radiation therapy as an effective tool to fight cancer in women: future trends r. sankaranarayanan...
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Radiation Therapy as an Radiation Therapy as an
Effective Tool to fight cancer Effective Tool to fight cancer
in Women: Future Trends in Women: Future Trends
R. Sankaranarayanan MDR. Sankaranarayanan MD
Screening GroupInternational Agency for Research on Cancer,
World Health OrganizationLyon, France
CANCER TREATMENT IN CANCER TREATMENT IN DEVELOPING COUNTRIES DEVELOPING COUNTRIES
Vast range in health service infrastructure
Wide range in health care resources
Problems in
Availability
Accessibility
Affordability
CANCER IN WOMEN: BASIC CANCER IN WOMEN: BASIC TREATMENT MODALITIESTREATMENT MODALITIES
Cancer site Surgery Radiotherapy Chemotherapy
Breast ++++ ++ +++
Cervix ++ ++++ ++
Body uterus ++++ ++
Ovary ++++ + +++
Vagina + ++++
Vulva +++ +
WORLD-WIDE BURDEN OF WOMEN WORLD-WIDE BURDEN OF WOMEN CANCER: AROUND 2002 ADCANCER: AROUND 2002 AD
1 849 000 new cases
809 000 deaths
6 354 000 prevalent cases
WORLD-WIDE BURDEN OF WOMEN WORLD-WIDE BURDEN OF WOMEN CANCER: AROUND 2015 and 2030 ADCANCER: AROUND 2015 and 2030 AD
2015 2030
Cases 2 446 000 3 169 000
Deaths 1 081 000 1 442 000
GLOBOCAN 2002
WORLD-WIDE BURDEN OF CERVICAL WORLD-WIDE BURDEN OF CERVICAL CANCER: AROUND 2002 ADCANCER: AROUND 2002 AD
493,000 new cases annually
274,000 deaths annually
1.4 million prevalent cases
More than 80% in developing countries
WORLD-WIDE BURDEN OF CERVICAL WORLD-WIDE BURDEN OF CERVICAL CANCER: AROUND 2015 and 2030 ADCANCER: AROUND 2015 and 2030 AD
2015 2030
Cases 645 000 810 000
Deaths 365 000 475 500
GLOBOCAN 2002
0 20 40 60 80 100
Uganda
Gambia
Philippines
ZimbabweAfrican
India
Costa Rica
Cuba
Thailand
Turkey
Singapore
China
SouthKorea
5-Year Age Standardised Relative Survival (0-74 yrs)
Cervix Cancer (ICD-10:C53)• Highest in Seoul, South
Korea• Least in Kampala,
Uganda
Intra country variation• Pronounced in China
(urban vs rural ) & India
• No difference in South Korea & Thailand
Data from developed countries
• US-SEER: 70%• Eurocare: 62%
CERVICAL CANCER CONTROL CERVICAL CANCER CONTROL
Prevention – HPV Vaccines
Early detection by screening
Clinical early detection
Treatment
1920 1940 1960 19800
10
20
30
40
50
Stage I
Stage II
Stage III
Stage IV
Per
cen
t
Year
60
Data on stage distribution at time of diagnosis at the Radiumhemmet (Heyman, 1937-1952; Heyman, 1953-1955; Kottmeier, 1958-1961; Kottmeier, 1964-1967; Kottmeier, 1973-1976; Kottmeier, 1979-1982; Pettersson, 1988-1991).
