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

National cancer institute workshop on advanced technologies in radiation oncology december 1 2006
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Edward C. Halperin, M.D., M.A. Dignitary 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 . Dynamic Membership = 1.

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

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

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

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Active Membership = 1

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I have consequently agreed with myself and can guarantee you that the accompanying perspectives speak to the consistent feeling of the dynamic participation.

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

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Compare, in reference to danger and survival, for adolescence growth, radiotherapy with conformal v. stereotactic v. IM/IGRT v. proton, neutron, carbon particles, pions et al. systems

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Outline Is the question(s) unsettled? Is the answer(s) plainly obvious? What questions didn't Dr. Vikram ask that he ought to have? What do the information appear in reference to the charge I have been given? What might we do?

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Is the question(s) disputable?

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ACGME Requirements in Radiation Oncology for Residency Training "The clinical main subjects should incorporate involvement in . . . pediatric [tumors]. . . . Occupants must treat no less than 12 pediatric patients [in 4 years of residency] of whom at least 9 have strong tumors."

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On 10/12/06 there were 79 authorize radiation oncology residencies in the U.S. with 569 inhabitants on obligation or ~ 142/year.

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A gauge of the quantity of pediatric radiation oncology patients every year in the U.S. accessible for residency preparing and, conceivably, for examination of radiation treatment methodology

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… .enormous suppositions: No cases go to private practice. Cases are consistently circulated (Wills, St. Jude, MSKCC, CHOP, and so on)

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Example: ALL (CNS prophylaxis, testicular backslide, TBI) 124 cases/year ÷ 569 learners = 0.2 cases/year/student

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So, in a 4-year residency, throwing away the issue of the "huge presumptions," our student will see 0.8 instances of the most well-known threat of adolescence.

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"The main thing I truly need to think about pediatric radiotherapy in the wake of completing this residency program is your telephone number."

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"… in the event that you need to lead, you need to conform to the earth in which you get yourself. You can't sit tight for it to acclimate to you." J.L. Gaddis, portraying Dean Acheson. New Republic , 10/16/06, p.28

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Many individuals affirm that the Watergate outrage exhibits that a free press is fundamental to majority rules system. All types of print and electronic press are satisfied to assume acknowledgment for this accomplishment.

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It can be contended, in any case, that it wasn't the press everywhere who broke the Watergate story, it was two Washington Post correspondents: Woodward and Bernstein.

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Similarly, we have all observed emotional pictures used to advance IMRT/IGRT and proton treatment in youth tumors. It is inappropriate to advance this innovation on the premise of, from a general wellbeing stance, a minor number of cases.

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It is guileful to demonstrate your healing facility chairman proton dosimetry for regarding adolescence craniopharyngioma as a method for getting him/her to purchase protons for treating bone metastases.

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Is the answer(s) plainly obvious?

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"There is never any motivation to give any measurements to uninvolved typical tissue. An expansion in measurement to the tumor will, to a point, enhance nearby control. Accomplishing these destinations is self-obviously genuine and does not require randomized planned trials."

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After whatever, we didn't require randomized trials to demonstrate the advantages of _____________. Test systems LinAc v. Co 60

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Maybe we ought to have.

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"Change is unavoidable. Advance is discretionary." A. Stern, cited in Penn. Gaz ., 11/12/2006, p. 54

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Set the bar of verification higher when the cost is higher.

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The Aspirin Analogy

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Of ~56 African nations, 64% have no radiotherapy offices. Lancet Oncol , 2004;5:695

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In Africa in 2002, the supply of Co 60 and straight quickening agents was 18% of the assessed require. Lancet Oncol 2006;7:584

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Perhaps we ought to stress more over the arrangement of administrations to a greater amount of the total populace, and less about unnecessarily costly machines of problematic advantage for the rich?

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"… in reality as we know it where a greater amount of the 100 biggest financial elements are organizations (52) than nations (48), another arrangement of tenets will unavoidably apply." Penn. Gaz ., 11/12/2006, p. 54

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Is the appropriate response plainly obvious?

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These are a few destinations/circumstances in which the objective is with the end goal that it is about difficult to imagine a change by new innovation over standard procedures.

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The objective is the whole structure and, while IMRT/IGRT could be utilized to manage tissue heterogeneity, that is probably going to be "a long keep running for a short slide." Also, with current innovation IMRT may build second harmful neoplasms.

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TBI Prophylactic cranial illumination Testicular backslide radiotherapy Whole midriff light to 10 Gy

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For a few maladies the neighborhood control rate is bleak, couple of kids live to endure late impacts, dosage heightening has by and large been unprofitable, and high LET treatment has either been without advantage or aggravated an awful circumstance.

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Brain stem glioma High review supratentorial astrocytoma

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For a few ailments, the radiation dosage is low to the point that it is difficult to envision a discernable advantage to mechanical advancement. (A superior measurements appropriation does not equivalent a discernable advantage.)

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Langerhans cell histiocytosis (4-6 Gy) Post-transplant lymphoproliferative confusion (4-8 Gy) Transplantation Aplastic pallor Fanconi's iron deficiency Sickle cell sickliness Intentional enlistment of chimerism

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What questions didn't Dr. Vikram ask that he ought to have?

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The untoward burdens of innovative change

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In adolescence tumor the push to utilize IMRT, IGRT, protons, and so forth (all outside shaft procedures) hinders the judicious utilization of unrivaled choices.

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

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The measurement needs to go some place; or the instance of the pancytopenic pineal patient

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What do the information appear in reference to the charge I have been given?

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Hearing misfortune for cisDDP treated patients getting back fossa light (at the cost of endocrinopathy?) Neuroendocrine, salivary organ, and TMJ damage in adolescent nasopharngeal angiofibroma and of nasopharngeal carcinoma and rhabdomyosarcoma

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IQ misfortune in limited intracranial illumination Thyroid, heart, aspiratory, and GI harm in craniospinal illumination Sarcoma treatment

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"[The] clinical advantages of innovative advances [in radiotherapy] including picture guided radiotherapy, are trying to portray. Randomized information for patients treated with and without picture direction is probably not going to ever exist." Dawson and Sharpe (PMH) Lancet Oncol 2006;7:848

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Adequate field arrangement is corresponded with tumor control in pediatric Medullablastoma Ewing tumor Hodgkin illness IJROBP 1997;37:523

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Halperin's First Rule of Pediatric Radiotherapy: "Most tumors are radioresistant in the event that you miss them."

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To be tried…

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Cardiac saving WLI Hepatic/renal parenchymal saving WAI

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What should we do? 1. Re-building Linacs 2. Scientific pathology 3. Putting resources into late impacts clinical research 4. Measurements heightening in ependymoma 5. Put resources into sensibly estimated radiotherapy solutions in low-pay nations 6. Erase pediatrics from most radiotherapy residency programs 7. Build up late impacts of youth tumor fellowship preparing Thank you.

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