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D. Yalman
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SC09 - Radiotherapy for a Global Cancer (ID 333)
- Event: WCLC 2016
- Type: Science Session
- Track: Radiotherapy
- Presentations: 4
- Moderators:Y. Nakayama, D. Yalman
- Coordinates: 12/05/2016, 16:00 - 17:30, Hall C8
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SC09.01 - Global Access To Radiotherapy: Are We There? (ID 6632)
16:00 - 16:20 | Author(s): D. Palma
- Abstract
- Presentation
Abstract not provided
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SC09.02 - The Quest for High Quality Affordable Radiotherapy in Developing Countries (ID 6634)
16:20 - 16:40 | Author(s): O. Mohamad, H. Choy
- Abstract
- Presentation
Abstract:
In 2030, 60% of all new cancer diagnoses (15/25 million cases) and 80% of cancer related deaths (10/13 million deaths) will occur in low and middle income countries (LMICs) [1]. This explosion in cancer incidence is attributed to prolonged life expectancy in steadily growing populations with high levels of modifiable risk factors such as tobacco/alcohol and unhealthy diets. Despite the significant health burden, LMICs spend less than 10% of the global cancer budget. Cancer therapies are exponentially sprouting in rich countries but LMICs are not proportionally benefitting from this growth. Corruption, lack of infrastructure, poverty, and absence of national cancer policies/goals have hindered the development of quality cancer care programs. Radiotherapy has particularly suffered because of the perceived assumption that establishing quality radiotherapy centers in LMICs is unaffordable, non-sustainable and therefore unattainable and should not be pursued. Currently, up to 90% of LMIC inhabitants lack sufficient radiotherapy access and about 30 countries in Africa do not have a single treatment machine. It is estimated that by 2020, >9000 treatment machines, >10,000 radiation oncologists, and thousands of physicists and therapists are needed to treat patients in LMICs per evidence-based radiotherapy recommendations [2]. Recently, a group of experts with the Lancet Oncology Commission [3] reviewed the current radiotherapy capacity in LMICs and estimated the 20-year burden of cancer requiring radiotherapy and the needed investments to bring radiotherapy capacity in these countries to the needed levels. The published report provides compelling evidence that investment in radiotherapy not only will save millions of lives but will also bring significant economic benefits. The initial capital costs of scaling up radiotherapy may appear prohibitive, but these figures are based on estimations and projections that promise to deliver radiotherapy that is safe, timely, effective, efficient, equitable and patient centered. By aiming at quality care delivery, we can guarantee the highest returns on investments not only in oncologic outcomes but also in curbing loss in health-related productivity and life years. We hereby discuss few strategies to directly or indirectly reduce the capital or operating costs of such an expansion: - Trans-national, public and private partnerships: International organizations (such as the WHO, IAEA, etc) in collaboration with interested academic consultants and national governments should plan the required radiotherapy centers based on individualized national cancer priorities in the setting of a wide cancer care policy. This will require however a significant buy-in from national governments which are expected to establish effective social security systems with universal health coverage, create reliable cancer registries, implement effective cancer preventative and early diagnosis programs and finally promote outreach health literacy programs in real-world settings. Once international investments are coupled to national needs/efforts, minimal wasting of resources and maximal return on investment will be attained. - Centralization and pooling of resources regionally and internationally: This is a crucial step to at least jump start radiotherapy programs especially in the very low income countries where efforts are generally starting from nothing or close to nothing at best. High quality radiotherapy/simulation units donated by and refurbished in developed countries can provide a starting point around which other resources can be pooled. Regional centers can create circles of remote dosimetry/physics support and chart rounds via video conferencing to promote continued education and high quality treatment plans. These regional networks can be also connected to international cancer centers of excellence for further support and collaboration. Tax breaks could be offered to academic institutions or manufacturers in rich countries to participate in this process. - Investing in technology/science adapted to local needs in developing countries: Even if the capital is available, current manufacturing capabilities will not be able to build the required number of machines by 2020 as required. There is thus an immense need for innovative low cost, high quality radiotherapy units. Research and development departments should be offered incentives to create these tools. Optimizing the use of radiation techniques and per-unit activity to adapt to the treatment demands in developing countries will also improve benefit to cost ratio. - Hypofractionation: The number of “radiation fractions per year” is used as a surrogate for radiotherapy demand. Hypofractionation, thus, is a major strategy to optimize radiotherapy utilization and decrease operating costs without compromising outcomes in many cancer sites. For example, in the case of 1000 early breast [4] and 1000 early prostate cancer [5] patients requiring radiotherapy per year, using evidence-based hypofractionated treatments, not necessarily the extremely hypofractionated high-tech stereotactic radiation, would decrease the number of needed treatment machines from 10 to 6 and the number of therapists from 25 to 14. It will also decrease the duration of treatment per patient and thus allow more patients to be treated daily. Despite these benefits, hypofractionation remains widely underutilized even in developed countries [6]. Figure 1 - Investing in building local skills: Skilled radiation oncologists, therapists and physicists are very expensive commodities. While initial external support is crucial, new radiation centers need to eventually become self-sufficient and sustainable. Establishing local training programs should be a national priority in developing countries to decrease the cost of external training and limit brain drain. There is no magic wand to decrease the initial cost of investing in building radiotherapy capabilities but through careful planning and strong collaborations, millions of lives can be saved. Cost is crucial but we should not lose compass of our goal: delivering quality radiotherapy treatments to cure, improve the quality of life and alleviate pain in of millions of patients with cancer who are desperately in need.
