Techniques and Technologies in Radiation Oncology 2018

Transcription

1 Techniques and Technologies in Radiation Oncology 2018 The Royal Australian and New Zealand College of Radiologists The Faculty of Radiation Oncology

2 Name of document and version: Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Approved by: Faculty of Radiation Oncology Council Date of approval: September 2018

3 CONTENTS 1. Objectives About Radiation Oncology FRO Technology Scanning Why? FRO Definition of Radiation Therapy Techniques FRO Definition of Radiation Therapy Technologies Why Differentiate Between Techniques and Technologies? Faculty of Radiation Oncology Position Radiation Oncology Techniques... 7 Appendix i: Technology Scan Table Appendix ii: Radiation Therapy Techniques...14 Appendix iii: Related Innovations...21 Appendix iv: Glossary...25 Acknowledgements...28 References...28

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5 ABOUT THE COLLEGE The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand. The Faculty of Radiation Oncology, RANZCR, is the peak bi-national body advancing patient care and the specialty of radiation oncology through setting of quality standards, producing excellent radiation oncology specialists, and driving research, innovation and collaboration in the treatment of cancer. OUR VISION RANZCR as the peak group driving best practice in clinical radiology and radiation oncology for the benefit of our patients. OUR MISSION To drive the appropriate, proper and safe use of radiological and radiation oncological medical services for optimum health outcomes by leading, training and sustaining our professionals. OUR VALUES Commitment to Best Practice Exemplified through an evidence-based culture, a focus on patient outcomes and equity of access to high quality care; an attitude of compassion and empathy. Acting with Integrity Exemplified through an ethical approach: doing what is right, not what is expedient; a forward thinking and collaborative attitude and patient-centric focus. Accountability Exemplified through strong leadership that is accountable to members; patient engagement at professional and organisational levels. Code of Ethics The Code defines the values and principles that underpin the best practice of clinical radiology and radiation oncology and makes explicit the standards of ethical conduct the College expects of its members. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 5

6 1. OBJECTIVES The aim of this paper is to inform cancer professionals, health professionals, health administrators, consumers and interested individuals about the techniques and technologies used for the safe delivery of high quality radiation therapy. 2. ABOUT RADIATION ONCOLOGY Radiation Oncology is a medical specialty in which highly trained oncologists use their knowledge of radiation cell biology, and technology to treat cancer with radiation. Radiation therapy can be used to treat almost all cancers, anywhere in the body. Radiation therapy has a major positive impact on local cancer control and is a highly effective therapy for control of cancer symptoms such as pain or bleeding. The safe and accurate delivery of this treatment requires the skills of a multidisciplinary team of radiation oncologists, radiation oncology medical physicists and radiation therapists as well as cancer nurses, engineers and allied health staff. The treatment (radiation) is delivered using various specifically chosen techniques to deliver a prescribed radiation dose to the target (such as a tumour) while ensuring that the radiation dose to the surrounding normal tissues is as low as possible. The overall optimal radiation therapy utilisation rate for all cancer patients, based upon the best available evidence is 48.3% 1. This means that one in two people diagnosed with cancer would benefit from radiation therapy at some point in their cancer journey. Those patients who miss out on clinically appropriate radiation therapy treatment can be adversely affected. The consequences can include compromised health outcomes, inadequate symptom control, reduced quality of life, and increased suffering and premature death. Utilization in Australia between 2001 and 2009 has remained at 38% 2,3. This is despite a significant investment in radiation therapy infrastructure, which has appeared merely to have kept pace with increases in the number of patients for whom there is an indication for radiation therapy 4. Utilization in New Zealand is currently at a national intervention rate of 37% FRO TECHNOLOGY SCANNING WHY? There is confusion regarding the difference between advances in treatment techniques, in the technologies used to deliver those techniques, and in the implementation priorities for these techniques and technologies. This information shortfall, along with technology assessment mechanisms that are unsuitable for radiation therapy, have been contributing factors towards slow uptake of new radiation therapy techniques and delivery technologies in Australia and New Zealand compared with other developed and developing countries. The Faculty of Radiation Oncology is seeking to improve this understanding via a number of ongoing initiatives, foremost of which is the radiation oncology horizon scanning project that was developed in 2011 and which is updated with new information and evidence on a biennial basis. This document has since been renamed the Faculty of Radiation Oncology Technology Scan to more accurately reflect the content. The technology scan is to be discussed with key stakeholders that include policymakers, advocacy groups, consumers and industry. This Position Paper is intended to accompany the Technology scan (included in Appendix ii) discussed at the Technology Scan Industry Roundtable and the Radiation Therapy Innovations Summit. 4. FRO DEFINITION OF RADIATION THERAPY TECHNIQUES The term technique is used to describe a concept in radiation therapy planning or treatment. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 6

