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Melanie Cole: Welcome to GW Doc Pod a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole. And joining me is Dr. Yuan James Rao. He's an assistant professor of radiation oncology at the GW Cancer Center, and he's here to highlight radiation oncology. Dr. Rao, it's a pleasure to have you join us today. Can you please start with the evolution a little bit about radiotherapy for cancer, how that's evolved over the years and help us to understand the role and effectiveness specifically of radiation therapy and the cure and palliation of many cancers?

Dr. Yuan James Rao: Radiation started out as a very simple science, it's become very complex. Over the years, we started out with something known as either 2d or 3d conformal techniques, where we designed radiation from a number of different angles, overlapping in the area of the tumor. However, more recently we've started developing techniques, known as intensity modulated radiation therapy, or IMRT, where we use computer optimization. We design the targets in 3d space, inside of a computer. And we design the areas that we want to avoid.

So normal organs around the tumor, and it runs a optimization algorithm where it selects from which angles and from which beam designs from those angles best covers a tumor while avoiding the normal structures in the body. And the dose contributed by these beams from these different angles adds up to the total dose that we want in the tumor while maximally avoiding the surrounding structures. And this is known as intensity modulated, radiation. It's become the standard of care for a number of tumor types within the body, including head and neck cancer, prostate cancer and GYN cancers.

Melanie Cole: It's fascinating. IMRT is. So why has this excited the profession of radiation oncology more than any other new invention since the introduction of the linear accelerator and why is head and neck region, head and neck cancers, an ideal target? We're gonna talk about prostate cancer as well today, but for right now, head and neck cancer, why is this such an ideal target for this type of technology?

Dr. Yuan James Rao: Well, the head and neck region is high value real estate. Most tumors occur within the back of the throat, the oral pharynx, the throat itself, or the larynx or somewhere inside the mouth. The oral cavity. Surrounding these structures are very important things such as the spinal cord, the brain stem, but also things that contribute to quality of life, such as the salivary glands and the muscles that contribute to swallowing.

So if we're able to identify these organs on imaging, and avoid them using IMRT, limiting the dose of these structures. We can make sure that our treatment is number one safe, and then number two, limiting the doses to the swallowing organs and the salivary glands we can limit the long term and the short term side effects of radiation. These can include dry mouth, changes in taste or changes in the production of salivation.

Melanie Cole: Such point that you made about protecting sparing those normal structures. Now tell us a little bit about brachy therapy and where you're using that and why?

Dr. Yuan James Rao: That's a very good question as well. So brachy therapy can sometimes be applied to tumors of the head and neck, but are better applied to tumors within the pelvis because they're more reachable with internal radiation. So the first one that I'll talk about is for prostate cancer. We had mentioned IMRT for prostate cancer and it's a very advanced tool, but brachy therapy may allow radiation to be reduced even more to normal structures.

Nowadays, we use a technique called high dose rate brachy therapy, where we, instead of inserting permanently radioactive materials, we insert catheter. Into the prostate that are guided by ultrasound image guidance. And after these catheters are inserted, we do a scan to localize the regions within the prostate that we wish to treat. And then we connect these catheters to a machine, essentially, a robot that inserts a radioactive source into each of these catheters. And by doing this, the implant is temporary, meaning that the patient is not radioactive after the end of tr treatment.

And there's no radioactive seeds left inside. It also allows us to be more gentle, so to speak with our planning and allows us to dynamically sculpt the radiation dose away from things like the rectum, the bladder, as well as a urethra, which runs right in the middle of the prostate in a way that's better than what could be achieved in the past. The second disease site that I'll talk about for brachytherapy is for GYN malignancies and in particular cancers of the cervix and the uterus. Here at GW, we have extensive experience with brachytherapy, with these cancers, having treated more than 300 patients in the last few years.

And for Cervix cancer, it can be used instead of surgery to eliminate cancers of the cervix by inserting catheters, through the cervix and a little bit into the uterus to give high dose radiation, right where the cancer is, while sparing as much as possible, the organ surrounding it. For cancers of the uterus after surgery, we'll sometimes place catheters in the upper vagina to just give a small amount of radiation, right where the surgery is done to ensure that cancer doesn't come back after the surgery. And often these treatments can be done very simply, conveniently, and with a low amount of side effects.

Melanie Cole: What an exciting time to be in your field. Dr. Rao, how have you been integrating MRI into clinical radiation therapy, planning and monitoring? How has that added value of real time physiologic, MRI for treatment planning and response assessment addressed a long standing challenge for radiation oncologists and how it might be especially useful for mobile tumors, which can change position in unpredictable ways. Tell us how you're using this in some of the advantages and challenges?

Dr. Yuan James Rao: Those are very good questions. And thank you for bringing that up. In the world of head and neck cancer. Sometimes either before surgery or before radiation we'll use an MRI. And that gives us much better soft tissue definition of the tumor versus surrounding organs so that we can be much more precise with our radiation treatment volumes. Allowing us to treat a smaller part of the body with radiation compared to techniques that don't involve the use of MRI imaging.

