Darrell Rebouche (Host): Hello and welcome to Health on Point, presented by Willis Knighton Health. Radiation-oncology and radiation medicine are ever evolving, and our guest today is at the point of the spear. Dr. Lane Rosen is internationally sought after as a speaker, a presenter, and an expert. Dr. Rosen, thank you for joining us today.

Lane R. Rosen, MD: Darrell, thank you for having me. I'm excited to be here.

Host: We'll talk about your international experience. Will you outline that us a little bit? And then, tell us how you found your path to radiation medicine.

Lane R. Rosen, MD: I'm very fortunate that I was able to work in the city where I grew up. And I think when I was in medical school, I'd always had an interest in cancer. But my high school best friend and medical school best friend also died of malignancy. And I think, in a lot of ways, that shaped the future path that I've been on.

Host: So now, we want to talk about what's new as well as what's tried and true in radiation medicine. And Willis Knighton, we've always been pioneers in this field, and that's primarily thanks to your vision and your leadership. How is it that Shreveport and Willis Knighton have been an early adopter of so many advanced technologies? And can you line out some of those for us please?

Lane R. Rosen, MD: Sure. I mean, we've been very fortunate. We have a really wonderful team here. We put together a number of experts who are culturally bought into the idea of forwarding the field of radiation-oncology.

So early on, even as early as 1997, we began to offer something called IMRT or intensity-modulated radiation therapy. And that's actually a very common form of treatment. It's used at almost every cancer center in the world. We brought it because we wanted to have a treatment option for patients who had failed traditional treatment or patients who needed a second course of therapy.

It ends up we were one of the first 15 sites in the world to use iMRT. And actually, we hosted one of the world's first image-guided IMRT meetings here in Shreveport. And I think a lot of that comes from having a very, very strong physics and dosimetry team and people who really are working together to make that happen.

Host: You talk about IMRT, IGRT. What does that mean for the patient? What do you use these techniques to treat?

Lane R. Rosen, MD: These are just techniques that can essentially bend a radiation beam so that you can target whatever your tumor is very conformally. These techniques are all used. They use CT scans, MRI scans, PET scans as a way of delivering the radiation to a target and completely sparing the structures near them. That is in fact the whole purpose of the field of radiation-oncology. But there are new ways of shaping that beam, modulating that beam with IMRT and image-guided radiation therapy using CAT scans being the foundation for what has come since then.

Host: A generation ago, there would be a lot of healthy tissue that would be adversely affected by radiation treatments. Because of this technology and more technology we're going to speak of in a few minutes, that has changed dramatically in a very positive way. Can you elaborate on that please?

Lane R. Rosen, MD: Yes, it's reduced side effects dramatically. You know, from the early days of radiation, cobalt therapy where people developed skin reaction that was very severe, 3D conformal therapy used CAT scans. And all of a sudden, we started to see a reduction in healthy tissue. IMRT managed to shape the beam perfectly to the tumor, but it came at the cost of a low-dose of radiation to a larger field.

So, the next really great development, and it's one of the areas where Willis Knighton was a true pioneer, was proton therapy, image-guided proton therapy. Protons are a form of particle irradiation. They're a form of radiotherapy. But instead of giving an x-ray beam, proton therapy is a heavy particle that's fired at a target. And it's like a billiard ball, pushes things out of the way. And when it strikes the tumor, it deposits all of its dose right on the target and it's annihilated. There is no exit dose. So where if with a traditional form of radiation, if I took an x-ray of you and put film behind you, we would see your bones. If I treated you with a particle beam, the particle would never exit your body and the x-ray film would be blank. So, particles, which are a very expensive technology, revolutionized radiation-oncology. And at Willis Knighton, we were actually the first community-based proton center in the whole world.

Host: You know, that sounds very space age and cool. I can imagine just the thought of it though, conceptually, might be a little bit frightening or off-putting to some patients. Can you talk to us about the patient experience for these techniques you've talked about, particularly the proton therapy chamber? I mean, that's a beautiful space. There's nothing to be afraid of.

Lane R. Rosen, MD: You're exactly right. In fact, for the patient, they will notice no difference between getting protons versus IMRT on a more traditional machine, which we call linear accelerators. What's happening is what's happening behind the wall. For proton therapy, we have a, 500,000-pound cyclotron that can generate these particles and accelerate them to two-thirds of speed of light. There's a massive gantry that's also extremely heavy, two stories in size, heavy steel, and yet those devices can rotate around a half millimeter access with accuracy. So, there's a lot happening behind the wall. But for the patient experience, it's lying on a table very comfortably for typically 10 minutes and they feel absolutely nothing. Rather, you're getting IMRT or proton therapy.

