# Presentation: 506897

## National Cancer InstituteWorkshop on Advanced Technologies in Radiation OncologyDecember 1, 2006

## Edward C. Halperin, M.D., M.A.Dean of the School of MedicineFord Foundation Professor of Medical EducationProfessor of Radiation Oncology, Pediatrics, and HistoryUniversity of Louisville

## The Club of Radiation Oncology Deans	Samuel Hellman	Allen Lichter	Edward Halperin	

## Active Membership = 1

## Slide 5

## I have therefore concurred with myself and can assure you that the following views represent the unanimous opinion of the active membership.

## Charge per Dr. Vikram’s email of 8/17/06

## Compare, in reference to toxicity and survival, for childhood cancer, radiotherapy with conformal v. stereotactic v. IM/IGRT v. proton, neutron, carbon ions, pions et al. techniques

## Outline	Is the question(s) moot?	Is the answer(s) self-evident?	What questions didn’t Dr. Vikram ask that 		he should have?	What do the data show in reference to 		the charge  I have been given?	What shall we do?  			

## Is the question(s) moot?

## ACGME Requirements in Radiation Oncology for Residency Training	“The clinical core curriculum shall include experience in . . . pediatric [tumors]. . . . Residents must treat no fewer than 12 pediatric patients [in 4 years of residency] of whom a minimum of 9 have solid tumors.”

## On 10/12/06 there were 79 accredited radiation oncology residencies in the U.S. with 569 residents on duty or ~ 142/year.

## An estimate of the number of pediatric radiation oncology patients per year in the U.S. available for residency training and, potentially, for investigation of radiation treatment modality

## Slide 14

| 
Total Number ofChildhood Cancer cases/year | 

X | 
% of the cancer type | 

X | 
% of the cases
Requiring
Radiotherapy
 | 

 = | 
Total teaching cases/year |
| --- | --- | --- | --- | --- | --- | --- |

## Slide 15

| 
Total Teaching cases/ Year
 | 

÷  | 
Residents on Duty | 

= | 
Teaching cases/
Residents/Year |
| --- | --- | --- | --- | --- |

## ....big assumptions: No cases go to private practice.Cases are uniformly distributed (Wills, St. Jude, MSKCC, CHOP, etc)

## Example:  ALL (CNS prophylaxis, testicular relapse, TBI)

**124 cases/year  ÷****  569 trainees  =  0.2 cases/year/trainee**

| 
8600 cases/
year | 

X | 

18% | 

X | 

8% | 

= | 
124
cases/
year |
| --- | --- | --- | --- | --- | --- | --- |

## So, in a 4-year residency, casting aside the problem of the “big assumptions,” our trainee will see 0.8 cases of the most common malignancy of childhood.

## Slide 19

| 
Diagnosis | Teaching cases/
year | Teaching cases/year/ Resident  | Cases
in 4 years
 |
| --- | --- | --- | --- |
| ALL | 124 | 0.2 | 1 |
| ANLL | 28 | 0.05 | <1 |
| Lymphoma | 481 | 0.8 | 3 |
| Medulloblastoma | 232 | 0.4 | 2 |
| Asrocytoma, including brain stem | 348 | 0.6 | 2 |
| Ependymoma | 77 | 0.1 | <1 |
| Neuroblastoma | 86 | 0.2 | 1 |
| Retinoblastoma | 103 | 0.2 | 1 |

## Slide 20

|    
Diagnosis | Teaching Cases/
year | Teaching Cases/year/
Resident
 | 
Cases |
| --- | --- | --- | --- |
| Wilms | 34 | 0.06 | <1 |
| Ewing | 103 | 0.2 | 1 |
| Rhabdomyosarcoma | 103 | 0.2 | 1 |
| NRSTS | 52 | 0.09 | <1 |
| Hepatic Tumors | 17 | 0.03 | <1 |
| Germ cell and trophoblastic neoplasms | 26 | 0.04 | <1 |
| Epithelial neoplasms | 23 | 0.04 | <1 |

## “The only thing I really want to know about pediatric radiotherapy after finishing this residency program is your phone number.”

## “... if you want to lead, you have to adjust to the environment in which you find yourself.  You cannot wait for it to adjust to you.”						J.L. Gaddis, describing 			Dean Acheson. New Republic, 			10/16/06, p.28	

## Many people assert that the Watergate scandal demonstrates that a free press is essential to democracy.  All forms of print and electronic press are pleased   to take credit for this achievement.

## It can be argued, however, that it wasn’t the press at large who broke the Watergate story, it was two Washington Post reporters: Woodward and Bernstein.

## Similarly, we have all seen dramatic images used to promote IMRT/IGRT and proton therapy in childhood tumors.  It would be wrong to promote this technology on the basis of, from  a public health standpoint, a tiny number of cases.

