National cancer institute workshop on advanced technologies in radiation oncology december 1 2006
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National Cancer Institute Workshop on Advanced Technologies in Radiation Oncology December 1, 2006. Edward C. Halperin, M.D., M.A. Dean of the School of Medicine Ford Foundation Professor of Medical Education Professor of Radiation Oncology, Pediatrics, and History University of Louisville.

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National cancer institute workshop on advanced technologies in radiation oncology december 1 2006
National Cancer InstituteWorkshop on Advanced Technologies in Radiation OncologyDecember 1, 2006


Edward C. Halperin, M.D., M.A.Dean of the School of MedicineFord Foundation Professor of Medical EducationProfessor of Radiation Oncology, Pediatrics, and HistoryUniversity of Louisville


The club of radiation oncology deans samuel hellman allen lichter edward halperin
The Club of Radiation Oncology Deans Samuel Hellman Allen Lichter Edward Halperin



I have therefore concurred with myself and can assure you that the following views represent the unanimous opinion of the active membership.


Charge per dr vikram s email of 8 17 06
Charge per Dr. Vikram’s email of 8/17/06 that the following views represent the unanimous opinion of the active membership.


Compare, in reference to toxicity and survival, for childhood cancer, radiotherapy with conformal v. stereotactic v. IM/IGRT v. proton, neutron, carbon ions, pions et al. techniques


Outline childhood cancer, radiotherapy with conformal v. stereotactic v. IM/IGRT v. proton, neutron, carbon ions, pions et al. techniques Is the question(s) moot? Is the answer(s) self-evident? What questions didn’t Dr. Vikram ask that he should have? What do the data show in reference to the charge I have been given? What shall we do?


Is the question s moot
Is the question(s) moot? childhood cancer, radiotherapy with conformal v. stereotactic v. IM/IGRT v. proton, neutron, carbon ions, pions et al. techniques


ACGME Requirements in Radiation Oncology for Residency Training “The clinical core curriculum shall include experience in . . . pediatric [tumors]. . . . Residents must treat no fewer than 12 pediatric patients [in 4 years of residency] of whom a minimum of 9 have solid tumors.”


On 10/12/06 there were 79 accredited radiation oncology residencies in the U.S. with 569 residents on duty or ~ 142/year.


An estimate of the number of pediatric radiation oncology patients per year in the U.S. available for residency training and, potentially, for investigation of radiation treatment modality


….big assumptions: patients per year in the U.S. available for residency training and, potentially, for investigation of radiation treatment modalityNo cases go to private practice.Cases are uniformly distributed (Wills, St. Jude, MSKCC, CHOP, etc)


Example all cns prophylaxis testicular relapse tbi
Example: ALL (CNS prophylaxis, testicular relapse, TBI) patients per year in the U.S. available for residency training and, potentially, for investigation of radiation treatment modality

124 cases/year ÷ 569 trainees = 0.2 cases/year/trainee


So, in a 4-year residency, casting aside the problem of the “big assumptions,” our trainee will see 0.8 cases of the most common malignancy of childhood.


“The only thing I really want to know about pediatric radiotherapy after finishing this residency program is your phone number.”


“… if you want to lead, you have to adjust to the environment in which you find yourself. You cannot wait for it to adjust to you.”J.L. Gaddis, describing Dean Acheson. New Republic, 10/16/06, p.28


Many people assert that the Watergate scandal demonstrates that a free press is essential to democracy. All forms of print and electronic press are pleased to take credit for this achievement.


It can be argued, however, that it wasn’t the press at large who broke the Watergate story, it was two Washington Post reporters: Woodward and Bernstein.


Similarly, we have all seen dramatic images used to promote IMRT/IGRT and proton therapy in childhood tumors. It would be wrong to promote this technology on the basis of, from a public health standpoint, a tiny number of cases.


It is disingenuous to show your hospital administrator proton dosimetry for treating childhood craniopharyngioma as a technique for getting him/her to buy protons for treating bone metastases.


Is the answer s self evident
Is the answer(s) self-evident? proton dosimetry for treating childhood craniopharyngioma as a technique for getting him/her to buy protons for treating bone metastases.


“There is never any reason to give any dose to uninvolved normal tissue. An increase in dose to the tumor will, to a point, improve local control. Achieving these objectives is self-evidently true and does not require randomized prospective trials.”


After all we didn t require randomized trials to prove the benefits of simulators linac v co 60
After all, we didn’t require randomized trials to prove the benefits of _____________. Simulators LinAc v. Co60


Maybe we should have
Maybe we should have. the benefits of _____________.


