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Introduction
Volume 12 No 4
I
September 2016
7
This is an exciting time in the world of
radiation therapy, with an evolving and
expanding repertoire of new treatments
and imaging techniques, technology
and the development of novel systemic
agents.
There is a trend to both an increase in
radiation treatment complexity and a
reduction in the number of fractions
used, in a reimbursement system
where using more fractions is currently
rewarded financially. Our attention must
remain on delivering the highest quality
patient-centred radiation therapy.
The past decade or two has seen an
emphasis on the implementation of
more focused radiation therapy in the
form of intensity modulated radiation
therapy (IMRT). We have also seen
changes in fractionation. There is now
clear evidence that hypo-fractionation is
appropriate for women with early breast
cancer and emerging evidence that it
may be appropriate in localised prostate
cancer. Recent advances in hardware
and software have also allowed the
widespread expansion of stereotactic
ablative body radiation therapy (SABR),
which also reduces the number of
fractions used to treat early lung cancer.
Techniques like SABR and accelerated
partial breast irradiation (APBI), which
use fewer fractions, are more complex
and resource intensive than conventional
radiation therapy, thus requiring more
machine and planning room time,
despite fewer fractions being used.
Expanding indications for hypo-
fractionated, ablative and high dose
radiation therapy (e.g. for brain, lung
and bone metastases) place new and
different demands on radiation therapy
providers.
In Australia and New Zealand, new
treatments will only be funded
by governments or insurers after
appropriate health and economic
assessments. There are two aspects
to this form of evaluation: firstly,
ensuring the technical accuracy and
reproducibility of the technique; and
secondly, the efficacy, in terms of cancer-
related and toxicity outcomes.
Ironically, to ensure that a new therapy is
“at least as good as, or not significantly
worse than” (non-inferior to) the current
gold standard, requires enrolment of
substantially more subjects than it does
to demonstrate superiority of a new
therapy. New therapies are not always
expected to result in substantially
different oncologic outcomes, but may
provide substantial patient benefits.
Examples include the use of IMRT
in head and neck cancer, where one
can prevent permanent, disabling
xerostomia.
Once the technical aspects are fully
assessed, and the efficacy proven, it
is necessary to test the effectiveness
of the new therapy. The evaluation
required is then necessarily not limited
to cancer-related outcomes (local
control or overall survival) and acute and
late treatment related toxicity, but must
encompass both micro- and macro-
economic concepts. These may include
the benefits to the individual (e.g.
days of life saved, time spent without
Cancer Treatments,
Frontiers and Challenges
Dr Dion Forstner and
Dr Brigid Hickey
“Our attention must
remain on delivering the
highest quality patient-
centred radiation
therapy.”