Posts Tagged ‘external beam radiation’

External Beam Radiation Therapy and Brachytherapy

Larry H Bernstein, MD, FCAP, Curator


Radiation therapy


Radiation therapy uses targeted energy (e.g., X-rays, radioactive substances) to destroy cancer cells, shrink tumors, and/or alleviate certain cancer-related symptoms. It may be used:

  • As a primary treatment to destroy cancer cells
  • In combination with other treatments to stop the growth of cancer cells
  • Before another treatment to shrink a tumor
  • After another treatment to stop the growth of any remaining cancer cells
  • To relieve symptoms of advanced cancer

At Cancer Treatment Centers of America® (CTCA), our radiation oncologists are experienced in using advanced technologies to deliver targeted radiation therapy while also proactively managing side effects.

Types of radiation

Some radiation therapy delivery methods include:

  • External beam radiation therapy – radiation is directed from a machine outside the body onto cancerous cells within the body. (Examples: 3D conformal radiation therapy, IMRT, IGRT, TomoTherapy, stereotactic radiosurgery)
  • Internal radiation therapy – radioactive material is placed (via a catheter or other carrier) directly into or near a tumor. (Example: high-dose rate brachytherapy)
  • Systemic radiation therapy – a radioactive substance (that is swallowed or injected) travels through the blood to locate and destroy cancerous cells. (Example: radioactive iodine therapy)

Individualized treatment approach

Radiation therapy is an important part of treatment for many of our patients. Since each cancer type requires a different approach, your treatment plan will be based on your unique needs and treatment goals.

Our radiation oncologists use advanced imaging techniques before and during radiation treatment so we can closely track the tumor. We use highly targeted radiation technologies to deliver maximum radiation doses to tumors, with less impact on healthy tissues and organs. Thereby, we can often provide options to patients who have reached their maximum tolerated dosage of traditional radiation.

Depending on your individual needs, you may receive radiation therapy alone or in combination with other treatment modalities like surgery, chemotherapy, hormone therapy and/or immunotherapy. Throughout your treatment, your radiation oncologist will monitor the effectiveness of the radiation therapy and modify your treatment plan accordingly.

Managing radiation side effects

Typical radiation therapy can be damaging to the body and cause unpleasant side effects, such as skin changes, fatigue, nausea, and other side effects, depending on the part of your body being treated. During your radiation treatment, clinicians from a variety of integrative oncology services will work with you to reduce side effects and improve your quality of life.


It is extremely important that there be a dieititian consult. The lean body mass has to be maintained by adequate protein intake.  This is difficult in the face of the systemic inflammatory response to treatment, and if it declines progressively, it is a negative sign. Such may occur in the later stages with cachexia.


The Global External Beam Radiotherapy Market is driven by changing cancer treatment technology and growing number of cancer patients. The market value of this market was $4,108 million in 2013 and is estimated to be $4,820 million by 2018, at a CAGR of 3.20%. The External Beam Radiotherapy Market is the largest segment of $4,108 million radiotherapy devices market. High Energy Linear Accelerators segment accounts the largest share with 80% of the global external beam radiotherapy market.

The report “External Beam Radiotherapy Market Forecast, 2012-2018”, analyzes the market in terms of devices such as compact advanced radiotherapy systems, proton radiotherapy Systems, and electron emitting high energy Linear Accelerators (LINAC). All the segments of external beam radiotherapy will experience a positive growth till 2018 with an increase in cancer patient pool, increased awareness for procedures, and sophisticated diagnostic techniques. With a market value of $3,299 million and $541million, the segments of high energy LINAC and compact advance radiotherapy systems have been accounting 80% and 13% in terms of the total external beam radiotherapy devices market. Both the markets of external beam radiotherapy have been witnessing maximum growth because of increase in cancer patient pool. Technologies of External Beam Radiotherapy are Intensity Modulated Radiation Therapy (IGRT), Image Guided Radiotherapy, Stereotactic Technology, 3D Conformal Radiotherapy, Proton Beam Therapy, Volumetric Modulated Arc Therapy, Adaptive Radiation Therapy and Tomotherapy.

In North America (US, Canada), Europe (Germany, France, Italy, Spain, UK), and Asia (India, China, Japan) the rising rates of cancer population have been driving the market growth. The external beam radiotherapy market growth for external beam radiotherapy is significantly higher in North America because it is always inclined to the newer techniques while comparatively slow-moving markets such as Europe and Japan are maturing using both old and new technologies. North America is the most dynamic, highly competitive and the largest market for external beam radiotherapy devices globally.

The U.S. and Europe comprise the maximum share of external beam radiotherapy market but developing countries such as Asian countries and other regions of the world are adopting new policies to welcome this therapeutic procedure to fight against cancer.

