New Radiation Oncology Technologies for Diagnosis & Treatment of Common Cancers

thank you for joining us today welcome to oncology watch radiation oncology 101 new technologies for diagnosis and treatment of common cancers this event will be presented by dr patrick richard and dr daria poshlick radiation oncologist at rocky mountain cancer centers boulder clinic welcome gentlemen for our viewers we will be monitoring the comments section during the presentation if you have any questions please put them in a comment and we'll address them at the end doctors richard and poshlick thank you again we are eager to hear what you have to say thank you so much jessica i appreciate uh the introduction and um obviously dr poshlich and i are uh very excited to cover a lot of the the basics and recent advances in radiation oncology we've had quite a bit of change in our boulder clinic uh since the start of the year and so we're excited to share some of the new and advanced options that we have for a variety of malignancies the obligatory glamour shots of myself and dr poshlich as well as our credentials and first and foremost we're uh very blessed to have such a beautiful uh clinic to operate out of and um located in uh what we feel to be one of the uh most healthy and uh beautiful parts in our country in boulder some screenshots of the front of our clinic our center for integrative care here which a lot of our patients utilize for complementary medicine and then we have a wonderful medical oncology suite upstairs that our medical oncologists operate out of so very beautiful uh fortunate place we can we can work out of as we frame the discussion today it's really important as always to highlight the most common cancers that people are affected by in the united states and these happen to be the most common cancers that we treat in our boulder clinic we see a very wide range but the ones in the box here are the most common whether it be prostate cancer in men breast cancer in women we see a fair amount of lung and thoracic malignancies colorectal as you go down these are less common but again we have a good experience treating them in our in our facility here this is a little bit of an outline and framework for what dr poshlich and i will cover today i'll start off by talking a little bit about how we diagnose and stage various cancers with an emphasis on a new scanner that we have available here in our boulder clinic our multidisciplinary discussion cancer conference and tumor boards where we put it all together and come up with team-based recommendations and approaches that we then present to our patients and then dr poshlich will cover the details of how we approach cancer from a radiation point of view so first with imaging so one thing i wanted to highlight is one very important tool that we use to assess the location and extent of a cancer and that's with a pet ct scan as we all know staging is very important because it helps us determine whether we're dealing with a more localized process or early stage cancer or something that unfortunately could have spread to other parts of the body these staging studies really impact what treatment options are available the prognosis and efficacy of treatment you can see this visual here which is trying to show us what happens during a pet scan we use this for various malignancies as i just mentioned we have a very common pet tracer which i'll cover that's used in locally advanced breast cancer and one of the more recent approvals was for a prostate specific pet tracer what generally happens is that we ask you to fast before this pet scan and as you can see in this animation we give you an injection one hour before the scan we allow that pet tracer to circulate throughout the body and then we image with a ct scan and a pet scan we're able to detect how the anatomy looks and any abnormalities that we see that could be related to the cancer beginning this year we formed a strong partnership with boulder community health in which allowed us to really look at our facility and our technology and provide some very critical upgrades we installed a brand new ge scanner that we've been using since the beginning of the year some of the basic highlights of the scanner is that it has a very high spatial resolution so that we can distinguish anatomy a little bit more clearly it has a higher ability to detect the actual pet tracer that is emitted from the injection and very importantly it actually this the ct scanner has a reduced dose compared to some of the older models it also has very sophisticated software that processes our imaging and improves the quantitative accuracy with this clear technology at rocky mountain cancer center we're fortunate to have many imaging clinic locations throughout the greater denver area so if you're not in our immediate boulder catchment chances are we have a very convenient imaging center close to you so certainly bring this up if your provider is recommending that you get imaging of that of that type one thing i wanted to touch upon is one of the new tracers that we feel is going to really be a game changer for men with prostate cancer is called a psma pet scan there's two tracers that we offer one called gallium and the other called polarify and it we've been very limited historically in our ability to accurately detect prostate cancer specifically we've had some pet tracers that have been used in the past such as prostastin but due to a variety of reasons it wasn't given us the clarity and accuracy that that we really need to stage and assess prostate cancer so this psma has been a game changer it was fda approved earlier this year and so we've started to use this tracer and most of our imaging centers it is a little bit limited and for mainly medicare population only as they have provided us the information we need to build and get reimbursement we do feel that the commercial payers are going to follow suit here pretty soon but a lot