As a medical oncologist, I’m often asked by patients about radiation therapy. When is the best time to consider it? What is the best type of radiation therapy to be given? Why can’t we treat all sites of metastatic disease? The question of using radiotherapy will depend on many factors, such as cancer types, biology, molecular alterations, organ involvements, co-morbidities, patient preferences, treatment intentions, radio-sensitivity or resistance like most bone sarcomas, etc. I can tell you that most radiation oncologist are by far the most thoughtful folks of the multi-disciplinary team and consider all the above factors for when to consider radiotherapy. I am hoping this article will summarize at a high level with patient examples that make it easier to understand the use of radiotherapy for patients fighting cancer!
For me, the treatment intention is one of the most important question we ask when considering radiotherapy for patients. If the intention is to cure for the long term, then we are willing to take some risk to effectively treat the tumor. If the intention is to palliate and prolong survival, then treatment with radiation is meant to alleviate a specific symptom using light doses of radiation to minimize toxicity.
I recently saw a patient with malignant melanoma who was diagnosed almost a decade ago. He ultimately, he had progressive metastatic melanoma to the lung and brain in late 2013. He responded well to upfront immunotherapy with a near complete response to lung metastasis. However, between late 2013 to early 2015, every 3 months when we ordered an MRI brain scan, he had 1-3 new CNS oligometastatic lesions. Oligometastatic disease is where there is a limited tumor to one organ system where the tumor can be effectively controlled with local therapies such as resection, ablation or radiation. Fortunately, I was able to call on our radiation oncologist who can provide SRS or stereotactic radio-surgery to each of the CNS lesions we found. Surprisingly, this patient had a total of 14 brain metastasis progress between 2013-2015 however amazingly, all lesions were treated and his last brain metastasis was diagnosed and treated in Feb 2015. To date, this patient has not had any recurrent CNS disease!
I have two GI patients this past week diagnosed with esophageal squamous cell carcinoma (ESCC) and Anal cancer. Historically, these patients may have been treated with morbid surgery alone or a combination with surgery, chemotherapy, radiation, however today, patients can be treated with curative intent treatment using definitive combination of chemo-radiation alone without the need for a morbid surgery. Long term disease control rates are greater than 40-50% and 70-80%, respectively for ESCC and Anal cancer. Another example of localized radiotherapy are in folks with limited liver or lung disease. Elderly patients with unresectable or inoperable malignant liver HCC or Cholangiocarcinoma or a small malignant lung nodule of any type can be effectively treated with high dose localized radiotherapy (SBRT).
When the treatment intent is palliative, then we call our radiation oncologist to deliver “light” doses of radiation to treat a symptomatic tumor. Metastatic bone tumor with compression to the spinal cord with resultant loss of motor function, urinating or defecating inappropriately. Metastatic expansile tumors causing severe pain where patients are taking doses of pain medications. Tumors involving the airways with resultant severe cough or bleeding. Tumors involving the food pipes with resultant troubling getting food down or keeping it down. Palliative radiotherapy is usually done in sequence with systemic therapies as to minimize the risk for toxicities to the patient. Sometimes systemic therapy and radiation do not always “play well together” depending on the drug given like Anthracyclines or BRAF inhibitors
Radiation therapy, also known as radiation treatment, radiotherapy, irradiation, or x-ray therapy, uses high-energy particles or waves to destroy or damage cancer cells.
The goals of radiation therapy are as follows:
- To cure or shrink early-stage cancer: Radiation therapy may be used by itself or with other treatments such as chemotherapy to make the cancer shrink or completely go away. In some cases, radiation may be used before surgery to shrink the tumor or after surgery to help prevent the cancer from coming back.
- To stop cancer from coming back (recurring) somewhere else: Radiation therapy may be used to treat an area where cancer is most likely to spread to, even when there is no visible cancer there. This is done to help prevent cancer from spreading to that area.
- To treat symptoms caused by advanced cancer: Radiation therapy may be used to make advanced tumors smaller so that the person can feel better. This is called palliative radiation.
- To treat cancer that has returned (recurred): If a person’s cancer has returned, radiation therapy may be used to treat the cancer or to treat symptoms caused by advanced cancer.
Radiation therapy has come a long way in recent years, with many different types available to treat cancer. Three main types are external-beam radiation therapy, brachytherapy, or systemic radio-conjugated therapies. External-beam radiation therapy involves a machine that delivers high-energy radiation to the cancer cells from outside the body, while brachytherapy involves placing radioactive material directly into or near the tumor (ie prostate cancer, rarely rectal cancers). Radio-conjugated therapies deliver treatment intravenously and a good example of this that we use frequently in the GI world would be Lutathera in metastatic neuroendocrine tumor where there are active receptor “targets”. Radiation therapy can have adverse effects, including fatigue, skin changes, and hair loss. However, many side effects can be managed with medication and other supportive measures. Usually with time, these symptoms resolve.
It’s important to remember that every patient’s situation is unique. If you or a loved one has been diagnosed with cancer, it’s crucial to discuss your treatment options with your oncologist. It’s ok to ask about other options like surgery and radiation. Why these types of treatments can or cannot be utilized in your care. They can help you understand the risks and benefits of different treatments, and work with you to develop a personalized treatment plan that is tailored to your specific needs. By working together with your oncologist, you can make informed decisions and feel confident in your treatment plan.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.
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