Prevalence of cancer worldwide, registering 7.4 million (53%) in males and 6.7 million (47%) in females, with a male and female ratio of 10:9. In 2012, there were an estimated 14.1 million new cases of cancer in the world. In 2014, there is an estimate of 1,665,540 new cancer cases to be diagnosed and 585,720 cancer deaths in the US alone. Cancer remains the second most common cause of death in the US, accounting for nearly one of every four deaths.

The report provides an extensive competitive landscaping of companies operating in this market. The key players of the market covered in this report are Varian Medical Systems, ELEKTA AB, Accuray Incorporated, Siemens, IBA S.A, Covidien Ltd., ProTom International,Inc., and Mevion Medical Systems, Inc. The details of segment and country-specific company shares, news and deals, M&A, segment-specific pipeline products, product approvals, and product recalls of the major companies is also covered in the report.

Product Analysis

  • Usage pattern (in-depth trend analysis) of external beam radiotherapy products (segment-wise)
  • Product matrix which gives a detailed comparison of product portfolio of each company mapped at country and sub-segment level
  • End-user adoption rate analysis of the products (segment and country wise)
  • Comprehensive coverage of product approvals, pipeline products, and product recalls

Epidemiology Data

  • Country specific prevalence and patient pool of prostate cancer, cancer in female breast and genital organs, lung and pleura cancer, head and neck cancer, colorectal cancer, spine cancer and brain cancer
  • Disease progression (pattern analysis)

Procedure Volume Data

  • Number of prostate cancer, brain cancer, lungs, and head and neck cancer surgeries performed annually in each country tracked till sub-segment level.


Radiation therapy can damage normal cells as well as cancer cells, so our radiation oncologists plan treatments very carefully to minimize side effects.

The most common side effects of external-beam radiation therapy include:

  • changes to the skin and hair in the area being treated
  • fatigue
  • loss of appetite

In most cases, these effects are temporary, but you should tell your doctor or nurse about them so that you can be evaluated.

Some side effects of external-beam radiation therapy are specific to where the radiation is given.

  • Radiation therapy to the head and neck may cause dry mouth, difficulty swallowing, mouth and gum sores, or stiffness in the jaw.
  • Radiation therapy to the chest may result in shortness of breath, breast or nipple soreness, or shoulder stiffness.
  • Radiation delivered to the abdomen may cause nausea, vomiting, or diarrhea, while radiation to the pelvis can cause rectal bleeding, incontinence, and sexual problems.

Side effects of brachytherapy are similar to those seen with external-beam radiation therapy, although they are usually less intense. In addition, you may experience swelling, bruising, or bleeding where the seeds were implanted. These side effects usually subside within a few days after treatment is finished.

Before you begin external-beam radiation treatment, you are scheduled to come in for a simulation session, which allows our staff to ensure that we deliver the correct dose of radiation to the precise spot needed to treat the cancer effectively while minimizing exposure to nearby tissue. Our doctors will incorporate imaging methods (CT, PET, or MRI) to map out the treatment area. The simulation session will be followed by a setup appointment in the treatment room to confirm that the treatment planned for you will be delivered as prescribed.


For the simulation, you’ll change into a gown and our therapists will help position you on the same type of table that will be used during your actual radiation therapy treatment. During the simulation, we’ll take a CT scan to record images of the parts of your body to be treated. We may also use PET, MRI, or some combination of the two, depending on your specific case. We’ll also take x-rays and mark your skin to define the treatment area. Depending on where the tumor is located, our radiation therapist may recommend using foam sponges, headrests, molds, or specially designed plaster casts to ensure that you stay in exactly the same position throughout each radiation treatment.

Based on information and CT images gathered from your simulation, our radiation oncologists will carefully design your treatment plan. Three-dimensional planning computers can show the size and shape of the targeted tumor from all angles. This technology assists the radiation oncologist in determining the exact points at which radiation will enter your body, minimizing exposure to surrounding normal tissues.

Setup for Treatment

Usually within a week after your simulation, you’ll come for a setup appointment, which allows us to verify that the treatment planned for you will be delivered as prescribed. The setup appointment usually takes about an hour.

During the setup, you’ll again change into a gown and our radiation therapists will bring you to the actual room where you’ll receive your treatment each day. The therapist will help position you on the treatment table exactly as you were the day of your simulation, and x-rays of the radiation beams will be taken to make sure your position is correct and that the treatment will go to the right place. We’ll schedule you to begin treatment within several days after your setup.

External-beam radiation therapy is the most common form of the treatment. It is applied to the body by a machine, most often in the form of x-rays but sometimes as charged particles called protons or other types of energy.

Types of external-beam radiation therapy include image-guided radiation therapy, intensity-modulated radiation therapy, stereotactic body radiation therapy, and proton therapy.

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Reporter: Ritu Saxena, Ph.D.