7 5. FRO DEFINITION OF RADIATION THERAPY TECHNOLOGIES The term technology is used to describe a method utilized to deliver a radiation therapy technique. 6. WHY DIFFERENTIATE BETWEEN TECHNIQUES AND TECHNOLOGIES? As with many other branches of medicine, in radiation oncology there are various vendors/suppliers that produce and distribute treatment equipment. The range of equipment often has different configurations; however, the techniques delivered may be the same or similar. An example of this is Intensity Modulated Radiation Therapy (IMRT). This treatment technique can be delivered using a number of different technologies: (1) via static fields with a standard configuration linear accelerator; or (2) via rotational IMRT delivered with a standard configuration linear accelerator (linac) and (3) via helical IMRT that is delivered with a linear accelerator that is mounted in the style of a CT scanner. All of these technologies deliver IMRT, although the technologies involved are produced by various manufacturers and can be differently configured. Every attempt has been made in this Horizon scan document to use generic terms, rather than proprietary names to describe techniques and technologies. 7. FACULTY OF RADIATION ONCOLOGY POSITION It is the Faculty position that timely patient access to appropriate radiation therapy treatment techniques is of paramount importance. Service planning and reimbursement should be centred on essential radiation therapy techniques. In 2017, the Faculty views the following techniques as being essential (i.e. clinically indicated) for Australian and New Zealand patients: - Image Guided Radiation Therapy (IGRT) - Intensity Modulated Radiation Therapy (IMRT) - Stereotactic Radiation Treatments (including SRS, SRT and SBRT/SABR) - Advanced Imaging for Treatment Planning (including 4DCT, PET-CT, ultrasound, MRI) - Motion Management techniques - Adaptive IGRTand IMRT techniques - Brachytherapy - Particle and Heavy Ion Therapy These radiation therapy techniques are delivered using a variety of technologies, as described in Section 8. It is the Faculty position that some techniques must be available in every radiation therapy department i.e. Linear accelerator with IGRT capability, while other techniques may only be justified at one facility in Australia and/or New Zealand i.e. particle therapy. In 2017, the Faculty has reviewed, updated and made public via its Technology Scan its view on implementation priorities and projected uptake for radiation therapy treatment techniques and technologies. 8. RADIATION ONCOLOGY TECHNIQUES 8.1 Image Guided Radiation Therapy (IGRT) Image-guided radiation therapy (IGRT) is the process of frequent two and three-dimensional imaging that is captured as close as possible to the time of treatment. Correction to the position of the patient and the target of the radiation based on these images is applied immediately prior to treatment delivery 6. Increasing complexity in planned treatments and when setup reproducibility is in question Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 7

8 are indications for IGRT 7. IGRT is an essential component of intensity modulated radiation therapy. Indications for IGRT are included in the Faculty of Radiation Oncology s Position Paper on Image Guided Radiation Therapy (IGRT) 8. Delivery Technologies: Daily Online Correction using 2D (MV or kv) or 3D (kv, CBCT or CT on rails), pre-treatment ultrasound imaging, MRI guided IGRT in development. 4D kv is in development and used in clinical trials (e.g. SPARK Study (ACTRN ) TROG 15.01; TROG Trial in development: TD 17.03, (LARK) Liver Ablative Radiotherapy utilizing Kilovoltage intrafraction monitoring ). Priority and Projected Uptake: Some form of IGRT should be available in every radiation oncology facility. Image guided radiation therapy is currently in use in Australia and New Zealand and it is the Faculty position that image guided radiation therapy is essential for patients. 8.2 Intensity Modulated Radiation Therapy (IMRT) Intensity modulated radiation therapy (IMRT) is a way of delivering external beam radiation therapy using high energy megavoltage x-rays that allow the radiation dose to conform more closely to the shape of the tumour by changing the intensity of the radiation beam as it exits from the linear accelerator and before it impacts onto the patient. This technique results in very sharp drop-off in effective dose adjacent to both the targeted tumour and organs at risk, increasing the consequences of any geometric uncertainty (i.e. missing the target) 9,10 making daily image guidance an essential component of quality IMRT. It is the tumour location, size, adjacent organs and dosimetry that define the appropriate role for IMRT, supporting an approach where the clinical circumstances in addition to specific diagnoses are the most important determinants for using IMRT 11. Failure to deliver radiation therapy accurately has potentially catastrophic consequences for both cancer-control outcomes and normal organ toxicity 12. Delivery Technologies: Linac-based (1) fixed beam, (2) volumetric (i.e. rotational or helical), and (3) hybrid of fixed and volumetric. Priority and Projected Uptake: Some form of IMRT should be available in every radiation oncology facility. It is anticipated that the majority of IMRT would be delivered via conventional linac, with several departments per state offering other methods of IMRT delivery. Intensity modulated radiation therapy is currently in use in Australia and New Zealand and it is the Faculty position, with evidence, that intensity modulated radiation therapy is essential for some patients. 8.3 Stereotactic Radiation Therapy (SRT), Radiosurgery (SRS), Stereotactic Body Radiation Therapy (SBRT), and Stereotactic Ablative Body Radiation Therapy (SABR) Stereotactic radiosurgery allows non-invasive ablative treatment of benign (e.g. arteriovenous malformations) and malignant tumours that would be inaccessible or inappropriate for open surgery. Although stereotactic radiosurgery is often completed in a one-day session, multiple treatments are sometimes used. These multiple treatments are usually referred to as fractionated stereotactic radiation therapy when more than two treatments are given. When treatment is given to areas other than the head, the terms stereotactic body radiation therapy and stereotactic ablative body radiation therapy are used. SRS, SRT, SBRT and SABR are alternatives to invasive surgery 13. Delivery Technologies: Linac and Robotic-arm linac-based SRS, Cobalt-based SRS. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 8

