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Regional Oncology Update - Summer 2003

Prostate Cancer: Part Two, Methodology
Once the decision has been made to treat prostate cancer with brachytherapy, (see Regional Oncology Update, Fall 2002), we initiate the process with a volume study. During this procedure, an ultrasound study produces images of the prostate and the surrounding organs that are used to produce a treatment plan. This plan allows us to insert applicators and subsequent radioactive material in a manner to yield high doses to the tissue known to contain malignancy and more or less spare the normal surrounding stroma.

The clinical physics team coordinates this activity with the clinicians and assumes primary responsibility to procure a plan, which allows placement of the applicators and delivery of the dose to fi t the desires of the clinicians. The radiation oncologist and the urologist on the team may alter the plan to conform to their unique vision of the clinical situation at hand. Aside from the estimation of the tissue volumes, the clinicians and the physics team estimate the degree of interference from the pubic arch, the probability of extension of the malignant process, and the radiosensitivity of the surrounding normal tissue.

Compounding the planning process is the determination of the route and position of the urethra. It is critical to maintain a degree of safe dose to the urethra which lies within the gland and thus within the area where we have to concentrate tumoricidal doses. This is not possible with the utilization of external beam therapy as monotherapy and is therefore a positive consideration for the use of brachytherapy in this circumstance.

Seed based therapy, while preserving in theory the possibility of producing a plan as noted above, is much less exact than the high dose rate brachytherapy. Even though the seeds may be placed with great precision, the probability of seed drift is substantial and the incidence of urinary dysfunction is substantial.

After the plan has been constructed, reviewed, revised and approved, the patient is anesthetized either by inhalation or regional anesthesia and a grid is attached to our ultrasound transducer. This allows for the placement of the applicators with precision.

In the case of seed based brachytherapy, the seeds are introduced sequentially into their pre-assigned positions at this time. In the case of the high dose rate (HDR) brachytherapy, the patient is transferred to the CT scanner where we are able to determine the precise placement of the applicators. Images are obtained and then we are able, with the aid of the treatment-planning computer, to determine the position and time of irradiation to the multiple points of interest. Typically, the HDR protocol exceeds 100 points of interest to deliver the dose profi le consistent with objective of treating the malignancy to tumoricidal doses while sparing the bladder, rectum and urethra.

The treatment team at the Evansville Cancer Center has performed more than 500 brachytherapy procedures to the prostate and is among the more experienced teams in the country. We have indeed instituted a service which allows persons to remain within their community to receive treatment delivered by a highly skilled team in an competent, comfortable, safe outpatient environment. There is no need for persons to leave their community to receive this procedure that often will be delivered by teams less experienced than ours.

- Al Korba, M.D., FACRO

Dr. Korba is a Radiation Oncologist who has been practicing in the Tri-State since 1976. He has been internationally recognized as a pioneer in the development of High-Dose Radiation. In 1992, he received the Kurt Sauerwein International Award for his work in brachytherapy and is a frequently requested lecturer. Dr. Korba is a Fellow of the American College of Radiation Oncology.
Intensity Modulated Radiation Therapy (IMRT)
Finally, A Dream Come True...
Intensity modulated radiation therapy (IMRT) became a reality as a result of advances in medical imagery, the emergence of high speed computer workstations and continued research and development by the radiation therapy industry. During the past 25 years, radiation oncologists passed through many eras of radiation treatment plans. It started with the primitive hand calculated plans, to the simple two dimensional (2D) plans to advanced three dimensional (3D) plans to the new era of lMRT. Contrary to the forward treatment planning used in 3D by which several plans are generated and the radiation oncologist selects the optimum plan; IMRT has an inverse treatment plan through which the radiation oncologist enters a prescription into the computer. The computer does a search through many alternative ways and comes up with a plan for the treatment of such patients satisfying the physician’s goals.

The data from the Radiation Therapy Oncology Group (RTOG) Patterns of Care Study, Fox Chase, and Memorial Sloan Kettering show a high local cure and better survival for patients with cancer of the prostate through radiation dose escalation with the use of lMRT. Doses greater than 75.6 Gy showed a local control of 71% compared to 54% with lower doses of radiation. IMRT made higher doses of radiation feasible to deliver to the prostate; at the same time limiting the parameters of doses to be delivered to other organs such as bladder, rectum and the heads of femoral bones. For example IMRT allowed us to save more rectal wall from radiation injury than when conventional radiation therapy or conformal radiation therapy (CRT) are utilized. Grade 2 and 3 toxicity was lowered from 16% with the use of conventional radiation therapy to less than 3% with the use of lMRT.

Prostate cancer is not the only indication for utilizing IMRT. For example, IMRT has applicable benefit in treating head and neck cancer by allowing a high dose to the tumor, while sparing most of the parotid gland from the radiation field. This yields objective and subjective improvement in both xerostomia and quality of life scores in such patients. Furthermore, IMRT is also utilized for treatment of lesions of the basal skull, spine lesions and boost of residual lung lesions.

At the Evansville Cancer Center, we introduced the IMRT state of the art technology to Southwest Indiana. In June, 2003, we started treating patients with IMRT following several months of intensive training of the radiation oncologists, medical physicists, dosimetrist and staff technicians. This new technology which has been a dream for the radiation oncologists will translate into a higher cure rate with less toxicity to cancer
patients.