Host: I think it's important to emphasize that, thanks to your leadership and the administration at Willis Knighton, Willis Knighton was a world leader in the implementation of this proton therapy. Can you elaborate on that please?

Lane R. Rosen, MD: Yes, actually. So, there were only 13 proton facilities in the United States when Willis Knighton became a proton site. However, most of those sites were $200 million, $180 million sites. They required a football field in space. What makes the program at Willis Knighton unique was that our machine, our unit, is compact. It's much smaller. It has a robotic table. It had built-in CAT scan guidance. In fact, not only was it the first community proton center in the world, it was also the first compact image-guided proton facility in the world.

So, we were able to do this, number one, as you mentioned, we had tremendous support from our administration. Now, you don't become a proton therapy site because you want to. You have to have a team in place. In particular, we were very fortunate. We have a very strong physics team under the leadership of Dr. Terry Wu, who's internationally renowned, and a number of really, really great people that allowed us to bring this to Shreveport. Compact proton therapy, which has now become the standard, almost no one is buying large proton units anymore, but to introduce something like that requires a number of people moving in the same direction. We are really proud that now, for example, I think there's 50 or so Proteus ONE machines around the world. And most of them visited our site.

In fact, as you may know, Darrell, we were offering proton therapy in Shreveport, Louisiana before some pretty famous places like Memorial Sloan Kettering Cancer Center in New York City, Mayo Clinic, Johns Hopkins.

Host: I want to give Dr. Wu and his physicist and your dosimetrist their flowers in a few minutes. But let's talk about what kind of patients you are seeing with these techniques. And we have more still to come. But when we talk about proton therapy, we talk about IMRT, IGRT, who are your ideal or perhaps your most common candidates, if those intersect?

Lane R. Rosen, MD: You know, actually, it's interesting. There was also a separate set of patients that I'll briefly mention where IMRT and IGRT came together and allowed us to do something, and we were early pioneers in this as well, called SBRT. We're giving a number of initials here, but SBRT stands for stereotactic body radiotherapy. And that's a technique where we used to take patients who would come to us with small lung cancers who were really considered incurable, unless they could have surgical resection. And so, they would be sent for radiation and you would give them seven or eight weeks of radiation therapy, but with recognition that you would cure very few.

We were able to use this technique called SBRT, which we've been doing here for 23 years at Willis Knighton, to deliver eight weeks of radiation in only four or five days. And when you deliver that really, really high dose of radiation concentrated to a small area, all of a sudden we were seeing cure rates that rivaled surgery. And when we first started doing that, and I was very fortunate to lecture in a couple of dozen countries on this technique, which they still use in many places, it eventually became the standard of care. And now, most modern radiation-oncology departments offer SBRT as part of their cabinet of weapons.

As far as patients that are selected for these treatments, IMRT has become standard. It's used in probably 90% of radiation therapy patients where we find proton therapy or SBRT to be more helpful is in patients where you are very, very concerned about a critical healthy structure that's sitting near your tumor. So for example, prostate cancer, we know that the prostate sits near the bladder and near the rectum or bowel. And if we can deliver a very high dose of radiation to that prostate and spare those healthy structures, there's been a lot of data, including for very high-risk patients that demonstrate improved outcomes.

In some cases, the data suggests it superior to surgery or traditional IMRT. Head and neck patients, recently, a clinical trial, a national clinical trial, which our team was fortunate to be part of, demonstrated that proton therapy offered a survival advantage in head and neck patients over traditional IMRT. In brain tumors, a recent publication demonstrated that some of the meanest and most terrible brain tumors have a better response, better tolerance, and a better ability to receive other therapies like chemotherapy when they undergo proton therapy.

So, proton therapy is not for everybody. You really have to select your patient. And we're very fortunate here. In addition to IM-RT, IGRT, SBRT, our barrel of letters, and proton therapy, we also do something here called brachytherapy. And brachytherapy is a type of radiation where you put a radiation source directly where a tumor sits. And back in the day, when the American Brachytherapy Society used to have a training program, we were one of the sites, I think Harvard and UCLA, Willis Knight. And we trained other doctors how to do high dose rate brachytherapy. And our program has treated thousands of patients with that. In fact, our national society, ASTRO, the American Society Therapeutic Radiation-Oncology, some of their pamphlets on brachytherapy and gynecologic malignancies and their pamphlets and videos on brachytherapy were made and filmed in this office.

Host: Well, the newest thing, newest treatment offered in your department is nuclear oncology. Nuclear oncology, that sounds interesting. And radiopharmaceuticals. So, what's that? What's going on there?

Lane R. Rosen, MD: Darrell, the future of radiation-oncology is very exciting. And one of the areas where I am really, really excited about the potential is this concept of radiopharmaceutical therapy. We have been giving radiopharmaceuticals in our department at Willis Knighton for 28 years. But a few years ago, there were some developments that changed everything.

