CANCER ENCOMPASSES THE DISEASES THAT ARE AMONG THE MOST CRITICAL DISORDERS WHICH AFFLICT THE ERA. MEDICAL SPECIALISTS ENDEAVOR TO ELIMINATE THESE DISEASES THROUGH EARLY DIAGNOSIS AND EFFECTIVE TREATMENT. ADOPTION OF A MULTIDISCIPLINARY APPROACH HAS BECOME PROMINENT IN MANAGING CANCER. RADIOTHERAPY AND INTERVENTIONAL RADIOLOGY PROCEDURES OFFER METHODS THAT CAN SUPPLEMENT MEDICAL ONCOLOGY.
As technology continues to advance, new treatment methods come to the fore in treatment of cancer. Treatment alternatives keep increasing with the development of targeted drug therapy and immunotherapy techniques in medical oncology. Furthermore, new-generation radiotherapy devices make it possible for the organs outside of the cancer area to be protected at a maximum level, as well as enabling treatment of cancer and, in suitable cases, prevention of recurrence. Interventional radiology applications, on the other hand, reduce the recovery period and ensure for cancer cells to be destroyed with a minimum extent of incisions.
We have consulted the medical oncologists, radiation oncologists and interventional radiologists from the Cancer Centers of Acıbadem Healthcare Group for more information on the importance of medical, radiation oncology and interventional radiology procedures, as well as their place in treatment of cancer.
|WHEN IS RADIOTHERAPY USED?|
RADIOTHERAPY IS VITAL IN ONCOLOGIC TREATMENT
Radiotherapy (radiation treatment), which is intended to destroy cancer cells via administration of high-energy radiation, has been in use for many years. Currently, it is applied with new-technology devices that are much more effective and less exhaustive for the patient. Furthermore, they ensure for the damage to healthy tissues and organs to be minimized and for such other organs and tissues to be protected through avoidance of radiation of the areas outside of the cancer region. Professor Meltem Serin, a radiation oncologist at Acıbadem Adana Hospital, explains the role of radiotherapy in oncology, as well as the technologies that are used with it, as follows: “Whether on its own or together with surgery and chemotherapy, radiotherapy has a major role in cancer treatment. At least half of patients diagnosed with cancer benefit from radiotherapy. In the Radiation Oncology Department of our hospital, we make use of the Trilogy, TrueBeam STx and HDR Brachytherapy devices. TrueBeam STx operates with a technological method which makes administration of new-generation radiotherapy possible in cancer treatment. We have expanded the range of our hospital greatly with this device, which was used for the first time in our hospital in Adana and the surrounding region. TrueBeam STx is particularly preferable in treatment of brain tumors, as well as other small-sized body tumors that are close to risky organs. The device, which reduces the radiotherapy duration with its fast radiation feature, prevents healthy tissue from being damaged during radiation as well. TrueBeam STx provides great convenience in radiotherapy on tumors in organs which require for respiration to be monitored, such as the lungs, liver and breasts. Since it makes it possible for radiation to be administered while respiratory movements are tracked, radiologists become able to apply a high treatment dose directly on the tumor area. The high image quality makes positioning more precise and ensures for radiation to be administered on the right spot. In addition, patients who have SGK (Social Security Institution) insurance are not charged any extra fees for this treatment.”
PATIENT COMFORT IS PRIORITIZED
Underlining that with the continuously developing technology, the new devices used in radiotherapy have made the job of doctors easier and increased the life quality of patients, Associate Professor Serdar Sürenkök, a radiation oncologist at Acıbadem Eskişehir Hospital, says, “The center at our hospital makes use of the device referred to as Trilogy. The planning systems of this device ensure for treatment to have much higher quality and less side effects. This enables application of higher doses without causing discomfort to the patient. Before treatment, the patient undergoes an imaging procedure. The pre-treatment images are compared to ones produced during treatment. This makes it possible for radiologists to check whether there are any slips. The necessary corrections can be made by moving the treatment bed or guiding the patient into another position. Another device which is used in treatment is Unique. The treatment method of this device, referred to as VMAT or Arc Therapy, can be administered with Trilogy as well. The devices apply radiation while rotating. This feature ensures for the treatment duration to be reduced from 15 to 20 minutes down to 5 or 6 minutes. Since cancer patients tend to be very sensitive during the treatment period, reduction of treatment periods is very comforting for them”.
