know we hit go on the radiation. The. Imaging. That we have right on the table is a little bit limited and. So even, now we're not seeing everything, all the time you, know as we're treating but. If you have fast enough radiation where you can get a clearer picture right, at the beginning right when you're about to fire and then, everything. Is lined up and you go that's, actually, got the potential to be more accurate than what we do now yes, and all the motions frozen, but, the the. Really exciting thing that we're discovering and this is now in laboratory. Research. We're. Developing, the technology, to do this very fast. Flash, treatment in humans but. Using some existing, ticket we're, able to test this in very, small patience, like mice, and. What, we found is, you can be given a range of cancers that can.
Be Then used as test crowns, right right and what, we found preliminarily, even a big tumor give me a big tumor in a mouse is gonna be a little tumor in a human exact so if you can get good with that you can imagine it being very reassuring, they also are not very good at holding their breath on purpose exactly, right oh great right and. So they're the questions, is, not even the precision, part right but just what's the fundamental, biology that, happens when very, fast, treatment, is going and. What we and a few other labs around the world have. Started to see is. That when. The radiation is given in a flash we. See equal or better tumor killing but. Much better normal. Tissue protection. Then, with the conventional, speed of radiation so ah this is very interesting so you're saying that the biological response. To, the radiation actually, might be different, based, on how it if it gets a lot in a short time versus, a little bit over a long time and then you're telling me also, that, this is actually kind of good news that for, whatever reason, normal. Tissues seem to be able to withstand this. High flash a little bit better than the cancer tissues do we understand why that happens that's a very active area of research right now so we're just at the beginning of trying to understand, that but. What we have, seen is this consistent phenomenon. Now across. Multiple labs and even in a few different species of animals, that that. This effect, is occurring, and. If that translates to humans that's a huge breakthrough, so, speaking of the biology, let me ask you about resistance, everybody, knows that in chemotherapy the, big thing that you worry about is that you're going to become resistant. To the chemotherapy it's not gonna work anymore the, cells stopped dying because they figure out a way around it is resistance. A thing in radiation. Therapy to. A much less extent, because radiation, cuts, across, many, more molecular pathways, then you. Know drugs that may, work on a few molecular, pathways. So. The, cancer, cells can. Have different, sensitivities, to radiation, but. Resistance. Is still. Much. Less of an issue with radiation, than with the, drug, there so that's quite good news this, is the future of everything I'm Russ Altman more, with dr. bill Liu about radiation therapy, and its future next, on Sirius XM insight. 121. From. The campus, of Stanford University people. Are worried about data they're worried about their privacy and their security they should be we need secure, systems, this, is the future of everything but we can't have a system that closes. That data off it is too rich of a source of inspiration. Innovation. And discovery for, new things in medicine with your host Russ Altman, welcome. Back to the future of everything I'm Russ Altman I'm speaking with dr. bill Liu about radiation therapy, it's applications. And its future. So. Bill one of the really fascinating things in, preparing, for our conversation. Was, the idea that radiation, therapy might actually be useful for things other than cancer, and. I think you've kind of led in some areas so what would be the theory of using radiation for other diseases, right. Well so radiation, and cancer is used we, think primarily to kill cancer cells it actually has a lot of other biological. Effects that can contribute, to that that. You, know it's much more complicated, than that. But some, of the effects, that are, not directly, related to cell killing, you. Know it may modify, the function. Or response, of cells scar, tissue formation, or. Changes, in electrical. Conductivity of. Conducting, cells yes and so some of the applications, you. Know where we've, looked at treat, diseases that are potentially. Treated by surgery but. In patients who maybe cannot tolerate surgery. Because they have you. Know it's too dangerous for them right sometimes you're just not a surgical, candidate exactly, as I can't operate on this person right and so a couple of the applications, that have emerged. That. In, clinical. Studies is for. Example patients, who have bad emphysema. Of the lungs a portion. Of their lung is not working, because it's basically a big air bubble that's right so all the fine structure, of the lung has been damaged.
And Removed, and so they don't have a surface area for exchanging, oxygen with their bloodstream exactly. And what the treatments for severe emphysema is in fact to remove those non-functioning, parts of the lungs so other parts can work better yes and. We. Found, preliminary. Evidence and we're doing a clinical trial now where we use very focused, radiation, to. Which, we know you know how to do. Discussion. Right to, create an area of basically. Like scarring, to shrink. Down the portion of the emphysema, lungs it kind of pulls together all of that useless tissue and let's the other tissue expand, and do its thing correct, yeah yes so where is this in development, is this a, brand. New idea or are, you actually doing some trials, where are we in the in the research, pipeline. So it's a well, it has roots that are quite old but it we, actually have a current clinical trial that's ongoing that's, run. In collaboration, with Joe, Schrager who leads our thoracic. Surgery group. Here so is, it possible that this would wind up being even better than surgery and that for even people who, could, tolerate. The surgery they might elect to do this instead because I mean just thinking about it if you told me that I could either go on a surgical table or go, to the radiation therapy suite and have some you know zap, my lungs so, could. I guess it's too early or do we have any yeah. It's still very early days but I think the way that we've seen these sorts of things evolved, is that it's it's, not an either/or, it's not one replacing, the other but what it is is it allows us to individualize. For a given patient you, know expanding. The options, and what might be better you know depending, on what their risk factors are and. So it allows us to kind of tailor. The treatments better if we have more options so, I'm struck and that's, very exciting and people, and for the emphysema, is very, different from cancer and so it's it's fun to think about novel. Uses of these technologies, and I did want to just briefly ask you about the technologies, like what, does your laboratory, look like what are the kinds of work that your scientists. In your lab the technicians. The students, the postdoctoral fellows. What. Does it look like well, what for one thing is very multidisciplinary because. It pulls in collaborators. From a lot of different, areas so. Physics. Engineering, biology. And so. For. Example the, core. Linear accelerator, research, that we're doing for phaser is being, done led, by my colleague Sammy tantowi at SLAC National Accelerator, lab. So. Slack for those who are not familiar it, used to be used to stand for Stanford. Linear Accelerator but, I think now it just stands for slack and it's a big. Physical. Facility, in in the Bay Area with, a I think a 1 or 2 mile long, tunnel. That accelerates, these particles, to very high energies exactly.