Ponten et al., Int J Cancer, 1995; 60: 1-26
Crude stage-specific 5-year survival compiled from the material followed at the Radiumhemmet (Heyman, 1937-1952; Heyman, 1953-1955; Kottmeier, 1958-1961; Kottmeier, 1964-1967; Kottmeier, 1973-1976; Kottmeier, 1979-1982; Pettersson, 1988-1991)
1920 1940 1960 19800
20
40
60
80
100
Stage I
Stage II
Stage III
Stage IV
Per
cen
t
Year
Ponten et al., Int J Cancer. 1995; 60: 1-26
CANCER OF THE UTERINE CERVIX: CANCER OF THE UTERINE CERVIX: RADIOTHERAPY RADIOTHERAPY
Radical radiotherapy: Delivered with a curative intention; for stages I-IIIB; selected cases of IVA
Concurrent Chemoradiotherapy is an option for stage II and III disease
Dose delivery reference points: Points A & B
Post OP RT in high risk early stage disease after surgery
Palliative radiotherapy
CANCER OF THE UTERINE CERVIX: CANCER OF THE UTERINE CERVIX: RADICAL RADIOTHERAPY RADICAL RADIOTHERAPY
A combination of external-beam pelvic irradiation covering the uterus, parametria and the lymphnodes and intracavitary irradiation for the central disease is used
The aim is to deliver a total dose of around 80 Gy to point A
CANCER OF THE UTERINE CERVIX: CANCER OF THE UTERINE CERVIX: EXTERNAL RADIOTHERAPY EXTERNAL RADIOTHERAPY
Parallel pair of portals
Four-field beam arrangement
Special midline shields (after 20 Gy in stages I & II; after 40 Gy in stage III)
40-50 Gy in 20-25 F over 4-5 weeks
CANCER OF THE UTERINE CERVIX: CANCER OF THE UTERINE CERVIX: INTRACAVITARY RADIOTHERAPY INTRACAVITARY RADIOTHERAPY
LDR: 1 (for stage III) or 2 (for stages I & II if midline shield is used) applications of 30 Gy to point A
HDR: 5 weekly applications of 7 Gy to point A (for stages I and II if midline shield is used) or 3 applications of 7 Gy to point A (for stage III)
1 – Tandem
2 – Rectal marker
3 – Marker seeds
4 – Flange
5 – Right ovoid
6 – Urinary catheter balloon
1 – Rectal marker
2 – Tandem
3 – Ovoids
CANCER OF THE UTERINE CERVIX: CANCER OF THE UTERINE CERVIX: PALLIATIVE RADIOTHERAPY PALLIATIVE RADIOTHERAPY
In most cases of IVA and IVB
30 Gy in 10 F over 2 weeks
BREAST CANCER IN THE WORLD
1.15 million new cases
Incidence increasing in most countries
470 000 deaths
Half of the global burden in low- and medium-resourced countries
WORLD-WIDE BURDEN OF BREAST WORLD-WIDE BURDEN OF BREAST CANCER: AROUND 2015 and 2030 ADCANCER: AROUND 2015 and 2030 AD
2015 2030
Cases 1 531 000 2 004 000
Deaths 549 000 737 500
GLOBOCAN 2002
ROLE OF RADIOTHERAPY IN ROLE OF RADIOTHERAPY IN BREAST CANCERBREAST CANCER
Breast conservation
Adjuvant radiotherapy
Palliative radiotherapy
0
50
100
150
200
250
1965 1970 1975 1980 1985 1990 1995 2000 2005
ASR
(w
orl
d)
per
100,0
00
USA (SEER)
England
Norway
Finland
Slovakia
The Netherlands
J apan (Osaka)
Breast cancer incidence rates (age 35-74) in Breast cancer incidence rates (age 35-74) in selected developed countriesselected developed countries
0
20
40
60
80
100
120
1968 1973 1978 1983 1988 1993 1998
ASR
(w
orl
d)
per 100,0
00
Other Asia(Singapore, Manilaand Chinag Mai)
China (Hong Kongand Qidong)
India (Bombay andMadra)
Africa (Kampalaand Harare)
South America(Cali, Quito andCosta Rica)
Breast cancer incidence rates (age 35-74) in Breast cancer incidence rates (age 35-74) in selected developing countriesselected developing countries
0
10
20
30
40
50