of the commercial page payers have not developed policy in terms of their coverage of this tracer so again just you know ask if it's something that would be covered based on your insurance besides the psma tracer we have a full portfolio of other tracers that we use for various cancers the workhorse up into this time has been the fdg or f-18 tracer which we use in breasts melanoma head and neck to help a stage and then we have a unique tracer called the gallium 68 dota tape tracer which is for specific neuroendocrine tumors this is an example of what a pet scan looks like it's it's actually a combination of two scans the ct scan and the actual pet scan so it affords us an ability in within one visit in one scan to assess the anatomy for any irregularities and then we can see whether that specific irregularity is actually metabolically active this is an example of a psma pet scan where we actually see normal anatomy that lights up and when i go through these images with my patients i always go slice by slice and highlight certain things that we normally see active in this example we see the salivary glands up in the head neck region we see the liver the intestines and so forth if you look at the image on the right we would not expect to see an uptake in the bone and so this is an example of something that would clue us into a possible active cancer in this patient's bone these are other images that we use we'd use this for prostate cancer but in reality they're used for other malignancies like breast we have bone specific imaging which we call bone scan or spec scan which as you can see the skeleton is very highlighted in the skin so we can detect abnormalities in the bone but the soft tissue is not well visualized ct scans and mri on the other hand are really good for soft tissue it can give us clear anatomy but we don't can't often see whether that area is metabolically active and again this is the same image i just showed you where we get the best of both worlds with a pet scan not to get too scientific here but basically the two big criteria that we look at when we're comparing which image is the best for each patient is what's called sensitivity and specificity uh to cover the basic definition of this sensitivity is when somebody comes to me with an act of cancer i want to image and detect it the the the sensitivity is our ability of detecting people who actually have active cancer on the flip side is what's called specificity where some somebody comes to me with no active cancer i want to be able to rule them out and not have a false positive that something could be going on that's not related to cancer when we combine these two is really where the psma pet scan for prostate cancer shines this is a single institution trial of 80 patients that looked at various imaging modalities for prostate cancer and it was determined that the psma had really the highest combination of sensitivity and specificity and that's why we feel we really have an advancement here finally to stage men with prostate cancer another a little bit of a larger multi-institutional trial looking at the psma compared to some of our older imaging tests again demonstrating that the sensitivity and specificity is greatly improved with psma this bullet point here is very important to us as radiation oncologists as we'll get into in a bit with dr poshlich we are a local therapy we do not treat the entire body and it's best utilized with radiation when we have clearly defined targets so an imaging tool that's giving us that better ability to detect cancer whether it be in the lymph nodes or elsewhere in the body is really important and psma is much better able to do that so for example if we find cancer in the lymph nodes we can then target them with radiation in many examples and if we're finding cancer that is more extensive throughout the body radiation may not even be the best initial treatment option uh specifically with psma there are certain indications for what's appropriate and what's not and this is a little bit of a evolving paradigm as we get more information about psma it was initially used in guys that had had treatment cancer had come back we were using the pet scan for that but what's really exciting is that we're now using it as upfront staging in men with prostate cancer that are unfavorable intermediate risk or higher so we no longer need to do any ct scans or bone scans this is the wave of the future where we can start off with psma and get all the information with one convenience scan so switching gears a little bit to the way that we put all of these studies together and i didn't cover a lot of the other work up and staging studies but what's really critical when you're dealing with cancer treatment is that we all come together as a team discuss the case and provide our best recommendation and treatment approach and that's what's called multi-disciplinary discussion and assessment we commonly refer to this as tumor boards or cancer conferences we're very blessed at rocky mountain cancer center to have a wide array of cancer specialists one of our largest groups are our medical oncologists and hematologists we provided names and pictures of our group here in boulder very diverse group seeing a wide range of malignancies and all very much experience with with providing these recommendations one thing we're very excited about is the fact that we have a growing surgical oncology division within rocky mountain cancer center the two i'd like to highlight are dr galinda tynan who is a breast surgeon specialist up in longmont and one of our more recent surgeons to join the group is dr katrina ayagi also a breast surgery surgeon out in superior so we come together we have our radiologists our pathologists that are not visualized on this on the slide but that we review the imaging the pathology to make sure that we have a comprehensive assessment of each case one important thing is considering clinical trials i'd