And So they're using this for medical research because everybody thinks of it as kind of energetics, and nuclear research but this is for medicine as well well it turns out that pushing, the limits of that technology. To. You, know study very high energy physics allows. Has. Other applications and translates, into, you. Know the medical technology, as well and that's what we're capitalizing on in. This collaboration, and I would guess that you have people who are essentially, robotics, experts, as well in, terms of this tracking, and moving the beams is that true well, in. This particular incarnation. Because, of the speed we actually want to eliminate all the mechanical, moving parts so it's all done electronically, but I. Mean. If this. Is the future of everything I'm Russ Altman and I'm speaking with bill Liu about radiation, therapy I wanted. To kind of I'll, also ask you about okay, now you do this discovery, you get these amazing, new technologies, there's. A responsibility. To get it out into the world and and how do you do that and I can imagine that there's one issue getting it out in, the US where it were your based but, I imagine, that there's another issue and set of opportunities with getting it even more broadly around. The world how, do you even think about that, yeah absolutely well, the major problem, that, we face in cancer, is that about. Half of the patients in the world today. Despite. The fact that radiation is such an important treatment about half of patients have no access at all, for. Technological. And logistical. Really. Benefit correct, yeah so that means that millions of patients who could potentially be receiving, curative cancer therapy are getting treated, purely, palliative, ly and. So that's a huge tragedy that. You, know it's it's an emergency, of our day here now. And so if. You. Know whatever revolutions. That we come up with in technology. If. It's going to impact that it. Needs to be something that can be practical, in. The sense of it has to be compact, it. Has to be economical, it has to be reliable, it. Has to be clinically efficient, and so those are, kind of core design, principles, that we've kept in mind from the very beginning when. Thinking about the phaser technology, because we don't want to create a solution that you know everyone in the world has to come here to get right right, that would be great. But you, know he's gonna have it's gonna have limited impact right, and so that's, been a core principle from the beginning so, that that is a really fascinating prompt cuz of course one of the things that comes to mind is it has to be robust that you know you're working in a very high-end. Medical. Facility. But, the people who have the Cantonese 50%, of people with cancer around the world many of them are living in very harsh conditions in. Villages, and and whatnot and we have to figure out how to get these machines, and have them be robust and well powered, and safe so, is this, something you do as, a side, project or are there people who are devoted, to this kind of robusta. Fication a word that I just made up yeah of these technologies, like whose problem, is that so. It's a it's a problem that you. Know we were tackling, from the very beginning so, not. Only do we want to increase, the performance, of the technology, but. It has to be robust as well and, that that's one of the breakthroughs. That. It. You know on, the accelerator, side you know from my. Colleagues a mutant ami Chris. Company, smile accelerator. Around, the world so obviously, need to turn that accelerator, interesting, is that going to be technically, possible to get those kinds of energies in smaller, devices we, believe that the. Entire system that we're developing will. End up being able to fit into a standard, cargo, shipping container okay and, be powered by solar power, and batteries, you know so really a. Portable. Solution now. How do the companies that build these but, you so you make the inventions, you make the protocols, there, has to be some industrial, interest. That kind of scales it and, as, many as are needed, how. Do they think about these. Markets, where perhaps the levels, of income are not as high the ability, to pay it seems like there's some real challenges in, getting high-tech innovations.
Out Into, the developing, world yeah. That is a definitely, a challenge, you. Know, that. I, think, there are resources. At. Least to some degree, to. To. Pay for cancer care there are initiatives to, do that, you. Know you. Know that needs to be worked on you know from a health policy angle. As well I would imagine there might be some foundations, who would take a particular interest, in this yeah, and also there has been I've, noticed a tendency sometimes for. Things that you design for, robust, deployment in the field actually become. Useful even at home exactly. And I, think that's the key thing it's like you know your cell phone it's burying, the complexity. You know you had a supercomputer in your pocket that even kids can use right and. Yet that power is, something that's very relevant to all of us every day so in fact, the ultimate machine for. Africa. Or other, underserved. Areas, in the world is exactly what I would want to use in my clinic, thank. You for listening to the future of everything I'm Russ Altman if you missed any of this episode listen anytime on demand. With, the Sirius, XM, app.
2019-03-06