With the number of cancer cases plummeting every year, there is a dire need for finding a cure to wipe the disease out. A number of therapeutic drugs are currently in use, however, due to heterogeneity of the disease targeted therapy is required. An important criteria that needs to be addressed in this context is the –‘tumor response’ and how it could be predicted, thereby improving the selection of patients for cancer treatment. The issue of tumor response has been addressed in a recent editorial titled “Tumor response criteria: are they appropriate?” published recently in Future Oncology.

The article talks about how the early tumor treatment response methods came into practice and how we need to redefine and reassess the tumor response.

Defining ‘tumor response’ has always been a challenge

WHO defines a response to anticancer therapy as 50% or more reduction in the tumor size measured in two perpendicular diameters. It is based on the results of experiments performed by Moertel and Hanley in 1976 and later published by Miller et al in 1981. Twenty years later, in the year 2000, the US National Cancer Institute, with the European Association for Research and Treatment of Cancer, proposed ‘new response criteria’ for solid tumors; a replacement of 2D measurement with measurement of one dimen­sion was made. Tumor response was defined as a decrease in the largest tumor diameter by 30%, which would translate into a 50% decrease for a spherical lesion. However, response criteria have not been updated after that and there a structured standardization of treatment response is still required especially when several studies have revealed that the response of tumors to a therapy via imaging results from conventional approaches such as endoscopy, CT scan, is not reliable. The reason is that evaluating the size of tumor is just one part of the story and to get the complete picture inves­tigating and evaluating the tissue is essential to differentiate between treatment-related scar, fibrosis or micro­scopic residual tumor.

In clinical practice, treatment response is determined on the basis of well-established parameters obtained from diagnostic imaging, both cross-sectional and functional. In general, the response is classified as:

  • Complete remission: If a tumor disappears after a particular therapy,
  • Partial remission: there is residual tumor after therapy.

For a doctor examining the morphology of the tumor, complete remission might seem like good news, however, mission might not be complete yet! For example, in some cases, with regard to prognosis, patients with 0% residual tumor (complete tumor response) had the same prognosis com­pared with those patients with 1–10% residual tumor (subtotal response).

Another example is that in patients demonstrating complete remission of tumor response as observed with clinical, sonographic, functional (PET) and histopathological analysis experience recur­rence within the first 2 years of resection.

Adding complexity to the situation is the fact that the appropriate, clinically relevant timing of assess­ment of tumor response to treatment remains undefined. An example mentioned in the editorial is – for gastrointestinal (GI) malignancies, the assessment timing varies considerably from 3 to 6 weeks after initia­tion of neoadjuvant external beam radiation. Further, time could vary depending upon the type of radiation administered, i.e., if it is external beam, accelerated hyperfractionation, or brachytherapy.

Abovementioned examples remind us of the intricacy and enigma of tumor biol­ogy and subsequent tumor response.


Owing to the extraordinary het­erogeneity of cancers between patients, and pri­mary and metastatic tumors in the same patients, it is important to consider several factors while determining the response of tumors to different therapie in clinical trials. Authors exclaim, “We must change the tools we use to assess tumor response. The new modality should be based on individualized histopathology as well as tumor molecular, genetic and functional characteristics, and individual patients’ charac­teristics.”

Future perspective

Editorial points out that the oncologists, radiotherapists, and immunologists all might have a different opinion and observation as far as tumor response is considered. For example, surgical oncologists might determine a treatment to be effective if the local tumor control is much better after multimodal treatment, and that patients post-therapeutically also reveal an increase of the rate of microscopic and macroscopic R0-resection. Immunologists, on the other hand, might just declare a response if immune-competent cells have been decreased and, possibly, without clinical signs of decrease of tumor size.

What might be the answer to the complexity to reading tumor response is stated in the editorial – “an interdisciplinary initiative with all key stake­holders and disciplines represented is imperative to make predictive and prognostic individualized tumor response assessment a modern-day reality. The integrated multidisciplinary panel of international experts need to define how to leverage existing data, tissue and testing platforms in order to predict individual patient treatment response and prog­nosis.”


Editorial : Björn LDM Brücher et al Tumor response criteria: are they appropriate? Future Oncology August 2012, Vol. 8, No. 8, 903-906.

Miller AB, Hoogstraten B, Staquet M, Winkler A. Reporting results of cancer treatment. Cancer 1981, 47(1),207–214.

Related articles to this subject on this Open Access Online Scientific Journal:

See comment written for :

Knowing the tumor’s size and location, could we target treatment to THE ROI by applying

http://pharmaceuticalintelligence.com/2012/10/16/knowing-the-tumors-size-and-location-could-we-target-treatment-to-the-roi-by-applying-imaging-guided-intervention/imaging-guided intervention?

Personalized Medicine: Cancer Cell Biology and Minimally Invasive Surgery (MIS)


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