Radiotherapy needs to become more individualised

Dr Verellen, what have been the big recent achievements in radiotherapy?

In the past, developments in radiotherapy were driven by a sort of pendulum motion between clinical experience and radiobiology. This is what happened over the last decades. Today, however, it is juggling between biology, clinical experience and technological improvements. With these new technologies we can improve targeted delivery of doses, what we need now is to be even more accurate in assessing delivered dose and feed this back into our radiobiological models. If we do that on a voxel level – an improved three dimensional imaging – we might start to understand the true radiobiology of tumours and healthy tissues, and this is what research projects should go for.

Do you think the Horizon 2020 programme could help with that?

From a personal point of view, I believe we need to move to truly individualised biological intervention using ionizing radiation. We think we are almost there, but we are not there yet. Just as a surgeon needs to see his scalpel and the tissue that he is cutting, we need to see our scalpels better (the treatment beam) and where the beam is going on a cellular level (inside the patient during treatment delivery, not based on some CT-scans or MRI images acquired a few days before treatment). This requires more efforts in imaging and assessing treatment response, and adapting our strategies in real-time. So looking at the challenge posed by Horizon 2020, we need to develop tools for accurate assessment of dose, integrated into inter-fractional (from day-to-day) and intra-fractional (dealing with respiration and peristaltic motion of anatomy) dose accumulation, and we need to understand this from the biology inside the patient, not just in petri-dishes. This requires more communication between biology and physics. We need to collaborate more through projects working on these issues.

What else could radiotherapy gain from Horizon 2020?

“

‘Reimbursement should be results driven, more than simply being payment for the technology (or drug for that matter) itself’

Horizon 2020 includes provision for research relating to patient safety. We have seen the development of very complicated new machines in our field. So we have been adapting and improving to make machines safer, but they are much more complex, and we have not changed our fundamental safety procedures. Many of our key safety tests reflect older technology, and since we have added new procedures and features we have never really redesigned the control process to reflect the characteristics of these new procedures, which are becoming extremely complicated.

Can you explain a bit more about the safety techniques?

If you look at the physics, a lot of time has been spent on validating and treating plastic dummies. But vendors are selling complex ‘plug-and-play’ machines in an environment where departments are frequently understaffed and under trained, which is a dangerous situation. Hospitals are buying machines without adapting their workflows to these new technologies. The interaction between machines and the living breathing (unpredictable) patient is a real challenge. In addition the software and hardware is being updated constantly, which carries many risks. The aim of radiotherapy can only be realised if we know that the correct tissue is treated in the correct patient with the correct dose and this must be accomplished in the most complicated of modern technological settings, so this is one of the big challenges and I think that the European Society for Radiotherapy & Oncology could initiate collaborative projects into overcoming these challenges.

Do you have any overriding ideas of where to start?

I believe we should move to a ‘process oriented’ rather than ‘device oriented’ quality management system. So you follow the patient though the processes and then identify the critical procedures where there may be a higher frequency of errors or risk, whether these errors can be easily detected or not and, if they would occur, how severe it would be (in short Failure Modes and Effects Analysis). And then you can score the difficulties and figure out the higher priorities in the safety procedure.

Your sector is currently undergoing massive technological change, what challenges does that carry?

We have to be careful that instead of technology looking for problems we should keep our focus on problems looking for technological solutions. We need to develop technology looking to solve issues within the challenge of healthcare budgets (low-cost, high-yield solutions). Technology for the sake of technology is a risk. For example, we are putting a lot of effort into new machines that allow us to track changes in patient anatomy due to respiration, but the clinical reality is that this is of interest for a small group of patients only, where tumours move more than a centimetre. We need to bear in mind that society pays for this, and let’s face it, there will be cuts in the health care budgets. We don’t necessarily need more budgets in health care, but a redistribution. Too much of the financial resources go to treatments that show limited benefit for the patient. The rise in expenses related to drugs and supportive drugs is but one example and we need new financing mechanisms such as Coverage with Evidence Development. One point I would like to make is that reimbursement should be results driven, more than simply being payment for the technology (or drug for that matter) itself. Radiation oncology is ideally placed to play a central and pivotal role in the management of cancer patients, and this position should be made clear to policy makers and patients.