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SC09.03 - Machine Learning for Individualized Radiotherapy Prescription (ID 6635)
16:40 - 17:00 | Author(s): P. Lambin
- Abstract
Abstract not provided
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- Abstract
- Presentation
Abstract:
Cancer incidence and mortality have been increasing in mainland China, making cancer the leading cause of death since 2010 and a major public health problem in the country. Much of the rising burden is attributable to population growth and ageing and to socio-demographic changes. According to the National Central Cancer Registry of China (NCCR), an estimated 4292,000 new cancer cases and 2814,000 cancer deaths would occur in mainland China in 2015, with lung, stomach, esophageal, liver and colorectal cancer being the most five common incident cancers and the leading cause of cancer death, for which radiotherapy always plays an important role in the comprehensive therapy. The earliest record of radiation therapy for cancer in China dates back to the early 1930s. The establishment of the Sino-Belgian Radium Institute in 1931 signified the initiation of modern radiation oncology in China. However, the development of cancer treatment has been hampered by several major wars and political turmoil in the following decades until the late 1970s and early 1980s: the era of national economical reform in mainland China. It was at this point when the academic and research bodies started to focus on the availability of radiation oncology service and their access by cancer patients. In the next over 30 years, China has undergone a period of incredible economic growth and radiation oncology, has clearly improved in terms of equipment and its utilization, although the shortage of facilities and workforce remain to be improved. The Chinese Society of Radiation Oncology (CSTRO) started its survey of the personnel and equipment in radiation oncology in mainland China since 1986. The updated survey results of 2015 were recently compiled and analyzed. Comparison of these crucial data clearly demonstrates the increase in the number of the facilities as well as advances in the quality of service (Figures 1 and 2). Based on the report of the third survey (of 1997) (first English-vision survey published in the International Journal of Radiation Oncology * Biology * Physics), there were 453 radiation oncology centers equipped with 286 linear accelerators, 381 cobalt units, 179 deep X-ray machines, and 302 brachytherapy units. These facilities were staffed with 3,440 physicians, 423 physicists, and 2,245 radiation therapists. It is important to note that less than 1,200 physicians were trained at major cancer centers within the radiation oncology specialty. The rest were of other specialties (e.g., surgeons) and received only several months of “practical training” (i.e., mentorship by experienced radiation oncologist with customized lectures) in a few major cancer centers mostly in major cities such as Beijing, Shanghai, and Guangzhou, rather than formal residency training in radiation oncology. The ratio of medical physicists to radiation oncology centers was less than 1 as well. (Figure 1) The two decades after 1997 signifies a rapid advance in the quality of radiation therapy facilities as well. The number of linear accelerators exhibited a nearly 6-fold increase in these 20 years, and more facilities are now equipped with computerized treatment planning systems (increased from 177 to 1,921) as well. On the other hand, the registered radiation oncology centers were established in most of the major cities, increased to 1,431 (a 210% increase from the 1997 survey), which makes radiotherapy much more easily accessed by cancer patients. The number of radiation oncologists increased to 15841 (a 360% increase). Besides, medical physics, a crucial specialty for the quality and safety of the clinical application of radiotherapy, has substantially improved. The number of trained medical physicists has undergone a nearly 7-fold increase to 3,294 in total. (Figure 2) At the same time period for accelerated development regarding radiation therapy capacity, the population and cancer incidence of mainland China had also increased, which resulted in the radiotherapy remained much