Joey Wahler (Host): There are new, innovative ways of fighting cancer, so we're discussing the treatment options at Wood County Hospital. Our guest, Dr. Dhaval Parikh. He's a Radiation Oncologist and Medical Director of the Maurer Family Cancer Care Center. This is Health Matters, insights from WCH Medical Experts. Thanks for joining us.

I'm Joey Wahler. Hi there, Dr. Parikh. Thanks for being with us.

Dhaval Parikh, MD: Hello, how are you doing?

Host: Great. Yourself?

Dhaval Parikh, MD: Not bad.

Host: Alright, well thanks for hopping aboard. First, for those uninitiated, what exactly in a nutshell is radiation oncology?

Dhaval Parikh, MD: So, generally speaking, there are three ways of treating cancer. One is surgery, where you go and take the cancer out of the body. If you get everything, yay. But if you leave something behind, that's still got to get treated. Chemotherapy is the other aspect where it's, medicine that goes into the body, travels throughout the body, fights the cancer everywhere.

It's not as localized or precise as surgery is, where you're just taking it out, but it does cover everything. Radiation's sort of between the two. Radiation is a way of treating part of the body, not the whole body, just that area, and getting rid of any cancer cells that are there. So it's, uh, more of a local treatment.

Host: Gotcha. So what are some of the most common cancers you're seeing these days?

Dhaval Parikh, MD: We see everything here. You know, obviously the three biggest cancers, lung, breast, prostate, but, you know, the colon cancer, rectal cancers, some types of skin cancers we treat with radiation as well. But, the whole gamut, really.

Host: And so, while naturally a cancer diagnosis can be very scary, to say the least, as we mentioned, there are new advanced treatments which we'll discuss in more detail in a moment. But first, what would you say, Doctor, some common misconceptions patients generally have about their options?

Dhaval Parikh, MD: Patients don't always understand the different modalities. We're not competing with each other. It's not that you get to choose whether you have surgery or chemotherapy or radiation. In some cases you do, but a lot of the times it's trying to figure out what's the best treatment for each patient. They're all different tools in the toolbox. And when you meet with the different specialists in the team, they each tell you how their tool can work to fight your cancer. And usually it's in combination, where it's not just one modality that takes care of it. Though that is the case sometimes, but not always.

Host: So, the two main types of radiation therapy are external and internal. So, what are the basic differences between those?

Dhaval Parikh, MD: So, external radiation is what is given to the vast majority of patients undergoing radiation therapy. And that's where we have, patients lie on a table and we have a machine called a linear accelerator that generates very high energy x-rays that are then directed right to where the cancer is. And we target the cancer in three dimensions, sometimes four dimensions when we allow for movement with breathing and things like that. And it's a precise way of treating just that area. The patient is on the table. They spend a lot of time just making sure they're set up properly, but the machine is typically only on for about 10 minutes or so. Patient just lies still. They don't feel anything during that treatment.

They just, stay where they are. And after the treatment's done, we get them off the table, they get dressed, they go home. And typically radiation treatments are done on a daily basis, Monday through Friday, five days a week. And the course of treatment can be anywhere from two weeks to eight weeks, depending on the type of cancer and the type of treatment you're getting.

Like I said, external radiation given with a linear accelerometer is the most common way patients are treated with radiation. The other type of radiation is internal radiation, sometimes called brachytherapy, and that's where we put radioactive sources inside the patient, and those can either be temporary or permanent, and they give radiation from the inside out.  t That can be very useful for certain cancers where you can get a very high dose to a small area, but that requires more of a procedure and it's, it's used for cervical cancers, for some types of prostate cancers. but the vast majority, it's external radiation.

Host: What are some examples of the new technology available at Wood County Hospital for treating cancer?

Dhaval Parikh, MD: So one of the things I touched on was the four dimensional planning. We've been that here for a while. It allows us to target the cancer, not just where it is, but where it will be during breathing. Now, imagine someone who has lung cancer, their tumor is right in that spot. Now, we know that the cancer does move with respiration.

So it may move this way, it could move that way. We're not completely sure. So in the past we'd have to treat for, a cacer that's this big, we'd treat a large area around it, so if it's moving around, we're still treating it. That's a lot of normal lung that gets treated around there as well. We've now have the technology, it's four dimensional treatment planning, where when we're planning the patient's treatment, we do a four dimensional CT scan.

And that basically scans them while they're breathing. So we can see exactly how the tumor moves during the course of respiration. Some tumors move more up and down, more left, right, whatever it is, we can see that actual motion. And then we shape the fields to treat just that region. Cuts down on side effects, cuts down on complications.

In some cases, what we're doing is not just, you know, if we see that there is too much movement, we could actually gait their treatments, which means that we only treat them during a certain phase of treatment. And that's another advance that's happened recently. And that's, especially for breast cancer patients.

When we're treating the left side, obviously the heart is right there. We want to minimize the dose to the heart and the lungs. So we'll have a patient take a deep breath and hold it. and their treatment will be given at that time. By taking that deep breath, they're creating space between the breast tissue and the underlying heart, so that way the x-rays can treat the breast while minimizing the dose to other structures there.

We've got a special camera on the linear accelerator that can see the contour of the patient's body and match that within about 0.2 millimeters of accuracy. So it's incredibly accurate there. And if we see that, they take a deep breath, they hold it, at some point they're going to want to breathe, this is a good thing, and when they do, the camera will see that they're letting their breath out. It'll immediately stop the machine. We let them take a couple of regular breaths. They take another deep breath and hold it, get right back in position. Machine picks up right where it left off. And by doing that, we can be much more accurate with the treatments.

