Radiation Therapy Now More Targeted and Tolerable in GI Cancer

Radiation therapy for gastrointestinal (GI) cancers has advanced significantly, offering more precise treatment with fewer side effects, according to an Dr. Rachit Kumar.

Kumar sat down for an interview with CURE where he discussed the importance of multidisciplinary care, advances in radiation therapy and how treatment has the potential to be personalized based on each patient’s needs.

Kumar is an assistant professor of radiation oncology and molecular radiation sciences at The John Hopkins University School of Medicine in Washington, D.C.

CURE: Many patients hear radiation and immediately think of significant side effects. How has radiation therapy for GI cancers evolved to minimize these side effects and improve quality of life during and after treatment??

Kumar: That's a really key concern that we hear a lot from patients. Radiation is a scary word, and I think that when you're dealing with a new cancer diagnosis, which is already frightening, to come into our office and think about the past, where patients experienced severe radiation burns, severe radiation toxicity, and debilitating side effects, that's what many people come in expecting, frankly.

What is very helpful for us is to be able to tell patients that although this process isn't without its challenges, it's not a walk in the park, we know that our technology has evolved significantly. It has gone from basically pointing a beam of radiation at a patient and accepting that there would be collateral damage throughout that area. Now, we can say much more comfortably that we have the ability to shape radiation, to avoid normal tissues, to actually measure in detail how much radiation normal tissues are receiving, and to use the most advanced technology to direct radiation away from those normal tissues and really concentrate it on the target tissue. This is leading to a much better quality of life.

So, technologies such as intensity-modulated radiation therapy, stereotactic radiation and proton therapy are all different modalities that we can say with very high confidence have drastically improved the quality of life of patients undergoing radiation for gastrointestinal cancer.

For patients with GI cancers, how do you personalize treatment plans, especially considering the diverse locations and stages of these cancers. What factors do you weigh to determine if radiation is the best option?

The areas of the GI tract are numerous, ranging from the upper GI tract, including the liver, pancreas, and stomach, down to the lower GI tract, encompassing the rectum and anus. Throughout all these areas, there are many very sensitive structures. When it comes to deciding the best treatment method, we must consider the type of cancer the patient has, the stage of the cancer, and also the patient's wishes and desires.

For example, if I have a 70-year-old patient with newly diagnosed rectal cancer who is not interested in surgery, we want to try to do everything we can to help them avoid it. This will likely mean a combination of aggressive chemotherapy and aggressive radiation. Conversely, if a patient is 35 years old with rectal cancer — and we are seeing many younger patients with that diagnosis — that patient may want to have more children in the future.

So, how can we tailor our treatment to try to limit the effect on the reproductive organs? Across the spectrum, we can have the same stage of disease and need to address it very differently depending on the patient's needs.

It can be the same cancer type, same stage, but with two very different patients and two very different needs. Therefore, it's not a boilerplate answer. It's very much patient-dependent, which also helps us decide, of all these different tools, which ones in our toolbox should we apply? Should it be intensity-modulated radiation? Should it be stereotactic radiation? Or, in some cases, should we look at omitting radiation and using something else instead?

What are some of the latest advances in radiation therapy, such as stereotactic body radiation therapy (SBRT), that are making a difference in treating GI cancers, and what are the benefits of these newer technologies?

SBRT is a very fancy way of describing high-dose, short-course radiation, as opposed to standard radiation, which we know involves longer treatment durations with lower doses per day. By using these high doses in short courses, we achieve a greater impact each day and also reduce the overall treatment time for patients. This allows us to integrate radiation treatment more effectively between chemotherapy cycles, and patients who previously had to travel long distances for treatment now have fewer trips. We've found that this approach improves patients' quality of life, as they don't have to worry about treatment being as time-consuming as it once was.

Furthermore, this high-dose, short-course radiation often improves our ability to treat the cancer. The biological effect on the tumor is enhanced. We've seen this, for example, in select patients with pancreas cancer, where this high-dose, short-course radiation, or stereotactic radiation, yields really optimal tumor control. We also see its effectiveness in treating metastases. For instance, if a patient has disease in the liver that has spread from elsewhere, we can use these high-dose, short-course radiation treatments to target that area, as well as for primary liver cancer, or hepatocellular carcinoma, where high-dose, short-course radiation is showing some impressive outcomes.

So, stereotactic radiation has made a major difference. Additionally, we are increasingly using proton therapy for gastrointestinal cancers, taking advantage of its physics to limit exposure to normal tissues. By and large, these many advances in radiation are not only improving outcomes in terms of tumor control but also significantly enhancing patient quality of life.

What advice would you give to a patient newly diagnosed with a GI cancer who is considering radiotherapy, what are the key questions that they should be asking their medical team?

I think the important things to consider when you have a new diagnosis of GI cancer are: what is your team doing to help address your cancer? So, I think ensuring that you are part of a multidisciplinary team and that there is a tumor board discussion is crucial, because having more perspectives in the room has been shown to lead to better outcomes.

It's also important to make sure that the team you're working with has experience with the specific type of cancer you have. While it's hard to assess the technology — I don't think it's fair to expect a patient to come in and know, "Okay, I have this cancer. What kind of technology should my radiation oncologist be using?" — I think it's a very fair question to ask your team, "Can you talk to me about the technology that you use in a way that I can understand it and how it can be used to also improve my quality of life?"

I think doing that will not only give the patient some comfort in being able to connect with their radiation oncologist but also provide a better understanding of how that technology is going to help them both treat their cancer and maintain their functionality.

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