insufficient. According to the recently cancer statistics in mainland China, the cancer incidence was 4.29 million in 2015. Given that approximately 50% require RT as part of definitive treatment, around 2.15 million Chinese cancer patients need RT annually. This number is most likely higher, since it does not include recurrent and palliative indications (estimates put this number into the 65-75% range for all malignancies), and cover all the area in mainland China. In fact, the numbers of annual new radiotherapy consultation and daily treatment was 919,339 and 76,612 in 2015. Therefore, only 50% patients who would need radiotherapy received radiotherapy in Mainland China in 2015. The current status is caused by two main reasons. First, the ratio of tele-therapy facility (linear accelerator and Co60 combined) per million was 1.49 in 2015, which are quite low compared to 8.2 in the United States, 7.5 in France, 3.4 in the United Kingdom, and 2-3 recommended by the World Health Organization. Second, the distribution of radiotherapeutic resources is uneven by region. For example, the ratio in Beijing, Tianjin, Shanghai, and Shandong municipalities/province, where are considered regions of better economic development, is 3.07, 3.28, 2.19, and 2.28, respectively. Meanwhile, rural and/or less populous regions such as Tibet are often under 1.00. In conclusion, it is still obvious that cancer patients have limited access to radiotherapy facilities as well as qualified radiation oncologist, though remarkably robust development in all facets of radiation oncology over the last 30 years in mainland China. Clearly, much more effort should be made in regards to access to radiation oncology facilities and their service for cancer patients.Figure 1 Figure 1. The growth radiation therapy equipment in China from 1986 to 2015 based on the2015 CSTRO report by Lang et al. Figure 2 Figure 2. The changes in the configuration of radiotherapy team in China from 1986 to 2015 based on the 2015 CSTRO report by Lang et al. References 1. Gu XZH, Feng NY, Yu Y, et al. Investigation report on the composition of equipment and technical level of radiation therapy team in China. Radiat Oncol China. 1989, 3(1): 41-43. [Published in Chinese] 2. Yin WB, Chen B, Gu XZH, et al. General survey of radiation oncology in China. Chin J Radiat Oncol, 1995, 4(4):271-275. [Published in Chinese] 3. Yin WB, Tian FH, Gu XZH. Radiation Oncology in China: the third survey of personnel and equipment in radiation oncology. Int J Radiat Oncol Biol Phys, 1999, 44(2):239-241. 4. Yin WB, Tian FH. Survey report on national radiation therapy personnel and equipment in 2001. Chin J Radial Oncol, 2002, 11(3): 145-147. [Published in Chinese] 5. Chinese Society of Radiation Oncology (Yin WB, Yu Y, Chen B, et All). Fifth nationwide survey on radiation oncology of China in 2006. Chin J Radial Oncol, 2007, 16(1): 1-5. [Published in Chinese] 6. Chinese Society of Radiation Oncology (Yin WB, Chen B, Zhang CL, et al). The sixth nationwide survey on radiation oncology of continent prefecture of China in 2011. Chin J Radiat Oncol, 2011, 20(6): 453-457. [Published in Chinese] 7. Yin WB, Chen B, Tian FH, et al. The growth of radiation oncology in mainland China during the last 10 years. Int J Radiat Oncol Biol Phys, 2008, 70(3): 795-798. 8. Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin. 2016, 66(2):115-132.
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Author of
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P2.05 - Poster Session with Presenters Present (ID 463)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Radiotherapy
- Presentations: 2
- Moderators:
- Coordinates: 12/06/2016, 14:30 - 15:45, Hall B (Poster Area)
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P2.05-011 - The Current Status of Radiotherapy in the Definitive Treatment of Lung Cancer in a Developing Country: Turkey (ID 4596)
14:30 - 14:30 | Author(s): D. Yalman
- Abstract
Background:
To investigate the current status of radiotherapy (RT) trends in the definitive treatment of lung cancer in Turkey.
Methods:
A questionnaire consisting of 46 questions about the technical facilities, and indications regarding the definitive radiotherapy of lung cancer was sent to 62 centers in Turkey, and was answered by 47 centers.