9 Priority and Projected Uptake: Some form of Stereotactic Radiation Treatment should be available in several departments per state. Stereotactic radiation treatment is currently available in Australia and New Zealand and it is the Faculty position, with evidence, that stereotactic radiation treatment is essential for some patients. 8.4 Advanced Imaging for Treatment Planning Advanced imaging for treatment planning utilizes datasets from diagnostic and functional imaging modalities in addition to the dataset from the usual CT scan that is used for radiation therapy planning and dosimetry. These advanced planning technologies include 4DCT, which provides organ and tumour motion information, PET, SPECT and hypoxia imaging scans which provide functional information, as well as MRI and ultrasound. The latter two modalities provide superior soft tissue definition compared with CT scans. These additional datasets are fused with the planning CT data set and can be used to provide additional anatomical detail as well as functional and tumour motion information. Delivery Technologies: 4DCT, PET, SPECT, ultrasound and MRI, with emerging and developing use of many other structural and functional imaging modalities 14. Priority and Projected Uptake: Some form of Advanced Imaging for Treatment Planning should be available to every radiation therapy facility. Advanced imaging for treatment planning is currently available in Australia and New Zealand and it is the Faculty position, with evidence, that advanced imaging for treatment planning is essential for some patients. 8.5 Motion Management Techniques for Radiation Therapy Motion management techniques in radiation oncology use imaging of anatomy or other surrogates to track and account for the movement of the tumour during treatment. Gated radiation therapy is currently available to manage intra-fraction (during treatment) motion in radiation therapy. In gated radiation therapy, the delivery of radiation is based on the anatomic location of the tumour throughout the breathing cycle (with this information collected via 4DCT or other method). Using gating software, a specific window in the breathing cycle is defined when it is optimal to turn on the radiation beam 15. Tumour tracking software and hardware is currently in development for both static field and volumetric arc treatments in which imaging follows the movement of the tumour during treatment and the MLC leaves move dynamically to follow this movement. Several forms of motion management are currently available in Australia and New Zealand however it is the Faculty position that motion management is currently supported by insufficient evidence to form a view. Clinical trials are underway, for example, the Trans Tasman Radiation Oncology Group (TROG) SPARK study (ACTRN ) TROG Adaptive Radiation Therapy Adaptive radiation therapy systematically manages changes in the targeted tumour size and shape that occur during the radiation therapy course due to treatment response or variation in its deformity due to volumetric changes in adjacent normal organs. This can be especially important in cancers or targeted tumour bearing-organs (e.g. bladder tumours) that can change in size rapidly over the course of treatment and are located in close proximity to critical dose-limiting structures. Adaptive radiation therapy represents a variation of standard radiation therapy, where a pre-designed adaptive strategy replaces the typical single pre-designed plan. That is, multiple plans are used as the targeted tumour responds during the course of treatment. IGRT is an essential component of adaptive radiation therapy. This is an area of significant ongoing research, as investigators seek to define the patient groups for whom a pre-designed adaptive strategy would offer the most benefit 16,17. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 9

10 Adaptive radiation therapy is currently available in Australia and New Zealand however it is the Faculty position that adaptive radiation therapy is currently supported by insufficient evidence to form a view. Clinical trials are underway, for example, the TROG Bladder study (NCT ) TROG (RAIDER). 8.7 Brachytherapy Conventional high dose-rate (HDR) brachytherapy uses a radioactive source (commonly Iridium 192) and an automatic afterloader to deliver radiation therapy. Low dose-rate (LDR) brachytherapy (commonly Iodine 125) is usually handled manually and implanted into tissues or organs via needles. Electronic brachytherapy utilizes a miniature low energy x-ray tube where. the radiation source is a miniature low energy x-ray tube and is inserted into a pre-positioned applicator within body/tumour cavities or on the skin surface to deliver high doses to target tissues sparing non-target tissues. Brachytherapy may be used in intra-operative radiation therapy Delivery Technologies: Automatic afterloader for conventional HDR brachytherapy; manual loading for LDR brachytherapy; and development of electronic brachytherapy. Priority and Projected Uptake: Brachytherapy should be available in several radiation therapy departments per state. Brachytherapy treatment is currently available in Australia and New Zealand and it is the Faculty position, with evidence, that brachytherapy is essential for some patients. 8.8 Particle and Heavy Ion Therapy Particle beam therapy is a form of external beam radiation treatment that uses heavy charged particles (typically protons with carbon ions 18 also now available in certain countries) or neutral (neutrons) particles rather than electrons or X-rays. The physical characteristics of the particle therapy beam allow the radiation oncologist to more effectively treat certain types of cancer 19 and other diseases by reducing the radiation dose to nearby healthy tissue. In addition, particle therapy is more effective than photon and electron therapy in causing irreparable cell (both tumour & normal) damage. Particle therapy is used in unique clinical situations 18. Developmental work is being undertaken overseas for pions, helium, silicon, neon and argon particles. Delivery Technologies: Cyclotron facilities are required to deliver conformal proton therapy, intensity modulated proton therapy (IMPT), and heavy ion therapy. Priority and Projected Uptake: Australian and New Zealand patients must have access to particle therapy. Particle beam therapy is not currently available in Australia or New Zealand however it is the Faculty position that particle beam therapy is essential for some patients with evidence. Australia s first proton beam facility is expected to be operational by Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 10

