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Power, Precision, and Patience

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LEXINGTON The power of the atom is expensive to harness and difficult to understand, but in the right hands, it can be very efficacious. Janalyn Prows, MS, MD, and Falguni Amin-Zimmerman, MD, radiation oncologists at Lexington Clinic’s John D. Cronin Cancer Center, are those right hands. They utilize that power on a daily basis, as they utilize Intensity Modulated Radiation Therapy (IMRT), Image Guided Radiation Therapy (IGRT), and Brachytherapy, combined with their clinical judgment and deliberate planning, to make an immediate impact on the lives of cancer sufferers.

Harnessing the potential – of the atom and these technologies – and integrating it with their own medical judgment allows them to treat tumors precisely, but a course of radiation treatment is more involved than many doctors and patients assume. “It’s a time-consuming process of determining a course of treatment that will maximize focus on cancer and minimize damage to surrounding tissues,” says Prows.

Both Prows and Amin-Zimmerman are board certified in Radiation Oncology and find their field very rewarding and engaging. Prows, who joined Lexington Clinic in 2004, notes, “It is very rewarding to see a patient that you treated years before doing well and cancer-free.” For Amin-Zimmerman, who came to Lexington Clinic in 2007, “Being part of a team of physicians – surgeon, medical oncologist, and primary doctor – who work together towards the goal of getting a patient through treatment and recovery is very appealing to me.”

Pinpoint Precision

Since the 1990s, radiation therapy has been honing its precision; the accelerators that produce the beams are becoming more sophisticated all the time. Adjusting beam number, trajectory, and intensity, in light of tumor size and location data collected through CT and MRI scans, is the primary tactic of the radiation oncologist. The basic tool of 3-dimensional conformal radiation therapy (3DCRT) has been advanced to IMRT, which allows for better treatment of concave tumors often found wrapped around organs. Now IGRT can allow better targeting of tumors, because it accounts for internal organ motion.

Processing this data to produce an optimal course of treatment is a measured and artful act. The computer planning can give the physician options. The physician must then employ clinical judgment to choose which option is most appropriate and beneficial. “It takes a significant amount of time to contour your target volume,” Amin-Zimmerman says. Prows adds that to get the most actionable information out of the imaging equipment, “You really need to know your anatomy.” Reading the imagery carefully and inferring beyond its limitations before contouring your target and planning therapy is the fundamental task. “Your plan is only going to be as good as your accuracy of telling the computer, ‘This is what I want to treat and these are the structures I want to avoid,’” says Prows. This necessary deliberation runs counter to most people’s perception of radiation therapy as a quick blast that “zaps” a tumor.

Honing In

Prows has a special interest in treating head and neck cancers. Successfully completing a course of treatment for these tumors is challenging because of the high dose needed for cure and the potential for significant toxicity that can be debilitating. Early detection may preclude the very toxic combination of radiation therapy and chemotherapy. “If you can get by with radiation alone, you have smaller volumes treated with less acute toxicity and less long-term complications,” she explains. IMRT is very useful as it allows for better sparing of surrounding normal tissues.

One of Amin-Zimmerman’s areas of interest is in treating prostate cancer. Brachytherapy, implanting radioactive iodine seeds, is a valuable tool here, though not every man is a candidate for it. IGRT is also very useful when delivering high doses of external beam therapy, as the prostate tends to move as the bladder and rectum volumes change. Amin-Zimmerman finds that, “The beauty of prostate cancer treatment is that, in early cases, you may have multiple ways to treat it: brachytherapy, surgery, and external radiation can all be options.”

Spreading the Word

Both agree that patients and referring physicians could benefit from increased information regarding radiation therapy treatment. Educating patients about radiation therapy side effects is important. Many patients erroneously assume any malady that occurs during their course of radiation therapy, or thereafter, is due to radiation toxicity. “If I am radiating someone’s lung that would not have caused the rash on their leg. We hear such complaints more often than you would think,” says Prows. Amin-Zimmerman and Prows find that some referring physicians are complicit in this thinking. “We are trying to educate other physicians and the public that radiation is a targeted treatment with local side effects,” says Prows.

Another misconception radiation oncologists face is that people think radiation therapy is more expedient than it is. “Most patients are very anxious to get their treatment started,” Prows states. “But planning a course of therapy is often a time-consuming process that requires a team effort to ensure patient safety.” Many doctors also have a simplified view of what has to happen before a course of radiation is administered. “Some referring doctors don’t realize how much work is involved up front before a patient can start on a very precise, high dose course of radiation,” she adds.

Patience and Perseverance

Advances in the field of radiation therapy have slowed to some degree in recent years. Work is being done on how to best combine radiation and chemotherapy, and new ways of delivering radiation are being explored. Cost, and how it will affect their ability to treat patients, is a concern for Amin-Zimmerman and Prows. “You have so much cost incurred by having the equipment required to do what we do,” says Amin-Zimmerman. Both doctors believe that insurance companies also need education so they do not deny coverage. Prows has noticed that sometimes the people who are making the decisions regarding payment “can’t understand why you need to do something in a more complex and expensive way.

Radiation therapy, and the radiation oncologist’s expert use of it, is a powerful tool in the fight against a deadly disease. If properly understood by patients and their physicians, this can lead to more beneficial outcomes.