IMAGES ARE PRODUCED IN A VERY SHORT TIME
Radiation Oncologist Kadir Uçar of Acıbadem Kayseri Hospital states that the diagnosis and treatment systems in the field of radiology have developed a great deal with the advances in technology and that the device named RapidArc has increased the comfort of patients to a major extent. Doctor Uçar says, “In the world of science, RapidArc is described as a cancer treatment device which makes use of the method ‘Volumetric Modulated Arc Therapy’. In order to explain the features of RapidArc, which is also a linear accelerator (LINAC), it is necessary to form an understanding of linear accelerators in general. The x-rays produced by linear accelerators, which have become standard in radiotherapy in recent years, are administered to the disease area within scope of specific treatment plans. While the treatment beams are applied to the patient from a certain distance, patients are required to remain motionless during treatment in order to insure high accuracy during the procedure. Linear accelerators are used with various methods, depending on the area which is treated. Treatments on the head and neck areas require special thermoplastic masks while some other areas require special treatment beds and technologies that ensure for the patient to remain motionless”. Treatment generally last 5 to 10 minutes. Doctor Uçar states that the duration in IMRT (Intensity-Modulated Radiation Therapy) procedures, which have been in use during recent years to minimize the damage to normal tissues, varies between 15 and 30 minutes. In IGRT (Image-Guided Radiation Therapy), this duration is extended by 4 or 5 minutes. This increase is due to the fact that in each session, the treatment area is checked through an imaging procedure before the advanced radiation technology is used.
SPECIAL PRIVILEGES FOR CHILDREN
Comfort is just as important as the quality of treatment. Professor Fulya Ağaoğlu, a radiation oncologist at Acıbadem University Atakent Hospital, states that this is why they have included special waiting rooms and play areas for child patients in their hospital and says, “The Radiation Oncology Department of our hospital, which was opened in 2014, also offers the option of treatment under general anesthesia for child patients. The patients are treated and followed up by an experienced team and intended to recover with minimum amount of side effects with supportive monitoring”.
CAPABILITY TO TREAT CERTAIN CANCER TYPES SINGLE-HANDEDLY
In addition to preventing recurrence of the disease, increasing the effectiveness of chemotherapy and reducing the paid and other adverse effects experienced patients, radiotherapy can also be a treatment option in oncology. Whether radiotherapy can be used for treatment purposes is decided after assessments on the type and stage of the cancer. It is possible to treat certain cancer types such as throat and prostate cancers through radiotherapy only. Doctor Aslı Saran, a radiation oncologist at Acıbadem Bursa Hospital, states that while radiotherapy is used in many ways in cancer treatment, these ways are determined through a multidisciplinary approach. Doctor Saran says, “The treatment model which is the best for the patient, as well as timing and order of treatments, have to be decided through collaboration of specialists from the fields of radiation oncology, medical oncology and other relevant branches”.
APPLICABLE ON PATIENTS OF ALL AGES
Doctor İlker Tosun, a radiation oncologist at Acıbadem Bodrum Hospital, states that they protect other organs at maximum level through administration of radiation on specific targets with high-technology devices and that then procedures to be performed on the patient are simulated three-dimensionally before being carried out: “The radiation is administered to the cancer area in a very detailed and planned manner. The latest technology makes it possible for even small areas to be treated safely. For instance, during radiotherapy on a patient with lung cancer, the heart and other tissues are provided with maximum protection from harm. Therefore, the method can be used on patients of all ages. This type of treatment does not cause hair loss when not used for brain areas; it stops pain and bleeding arising from the tumor and slows down or hinders the progress of the disease at the early stage. The procedure, which last 5 to 10 minutes, has many benefits for patients.”
