Jan 2009 Oncology Nursing Society (ONS) "Radiation Therpay 101.5"

1. Joe L. Meadows, M.S. DABMP Medical Physicist The Lacks Cancer Center Saint Mary’s Health Care Grand Rapids, MI Joe Meadows M.S. ONS Jan.2009 Radiation Therapy 101.5 Jan 20, 2009 Hope Lodge

3. Trust Me I am an Expert! “ An expert is a man who has made all the mistakes which can be made in a very narrow field” Niels Bohr DISCLAMER I am NOT: Physician,Radiobiologist,Pathologist,Epidemiologist or any other “ologist”. I am only a Physicist!

4. What is “Radiation”??

5. What is “Radiation”?? http://hko.gov

7. What is “Radiation”??

9. This is a test! Is still “radiation”, but NOT ionizing. It doesn’t have enough energy to break a chemical bond

11. What is “Radiation”?

12. Not All Radiation Is Equal! http://hko.gov

13. X-ray or  - ray? http://hko.gov  rays and x-rays are similar, the major difference is their origins.  rays are emitted from the nuclei of unstable atoms during radioactive decay, while x-rays are from the electron cloud as the result of electron excitation.

14. Where Does All It Come From? http://hko.gov Percentage of different types of radiation dose in daily life

15. Where Did X-rays Come From?

16. Where Did X-rays Come From?

17. Where Did X-rays Come From? That’s a lot of HEAT!!

18. Are You Still Awake?

19. Sometimes We Use Particles

20. Radiobiology Effects Of Ionizing Radiation http://images.google.com/imgres

21. Radiobiology- How are the effects classified?

22. Radiobiology- How are the effects classified?

23. Radiobiology- Early & Late Effects

24. How does radiation interact with tissue?

25. How does radiation interact with tissue?

26. “ A Picture Is Worth 2 Slides”

27. “ The Life Of a Photon”

28. Target Theory

30. Radiosensitivity

31. What Else Determines Response?

33. Let Me Prove It To You! Sample calculation On second thought, trust me I am a Physicist!

34. What Does Damage Look Like?

35. Where We Live- A Fine Line

36. 2007 Estimated US Cancer Deaths ONS=Other nervous system. Source: American Cancer Society, 2007. Men 289,550 Women 270,100 26% Lung & bronchus 15% Breast 10% Colon & rectum 6% Pancreas 6% Ovary 4% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Brain/ONS 2% Liver & intrahepatic bile duct 23% All other sites Lung & bronchus 31% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4% bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney 3% All other sites 24%

37. 2007 Estimated US Cancer Cases *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2007. Men 766,860 Women 678,060 26% Breast 15% Lung & bronchus 11% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia 21% All Other Sites Prostate 29% Lung & bronchus 15% Colon & rectum 10% Urinary bladder 7% Non-Hodgkin 4% lymphoma Melanoma of skin 4% Kidney 4% Leukemia 3% Oral cavity 3% Pancreas 2% All Other Sites 19%

38. Source: American Cancer Society, 2007. Five-year Relative Survival (%) During Three Time Periods by Cancer Site Better GOOD BAD!! WHY? Site 1975-1977 1984-1986 1996-2002 All sites 50 53 66 Breast (female) 75 79 89 Colon 51 59 65 Leukemia 35 42 49 Lung and bronchus 13 13 16 Melanoma 82 86 92 Non-Hodgkin lymphoma 48 53 63 Ovary 37 40 45 Pancreas 2 3 5 Prostate 69 76 100 Rectum 49 57 66 Urinary bladder 73 78 82

42. Why Is Lung Cancer Still BAD ? Ask 10 “experts”, get TEN answers!

43. PET/CT- Metabolic Targeting Functional imaging obtained by PET, which depicts the Spatial distribution of metabolic or biochemical activity in the body which can be precisely aligned with anatomic imaging obtained by CT scanning.

44. Why Is PET Helpful? Where is the tumor? When the CT alone is used, often time for lung cancer it is difficult (at best) to discern tumor from collapsed lung.

45. What is “Radiation”??

46. How Do We Make Radiation?

47. Some Treatment Techniques How we have been treating prostate cancer for the past 25 years using 4 static beams. All the intervening tissues get dosed as well! Today, you can have your treatment on a device that uses THOUSANDS of beams directed at the tumor while missing most of the normal anatomy!

48. Image Guided Radiotherapy (IGRT) 2D radiographic film 3D Ultrasound Full Helical CT localization

49. Why Is IGRT Important? Uncorrected treatment Corrected Treatment Note : Large tumor cold spot if treatment is not corrected. If you can’t see what you are doing clearly, you may not get the desired outcome!

50. Contemporary Technologies

51. What to Do If Feel Lost? If all of this is starting to make your head spin, I have a recommendation for all the Medical Device companies to add this menu to their product

52. What Is Next- Protons? Due to their relatively enormous mass, protons scatter less easily whereby minimizing lateral damage to surrounding tissue. Furthermore, the dosage to tissue is maximum just over the last few millimeters of the particle’s range; this maximum is called the Bragg Peak . This depth can be optimized to match the tumor depth by varying the proton energy. In theory it is possible to focus the cell damage due to the proton beam at the very depth in the tissues where the tumor is situated; Still River Tomo Proton DWA Mobile Proton Accelerator That’s What I’m Talking About!

53. What Is Next- Protons? Example : Two Field approach in the head and neck region showing resulting entrance and tumor doses How many proton beam therapy centers are enough? The United States now has 5 in operation with at least 10 more on the horizon. The price tag is mind-boggling, upward of $200 million for a single PBT facility. To justify this huge capital investment, a proton center needs a strategic model, in other words, a high-volume disease, such as prostate cancer. Table 1. Proton facilities operating in the US • The James M. Slater, MD, Proton Treatment and Research Center - Loma Linda, California • Midwest Proton Radiotherapy Institute at Indiana University - Bloomington, Indiana • Francis H. Burr Proton Therapy Center - Massachusetts General Hospital-Harvard, Boston • M.D. Anderson Proton Therapy Center - Houston • University of Florida Proton Therapy Institute - Jacksonville, Florida Selected proton facilities under development in the US • The Roberts Proton Therapy Center at University of Pennsylvania Health System, Philadelphia • Hampton University, Hampton, Virginia • Seattle Cancer Care Alliance • The Oklahoma ProCure Treatment Center, Oklahoma City • Siteman Cancer Center – St. Louis, Missouri. • The Northern Illinois Proton Treatment and Research Center -- Chicago The big advantage of CPT, however, is that as these charged particles traverse through tissue they initially deposit energy at a low LET, followed by a sharp increase to high-LET deposition at the Bragg peak. The tissue depth of this peak can be tailored to each treatment.