## It is disingenuous to show your hospital administrator proton dosimetry for treating childhood craniopharyngioma as a technique for getting him/her to buy protons for treating bone metastases.

## Slide 27

## Is the answer(s) self-evident?

## “There is never any reason to give any dose to uninvolved normal tissue.  An increase in dose to the tumor will, to a point, improve local control.  Achieving these objectives is self-evidently true and does not require randomized prospective trials.”

## After all, we didn’t require randomized trials to prove the benefits of _____________.			Simulators		LinAc v. Co60

## Maybe we should have.

## “Change is inevitable.  Progress is optional.”				A. Stern, quoted in Penn. Gaz., 		11/12/2006, p. 54

## Set the bar of proof higher when the price is higher.

## Slide 34

## The Aspirin Analogy

## Of ~56 African countries, 64% have no radiotherapy facilities.			Lancet Oncol, 2004;5:695

## In Africa in 2002, the supply of Co60 and linear accelerators was 18% of the estimated need.						    Lancet Oncol 2006;7:584

## Slide 38

## Slide 39

|  | 
Developed
Countries | Less Developed Countries |
| --- | --- | --- |
| Radiotherapy
Units | 67% | 33% |
| Population | 21% | 79% |
| Countries with no units | 0% | 43% |
| % of linear accelerators | 85% | 30% |

## Perhaps we should worry more about the provision of services to more of the world’s population, and less about inordinately expensive machines of unproven benefit for the wealthy?

## “... in a world where more of the 100 largest economic entities are companies (52) than countries (48), a new set of rules will inevitably apply.”								Penn. Gaz., 11/12/2006, p. 54 

## Is the answer self-evident?

## These are some sites/situations    in which the target is such that it   is nearly impossible to envision   an improvement by new technology over standard techniques.

## The target is the entire structure and, while IMRT/IGRT could be used to deal with tissue heterogeneity, that is likely to be “a long run for a short slide.” Also, with current technology IMRT may increase second malignant neoplasms.

## Slide 45

## TBIProphylactic cranial irradiationTesticular relapse radiotherapyWhole abdomen irradiation to 10 Gy

## For some diseases the local control rate is dismal, few children live to suffer late effects, dose escalation has generally been fruitless, and high LET therapy has either been without benefit or made a bad situation worse.

## Slide 48

## Brain stem gliomaHigh grade supratentorial astrocytoma

## For some diseases, the radiation dose is so low that it is hard to imagine a discernable benefitto technological innovation. (A better dose distribution does not equal a discernable benefit.)

## Langerhans cell histiocytosis (4-6 Gy)Post-transplant lymphoproliferative  disorder (4-8 Gy)Transplantation      Aplastic anemia      Fanconi’s anemia      Sickle cell anemia      Intentional induction of chimerism

## What questions didn’t Dr. Vikram ask that he should have?

## The untoward detriments of technological change

## In childhood cancer the push  to use IMRT, IGRT, protons, etc.      (all external beam techniques) inhibits the prudent use of superior alternatives.

## Slide 55

## Plaques for retinoblastoma (<entire anlage)	I125	RutheniumIntra-operative radiotherapyIntra-oral coneP32 for Askin and DSRBCT

## The dose has to go somewhere; or the case of the pancytopenic pineal patient

## Slide 58

## What do the data show   in reference to the charge I have been given?

## Slide 60

## Slide 61

## Hearing loss for cisDDP treated patients receiving posterior fossa irradiation (at the price of endocrinopathy?)Neuroendocrine, salivary gland, and TMJ injury in juvenile nasopharngeal angiofibroma and of nasopharngeal carcinoma and rhabdomyosarcoma

## Slide 63

## IQ loss in localized intracranial irradiationThyroid, cardiac, pulmonary, and   GI injury in craniospinal irradiationSarcoma treatment

## Slide 65

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## Slide 72

## “[The] clinical benefits of technological advances [in radiotherapy] including  image-guided radiotherapy, are challenging to describe.  Randomised data for patients treated with and without image guidance is unlikely to ever exist.”       				Dawson and Sharpe (PMH)				Lancet Oncol 2006;7:848	 

## Adequate field placement is correlated with tumor control in pediatric	Medullablastoma	Ewing tumor	Hodgkin disease							IJROBP 1997;37:523

## Halperin’s First Rule of Pediatric Radiotherapy:“Most tumors are radioresistant if you miss them.”

## Slide 76

## Slide 77

## To be tested...

## Cardiac sparing WLIHepatic/renal parenchymal sparing WAI

## What shall we do?	1. Re-engineering Linacs	2. Forensic pathology	3. Investing in late effects clinical research	4. Dose escalation in ependymoma	5. Invest in reasonably-priced radiotherapy 		solutions in low-income countries	6. Delete pediatrics from most radiotherapy 		residency programs	7. Establish late effects of childhood cancer	    	fellowship trainingThank you.