Implications of Radiotherapy Utilization in Korea from 2010 to 2019.

BACKGROUND: This study was to assess the rate of radiotherapy (RT) utilization according to the modality in South Korea to identify the implications of contemporary RT patterns. METHODS: We collected information from claims and reimbursement records of the National Health Insurance Service from 2010 to 2019. We classified the location of each institution as capital (Seoul, Incheon, and Gyeonggi-do) and non-capital areas. RESULTS: The rate of RT utilization in total cancer patients nationwide was 24.5% in 2010, which consistently has increased to 36.1% in 2019 (annual increase estimate [AIE], 4.5%). There was an abrupt increase in patients receiving intensity-modulated RT (IMRT), with an AIE of 33.5%, and a steady decline in patients receiving three-dimensional conformal RT (3DCRT), with an AIE of -7.1%. The commonest RT modality was IMRT (44.5%), followed by 3DCRT and stereotactic RT (SRT) (37.2% and 13.5%) in 2019. An increasing trend of advanced RT (such as IMRT and SRT) utilization was observed regardless of the region, although the AIE in the capital areas was slightly higher than that in non-capital areas. CONCLUSION: The utilization of overall RT application and especially of advanced modalities remarkably increased from 2010 to 2019. We also found gaps in their AIEs between capital and non-capital areas. We should ensure that advanced RT is accessible to all cancer patients across South Korea.

Image guidance: past and future of radiotherapy.

Image guidance has been playing a decisive role throughout the history of radiotherapy, but developments in 3D-and 4D imaging data acquisition using computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) have significantly boosted the precision of conformal radiotherapy. An overarching aim of radiotherapy is conforming the treatment dose to the tumor in order to optimally limit a high radiation dose outside the target. Stereotactic, intensity modulated, and adaptive radiotherapy are all largely based on appropriately using imaging information both before and during treatment delivery using on-board imaging devices. While pretreatment imaging for planning has reached a very high level in the past two decades, the next step will be to further refine and accelerate imaging during treatment delivery, resulting in adaptation of the dose fluence during a patient's treatment in various scenarios, some of which are discussed in this article.

A Survey of Radiation Therapy Utilization in Korea from 2010 to 2016: Focusing on Use of Intensity-Modulated Radiation Therapy.

BACKGROUND: This study aimed to assess the recent changes of radiation therapy (RT) modalities in Korea. In particular, we focused on intensity-modulated radiation therapy (IMRT) utilization as the main index, presenting the application status of advanced RT. METHODS: We collected information from the Korean Health and Insurance Review and Assessment Service data based on the National Health Insurance Service claims and reimbursements records by using treatment codes from 2010 to 2016. We classified locating region of each institution as capital vs. non-capital areas and metropolitan vs. non-metropolitan areas to assess the regional difference in IMRT utilization in Korea. RESULTS: IMRT use has been steadily increased in Korea, with an annual increase estimate (AIE) of 37.9% from 2011 to 2016 (P < 0.001) resulting in IMRT being the second most common RT modality following three-dimensional conformal radiotherapy. In general, an increasing trend of IMRT utilization was observed, regardless of the region. The rate of AIE in the capital areas or metropolitan areas was higher than that in non-capital areas or non-metropolitan areas (40.7% vs. 31.9%; P < 0.001 and 39.7% vs. 29.4%; P < 0.001, respectively). DISCUSSION: The result of our survey showed that IMRT has become one of the most common RT modalities. IMRT is becoming popular in both metropolitan and non-metropolitan areas, while metropolitan area has faster AIE possibly due to concentration of medical resources and movement of advanced patients.

Current diagnosis and treatment of basal cell carcinoma.

Basal cell carcinoma represents is most common tumor in fair-skinned individuals. In Germany, age-standardized incidence rates are 63 (women) and 80 (men) per 100,000 population per year. Early lesions may be difficult to diagnose merely on clinical grounds. Here, noninvasive diagnostic tools such as optical coherence tomography and confocal laser scanning microscopy may be helpful. The clinical diagnosis is usually confirmed by histology. Standard therapy consists of complete excision with thorough histological examination, either by means of micrographic surgery or, depending on tumor size and location as well as infiltration, using surgical margins of 3-5 mm or more. In particular, multiple basal cell carcinomas (such as in Gorlin-Goltz syndrome) and locally advanced as well as rarely also metastatic basal cell carcinoma may pose a therapeutic challenge. In superficial basal cell carcinoma, nonsurgical therapies such as photodynamic therapy or topical agents may be considered. In case of locally advanced or metastatic basal cell carcinoma, an interdisciplinary tumor board should issue therapeutic recommendations. These include radiation therapy as well as systemic therapy with a hedgehog inhibitor.

