Regional Oncology Update - Spring 2004 (click here to download as a PDF)
|Zeroing In On The Target: The BAT System
|The delivery of high dose radiation with Intensity Modulated Radiation Therapy (IMRT) to tumors in proximity to sensitive normal tissue may be limited by the uncertainty of the precise position of the target.
In the specific case of treating prostate cancer to high radiation doses while sparing critical organs (bladder and rectum), radiation oncologists have been constrained by the ability to localize organs with high degree of certainty.
The prostate gland moves 1-2 cm. Increasing the target volume to nullify this effect may lead to potential radiation injury to the bladder and rectum. Using a more precise system ensures the prostate gland is in the same treatment position during daily radiation treatments.
A new state of the art imaging equipment, the B-Mode Acquisition Targeting (BAT) became available.
This ultrasound based targeting system is linked to our IMRT delivery system and allows the oncologist and the therapist to localize the organs of interest on a daily basis before the treatment is initiated. We are now capable of hitting the moving target with little margins and sparing tissue that needs not and should not receive high radiation doses.
BAT is easy to use. It only adds about 3 minutes to a patient’s setup to align a specific organ in the right place. The BAT system allows us to ensure that the treatment planning utilizing IMRT is delivered appropriately to the patient.
The Evansville Cancer Center has recently introduced the first BAT system to the Tri-State area. It has developed an experience base with the BAT system for the close to real time localization of the prostate, bladder and rectum and in conjunction with our IMRT system allows us to utilize dose escalation to targets which are surrounded by non malignant, sensitive structures. We are currently developing systems that allow visualization of other targets such as breast, kidney and pancreas which will facilitate dose intensification to tumors located in difficult to treat areas.
Aly Razek, M.D., FACRO - Dr. Razek graduated from Cairo University. He completed his residency at Washington University in St. Louis, Mo. He is board certified in both radiation oncology and pediatrics. He co-authored four text books in radiation oncology and contributed to more than 20 publications in oncology journals. He served on the national committee of the Southwest Oncology group, Intergroup Ewings sarcoma and National Wilms Tumor Committee. Dr. Razek is a fellow of the American College of Radiation Oncology.
|Overall View of Cancer Pain Management
|The National Cancer Institute estimates that there are approximately 9.6 million persons with a history of cancer in the United States. Pain is one of the most prevalent symptoms reported by persons experiencing cancer. It is estimated thirty to fifty percent of those in active treatment experience pain with the percentage increasing between seventy-five to ninety percent in advanced disease. Literature reports that many persons suffer needlessly from unrelieved cancer pain even though studies concur that approximately ninety percent of cancer pain can be controlled with the use of available therapies.
In an enlightening survey by Cleeland et al, 1,308 outpatients with metastatic cancer from 54 treatment sites were surveyed. Patients were asked to rate their severity of pain during the previous week, degree of pain related functional impairment and the degree of relief provided by the analgesics prescribed. 67% reported pain and 36% had pain severe enough to interrupt their ability to function as desired. 42% of those with pain were given inadequate analgesic therapy. Upon determination of what factors resulted in poor pain relief, it was determined that the discrepancy between patients and physicians estimation of the severity of pain was predictive of inadequate pain management. Other significant factors that place a person with cancer pain at risk were:
a) presence of pain perceived by the physician as unrelated to the cancer,
b) good performance status,
c) being age 70 and older,
d) being a member of a minority race,
e) and being female.
Quality of pain management can easily be improved for those with cancer pain. It begins with a complete assessment of the pain experience. The assessment will enable the physician to determine which cancer pain syndrome is the source of the discomfort. The cancer pain syndromes were defined in the eighties and consist of pain related to musculoskeletal tumor involvement, pain related to tumor involvement of the viscera, pain associated with peripheral or central nervous system involvement and postsurgical pain associated with treatment for the cancer. As our clinical experience grows, guidelines (World Health Organization, Agency for Health Care Research and Quality, National Comprehensive Cancer Center, and American Pain Society) have been developed to assist the physician in treating the cancer pain syndromes.
The treatment plan will be based on the etiology of the pain, the nature and extent of the cancer, and any concurrent health problems. Although cancer pain is often a complex issue, persons need to be assured that relief is attainable. The goals of the assessment are to identify the source of the pain, to listen to the patient’s report, and to believe what the patient is saying. The foundation of the treatment program for moderate to severe cancer pain includes the use of opioids. Even when the etiology of the pain is not yet determined, symptom relief is paramount while the investigation occurs.
The American Pain Society’s guiding principles of analgesic use are:
- Individualize the drug, dose, route and administration
- For pain present most of the time, prescribe on a regular schedule based on duration of action of the chosen drug.
- Be comfortable with the principles of titration, rescue dosing, and equianalgesic conversion
- Evaluate and monitor closely when initiating opioid therapy as well as when prescribing increases
- Recognize and treat side effects proactively
- Do not use meperdine and mixed agonists-antagonists when treating pain from cancer
- Do not use placebos to determine the presence of pain
- Expect physical dependence and prevent withdrawal
Relief from pain related to cancer and/or the treatment of the cancer should be a priority for physicians. How pain is experienced by the patient and understood by the physician determines its value and how it is treated. As David Morris quoted in his book, The Culture of Pain: “not relieving pain comes perilously close to willfully inflicting it.”
Julia Georgesen, RN, MSN - Julia Georgesen, RN, MSN, Fellow in the American Academy of Pain Management, works closely with the center’s oncologists. She provides consultations in pain and symptom management developing an individualized plan of care for persons experiencing discomforts due to their cancer.
|Collaborative Efforts of Prostate Brachytherapy Program
to be Internationally Spotlighted
|The Evansville Cancer Center’s prostate program better known as the Tri-State Prostate Center began delivering care in 1999. This is a cooperative program utilizing the skills of Dr. W. Fisher, Dr. K. Foertsch, Dr. T. Gadient, Dr. P. Gilson, Dr. A. Korba, Dr. S. Lamb, Dr. A. Razek, Dr. B. Romick, Dr. B. Samm, Dr. P. Siami, Dr. S. Shah, and Arnold Sorensen.
In 2002, the treatment protocol that combined external beam radiotherapy with high dose rate brachytherapy became the modality of choice for localized prostate cancer. This multimodality protocol reduces the acute rectal and bladder symptomology.
A presentation, ‘Prostate HDR Brachytherapy: An Outpatient Approach’, outlining the results of the treatment will be presented at a joint meeting in Barcelona, Spain of the American Brachytherapy Society (ABS), European Society for Therapeutic Radiology & Oncology (ESTRO), Groupe Europee de Curietherape (GEC), and Groupe Latino Americano de Curieterapia (GLAC).