Gail, I hope he is willing to contribute. I also hope my comment was not taken as harsh. I worry about the many people that come here and read these posts daily. What I watch for is information that may either worry them (for no good reason) or lead to a misunderstanding. As I said in an earlier post, the RO is the one that needs to make these judgments. I am rather sure that an IMRT system could be programmed to deliver the same amount and coverage as a non-IMRT machine. In the real world they probably wouldn't do that because of the time and expense of programming. It is much more simple to use traditional XRT to cover a wide field. In addition, I would make an educated guess that the actual treatment time in the machine is faster with XRT. This means more patients per day and that means lower cost. (Or higher revenue). There are many of these older machines still installed that probably means they are going to be used.

The original post was to question if IMRT was preferred over XRT. The bottom line, I think, is that it IS preferred IF the RO running it believes so. Several of the subsequent posts seem to call into question the efficacy of one over the other. That is where the RO needs to be relied on not us. The only thing we should do is provide awareness of options.

I have a concern when a local Doc sends someone to a local RO to have XRT when IMRT might be available regionally. This kind of thing does happen and will probably result in worse, permanent side effects for the patient. That someone elects to have XRT in the end because of confidence, convenience or cost is certainly up to them. That is where multiple opinions and consultations are needed.

You might have guessed that this is my personal story. I was treated with XRT locally, IMRT was probably available regionally, and I was totally unaware of the option. As a result I do have serious long term side effects that I would not wish upon anyone. I do not know if I could have had IMRT and I do not want to sound like I feel my RO didn't do a good job. In fact I think he did an outstanding job. Just the same, I wish I knew then what I know now. That is the kind of advocacy I hope to provide others.

Minnie, See the M.D. Anderson study published in Int. J. Radiation oncology Biol. Phys., Vol. 59, No. 1, pp. 43-50, 2004, entitled "Intensity-Modulated Radiation Therapy for Orophayngeal Carcinoma: Impact of Tumor Volume" By Chao, et al.

It states that only a few reports benchmarking the treatment outcome of H&N cancers (using IMRT) have been published. I believe this is the largest study reporting IMRT outcomes using 75 people with cancer of the tonsil, BOT or Soft Palate. It compares the IMRT Disease Free Survival % with 7 older studies done with conventional radiation. The results are impressive in comparison especially when comparing the combination of surgery and IMRT (Stage IV DFS of 92%). (A mix of patients getting either surgery/IMRT or just IMRT gave a Stage IV DFS of 73% and Stage III DFS of 90%.) This study showed tumor volume to be of significance. It breaks down the results in numerous ways and provides information about the IMRT target volume determination guidelines.

I haven't been able to locate any other large studies specifically about IMRT treatment outcomes.

Mark, your last paragraph impresses me a lot since this is exactly my experience. My family have actually asked me to lodge a complaint to the Hospital Authority because I was not told that there was a better option available at my time of treatment to reduce the side effect. If I did that, my oncologist would be involved and I really don't want to bring him troubles since he has always been a very caring and supportive doctor. Moreover, I have learnt to cope with the side effects these years. Although I choose to retire early from my teaching job, it is the work stress rather than the side effect that causes my decision.

Karen

Mark and Gary, wonderful postings as usual, full of knowledge.

cclark, thank you for the link, it was good reading.

I am beginning to wonder now if I had 3D conformal radiation. What makes me believe this is that they spared salivary glands on my good side. Can that be done with XRT?? Also, I received less radiation on my "good side" then the cancerous side. Every day they would make lines on my neck, and there was a literal map drawn on my mask. The techs would change the machine alot. Guess I need to ask just what kind I had. I do know it was not IMRT.
Minnie

Minnie,
the difference between XRT and IMRT is similar to the difference between a shotgun and a sniper bullet, with XRT being the shotgun approach.

The techs will use beam blocking and shadow trays to protect sensitive areas such as the spinal chord. From your description it sounds like you had XRT.

We can talk about the merits and demerits of both but it must be emphasized that you must be a suitable candiate for IMRT according to your medical team.

Thanks Gary,
So there is no difference between 3D conformal and XRT?

Hi all --

Doing some research for meeting tomorrow with RO and (hopefully the rad physicist as well as I wanted to ask him some questions for this forum.)