Radiotherapy for head and neck cancer: an increasing dependence on innovative imaging.

Technical improvements in computed tomography and magnetic resonance imaging as well as the wider availability of biological imaging have facilitated the implementation of high-precision 3-dimensional conformal and intensity-modulated radiotherapy (RT) in head and neck cancer. The integration of recent advances in functional and molecular imaging has already improved RT delivery, response prediction, and follow-up. Rational clinical use of all modalities should be encouraged, especially in the setting of imaging-intensive investigational RT protocols such as adaptive therapy. An expanded development of imaging markers that can predict radioresistance or outcome could further customize treatment. The continued successful use of innovative imaging in routine clinical practice will ultimately depend on well-designed clinical studies with adequate follow-up.

[Malignant lymphomas: clinical appearance, classification, therapy and prognosis]. / Maligne Lymphome: Klinik, Klassifikation, Therapie und Prognose.

CLINICAL ISSUE: Malignant lymphomas are the most common cancers of the hematopoietic system. STANDARD TREATMENT: The treatment is usually cytotoxic chemotherapy after the appearance of symptoms in indolent lymphoma and immediately in aggressive lymphoma. Local therapy, such as radiotherapy is sometimes required in addition to systemic treatment. TREATMENT INNOVATIONS: By the introduction of targeted therapies the prognosis has improved. The monoclonal antilymphoma antibody rituximab is a prototype for many other cancers. DIAGNOSTIC WORK-UP: A biopsy is mandatory for diagnosis. Additional immunohistological and molecular genetic analyses may provide prognostic information. Imaging techniques, such as computed tomography (CT), ultrasound or positron emission tomography (PET) are used for staging, restaging and follow-up. Following chemotherapy for Hodgkin's disease PET can be considered to identify patients who do not require additional radiotherapy. PERFORMANCE: Aggressive lymphomas are often curable. In Hodgkin's disease the long-term survival rate is over 90% and in diffuse large cell lymphoma between 60-90%. Indolent lymphomas are not curable by standard therapy, however, the survival rate is also high. ACHIEVEMENTS: After introduction of rituximab, the survival chance has improved by at least 10% in both indolent and aggressive lymphomas. Other targeted therapies and autologous or allogeneic transplantation have made additional contributions. PRACTICAL RECOMMENDATIONS: Due to the rapid increase of knowledge patients should be treated in experienced centers and whenever possible, in clinical trials. Using molecular genetic analyses and functional imaging, the treatment can be individualized even more.

[New aspects of primary radiochemotherapy in head and neck cancer. Highlights from the 2011 ASCO Congress]. / Neue Aspekte der primären Radiochemotherapie bei Kopf-Hals-Tumoren. Highlights vom ASCO-Kongress 2011.

Primary radiochemotherapy is a treatment option for patients with locally advanced or unresectable head and neck cancer. Compared to conventional radiotherapy, intensity-modulated radiotherapy (IMRT) is associated with fewer long-term toxicities and better quality of life. Whether IMRT improves local control in these patients needs to be further investigated. The risk factors and treatment toxicities must be taken into consideration and discussed with the patients. New approaches combining radiotherapy and biological targets are a treatment option. The implementation of these substances in treatment protocols is increasing. Sensitive and specific prognostic biomarkers for patient identification to optimize treatment selection are important, but reliable parameters are still missing.

Four dimensional radiotherapy: a review of current technologies and modalities.

Organ motion is a substantial concern in the treatment of thoracic tumours using radiotherapy. A number of technologies have evolved in order to address this concern in both the fields of CT imaging and radiation delivery. This review paper investigates the technologies which have been developed for the delivery of radiotherapy as well as the accuracy and workload implications of their use. Treatment techniques investigated include: breath hold, breath gating, robotic compensation and MLC manipulation. Each technique has its own advantages and drawbacks in regards to accuracy, treatment time, linac alterations and workload. Further, some treatment techniques have specific requirements for what kind of CT scans needs to be used in the planning process. This, along with the aforementioned considerations, could influence the decision as to implement some of these treatment techniques in the clinic.

