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Cancer center shares how they improve patients’ lives

Brachytherapy

The hospitals and care centers comprising the Willis-Knighton health system (Shreveport-Bossier, Louisiana, USA) constitute a critical healthcare resource for local residents and patients throughout Southern Arkansas, East Texas and North Louisiana, a combined catchment area of about one million people.

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Radiation Oncologists Michael L. Durci, MD; Sanford R. Katz, MD; J. Ben Wilkinson, MD; Lane R. Rosen, MD

The only locally owned, locally operated not-for-profit health system in Shreveport-Bossier, Willis-Knighton is committed to providing world-class care to its community and state. One way it fulfills this mission is through the acquisition and use of advanced treatment solutions. In recent years, Willis-Knighton Cancer Center, has acquired a Flexitron® brachytherapy afterloader, MOSAIQ® Oncology Information System and two Versa HD™ linear accelerators. In Elekta, Willis-Knighton saw a company that wanted to help them improve patients’ lives with innovative technology.

The articles presented in this issue of Wavelength reflect Willis-Knighton Cancer Center’s preeminence in brachytherapy and medical physics training and its acquisition and first use of Elekta’s Versa HD system.

Brachytherapy immersion

Willis-Knighton Cancer Center presents radiotherapy fellows the world of brachytherapy in intense week of training

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Three radiation oncology residency graduates each year will feel like they’re back in medical school digesting enormous amounts of information. During Willis-Knighton Cancer Center’s one-week HDR Brachytherapy Scholarship Program – supported by the American Brachytherapy Society (ABS) – the student will receive an intense immersion in brachytherapy clinical value and practice unlike anything he or she has experienced during their four years of medical residency.

Willis-Knighton Cancer Center’s Medical Director, Radiation Oncologist Dr. Lane R. Rosen, MD and his colleagues refer to the week’s program activities as “Shark Week” for good reason. The student will observe between 15 to as many as 40 HDR brachytherapy procedures treating a wide range of targets in the breast, cervix, vagina, lung, prostate and skin, and employing the full scope of brachytherapy techniques, such as intracavitary, topical, interstitial, APBI with a variety of catheters and AccuBoost. On top of that, the program participant also attends eight to 10 lectures encompassing brachytherapy physics, site-specific brachytherapy techniques and results, quality assurance, treatment planning, billing and documentation, nursing, the placement of brachytherapy-specific devices such as Smit sleeves and APBI patient selection.

“During ‘Shark Week’ it’s like the student is drinking through a fire hose,” Dr. Rosen says. “A typical radiation oncology resident may see only 50 to 60 brachytherapy procedures throughout their entire residency, and we’re doing a comparable amount in a single week. It’s a lot of learning pushed on each student very quickly, but they enjoy it.”

In addition to Willis-Knighton – which began its program in 2013 – six other North American centers have established an HDR Brachytherapy Scholarship Program either for physicians or physicists, all of which are sponsored by ABS and Elekta.

The Willis-Knighton way

Students who participate in Willis-Knighton’s HDR Brachytherapy Scholarship Program find out quickly that a department that prioritizes brachytherapy can develop ways to make the procedure extremely efficient. This is especially true for cervical cancer brachytherapy, which together with other GYN indications represents approximately seventy percent of brachytherapy cases at Willis-Knighton.

“Many clinicians don’t want to perform cervical tandem-and-ring or ovoid brachytherapy because they would end up spending five to eight hours in the operating room or in planning, taking them away from seeing other patients,” he says. “This will be the case if you anesthetize or sedate the patient. While this is an appropriate option and is comfortable for the patient, it does take a lot more time. The vast majority of our patients are treated with mild pain medication and without sedation or anesthesia. This means I can do the same procedure in only 90 minutes to three hours all in the office. We have validated and improved this method by treating hundreds of patients without complaint and with favorable outcomes.”

In addition to this technique, Dr. Rosen works with gynecologic oncologists Destin Black, MD and Robin Lacour, MD to insert Smit sleeves (versus time-consuming daily cervical dilation). A full complement of ancillary tools and applicators for brachytherapy is available, enhancing the physician’s choices. Dedicated disease site-specific nurses and an in-room dedicated compact CT scanner for all fractions make the treatment more expedient.

“Using the in-room CT system allows me to check the position of the tandem immediately after placement so I can readjust when necessary without delay,” Dr. Rosen notes. “This technique has allowed the Willis-Knighton team to further reduce time from the procedure.”

Exemplary planning for all brachytherapy cases is paramount and physicists are scrupulously trained to do the task well.

“We require all the medical physicists rotate through the department’s brachytherapy division so they become very familiar with planning aspects and can do it quickly,” he says. “The reason is to improve planning quality, not to increase throughput. In fact, we do two comparative plans for every patient. When we started out we did it because we thought it would be good for our physics residents. But after a while we realized that if you do a single-channel plan and a multi-channel plan, eight out of 10 times the multi-channel plan is better, but sometimes the single-channel plan is superior. There are no short-cuts – the dosimetrist and physicist only contour healthy tissues, the doctors contour all malignant targets. It’s a process, but it is a highly individualized process based on our experience.”

Students who go through “Shark Week” also gain an appreciation for Willis-Knighton’s emphasis on brachytherapy and several have been inspired to exploit this appreciation and new-found brachytherapy knowledge on returning to their centers. Nine students to date have completed the program.

