Radiation Protection in Radiotherapy Part No 1, Lesson No 1 Aim IAEA Training Material on Radiation Protection in Radiotherapy Radiation Protection in Radiotherapy Part 1 Aim and Role of Radiotherapy Introductory Lecture Part 1: Aim and role of radiotherapy Lesson 1: Introduction Learning objectives: On completion of the module the student will be able: To understand the principles of radiotherapy To discuss the role of radiotherapy in cancer management To name professionals involved in the delivery of radiotherapy To appreciate the importance of radiation dose in radiotherapy Activity: Lecture Duration: 1 hour for people from non-radiotherapy background - 15min for radiotherapy professionals Materials and equipment needed: Slide or powerpoint projector References: IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Radiotherapy One of the main treatment modalities for cancer (often in combination with chemotherapy and surgery) It is generally assumed that 50 to 60% of cancer patients will benefit from radiotherapy Minor role in other diseases Siemens Oncology Explanation or/and additional information Only in few countries of the world the optimum radiotherapy utilisation rate of 50 to 60% is achieved. It should be mentioned that radiotherapy is typically a very cost effective treatment modality. While radiotherapy does not play an important role for the treatment of non-malignant diseases yet this role can be expected to increase. A particular example is endovascular brachytherapy for the prevention of restenosis. Instructions for the lecturer/trainer Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Objectives of the Module Part No 1, Lesson No 1 Aim Objectives of the Module To become familiar with the principles of radiotherapy the role of radiotherapy in cancer management the cost effectiveness of radiotherapy To appreciate the importance of radiation dose in radiotherapy Explanation or/and additional information Cost effectiveness is always a difficult point to judge as it depends on the type of cancer treatment available and the notion of benefit if someone lives longer or just a life with better quality. Nevertheless it can be said that radiotherapy is typically cheap compared with chemotherapy. Instructions for the lecturer/trainer Provided the appropriate information is available, the lecturer could ask how much people think a course of radiotherapy costs in a country relevant for the course. Obviously, the costs depend very much on the facility, the complexity of the treatment and the resources required - however, about $US 3,000.- would cover a typical radiotherapy treatment in most ‘western’ countries. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Contents of the Lecture Part No 1, Lesson No 1 Aim Contents of the Lecture 1. Cancer management and radiotherapy 2.Approaches for dose delivery External beam radiotherapy Brachytherapy 3. Features of a radiotherapy department 4.Self test at the end of the lecture ”Quick test” Explanation or/and additional information The aim of the lecture is not to provide a deep understanding of radiotherapy but to introduce the larger picture in which radiotherapy is positioned and give a basic understanding of the discipline. Instructions for the lecturer/trainer Students should be made aware of the test which follows each lecture. Point 4 should be omitted if the present lecture is part of an opening ceremony in which a test would be inappropriate. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Cancer incidence (WHO) Part 1: Introductory lecture

