February, 2012

Nothing Personal

By Michael J. Katin, MD

The beginning of each year brings usually brings to us a rehash of the top events in various categories, stirring up controversy for at least several weeks until purged from our brains to make room for details of the next Kardashian. adventure. However, one particular 2011 review needs to remain in our purview for now considering the questions it raises about the future of our specialty. You may have all by now seen the American Society of Clinical Oncology's 2011 Annual Report on Progress Against Cancer. This 45-page glossy publication is the seventh annual edition of a publication whose goal is to "document the important progress being made in cancer research and to highlight emerging trends in the field," and lists " major" and "notable" advances for each disease category.

Of the "major" and "notable" advances listed, a grand total of one relates directly to radiation oncology. The second of two "major" advances in the "Breast Cancers" section is that "Adding Regional Nodal Irradiation Decreases Recurrences in Women with Early Breast Cancer." This is the result of a phase III study involving 1,832 women with high-risk breast cancer (total breast cancer incidence estimated 230,480 for women, 2140 for men, high-risk percentage estimated at least 30% for invasive carcinomas Five-year freedom from recurrence increased from 84% to 89.7% when regional node irradiation was added to whole breast irradiation, freedom from locoregional recurrence was 96.8% versus 94.5%, and distant disease-free survival increased to 92.4% from 87.0%. This same study is listed as the third of three advances in the "Reducing Cancer Recurrence" section. The first of these three is that imatinib given for three years improves survival for high-risk patients with gastrointestinal stromal tumors (incidence of all GIST tumors, low- or high-risk, 10-20 per million, 3,500-5,000 per year in the United States, phase III study of 400 patients showing 81.7% five-year survival in patients treated for one year and 92% survival in patients treated for three years) and the second is that giving methotrexate in large consistent doses rather than gradually increasing doses in the standard regimen for treatment of acute lymphoblastic leukemia (incidence 9,050 adult and pediatric cases per year in the United States, phase III study enrolling 3,154 and then evaluating 2,426 patients age 30 and under, with a 5-year event-free survival of 82% with high-dose methotrexate versus 75.4% on escalating methotrexate regimen) was more effective to prevent relapses and extend survival.

Other than references to the regional nodal irradiation study, reference to radiation therapy occurs only in the listing of clinical cancer issues in the mission statement (one of 15 items and listed as one of the "traditional" treatments), and in the section on "Central Nervous System Cancers," as a supporting player in the paragraph describing that ". . . it has been difficult to predict which patients with glioblastoma will do well with radiation therapy and adjuvant chemotherapy with the drug temozolomide . . . giving intense temozolomide with standard radiation did not help patients with newly diagnosed glioblastoma live longer than with the usual dose." There is one more reference to radiation therapy, In the section on "Sarcomas" it is stated grammatically poorly that "while the treatment with surgery, chemotherapy, and radiation are standard for many patients, researchers are beginning to see the results of phase II and phase III trials showing the effectiveness of targeted therapies for soft tissue sarcomas."

That's it. No mas . All she wrote. End of story. I apologize if there are other references to radiation therapy in these 45 pages, but I didn't see them. Not even a mention of the words "radiation therapy" or even "radiation" or even "disfiguring, traumatic, morbid, paleolithic, debilitating radiation therapy" in the sections on "Genitourinary Cancers" and "Gynecologic Cancers." Not even, for better or worse, a reference to proton beam therapy . Not even a mention in the sections on "Lung Cancers" and "Prevention and Screening," even though a "major advance" is lung cancer deaths being reduced by low-dose CT screening. The last I checked, one of the treatments is stereotactic radiation therapy.

I suppose we should be grateful that a discovery of more comprehensive use of radiation therapy was mentioned at all, even considering that conclusions about treatment for breast cancer will affect many times more people than decisions on GIST and ALL combined.. The question remains as to why such a minuscule amount of recognition was given to two of the primary modes of treatment of cancer, radiation therapy and surgery, in "ASCO's Annual Report on Progress Against Cancer", rather than "ASCO's Annual Report on Progress Against Cancer Not Involving Treatments That Medical Oncologists Can't Do ."

That leaves only three possible explanations:

  1. Nothing much happened in radiation oncology in 2011.
  2. Our specialty is not getting any respect
  3. See #2 above.

We may have only a few ways to get back into the picture. Nearly all the studies in this publication were from ASCO abstracts. The easiest way is to start an "Occupy ASCO" movement to try to make up for the much higher numbers of medical oncologists. We need to have every single (or married) radiation oncologist join ASCO and get to every session. We could do a caucus-type strategy by taking over positions in organizations in smaller states (the Idaho Society of Clinical Oncology, Dakota Oncology Society, or the Hawaii Society of Clinical Oncology). We can then try to contend for regional and national offices, while at the same time overwhelming the next annual meeting with abstracts .

It may be necessary, however, to recognize that the majority of topics considered "major" and "notable" involve targeted therapies. Personalized treatment is the new darling of the media. There are new pharmaceutical agents and drugs in development which will work only when a specific genetic abnormality is present. These generate studies, generate abstracts, and generate recognition in the Annual Report on Progress Against Cancer. Both for professional recognition and patient satisfaction we need to go back and evaluate gene abnormalities that may allow us to individually design programs radiation therapy treatment in terms of type of irradiation, dose per fraction, fractionation schedule, and total dose. Although over the years analysis has been done of factors contributing to radiation response, since radiation therapy works most of the time, there has not previously been enough incentive to devote time and effort to personalize treatment, but the writing is on the wall that we need to be able to compete in this field. We will increasingly be treating members of the " Me Generation ," and we need to accommodate this.

And if this isn't enough, there's one more way we can schedule treatments to reflect the individuality of each patient.