CYBERKNIFE: THE DEVICE THAT CAN ADMINISTER RADIATION FROM HUNDREDS OF ANGLES
The robotic radiosurgery system CyberKnife, which has been designed for cancer treatment with millimetrical precision in the entire body, makes it possible for cancer tissues in the brain and the rest of the body to be treated with high doses via focal use of radiation beams. This ensures for normal tissues to be protected from the effects of radiation at maximum level. Professor Enis Özyar, a radiation oncologist at Acıbadem Maslak Hospital, states that this treatment device, which operates with a computer-controlled robotic technology, performs procedures by applying radiation from hundreds of angles by rotating around the patient as if in a dance routine; Professor Özyar explains the areas in which CyberKnife is used as follows: “The device can be used on brain tumors and all lesions in the brain and head-and-neck areas, regardless of the location and size of tumors and lesions. In addition to single-session high-dosage radiation treatments which are collectively referred to as radiosurgery, tumors that are close or adjacent to risky organs for which there is the potential of harm can also be treated with CyberKnife through stereotactic radiotherapy. CyberKnife is preferable in malign and benign brain tumors, metastases, arteriovenous malformations, certain functional disorders, lung cancers, prostate cancers, head-and-neck cancers, vertebral tumors, pancreas cancers, certain metastases of limited numbers which cannot be treated with other methods, lung or liver tumors which change position with respiratory or bowel movements, and certain other tumors which could not be treated or could only be treated with mutilating surgeries in the past.”
It is possible to treat all these conditions safely and without harming the patient through use of CyberKnife. For instance, CyberKnife can be used on tumors around the eye which require surgical removal of the eye, or diseases of the spinal cord, which is extremely sensitive to radiation. The device can also be used for patients who, despite having received radiotherapy previously, return for further treatment due to recurrence of the disease at the same spot. Secondary applications can be performed in such conditions.
|WHEN IS CHEMOTHERAPY USED?|
COMBINATION OF CHEMOTHERAPY AND RADIOTHERAPY
Saying, “When used together with chemotherapy for treatment purposes, radiotherapy ensures for the body to overcome the disease more easily”, Doctor Hilmi Ege, a medical oncologist at Acıbadem Bodrum Hospital, explains the areas of use and effects of radiotherapy in cancer treatment as follows: “It is possible to treat cancer cases at early stages with surgical intervention. However, in advanced cases, chemotherapy can also become a treatment option, either on its own or together with radiotherapy. When chemotherapy and radiotherapy are applied in combination, tumors that are difficult to be treated via either of these methods become much easier to be dealt with. In addition to treatment, radiotherapy can also be used for purposes of controlling the disease. It is possible for cancer cell remains to be left in the body after surgery. Radiotherapy can be applied for a further period in order to eliminate such remains, achieve local control and prevent recurrence of the disease. Furthermore, radiotherapy can also be used to alleviate the pain and other adverse effects from cancers at advanced stages. In other words, radiotherapy boosts treatment when used together with chemotherapy, as well as preventing the risk of recurrence and palliating the complications of the disease.”
CHANGING RULES, EMERGENCE OF NEW APPROACHES
Medical oncology coordinates the whole treatment process for cancer patients by cooperating with the other relevant departments. Professor Hüseyin Abalı, a medical oncologist at Acıbadem Adana Hospital, states that in the conventional sense, all procedures involving targeted treatments, chemotherapy, immunotherapy and management of problems such as nausea, vomiting and pain are carried out by medical oncologists.
Also stating that a paradigm shift has occurred in cancer treatment during the last 10 years and that there are now technologies which are used to identify the genetic conditions that cause cancer and to develop drugs specifically for these conditions, Professor Abalı emphasizes the way in which new approaches constantly develop and change cancer treatment by saying, “In addition to these developments, the method of ‘immunotherapy’, which involves treatment via strengthening of the immune system, becomes more and more important with each passing day. On the other hand, the said target-specific drugs show various, unusual side effects and cancer cells resist new drugs by adapting to these; all of these lead to development of new concepts. Understanding the extent of this resistance requires repeated biopsies. Currently, research focuses not only on diagnosis but also on the molecular structure and the way in which this structure changes upon treatment. It is possible for the said change to affect application of secondary and tertiary targeted treatments. According to the data acquired so far, it can be said that targeted treatments are best applied by medical oncologists”.