Change is inevitable progress is optional a stern quoted in penn gaz 11 12 2006 p 54
“Change is inevitable. Progress is optional.” the benefits of _____________.A. Stern, quoted in Penn. Gaz., 11/12/2006, p. 54



The aspirin analogy
The Aspirin Analogy the benefits of _____________.


Of 56 african countries 64 have no radiotherapy facilities lancet oncol 2004 5 695
Of ~56 African countries, 64% have no radiotherapy facilities.Lancet Oncol, 2004;5:695


In Africa in 2002, the supply of Co facilities.60 and linear accelerators was 18% of the estimated need.Lancet Oncol 2006;7:584


Perhaps we should worry more about the provision of services to more of the world’s population, and less about inordinately expensive machines of unproven benefit for the wealthy?


“… in a world where more of the 100 largest economic entities are companies (52) than countries (48), a new set of rules will inevitably apply.”Penn. Gaz., 11/12/2006, p. 54


Is the answer self evident
Is the answer self-evident? entities are companies (52) than countries (48), a new set of rules will inevitably apply.”


These are some sites/situations in which the target is such that it is nearly impossible to envision an improvement by new technology over standard techniques.


The target is the entire structure and, while IMRT/IGRT could be used to deal with tissue heterogeneity, that is likely to be “a long run for a short slide.” Also, with current technology IMRT may increase second malignant neoplasms.


TBI could be used to deal with tissue heterogeneity, that is likely to be “a long run for a short slide.” Also, with current technology IMRT may increase second malignant neoplasms.Prophylactic cranial irradiationTesticular relapse radiotherapyWhole abdomen irradiation to 10 Gy


For some diseases the local control rate is dismal, few children live to suffer late effects, dose escalation has generally been fruitless, and high LET therapy has either been without benefit or made a bad situation worse.


Brain stem glioma high grade supratentorial astrocytoma
Brain stem glioma children live to suffer late effects, dose escalation has generally been fruitless, and high LET therapy has either been without benefit or made a bad situation worse.High grade supratentorial astrocytoma


For some diseases, the radiation dose is so low that it is hard to imagine a discernable benefitto technological innovation. (A better dose distribution does not equal a discernable benefit.)


Langerhans cell histiocytosis (4-6 Gy) hard to imagine a discernable benefitPost-transplant lymphoproliferative disorder (4-8 Gy)Transplantation Aplastic anemia Fanconi’s anemia Sickle cell anemia Intentional induction of chimerism



The untoward detriments of technological change
The untoward detriments of technological change hard to imagine a discernable benefit


In childhood cancer the push to use IMRT, IGRT, protons, etc. (all external beam techniques) inhibits the prudent use of superior alternatives.


Plaques for retinoblastoma (<entire anlage) etc. (all external beam techniques) inhibits the prudent use of superior alternatives. I125 RutheniumIntra-operative radiotherapyIntra-oral coneP32 for Askin and DSRBCT


The dose has to go somewhere or the case of the pancytopenic pineal patient
The dose has to go somewhere; etc. (all external beam techniques) inhibits the prudent use of superior alternatives.or the case of the pancytopenic pineal patient



Hearing loss for cisDDP treated patients receiving posterior fossa irradiation (at the price of endocrinopathy?)Neuroendocrine, salivary gland, and TMJ injury in juvenile nasopharngeal angiofibroma and of nasopharngeal carcinoma and rhabdomyosarcoma


IQ loss in localized intracranial irradiation fossa irradiation (at the price of endocrinopathy?)Thyroid, cardiac, pulmonary, and GI injury in craniospinal irradiationSarcoma treatment


“[The] clinical benefits of technological advances [in radiotherapy] including image-guided radiotherapy, are challenging to describe. Randomised data for patients treated with and without image guidance is unlikely to ever exist.”Dawson and Sharpe (PMH)Lancet Oncol 2006;7:848


Adequate field placement is correlated with tumor control in pediatric Medullablastoma Ewing tumor Hodgkin diseaseIJROBP 1997;37:523


Halperin s first rule of pediatric radiotherapy most tumors are radioresistant if you miss them
Halperin’s First Rule of Pediatric Radiotherapy: pediatric“Most tumors are radioresistant if you miss them.”


To be tested
To be tested… pediatric


Cardiac sparing wli hepatic renal parenchymal sparing wai
Cardiac sparing WLI pediatricHepatic/renal parenchymal sparing WAI


What shall we do? pediatric 1. Re-engineering Linacs 2. Forensic pathology 3. Investing in late effects clinical research 4. Dose escalation in ependymoma 5. Invest in reasonably-priced radiotherapy solutions in low-income countries 6. Delete pediatrics from most radiotherapy residency programs 7. Establish late effects of childhood cancer fellowship trainingThank you.


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