like to highlight our partnership with western state's cancer research program which we partner with boulder community health as well this is an nci-affiliated clinical trial program that gives us and our patients access to some of the state-of-the-art national large trials that are being conducted through cooperative groups in the country these are just a few examples we have pretty much every disease site options available the one i'd like to highlight for brass is what's called the taylor r t trial as dr poshless may cover with breast cancer there are many different targets that we can go after which means more or less radiation exposure to other parts of the body depending on whether we're treating the lymph nodes and so forth this is using actually a genomic test called the oncotype test to determine whether we actually need to do that if somebody has a low genomic risk of cancer spreading we may not have to treat such a wide area with radiation so it's an interesting approach in regards to that with prostate i really like the swog trial it's actually for guys with very advanced prostate cancer determining whether we can get a benefit um through actually treating the prostate gland so it used to be where we would actually just treat them with systemic therapy but there's actually some recent data that we can improve overall survival and progression-free survival by focusing on where it all started in the prostate gland and this is a good option for those that are interested in that and then there's also several trials looking at the use of genomic testing and prostate cancer to either de-escalate or escalate hormone therapy one that we're really excited about for early stage lung cancer stage one or stage two is the swat trial we know that many lung cancers respond very well to immunotherapy and that's been a game changer for advanced pro lung cancer but in early stage we haven't used it as much so it's actually investigating whether we can start off with immunotherapy therapy to potentially reduce the size of a lung cancer and dr poshless will cover sbrt which is a advanced form of radiation where we can ablate small tumors and so this is a non-invasive approach to lung cancer treatment so i want to switch gears now to dr poshlich who will again give us a historical perspective on where we've come with our radiation approach and then take us into the modern day age of where we where we are and where we're going to go so i'll turn it over to you dr poshlich thank you so much dr richard really really great summary of you know our ability to diagnose and then collaborate you know as a team to really figure out what's the best approach for patient care you know i want to really take this opportunity to focus in more on the radiation side of things which is what dr richard and i do and it really starts with sort of the evolution of radiation therapy and what the goals of radiation therapy are you know radiation's been around for over 100 years um radiation was first discovered uh in 1890 1893 and the first case of a radiation treatment for curative intent was in 1896 so we've been at this for a really long time the difference though is that you know we started off being able to treat a large area like a tumor here but we'd also be treating a lot of surrounding normal tissue which can lead to side effects both short term and long term as we got more sophisticated with our technology we developed something called 3d conformal radiation in the 1970s 80s and 90s and were able to still treat the cancer the tumor here but also treat less of the normal surrounding tissue it's not really until the last say you know 15 20 years or so that we've really made significant advancements through the form of imrt and something called sbrt or stereotactic radiation where we can really focus in our treatment in to the tumor and have very very little radiation dose to the surrounding tissue that's really the the goal of radiation is to design a radiation plan that is specific and individual to your anatomy so that we can minimize radiation exposure to the surrounding normal tissue in the case of prostate cancer for example that means you know avoiding radiation to areas like the rectum the bladder the bone but also with the breast you know if if we're treating breast cancer avoiding radiation to the lung and to the heart but it's not only enough to design a radiation plan i think you have to be able to deliver it and take the theoretical design and make it practical and that requires that we do it in a timely manner you know to finish the radiation uh each day on on time and um have you on the table for a comfortable period of time we also have to ensure that there's consistent daily setup through rigorous image guidance really making sure that we're targeting the area that we're meant to target while minimizing radiation to the surrounding tissue so there's a general term for radiation called external beam radiation therapy which you know is really meant to just signify that the radiation comes from a machine that rotates around you as you can see here the machine delivers radiation as it rotates around you and there's metallic leaves that can shape the radiation dose to a specific contour you know in the case of a lung cancer or breast cancer it can really mold that radiation to the shape of that of that cancer itself and that's what we call external beam radiation therapy there are a number of different forms of external beam radiation therapy the simplest is something called 3d conformal radiation and what you see here is you know the anatomy of a patient sitting on our radiation treatment table kind of looking at them from the feet up so the design here is pretty simple there's radiation being coming from the front from the back and from the sides and we're targeting the prostate gland in this case and minimizing you know radiation to the surrounding tissue since then we've really evolved our treatments