11 APPENDIX I: TECHNOLOGY SCAN TABLE Radiation therapy is a proven, safe, effective and economical cancer treatment; however, the radiation oncology sector has not been systematic or strategic in implementing new and evolving technologies in Australia and New Zealand. In the non-radiation oncology community, there is confusion and limited understanding regarding implementation priorities and the difference between advances in treatment techniques and in the technologies used to deliver those techniques. The purpose of the Technology Scan Table (Table 1) is to assist in building expert consensus and to inform policy makers and consumers about the relevance of emerging and evolving techniques and technologies necessary in radiation therapy to optimise patient outcomes. Cost implications of different technologies are outside the scope of this Technology Scan. Prior to 2015, the Faculty of Radiation Oncology Horizon Scan paper contained three tables, showing radiation therapy techniques, technologies and related innovations. The increasing scope of new technologies enabling advanced and innovative techniques has required an update to the tabulation of information. From 2015 and 2016 inclusive, the Horizon Scan paper displayed one table, showing radiation therapy techniques. From 2017, the Horizon Scan Table has been renamed Technology Scan Table to better reflect the content. The Technology Scan Table is included in this paper as Appendix I. It provides a summary of the radiation therapy techniques currently used, the technologies that are used to deliver such techniques, and associated comments. Descriptions of the different radiation therapy techniques are included in Appendix II. Related innovations are included as Appendix III. Priority and Projected Uptake The Priority and Projected Uptake described in the Radiation Oncology Techniques, Item 8 (page 6 onwards) of this paper describes the Faculty of Radiation Oncology position relating to the projected uptake of the described technology that may be appropriate for Australia and New Zealand. The projected uptakes noted may change over time as further research is undertaken. Technique Categories The Technology Scan Table shows a traffic light system to describe the priority category that the Faculty of Radiation Oncology has assigned to the various treatment techniques. The four categories are as follows: Essential for some patients with evidence Available alternative Evidence gathering underway Not yet commercially available for treatment Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 11

12 Radiation Therapy Technique Technology used to deliver this Radiation Therapy Technique Explanatory Notes Image Guided radiation therapy (IGRT) Daily online correction using 2D (MV or KV) or 3D (CBCT or CT on rails) imaging. Ultrasound guidance. MRI guided IGRT and 4D-CBCT in development. Image-guided radiation therapy (IGRT) is the process of frequent two and three-dimen close as possible to the time of treatment. Correction to the position of the patient and these images is applied immediately prior to treatment delivery. Increasing complexity situations in which when setup reproducibility is in question are indications for IGRT. G confirm that the target is within the treatment portal during the entire 'beam-on'. Intensity Modulated radiation therapy (IMRT) Linac based Static or Volumetric IMRT. Volumetric IMRT may be Rotational, Helical or HybridArc (Static and Rotational) IMRT. Intensity modulated radiation therapy (IMRT) is a way of delivering external beam radi megavoltage x-rays that allows the radiation dose to conform more closely to the shap intensity of the radiation beam as it exits from the linear accelerator and before it impa involves results in very sharp drop off in effective dose adjacent to both the targeted tu consequences of any geometric uncertainty (i.e. missing the target), making daily imag quality IMRT. Stereotactic Radiosurgery (SRS), Stereotactic radiation therapy (SRT), and Stereotactic Body radiation therapy (SBRT), Stereotactic Ablative Body Radiotherapy (SABR) Linac and Robotic-arm linac based SRS; Cobalt based SRS. Helical IMRT based stereotactic radiation treatment Stereotactic radiosurgery allows non-invasive ablative treatment of benign (eg arteriov tumours that would be inaccessible or inappropriate for open surgery. Although stereo a one-day session, multiple treatments are sometimes used. These multiple treatment stereotactic radiation therapy when more than two treatments are given. When treatm head the terms stereotactic body radiation therapy and stereotactic ablative body radia and SABR are alternatives to invasive surgery. Advanced Imaging for Treatment Planning 4DCT, PET-CT, MRI, UIltrasound, SPECT- CT. PET Hypoxia Imaging and PET-MRI with MRI fiber tracking in development Computed tomography (CT) scans acquired in the radiation therapy treatment position remain the gold standard imaging modality for contouring tumour target volumes and o calculation in radiation therapy planning. Standard CT has limitations however, as it on at one point in time and does not provide functional information. The ability to fuse da the planning CT allows sophisticated contouring and dosimetry compared to conventio functional information, 4DCT shows the motion of tumours and/or organs at risk, MRI and MRI fiber tracking can provide further anatomical definitions. Motion Management Techniques for Radiation Therapy Adaptive radiation therapy Brachytherapy Real-time Gated radiation therapy, Motion managed radiation therapy Target tracking treatment tool. Various strategies are implemented to manage changes in tumour size/shape over the course of treatment Conventional high dose rate (HDR) and low dose rate (LDR) radioactive source based brachytherapy, low energy and high dose rate electronic brachytherapy, intra-operative brachytherapy Motion management techniques for radiation therapy attempt to account for tumour m radiation therapy, the delivery of radiation is based on the anatomic location of the tum (with this information collected via 4DCT or other method). Delivery of gated radiothera Using gating software, a specific window in the breathing cycle is defined when it is op motion adaptive radiation therapy, the multileaf collimators are moved dynamically to t (e.g. lung). In addition to motion adaptive treatment of fixed beam radiation therapy, st adaptive treatment in volumetric arc treatment. Another method is to move the entire li has the linac attached to a robotic arm) to follow tumour movements. Adaptive radiation therapy systematically manages changes in the tumour size and sh therapy course. Adaptive radiation therapy represents an advancement of standard ra adaptive strategy replaces the typical single pre-designed plan. That is, multiple pla responds during the course of treatment. Ongoing research is underway to identify op treatment strategies. Conventional high dose rate brachytherapy uses a radioactive source and automatic a brachytherapy involves the permanent implantation of radioactive seeds into the patie brachytherapy utilizes a miniature low energy x-ray tube. The miniature low energy x-r applicator within body/tumour cavities or on the skin surface to deliver high doses to ta doses to non-target tissues. Particle Therapy Conformal proton therapy, intensity modulated proton therapy (IMPT), heavy Ion therapy with facilities to produce cyclotrons. Particle beam therapy is a form of external beam radiation treatment that uses heavier ions) instead of X-rays or electrons. The physical characteristics of particle beam thera treatment of certain types of cancer and other diseases by reducing the radiation dose therapy is used in unique clinical situations. Disclaimer: The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 12