[Modern radiotherapeutic concept - stereotactic, adjuvant, palliative]. / Moderne strahlentherapeutische Konzepte - stereotaktisch, adjuvant, palliativ.

Radiotherapy is an important and well integrated part in modern treatment concepts for cancer of the lung and pleura. Thanks to technical progress in the last years radiotherapy has managed to prove its role in all stages of lung cancers and has opened a spectrum of new treatment options. Stereotactic radiotherapy of the early NSCLC has become the standard treatment for radically inoperable patients. It provides better local control rates than traditional conventionally fractionated radiotherapy. In stage III NSCLC, simultaneous radiochemotherapy is an effective option with equal results compared to surgery. The standard treatment for limited disease SCLC is primary simultaneous radiochemotherapy. All patients with good response after primary treatment profit from prophylactic cranial irradiation. Adjuvant radiotherapy is a component of the trimodal treatment for curative approaches in patients with pleura mesothelioma. Palliative radiotherapy is the standard treatment for brain metastases, bone metastases and compression or obstruction from thoracal tumour mass.

Early prostate cancer--which treatment do men prefer and why?

STUDY TYPE: Preference (prospective cohort). LEVEL OF EVIDENCE: 1b. What's known on the subject? and What does the study add? In general the literature suggests that there is a need for improvement in aiding men diagnosed with early prostate cancer in their decision making about treatment options and that our understanding of this process is inadequate. There is limited data analyzing the reasons why these men decide between potentially curative or observational treatments and data evaluating patients' views before and after definitive therapy are scarce. This study begins the process of understanding the reasons underlying a patient's final treatment decision. Being a prospective study, it looks at the thought processes of these men before treatment during the time the decision is made. It also documents how satisfied patients are with their choice after their treatment and whether they would choose the same treatment again. OBJECTIVE: To identify the reasons for patients with localised prostate cancer choosing between treatments and the relationship of procedure type to patient satisfaction post-treatment. PATIENTS AND METHODS: 768 men with prostate cancer (stage T1/2, Gleason≤7, PSA<20 ug/L) chose between four treatments: radical prostatectomy, brachytherapy, conformal radiotherapy and active surveillance. Prior to choosing, patients were counselled by a urological surgeon, clinical (radiation) oncologist and uro-oncology specialist nurse. Pre-treatment reasons for choice were recorded. Post-treatment satisfaction was examined via postal questionnaire. RESULTS: Of the 768 patients, 305 (40%) chose surgery, 237 (31%) conformal beam radiotherapy, 165 (21%) brachytherapy and 61 (8%) active surveillance. Sixty percent of men who opted for radical prostatectomy were motivated by the need for physical removal of the cancer. Conformal radiotherapy was mainly chosen by patients who feared other treatments (n=63, 27%). Most men chose brachytherapy because it was more convenient for their lifestyle (n=64, 39%). Active surveillance was chosen by patients for more varied reasons. Post-treatment satisfaction was assessed in a subgroup who took part in the QOL aspect of this study. Of the respondents to the questionnaire, 212(87.6%) stated that they were satisfied/extremely satisfied with their choice and 171(92.9%) indicated they would choose the same treatment again. CONCLUSION: Men with early prostate cancer have clear reasons for making decisions about treatment. Overall, patients were satisfied with the treatment and indicated that despite different reasons for choosing treatment, they would make the same choice again.

[Radiotherapy of prostate cancer]. / Strahlentherapie des Prostatakarzinoms.

