Radiation oncology, also known as radiation therapy, uses a beam of radiation aimed at the cancer area.
We use radiation to shrink or destroy the cancer cells while missing critical organs and normal tissue.
The practice of radiation therapy is performed by physicians who are board certified in radiation oncology and can offer treatment for malignant (cancerous) or benign (non-cancerous) tumors.
The radiation oncologist will work closely with your other physicians to provide the best care available. A radiation oncologist will work closely with a dosimetrist, someone who is specially trained to calculate the dose of radiation and generate radiation plans that will treat the cancerous area while avoiding normal structures. Also, part of the team is the radiation physicist, radiation therapist, and radiation nurse. Each of these team members is critical in the treatment of cancer with radiation.
There are different ways to deliver radiation and your physician will discuss each option with you to make a decision regarding treatment.
Choosing the Right Treatment Center
Radiation oncology treatments may use sophisticated and expensive technology. In order to gain full advantage of the technology available there needs to be a commitment to provide highly trained staff and equipment resources. Many radiation therapy centers do not treat enough patients to consistently offer the most current technology. If you have the option to decide where you will be treated, you should ask the following questions of your radiation therapy provider prior to selecting a radiation oncology center :
- Do you have more than one radiation oncologist, are they all board certified in radiation oncology, and is there always a board certified radiation oncologist on site during all normal clinical hours?
- Why? Board certification in radiation oncology indicates a level of competency and commitment to this specialty. If a patient has a medical issue while under treatment there should be a trained oncology physician available to assist. Many facilities "cover" a facility without a radiation oncologist being on site during all clinical hours. A physician group with several physicians allows direct communication to a provider who will be able provide care to you in the event your primary caregiver is unavailable. Since radiation treatments are usually daily for many weeks you should have daily access, if necessary, to a highly trained and informed provider while under treatment and have a radiation oncologist on call 24 hours a day.
-Do you have physics, dosimetry, and biomedical support available on site for all normal clinical hours?
- Reasons: If there is a question concerning the proper clinical setup, correct system performance or repair of the equipment; it is beneficial to have trained individuals readily available to assess the situation. Many minor repairs may be done in a short time and allow the daily treatment to be completed safely without a significant interruption. Physicists facilitate solutions to complex problems and are responsible for the proper functioning of the technology used for radiation delivery. Dosimetrists provide sophisticated treatment delivery options. Some of this information needs to be communicated through direct dialog and physical presence and there is less chance for miscommunication when the staff who develop the computer plan are on site when it is delivered. A number of centers hire consulting physicists or dosimetrists part time and these resources are not typically directed at continuous improvement but are just maintaining the service. The accurate transfer of information is more difficult when part time services are present.
-Has one of your radiation treatment system systems been purchased within the last several years and how many patients on average are treated per day in radiation oncology?
- Explanation: Radiation oncology centers that treat less than an average of 30 patients a day typically have only one treatment system. Due to the cost, this system is replaced at an interval of ten years or more. New advances in technology are generally not available and complex treatment options are not offered due to less resources. When a center sees a larger number of patients, they are familiar with the many different options and needs necessary for challenging cases.
-Does your center routinely provide image guided radiation therapy (IGRT), intensity modulated radiation therapy (IMRT), and have the ability to compensate for respiratory motion?
- The use of intensity modulated treatments allows for better dose distributions and may reduce side effects. Three dimensional imaging on the treatment system improves dose targeting and may improve outcomes. CT scanners and delivery systems require special technology to account for tumor motion while someone is breathing. A patient may be better served with current technologies.
-Are there comprehensive medical oncology services available in close proximity to the radiation oncology service?
- Importance: It is common to have medical oncology (chemotherapy) and radiation therapy occur on the same day. If they are nearby, a patient may have times scheduled to have one treatment follow the other so care is obtained and coordinated in one trip. Professional staff from medical oncology and radiation oncology may be able to easily exchange treatment options if they are located in the same area.
-What options are available for the unusual case that may benefit from experimental care?
- Why? If a patient presents with an unusual situation the facility should recognize the possibility of sending that patient to a center that specializes in unique treatment options. A larger facility generally has developed those pathways before and will refer to national research centers and participate in research protocols.
