Advanced radiotherapies: What are the challenges and opportunities?
Professor Karen Kirkby and Professor Ananya Choudhury
Advanced radiotherapies are redefining the kinds of cancer treatment that are possible. These developments are exciting, but they also present new challenges. One challenge for researchers and clinicians is how to support policy-makers, tasked with developing treatment and care standards across the NHS. So, what are these new treatments, what do they mean for patient choice and what steps can we take to make the most of these opportunities?
Proton Beam Therapy
The Proton Beam Therapy (PBT) Centre at The Christie in Manchester was the first NHS site in the UK to provide radiotherapy using high energy protons to the public. The Centre houses a state-of-the-art particle accelerator that accelerates protons to two-thirds of the speed of light, before delivering them to the tumour site. This precision means that protons can be used in very complex radiotherapy treatments for example treating tumours that are dangerously close to critical organs. Proton therapy is also used for treating children as it causes less damage to healthy tissues and so reduces the chances of ‘secondary malignancies’ (cancers which may have been caused by previous cancer treatments) later in life.
There is a national ‘Indications List’ of the types of tumours proton therapy can best be used on. Referrals are made by clinicians and approved by a national panel with discretion to approve treatments for non-listed tumours, if the tumour location or patient’s anatomy mean that protons are likely to be the most effective method. This provides a valuable flexibility in determining the best course of action for every patient.
Another new type of advanced radiotherapy, known as FLASH radiotherapy, is also showing promising signs of becoming a new precision treatment for cancers. At The Christie researchers are using FLASH proton beams in the research room in the clinical PBT centre. FLASH uses very high dose rates and appears to spare normal tissue while still destroying the tumour. Researchers, including teams at The Christie, are undertaking research to understand the mechanisms that cause the FLASH effect. This will also help to understand how FLASH might best be used in the clinic and which patients might benefit most.
The Proton Beam Therapy (PBT) Centre at The Christie in Manchester was the first NHS site in the UK to provide radiotherapy using high energy protons to the public.
MR-LINAC: Integrating imaging directly into treatment
Here at The Christie in Manchester, we have also been developing the use of a new radiotherapy technology known as MR-LINAC. This technology combines Magnetic Resonance (MR) imaging with a photon Linear Accelerator (LINAC), and performs MRI scans during treatment. We are now investigating the potential of this innovation to help clinicians tailor treatment choices based upon an enhanced understanding of the individual patient’s response. MR-LINAC technology offers us the potential for realtime monitoring of the tumour and normal organs during a treatment course, and the agility to adapt that treatment based on what we see. This integration of sophisticated imaging technology directly into the radiotherapy treatment pathway is another breakthrough for Manchester’s cancer sciences research that will enable a new level of personalised, precision treatment.
MR-LINAC treatment is more expensive than standard treatment as it takes longer to deliver and requires more expert input from healthcare professionals (a one hour appointment slot versus a twenty minute appointment), so the gains must be balanced by the increased cost in resources.
These techniques are so early in their development that we are still conducting the research that will allow us to decide the best ways in which this technology can be used in the health service. This evidence will also allow researchers and policy-makers to produce a full costbenefit analysis of material costs, changed outcomes, and overall viability of MR-LINAC treatment as part of the treatment standard for different forms of cancer.
New advances and patient consent and choice
Another new development that we are working on relates to informed consent and the involvement of patients in determining their treatment. Advances in clinical research and technology have allowed us to start work on forms of ‘patient-guided’ radiotherapy, particularly in cases of head and neck cancers. These techniques allow clinicians to present patients with a toolkit that will allow them to understand and play an active role in choosing how their treatments are designed. For example, we will be able to ask patients whether they would rather choose a course of therapy that may impair their hearing against another which might impact their ability to comfortably swallow. Of course, choices like these will not be happy ones, but by bringing the patient in as a fuller participant in their own treatment, we get their full and informed consent for their treatment course. This approach also offers the patient the agency and dignity involved in taking some control over the direction of their treatment.
Ideas and implications
In the field of FLASH radiotherapy, the Cancer Research UK ‘Radiation Research Network’ (RadNet) is currently bringing together clinicians, clinical scientists, radiographers and researchers to discuss which tumours might benefit most from FLASH and start develop of a potential ‘indications list’ for FLASH therapies. The development of this at a national scale (modelled after the existing arrangements for PBT), will be the next step if FLASH radiotherapy delivers on its promises. We see a role for policy-makers in the Department for Health and Social Care, and for parliamentarians with interests in cancer and radiotherapy, to help accelerate the process of getting from clinical discussion into policy and practice.
As researchers, we also seek engagement with and leadership from health policy-makers on the new opportunities for enhanced and informed patient consent. For example, should the use of toolkits such as the one we are developing for head and neck treatments become the norm for bringing patients into decision-making around their own treatments? We are beginning to see how technologies such as the MR-LINAC can play a role in supporting patient choice. A better understanding of treatment response means greater capacity to advise and empower patients to help determine their course of treatment.
While these technologies continue to develop, the discussion about their potential use should be led by the Department for Health and Social Care. It should also involve the National Institute for Health and Care Excellence (NICE), NHS England, NHSX, and the Medicines and Healthcare products Regulatory Agency (MHRA), as well as clinical experts from across the world. This dialogue will benefit from integration into policy discussions via a work programme that we can help to develop between these agencies and the clinical research community.
As researchers, we also seek engagement with and leadership from health policy-makers on the new opportunities for enhanced and informed patient content.
Building connections, creating new standards
Building and maintaining the connection between advanced radiotherapy research and policy-makers is essential and often overlooked. We as researchers need to show what PBT can achieve and how it can best fit into the treatment landscape. However, we need to understand more about how non-clinical constraints affect public policy and have a regular and ongoing correspondence with decisionmakers to give them a better idea of where our research can help achieve their objectives and, importantly, where it can’t.
In making these recommendations – for supporting the development of a FLASH indications list and national panel formation; for developing a formal work programme to discuss new standards for informed consent in treatment pathways; and for maintaining a sustainable and dynamic forum for correspondence between researchers and policymakers – we seek to show policy audiences the next steps that we need to take.
These clear, measurable, and reachable goals will have far-reaching benefits, moving us closer to the cancer health outcomes made possible by these advanced new technologies.
About the authors
Professor Karen Kirkby
Karen Kirkby is Professor of Proton Therapy Physics – a joint post between The University of Manchester and The Christie. Karen is responsible for developing a programme of international leading proton research and innovation to deliver direct patient benefits. This goes from basic research, through pre-clinical and translational research to clinical trials.
Professor Ananya Choudhury
Professor Ananya Choudhury is Chair and Honorary Consultant in Clinical Oncology at The Christie and The University of Manchester. Ananya specialises in urology and has a strong interest in translational research. She is clinical lead for advanced radiotherapy including the MR-LINAC project and is co-Group Leader of The Translational Radiobiology Group within the Division of Cancer Sciences.