Op-Ed: Dropping Cancer Death Rates and the Role of Radiation Therapy

Mackie_rockRadiation therapy is the most overlooked of cancer therapies. While attention has primarily been given to  chemotherapy and immunotherapy, the truth is that for every 100 people who survive cancer, about 50 can principally thank surgery, 45 are alive because of radiation therapy and perhaps 5 survive due to all other therapies. As cancer death rates continue to decline, we must recognize and support the critical role that radiation therapy plays in this trend.

Of the $2.2 trillion spent by the U.S. economy on healthcare, less than one percent (about $800 million) is spent on radiation therapy equipment—this, despite the fact that radiation therapy serves as our safest, most convenient and cost-effective method of treating cancer.

Consider this: Unlike surgery, most people receiving radiation therapy are not hospitalized. Most patients who undergo radiation therapy experience minimal side effects, and the incidence of complications is dropping rapidly as survival rates continue to improve. Modern radiation therapy solutions are an important part of this progress. Recently published results1 of an ongoing clinical trial for the treatment of lung cancer—the most deadly of all cancers—illustrates this very fact.

Encouraging early results

The Phase I clinical trial, led by the University of Wisconsin School of Medicine and Public Health, shows that using TomoTherapy technology to safely deliver a higher-than-normal biologically-effective dose to stage I-IV non-small cell lung cancer patients results in increased overall survival, and reduced rates of toxicity to lung and esophagus. 

A key area where the treatment technique differed from traditional radiotherapy is that all patients received just 25 treatment fractions and the dose per fraction was set according to the likelihood of radiation-avoiding lung pneumonitis and esophagitis. Some patients were able to receive a higher dose per fraction than others (mostly because their tumor was smaller), taking advantage of the increase in survival known to be associated with increased tumor dose. 

Unlike most dose escalation studies, increased dose was not achieved by increasing the total number of fractions (and total duration of the treatment course), as this can allow time for the tumor to begin re-growing.

Highlights of the study

The authors state that “higher doses of radiation therapy than are conventionally administered (~60 Gy) may be delivered safely in a hypofractionated schedule with helical TomoTherapy.”

For the 46 patients in the study, overall survival 2 years after treatment was 46.8%. This compares with historical rates of only 21.5% for the same stage-range of disease.

No patient experienced grade 3 or higher pneumonitis and no patient experienced grade 3 or higher esophagitis.
 It is important to note that this study does not employ a stereotactic body radiotherapy (SBRT) technique, which benefits a much smaller number of patients (mostly very small, Stage I tumors). The majority of patients in this study had Stage III or IV lung cancer, as do about 60% of lung cancer patients at diagnosis.

Radiation therapy as a wonder drug

Everyone hopes for a wonder drug like penicillin or a vaccine to cure cancer. Imagine for a moment that radiation therapy were a drug. It could be administered in dosages accurate to within a few percent. It could be instantly detected in the smallest quantities. The tumor would not build up tolerance to it. It would be inexpensive to deliver. And it would accentuate the tumorcidal effects of other drugs.

Now imagine that where the drug acts were visible with medical imaging, and that it could be delivered anywhere in the body with minimal side effects. Surely, it would be heralded as the wonder drug of our age.

Radiotherapy is that wonder drug—for certain cancers. This type of therapy is able to treat those hard-to-treat cancer cases. Advances in computer and radiation technology have made it possible to create new radiation delivery systems that target the tumor and spare surrounding healthy tissue. For example, it is now possible to accurately treat cancers where the tumor is very near to a critical organ like the spinal cord. The company that I co-founded in Madison, Wisconsin, TomoTherapy Incorporated, has developed such a device that is being used throughout the country and world.

Incorporating CT scanning technology, the TomoTherapy Hi·Art treatment system is able to visualize and treat deep-seated tumors that are larger than any ever even attempted, and achieve unprecedented avoidance of surrounding normal tissues. 

