Thursday, March 6, 2014

Radiation therapy in modern era of cancer management:

Radiation therapy in modern era of cancer management:

Radiation therapy is being used successfully in cancer treatment for more than a century and is one of the corner stone of success in fight against cancer.  In early days, radium, caecium, radon capsules, which are radioactive materials were inserted in cervix for management of cervical cancer. Dramatic response in these tumours had resulted in interest with radioactive material in cancer management. Initial euphoria regarding the usage of radioactive materials attracted many researchers and there was surge in the indications of it's usage. The potential of gamma rays and x-rays in damaging the tumour cells were used to cancer. With gamma and x-rays, the tumour cell DNA is damaged more than the normal cells, and hence tumour cells are killed where as normal cells are relatively spared. After invent of x-rays, deep x-rays were used to treat tumours. Several x-ray machines were introduced and x-ray was being used to treat almost all diseases including peptic ulcer, ankylosing spondylosis (bone problem), psoriasis (skin problem). However, the progress was halted with evidences of reactions, second malignancies and other toxicities. There was a lull period for few decades in the development of radiation oncology specialty. And, during 1960s and 70s after the discovery of artificial radioactive materials, there was again revival of this specialty with 'tele-cobalt' machines. There was 'simulator' for planning treatment, scientific dose calculation methods, and accurate treatment delivery technology. 'Shields' and 'blocks' were being used to protect normal tissues and deliver higher dose of radiation to the target- 'tumour'. Favourable outcome with this modern radiation therapy gave the required confidence to the clinicians and more and more cancer patients were treated with radiation therapy with success. However, still there was lot of limitations in both treatment delivery and planning. There was no imaging to see the target, no proper computer assisted planning tools and there was visible scope of improvement of treatment delivery technology.
Modern day radiation therapy coincided with the advent of computers, imaging and mechanical revolution and also incorporation of technology in medical science. In 1990s, with advent of computers, CT and MRI scan and most importantly active involvement of technologists in research and development has revolutionized radiation therapy speciality. Modern radiation therapy is one of the 'most sort after' and 'high tech' medical specialty. Computer guided planning enables us to deliver high dose of radiation to the tumour and spare normal tissues. Intensity modulated radiation therapy and Image guided radiation therapy is the advanced radiation therapy delivery technology with most modern techniques. Now, robotic radiosurgery has enabled us to deliver high dose of radiation in very short time and complete radiation therapy in less than one-week time. Side effects of radiation have dramatically reduced and now radiation therapy is more acceptable to the patients. Radiation therapy is the standard of care in early head & neck cancer, cervical cancer and an important component of organ preserving procedures such as breast conservation. After surgery, majority of advanced cancers are treated with radiation therapy. Stereotactic radiosurgery is now the alternative to surgery in deep-seated 'difficult to do surgery' cases. There are numerous randomized studies with level-I evidences showing survival (mainly loco-regional control and also over all survival) benefit of radiation therapy in brain tumours, head & neck cancers, breast cancer, cervical cancer and other cancers.
Radiation therapy is a cost-effective option in management of metastatic diseases and palliative situations such as bone metastasis and brain metastasis. In developing countries like India with resource constraints radiation therapy should be used in most of the clinical situations, especially in palliative and management of pain.
In future, proton beam therapy, intra-operative radiation therapy and shorter course of radiation therapy (fractionated radiosurgery) will be the one of the main ammonium to fight against cancer. However, there are still many challenges in radiation oncology that needs to be addressed.

More than 70% of cancers need radiation therapy at some point of time. In 2020, India will have one of the largest numbers of cancer patients in the world and there will be two times than the present cancer burden. Unfortunately, there are in a severe scarcity of radiation therapy facilities in developing countries like India. At present situation, with available radiation facility in India only 30% of patients who require radiation treatment can avail radiation therapy. Majority of the patients need to travel far from their native place for treatment, only a small proportion of patients who need treatment receive radiation therapy, there is lack of awareness and cost of the treatment (facility) is also an issue. There is a need for more number of cancer facility including radiation therapy machines in different small cities and towns in India.  

The author of this article is Dr.Debnarayan Dutta, consultant, Apollo Speciality Hospital 

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