Just a few years ago the word «cancer» was perceived as marking an inevitably fatal disease, and the treatment could only extend the patient’s life for a finite period. But today, things have changed substantially. Though the changes are not so obvious, and cancer is still fought by means of surgery, chemotherapy and radiation, the potential and safety of these methods have developed enormously.
Radiation therapy is perhaps the cancer treatment which has advanced most dramatically during the last few years, at least at the Department of Radiation Oncology at the University Hospital of Zurich, one of the leading medical centers in Europe. Here the head of the department, Professor Guckenberger, tells us about innovations in the field of radiotherapy and its new potential.
– Professor Guckenberger, is it true that we should change our views concerning the potential of Radiation Oncology in cancer treatment?
– Yes it is. Over the last few years, many things have changed. First of all, collaboration between doctors, specialists in surgery, radiation oncology, and medical oncology has become better coordinated, and the exchange of information between them now happens very quickly and concisely. Secondly, and this is the main issue, cancer treatment by use of radiation has become more precise and therefore more effective. The capabilities of the emergent digital technologies are now tremendous in comparison to what we could apply just a few years ago. In my department we use the most modern treatment equipment, including robotic devices, allowing us to direct radiation precisely to the areas we need it in, with sub-milimetre accuracy, therefore sparing the surrounding healthy tissue. We call this method image-guided radiosurgery.
Take, for instance, prostate cancer, the most widespread oncological disease among men. Today, with radiation therapy, we can treat it as effectively as with surgery. The duration of treatment has also been sig-nificantly reduced. Earlier radiation treatment lasted for at least 6–8 weeks and it also affected the tissue surrounding the prostate, the nerves, the bladder and the rectum. And now we only need two weeks with five highly-focused radiotherapy sessions. If necessary, one can get medical treatment even during the holidays.
– Does this method offer hope that the disease will be defeated completely?
– It does. And every year, with radiotherapy alone or with radiotherapy combined with surgery and chemotherapy, we can cure many cancers and offer our patients the chance of a normal life. With prostate cancer, depending on several factors, up to 90% of patients can be cured with radiotherapy. But, unfortunately, even today, having the best doctors and the most modern equipment, we cannot cure all of our patients.
– Can radiation treatment replace surgery completely for prostate cancer? Which treatment method is preferable, in your opinion?
– Surgery and radiation treatment provide equally good outcomes and chances of a cure. The differences can be seen in a patient’s individual tolerance of a particular treatment type and in its side effects. After surgery, problems occur, especially in the sexual sphere, with impotence being a frequent side effect. Additionally, incontinence appears if the sphincter muscle of the urinary bladder is affected, then the patient has to wear special sanitary pads for several weeks or even for months after surgery. Usually after radiation treatment, such effects appear with much lower frequency and severity. However, radiation treatment does also have side effects, and the rectum in particular is at higher risk of damage compared to surgery. Usually, we explain to the patient that there are two options, and the patient makes the decision on his/her own as to which treatment method to use, on the basis of the information we provide.
Fatigue is one of the most common side effects of radiotherapy or chemotherapy. In this case, we offer additional treatment including mind/body medicine – relaxation techniques to to alleviate or even prevent side effects.
– Is radiotherapy helpful in cases when metastases have already spread into other organs?
– Traditionally, it was thought that patients with metastatic diseases cannot be cured, that life should be prolonged with the best quality-of-life possible. But during the last five to ten years we have learned about the so-called oligometastatic state of a malignant disease, when only a limited number of metastases (usually three, maximum five) appear. In such situations, some patients can still be saved if all metastases are treated radically. In some cancers, up to one quarter of the patients – e.g. in rectal cancer – have a chance of longterm survival; in other cancers, e.g. melanomas, the success rate is lower.
Thanks to the equipment we have today and our experience in using this complex equipment, we can destroy these metastases using precise irradiation techniques, irrespective of where the metastatic lesions are located: in the spine, the lung, the liver or the brain… 90% of the disease sites can be destroyed and thus the patient gets a second chance after relapse. Often radiation therapy is the only option for such patients because such radical (and, at the same time, safe) treatment is not possible with any other method.
– And in which cases is a cure still not possible?