Major indications for radiotherapy Part No 1, Lesson No 1 Aim Major indications for radiotherapy Head and neck cancers Gynaecological cancers (e.g. Cervix) Prostate cancer Other pelvic malignancies (rectum, bladder) Adjuvant breast treatment Brain cancers Palliation Explanation or/and additional information Cancer incidence varies in different countries. So do treatment approaches. Instructions for the lecturer/trainer The list above is only of general guidance - a more specific list for the country of interest can be provided by most national cancer institutes. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Approaches Palliative radiotherapy to reduce pain and address acute symptoms – e.g. bone metastasis, spinal cord compression, ... Radical radiotherapy as primary modality for cure – e.g. head and neck Adjuvant treatment in conjunction with surgery – e.g. breast cancer Lecture notes: Modern cancer treatment is often a combined approach with radiotherapy one part. In head and neck cancer radiotherapy is often the primary modality as it offers the prospective of cure with a larger chance of sparing organs than surgery. As a consequence radiotherapy patients are more likely to preserve voice or hearing than patients undergoing major surgery. Instructions for the lecturer/trainer Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Aim Patient Critical organs To kill ALL viable cancer cells To deliver as much dose as possible to the target while minimising the dose to surrounding healthy tissues target Beam directions Lecture notes: This is the central idea of radiotherapy and the lecturer should emphasis the local cancer therapy approach of radiotherapy which is particularly well suited to localised cancers. Chemotherapy, which attacks the cancer cells systemically is often complementing the localised treatment offered by surgery or radiotherapy. A consequence of this localised approach is that the spatial accuracy of the radiation delivery must be as high as possible. The accuracy of modern radiation deliver techniques can be better than a few millimeters, for example in stereotactic radiosurgery. Also conformal radiotherapy requires means of delivering radiation to a target with millimeter accuracy on many consecutive occasions (= treatment fractions). Instructions for the lecturer/trainer The lecturer can point out that directing a machine weighting many tons with millimeter accuracy in a living target is a major technological challenge which requires significant quality assurance and verification steps. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Prognostic Factors Cancer type and stage Patient performance Radiation dose ... Good prognosis survival The figure illustrating the prognostic factors shows a survival curve for prostate cancer treatment. Other prognostic factors could be age, gender and a variety of other factors Bad prognosis time Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Accurate dose delivery Part No 1, Lesson No 1 Aim Prognostic Factors Cancer type and stage Patient performance Radiation dose ... Accurate dose delivery matters! This is a very important link which should be emphasized - accurate dose delivery is highly correlated to treatment outcome. This appears to be obvious but is not always as well proven as in radiotherapy. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Dose response 100% response means the tumour is cured with certainty (TCP) or unacceptable normal tissue damage (e.g. paralysis) is inevitable The lecturer should point out that the dose scale in Gy refers to a total dose given in 2Gy fractions to the target. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Dose response Therapeutic window: Part No 1, Lesson No 1 Aim Dose response Therapeutic window: Maximum probability of Complication Free Tumour Control The therapeutic window is typically relatively small - good technique can help to increase its size. The width of the therapeutic window and the steepness of the dose response curve determines how accurate the dose must be delivered. This theme should be mentioned here as it is continued on the next slide. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Dose should be accurate Part No 1, Lesson No 1 Aim Dose should be accurate To target: 5% too low - may result in clinically detectable reduction in tumour control (e.g. Head and neck cancer: 15%) To normal tissues: 5% too high - may lead to significant increase in normal tissue complication probability = morbidity = unacceptable side effects Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

“Deviations from Prescribed Dose” Part No 1, Lesson No 1 Aim “Deviations from Prescribed Dose” May involve severe or even fatal consequences. IAEA Basic Safety Standards (SS 115): ”…require prompt investigation by licensees in the event of an accidental medical exposure…” Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Options for dose delivery Part No 1, Lesson No 1 Aim Options for dose delivery External beam radiotherapy = dose is delivered from outside the patient using X Rays or gamma rays or high energy electrons (refer to part 5 of the course) Brachytherapy = dose delivered from radioactive sources implanted in the patient close to the target (brachys = Greek for short distance; refer to part 6 of the course) Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

External beam radiotherapy Part No 1, Lesson No 1 Aim External beam radiotherapy The picture shows an anthropomorphic phantom on the treatment couch of a linear accelerator. The lecturer could point out that instead of a patient an anthropomorphic phantom is shown. These phantoms are used for verification of treatment procedures. Many slides throughout the lecture will show phantoms rather than patients for confidentiality purposes - no patient should ever be identified without written informed consent. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

External Beam Radiotherapy Part No 1, Lesson No 1 Aim External Beam Radiotherapy Typically fractionated - e.g. 30 daily fractions of 2Gy up to a total dose of 60Gy Superficial/orthovoltage photons (50 to 400kVp) for skin or superficial lesions Megavoltage photons (60-Co or linear accelerators = linacs) for deeper lying tumours. Megavoltage electrons from linacs for more superficial lesions Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Superficial/orthovoltage unit Part No 1, Lesson No 1 Aim Superficial/orthovoltage unit Therapax Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Modern Cobalt 60 unit Theratronix Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Linear accelerator with electron cone Part No 1, Lesson No 1 Aim Linear accelerator with electron cone Varian Clinac 21C The lecturer can point out that these units will be discussed in more detail in part 5 and 10 of the course. Electron applicator Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Brachytherapy Interstitial implant for breast radiotherapy Part No 1, Lesson No 1 Aim Brachytherapy Left a photo of an Ir implant Right an X-ray showing the location of a gynaecological applicator The overlays appear in a slide show!!! Interstitial implant for breast radiotherapy Intracavitary gynecological implant Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Brachytherapy Implant of radioactive materials (e.g. 137-Cs, 192-Ir) close to the target area Intracavitary, interstitial and mould surface applications Low dose rate, LDR, (60Gy in about 5 days) and high dose rate, HDR, (several fractions of several Gy in few minutes each) applications Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Example for HDR Brachytherapy Part No 1, Lesson No 1 Aim Example for HDR Brachytherapy The picture shows a tongue implant treated using a Nucletron High Dose Rate (HDR) remote afterloading unit. The unit is equipped with a single 192-Ir source of some 10Ci activity. The source travels via the transfer tubes into the mould, one channel at a time. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

