Julian Malicki

The importance of accurate treatment planning, delivery, and dose verification

In recent years, the spectacular technological advances in radiotherapy have generated much enthusiasm.1 Newer techniques take advantage of increased computing power and real-time imaging to provide pinpoint accuracy and dose conformity. The most widely adopted of the new techniques is undoubtedly intensity-modulated radiation therapy (IMRT) and variations thereof. Described as “perhaps the most significant technical advances in radiation therapy since the linear accelerator”, IMRT gives us the ability to deliver highly conformal nonconvex dose distributions to the target with astonishing precision.2 Compared to 3D-CRT, IMRT offers many advantages, particular better dose distribution in concave target volumes and lower doses to organs at risk (OAR).3,4 IMRT is surely an immense technological leap forward, though not without certain risks.

Radiotherapy equipment and departments in the European countries: final results from the ESTRO-HERO survey.

BACKGROUND Documenting the distribution of radiotherapy departments and the availability of radiotherapy equipment in the European countries is an important part of HERO - the ESTRO Health Economics in Radiation Oncology project. HERO has the overall aim to develop a knowledge base of the provision of radiotherapy in Europe and build a model for health economic evaluation of radiation treatments at the European level. The aim of the current report is to describe the distribution of radiotherapy equipment in European countries. METHODS An 84-item questionnaire was sent out to European countries, principally through their national societies. The current report includes a detailed analysis of radiotherapy departments and equipment (questionnaire items 26-29), analyzed in relation to the annual number of treatment courses and the socio-economic status of the countries. The analysis is based on validated responses from 28 of the 40 European countries defined by the European Cancer Observatory (ECO). RESULTS A large variation between countries was found for most parameters studied. There were 2192 linear accelerators, 96 dedicated stereotactic machines, and 77 cobalt machines reported in the 27 countries where this information was available. A total of 12 countries had at least one cobalt machine in use. There was a median of 0.5 simulator per MV unit (range 0.3-1.5) and 1.4 (range 0.4-4.4) simulators per department. Of the 874 simulators, a total of 654 (75%) were capable of 3D imaging (CT-scanner or CBCT-option). The number of MV machines (cobalt, linear accelerators, and dedicated stereotactic machines) per million inhabitants ranged from 1.4 to 9.5 (median 5.3) and the average number of MV machines per department from 0.9 to 8.2 (median 2.6). The average number of treatment courses per year per MV machine varied from 262 to 1061 (median 419). While 69% of MV units were capable of IMRT only 49% were equipped for image guidance (IGRT). There was a clear relation between socio-economic status, as measured by GNI per capita, and availability of radiotherapy equipment in the countries. In many low income countries in Southern and Central-Eastern Europe there was very limited access to radiotherapy and especially to equipment for IMRT or IGRT. CONCLUSIONS The European average number of MV machines per million inhabitants and per department is now better in line with QUARTS recommendations from 2005, but the survey also showed a significant heterogeneity in the access to modern radiotherapy equipment in Europe. High income countries especially in Northern-Western Europe are well-served with radiotherapy resources, other countries are facing important shortages of both equipment in general and especially machines capable of delivering high precision conformal treatments (IMRT, IGRT).

Radiotherapy staffing in the European countries: Final results from the ESTRO-HERO survey

BACKGROUND The ESTRO Health Economics in Radiation Oncology (HERO) project has the overall aim to develop a knowledge base of the provision of radiotherapy in Europe and build a model for health economic evaluation of radiation treatments at the European level. The first milestone was to assess the availability of radiotherapy resources within Europe. This paper presents the personnel data collected in the ESTRO HERO database. MATERIALS AND METHODS An 84-item questionnaire was sent out to European countries, through their national scientific and professional radiotherapy societies. The current report includes a detailed analysis of radiotherapy staffing (questionnaire items 47-60), analysed in relation to the annual number of treatment courses and the socio-economic status of the countries. The analysis was conducted between February and July 2014, and is based on validated responses from 24 of the 40 European countries defined by the European Cancer Observatory (ECO). RESULTS A large variation between countries was found for most parameters studied. Averages and ranges for personnel numbers per million inhabitants are 12.8 (2.5-30.9) for radiation oncologists, 7.6 (0-19.7) for medical physicists, 3.5 (0-12.6) for dosimetrists, 26.6 (1.9-78) for RTTs and 14.8 (0.4-61.0) for radiotherapy nurses. The combined average for physicists and dosimetrists is 9.8 per million inhabitants and 36.9 for RTT and nurses. Radiation oncologists on average treat 208.9 courses per year (range: 99.9-348.8), physicists and dosimetrists conjointly treat 303.3 courses (range: 85-757.7) and RTT and nurses 76.8 (range: 25.7-156.8). In countries with higher GNI per capita, all personnel categories treat fewer courses per annum than in less affluent countries. This relationship is most evident for RTTs and nurses. Different clusters of countries can be distinguished on the basis of available personnel resources and socio-economic status. CONCLUSIONS The average personnel figures in Europe are now consistent with, or even more favourable than the QUARTS recommendations, probably reflecting a combination of better availability as such, in parallel with the current use of more complex treatments than a decade ago. A considerable variation in available personnel and delivered courses per year however persists among the highest and lowest staffing levels. This not only reflects the variation in cancer incidence and socio-economic determinants, but also the stage in technology adoption along with treatment complexity and the different professional roles and responsibilities within each country. Our data underpin the need for accurate prediction models and long-term education and training programmes.

Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature

Abstract Background. Head and neck squamous cell carcinoma (HNSCC) is a disease of middle-aged to elderly adults. However, an increased incidence of HNSCC in young people under 45 years of age has been reported recently. In the present review, we focused on the epidemiology and aetiology of HNSCC in adults under 45 years of age. Methods. We reviewed literature related to HNSCC in adult patients less than 45 years of age and discussed current treatment options and prognosis. Results. HNSCC in young adults is associated with a higher incidence rate in nonsmokers, lower female-to-male ratio, a higher percentage of oral cavity and oropharynx tumours, and fewer second primary tumours. However, aside from traditional risk factors of tobacco and alcohol exposure, the causes of these cancers in young adults remain unclear. Agents that might contribute to risk include infection with high-risk human papillomavirus subtypes as well as genetic factors or immunodeficiency status. The expected increase in incidence and mortality of the young with HNSCC may become a major public health concern if current trends persist, particularly lifestyle habits that may contribute to this disease. Conclusions. Given the younger age and potential long-term adverse sequelae of traditional HNSCC treatments, young adults should be treated on a case-by-case basis and post-therapy quality of life must be considered in any treatment-decision making process.

The optimal utilization proportion of external beam radiotherapy in European countries: An ESTRO-HERO analysis.

BACKGROUND AND PURPOSE The absolute number of new cancer patients that will require at least one course of radiotherapy in each country of Europe was estimated. MATERIAL AND METHODS The incidence and relative frequency of cancer types from the year 2012 European Cancer Observatory estimates were used in combination with the population-based stage at diagnosis from five cancer registries. These data were applied to the decision trees of the evidence-based indications to calculate the Optimal Utilization Proportion (OUP) by tumour site. RESULTS In the minimum scenario, the OUP ranged from 47.0% in the Russian Federation to 53.2% in Belgium with no clear geographical pattern of the variability among countries. The impact of stage at diagnosis on the OUP by country was rather limited. Within the 24 countries where data on actual use of radiotherapy were available, a gap between optimal and actual use has been observed in most of the countries. CONCLUSIONS The actual utilization of radiotherapy is significantly lower than the optimal use predicted from the evidence based estimates in the literature. This discrepancy poses a major challenge for policy makers when planning the resources at the national level to improve the provision in European countries.

Physics and technology in ESTRO and in Radiotherapy and Oncology: Past, present and into the 4th dimension

‘Those who cannot remember the past are condemned to repeat it’: George Santayana, The Life of Reason, volume 1, 1905 ‘History is more or less bunk. It’s tradition. We dont want tradition. We want to live in the present’: Henry Ford, interview in the Chicago Tribune, May 25th 1916 ‘Prediction is difficult, especially about the future’: attributed to Neils Bohr (citing Storm P, Danish comedian and cartoonist)

Guidelines for equipment and staffing of radiotherapy facilities in the European countries: Final results of the ESTRO-HERO survey

BACKGROUND AND PURPOSE In planning to meet evidence based needs for radiotherapy, guidelines for the provision of capital and human resources are central if access, quality and safety are not to be compromised. A component of the ESTRO-HERO (Health Economics in Radiation Oncology) project is to document the current availability and content of guidelines for radiotherapy in Europe. MATERIALS AND METHODS An 84 part questionnaire was distributed to the European countries through their national scientific and professional radiotherapy societies with 30 items relating to the availability of guidelines for equipment and staffing and selected operational issues. Twenty-nine countries provided full or partial evaluable responses. RESULTS The availability of guidelines across Europe is far from uniform. The metrics used for capital and human resources are variable. There seem to have been no major changes in the availability or specifics of guidelines over the ten-year period since the QUARTS study with the exception of the recent expansion of RTT staffing models. Where comparison is possible it appears that staffing for radiation oncologists, medical physicists and particularly RTTs tend to exceed guidelines suggesting developments in clinical radiotherapy are moving faster than guideline updating. CONCLUSION The efficient provision of safe, high quality radiotherapy services would benefit from the availability of well-structured guidelines for capital and human resources, based on agreed upon metrics, which could be linked to detailed estimates of need.