Much has been written about why the cancer death rate is dropping. Better screening, earlier detection and improved lifestyles have been reported on extensively by the media. This is justified and serves a good purpose. But let us also raise awareness of an improved application of a weapon that has long been an essential component in our battle against cancer, radiation therapy. As a nation, we need to continue supporting these efforts because they do work and, with the proper research and development put into them, they will continue to improve—and prove ever-more effective in the fight against cancer.

Thomas Rockwell Mackie, Ph.D.

Dr. Mackie is a professor at the University of Wisconsin and co-founder and Chairman of the Board of TomoTherapy Incorporated.1 “Dose Escalated, Hypofractionated Radiotherapy Using Helical Tomotherapy for Inoperable Non-Small Cell Lung Cancer: Preliminary Results of a Risk-Stratified Phase I Dose Escalation Study,” Technology in Cancer Research and Treatment (Technol Cancer Res Treat. 2008 Dec;7(6):441-8.)

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  1. The only precautions you really need are those that make sense. He’s not going to make you ill, so don’t be afraid to do the embrace. Secondly, he may be sensative to be as gentle as possible, but don’t be afraid to be firm and stable. Thirdly, touch and hug alot! Cancer patients get to feeling like “untouchables” sometimes because relatives become afraid to do more harm than good. So especially considering his advanced age… make the time you have quality time with lots of love as much as you can personally manage. Those are the most important things to those in oncology circumstances. Good luck and my best wishes for a peaceful & relatively painless remedy to your loved one’s pain.

  2. This is a very interesting blog! I am a Radiation Oncologist and while reading the comments have had many “hmmm” moments.
    There are details in the care of patients that a great majority of you don’t seem to know about. An example of this is the notion that treating a patient with palliative intent in one fraction is as good as 10 fractions. There are many issues such as late tissue tolerances, palliative intent, acute toxicity, volume of coverage etc …especially if the has also or is also receiving concurrent chemotherapy. Durability of palliation is also pertinent in this setting.
    Treating a patient with palliative intent with a large single fraction of radiation therapy is feasible in the setting of a patient that comes on a stretcher who has a very short (days to weeks) life expectancy. Potential radiotherapy toxicity in this scenario is meaningless as the patient will likely be long gone before the toxicities present themselves.
    However, in the patient who has a life expectancy of many months to <1 year (most of the patients that we see for palliative radiation therapy) treating with large single fractions can diminish the patients quality of life. This is especially true in the common scenario where patients have received multiple rounds of chemotherapy and continue on a maintenance regimen. Treating with a single large fraction would likely lead to acute and sub-acute quality of life decrements. The probability of inducing these decrements would be higher with the single large fraction and would go against the very intent of palliative radiation therapy.
    The CMS Radiation Oncology budget is in the same order of magnitude as the CMS budget for Procrit. Procrit is utilized by our Medical Oncology colleagues to combat one of the hematologic side effects of the chemotherapy that they prescribe. So to restate, the CMS Radiation Oncology budget is on the same order of magnitude as the CMS budget for procrit (which has never cured anyone)…hmmm!
    What are the pressures for medical oncologists to utilize chemotherapy? Why do some Medical Oncologists give cytotoxic chemotherapy to postmenopausal breast cancer patients when others don’t for patients with the same risk factors? Is this another scenario where there are details in the care of these patients that we don’t know about? Or, is this another example of when variability in care is driving up health care costs?
    Though not absent, reimbursement pressures have not been heavily influential in the Radiation Oncology specialty (as reflective in the CMS budget). This is about to change in a big way. Proton therapy is on the horizon and as is customary in healthcare, an outside interest (venture capitalists) has taken notice. Can our current system manage the pressures to utilize Proton Therapy in the absence of a clear superiority over the current standard of Photon therapy? Keep in mind, though, there may be details in the care of these patients that a we don’t know about!!