- 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.
Indiana Cancer Consortium Requests Volunteers and Targets A Control
Plan Statewide for Cancer
The Indiana Cancer Consortium (ICC) is currently seeking oncologists, nurses, other health care providers or interested groups who would like to help develop a statewide cancer control plan. The ICC is a statewide network of public and private partnerships, and includes members from the Indiana State Department of Health, American Cancer Society, the Wellness Community, Eli Lilly and Company, the Indiana Public Health Association, the Indiana Minority Health Coalition, Little Red Door, Indiana Rural Health Association, DaimlerChrysler, the Northern Indiana Cancer Consortium CCOP, Ball State University, Indiana University, Purdue University, ANTHEM, Indiana Health and Hospital Association, Midwest Center for Rural Health, the Walther Cancer Institute, Community Cancer Care, Meridian Medical Group, Smokefree Indiana, Indiana Primary Health Care Association, Advantage Health Plan, St. Vincent Oncology Services, St. Elizabeth Medical Center, American College of Surgeons, Sagamore Health Network, the Indiana University Cancer Center as well as many other private and public organizations.

The ICC is a volunteer organization whose mission is to reduce the cancer burden in Indiana through the development, implementation and evaluation of a comprehensive plan that addresses cancer care across the continuum from prevention through palliation. Although first established in 2001, the ICC is only now beginning to develop the Indiana State Comprehensive Control Plan, a five year plan to be targeted initially at six specific areas: breast cancer, colorectal cancer, prostate cancer, tobacco use, data collection and advocacy. The final plan will be submitted to the Centers for Disease Control and Prevention (CDC), which in turn, supports the ICC.

Although anyone with cancer expertise is welcome, we are in need of individuals/groups from outside Indianapolis and Marion County, particularly for the Prostate Advisory Group. There are two full ICC meetings convened each year as well as semi-regular meetings for each targeted area. Participation can range from attending each meeting to simply receiving the ICC newsletter.

Now is the perfect time to join if you want to help determine how the state of Indiana will address the many burdens imposed by cancer. For more information, please contact Dr. Anna Miller at
annamill@iupui.edu. If you are interested specifically in the Prostate Advisory Committee, you may also contact Dr. Brian Giesler at bgiesler@iupui.edu.
Evansville Cancer Center's Skin Cancer Awareness Efforts
May was skin cancer awareness month. In an effort to help educate our community on the dangers of tanning and skin cancer, Evansville Cancer Center was involved in several health fairs, public events and industry in-services throughout the month of May. Marketing Director for Evansville Cancer Center, Robin Lawrence-Broesch, who was diagnosed with malignant melanoma last March 2002, worked with her dermatologist Dr. Jane Lim and dermatologist Dr. Mary Tisserand, to offer free skin cancer screenings and educational programs for the public. The response was overwhelming and the results from the screenings were very alarming.

On Thursday, May 8th, Dr. Lim conducted full-body screenings on 61 individuals at the Deaconess Women's Hospital. Of the people who were screened, 21 had signs of basal cell, squamous cell or malignant melanoma skin cancers. They were instructed to seek further treatment with their health care provider. Dr. Tisserand also conducted full-body screenings at St. Mary's Warrick Hospital on Thursday, May 22nd. Over two-thirds showed signs of skin cancer and were instructed to seek follow-up care.

In addition to the screenings, Robin Lawrence-Broesch presented an instructional program on skin cancer which included her personal testimony. Educational materials were available courtesy of American Academy of Dermatology, the American Cancer Society, and Chiron and Schering pharmaceutical companies. Free sunscreen was distributed, courtesy of Banana Boat.

Evansville Cancer Center would like to personally thank Dr. Lim and Dr. Tisserand for the volunteering of their time and expertise in providing these services for our community.
If you would like brochures and/or shower cards addressing the early awareness and detection of melanoma to have available for your patients or 'Rationale for Sentinel Lymph Node Mapping' booklet for you and/or posters showing the A,B,C,D's and staging of melanoma which you can display in your exam rooms, please call Robin at (812) 474-6000 or e-mail her at robinbroesch@att.net. She'll gladly deliver them to your office.
“Bob Dole Speaks Out” at Prostate Cancer Awareness Program

Saturday, August 23rd, 2003
11:30 a.m. Luncheon with Bob Dole

Meet and have your photograph taken with Bob Dole!

Receive his book 'Great Political Wit; Laughing (Almost) All the Way to the White House' autographed by Mr. Dole

Guest Speaker Dr. Brian Giesler, American Cancer Society grant recipient, 'The Quality of Life Following Treatment for Clinically Localized Prostate Cancer'

Tickets for the luncheon are $225 each (which includes 2 p.m. program) by calling TicketMaster at 812-435-5770, ext #11 or at The Centre box office.


2 p.m. 'Bob Dole Speaks Out' Program

The Centre, Downtown Evansville Tickets for the program are $10 each with reserved seating. Tickets are also available through TicketMaster by calling 812-423-7222 in IN or 270-926-6661 in KY, call Robin Lawrence-Broesch at Evansville Cancer Center at 812-474-6000 or stop by ECC on Burkhardt Road.

Proceeds from 'Bob Dole Speaks Out' will benefit Cancer Care Options, Inc., a not for profit organization that provides emergency assistance to any person with cancer who cannot afford the medications related to cancer/pain their physician has prescribed for them.




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