13 sional imaging that is captured as the target of the radiation based on in planned treatments and individual old Standard IGRT is the ability to ation therapy using high energy e of the tumour by changing the cts onto the patient. This technique mour and organs at risk, increasing the e guidance an essential component of enous malformations) and malignant tactic radiosurgery is often completed in s are usually referred to as fractionated ent is given to areas other than the tion therapy are used SRS, SRT, SBRT during the treatment planning process rgans at risk as well as for dose ly provides anatomical information ta-sets from functional imaging with nal processes. PET scans provide provides superior soft tissue delineation otion during treatment delivery. In gated our throughout the breathing cycle py can be done via several means. timal to turn on the radiation beam. In rack the movement of a moving tumour udies are also underway of motion nac (the current system allowing this Supportive Statements FRO Position Statement: IGRT represents and has represented standard of care radiation oncology practice for many years. Technologies that encourage image guidance are to be supported as a selfevident quality imperative ASTRO (American Society for Radiation Oncology) purports that tumour location, size, adjacent organs and dosimetry define the appropriate role for IMRT, and support an approach where the clinical circumstances in addition to specific diagnoses are the most important determinants for using IMRT. Stereotactic radiosurgery (SRS) and stereotactic radiation therapy (SRT) have a well-established role for the treatment of benign and malignant intracranial disease and the efficacy of SRS for the treatment of brain metastases has been demonstrated in several randomized trials. Stereotactic body radiation therapy is increasing in use for sites such as the spine and lung (stage 1 non-small cell lung cancer) Advanced imaging for use in radiation therapy treatment planning is essential for some patients. Although a planning CT scan is still required at this time for treatment calculations, there are some treatment sites in which other (advanced) imaging techniques provide superior anatomic or functional information. This information can show the location and extent of the tumour with increased clarity, the metabolic activity of the tumour as well as the motion of the tumour and/or adjacent healthy organs. First Clinical Use Worldwide Electronic portal imaging (first generation of imagage guidance) first commercialised in the early 1990s 1995 Late 1960s MRI from early 1980s, PET-CT from late 1990s, 4DCT from 2003 Gated radiation therapy from Motion adaptive radiation therapy in development Current uptake in Aus/NZ 99.5% of linear accelerators in Australia and 100% in new Zealand are equipped with electronic portal imaging (2D) and 83.4% of linear accelerators in Australia and 93.5% in New Zealand are equipped with kv imaging (2D and 3D). 99.5% of linear accelerators in Australia and 96.8% in New Zealand are capable of delivering fixed beam IMRT. 80.9% of linear accelerators in Australia and 90.3% in New Zealand are capable of delivering rotational IMRT. There are 5 non c-arm based linear accelerators delivering helical IMRT in Australia and none in New Zealand. In Australia, 39 facilities deliver SRS and SBRT. In New Zealand, 5 facilities deliver SRS and SBRT. Yes Yes Technique Category ape that occur during the radiation diation therapy, where a pre-designed ns are used as the targeted tumour timal sites for the use of adaptive Early 2000s Yes fterloader while low dose rate nt with manual loading. Electronic ay tube is inserted into a pre-positioned rget tissues while maintaining low particles (such as protons or carbon py allow for the more effective to nearby healthy tissue. Particle Experience has shown brachytherapy to be a valid treatment option for many types of cancer, however there are few randomized trials directly comparing brachytherapy with external beam radiation therapy. ASTRO Emerging Technologies Committee Evaluation of Proton Beam Therapy: There is reason to be optimistic about the potential developments in proton therapy and the prospective research that is ongoing at centres worldwide. In all fields, however, further clinical research is needed and should be encouraged. The paediatric solid tumour population potentially has the most to gain from more widespread use of PBT because of the potentially devastating side effects of impaired growth and function, the increased risk of second malignancies, and the high likelihood of cure Yes First patient treated with protons in 1961, first hospital based cyclotron late 1980s No = Essential for some patients with evidence = A viable alternative = Available for treatment, evidence gathering underway = Not commercially available for treatment purposes Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 13