  3. I often thought about the problem of unintended self-interest bias which may be a factor in this situation.
    Some years back, the government had asked Joseph P. Newhouse, a health policy professor at Harvard, and his colleagues to look into how the Medicare reimbursement system may affect how doctors prescribe chemotherapy.
    His study “Does Reimbursement Influence Chemotherapy Treatment For Cancer Patients?” co-authored with Dr. Craig C. Earle, was finally published in Health Affairs in 2006. This joint Michigan/Harvard study added to the ‘smoking gun’ survey by Dr. Neil Love, “Patterns of Care.”
    I wrote to both of them to ask if their study methodology on reimbursements influencing chemotherapy treatments, could be applied to reimbursements influencing radiation treatment?
    Before the days and widespread use of Stereotatic, Gamma-Knife, Cyber-Knife, IMRT, TomoTherapy, and the like, the most expensive treatment for postoperative brain surgery for a solitary brain metastasis was whole brain radiation. With the newer treatments, whole brain radiation was abandoned because of the substantial neurological deficits that resulted with its use, sometimes appearing a considerable time after treatment. Today, cutting-edge clinical practices use a more “focused” radiation field.
    During the last twenty years when the preponderance of cancer care shifted from the institution-based, inpatient setting to community-based, ambulatory sites for treating the majority of the nation’s cancer patients, many of these community-based settings did not have the cutting-edge high-tech toys.
    Was there an incentive for radiation oncologists at community cancer centers to chose whole brain radiation treatments, as these were the most expensive, for them? Could Newhouse’s methodology collect data documenting a clear association between reimbursement to radiation oncologists for whole brain radiation treatment which is based on how much incentive occurs to the radiation oncologist?
    They thought that there were similar issues, but their methodology would be different because radiation isn’t something that individual doctors buy, sometimes at a discount, and then profit from if they’re reimbursed more for it, as in the case with chemotherapy.
    They relied upon price variation across regions in Medicare, which was pseudo-random and had been eliminated. To their knowledge, there was no comparable price variation in radiology that they could have used.
    However, they did mention a radiation oncologist, who had done some work looking at the number of palliative fractions of radiation given to patients with advanced lung cancer as being a situation in which there is a lot of discretion on the part of the physicians: one fraction is as good as 10, but 10 will reimburse more.
    Whatever the means of “localized” radiation therapy, it is the “radiation technique” that delivers focal treatment to the local tumor site and a small area of surrounding tissue that is important here.

  4. Brad,
    I am always advocating focussing on diagnostics and treatments that give you good “bang for the buck” and I know that the US healthcare is extremely wasteful.
    On the other hand, to me (non oncologist specialty physician), it looks like the battle against cancer is fought in tiny incremental steps. Possibly, this is one of them.
    In my opinion, the real waste in the US system is not in the (at times maybe overly ressource intensive) fierce battle for increased survival in cancer patients, but in useless diagnostics either for common benign conditions and/or tests to rule out differential diagnostic considerations that are either remote and/or untreatable … and re. treatment, waste is in overly expensive drugs with marginal benefits, and in unnecessary/harmful surgery.
    I am skeptical how much counselling helps, given the fact that most people roughly know the basics of a healthy lifestyle. I will try to find something on medline re. the success of such intervention … if you or anyone else know(s) of something, let me know. But I think the more promising approach would be to convert the little enticing long term benefits of a healthy lifestyle to short term perks (e.g. insurance rebates etc.)

  5. While this reads genuinely, and I am sure it is, this is *exactly* what every device, antibiotic, equipment supply, diabetic care supporter, cardiac interventionalist, et al, states–regardless of what slice of the pie they are currently getting.
    The issue is not so much the intentions of these folks, they are good, but utilization, appropriateness (in this case cost/QALY) and target population. If every heart felt plea is abided, our system can and will go broke.
    It would have been helpful to see costs, NNT, etc., mentioned above to buttress case. More reason to have a CER enterprise. Should we spend our dollars on RT or community health to improve health disparities and improve screening, tobacco and nutritional counseling.