60
70
1965 1970 1975 1980 1985 1990 1995 2000 2005
ASR
(w
orl
d)
per 100,0
00
USA
UK
Italy
Finland
Hungary
Australia
France
Breast cancer mortality rates (age 35-74) in Breast cancer mortality rates (age 35-74) in selected developed countriesselected developed countries
0
5
10
15
20
25
30
35
40
1965 1970 1975 1980 1985 1990 1995 2000 2005
ASR
(w
orl
d)
per 100,0
00
Republic of Korea
J apan
China (selectedareas)
Singapore
Thailand
Breast cancer mortality rates (age 35-74) in Breast cancer mortality rates (age 35-74) in selected Asian countriesselected Asian countries
BREASTCONSERVING
SURGERY
Breast cancer screening programs
Increase mass awareness
Patients with earlier stages presenting
to clinic
Better psycho-social Adjustment
BREAST CONSERVING THERAPYBREAST CONSERVING THERAPY(BCT)(BCT)
Better Quality of life
MRM Vs BCT
Randomized trials
Meta-analysis
Comparable local control, Overall survival
Better cosmetic outcome
BCT: EFFECT OF RADIOTHERAPY ON BCT: EFFECT OF RADIOTHERAPY ON LOCAL RECURRENCELOCAL RECURRENCE
EBCTCG meta-analysis. Lancet 2005; 366: 2087–2106
5 year gain 16.1%
5 year gain 30.1%
Node Negative Women Node Positive Women
BCT: BREAST CANCER AND OVERALL BCT: BREAST CANCER AND OVERALL MORTALITYMORTALITY
EBCTCG meta-analysis. Lancet 2005; 366: 2087–2106
15 year gain 5.4%
15 year gain 5.3%
Breast Cancer Mortality Overall Mortality
ADJUVANT RADIOTHERAPY ADJUVANT RADIOTHERAPY
Indications of Radiation therapy Patients with 4 or more positive lymph
nodes Presence of extracapsular extension,
positive or close margins T3 tumors with positive lymph nodes,
medial quadrant tumors Any T4 tumors and pectoral fascia
involvement
MASTECTOMY: EFFECT OF RADIOTHERAPY ON MASTECTOMY: EFFECT OF RADIOTHERAPY ON LOCAL RECURRENCELOCAL RECURRENCE
Node negative disease (1428 women )
Node positive disease (8505 women )
EBCTCG meta-analysis. Lancet 2005; 366: 2087–2106
MASTECTOMY: EFFECT OF RADIOTHERAPY MASTECTOMY: EFFECT OF RADIOTHERAPY ON BREAST CANCER MORTALITYON BREAST CANCER MORTALITY
Node negative disease
(1428 women)
Node positive disease (8505 women)
EBCTCG meta-analysis. Lancet 2005; 366: 2087–2106
15 year loss 3.6%
15 year gain 5.4%
EBCTCG meta-analysis. Lancet 2005; 366: 2087–2106
MASTECTOMY: BREAST CANCER AND MASTECTOMY: BREAST CANCER AND OVERALL MORTALITYOVERALL MORTALITY
NODE POSITIVE WOMENNODE POSITIVE WOMEN
15 year gain 5.4% 15 year
gain 4.4%
Breast Cancer Mortality Overall Mortality
Dose: 45Gy/25#/5 wks with 6/10MV LA or telecobalt
RECENT ADVANCES IN RECENT ADVANCES IN RADIOTHERAPYRADIOTHERAPY
CT simulators and Portal imaging
3DCRT
IMRT
IGRT
Portable LA for IORT
Only 20% of population has access to RT in Africa; 40 % in Asia and 50 % in Latin America
EARLY DETECTION APPROACHES
Screening: mass application of screening test in asymptomatic populations at regular intervals
Early clinical diagnosis: detection of early clinical stages of disease in symptomatic or high-risk subjects
HOW TO DEVELOP CANCER TREATMENT HOW TO DEVELOP CANCER TREATMENT SERVICES IN DEVELOPING COUNTRIES SERVICES IN DEVELOPING COUNTRIES
National policy - NCCP
Resource allocation/ Phased development
Human resource development
Investments in diagnosis/ treatment
Comprehensive basic services
Team approach
National guidelines of Rx
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