I did come up with three interesting and pertinent papers presented at the last ASTRO meeting (2004) which compare IMRT to conventional RT, and also, IMRT to tomotherapy.

Jabbari, S. et al. Xerostomia and quality of life (QOL) after parotid-sparing IMRT for head and neck (HN) cancer: A matched case-control comparison with standard radiotherapy (RT). Authors concluded that xerostomia and QOL worsened shortly after sompletion of therapy in all patiants. Patients receiving standard RT did not report any improvement during the first year after therapy. In contrast patients matched in clinical factors (prior to treatment) reported significant improvement over time in both XQ and QOL.

Pacholke, H. et al. Xerostomia quality of life in head and neck cancer patients who are beyond the acute recovery phase following radiotherapy: IMRT versus conventional radiotherapy. The authors looked at 5 groups of patients who were more than 1 year out of therapy, grouped by the extent to which the radiotherapy impinged on the parotid glands. They concluded that IMRT improves quality of life compared to conventional RT in all groups.

Harari, P. et al. Refining target coverage and normal tissue avoidance with helical tomotherapy vs. Linac-based IMRT for oropharyngeal cancer. 20 patients had treatment plans drawn up for both IMRT and tomotherapy and the results (dosage to primary and subclinical targets and to normal tissues) compared. All treatment plans met prescribed doses. The helical tomotherapy delivered somewhat more dose to targets (4%) and significantly less to normal tissues of parotid gland, spinal cord and oral cavity (up to 50% less). Tomotherapy offered a significantly larger number of projections (up to 1000) over the 7 beams from conventional IMRT. The authors have another study underway evaluating functional outcome and QOL in patients receiving tomo vs. conventional IMRT.

Anyway, will try to get to our RP and ask him what he thinks about these issue...

Gail

Minnie that is not what I said at all.

There is very little difference between 3D conformal and IMRT.

I went back and re-read the second paragraph and see my mistake. I understand now.

As you all know I talk with doctors daily about treatments and what is coming down the pike. I will also be at the upcoming Astro Meeting in Colorado. There is little question that IMRT is a leap ahead. I have posted on it here twice in detail, and if you want the total answer you need to search for those postings, because I don't have time to do this in full again right now. RO's now need to know anatomy as well as a surgeon, they didn't in the past. Mapping the radiation isn't as simple as lead blocking was. There is going to be a period where they get up to speed on the technology. The machine doesn't do everything - the RO still has to tell it what to do. This reminds me of a friend who now thinks he's a graphic designer because he can use the stock tools in Photoshop to put in drop shadows in his images etc.... just because you have a powerful tool doesn't mean that you can use it properly. I call him a monkey with a shotgun. He's got a powerful design tool but with no basis for knowing how to use the tool properly he may be only partially effective in doing so. His advertisements still look like crap and he hasn't mastered the subtleties of the program.

I want to know that my RO has done a ton of cases with IMRT. He is the artist that is going to paint the area with radiation and determine what vital structures are going to be missed, what amount of radiation a particular pathway or areas is going to get and for how long, from what angle, etc. Given this tool he could just as easily UNDER paint areas that, even though near vital structures and things that effect QOL like the parotids, he may actually need to nuke them more to get rid of something that is hiding there in an occult fashion. (Eliminating some of the positive QOL issues in the process but getting all the disease.) It isn't black and white, and the way all of you talk about it, it would appear that you think so. This is a thousand shades of gray. The use of IMRT properly is a judgment call as much art as technology, and there are no absolutes or Cliff's Notes for this. Our OCF Board member Dr. Kian Ang, the head radiation doctor at MDACC used IMRT selectively on patients for over a year before he felt that he mastered all the nuances, and was actually SEEING the results he expected before he began to use it widely in the hospital. This is a guy that holds the Fletcher chair in radiation at the best of the best institution. That has to tell you something.

When I see that the 2, 5, and 7 year data in survival from IMRT is as good as we all hope that it is going to be, while sparing the QOL structures, I'll be the first to jump up and down. You can read all the studies that are out there. Is it for everyone right now? I hope after reading this you don't think so. Is it a better technology? You betcha. That doesn't mean the results of that study you are reading are going to apply to your doctor, your institution, or in particular -YOU. A doctor of lesser skills or judgment in an institution of lesser end results, using the same technology on a patient isn't going to get the same result as the best of the best using it. It isn't just about the technology...