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Saving lives by changing the way we deliver radiotherapy

German physicist Professor Wilhelm Röentgen was the first person to report using X-rays back in 1896. His first X-ray picture was of his wife’s hand, and when she saw the picture, she exclaimed "I have seen my death!”. But just weeks after Röentgen’s discovery, Emil Grubbé – a student doctor in Chicago – saw the potential of using X-rays not only in scans but in therapy – and started using radiation to treat cancer. Early radiotherapy consisted of a single massive dose of radiation, typically lasting an hour, and understandably, side-effects were severe. Over one hundred years later radiotherapy has advanced tremendously. Many thousands of cancer patients benefit from radiotherapy every year, and it is, for instance, the most commonly used treatment to cure localised prostate cancer in the UK. Radiotherapy still has a rather old-fashioned image but it’s actually an incredibly sophisticated technique that is being used very effectively to target tumours.

Up until the late 1980s, planning radiotherapy was done using two-dimensional X-ray imaging. Now, owing to advances in computer technology, doctors are able to see the tumour in three-dimensions, and these scans are used to guide radiation beams so that they follow the shape of the tumour more closely – avoiding healthy tissue as far as possible. This breakthrough in radiotherapy is called 3-D conformal radiotherapy (3-D CRT) and intensity-modulated radiotherapy (IMRT) is one of the major developments in this field that has occurred in the last 10–15 years. IMRT accurately conforms to the 3-D shape of the tumour by modulating or controlling the intensity of the radiation beam in multiple small volumes, making it much safer and tolerable to the patient, and less likely to cause long-term complications compared with other older radiotherapy techniques.

Here at The Institute of Cancer Research, London, Professor David Dearnaley, Professor of Uro-oncology, has been a pioneer in the development of 3-D CRT treatments for prostate cancer. Professor Dearnaley says: “The Institute of Cancer Research (ICR) has a long history of being innovators in improving 3-D CRT. We began treating patients using IMRT 13 years ago and the technology has since been adopted across the country. We were delighted when trials conducted at the ICR and The Royal Marsden resulted in NICE guidance recommending high dose 3-D CRT as the national standard of care for prostate cancer in 2008. But despite these recommendations, many patients still do not have access to advanced radiotherapy because of the lack of capacity in radiation services. Thankfully things are changing owing to the launch of the Government’s £23 million Cancer Radiotherapy Innovation Fund, and we are beginning to see considerable improvements in standards of care. The clinical trials of IMRT led by the ICR have been key in generalising these advanced techniques and have approximately halved the reported rate of radiotherapy side-effects, which is very good news for prostate cancer patients.”

Continuing our research into the benefits of conformal and IMRT radiotherapy, the ICR and The Royal Marsden are now leading one of the largest academically led prostate studies in the world – the CHHiP trial. Early safety data from this trial show that less overall radiotherapy delivered in fewer but higher doses was found to be as safe as the standard lower doses for treating prostate cancer. “The safety data was very pleasing and we are looking forward to the results of the next phase of the trial to see if this method ultimately offers patients better tumour control or fewer side-effects,” says Professor Dearnaley. “Hopefully this will also equate to men having fewer hospital trips and less radiotherapy overall – something men and their families will appreciate.” Researchers are now monitoring over 3,000 men with prostate cancer for tumour control, and effects on the bowel, bladder and sexual function.

Professor Dearnaley continues to push for advances in radiotherapy and says: “I’m extremely hopeful that in the future, we can make further improvements in radiotherapy techniques for prostate cancer and get these introduced nationally. It is largely unknown how to tailor radiotherapy individually to the patient other than coping with their individual geometry. But now we are collecting further individualised patient data on biomarkers and radiogenomics – these may help to predict the best radiotherapy dose and fractionation and will help us to explore the differences in individual radio-sensitivity. We ultimately want to truly personalise radiotherapy treatment, so we can maximise the benefits and minimise the side-effects for patients – we are well on the way to making this a reality.”

Radiotherapy has progressed remarkably since that first X-ray of Mrs Röentgen’s hand over one hundred years ago. And thankfully, her ominous association of X-rays with death couldn’t be further from the truth.

Hand mit Ringen (Hand with Rings) 1896: a print of one of the first X-rays by Wilhelm Röntgen (1845–1923) of the left hand of his wife Anna Bertha Ludwig.
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