July 2000

A Revolting Development - Part I

By Michael J. Katin, MD

July 4 is approaching and, thanks to Mel Gibson, the public is temporarily aware of the historical reality of the American Revolution. Although this phenomenon may only last for a few months before people start confusing the details of The Patriot with Braveheart and Lethal Weapon IV, it gives us the opportunity to reflect on the long-term consequences of events and provides a feeble link to the topic of radiation oncology, thus justifying this column. We are taught that after the war Washington wrote the Declaration of Independence, which freed the slaves, until Lincoln had to defeat the Germans to guarantee the right to remain silent, and to an attorney (if you do not have one, one will be appointed for you).

In fact, things were much more complicated than that. There was a huge amount of dissension as to the nature of the government that would run the new country now that the British had temporarily left, until they returned in 1964 to take over our music and motion picture industry. The Federalists wanted a strong central government, possibly even with General Washington as King, whereas Democratic-Republicans wanted a weaker government with more power locally. As we all know, the Democratic-Republicans prevailed, leaving us with our current system in which 104% of our income goes to taxes and we have warning stickers on ladders advising us not to stand on the top rung. All of which goes to show that initial intentions may not result in the long-term effects expected.

This brings us back to the link with radiation oncology and to rehash a previously-expressed concern. For the past generation of radiation oncologists, a treatment setup was straightforward only because of the lack of options. Head and neck cancer and cervix cancer were appropriate for treatment because it was possible to feel confident about hitting the target and visualizing tumors responding, even if on a delayed basis. It was an art to get a patient through the course of treatment in terms of how much short-term morbidity could be tolerated although this effect was obvious to the patient and the physician since the skin was often the most affected organ. Long-term sequellae were uncertain although often the total dose was limited by the short-term effects anyway.

In the late 1900s, this all changed. It became possible to deliver higher and higher doses with fewer short-term problems, especially with medications available to try to control some of the effects, counteracted by the risk of increased morbidity due to concomitant treatment such as chemotherapy. It has now become politically correct to try to deliver higher and higher doses using sophisticated treatment planning techniques, first with 2-D CT assistance, then 3D conformal therapy, and now IMRT. We are at risk of entering a phase in which too many radiation oncologists seem to believe the publicity about accurately targeting "only the tumor" and that the target volume can be assured of being exactly in the same place for each treatment. Although with extremely sophisticated and impracticably time-consuming verification techniques, done each and every treatment rather than just every week (and in an environment that will not make this financially realistic) it may be possible to approximate this, regardless there remains the potential that implementation of techniques with the best of intentions of helping patients could result in a significant increase in long-term complications.

Now combine this with the fact that we usually cannot get rapid feedback on the response of an individual's cancer to treatment and we are left with an intellectually and emotionally frustrating situation. Like the participants in the Revolutionary War, it may take a long time to find out what we're actually accomplishing.

email: mkatin@radiotherapy.com