Technological advancement is one of the core parts of the development of radiotherapy, much in the same way that radiation therapy is one of the core parts of the treatment of many lesions, tumours and types of cancer.

Because of this, radiotherapy tends to be one of the most unique and fast-moving fields of research in all of medicine, as each revolutionary change serves to make treatments that were previously impossible almost routine in their effectiveness.

One of the most interesting recent developments is in the field of Biology-Guided Radiotherapy (BgRT), a promising emerging field of radiotherapy that allows for more adaptive treatments and avoids overly cautious treatment plans that might make certain tumours inoperable due to unacceptable levels of risk.

At this early stage, only a few treatment centres are using BgRT, but as the concept increases in its capabilities and more radiotherapy centres look to adopt the most state-of-the-art technological advances, here is everything you need to know about this new field.

What Is Biology-Guided Radiotherapy?

The core principle behind BgRT is that it combines radiotherapy treatments with positron emission tomography (PET), a system that creates digitised, detailed imagery of the body as it is currently functioning, rather than a static two-dimensional or three-dimensional model of how it looks.

It works through the use of a radiotracer, which is injected into the bloodstream and through tracking the activity of this radioactive substance in real-time, can also track the exact position of cancerous cells at a given time.

PET is often used in conjunction with CT scans for more accurate readings, but in radiotherapy, it delivers something potentially far greater and something that can unlock a very powerful treatment that it would be impossible to use otherwise.

How Would It Change Treatments?

At present, radiotherapy is undertaken through the use of a static body scan (typically a CT scan) that is used to coordinate and prepare the treatment, as well as explore what exact options are available.

The problem with a static scan is that whilst the scan itself is accurate and detailed and static, the human body it is depicting is very much not, and various organs and parts of the body can shift and change position in the body, both naturally and as a process of movement.

This means that where the tumour was when the CT scan was made days or even weeks before, and where it is when the radiotherapy treatment takes place can be very different indeed, and in order to compensate for this, radiotherapy treatments tend to be broader than they perhaps need to be.

Because there is the potential for collateral harm, radiotherapy is often best used with smaller tumours, and is often combined with chemotherapy or other forms of cancer medication to shrink the tumour and make it far easier to destroy without damaging too much healthy tissue.

The best way to undertake radiotherapy, therefore, would be to combine it with a real-time diagnostic imaging system, as there would be no difference between the scan and the body that was being treated and this would lead to radically more accurate treatments.

There are a lot of ways to do this potentially, with explorations into using real-time CT scans and even modified forms of ultrasound, but the one with the most potential is BgRT, because of the inherent real-time nature of how PET interacts with cancer cells.

Cancer tends to be particularly easy to spot with PET, and even if it moves, it is very clear to see where it is at any given point, allowing for rapid adaptation to tumours that are moving around the body.

This not only leads to more accurate treatment and faster recovery times for treating tumours and growths that are already managed through other more conventional forms of treatment, but also allows for more complex cancers to be treated.

In particular, treating multiple tumours is a complex process that requires each tumour to be treated individually, with a separate CT scan and planning process for each.

This novel BgRT approach allows for several tumours to be treated at once, helping to reduce overall treatment times and ensure there are fewer complications.

It also allows for subtle patient movements to be factored in, which means that patients do not necessarily have to be held completely still in order for a treatment to be effective.

It could potentially mean that tumours too close to vital organs to be viably operable up to this point could be treatable in the near future.

It has often been said that in Western countries with long life expectancy, around one in two people will get cancer at some point in their lives. This can come in many forms, but it is also a threat that is increasingly preventable and treatable. Both these facts will shape how cancer is approached in the years to come.

What we now know compared to a few decades ago is highly significant. In the early 20th century, for example, it was believed that smoking was a healthy thing to do, while it was also believed that exposure to radioactivity could have some health benefits.

In time it was learned that one of these things was not true and efforts to bring smoking levels down have been largely successful, reducing the risks of diseases like lung cancer. In that case, prevention has been the lead strategy.

The Reality Of Radioactivity

Radioactivity is another matter. We are all exposed to it at low levels, from natural background radiation and also ingesting mildly radioactive substances vital to life, like potassium (bananas are mildly radioactive). These levels are perfectly safe, as are things like X-rays and other medical treatments with low levels of radioactivity.