With the development of modern radiation techniques, such as intensity-modulated radiotherapy (IMRT), a dose escalation in the definitive radiotherapy of prostate cancer and a consecutive improvement in biochemical recurrence-free survival (BFS) could be achieved. Among others, investigators at the Memorial Sloan-Kettering Cancer Center (MSKCC) saw 5-year BFS rates of up to 98%. A further gain in effectiveness and safety is expected of hypofractionation schedules, as suggested by data published by Kupelian et al., who saw a low 5-year rate of grade ≥2 rectal side-effects of 4.5%. However, randomized studies are just beginning to mature. Patients with intermediate or high-risk tumors should receive neoadjuvant (NHT) and adjuvant (AHT) androgen deprivation. Bolla et al. could show an increase in 5-year overall survival from 62-78%. The inclusion of the whole pelvis in the treatment field (WPRT) is still controversial. The RTOG 94-13 study showed a significant advantage in disease-free survival after 60 months but long-term data did not yield significant differences between WPRT and irradiation of the prostate alone.The German Society of Urology strongly recommends adjuvant radiotherapy of the prostate bed for pT3 N0 tumors with positive margins. In a pT3 N0 R0 or pT2 N0 R+ situation, adjuvant radiotherapy should at least be considered. So far, no randomized data on NHT and AHT have been published, so androgen deprivation remains an individual decision in the postoperative setting. In a retrospective analysis Spiotto et al. reported a positive effect for adjuvant WPRT and biochemical control.This article summarizes the essential publications on definitive and adjuvant radiotherapy and discusses the additional use of androgen deprivation and WPRT.

[Treatment of advanced metastatic melanoma]. / Therapie des inoperabel metastasierten Melanoms.

In the past therapy of advanced melanoma with distant metastases was characterized by limited success. In recent years the increased understanding of the pathogenesis of melanoma as well as tumor immunology, however, has allowed the development of new promising therapeutic options for certain subgroups of melanoma patients. In the present review these molecular-targeted and immune-modulating therapies, as well as already established therapies such as radiation or chemotherapy, will be discussed.

[Acoustic neuroma (vestibular schwannoma) therapy from an oto-rhino-laryngological perspective]. / Therapie des Akustikusneurinoms (Vestibularisschwannoms) aus der Sicht der HNO-Heilkunde.

Acoustic neuroma/vestibular schwannoma treatment has changed considerably since the 1990s, when surgical treatment was recommended in all cases of schwannoma, whereas nowadays a more differentiated approach is taken. The three classical approaches (translabyrinthine, transtemporal, and suboccipital) still have their surgical value; however, greater importance is apportioned to radiotherapy (radiosurgery, gamma- and cyber-knife). Magnetic resonance imaging in particular has changed diagnostics and how tumor growth is followed. Electrophysiological monitoring of facial and auditory nerves has helped lower postoperative morbidity. New issues have been raised regarding quality of life. Neuropsychological investigations for cognitive and mnestic performance following procedures in the cerebellopontine angle have highlighted problem areas receiving hitherto little attention. Finally, the therapy of this benign lesion should be planned individually, taking the patient's age as well as their professional and personal status into consideration.

Under-recognized toxicities of cranial irradiation.

Cranial irradiation of primary or metastatic lesions is frequent, historically with 3D-conformal radiation therapy and now with stereotactic radiosurgery and intensity modulation. Evolution of radiotherapy technique is concomitant to systemic treatment evolution permitting long time survival. Thus, physicians have to face underestimated toxicities on long-survivor patients and unknown toxicities from combination of cranial radiotherapy to new therapeutics as targeted therapies and immunotherapies. This article proposes to develop these toxicities, without being exhaustive, to allow a better apprehension of cranial irradiation in current context.

[Overcoming of radiation resistances]. / Strahlenresistenzen und ihre Überwindung.

Despite good achievements in prevention and control, cancer is still a leading cause of death worldwide. The development of resistances against conventional treatment modalities is one of the main causes of failure in the treatment of cancer. Radio- and chemotherapies fail frequently due to intrinsic or acquired resistances in apoptotic signalling pathways or alterations in DNA-repair processes. Targeted radiotherapies employing α-particle-emitting radionuclides and Auger-emitting electrons are a promising approach in cancer treatment to break radio- and chemoresistance by overcoming DNA-repair mechanisms and reversing deficient activation of apoptotic pathways in cancer cells.

The SIOP-Renal Tumour Study Group consensus statement on flank target volume delineation for highly conformal radiotherapy.