The impact of cancer incidence and stage on optimal utilization of radiotherapy: Methodology of a population based analysis by the ESTRO-HERO project

BACKGROUND AND PURPOSE The impact of differences in the distribution of major cancer sites and stages at diagnosis among 4 European countries on the optimal utilization proportion (OUP) of patients who should receive external beam radiotherapy was assessed within the framework of the ESTRO-HERO project. MATERIALS AND METHODS Data from Australian Collaboration for Cancer Outcomes Research and Evaluation (CCORE) were used. Population based stages at diagnosis from the cancer registries of Belgium, Slovenia, the Greater Poland region of Poland, and The Netherlands were used to assess the OUP for each country. A sensitivity analysis was carried out. RESULTS The overall OUP by country varied from the lowest of 48.3% in Australia to the highest of 53.4% in Poland; among European countries the variation was limited to 3%. Cancer site specific OUPs showed differences according to the variability in stage at diagnosis across countries. The most important impact on the OUP by country was due to changes in relative frequency of tumours rather than stage at diagnosis. CONCLUSIONS This methodology can be adapted using European data, thus facilitating the planning of resources required to cope with the demand for radiotherapy in Europe, taking into account the national variability in cancer incidence.

Cancer incidence and mortality in the Greater Poland Region—Analysis of the year 2010 and future trends

BACKGROUND AND AIM The Greater Poland Region is one of the most industrialised areas of Poland, with a high rate of cancer incidence and mortality. The present report estimated incidence and mortality data for Greater Poland in the year 2010. METHODS Statistical reports in this study include absolute number of cases and crude incidence rates. The derived age-, sex-, and site specific rates were age-standardised (ASRs per 100,000 person-years) using the European (ASRE) standard population. RESULTS In 2010, a total 13,581 new cancer cases were reported to the Greater Poland Cancer Registry. The number of new cases increased by 24% compared to 2001. Greater Poland has the second-highest ASR for both females and males among the 16 regions in Poland. The most common cancers are similar to those in other Western European countries. Among men, the most common cancers are lung (C34), colorectal (C18-C21), and prostate (C61) cancer. In women, breast cancer is the most common (C50), followed by colon (C18-C21) and lung (C34) cancer. Lung cancer in males accounts for more than one-third of all cancer-related deaths in Greater Poland. As in 2009, lung cancer is the leading cause of death in women. CONCLUSIONS Given the ageing of the population, the incidence of chronic diseases, including cancer, is expected to grow. These data indicate that cancer will continue to represent an important challenge both to local health authorities and the National Health Fund, which will need to meet the growing demand for cancer care.

The rotary dual technique for total skin irradiation in the treatment of mycosis fungoides - a description of the applied method

Summary Background The aim of total skin electron irradiation in the therapy of mycosis fungoides is to obtain total or partial remission of the disease while concurrently lowering the toxicity level. Total skin electron radiotherapy should fulfi ll the EORTC requirements from the year 2002. Aim The aim of this work is to present the rotary dual method for total skin electron irradiation used in the Great Poland Cancer Centre including its specifi c technical and physical aspects. These aspects include the parameters and conditions for the treatment (geometrical conditions of the technique, homogeneity of the dose, patient’s positioning, additional fi elds and the method of dose fractionation), the absolute dosimetry (parameters and functions characterizing the electron irradiation beam used in the rotary dual method of the rotary dual method of the total skin electron irradiation) and in-vivo dosimetry conducted during the therapy with rotary dual fi elds, which allowed to control the dose distribution and to indicate additional skin areas, which should be irradiated with local fi elds. Materials/Methods The rotary dual method of the Total Skin Electron Irradiation proposed by the author, is based on the combination of the two most frequently used methods: 1) six dual fi elds’ method and 2) rotary method. The original, calculation algorithm elaborated by the author was based on the two dimensional algorithm proposed by Podgorsak et al.