The use of a specialized PET scan, which, again, Willis Knighton has been using PET scans longer than many places in the world, but there are now specialized imaging on PET scans that are cancer-specific. For example, for a prostate cancer, you could use a PET isotope to image a patient with prostate cancer and see everywhere their cancer has spread much more effectively than you could with the common PET scan that's used all over the world.

Well, once you've got that isotope that can find that cancer very carefully, you could switch out the diagnostic isotope, the radioactive source that lights up on the PET scan and replace it with a therapeutic source, a source that can kill cancer like we've been doing with brachytherapy for decades, frankly, more than a hundred years.

So, what happens is you take that same isotope, radio-label it, if you will, with this therapeutic, very effective cancer-killing tool, and inject the patient. And this isotope travels throughout the body and everywhere where it sees disease, it attaches. And the radioactive source next to it delivers a very potent dose of radiation just to the cancer. It is the most conformal treatment we have, even more so than protons or brachytherapy, but it's in its infancy and we're only using it for a few disease sites. But already, Willis Knighton has become an international leader in this division of our department, which we call nuclear oncology.

In our department, we now have a dedicated PET CT scan, a dedicated SPECT CT scan, one of the first in the world of its type, just for this type of radiopharmaceutical therapy, commonly called as theranostics. That means therapy and diagnosis or diagnostics mixed together. And so, we have a full-time theranostics fellowship where we've recruited PhD-level folks who will help learn about this technique and spread it around the country. We have researchers, dedicated physicists and dosimetrist because we are trying to advance the field of radiopharmaceuticals. It's a very exciting future.

Host: This is Health on Point presented by Willis Knighton Health. Our guest is Dr. Lane Rosen, who is the Director of Radiation-Oncology at the Willis Knighton Cancer Center. Dr. Rosen, I know patients will focus the doctors on you and your partners, but there are a lot of healthcare professionals who are there to help you working side by side with you, dosimetrist, medical physicists, and so much more. Your department is structured in three distinct departments. Can you explain that to us please?

Lane R. Rosen, MD: Absolutely. So, we have three divisions, as you mentioned. We have our general radiation-oncology department, which includes the linear accelerators and brachytherapy. We have our proton therapy division, And we have the newest division, which we call nuclear oncology, where theranostics is delivered.

In order to make those three divisions work, you have to have very specialized masters-level or PhD-level physicists who work in those areas. We have eight, five of which are PhD level physicists. And we also have three very dedicated dosimetrists, some who've won national contest and treatment planning who work hand in hand with our physicians, our nurses, our physician assistants, and our radiation therapists who actually deliver the treatment each day.

This department depends not just on all of those specialists, but the outstanding group of nurses, ancillary staff, even as far as our secretaries. Everyone in this department works together for the patient's good. And it's something we're known for nationally because, if you're not an aligned department and you have not always considered the patient the most important part of our department, you cannot offer these kind of things.

So as a result, I think people know, and we've been able to recruit these wonderful, talented people from all over the world from as far as Taiwan to come to Willis Knighton Cancer Center and be a part of this operation.

Host: Moreover, you mentioned the cancer center, I mean, you are one very, very bright, shiny aspect of. But the center works as a whole with your leadership and the leadership of some other people in the building to try to make everything as efficient as it can be, as friendly and warm as it can be for the patients. You were there for the groundbreaking of the Willis Knighton Cancer Center. So, just tell us how the whole building, the whole operation is integrated.

Lane R. Rosen, MD: So, you're right. So radiation-oncology is how the cancer center began with our linear accelerators, and we built the building around it. Since that time, we have been able to bring to this center eight outstanding medical-oncologist, what are called hematology oncologists. They're the folks that give chemotherapy, biological therapy, targeted agents, immunotherapy. And we work hand in hand with them.

We've brought in a world-class gynecologic oncologist who addresses specialty diseases like ovarian cancer and cervical cancer and uterine cancer. But we also have nutritionists, dieticians, physical therapists. We have foundations that help patients with transportation and housing. It's a remarkable one-stop shop, and it's one of the reasons why Willis Knighton is what we refer to as a tertiary cancer center.

We get referrals from all over the country, but certainly from this region. And our typical patients may travel, you know, a hundred miles to see us. So, upstairs, they're doing some real leading-edge clinical trials that as are we. And in order to work appropriately, you have to work hand in hand. And I think the communication that can occur in a private community, but very large cancer center like this, gives us an edge over some of the biggest academic centers in the world. We don't typically communicate by email or text. It's voice and person to person, and I think that's very valuable for our patients.

Host: We've talked about some of the things, some of the accolades honors you've received. You talked about your dosimetrist getting an award. George Starkschall Award is something that you are really particularly proud of. Can you tell us about that?