“A couple of them are starting brachytherapy programs in private practices, and two others have gone back to their academic programs and completely changed the way they do things,” Dr. Rosen reports. “We hope that physicians who start doing brachytherapy will continue to use us as a resource when they encounter difficult cases they might need help with. We’re a private hospital practice but to us the academic component of radiotherapy – the expertise that we as radiation oncologists have in treating cancer, which is very specialized and different than that of our medical oncology and surgical oncology colleagues – is what makes our field special. Our brachytherapy program improves constantly just by teaching people how to do these procedures.”

Our brachytherapy program improves constantly just by teaching people how to do these procedures.

Brachytherapy center of excellence

Willis-Knighton launched the cancer center’s HDR brachytherapy clinical service in 1997 and added CT-capable HDR brachytherapy applicators for image-guidance in 2004. The team of four physicians has made brachytherapy a radiation therapy department priority. With each physician a disease-site specialist, they perform approximately 600 brachytherapy procedures annually, GYN indications representing about 70 percent of the cases.

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Nucletron HDR devices in practice with Lane R. Rosen, MD and Crystal Cheney, RN

Endobronchial HDR – a rarely performed technique nationally – is utilized frequently for selected patients at Willis-Knighton with the oversight of Dr. Sanford Katz. The procedure can decrease tumor size and allow re-expansion of collapsed lungs earlier in radiation treatment to help patients feel better faster and more easily tolerate systemic therapy. The re-expanded lungs allow protection of uninvolved pulmonary tissue. The technique has been filmed and is given to customers who purchase an Elekta afterloader. Dr. J. Ben Wilkinson, a widely published author on the partial breast irradiation (PBI) technique, has extensive experience in HDR prostate brachytherapy and brings his expertise to the center. Dr Mike Durci specializes in LDR prostate cases and infusional brachytherapy, such as Y90 for liver metastasis.

“There is very little brachytherapy we don’t do – we’re pretty much a full-service sort of brachytherapy shop,” Rosen says.

The evolution of the cancer center’s brachytherapy service into a world-class program is a reflection of the organization’s long-standing dedication to the highest standards in cancer management, technology and medical education. In 2003, Willis-Knighton’s TomoTherapy system became the fourth worldwide to begin treating patients and the center hosted the first international TomoTherapy conference in 2005. In 2014, it became the site of the Proteus ONE (Ion Beam Applications), the world’s first compact pencil beam scanning option for proton therapy. Radiation oncologists at the center have been world leaders since 1998 with the early adoption of IMRT, IGRT and SBRT compared to larger academic departments. The department also is a spoke component of the United States’ largest medical physics residency program and is double accredited by the American College of Radiology (ACR) and the American College of Radiation Oncology (ACRO). In addition, the American Brachytherapy Society (ABS) named Willis-Knighton an HDR Brachytherapy scholarship training site.

Not surprisingly, the cancer center’s clinical and technological preeminence made it an obvious choice not only for medical students and physics residents to rotate through, but also for equipment vendors bringing physician guests to evaluate technology. The latter also presented a myriad of opportunities for doctors to witness the site’s brachytherapy service.

“This is where the idea of a brachytherapy scholarship program started,” Dr. Rosen recalls. “Every time an Elekta colleague would bring a doctor to see our HDR in action, the doctor would say something like: ‘Wow! You do this so much better than we do!’, and leave with that impression.

This went on for years; people would visit us for TomoTherapy or for proton therapy, but they would always commend our brachytherapy techniques. Eventually, we began talking to Elekta and ABS, offering to proctor people in brachytherapy. We told them we wanted to share our knowledge to help advance the field.”

Promoting brachytherapy through training is profoundly important to Dr. Rosen, who professes his frustration that nearly one-third of women with cervical cancer don’t receive brachytherapy1-3 – a consequence of physicians using competing radiotherapy technology (i.e., IMRT) or clinicians’ unfamiliarity with brachytherapy and a perception that it’s a complex, time-consuming procedure.

“If radiation oncologists aren’t comfortable with brachytherapy, they will be too reliant on technology like IMRT and that means the brachytherapy part of our field is in trouble,” he says.

“Brachytherapy is one of the true differentiators of radiation oncology. When ABS looked at our inquiry about becoming a training site – and they came out to evaluate us – I think their general feeling was that we were doing high level brachytherapy and a lot more of it than the vast majority of programs in the country.

“More importantly – in contrast to many centers – we were willing to commit the time to teach other people,” he adds. “Our vision is that we change the way physicians are trained in brachytherapy. There needs to be more proctoring and experience in the modality. I see no reason why radiation oncology residency programs that don’t have enough brachytherapy education shouldn’t be mandated to allow their residents to rotate at sites like ours where they could get more experience in this clinically proven technique.”

References

  1. Han K, Milosevic M, Fyles A, et al. Trends in the utilization of brachytherapy in cervical cancer in the United States. Int J Radiat Oncol Biol Phys 2013;87:111-119.
  2. Gill BS, Lin JF, Krivak TC, et al. National Cancer Data Base analysis of radiation therapy consolidation modality for cervical cancer: the impact of new technological advancements. Int J Radiat Oncol Biol Phys 2014 Dec 1;90(5): 1083-90.
  3. Bagshaw HP, Pappas LM, MStat. Patterns of care with brachytherapy for cervical cancer. Int J Gynecol Cancer 2014 Nov;24(9):1659-64.

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