What causes alarm in the minds of most people is the spectre of what high levels of radiation can do. Extreme causes such as the atomic bombings of Japan in 1945 or the nuclear power station accidents at Chernobyl and Fukushima can be cited as causing radiation sickness, with cancer one of the symptoms.

On a lesser level, too much of one form of naturally occurring radiation – the sun’s ultraviolet rays – poses a skin cancer risk for people with pale skin.

However, the fact that radioactivity can, when directed in the right way, actually fight cancer by destroying affected cells and tumours provides hope for life where otherwise there would have been nothing to do except receive palliative care before death.

Radiotherapy To The Rescue

Radiotherapy has been used for decades in this way and the invention in the 1960s of gamma knife surgery by Swedish professor of neurosurgery Lars Leksell provided a precision instrument for use in directing radiation in very sensitive areas, enabling brain tumours to be tackled with a focused gamma beam without any harm to the rest of the brain.

Professor Leksell developed a second gamma knife in the 1970s and an obvious avenue for further development of this technology in the future will be increased precision. The same may apply to various radiotherapy techniques.

What comes next and over the future decades is a matter that many experts in the field have given a lot of thought to.

What Does The Future Hold?

For instance, an article in Nature Reviews Clinical Oncology a decade ago noted that while radiotherapy has been used since 1895, it is in recent years that the most significant breakthroughs have been made.

It stated: “Such achievements, of major importance for the quality of life of patients, have been fostered during the past decade by linear accelerators with computer-assisted technology.”

This, it added, has been supplemented further by “proton and particle beam radiotherapy, usually combined with surgery and medical treatment in a multidisciplinary and personalised strategy against cancer.”

What this means is that the more recent technologies have been increasingly effective at focusing radiation treatment on the areas of the brain or body that need them most.

That the field has a lot of new developments to come, building on the foundations of various innovators (not just Prof Leksell) is a point emphasised by many others too.

Writing two years ago, British publication The Lancet said radiotherapy remains “the most poorly understood of the cancer disciplines,” but highlighted that a number of new developments promise to take this field to new levels.

The article alluded to the way data collation can help treatment and there is no doubt that AI may play a larger role, as it is already showing signs of being effective in helping with early diagnosis of conditions.

An obvious advantage of this is that it means treatment can start sooner and may be especially effective at ensuring the cancerous area is treated effectively using radiotherapy before it can progress further. That may mean less need for more advanced and specialised treatments in some cases, but also shorter treatment times and higher recovery rates.

A Role For AI?

While the next few years may see AI diagnostics bring the biggest advances, it is exciting to think about what may be achieved by 2050. In 2020, Molecular Oncology sought to answer the question with some bold predictions.

Not all of these are positive. It stated that the increase in cancer diagnoses in recent years will continue to soar, with the likely reason being a real-life increase in cancer, not just better detection. A larger global population will be part of the reason, but so too will lifestyle elements. 

Indeed, while smoking may be in decline and fair-skinned people take more care in the summer sun, issues like diet and more sedentary lifestyles may be an increasing problem in some countries as they get more affluent.

Meanwhile, in Europe, the rise in cases will not be down to an increase in population (the reverse will happen), but an increasingly aged population that is more medically vulnerable.

Whatever the causes of increasing cancer cases, they will drive the imperative to be better at detecting cancer, to do so sooner, and to find more effective treatments.

In the last case, it is not just about new technological developments, important as they will be, but how they are used. One prediction is for increased use of personalised oncology. This will enable more innovation; instead of arranging radiotherapy treatment programmes based on standard models, each one will be calibrated to the particular needs of individuals.

That could ensure gamma knife treatment becomes the primary means of treating some very specific conditions after an early diagnosis, with a personalised approach swiftly establishing that this is the best way to tackle a problem.

Whatever new developments come in the years ahead, here at Amethyst we will always seek to be at the forefront, using cutting-edge technology, treatments, data and understanding to help provide the best treatment and outcomes for our patients.

Prostate cancer is one of the more common cancers, but if detected early enough, men who suffer from it can have a very good chance of survival. Accessing a radiotherapy centre can often be a crucial factor in enabling them to do so.

However, the rates vary widely between countries, with Austria far from being among the worst affected. There are various reasons for this, not least ethnicity, as the majority of Austrians are white. Research in various countries has shown that, for example, black men are far more likely to suffer the disease.