Lane R. Rosen, MD: Yes. A few years ago, we were very privileged to produce a paper, a physics paper, on commissioning of our proton therapy unit, that was quite renowned. And in fact, out of the many thousands of submissions, our department received the George Starkschall Award for the best medical physics publication in 2019 by the American Association of Physicists in Medicine, AAPM is another set of initials. That had never really been given to a community department before. And we were very, very proud of that.

The other thing that we, I think, really are proud of—that's kind of a recent development—is the largest organization for proton therapy in the United States. It's known as PTCOG or the Particle Therapy Cooperative Group of North America. And this is a national organization where all of the major academic centers in the country that have proton therapy attend a yearly annual meeting. And this is usually held at places like MD Anderson or, last year, it was held at Memorial Sloan Kettering Cancer Center. Next year, it'll be held at Johns Hopkins Medical Center.

We were very proud that this year our department here in Shreveport, Louisiana hosted PTCOG North America. We were able to welcome the most, you know, famous cancer centers in the world here to Shreveport and show off the technology and the expertise and our beautiful cancer center. It was really heartwarming, especially for somebody who's, you know, from Shreveport. I really was proud.

Host: That is cool, because the world came to you. The nation came to you. But this has also happened in little smaller doses over the years, particularly when you started with proton therapy and the Proteus ONE. Tell us a little bit about some of the visitors you've had. I mean, you've had some pretty eye-popping people stepping in to just see what you got going on there at the cancer center at Willis Knight.

Lane R. Rosen, MD: Yes, I mean, it's been great. I think most of the major cancer centers in the world have traveled here either for brachytherapy or proton therapy, to learn about the center, to train. In fact, the first site to train in Spain in proton therapy, their team spent time at Willis Knighton for our training because they were going to be using our same Proteus ONE machine. We trained some folks from England. We've had international visitors from every major cancer center you can think of. And we've traveled to around the world teaching about proton therapy, about IMRT, our tomotherapy machine, which was the fourth treating TomoTherapy machine in the world back in 2003. We've traveled about that. So, yeah, it's been really special to have these folks come to Shreveport, learn because we're very comfortable in training people in these technologies.

Host: When you travel around the world for these topics and you present, do you find that people are surprised that this is going on in North Louisiana? And what do you tell them? How do you describe everything?

Lane R. Rosen, MD: You know, out of the country, people don't know the difference between Shreveport and and Dallas, so we don't see that internationally. But in the United States, I think a lot of people are surprised. A large community hospital in Shreveport, Louisiana is leading the way in every major category of radiation therapy.

That said, it's important to understand that Willis Knighton is a very large health system, right? I mean, you know, this is a system that's been written up as a top 10, top 12 center in Becker's Hospital Review. Willis Knighton is financially secure. It has a, I think, almost 7,500 employees. So, we're not a small system. But in oncology, I think that they're often surprised until they visit our center. When people visit our center, they recognize what we're doing here is leading the way. We've had wonderful evaluations from folks at Harvard and Mayo Clinic and the University of Pennsylvania. And they've written letters, University of Alabama, often, you know, saying frankly that they were, if you will, in a nice way, a little humbled that we're able to do what we're able to do in a community system. But I want to emphasize, I mean, I have very strong partners in this department. when you put the right people together with an administration that's supportive, it's resulted in some really good things.

Host: Let's play a quick game. One question. You have three choices. Agree, disagree, agree with caveats. Fair rules?

Lane R. Rosen, MD: Fair rules.

Host: Okay. In most cases, cancer patients within a day's drive of Shreveport, Louisiana can get a level of cancer care here that's as good as anything in the country.

Lane R. Rosen, MD: Definitely agree.

Host: Dr. Lane Rosen, thank you for your time today. Congratulations on everything that you've achieved. What's next?

Lane R. Rosen, MD: Well, thank you for having me, Darrell. I think the next development may also be starting here, and that's some advancements in the nuclear oncology radiopharmaceutical field. That's under development, and I think we still have a couple of years down the road, but we're coming very close to these advanced forms of radiopharmaceuticals that may cause up to a hundred times more cell-killing ability for cancer with perhaps a hundred times less damage to surrounding tissues than what exists right now.

So, the future is very exciting, and I think the integration of radiopharmaceuticals and what we're already doing in the radiation-oncology department with protons, IMRT, and SBRT will really be groundbreaking and change the future of cancer care.

Host: You never slow down, do you, Dr. Rosen?

Lane R. Rosen, MD: Can't afford to.

Host: Well, thank you. Thanks everybody for joining us for Health on Point, presented by Willis Knighton Health. I'm Darrel Rebouche. And again, for Dr. Lane Rosen, thank you so much.