For decades, radiotherapy with two opposing photon beams has been the standard technique used to cover the flank target volume in paediatric patients with renal tumours. Nowadays, many institutes are implementing advanced radiotherapy techniques that spare healthy tissue. To decrease the radiotherapy dose to healthy structures while preserving oncological efficacy, the conventional approach of flank irradiation has been adapted into a guideline for highly conformal flank target-volume delineation by paediatric radiation oncologists and representatives of the International Society of Paediatric Oncology's Renal Tumour Study Group (SIOP-RTSG) board during four live international consensus meetings. The consensus was refined by delineation exercises and videoconferences by ten collaborating paediatric radiation oncologists. The final guideline includes eight chronological steps to generate the tumour bed and clinical, internal, and planning target volumes, and it describes the optional use of surgical clips to optimise treatment planning. This guideline will be added into the radiotherapy guideline of the UMBRELLA SIOP-RTSG protocol for paediatric renal tumours to improve international consistency of highly conformal flank target-volume delineation.

Treatment planning for proton therapy: what is needed in the next 10 years?

Treatment planning is the process where the prescription of the radiation oncologist is translated into a deliverable treatment. With the complexity of contemporary radiotherapy, treatment planning cannot be performed without a computerized treatment planning system. Proton therapy (PT) enables highly conformal treatment plans with a minimum of dose to tissues outside the target volume, but to obtain the most optimal plan for the treatment, there are a multitude of parameters that need to be addressed. In this review areas of ongoing improvements and research in the field of PT treatment planning are identified and discussed. The main focus is on issues of immediate clinical and practical relevance to the PT community highlighting the needs for the near future but also in a longer perspective. We anticipate that the manual tasks performed by treatment planners in the future will involve a high degree of computational thinking, as many issues can be solved much better by e.g. scripting. More accurate and faster dose calculation algorithms are needed, automation for contouring and planning is required and practical tools to handle the variable biological efficiency in PT is urgently demanded just to mention a few of the expected improvements over the coming 10 years.

[Neoadjuvant and surgical treatment for rectal cancer]. / Neoadjuvante und operative Therapie des Rektumkarzinoms.

According to the 2008 guidelines on colorectal cancer, whether preoperative therapy is indicated for rectal cancer should be judged based on the T and N categories. A few centres limit the indication for preoperative radio(chemo)therapy to patients with tumours that, according to magnetic resonance tomography (MRT), extend to the fascia mesorectalis or are 1 mm or less away from it - so-called circumferential resection margin-positive or CRM-positive tumours. Omitting preoperative therapy for MRT CRM-negative tumours is, however, a matter that still requires further study in clinical trials. The high rate of distant metastases continues to be a problem. Assuming that pathohistological complete remission (pCR) is a predictive marker of long-term disease-free survival after neoadjuvant radiochemotherapy, attempts are now being undertaken to intensify the neoadjuvant therapy. Phase II trials show improved pCR rates by combining the preoperative radiation with the double combinations oxaliplatin or irinotecan plus infusional or oral 5-FU (capecitabine). In the case of limited T1 rectal cancer without further risk factors, transanal local excision can be used.

[Radiotherapy, chemotherapy and target therapy for treatment of head and neck cancer : new developments]. / Strahlen-, Chemo- und Targettherapie von Kopf-Hals-Karzinomen : Neue Entwicklungen.

Approximately 60% of patients initially treated for squamous cell cancer of the upper gastrointestinal tract suffer from advanced tumor disease (UICC stages III and IV). Multimodal strategies lead to overall survival rates of up to 50%. Recent studies show indications that the risk of distant metastases after induction chemotherapy (CT) is less than after primary radiotherapy (RT) or radiochemotherapy (RCT). Hyperfractionation or accelerated radiation with concomitant boost shows superior results compared to classic RT. Intensity-modulated radiotherapy (IMRT) is a new method for better adjusted dose distribution. Targeted therapy with specific antibodies against biological targets, such as epidermal growth factor receptor (EGFR), showed superiority over RT but the comparison to classic RCT is still pending. Targeted therapy against vascular endothelial growth factor (VEGR) showed antiangiogenetic effects on tumors. In cases of non-resectability or distant metastases, palliative CT and target therapy are recommended. Reirradiation or IMRT offer increased locoregional tumor control at the expense of higher toxicity. Overall, advances in research on tumor biology offer increasingly more prognostic factors and markers for customized individual targeted therapy and CT.