DIFFERENT TREATMENT METHODS ARE TRIED
As the current alternatives in treatment continue increasing, specialists start trying different methods for each type of cancer. Stating that the methods they use vary in accordance with the type and stage of the tumor and the condition of the patient, Professor Ali Arıcan, a medical oncologist at Acıbadem University Atakent Hospital, says, “Our department is a facility where treatment of all cancer types is performed. Lymphomas are eliminated completely through curative treatment. Recurrence of colon cancer is prevented with adjuvant therapy after a surgical intervention is carried out. In bone tumors, neoadjuvant therapy is used to increase the potential success of surgical interventions and protect organs. In advanced-stage pancreatic cancer, palliative treatment is made use of to shrink tumors and take symptoms under control”.
THE ORDER OF TREATMENT PROCEDURES IS IMPORTANT
Another important point in selection of the methods and procedures to be used in cancer treatment is identification of the order in which these will be applied. Professor Bülent Orhan, a medical oncologist at Acıbadem Bursa Hospital, states that all details, ranging from diagnosis to determination of the treatment stages, are taken care of by medical oncologists and continues as follows: “The duty of a medical oncologist begins when there is a suspicion of cancer. The medical oncologist has a major role in selection of diagnosis methods, making a definitive diagnosis and completing both diagnosis and staging as soon as possible by guiding the patient correctly. The most important job, however, is planning of the treatment. The medical oncologist is effective in both planning the manner of chemotherapy and putting the treatment options in order. All phases, such as planning of pre-operative chemotherapy or post-operative radiotherapy and determining the order of treatments, are carried out by the medical oncologist. Furthermore, the medical oncologists works actively in management of treatment complications and supportive treatment processes as well.”
PROMISING DEVELOPMENTS IN TREATMENT OF LUNG CANCER
Lung cancer constitutes the reason for a great portion of cancer-related deaths. Despite this negative aspect, there are important developments in treatment of lung cancer. Professor Abdullah Büyükçelik, a medical oncologist at Acıbadem Kayseri Hospital, states that the most significant of these is the fact that the life expectancy in cases of metastasized lung cancer (cancer that has spread) has been increased to 12 months and says, “In the past, lung cancer was classified as either ‘small cell lung cancer’ or ‘non-small cell lung cancer’ and the treatment was applied in accordance with the type. However, genetic and molecular developments that were understood in time revealed that ‘non-small cell lung cancer’ had subtypes, each of which responded differently to each treatment option. For instance, recent developments led to production of new drugs that are more effective in treatment of ‘adenocarcinomas’, which are a type of lung cancer. With these drugs, it is possible to get better results and less side effects in comparison to conventional chemotherapy drugs. This leads to options which keep cancer under control for longer periods and are collectively referred to as ‘maintenance treatment’”.
TARGETED THERAPY DRUGS
In addition to specific drugs that have been used for breast cancer for many years, there are now targeted therapy drugs for other cancer types as well. Associate Professor Hasan Üstün, a medical oncologist at Acıbadem Eskişehir Hospital, shares with us the following information on these drugs: “Standard chemotherapy drugs destroy cancer cells but have a great deal of side effects on health cells, particularly the ones in the bone marrow and the digestive tract. Patients tend to experience many problems related to this. Targeted treatments, however, involve drugs specially designed for the molecules that are only present in cancer cells. Since these drugs affect cancer cells the most, the healthy cells in the body receive much less damage. Such targeted therapy drugs have been in use for many years for breast cancer and now, they can also be used for lung cancer and malign melanomas. There is also ongoing research for development of such drugs for other cancer types. Studies in the field are promising. Currently, approximately 15% of the total cancer patient population can benefit from targeted therapy. This ratio may seem low but the lifespans of the patients in the said group are extended a great deal. In the future, we may have targeted therapy options for all subtypes of all cancers. For instance, let’s assume that three people (A, B and C persons) have the same type of cancer, which is adenocarcinoma. In the future, each of these patients will benefit from treatment through therapy forms that are specific to their conditions but currently, it is not possible to differentiate the varying targets in these people and they can only receive standard treatment, which provides benefit only to some of them.”
Does this mean that side effects are eliminated altogether? Associate Professor answers this question as follows: “It would not be true to say that all side effects are eliminated. For instance, the targeted therapy drugs for breast cancer can sometimes cause heart failure in patients. In such cases, the patient is monitored through echocardiography procedures once in every three months.”