14 APPENDIX II: RADIATION THERAPY TECHNIQUES 1. Image Guided Radiation Therapy (IGRT) Image-guided radiation therapy (IGRT) is the process of frequent two-, three- and four-dimensional imaging that is captured as close as possible to the time of treatment. Correction to the position of the patient and the target of the radiation is based on images done immediately prior to treatment delivery. It is used in many treatment sites and should be available in every radiation therapy department. Greater use of imaging is required to safely deliver increasingly complex treatments D and 3D Megavoltage IGRT Megavoltage (MV) image guidance is achieved by capturing an image using an electronic portal imaging panel mounted to the linear accelerator using the treatment beam. 99.5% of linear accelerators in Australia and 100% in New Zealand are equipped with EPI. To utilize kilovoltage imaging for image guidance, the linear accelerator must have an on-board kilovoltage imaging system. In such a system, a kilovoltage x-ray tube (attached at 90 0 to the linear accelerator gantry) and a corresponding detector panel (attached at to the linear accelerator gantry) are used to capture images. 83.4% of linear accelerators in Australia and 93.5% in New Zealand are equipped with kilovoltage imaging. 1.2 Ultrasound There are ultrasound systems available for image guidance of radiation therapy that allows automated ultrasound scanning from outside of the treatment room. In the case of prostate cancer, a probe positioned at the patient s perineum is used to visualize the prostate. Ultrasound can also be used for real-time dosimetry to account for movement of the implant and or the organ (e.g. prostate). The use of ultrasound may allow localisation of soft tissue targets without the use of ionizing radiation. Ultrasound based IGRT is used in treatment of the breast and prostate and further uptake will depend on the results of ongoing studies and development. 1.3 MRI guided IGRT The advantage of MRI as an image guidance tool is that it does not use ionising radiation and as such, reduces the overall radiation dose received by the patient while still allowing for daily on-line 3D imaging. A number of groups are working on this technology, combining a linear accelerator and MRI image guidance in Canada 21, the Netherlands 22 and Australia 23. A cobalt based radiation treatment system with MRI based image guidance is currently commercially available 24 although this system does make some compromises with both the strength of the magnet used for imaging and the use of cobalt-60 rather than linear accelerator-based radiation. Several vendors are currently developing systems combining a linear accelerator and higher strength magnet that should be commercially available in the near future. MRI guided IGRT would be of most benefit in the treatment of lung, abdomen and mobile soft tissue tumours with uptake in Australia and New Zealand depending on further development, research and the production of more advanced MRI-linac models. MRI for image guided radiation therapy is not currently in use in Australia or New Zealand. However, in mid-2018, MRI-linacs are on order in at least two Australian radiation oncology facilities. 2. Intensity Modulated Radiation Therapy (IMRT) 2.1 Fixed beam IMRT with conventional C-arm linac IMRT is a way of delivering radiation therapy that allows the radiation dose to conform more closely to the shape of the tumour by changing the intensity of the radiation beam. The sharp dose gradients adjacent to both targets and organs at risk involved in this technique increase the Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 14

15 consequences of any geometric uncertainty, making daily image guidance (IGRT) an essential component of quality IMRT. IMRT is used in many treatment sites and should be available in every radiation therapy department. 99.5% of linear accelerators in Australia and 96.8% in New Zealand are capable and commissioned to deliver IMRT. 2.2 Rotational IMRT - C-Arm linac based Rotational or volumetric IMRT delivers radiation by rotating the linac gantry through one or more arcs with the radiation continuously on. As it does this, beam parameters can be varied. These include: i) the MLC aperture shape, ii) the dose rate, iii) the gantry rotation speed and iv) the MLC orientation. This method of delivering radiation therapy can increase dose conformity to tumours located centrally within the body although it can result in a wash of low dose in the healthy tissue surrounding the target. Indications for rotational IMRT are the same as for fixed beam IMRT with evidence of dosimetric advantage of rotational IMRT in head and neck, prostate, brain and SBRT treatment. Rotational IMRT is largely considered to be the natural progression and more efficient use of IMRT. It is superior to fixed beam IMRT for treatment of some cancers but is not anticipated to completely replace this technique. 80.9% of Linear Accelerators in Australia and 90.3% in New Zealand are capable and commissioned to deliver VMAT. 2.3 Helical IMRT non-c-arm based linac Helical IMRT combines a CT scanner with a radiation therapy delivery system (linac), enabling daily 3D megavoltage imaging with radiation treatment as well as volumetric IMRT. Indications for helical IMRT are similar to rotational IMRT with potential advantages in highly complex and large treatment volumes. It is anticipated that helical IMRT will be available in multiple departments in Australia and New Zealand as an alternative to rotational IMRT using a C-arm linac. There are five non-c-arm based linear accelerators delivering helical IMRT in Australia and none in New Zealand. 2.4 Hybrid Arc IMRT Hybrid Arc is a novel treatment planning approach that combines optimized dynamic arcs with intensity-modulated radiation therapy (IMRT) beams. Hybrid Arc IMRT has the potential to incorporate the benefits of rotational IMRT (reduced treatment time) with fixed beam IMRT (reduced low dose wash over healthy tissue) and could be used for many treatment sites depending on the results of further research and development. 3. Stereotactic Radiation Therapy (SRT), Radiosurgery (SRS) and Stereotactic Body radiation therapy (SBRT)/Stereotactic Ablative Radiation Therapy (SABR) 3.1 SRT/SRS/SBRT/SABR - Linac Based Radiosurgery allows non-invasive ablative treatment of benign and malignant tumours. It is used as an alternative to surgery including for those in patients that are not surgical candidates due to comorbidities. SRS is used in the treatment of brain, spine, lung and liver tumours as well benign tumours and conditions. Frameless treatment is an option with linac based cranial SRS, meaning that invasive headframes are not required. Stereotactic body radiation therapy/stereotactic ablative radiation therapy use stereotactic principles to treat lesions throughout the body 25. In Australia, the current MBS item reflects single treatment SRS rather than fractionated SRT. Linac based stereotactic treatment is available in 39 radiation therapy facilities in Australia and 5 in New Zealand. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 15

