Image: Radiotherapy machine at The Royal Marsden Hospital (Credit: Jan Chlebik/the ICR)
Radiotherapy is a longstanding treatment for prostate cancer, the most common cancer affecting men in the UK.
In 1904 two French physicians Imbert and Imbert claimed to treat an advanced prostate cancer patient with x-rays to great results. And by the early 1920s radiation was moving into patient treatment more widely due to Marie Curie’s work on the theory of radioactivity.
Several decades later, in the 1940s, we opened our radiotherapy department and began researching ways to improve the technology. After World War II, radiotherapy treatment for prostate cancer was picking up in popularity with new methods making it a more viable treatment.
Since these initial treatments, radiotherapy has been refined to be more effective and precise.
Modern radiotherapy techniques are now so targeted, they leave patients with fewer side effects and deliver more cancer killing radiation to the tumour itself. Unfortunately, most people still think of radiotherapy as a basic, unsophisticated technique, with a lot of associated side effects.
CHHiP Trial
Medical practice can be slow to change but a clinical trial, CHHiP, which launched in the early 2000s with funding from Cancer Research UK, National Institute of Health Research and Biomedical Research Centre and led by Professor David Dearnaley, has already started to change how prostate cancer patients receive radiotherapy across the UK.
CHHiP involved testing different doses of intensity modulated radiotherapy (IMRT), a technique developed at the ICR with our hospital partner The Royal Marsden NHS Foundation Trust. IMRT was recently recognised as one of the NHS top 70 research achievements.
IMRT adjusts the size and shape of the radiation beam to match the tumour, providing precise treatment directly to the cancer and saving healthy tissue from exposure.
Higher dose, fewer radiotherapy sessions
The CHHiP trial importantly found that having a higher dose of radiation, across fewer sessions was just as effective when treating prostate cancer and reduced the level of side effects.
Previously patients needed to attend 37 appointments, every weekday across seven and a half weeks. The CHHiP trial brought this down to 20 sessions, taking just four weeks.
Professor David Dearnaley, who leads the CHHiP trial at the ICR and The Royal Marsden, says:
“The CHHiP study is the largest trial ever completed in localised prostate cancer. Its success has been possible due to the dedication of oncologists, radiotherapy physicists and radiographers across the country teamed with the remarkable enthusiasm of so many patients who want to take part in trials to improve treatment.”
Changing clinical practice
The CHHiP trial has already started making a significant impact on the way patients are being treated for prostate cancer. In December 2016 The Royal College of Radiologists extended their acceptable treatments to include just 20 sessions of radiotherapy for prostate cancer.
Shortly after in 2017, NHS England concluded that 20 sessions of higher dose radiotherapy was safe and effective and should be considered for most patients while just 19 sessions was appropriate in frailer patients who may not cope well with side effects.
Derek Tomlin (pictured right), a prostate cancer patient from Sanderstead, south of London, was treated at The Royal Marsden in Sutton.
His prostate cancer was just starting to spread outside of his prostate at the point of diagnosis. Derek’s radiotherapy plan was guided by the findings from the CHHiP trial and in 2017 he had just 20 sessions of IMRT.
Describing his experience, Derek said: “I found the 20 sessions of radiotherapy sessions extremely manageable. It was so much better psychologically to ‘get it over and done with’, and in terms of less disruption to my daily life, to have the sessions condensed was great.”
Why is this important
Reducing the number of radiotherapy appointments down to 20 has huge implications, both to patients and the NHS. It is already saving the NHS many millions a year. Healthcare teams implementing the CHHiP treatment plan across the country should lead to even greater savings, estimated to be £28million a year.
In real terms for patients, not only does IMRT with reduced treatments lead to fewer side effects, which previously could be debilitating levels of bowel problems and erectile dysfunction. The new treatment plan also allows patients to finish treatment sooner and start rebuilding their lives.
The reduction in some of associated side effects was quite profound.
“It’s gratifying that combining ‘state of the art’ radiotherapy using IMRT with shorter treatments has been so effective whilst about halving the bowel side effects that we saw before.
“It’s the type of research that the NHS makes possible and on this occasion is a ‘win-win’ situation – patients have improved treatment and the NHS saves resources,” says Professor Dearnaley.
Improving the experience for patients
As highlighted by Derek, visits to hospital come with a price. Not only the cost of travel or parking, which, depending on where a patient lives can prove to be very expensive.
But visits can also have an emotional toll – travelling every day into hospital and back when you are fatigued from treatment can be an unwelcome burden.
Derek said: “I have been lucky in a way. I haven’t had any particularly serious side effects from the treatment, and now live a normal life. This is a huge step forward in the development of radiotherapy treatment, it will save the NHS money and cause less disruption for the patient. It would be great if things continue to develop in this way.”
Derek now has just two years left of hormone injections, to try and reduce the risk of his prostate cancer returning. It is fantastic to see progress in radiotherapy not just making treatment more effective, but also focusing on improving patient experience and quality of life for men with prostate cancer.
Making further advances in radiotherapy
In the UK, guidelines now recommend the shorter course of radiotherapy. Internationally some guidelines are beginning to recommend either the shorter course of radiotherapy, or the previous course of 7-8 weeks.
Hopefully, the radiotherapy regime developed from the CHHiP trial will continue to be implemented more widely, and further research will shine a light on more ways in which radiotherapy can be improved.
Each year this will potentially save hundreds of thousands of men three and a half weeks of daily trips to the hospital and debilitating, sometimes life-long side effects.
But progress doesn’t stop here. Professor Dearnaley has already begun working on ways to further improve radiotherapy for prostate cancer patients.
“We already have trials underway to find out if further reduction in treatment sessions is possible. We are testing even more precise image guidance techniques including the recently approved MR Linac which becomes operational this year.
“The ICR’s Clinical Trials and Statistics Unit will continue to have the key role in developing and conducting these studies.”