World Cancer Research Fund International (WCRFI) data published in 2020 showed that the highest rates were in the French overseas territories of Guadeloupe and Martinique. Migration from those Caribbean countries to France may partly account for the fact that it was ninth on the list.

Caribbean countries featured heavily among the highest rates, reflecting the ethnic divide, with the top ten also including Barbados, St Lucia and the Bahamas. These countries all had rates of more than 98 per 100,000 men, compared with the global average of 30.7.

However, that was not the full picture; the third-highest rate was in Ireland, while Estonia and Sweden were also in the top ten, showing that European countries with mostly white populations were second-worst affected. High incidence rates in European countries may arise from secondary influences like obesity and high dairy consumption rates.

Another notable fact is that prostate cancer rates vary widely between European countries; EU and EFTA stats in 2018 had put Sweden slightly ahead of Ireland, with these being among five countries with over 200 cases per 100,000 that year.

Yet, at the opposite end of the scale, the rate was only 63.6 in Romania and 83.7 in Poland. The overall average was 151.2, with Austria well below this at 130.4.

However, the difference between the cancer incidence rate and mortality was the most notable finding of the WCRFI figures. No European country was in the top ten for death rates from the disease. Instead, Zimbabwe had the highest death rate, joined in the top ten by Zambia and the Ivory Coast. The other seven in this list were Caribbean nations.

In these countries, the mortality rates ranged from 29.5 per 100,000 in the Ivory Coast to 41.7 in Zimbabwe, compared with a global figure of 7.7. 

What this indicates is that the most deadly combination is that of a population more demographically prone to the disease and poorly resourced in terms of its cancer treatment facilities. This would certainly apply to a country like Zimbabwe, where controversial agricultural reforms in the 2000s brought the economy to its knees.

The WCRFI noted how the cancer survival rates for various forms of the disease can vary between countries, with higher-income nations benefitting from better screening and treatment services.

All this suggests that those with the means to travel from countries lacking in the necessary treatment facilities such as radiotherapy providers may find centres like ours the best place to get vital, potentially life-saving treatment.

All over the world, millions of people who have contracted brain cancer will have soon learned there is more hope for extended survival today than ever before, because of the wide range of treatments available.

For those learning about gamma knife surgery, there may be a lot of interest in this option and the circumstances in which it might be used as the best available means of treating a tumour.

Brain tumour surgery has certainly been in the news a lot recently, with news that the former US Open golf champion Gary Woodland has had surgery to remove most of a tumour.

The 39-year-old, who won his major title in 2019, revealed on his X (Twitter) account that he would have the operation on September 18th, having been diagnosed just over three months earlier. He had been seeking to use medication to treat the lesion but had agreed after consultation to undergo the operation.

A subsequent statement on his social media accounts revealed: “After a long surgery, the majority of the tumor has been removed and he is currently resting.” 

No further details of the nature of the operation were provided, but the use of the phrase ‘long surgery’ may be a strong indicator that this was a matter of invasive surgery in which the brain was physically accessed and most of the tumour excised.

A gamma knife operation would not be quite like this. Firstly, it does not actually involve any invasive surgery at all as it involves the focused direction of radiotherapy beams on the specific affected area of the brain.

Secondly, the time taken does not particularly fit the description ‘lengthy’. Although the duration of the procedure can vary, a period of less than one hour is perfectly normal.

Also, while Gary Woodland is ‘resting’ from his surgery and it required someone else to make the social media posts on his behalf – suggesting he may have been under general anaesthetic – this is different from gamma knife operations, where patients can often return to normal activities within a day or two, though regular check-ups will be needed thereafter.

Of course, the specific details of Gary Woodland’s condition are between him and his doctors, but some factors would determine that invasive surgery instead of gamma knife surgery might be required. Some of these could apply in his case, while others would not.

For example, a gamma knife may not be the best solution for those who are very young or very old, although this would not apply to a patient of Gary Woodland’s age.

Other issues favouring different options could include larger or more complex tumours (gamma knife treatment is best for small and well-defined tumours), bleeding disorders or having a metal implant in the head.

Finding the right treatment for brain tumours is important and there will be times when a gamma knife is not the best option. But when it is, it comes with a lot of advantages in enabling you to resume normal activity sooner than invasive surgery would normally allow.