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Radiation Therapy in the Elderly

Before discussing the implications of old age on cancer care, a definition of old age or geriatric seems needed. Unfortunately, a chronological definition of older age is difficult to provide. Old is a relative term. How societies define old age has several implications for their health, labor force, economy, laws, and family roles. In 1965, when the Social Security Act was passed, the average life expectancy…

Health Services Research in Radiation Oncology: Toward Achieving the Achievable for Patients With Cancer

What Is Health Services Research? Medical research may be considered as a continuum of four overlapping domains: basic or biomedical research, clinical research, health services research (HSR), and population health research. HSR aims to create the knowledge required to improve population health by improving the delivery of health services. Although there is some overlap between the domains of clinical research and HSR, their purposes are distinct.…

Overview of Oncology Clinical Trial Design

Clinical trials began to emerge in their modern form only in the early 20th century, with the first randomized controlled trials conducted in the 1940s, but are now firmly established as the fundamental basis of modern evidence-based medicine. An evidence-based approach based on clinical trials enjoyed an early start in cancer, with a commitment and sponsorship by the US National Cancer Institute (NCI), beginning in the…

Tumor Ablation in Interventional Radiology

Image-guided ablative techniques have been used by interventional radiologists and some surgeons to treat primary and metastatic tumors across several organ systems, including liver, kidney, lung, and the musculoskeletal system. Most treatments use percutaneous needle devices to deliver thermal or other energy to the tumor and its surrounding tissue, creating an ablation zone. These treatments may be performed for curative or palliative purposes, depending on tumor…

Nuclear Medicine

Molecular imaging techniques such as nuclear medicine and functional magnetic resonance imaging (MRI) are playing an increasingly important role in oncology. Hybrid functional/anatomic imaging modalities, such as positron emission tomography/computed tomography (PET/CT) and single photon-emission computed tomography/computed tomography (SPECT/CT), can provide more accurate initial staging and follow-up in oncology patients. More recently, combined PET/MRI has also become available. Since metabolic changes to therapy almost always precede…

Imaging in Oncology

Imaging in Oncology Imaging plays a key role in the diagnosis and assessment of treatment response of primary malignancies and metastatic disease throughout the body. Computed tomography (CT) and magnetic resonance imaging (MRI) are the primary imaging modalities used for this purpose, with ultrasound (US), radiography, and conventional angiography used in more specific capacities. Nuclear medicine, including positron emission tomography (PET)/CT and PET/MRI, will be addressed…

Principles of Systemic Cancer Therapy

A Brief History of Chemotherapy In the history of medicine, cancer was initially regarded as a localized disease, engaging the primary attention of surgeons and radiation oncologists. Metastatic disease was regarded as untreatable. With the arrival of cancer chemotherapy in the form of alkylating agents in the post–World War II era, it became possible for the first time to entertain the use of drugs to improve…

Surgical Principles

Surgery remains a central component in the treatment of most solid malignancies. Survival for patients is still most dependent on the stage of the disease, which is significantly related to the extent to which surgical resection can render the patient free of all known disease. Overall, surgical oncologists play a role in diagnosing, staging, treating with curative and/or palliative intent, as well as follow-up of malignancies…

Radiation Physics: Charged Particle Therapy

Introduction Through 2017, almost 200,000 patients received radiation therapy using charged particle beams. The majority, over 170,000, of these have been treated with proton therapy. The remainder has primarily been treated with carbon ion beams. Experience continues to grow worldwide and particle therapy continues to gain market share, despite a significant capital and infrastructure cost associated with planning, building, and supporting a facility. This is primarily…

Radiation Physics: Stereotactic

The field of stereotactic radiosurgery (SRS) is now over 60 years old. The intervening decades have seen numerous technical developments, facilitating clinical success in numerous disease sites throughout the brain and body. Yet the fundamental principles remain largely unchanged: the delivery of an ablative dose of radiation that is biologically distinct from conventional fractionation; the use of many nonoverlapping beams converging on a target from many…

Radiation Oncology Physics

Radiation oncology is a physical medical modality by which radiative energy, in the form of ionizing radiation, is delivered to a target volume to effect palliation or cure. An understanding of the particles and processes involved in imparting radiation energy to matter is fundamental to the clinical application of ionizing radiation to patients. In the irradiation of a biological system, physical and biological events occur in…

Biologics and Their Interactions With Radiation

Introduction Since the last edition of this seminal textbook, technological advances in “targeted” radiation therapy continue to improve our ability to deliver fractionated and at times ablative radiation doses even more accurately. Although these technical advancements have improved the radiation therapeutic ratio, resulting in reduced toxicities while increasing dose and decreasing overall treatment time, our ability to integrate radiation with therapies that target specific molecular aberrations…

Interaction of Chemotherapy and Radiation

Oncology has increasingly become a multidisciplinary field: (1) surgery remains the definitive local treatment modality; (2) chemotherapy remains the definitive systemic treatment modality; and (3) radiation therapy is the definitive locoregional treatment modality. Although, historically, these approaches have predominantly been used exclusively of one another, the past 30 years have seen an explosion of both preclinical and clinical efforts to combine these therapies for improved outcomes,…

Dose-Response Modifiers in Radiation Therapy

When cancer patients undergo radiation therapy, there is a clear dose-response relationship between the dose delivered and the response of the tumor to the radiation. This is illustrated in Fig. 3.1 . There is also an increase in normal tissue damage with increasing radiation dose; it is this complication that limits the total radiation dose that can be given safely. Substantial effort has been made to…

Molecular and Cellular Biology

The “hallmarks of cancer” were described by Hanahan and Weinberg in 2000 and detail the features required for a tumor to progress to an invasive malignancy. The “next generation” hallmarks, published in 2011, include sustaining proliferative signaling, evading growth suppressors, resisting cell death, enabling replicative immortality, inducing angiogenesis, activating invasion and metastasis, reprogramming energy metabolism, and escaping immune destruction. Boss et al. framed the hallmarks with the…

The Biological Basis of Radiation Oncology

What Is Radiation Biology? In the most general sense, radiation biology is the study of the effects of electromagnetic radiation on biological systems. Three aspects of this definition deserve special mention. First, effects may include everything from DNA damage to genetic mutations, chromosome aberrations, cell killing, disturbances in cell cycle transit and cell proliferation, neoplastic transformation, early and late effects in normal tissues, teratogenesis, cataractogenesis, and…

How Can Clinician Well-Being Be Improved and Sustained in Palliative Care?

Introduction and Scope of the Problem Individual and organizational investment in clinician well-being is required to sustain the careers of those providing care to the seriously ill. Among U.S. health care professionals in general, burnout is experienced by an estimated 54% of physicians, 35% of nurses, and 45% to 60% of medical students. Increased rates of clinician burnout have left health care organizations facing substantial costs…

What Is the Evidence Supporting the Use of Mobile Health Technologies in Palliative Care?

Introduction and Scope of the Problem There has been explosive growth in the creation and use of mobile technologies for health care in the past 10 years, accompanying exponential growth in access to mobile technology. The global mobile health market is anticipated to surpass $100 billion in 2021, a fivefold increase from 2016 figures. While 96% of Americans own a cellular phone, fewer Americans (81%) own…

What Is the Evidence for Integrative and Alternative Therapies in Palliative Care?

Introduction and Scope of the Problem Integrative medicine refers to a group of interventions that are used in conjunction with conventional therapies and that emphasize a patient-centered, holistic approach to care of the individual. Initially the term “complementary and alternative therapy” (CAM) was used, with the distinction being that alternative therapy was substituted for traditional Western medicine. Complementary and integrative medicine (CIM) is generally classified into…