CHEMOTHERAPY EXTENDS THE LIFESPAN IN SOME CASES
Underlining that chemotherapy is used to prevent recurrence of the disease or eliminate the risk of cancer cells spreading in the body, and stating that it is also preferable for purposes of shrinking tumors before surgery and increasing life quality of advanced-stage cancer patients, Associate Professor Üstün shares with us the following information: “For instance, let’s assume that there is a patient on whom breast-preserving surgery is necessary. The surgeon states that operating under the current conditions will be difficult and can be much easier if the tumor size is reduced. Chemotherapy is useful in such a case. There are some cases in which the disease has spread to a great extent, which are referred to as ‘metastatic’ disease cases. In most of these cases, eliminating the disease completely is not possible. There are some exceptions but these are very rare. The aim in administration of chemotherapy in such cases is to ensure for the patients to live the rest of their lives comfortably. In some situations, chemotherapy can extend the lifespan as well.”
LIQUID BIOPSY MAKES EARLY DIAGNOSIS POSSIBLE!
Early diagnosis has vital importance in cancer treatment. Underlining that the earlier the disease is diagnosed, the higher the rate of success is for treatment, Professor Osman Gökhan Demir, a medical oncologist at Acıbadem Maslak Hospital, says the following: “The upcoming years will bring many developments in cancer treatment. First of all, the concept of early diagnosis will change. Currently, tumors can only be diagnosed through radiologic imaging methods and biopsies. In the future, however, it will be possible for tumors to be diagnosed even at stages that are too early for radiologic detection. This will be performed via the methods of molecular diagnosis and “Liquid Biopsy”, which involves separation of tumor DNA from blood. For instance, specialists will determine whether a person has cancer at a very early stage through analysis for detection of the DNAs of most common cancer types. Determination of new molecular targets and genetic methods will make it possible for treatment to be performed specifically in accordance with the genetic characteristics of tumors and without requiring chemotherapy. Currently there is also ongoing research on definition of the genetic condition referred to as “driver mutation” which causes for the primary tumor to grow and use of targeted treatments for managing this. In 10 years, diagnosis and treatment of cancer will be nothing like the current diagnosis and treatment. With both developments in bioinformatics and the start of the use of nanotechnologies in treatment, the future looks very promising for us.”
|WHEN IS INTERVENTIONAL RADIOLOGY USED?|
WHAT IS INTERVENTIONAL RADIOLOGY?
Interventional radiology is a method which makes the diagnosis and treatment of all organs and systems easier through use of imaging techniques such as radiography, CT and MRI. Associate Professor Koray Güven, an interventional radiologist at Acıbadem Maslak Hospital, states that the procedures are performed with modern imaging devices of the latest technology and says, “The interventional radiology procedures that are applied make it possible for the patient to be treated in the most effective and least risky manner with minimum harm, pain and incisions when compared to other medical procedures. Furthermore, the patient is able to return to normal life much sooner. The said procedures are generally performed via entry through small incisions on the skin and use of needles or small tubes, referred to as catheters, of various sizes and diameters. Many diseases which could only be treated through surgery and large incisions, can now mostly be handled with minimal incisions and local anesthesia. This also reduces the severity of the trauma inflicted on the patient, as well as infections. For instance, specialists could only try to eliminate the arterial embolisms which could occur in any area of the body through the procedure referred to as bypass surgery; now, on the other hand, approximately 80% of the patients suffering from such embolisms can be treated through angioplasty, stent placement or similar procedures that involve small incisions. The range of the procedures performed by interventional radiologists is very wide and the field itself can be divided into subfields. The said procedures are used frequently in oncology, vascular diseases and non-vascular system disorders”.