16 3.2 SRT/SRS - Cobalt based Cobalt based radiosurgery uses approximately 200 Cobalt-60 sources to stereotactically treat brain cancers and benign brain conditions. Cobalt based stereotactic treatment is available in two facilities in Australia and none in New Zealand. SRT/SRS/SBRT/SABR - Helical IMRT Helical IMRT can also be used to deliver stereotactic treatment and could be especially useful in the case of larger treatment volumes (in stereotactic body radiation therapy) and multiple treatment targets. Stereotactic helical IMRT gives the ability to treat multiple targets in a single delivery sequence with a single setup and no isocenter shifts. Patient positioning occurs via IGRT using mega-voltage CT scans. There are five non-c-arm based linear accelerators that are capable of delivering stereotactic treatment in Australia and none in New Zealand. 3.4 SRT/SRS/SBRT/SABR - Robotic Radiosurgery Robotic radiosurgery is designed to treat tumours throughout the body with high precision and continuous image guidance. Robotic radiosurgery can be used in intra and extra-cranial stereotactic radiation therapy/radiosurgery. Robotic radiosurgery is available at two facilities in Australia and none in New Zealand. 4. Advanced Imaging for Treatment Planning 4.1 CT scanner with 4D CT software and hardware Four-dimensional (4D) CT is an imaging technique that provides information regarding organ motion during respiration (the fourth dimension being time). By using this information at the time of planning, the radiation oncologist has a more accurate assessment of target shape and trajectory than traditional 3D (static) planning CT scans 26. The clinical use of 4DCT data is important for optimal IGRT of tumours in the thorax and upper abdomen and should be available to all radiation therapy facilities. 79.3% of radiation therapy facilities in Australia and 100% in New Zealand have in-house access to 4DCT for treatment planning. 4.2 PET-CT for fusion with planning CT In PET-CT, a Positron Emission Tomography (PET) and an x-ray Computed Tomography are combined in a single system, so that images acquired from both devices can be taken sequentially, in the same session and combined into a single co-registered image. Thus, functional imaging (which has poor spatial anatomy) obtained by PET, can be precisely aligned or correlated with CT anatomic imaging. Functional imaging via PET increases the ability of the clinician to both visualise and therefore treat the entire active tumour, and also to choose appropriate patients for radiation therapy treatment 27 (it is more sensitive than CT alone in picking up small volume disease). The International Atomic Energy Agency states At present there is no compelling data to prove that patient outcomes are superior as a result of the use of PET in RT planning. Proving that PET-planning is superior would require a randomized trial in which some patients were randomized to a less accurate staging workup, thereby presenting significant ethical challenges. Nevertheless, in the opinion of the IAEA expert group, radiation therapy planning should be based on the most accurate available assessment of tumour extent. PET/CT may provide the best assessment for cancer patients at this time. 28 PET-CT scans can be acquired in the radiation therapy facility if this equipment is available, otherwise external diagnostic images can be imported into the treatment planning system. Ideally, PET-CT images will be acquired in the treatment position to allow for optimal accuracy in fusion to planning CT images. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 16