Results:
RT centers were mostly gathered in Marmara, Central Anatolia, and Aegean region (15, 12 and 8 centers respectively). The median number of patients with non-small cell (NSCLC) and small-cell lung cancer (SCLC) treated definitively in one year were 55 and 15 respectively. The cases are discussed in a multidisciplinary tumor board in 75% of the centers. All of the centers use at least the minimum technological standard which is CT-planned 3D conformal RT (3D-CRT) in the definitive treatment of lung cancer; 33% has 4D-CT simulation facility, 94% use PET/CT in RT planning, 75% apply RT under image guidance; 41% has stereotactic body radiotherapy (SBRT) facility, and 53% use SBRT routinely in early-stage NSCLC patients who are medically inoperable or who refuse surgery. Ninety-eight percent of the centers apply concurrent chemoRT (87% starting RT with the first chemotherapy course) in locally advanced NSCLC. Concurrent chemoRT dose is 60-66 Gy in 96%. Chemotherapy was given by the radiation oncologists in 34% of the centers. In stage IIIA(N2) potentially resectable disease 56% of the centers apply neoadjuvant treatment (chemoRT 67%, chemo 33%). Besides main postoperative RT indications 27% of the centers apply RT to patients with inadequate mediastinal dissection, 37% apply to patients with suboptimal surgery. Regarding definitive treatment of SCLC 17% of the centers apply 45 Gy bid, 50% apply 50-60 Gy, 28% apply 61-66 Gy concurrent with cisplatin-etoposide, starting with the first or second course in 87%. In extensive-stage SCLC 89% of the centers apply thoracic RT (50-66 Gy in 62%, 30 Gy in 26%) after chemotherapy. Prophylactic cranial irradiation doses were 25 Gy in 71%, 30 Gy in 22%. The patients are followed with 3-month intervals in 89% of the centers, however there is no consensus regarding follow-up workup among the centers.
Conclusion:
At least minimum world standards can be applied in the definitive RT of lung cancer in Turkey. The problems regarding optimal RT dose and fractionation and concurrent chemotherapy regimen, postoperative RT indications are similar, but as a developing country we need more multidisciplinary workup and develop our own guidelines taking into account our own resources and patient characteristics.
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P2.05-026 - Postoperative Radiotherapy in Non-Small Cell Lung Cancer: 20 Years' Experience in a Single Centre (ID 6393)
14:30 - 14:30 | Author(s): D. Yalman
- Abstract
Background:
The purpose of this study is to evaluate the long term outcomes of postoperative radiotherapy(PORT) in patients with NSCLC.
Methods:
A total of 130 patients with resected NSCLC who were treated with PORT between January 1994 and December 2014 were respectively evaluated. Among the whole group 86 patients(66%) were treated with Co60 machines till 2005, and 44 patients(34%) with 6-10 MV photons with linear accelerators. Median RT dose was 54 Gy(range, 48-66 Gy) with 2 Gy daily fractions. the treatment fileds covered the bronchial stump, ipsilateral hilum and mediastinum in 109patients(83.8%);bronchial stump,ipsilateral hilum, mediastinum and supraclavicular nodes in 15patients(11.5%);and bronchial stump and ipsilateral hilum in 6patients(4.6%).Cisplatinum-based chemotherapy was administered to 69(53%) patients. Chemoterapy was applied preoperatively in22 patients(17%), concomitantly in 27 patients(21%), and after PORT in 20patients(15%). Overall(OA) survival, locoregional-free(LRF) survival and distant-metastasis free(DMF) survival were calculated using the Kaplan-Meier method.
Results:
The median age of the patients was 59 years (range,35-75 years). The most frequently performed surgical procedure was lobectomy (64.6%), followed by pneumonectomy(19.2%), wedge resection (10%), and bilobectomy(6.2%). Stages included I(19.2%), II(42.3%), IIIA (30.8%), and IIIB(6,9%).Neoadjuvant chemotherapy was applied to 62% of stage III patients.The median overall survival was 48 months. The 5-year OA, LRF and DMF survival rates for whole group were 43%, 75%, and 63% respectively.Significant prognostic factors for OA survival were indicated in the table. Acute and subacute toxicities were Grade I to II esophagitis in 48 patients (37%), anemia in 11 patients(8%), pulmonary infection in 11 patients (8%),and Grade ≥II radiation pneumonitis in 11 patients(8%) Radiation-induced late toxicities including radiologic Grade I to II fibrosis were recorded in 22 patients (17%).The Prognostic Factors for Overall Survival
Characteristics 5-yearOA survival UnivariateAnalysis (Log-rank p value) Multivariate Analysis(Cox regression p value) Age(Years) <59 >=59 55 32 0.012 0.000 KPS 70-80 90-100 35 48 0.028 0.003 Laterality Left Right 31 54 0.011 0.005 Stage T1-T2 T3-T4 55 28 0.001 0.050 Dose <54 >=54 55 36 0.037 0.006
Conclusion:
Unfavorable prognostic factors for PORT were RT dose > 54 Gy, advanced T stage, poor Karnofsky performance status, advanced age, and left sided tumors. When irradiating left-sided tumors cardiac toxicity must be kept in mind.