APPLICATION IN ONCOLOGY
Interventional radiology is a modern treatment method which is particularly effective on liver tumors. While the most effective treatment method in primary liver tumors is surgery, it is possible to apply interventional radiology on three in every four patients due to reasons such as late diagnosis of the disease, multiple tumors, proximity of tumors to critical blood vessels or the biliary ducts. Furthermore, interventional radiology procedures increase the rate of success for treatments when used to supplement conventional surgical methods and chemotherapy in tumors that have metastasized into the liver. Professor Yurtkuran Sadıkoğlu expalians the interventional radiology procedures used in oncology as follows: “Non-vascular interventional radiology procedures that are performed for diagnostic purposes are image-guided biopsy applications. Biopsies are procedures in which a sample is taken from organs such as the prostate, liver, pancreas, lungs and kidneys or tumoral formations that are outside of these through assistance from imaging methods such as ultrasound and CT. The samples are acquired by accessing the tissue with a long needle. Whether the needle is precisely directed to the desired area can be seen before the sample is collected. This ensures definitive diagnosis. Treatment procedures in the field include use of methods such as destruction of tumors, blockage of the blood vessels that supply tumors and opening of the biliary ducts blocked by tumors. Another procedure that is special in the field is chemoembolization, which is administration of cancer treatment drugs directly on the organ with cancer or the blood vessel supplying the cancerous area through access via angiography. This ensures for the drug to be contained in the area and affect the tumor more efficiently; since the cancerous tissue is rendered unable to be supplied with blood, its destruction is accelerated. This procedure is generally used on liver tumors.”
The rate of success in treatment of cancer patients on whom interventional radiology procedures are applied is very high. Professor Sadıkoğlu states that treatments with interventional radiology procedures have higher success rates in comparison to the alternatives and says, “The technical success of the method is close to 100%. For instance, it is not possible for blocked bile ducts in the liver to be opened via any method other than interventional radiology procedures”.
TREATMENT METHODS INCREASE CONTINUOUSLY
Since the method does not involve large incisions, it has advantages such as minimization of side effects such as pain and infections. Furthermore, patients can be discharged right away after a hospitalization period of one or two days and are able return to normal life much faster. Interventional oncology treatments can be applied before, during or after other treatments; it does not hinder their application. Moreover, these treatments yield positive results in some patients. They make it possible for patients who are normally ineligible for surgery to be surgery candidates by shrinking tumors and lowering the stage of the disease. They can be tolerated easily by patients. The method has a low number of side effects and offers modern, targeted applications. The factors that affect the success rate of treatments include the type and size of the tumor, as well as the extent to which it has spread, the experience of the specialist and whether available treatment can be used effectively or in the proper order. When all requirements are met, treatment becomes very effective on diseases of which treatment is normally impossible and the life expectancy and quality of patients are increased significantly. Treatment options increase with each passing day as technology improves. Diseases that used to be defined as hopeless can now be treated with pleasing results.
INTERVENTIONAL RADIOLOGY HAS A MAJOR ROLE ON TREATMENT
Interventional radiology procedures, which have become indispensable to doctors in treatment of oncologic diseases, have a major role in diagnosis and treatment of cancer and related conditions. Doctor Mehmet Erdem Yıldız, an interventional radiologist at Acıbadem Kozyatağı Hospital, states that interventional radiology is a reliable option in issues such as precise identifiication of the tumor types and subtypes in diagnosed cases and the selection of the treatment method. Doctor Yıldız says, “Procedures such as blocking of the blood vessels that supply the tumor, direct treatment of the tumor with microwaves and radio waves and similar processes are performed in cases of tumors in organs such as the liver, kidneys, lungs and bones after a consensus is reached by the whole team. In general, these techniques are used in cases were the tumor is surgically unremovable or chemotherapy fails to be effective completely. They can also be applied in combinations. Furthermore, there are many supplementary interventional radiology procedures applied in order to eliminate or alleviate the issues arising from the disease or the treatment.”
MODERN TECHNOLOGIES ARE USED
Interventional radiology procedures make it possible for patients to be treated with devices of the latest technology. The treatment involves use of devices with high quality imaging technologies such as 64-Slice CT with three dimensional imaging, ultrasound, fluoroscopy and digital subtraction angiography. Depending on the type of the procedure, modern equipment and materials that are internationally approved, such as catheters, stents, special biopsy needles, ablation devices and embolization materials, are used during treatment. Associate Professor Can Çalışkan, an interventional radiologist at Acıbadem University Atakent Hospital, states that such technologies offer many advantages and all biopsy procedures are performed with visual assistance via use of ultrasound, mammography, CT and, sometimes, MRI. Associate Professor Çalışkan says, “This both maximizes procedure safety and reduces complication rates significantly. Another advantage is the opportunity to perform MRI-guided procedures on lesions which cannot be detected via methods other than MRI. This opportunity is made use of when biopsies on the prostate and other organs require it”.