to do something called intensity and intensity modulated radiation therapy or imrt where we use these little tiny beams that come from different directions that can minimize the radiation overall exposure and still target the prostate gland in this case an even more advanced form of imrt now is called volumetric modulated arc therapy where we're able to really shape that radiation curve that radiation dose around the structure that we're targeting while minimizing radiation to the surrounding tissue and we do that by allowing the machine to rotate around the patient and those metallic leaves that you saw they also shape and and change shape as as we're moving through the treatment altogether you know we we considered this all conventional external beam radiation therapy that we treat patients with over the course of six to nine weeks monday through friday we do a small dose each day and this has been kind of the standard of care for the last 20 30 40 years however with this new technology with imrt and vmat we've been able to do something called hypofractionated external beam radiation therapy where we can use larger doses each day and condense a treatment course into four to six weeks instead of six to nine weeks for example depending on which type of cancer we're treating and even more recently with advancements in technology not just on the machine side of things but in terms of being able to target the the the cancer accurately each day we do something called ultra hypofractionated external beam radiation therapy also known as stereotactic radiation therapy or sbrt and this is where we give a really large dose each day and we can actually finish a treatment as short of uh in as short as one to two weeks and sometimes even one day in in certain certain cases so recently our clinic has invested in a new machine that can really do it all and we're proud of that because it has the latest and greatest technology we have the variant truebeam edge here which is our newest machine that has high definition multi-leaf collimators and cones which are just the metallic leaves that you saw in that previous animation and essentially what it means is that we can really shape that radiation dose more finely around the tumor and minimize radiation dose to the surrounding tissue which is great for patients great for outcomes we also invested in a six degree freedom uh table and that's essentially the the area that our patients will sit on each day for their treatment and by having six degrees of freedom we can move that table in any direction up down left right pitch roll yaw and allow for little tiny adjustments in anatomy each day that can offset certain certain things and that really allows us to again accurately target the area while minimizing radiation to surrounding tissue so why did we choose to choose the truebeam platform and why are we so excited about this new technology in our clinic now there's a lot of different radiation machines and radiation technology out there there's the true beam there's tomotherapy there's cyberknife and they all have their pros and cons you know they are all essentially machines that deliver high-energy photon radiation or x-rays they're all linear accelerators uh again able to deliver high-energy x-rays to to the cancer they all kind of do the same thing you know they can treat conventional radiation so the six to nine weeks but they also do stereotactic radiation for the most part doing those really condensed treatment courses and they can also treat any location uh in the body but what really sets it apart is when you kind of dig into the technology and you dig into the pros and cons of everyday treatment here's an example this is a prostate cancer treatment for a patient same patient on all three platforms when we look at the time that's necessary to treat the patient for one treatment so one fraction it's about two and a half minutes on the true beam about seven minutes on the tomo therapy machine and about 17 minutes on the cyberknife when you add all this up each day you know if you're getting five treatments or 10 or 20 or 30 that time can really add up you can also look at the surrounding tissue you know the rectum here for example with a true beam we're able to spare much more of the rectum than we can with the tomotherapy machine for example or even the cyberknife similarly the bladder you know gets really similar sparing between the true beam and the cyberknife but as you can see here the tomotherapy machine is almost twice the dose so the combination of of timeliness with the truebeam as well as the sparing of the surrounding tissue made us really excited to invest in this technology and bring it to our community here in boulder it's really not enough just to invest in the technology that can deliver radiation we have to really have the technology where we can target the area finally each day and that's where this additional technology comes into play called brain lab exact track dynamic we're now able to monitor our patients motion and position on four different levels we use surface guidance where we can actually render uh your body in real time and see how you're moving on the table make any subtle adjustments based on that thermal guidance which takes that surface guidance a little bit deeper and especially helpful with our patients with darker skin complexions there's x-ray guidance so looking internally uh at the position of the tumor the position of bones or other anatomy and then there's real time tracking and monitoring during treatment so we can actually have the machine track the tumor track the cancer in real time and be able to make subtle adjustments as as we're treating patients so this really allows for submillimeters in precision and accuracy of setup and allows to be much tighter with our radiation dose delivery so really really exciting to combine both the true beam and the brain lab exact track dynamic technology into one to improve