– The smaller the number of metastases and the later they occur in the history of cancer, the better the chance for a cure. As already mentioned, it also depends on the type of cancer. Unfortunately, we are still all too frequently facing the «iceberg» problem. Patients have a small amount of metastases, and all these visible metastases are treated successfully with radiation or surgery – the patient seems free from cancer. However, the visible metastases were only the «tip of the iceberg.» Very small metastases (less than 3–5 mm) are invisible even to the most modern CT, MRI and PET imaging technologies. Cancer will recur in these patients. However, even if no cure was achieved in these patients, the progress of the cancer was delayed.
– With which other diseases, beside prostate cancer, should a patient apply to you first and foremost?
– One of the most common cancers is lung cancer, and most lung cancers develop in patients with a history of smoking. If lung cancer is detected at an early stage, many patients can be cured. But if the tumor has grown and spread to the lymph nodes and other organs, the chances of a cure are smaller. It is therefore important to detect the disease in good time. Here, as in many other cancers, there are two treatment options: surgery and radiation therapy. Earlier, all the patients were operated upon, and if someone could not be operated upon, there was hardly any chance for him to be cured and, in general, to survive. Today we successfully cure such «inoperables» with the help of radiation therapy. If patients do not want to run the risks of a long and invasive surgical procedure, radiation therapy again offers an equal chance of a cure.
We also have specialized teams for the treatment of gynecological tumors, breast cancer, prostate cancer, brain tumors and cancer in the areas of the head and neck. Among our patients there are children as well, including very little ones, as young as a few months of age.
– You and your team are also actively engaged in scientific research…
– Yes, our aim is to develop the treatment of tomorrow. Radio-oncologists are trying to understand why radiation therapy may appear effective in treating some patients and ineffective in treating others. How to level the chances for all patients? We also deal with advancing the equipment for radiotherapy – we are studying the issue of how to make exposure even less harmful and more accurate. Finally, we are advancing the concepts of treatment; we are trying to find out what combination of therapies will be successful in the future. That is why today we, as a University Hospital, are able to offer non-standard treatment which cannot be obtained in other clinics outside of the University and the academic environment. We carry out clinical research and use the most innovative techniques, techniques that are not readily available anywhere else.
– Patients arriving from abroad usually have their diagnosis already. Is it enough to prescribe a treatment schedule or should they have themselves carefully examined in addition?
– Both are possible. If patients arrive with a specific request (for example, to undergo radiation treatment) with all the required analyses and the screening results, we can start radiotherapy planning and treatment immediately. But with many patients, their examinations and imaging results are old and incomplete. In this case we carry out our own screenings and examinations, find out the current state of the cancer and, together with the patient, choose the most appropriate method of treatment.
– Professor, we have discussed everything with you: modern equipment, experienced doctors, different concepts of treatment. But what is the most important among this plurality of factors influencing the success of a treatment? When the choice is between life and death, one wishes to know who or what the result depends upon.
– Here, like in Formula 1, all of the three components are important. First of all, you need a fast car; no one has ever won a race in a Fiat Panda. The same situation with radiotherapy: you need the best equipment, and we have it. But the equipment alone cannot deliver a cancer treatment in itself; the pilot needs to be highly experienced to take advantage of the technology. Otherwise, the high complexity of it could become a disadvantage. For us, it is a team of the best trained radiation-oncology specialists, who have performed research work in their cancer fields for many years and have become internationally recognized experts. But an excellent car and a professional crew is not a guarantee of success: one more factor is a well coordinated team. And here we are at our best at the Zurich Cancer Center: we can combine all available methods of cancer treatment with radiation oncology, medical oncology and surgery. All the specialists of all the cancer disciplines are in the same place and for every patient, we discuss the treatment which offers him the highest chance of a cure. This excellent team work is the most important (open) secret of our success at the University Hospital Zurich.
professor and doctor of medical sciences, is one of the leading specialists in radiation-oncology in the world. He graduated from the medical faculty of Wurzburg University in 2003. For ten years he has been an active clinician and researcher at the University Hospital of Wurzburg, and the Institute of Cancer Research UK, London. In 2014, professor Guckenberger was assigned full professorship at the University of Zurich and became the chairman of the department of Radiation Oncology at the University Hospital of Zurich. He is an active member of the German Society of Radiation Oncology (DEGRO), the European Society of Radiotherapy and Oncology (ESTRO) and the European Organization of Cancer Research and Treatment (EORTC).