the view from the faculty of clinical oncology: a new … · management of late effects and better...

The View from the Faculty of

Clinical Oncology: a new era for

management of late effects and

better multidisciplinary working?

Dr Diana Tait

Registrar, Faculty of Clinical Oncology,

Royal College of Radiologists

Consultant Clinical Oncologist

The Royal Marsden NHS Foundation Trust.

RCR – FACULTY OF CLINICAL ONCOLOGY

HIGH QUALITY RADIOTHERAPY –

NATIONAL IMPLEMENTATION

MEASURING OUTCOMES

GUIDELINES ON MANAGEMENT

RCR-FACULTY OF CLINICAL ONCOLOGY

HIGH QUALITY RADIOTHERAPY

Escalate Dose to Target

Tumour Control

Minimise Normal Tissue Dose

Late effects

“Conformal radiotherapy, using multi-

leaf collimators which allow treatment

using an irregularly shaped beam, is the

optimum mode of delivery and all

centres should aim to provide this form

of treatment”

National Institute for Clinical Excellence

Guidance on Cancer Services

IMPROVING OUTCOMES IN UROLOGICAL CANCERS The Manual

September 2002



PELVIC RT

PROSTATE

BLADDER

GYNAE

RECTUM

ANNUS

THORACIC RT

OESOPHAGUS

OGJ

LUNG



CT

MRI

PET CT

TARGET

DEFINITION

IMRT

IGRT

SBRT

CyberKnife

Brackytherapy

HIGHLY

CONFORMAL

PORTAL

IMAGES

(MV, KV)

CONE BEAM

VERIFICATION



AVOID/ DOSE NORMAL TISSUES

PELVIC CONFORMAL TRIAL – 1st

RANDOMISED TRIAL

• LESS ACUTE TOXICITY

• LESS LATE EFFECTS

• IMPROVED QOL

• 1993 ACUTE EFFECTS

• 1997

• 1999 LATE EFFECTS



ANAL CANCER

ACT II CR Rate 94%

Grade 3-4 Acute Toxicity 61%

RTOG 98-11 - Similar results



ANAL CANCER - IMRT

RTOG 98 – 11 RTOG 0529

CLINICAL RESPONSES EQUIVALENT

REDUCED Grade 2-3 ACUTE TOXICITY

Intensity Modulated Radiotherapy (IMRT) solutions for anal cancer treatment


Axial and sagittal

composite plans.

Isodose lines:

Red = 50.4Gy

Green = 47.9Gy

Tomato = 30.6Gy

Forrest = 29.1Gy

Sky blue = 20Gy

Blue borders

indicate same PH1

IMRT plan

IMRT2

IMRT1

IMRT3

RCR-FACULTY OF CLINICAL

ONCOLOGY


Conformity Index

0

0.5

1

1.5

2

2.5

IMRT1 IMRT2 IMRT3

Co

nfo

rmit

y In

de

x CI Prim only

CI nodal


External Genitalia

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

V20Gy V40Gy V20Gy V40Gy V20Gy V40Gy

IMRT1 IMRT2 IMRT3

Me

an

% v

olu

me

PH2 primary patients

PH2 primary and nodal patients

Intensity Modulated Radiotherapy (IMRT)

solutions for anal cancer treatment

Organ sparing IMRT for Anal cancer:

A comparison conventional v IMRT plans

External Genitalia and Bowel

0.0

20.0

40.0

60.0

80.0

100.0

CONV IMRT1 IMRT2 IMRT3

Vo

lum

e (

%)

0

50

100

150

200

250

300

350

400

450

Vo

lum

e (

cc)

V_20Gy

V_30Gy

Bowel 30Gy

Median reductions in V20Gy and V30Gy for external genitalia and

V30Gy bowel. Bars indicate range of volumes

Pelvic nodes

Jackson et al, in progress

RMH RTOG

IMRT plan with nodal boost

IMRT can safely deliver 60Gy

to the pelvic lymph node regions

in patients with prostate cancer:

Report of a Phase I/II dose

escalation study

McVey G, Van As N, Thomas K, Bidmead M, South C,

Khoo V, Parker C, Huddart R, Horwich A, Dearnaley D

Royal Marsden Hospital

Pelvic IMRT Trial

60Gy/35# cohort (nodal regions)

135 pts

Nov. 2003 – Dec 2007

Median follow-up 2.9 years (1.9 – 5.8)

Demographics

Total number

patients treated

135

Age at diagnosis Median

(range)

65

(47-79)

Post-prostatectomy 16

Gleason score 6

7

8-10

45 (33%)

51 (38%)

39 (29%)

T-stage T1-T2

T3

T4

49 (37%)

80 (59%)

6 (4%)

Nodal status N0

N1

115 (85%)

20 (15%)

PSA pre-hormones Median

(range)

45 ng/ml

(25-164)

PSA pre-radiotherapy

Median

(range)

0.5 ng/ml

(0.03- 4.0)

Roach Formula risk of

nodal involvement

Median

(range)

40%

(31%- 75%)

Acute Toxicity: RTOG scale

Acute Bowel RTOG grade

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wk 0-1 Wk 1-2 Wk 2-3 Wk 3-4 Wk 4-5 Wk 5-6 Wk 6-7 Wk 7-8 Wk 10 Wk 12 Wk 18

Weeks since start of radiotherapy

4

2

1

0Bowel

Acute RTOG Bladder Toxicity

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wk 0-1 Wk 1-2 Wk 2-3 Wk 3-4 Wk 4-5 Wk 5-6 Wk 6-7 Wk 7-8 Wk 10 Wk 12 Wk 18

4

3

2

1

0

Bladder

0

20

40

60

80

100

0 1 2 3 4 5 6 7

Time to RTOG grade ≥ 2 Bowel Toxicity %

fre

e f

rom

gra

de ≥

2

To

xic

ity

Years since start of radiotherapy

135 123 84 49 24 8

14% (9%-21%)


HIGH QUALITY RADIOTHERAPY –

NATIONAL IMPLEMENTATION

NRAG

NRIG

PEER REVIEW


AUDIT

National Audit COAC

National Data Sets

MEASURING OUTCOMES

RCR – Audit of Carcinoma of Cervix

Outcomes

1243 Patients 42 UK Centres

RT CRT

5yrs ALL 44% 55%

IB 59 65

IIB 44 61

IIIB 24 44

Gd ¾ tox 8% 10%


Practice Guidance on the Management of

Acute and Chronic Gastrointestinal problems

arising as a result of treatment for cancer

Guidelines on Management

The View from the Faculty of Clinical

Oncology: a new era for management

of late effects and better

multidisciplinary working?

Dr Diana Tait

Registrar, Faculty of Clinical Oncology,

Royal College of Radiologists

Consultant Clinical Oncologist

The Royal Marsden NHS Foundation Trust.

the view from the faculty of clinical oncology: a new … · management of late effects and better...

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