what we can do in our in our clinic here's an example of how the brain lab exact track dynamic works so there's a camera that can monitor for the surface guidance as well as the thermal guidance again tracking you live as you're on the table uh the entire time and making subtle adjustments real time tracking internally at the deeper anatomy so combining both surface thermal and x-ray into one for every patient to give the most accurate treatment possible we can also use this to monitor your breathing during treatment and see you know if there's any subtle irregularities or changes and also verify internal anatomy and again we use it for all over the body whether it's cranial breast prostate really has been a game changer for our community to be able to offer this technology so really again i've already mentioned this we're increasing precision we're increasing accuracy and this all leads to less radiation dose to the surrounding tissue we can increase the speed of treatment deliveries that means less time on the table for our patients so it's more convenient and we're also providing convenience now by offering shorter treatment courses because we can deliver these larger doses each day now with accuracy reliability and confidence we can now offer much shorter radiation treatment courses so breast cancer for example traditionally we treated that over the course of six weeks now we can take that down to one week prostate cancer in some cases we've treated up to nine weeks that can now become two weeks rectal cancer we normally treat five weeks that can now become one week and brain and bone metastases normally we would treat these over the course of two weeks now it can be as short as one session or as long as five sessions but again taking everything and making it more convenient for our patients other cancers that we can treat in five treatments or less early stage lung cancer kidney cancer and liver cancer or liver metastases have all been new breakthroughs with the shorter treatment courses so just as an example early stage breast cancer like i mentioned we traditionally used to treat this over the course of six weeks now with this new technology and with our experience we can take this down to one week where we treat the breast tissue here you can see on the right hand side uh this this this breast tissue that is being treated with a partial breast approach um so we're able to spare the surrounding tissue and do it in a shorter time course as one week prostate cancer like i mentioned went from nine weeks to two weeks here you can see the patient receiving a stereotactic radiation course that's just focused on the prostate gland and those little seminal vesicles rectal cancer you know traditionally five weeks of treatment that was a fairly large treatment volume with our new technology we can decrease the volume of the surrounding tissue that's receiving radiation and do it in the short of a course is one week so just to give you an example the the red here is the high dose radiation which is now a little bit tighter with the shorter treatment course the green is the lower dose radiation again smaller amount of that low dose radiation leakage to the surrounding tissue all that means less side effects and more convenient treatment for our patients brain metastases you know that's something we would traditionally treat over the course of two weeks now we can do it as as fast as one to five treatment days so here's an example of a of a patient's anatomy with multiple brain metastases kind of spread apart through different parts of the brain we can target all of those in one treatment session and spare the surrounding brain tissue in between all those different spots from receiving unnecessary radiation again able to decrease the the side effects while maintaining accurate pinpoint radiation targeting and finally here we have an example of a metastasis to the spine we take this treatment course from two weeks to one to five days um again we can offer accurate precise steep dose fall off um so traditionally what we would do in these cases these are the first two panels we would do something called 3d conformal radiation therapy over the course of two weeks you can see the high-dose radiation is kind of in the orange and the low-dose radiation is in the blue the the bowel in the front would receive you know some of the low-dose radiation but now with this new technology we can focus that high-dose radiation just to the to the bone to the vertebral body while limiting low-dose radiation leakage the surrounding tissue so not only is this more accurate and and and more precise but also a shorter treatment course so in summary you know we're really excited to just offer leading evidence-based treatments within a multi-disciplinary setting we have wonderful medical oncologists surgeons pathologists radiologists you know all working together to give you the best possible treatment plan we have a wide clinical trial portfolio now that we can offer to patients who are interested in pursuing the the latest in in medical advancements we have advanced diagnostic imaging now with with pet ct scanning especially for our prostate cancer patients who prior to this didn't have this new tracer available to them and with this new technology within our radiation department we can again just deliver more precise more accurate radiation we can increase the speed and increase convenience through shorter treatment courses that's all very exciting and really wonderful for the community to have this available in your in your in your backyard without having to travel too far for for treatments elsewhere so with that we can leave it up leave it open for uh for questions thank you so much to both of you this has been just so enlightening for me um and i know for our attendees as well you know as i was watching i was thinking this is not my mother and grandmother's radiation anymore and and technology i mean it's just night