We can make the dose of radiation throughout the breast much more even, which cuts down on side effects, less skin reaction. And you know, it works very well for most patients.

Host: That's pretty amazing. What's your reaction when you get to use new technology like that?

Dhaval Parikh, MD: Oh, it's always cool. And that's one of the exciting things about cancer. The field is always changing. There's always new advances coming out. One thing you have to be cautious though, is that for every new, great thing that comes out, a lot of things that looked great in the past were tried and ended up not being quite as successful. So as much as you want to try the latest, newest technology, it pays to be just a little bit cautious and wait for some good data to come out to support its use; to show that that technology, that treatment regimen, truly is as effective and as safe as we want it to be.

Host: Interesting. Now, just to follow up on some of what you just discussed, it seems much of treating cancer now is really about targeting it more precisely than ever, sparing healthy tissue. Just maybe explain a little bit better, if you would, please, why that's so important.

Dhaval Parikh, MD: Well, again, one of the things to understand is that cancer is, it's your own cells that have gone a little crazy. They're replicating without any control on them. And because they're replicating, they just keep growing, and they can then cause a mass, that mass can break off, some of those cells can travel somewhere else, and that can, you know, lead to all sorts of problems.

One of the things to understand is the cells are very small. When you're looking at a, images, a PET scan is probably the most sensitive scanner we have to identify cancer. That can detect cancer down to about 7mm in size, reliably. A 7mm ball of cancer is 10 billion cells. So If we had a scanner that was a thousand times better than a PET scanner, which we don't, in fact, if we had something twice as good, that would be, that would make news.

But let's say we had something sometime in the future that is a thousand times better. We'd still be missing 10 million cells here, 10 million there, 10 million. So we're never going to get to the point where we can see every last cancer cell. Because of that, we have to, and specifically with radiation, we have to treat not where we see the cancer, but where we believe the cancer to be.

So we're going after the cancer we can't see. Because if you get rid of 100 percent of the cancer cells, you've cured the patient. If you get rid of 99.999 percent of the cancer, it's going to come back. My job is to get rid of all the cancer, even the cancer that I can't see, that doesn't show up on any studies or any imaging techniques that we have.

Because of that, I'm going to have to treat some of the normal tissue around where I do see the cancer. And it's very important to know how much dose those tissues can handle and keep that dose as low as possible. So I'm getting the highest dose to get rid of the cancer where I know the cancer is and a little bit less to the areas that are around it that are at risk, but maybe not show as much.

And there's a lot of studies that have been done figuring out what the optimal doses are for each one. Another thing that's used to help target cancer cells while sparing the normal cells, is the fact that we do the radiation treatments on a daily basis. What happens is when we treat with radiation, all of the cells in that area are going to get damaged a little bit. But the normal healthy cells can repair radiation damage very, very efficiently. So they get injured a little bit, but then they'll recover. The next day, they'll get injured again, they'll recover again. Next day, injured again, recover again. So as long as we give a small amount of radiation each day, the normal cells can keep recovering.

Now the cancer cells, which is right next to that normal cell, is getting that same dose. But because it's locked in that growth phase, where all it's doing is replicating, it doesn't do maintenance on itself. It gets injured and it stays injured. Next day it gets injured some more, then some more, and some more.

And over the course of these treatments, we're killing off the cancer cells by doing more and more damage to them, which keeps building up; while the normal cells, injured, recover, injured, recover, they survive. It's a little bit simplified, but that's basically how radiation works.

Host: Very educational indeed, to say the least. So Wood County Hospital has some of the same resources available at larger cancer centers. Therefore, I guess it's safe to say in this case, bigger isn't always better. Simply put, what does that mean in this case?

Dhaval Parikh, MD: There are specialized techniques that are only available at certain research centers, and when a patient is in need of something like that, I'll be referring them out. But the truth of the matter is, is that about 98 to 99 percent of treatments can be given here locally, and that makes it a lot easier for the patient.

 We have state of the art technology, comparable to what the vast majority of patients are going to need to give them the best quality care. And, Wood County Hospital has been very aggressive about staying up to date with the latest technology that can help the most patients here.

Host: And so in summary, Doctor, how rewarding is it for you and yours in doing such life changing and often literally life saving work?

Dhaval Parikh, MD: Frankly, it's humbling. I'm not the one doing the work. Yes, I'm directing it and things like that, but ultimately, the scientists who have learned these techniques, the other researchers that are developing it, they're doing some amazing work. The patients going through that are the ones going through the treatments.

They deserve a lot of the credit. We've got a fantastic team that works very hard to give the patients the best care that they can get. So it's humbling. Ultimately, you're doing the best you can for the patient and whether that's here or somewhere else, we'll get them to where they need to be.

Host: Very well said. Well folks, we trust you're now more familiar with Treatment at Wood County Hospital's Maurer Family Cancer Care Center. Dr. Dhaval Parikh, a pleasure. Continued great work and thanks so much again.

Dhaval Parikh, MD: Thanks for having me on.

Host: Absolutely. And for more information, please do visit woodcountyhospital.org/cancer.

If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. And thanks again for being a part of Health Matters Insights from WCH Medical Experts.