And after we're done with treatment, of course, we will often use MRI to follow up on how the tumors responding, making sure that it's shrinking or has gone away. In the world of prostate cancer, we almost always get an MRI before the start of radiation treatment to make sure that we know exactly where the prostate tumor is and to make sure that it hasn't broken out of the capsule of the prostate. Using this MRI as part of our treatment planning allows us to use a technique called focal boosted radiation, where we give a standard dose to the entire prostate, but an even higher dose to right where the tumor is as seen on the MRI.

And there has been randomized trials that have shown that this focal boosting technique improves the cure rates for radiation, for prostate cancer without increasing the side effects. And the world of cancer we don't get many freebees and I think this is an important one where we can improve the results without increasing the side effects. In the world of brachy therapy, we also use MRI. This allows us to determine exactly where we need to place the catheters and to make sure that we design the radiation loading within those catheters to best cover the tumor while not covering the surrounding organs. So we use MRI in all of these areas that we talk about, and it's been very helpful.

Melanie Cole: Certainly makes it more precise. Now for other providers, oncologists, primary care providers that are counseling their patients. Can you speak please Dr. Rao about technologic advances that have increased the safety of radiotherapy treatments, speak about any that have changed the landscape of treatment for you?

Dr. Yuan James Rao: Those are very good questions. So in the world of head and neck cancer, there is something known as volume reduction or volume deescalation in what we cover with radiation treatment. And it's best to understand this from a historical perspective. Back in the day. And I'm talking about a few years or decades ago without advanced imaging, such as MRI, we didn't really know precisely where the tumor was or where there were areas that the tumor could have spread to that were hard to see. And therefore, traditional radiation volumes to the head and neck were very large.

Encompassing the area that the tumor started and usually both sides of the neck, which cause considerable side effects in. But now with MRI and PET imaging and including some information from the surgery for patients who do get surgery, we're able to reduce the volume of the head and neck that we treat with radiation to precisely just what we need to cover and not give radiation to other parts of the neck. And this means that for some patients, we only need to treat one side of the neck or sometimes even only the primary cancer itself without covering the lymph node region.

This is known as omitting radiation to the elective lymph nodes. And this has allowed us to dramatically decrease the side effects of radiation in patients who need radiation. The other thing that we're doing at GW is for some patients we are using, what's known as an induction chemotherapy strategy where we give them some chemotherapy followed by surgery for their head and neck cancer. And for some patients, they may not even need radiation. And as everybody knows the most deescalation that we can do with radiation to decrease side effects is to give no radiation. And sometimes we're offer able to offer that to our patients.

Melanie Cole: I'd like you to speak about the importance of this multidisciplinary approach for all of these patients we're discussing here today, as we talk about complications that might arise. And how you manage those side effects and complications. There are many people involved, not only the radiation oncologist, but the oncologists and other providers, speak to that for us, if you would?

Dr. Yuan James Rao: Yes. First of all, we have a whole team of professionals that are involved in the care of every patient that we see for all these types of cancers, head and neck cancers, prostate cancers, and GYN cancers. This includes the radiation oncologist, the surgeon, the medical oncologist, but also in the world of head and neck cancer, it includes speech therapists, the dietician, and patient navigation, if necessary. So for patients who come to our clinic, we often have the patient see all three of the doctors so that we get the opinion of everybody. We then meet to have a discussion at tumor board about the optimal treatment for that individual patient.

And then if radiation therapy is necessary, we have the supporting professionals such as the speech therapist and the nutritionist see the patients on a regular basis to make sure. That their nutrition is optimized and that any sort of physical therapy to help them get through the treatment is done in an appropriate manner. And we find that this helps patients get through treatment while minimizing the side effects of our care, and then after treatment so that they recover much better than someone who doesn't have these supportive services.

Melanie Cole: Really great points. As we wrap up Dr. Row, please speak about the unique areas that set you apart. Why it's important to refer to the specialists at the George Washington University Hospital? And someone wants to refer a patient for treatment for radiotherapy, for head and neck cancers or GYN or prostate cancers, when is the best time to do that?

Dr. Yuan James Rao: Those are wonderful questions. So first of all, it's important to go to a radiation oncologist that sees a high volume of these types of cancers, and here at GW, myself and our team here has treated hundreds of patients with all of these types of cancers with very good results. And we're one of the highest volume centers for IMRT and for brachy therapy in the Washington DC area. And having this entire team and a team that sees many patients has been shown to actually improve. And be associated with an improvement in survival for patients with cancers of the head and neck.

So certainly it is very important. In terms of referral, I would say that patients should be referred. As soon as they know that they have cancer and may need radiation. So even at a very early step in the process, we can see the patient, talk to them about their options. And even if the diagnostic workup such as pet or MRI imaging hasn't been done yet, these are things that we can order here at GW and have results very quickly so that we can help move the process forward for every patient.

Melanie Cole: Great information. Thank you so much, Dr. Rao for joining us today and sharing your incredible expertise. For more information about this topic, you can visit GW hospital.com/cancer. To refer your patient, please call 1 888-4GW-DOCS. Or if you have a question for one of our specialists, please email physicianrelations@gwu-hospital.com. That concludes this episode of GW Doc Pod, a peer-to-peer podcast for medical professionals with The George Washington University Hospital. I'm Melanie Cole.

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