Nucletron Brachytherapy at Jefferson

Richard Valicenti, MD

Radiation oncologists at the Kimmel Cancer Center at Thomas Jefferson University (TJU) Hospital, Philadelphia, have been using a new brachytherapy device for treatment planning since April, and will soon begin to use it for seed placement as well. Manufactured by Nucletron BV, the Netherlands, the device enables real-time planning in the operating room, adding mechanical precision to a treatment that currently relies primarily on physician skill.

"Years ago—and people still do this today—we would plan or map the treatment beforehand, and then take the patient into the OR and try to reenact the plan there," said Richard Valicenti, MD, associate professor of radiation oncology at Jefferson Medical College of TJU. "The computer algorithms, the manner of calculating the dose and so forth was not so sophisticated."

One of the features of the Nucletron system is that it calculates dosage very quickly, within minutes, Valicenti explains. "That's an innovation in how we use this, because we are now basing everything on what we're actually observing in the OR. Not only that, but we're constantly updating and revising our plan. As you can imagine, things don't always go in exactly where we thought they might, but we can identify that and rerun the plan to ensure greater precision in the delivery of the radioactive pellets."

A major factor contributing to the precision of the planning is the device's multiplanar imaging capabilities. "We're not stepping through the prostate," Valicenti said, "we're doing a rotation through the imaging. The imaging's in the axial, sagittal, and coronal planes, and we do a precise lineation of the targets. We get a very good handle on what's going on there in real time."

So far the Nucletron device has been used on about 50 procedures, and radiation oncologists on staff are noticing considerably more efficiency than they were able to achieve with the legacy process for planning. "The process before was we'd bring the patient into our department, do an ultrasound, put the probe in his rectum, do a measurement of his prostate, print it out on the computer, and then do a plan for where we should put the seeds," Valicenti said. "He'd come back a few weeks later and we'd put him in the same position, but he'd be under general anesthesia, so he'd be more relaxed, and things didn't match up very well to what we had before. We'd match the preplan in the OR, and we'd struggle with it. Then we'd have an idea we were doing a good job, and the patient would come back a month later for evaluation. The imaging was done in one plane. Our volumetric data would be based on estimations."

Real-time data acquisition eliminates that degree of uncertainty. "The real benefit is being online with the treatment and the patient at the same time," Valicenti said. That real-time precision will come in handy, he says, when they begin using the robotic component of the device to place the seeds. "The afterloading system puts them exactly where they're supposed to be," he said. "We have to work, as human beings, within a certain reference frame. To judge a millimeter or two requires a steady hand—best to have a mechanical device do that."

Then comes the reimaging, which is equally efficient. "It does a simple rotation and a volumetric measurement so we know for sure there's a cold spot here or there, and we can fix it then," he said. "It's important to note that this gives us tremendous leverage in being able to minimize side effects. And it's potentially very time-efficient." The goal at TJU is to get the procedure down to 30 minutes, start to finish; the team is currently at about 90 minutes, but bringing in the robotic cartridge will reduce that figure significantly.

"It eliminates the human error, the human uncertainty," Valicenti said. "It takes the risk down to zero."

—Cat Vasko

Survivor Care Takes Center Stage at ASCO

Tools for oncologists, education for patients

Cancer remains a leading disease killer for people under age 85 in the United States. But the good news, as recent studies show, is that more and more Ameri-cans are surviving cancer. That's why initiatives that help physicians help cancer survivors—like those spearheaded by the American Society of Clinical Oncology (ASCO)—are so important. ASCO's latest efforts for breast cancer survivors build on the organization's previous work on a colorectal treatment template published online earlier this year.

Now, ASCO is expanding its tools to improve documentation and coordination of cancer treatment and survivorship care by developing a chemotherapy treatment plan and summary template for breast cancer patients. The goal is to improve communication among oncologists, patients, and other care providers to better manage breast cancer patients' treatment across health care settings. It will also make gathering data to evaluate and improve quality of care and patient outcomes more accurate and efficient.

The chemotherapy treatment plan, which the oncologist is to fill out before the patient begins receiving chemotherapy, maps out the patient's planned treatment. The treatment summary, developed after treatment is completed, describes what care the patient actually received.

Designed to assist physicians and educate patients, some of the core elements of the treatment plan and summary include:

• Diagnosis, including the cancer site, histology, and stage;
• Summary of the chemotherapy and other treatment that is planned and delivered;
• Reasons treatment was stopped or modified;
• Information on appropriate follow-up care and relevant providers; and
• Evidence-based survivorship and surveillance guidelines from ASCO.

In addition, ASCO has developed the Breast Cancer Survivorship Plan, which can be added to the treatment summary. It provides clarification on necessary follow-up care, including physical exams, post-treatment mammography, breast self-examination, and pelvic examinations.

"The adjuvant treatment plan and summaries, and the breast cancer survivorship plan, are not only tools for oncologists, but also an educational resource for patients," said Patricia Ganz, MD, professor of health services and medicine at the UCLA School of Public Health and director of the Division of Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center. "We expect that the discussion of the plan with the patient, and the sharing of the information with her primary care provider, will improve coordination of follow-up care after primary breast cancer treatment."

ASCO is continuing to develop and test treatment plans and summaries for additional diagnoses, including lung cancer. All ASCO treatment plans and summary templates are published in modifiable forms, allowing oncologists to customize and adapt them to suit their own practices. To learn more, visit www.asco.org/treatmentsummary.

—M. Matthews