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Y. Nakayama
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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
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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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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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SC03 - Advances in Radiation Oncology (ID 327)
- Event: WCLC 2016
- Type: Science Session
- Track: Radiotherapy
- Presentations: 1
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SC03.03 - Carbon-Ion Therapy of Lung Cancer (ID 6610)
11:40 - 11:55 | Author(s): Y. Nakayama
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Introduction Approximately 65 particle therapy facilities are in operation worldwide. Among them, only 10 have carbon-ion therapy (CIRT) facilities (5 in Japan, 2 in Germany, 2 in China, and 1 in Italy), and the remainder have proton therapy facilities. More than 137,000 patients were treated with particle therapy worldwide from 1954 to 2014, including 15,000 in 2014, 86% of which were treated with protons and 14% with carbon ions and other particles. (from the Particle Therapy Co-Operative Group: http://www.ptcog.ch/). The National Institute of Radiological Sciences (NIRS) Chiba, Japan, has been treating cancer with high-energy carbon ions since 1994. Most of the patients who have been cured of cancer worldwide with carbon ions were treated at NIRS (1). From NIRS’s data, the efficacy of CIRT for non-small cell lung cancer (NSCLC) has been suggested. Here those results are reviewed, and the issue of this modern technology is discussed. Characteristics of carbon-ion therapy CIRT has better dose distribution to tumor tissue, while minimizing surrounding normal tissue dose, compared with photon radiotherapy. Moreover, carbon ions have potential advantages over protons. They provide a better physical dose distribution due to lessened lateral scattering. Further, their higher relative biological effectiveness and lower oxygen enhancement ratio are desirable features for targeting radioresistant, hypoxic tumors. The difference between densely ionizing nuclei and sparsely ionising x-rays and protons offers further potential radiobiological advantages, such as reduced repair capacity, decreased cell-cycle dependence, and possibly stronger immunological responses. Carbon-ion therapy of early non-small cell lung cancer Surgical resection with lobectomy has been the standard treatment of choice for early-stage NSCLC. In a 2004 study of a Japanese lung cancer registry comprising 11,663 surgical cases, overall survival (OS) rates at 5 years for stages IA and IB disease are 82.0% and 66.8%, respectively (2). Radiotherapy is an option for patients who are not eligible for surgery or refuse it. Recently, hypofractionated radiotherapy is regarded as an alternative to surgery for localized NSCLC, using x-ray stereotactic body radiotherapy (SBRT) or particle therapy using protons or carbon-ions. With regard to CIRT, for peripheral stage I NSCLC, the number of fractions was reduced in different trials from 18 to 9, then 4, and finally to a single fraction at NIRS (Table 1). The results with CIRT in stage IA NSCLC are similar to the best SBRT results reported worldwide. For stage IB disease, CIRT results appear superior to those reported for photon SBRT in terms of local control and lung toxicity. Despite high local control, disease-specific survival is much lower in stage IB than in stage IA because distant metastatic recurrences are common. A combination of CIRT with systemic therapy is therefore essential to improve survival. CIRT demonstrates a better dose distribution than both SBRT and proton therapy in most cases of early-stage lung cancer. Therefore, CIRT may be safer for patients with adverse conditions such as large tumors, central tumors, and poor pulmonary function. Multi-institutional retrospective study of CIRT for stage I NSCLC was completed and will be presented at ASTRO 2016 by the Japan Carbon-ion Radiation Oncology Study Group (J-CROS). Carbon-ion therapy of locally advanced non-small cell lung cancer There was only one report about CIRT for locally advanced NSCLC. A prospective nonrandomized phase I/II study of CIRT in a favorable subset of locally advanced NSCLC was reported from NIRS (9). They showed that short-course carbon-ion monotherapy (72GyE/16Fr) was associated with manageable toxicity and encouraging local control rates. Among them, cT3-4N0M0 patients were good candidates for CIRT. There is otherwise a lack of evidence currently for CIRT for locally advanced NSCLC, and more study is needed. Moreover, concurrent systemic therapy is essential to improve survival for locally advanced NSCLC. Future directions We organized a multi-institutional study group of carbon-ion radiation oncology in Japan (J-CROS). This group is currently conducting trials on several tumor sites which are thought to be most attractive for CIRT, including NSCLC, head and neck disease, locally advanced unresectable pancreatic cancer, hepatocellular carcinoma, locally recurrent rectal cancer, and others. The outcomes of CIRT for stage I NSCLC at all Japanese carbon centers were pooled and retrospectively analyzed. Consequently, CIRT may be considered a low-risk and effective treatment option for patients with stage I NSCLC. J-CROS has now begun a confirmatory multi-institutional prospective study to confirm these results. References: 1. Kamada T, Tsujii H, Blakely EA, et al. Carbon ion radiotherapy in Japan: an assessment of 20 years of clinical experience. Lancet Oncol 2015; 16: e93-100. 2. Sawabata N, Miyaoka E, Asamura H, et al. Japanese lung cancer registry study of 11,663 surgical cases in 2004: demographic and prognosis changes over decade. J Thorac Oncol 2011; 6: 1229-35. 3. Miyamoto T, Yamamoto N, Nishimura H, et al. Carbon ionradiotherapy for stage I non-small cell lung cancer. Radiother Oncol 2003; 66: 127-140. 4. Miyamoto T, Baba M, Yamamoto N, et al. Curative treatment of Stage I non-small-cell lung cancer with carbon ion beams using a hypofractionated regimen. Int J Radiation Oncol Biol Phys 2007; 67: 750-758. 5. Miyamoto T, Baba M, Sugane T, et al. Carbon ion radiotherapy for stage I non-small cell lung cancer using a regimen of four fractions during 1 week. J Thorac Oncol 2007; 10: 916-926. 6. Sugane T, Baba M, Imai R, et al. Carbon ion radiotherapy for elderly patients 80 years and older with stage I non-small cell lung cancer. Lung Cancer 2009; 64: 45-50. 7. Takahashi W, Nakajima M, Yamamoto N, et al. Carbon ion radiotherapy in a hypofractionation regimen for stage I non-small-cell lung cancer. J Radiat Res 2014; 55(suppl 1): i26–i27. 8. Karube M, Yamamoto N, Nakajima M, et al. Single-fraction carbon-ion radiation therapy for patients 80 years of age and older with stage I non-small cell lung cancer. Int J Radiation Oncol Biol Phys 2016; 95: 542-548. 9. Takahashi W, Nakajima M, Yamamoto N, and et al. A prospective nonrandomized phase I/II study of carbon ion radiotherapy in a favorable subset of locally advanced non-small cell lung cancer (NSCLC). Cancer 2015; 121: 1321-7.Ref. Pts. Mean age T1: T2 Total dose (GyRBE)/ fractions F/U (months) 5-yr local control 5-yr cause-specific survival 5-yr overall survival Toxicity grade 3 < 3) 81 72 41: 41 59.4-95.4/ 9-18 52.6 76% 60% 42% lung 3.7% 4) 50 74.1 30: 21 72/ 9 59.2 94.7% 75.7% 50.0% skin 2% 5) 79 74.8 42: 37 52.8-60/ 4 38.6 90% 68% 45% 0% 6) 28 82 12: 17 52.8-72/ 4-9 NA 95.8% NA 30.7% 0% 7) 151 73.9 91: 60 36-50/ 1 45.6 79.2% NA 55.1% 0% 8) 70 83 39: 31 28-50/ 1 42.7 85.8% 64.9% 39.7% 0%
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