At the Martha Siekman Cancer Center located on the Appleton Medical Center campus, there are three full time, board certified, radiation oncologists and there is at least one present during all clinical hours and one on call twenty-four hours a day. There is also one physician assistant with special training in oncology. Since the center averages over 50 patients treated daily there are staffing resources available on site to provide physics, dosimetry, biomedical, nursing, dietary, and care support service programs for all aspects associated with cancer treatment. Our center was the first in Wisconsin (1999) to implement intensity modulated radiation therapy (IMRT) - treating over 1400 IMRT patients as of 2009 - and we continue to pride ourselves with offering new technologies as they become clinically available. In 2005 we purchased a Tomotherapy treatment system and in 2007 we added a CyberKnife robotic treatment delivery system. Our center was one of the first to add these technologies in the state and we were one of the first centers in the United States to have a conventional linear accelerator coupled with Tomotherapy and CyberKnife available at the same location. We improved our simulation capabilities by adding a new CT scanner in 2009 that is designed specifically for radiation oncology. This system allows for respiratory compensated imaging and, with the largest scanning field in the business, we can image all patients and have the best positioning flexibility available. Since we have the resources, each person's treatment is customized for our three unique treatment systems. Our cancer center also has medical oncology adjacent to radiation oncology which allows for convenient patient access to either specialty. We also participate in clinical research trials. Cancer care is more than technology and we have the staff and physicians who want to work with you through challenging times.
Thedacare has a daily process in place to discover any issues or potential challenges that exist in our clinical work flow and how to improve the treatment delivery for the patient. We set goals and expectations to minimize the time that a patient has to wait from their initial consult until their treatment begins.
Please call 920-380-1500 if you have any questions concerning the cancer services available at the Martha Siekman Cancer Center (Thedacare). Information is important and there are significant advantages to selecting cancer care from the largest and best equipped cancer center in the region - the Martha Siekman Cancer Center.
Summary of Personnel Resources at the Martha Siekman Cancer Center :
-Board Certified Radiation Oncologists
-Additional specialties available with the Thedacare Cancer Institute
-7 full time Board Certified Medical Oncologists
-Dietician
-Cosmetology services
-Genetic counseling
Summary of Equipment Resources at the Martha Siekman Cancer Center :
- 1 Varian High Energy Linear Accelerator Treatment System - Operational in 2001, this high energy linear accelerator features multileaf collimation and electronic imaging (additional information below).
- 1 Tomotherapy Treatment System - Operational in 2005, this is dedicated intensity modulated system with three dimension image guided alignment (additional information below).
- 1 CyberKnife Robotic Treatment System - Operational in 2007, this device specializes in radiosurgery and respiratory motion compensation (additional information below) .
- 1 Big Bore Philips 16 slice CT scanner - Operational in 2009 - The image capability greatly enhances respiratory motion correction and allows for special positioning (additional information below). 1
- PET-CT scanner - to be installed in 2010 (More info).
Details of Equipment Resources
- External Beam Radiation Therapy - The most common form of radiation therapy, external beam radiation therapy, uses high-energy X-rays or electrons generated by a special machine called a linear accelerator. Using a special planning system, the beam of radiation is sized and shaped to directly affect the tumor while sparing normal tissues.
- CyberKnife - CyberKnife radiosurgery is a revolutionary form of cancer treatment that is painless and noninvasive. That means no surgery is required. The CyberKnife system delivers precise radiation beams that kill cancer cells. There is also less risk of damage to surrounding healthy tissues. (Additional information or CyberKnife Patient Website)
- Tomotherapy Hi-Art - This innovative technology provides greater flexibility for the use of intensity modulated radiation therapy (IMRT). This system also incorporates three dimensional imaging immediately prior to each treatment to compensate for target movements that may have occurred. The use of three dimensional imaging as part of the daily treatment setup process is referred to image guided radiation therapy (IGRT). Our Tomotherapy system was the first community hospital system purchased in the State of Wisconsin and indicates our commitment to provide proven leading edge technology for cancer patients. Tomotherapy is able to customize and deliver superior radiation dose distributions to targets that are close to critical structures or to treatment volumes that may be large or irregular in shape. We periodically work together with this Madison, WI based manufacturer to clinically evaluate new products prior to commercial release. (Additional information or Tomotherapy Patient Website)
- Varian 21EX Linear Accelerator - This type of high energy linear accelerator has been the industry workhorse for many years and continues to provide optimal treatments for many types of cancers. Our system has multileaf collimation and two dimensional electronic portal imaging. IMRT treatments are available on this system. Since this system has seven different energy options, some targets and locations are better served by this linear accelerator.