and day difference um when you are talking to a patient and and you're trying to explain to them what makes the most sense for them and can you give us an idea of how you how you approach that how you have that that conversation with the patient and how you collaborate with the patient in terms of what makes the most sense for them from a treatment plan so they choose the best treatment for them absolutely yeah i can jump in here and as we make these advancements one thing that should not ever be neglected or not addressed is the wants and desires of each patient i think one thing that dr poshlich and i really pride ourselves on are spending the time to understand what this cancer means what each option is and giving the patient the information they need to make their own decision that's called shared decision making and that's a critical approach to cancer therapy um not all these approaches fit with what how patients want to live with or without their cancer and so we take time basically setting the stage for what the options are and give them the information they need we've often heard as we've seen quite a few patients for second opinions that have been you know elsewhere that wow i didn't realize there were so many options for radiation because historically yeah there weren't and either that or the the physician was not providing all the options or not offering you know some of these really convenient regimens that best serve our patient so you know to answer your question jessica i mean it's you have to spend the time explaining answering questions um and presenting all the options and and helping the patient arrive at the best choice that they feel they can proceed with thank you yeah that i the cancer journey is is such a such a challenge and it's it's so important for everybody to understand what the treatment is and what's what's the best outcome for them and make the best decision for them so it's it's lovely to hear how well you work with the patients so thank you so much for that um dr poshlich is there anything that you is coming up that you are excited about that's coming down the road in terms of of treatments or technologies that uh we hasn't come to the mainstream yet but that you're excited is coming soon yeah i think one of the things that's really exciting that we're also going to be offering more and more of especially here in boulder is radio pharmaceuticals you know it's the ability to link a radioactive material with a tracer like the pet scan for example that can then travel to the cancer directly with within the bloodstream and we already have some of these therapies available for prostate cancer for example things like zofigo but there are other new compounds and new trials coming out that are really really exciting that are pushing the envelope of our radiopharmaceutical arsenal you know to have more of those options for patients so i think the radiopharmaceutical component is is really really exciting i think there are a lot of options there we didn't have a chance to talk about that here obviously but i think that is something that we sometimes do in conjunction with the external beam radiation therapy sometimes we'll treat certain areas with external beam radiation therapy and then we'll add in the radiopharmaceutical as well on the tail end um so there are exciting new opportunities i think with within that space and i'd like to jump in and add a few things i'm excited about and it's you know along the same lines of what dr poshlus has already presented when it comes to these very focused high-dose radiation treatments i mentioned this in my discussion and slide on the clinical trials where we're really understanding stage 4 cancer very differently now i want to describe a specific a particular subset of stage 4 called oligometastatic cancer where as our systemic therapies our immunotherapies are targeted agents for a handful of cancers are getting better we're finding patients in a position where they don't have very disseminated rapidly progressing stage four cancer it tends to either be controlled or have one or two areas that are that are growing and everything else is under control and that's called oligomenostatic cancer it's very different historically we would treat this all with systemic therapy where we would just keep putting you on the medication until it didn't work now we're finding that things are quite different specifically for lung cancer there's quite a bit of literature that yes systemic therapy obviously is the backbone of treatment but that we can use an sbrt approach where we then come in and with systemic therapy precisely treat certain targets that maybe are a bit resistant to that systemic therapy we're again learning that that it makes a difference in terms of potentially overall survival for lung cancer we're seeing that in the prostate cancer literature so the the day and age of stage four cancer has changed we often describe it now as in some ways a chronic illness not a death sentence not something that jeopardizes someone's life immediately but something that we can help control support their quality of life and keep things under um better watch after that too so we're learning you know that you know how we can best utilize some of these advanced radiation approaches in ways that we hadn't thought of in years past just seems like it's it's the new frontier and and you know i think about in the last 10 to 15 years it seems like cancer treatment has just exploded in the capabilities that we are able to offer patients that just weren't around in in that time frame or at the beginning of that time frame so thank you both so so much for giving just such wonderful information we really appreciate it and of course thank you so much for the care that you provide to the patients i know that the patients appreciate it and we appreciate it as well thank you so much

2022-12-01 08:19

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