17 4.3 Magnetic Resonance Imaging (MRI) for fusion with planning CT Magnetic Resonance Imaging (MRI) often plays an important role in defining the location and local extent of disease. It provides a primary imaging role in CNS disease and in some other diseases (e.g., prostate and head and neck cancer). It defines organ or disease extent as well as spinal cord compression more accurately than other modalities. MRI has been shown to be superior to CT in the staging of some tumours and provides superior soft tissue definition compared with CT scans 29. MRI for fusion with planning CT is indicated for tumours within soft tissue where delineation between target and healthy tissue is difficult to accurately define using CT alone 30. MRI scans can be acquired in the radiation therapy facility if this equipment is available, otherwise external diagnostic images can be imported into the radiation therapy treatment planning system (ideally these images are to be acquired in the treatment position). The Faculty of Radiation Oncology s Imaging in Radiation Oncology A RANZCR Consensus White Paper 31 describes the tumour sites for which MRI is an appropriate tool for diagnosis and staging as well as for treatment and planning. It should also be noted that for some tumour sites there are limits or restrictions regarding MBS reimbursement in Australia. Currently there is significant work being undertaken looking at defining optimal MRI sequences (software involved with image acquisition and manipulation) and functional imaging in radiation therapy, both in treatment planning and treatment responses. 4.4 Ultrasound 3D ultrasound imaging is non-invasive and does not require any radiation for generation of images. Ultrasound information can be incorporated into treatment planning, either as a primary or secondary imaging modality. Utilizing 3D ultrasound for brachytherapy planning can allow plans to be prepared in real-time 32 (while the ultrasound images are being acquired). 4.5 SPECT-CT SPECT-CT is a nuclear medicine tomographic imaging technique that uses gamma rays. It is similar to conventional nuclear medicine planar imaging using a gamma camera, however it is able to provide true 3D information. Whereas PET imaging (without CT) shows a 2D representation of a 3D structure (in the same way that a plain x-ray does), SPECT shows a true 3D image and allows accurate localisation in space. SPECT-CT provides information about localised function in internal organs. Future uptake will depend on the results of ongoing development and studies to identify the sites and patient populations that will derive the most benefit. 4.6 PET hypoxia imaging Tumour hypoxia is an important contributor to radioresistance and increasing the radiation dose to hypoxic areas may result in improved locoregional control 33. Tracers are being refined that allow accurate detection of hypoxic tumour subvolumes using PET imaging. Current tracers that are used to identify hypoxic cells are characterized by slow tracer retention and clearance, resulting in low inter-tissue contrast. Refinement of tracers and further research publication will facilitate increased uptake of this technology. 4.7 PET-MRI Integrated PET-MRI scanners combine anatomic with functional imaging and may have a specific impact on the staging and treatment of head and neck cancer. Advantages of the PET-MRI system over current MRI and PET-CT systems include simultaneous imaging, reduced radiation dose, and increased soft tissue contrast. In tumour sites such as oropharyngeal and oral cavity tumours, integrated PET-MRI scanners may further improve the accuracy of GTV delineation. In addition, dynamic MRI studies such as dynamic contrast-enhanced MRI and blood oxygen leveldependent MRI, as well as MR spectroscopy, may add complementary functional information. PET-MRI combines the superior anatomical definition of MRI with the functional information of PET and uptake will depend on the results of ongoing development and studies 34. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 17

18 5. Motion Management Techniques for radiation therapy Treatment 5.1 Gated radiation therapy - planning, treatment and respiration monitoring system with gating capability In gated radiation therapy treatment, the delivery of radiation is based on the anatomic location of the tumour throughout the breathing cycle (with this information collected via Four-Dimensional Computed Tomography (4DCT) or other method). Using gating software, a specific window in the breathing cycle is defined when it is optimal to turn on the radiation beam. Gated radiation therapy can be used in the treatment of lung, breast and liver cancers, with further uptake depending whether on the results of development and studies indicate that this treatment technique offers clinically significant benefits to normal lung tissue 35, Motion Adaptive radiation therapy In motion adaptive radiation therapy, the multileaf collimators are moved dynamically to track the movement of a moving tumour (e.g. lung). Studies are also underway of motion adaptive treatment in both fixed beam and volumetric arc treatment. Motion adaptive radiation therapy is in development for fixed beam and volumetric arc radiation therapy 37 and is intended for use in the treatment of lung, breast and liver, with further uptake depending on the results of development and studies. 6. Adaptive radiation therapy Adaptive radiation therapy systematically manages changes in the tumour size that occur during the radiation therapy course. Adaptive radiation therapy represents a variation of standard radiation therapy, where a pre-designed adaptive strategy replaces the typical single pre-designed plan. That is, multiple plans are used as the tumour responds during the course of treatment. Currently, adaptive radiation therapy (ART) remains labour and resource intensive. As ART clinical outcomes mature and the incorporation of volumetric imaging into ART becomes increasingly sophisticated, it is possible that ART will evolve and become a commonplace approach for head and neck and a variety of other radiation treatments 38. The optimal frequency of assessment of treatment response and the ultimate clinical impact of ART remains to be defined. Adaptive radiation therapy is optimally used in either treatments in which the target size and shape can change on a daily basis such as bladder radiation therapy or in treatments in which the tumour is located in close proximity to critical structures that may move into the high dose region over the course of treatment due to tumour shrinkage such as head and neck radiation therapy. 7. Brachytherapy 7.1 Permanent Low Dose Rate (LDR) Implant Brachytherapy LDR permanent implant brachytherapy uses low dose rate radioactive seeds that are implanted into the treatment target. This method can be used to treat an intact structure (e.g. Prostate) or surgical cavity (e.g. Breast). This method of treatment is an accepted treatment option for men with low risk prostate cancer 39. LDR permanent implant brachytherapy requires further clinical trials to show that this is equivalent to other breast cancer treatments. This method of treatment could be very beneficial to those patients that do not live in close proximity to a radiation therapy facility. There are 17 radiation therapy facilities offering low dose rate brachytherapy in Australia and at least two in New Zealand. Techniques and Technologies in Radiation Oncology 2018, Version 1.0 Page 18