Treatment Planning Resources
- Philips Brilliance Big Bore CT Simulator - In order to identify treatment target locations, diagnostic, three dimensional images should be acquired. Our system is a sixteen slice scanner that allows for data to be collected faster than most simulation computer tomography (CT) systems. The large bore and image field allow flexibility in positioning and the size of the patient is not a problem to image. We also have the ability to compensate for target motion due to breathing. In our simulator room, patients will typically have special immobilization devices made to hold the area being treated in a reproducible and fixed position. This location is generally attached to the couch (the table the patient lays on) to keep the planned position the same as the treatment position. The radiation oncologist, simulator therapist, and dosimetrist will work closely together to align and image the patient. After proper immobilization and imaging, the information will be used for treatment planning. One additional advantage is that we are installing a Philips PET-CT scanner that is the same set-up configuration as the simulator. PET diagnostic scans are very useful to incorporate into treatment planning. (Additional information)
- Philips Pinnacle/ Tomotherapy/ CyberKnife Treatment Planning Systems - The data imaged on the CT simulator is directly transferred to the treatment planning systems (8 workstations available for 4 treatment planners). Here the target and critical structures are identified using the CT data as well as possibly combining data from PET (positron emission tomography), MRI (Magnetic Resonant Imaging), or other diagnostic studies. The radiation oncologist carefully determines the radiation goals and the dosimetrist provides treatment options and comparisons modeled on a computer workstation. Each patient has a customized plan that best solves the radiation delivery goals. Intensity Modulated (IMRT) treatment plans will also have a verification performed by a medical physicist on the treatment system prior to starting a patient's treatment. All approved radiation delivery data and plans will have at least one additional review to ensure that proper delivery occurs.
Brachytherapy - This type of radiation therapy uses radioactive sources implanted into the body. These sources may be implanted permanently (such as with seed implants for prostate cancer) or temporarily placed.
- Prostate seed implant program - One option in the treatment of prostate cancer is to use radioactive seeds and permanently implant them in the prostate. This procedure is a combined effort of a urologist, physicist, and radiation oncologist and is done as an outpatient procedure in the Groth Surgery Center at Appleton Medical Center. The procedure is performed on a real-time basis so that a patient has one visit that includes planning and customized placement. Most of the seeds are linked to allow for a more uniform spacing and dose distribution. Several hundreds of cases have been done by the implant team at Appleton Medical Center. We believe a better implant occurs when the target is planned at the time of surgery and not scanned weeks prior. Custom linking of seeds will provide an improved dose distribution.
Useful Definitions
-Intensity Modulated Radiation Therapy (IMRT): IMRT allows the radiation oncologist and dosimetrist to shape the beam of radiation to the tumor. Tumors are not a “normal” shape and with IMRT, the radiation can be contoured to conform around the tumor and limit the amount of radiation to healthy tissues. An advantage of IMRT is that there may be certain situations where the radiation dose to the tumor can be higher while sparing normal tissues.
-Image-guided Radiation Therapy (IGRT): IGRT helps the radiation oncologist deliver the radiation by performing a pre-treatment scan of the cancer area. Using the information obtained from the three-dimensional scan, the radiation oncologist can take into consideration organ motion and adjust the treatment volume. In some cases, physicians will implant markers to assist in the radiation treatment.
-Multileaf Collimation: A multileaf collimator (MLC) is a device made up of individual "leaves" of a high density material, that can move independently in and out of the path of radiation in order to block it. MLCs are used on some treatment machines to precisely shape the radiation beam to minimize damage to normal tissue.