A radiotherapy department is part of a health system Part No 1, Lesson No 1 Aim A radiotherapy department is part of a health system Radiotherapy Department National Cancer System This slide is not necessarily applicable to all countries - it should illustrate though that radiotherapy is not a standalone unit - it is typically part of other health related structures and institutions. This needs to be taken into account when talking about finances and organizational relationships. Oncology Host hospital Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Patient Flow in Radio-therapy Also within radiotherapy there is some complexity - the present slide does not include other complicating issues such as surgery or medical oncology (chemotherapy) or allied health services (social work, dieticians) …not necessarily a straightforward process Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Patient flow in radiotherapy Part No 1, Lesson No 1 Aim Patient flow in radiotherapy Depends on: disease site and stage departmental protocols treating clinician resources available The keyword ‘resources’ leads to the next slide Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Components of a Radiotherapy Department Part No 1, Lesson No 1 Aim Components of a Radiotherapy Department Diagnostic facilities (CT, MRI, …) Simulator (refer to part 5 of the course) Mouldroom Treatment planning External beam treatment units (parts 5 and 10) Brachytherapy equipment (part 6) Clinic rooms, beds, ... Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Layout of a Department It is not essential that the participants can read every details of the plan - the plan could also be a handout. The next slide will be used to explain the context more. Things to point out: Two linacs (on right) - should be located close to each other Department is at least 4 times larger than the space for the treatment unit (and this does not include hospital beds) Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Layout of a Department Physics & workshops Simulator Planning Clinics Two linac bunkers Offices Patient waiting Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Professionals in radiotherapy Part No 1, Lesson No 1 Aim Professionals in radiotherapy Radiation oncologists Other clinicians Medical radiation physicists Radiation therapists Nursing staff Radiation safety officer Information technology officer Administrative staff The lecturer can point out that other staff may also be involved - not mentioned here are porters, domestic staff, maintenance and many others - more discussion on this in part 8 occupational exposure Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Features of Radiotherapy Part No 1, Lesson No 1 Aim Features of Radiotherapy High and potentially lethal absorbed dose is required to cure cancer High technology environment Individualized treatment approach Complex treatment set-up This slide allows the lecturer to dwell on his or her own experience to illustrate the points. All points will also be discussed in more detail in particular in part 10 of the course- the important conclusion of this slide is shown on the next. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Features of Radiotherapy Part No 1, Lesson No 1 Aim Features of Radiotherapy High and potentially lethal absorbed dose is required to cure cancer High technology environment Individualized treatment approach Complex treatment set-up Quality assurance, treatment verification and radiation protection essential Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Summary Radiotherapy is an important cancer treatment modality Accuracy of dose delivery is essential for good outcomes The complex and high tech environment requires attention to quality assurance and radiation protection Let’s summarize the main subjects we did cover in this session. Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Where to Learn More Other parts of the course, handouts References: Radiotherapy physics textbooks (as per reference list) IUCC Cancer Statistics Radiotherapy textbooks (e.g. Perez and Brady 1998) Site visit of a radiotherapy department (day xxx of the course) Please edit slide to include the exact day of site visit(s) IUCC = International Union against cancer Perez C and Brady L (ed) Principles and practice of radiation oncology. Lippincott-Raven: Philadelphia 1998 Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Any questions? Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy

Part 1: Introductory lecture Part No 1, Lesson No 1 Aim Question: What is the main cancer treated with radiotherapy in your country and what would be a typical treatment approach? (Number of fractions? Total dose?) This question can be used either as stand alone question which can get the participants talking about their country and background. Alternatively, it can be build into the practical exercise which follows part 1. Typical answers are: Prostate (western countries) Breast Head and Neck (Asian countries) Part 1: Introductory lecture IAEA Training Material: Radiation Protection in Radiotherapy