Cancer in Developing Countries: Facing the Challenge
Emerging Technologies, Challenges and Opportunities: Role of Imaging in Breast Cancer
The session focused on the emerging technologies in the field of medical imaging and radiotherapy that are designed to diagnose and treat cancer, in particular breast cancer. Throughout these sessions, the emerging trends in nuclear medicine, radiology and radiotherapy, focusing diagnosis, treatment planning, therapy and response to treatment, were discussed from perspective of cancer control in the developed world. The discussions considered how these technologies can be delivered to developing Member States, their drawbacks, as well as their cost and effectiveness in implementation in the future. Digital communication provides an avenue for improved image sharing between imaging specialist and the clinicians, providing the fast and cost-effective access to medical images vital to patient management. The session offered a bird´s eye view of the new trends in science and technology and their promise for providing hope for improved patient care and cancer management in the near future.
Trends in the Field of Nuclear Medicine
Focusing on the developments in nuclear medicine that improve cancer management, emerging technologies include SPECT/CT and PET/CT. Their introduction further enhances the complementary role of nuclear medicine imaging with standard medical imaging modalities such as ultrasound, CT scan, optical techniques and MRI imaging techniques. The new nuclear medicine imaging techniques provide a visual representation of the biological processes at the molecular level. These techniques can improve the precision of cancer diagnosis and management by being able to characterize early response to treatment and predict and identify which patient will respond best to specific therapies. For example, combined imaging techniques for bone scans with SPECT acquisition and CT scan accurately localizes suspicious cancer lesions within areas of the body where earlier technologies had difficulty pinpointing the exact location of a lesion in a particular bony area. This multimodality imaging provides accurate information, which is beneficial to the cancer patient and improves management.
Positron Emission Tomography with fluorodeoxyglucose (FDG PET/CT) is a valuable hybrid molecular imaging technique for identifying metastatic disease in locally advanced breast cancer and assessing the response to therapy. Glucose metabolism is high in cancer cells. By studying the metabolism of a particular surrogate sugar, the aggressiveness of certain cancer types can be characterized. Technology has provided imaging specialists with a tool to track radiotracers similar to glucose (sugar), which enable clinicians to visualize the extent of the cancer´s spread. Likewise, a decrease in the accumulation of this surrogate sugar in cancer lesions during or after treatment would reflect a response to treatment. This information directs adaptive therapy in cancer management depending on the response to treatment. New tracers using DNA PET-FLT (fluoro-L-thymidine) can also provide a visual representation of the treatment response within days after the therapy´s initiation, allowing the clinician to make a decision if there is a need for the patient to stay on the treatment plan or whether a change in therapy is warranted. Other tracers would also allow the imaging specialist to assess if a patient would respond to a particular modality of treatment in certain types of cancer, further improving cancer care management as it impacts on cost and effectiveness of the treatment plan.
Trends in Field of Mammography
There are excellent tools available in developed countries to detect breast cancer and there is a need to find a way to implement these tools that allow earlier cancer detection. Triple diagnostic procedure (clinical examination, mammography and needle biopsy) has proven to preoperatively result in a correct diagnosis in more than 95% of patients with palpable lumps. There is a rapidly expanding role for medical imaging in cancer management with the introduction of improved technology, which would help the clinicians arrive at a diagnosis improving patient care. A cancer screening program in breast cancer detection is an intervention that has been demonstrated to contribute to a significant reduction in mortality in breast cancer when used with routine screening. Mammography is still the most valuable tool available for reducing breast cancer mortality by early detection through screening programs. There is a need to harmonize a high quality program in breast cancer screening for Member States´ use.
High quality mammography (both image acquisition and interpretation) is essential if the benefits are to be realized. New technologies in this field include the introduction of digital mammography, which is advantageous in women with dense breast providing improved accuracy in breast cancer detection. Digital mammography also facilitates telemedicine to improve access for under-served areas. New technique such as tomosynthesis (3D digital mammography) is currently going under evaluation, and aims to further improve cancer detection accuracy, as it allows cancer to be detected that is normally hidden in conventional mammogram. This technology allows the breast to be seen in a series of two- dimensional images, providing accuracy in cancer detection of cancer, reducing mistakes in diagnosis and avoiding unnecessary additional examinations.
In future, sophisticated targeted functional or molecular imaging (targeted agent), such as using microbubbles in ultrasound, will provide greater specificity, as well as prognostic or predictive information to guide optimal individualized therapy. This may provide a more practical and less expensive way to treat cancer.
Trend in Field of Radiotherapy
Radiotherapy is one of the most economical and effective treatment modalities for cancer. It uses high energy x-rays and similar rays (such as electrons) to treat disease. Among the various cancer treatment modalities, including surgery and chemotherapy, radiotherapy could be one of the most effective solutions for the cancer problems found in developing countries. Since the discovery of x-rays over one hundred years ago, radiation has been used more and more frequently in medicine, both to help in diagnosis (by taking pictures with x-rays), and as a treatment (radiotherapy). Many people with cancer will have radiotherapy as part of their treatment. Radiotherapy works by destroying the cancer cells in the treated area. Although normal cells can also be damaged by the radiotherapy, they can usually repair themselves. Radiotherapy treatment can cure some cancers and can also reduce the chance of a cancer coming back after surgery. It may be used to reduce cancer symptoms.
Newer technologies in this field include Charged Particle Radiotherapy or Proton Therapy and Carbon Ion Therapy. These technologies are characterized by very high concentrations of radiation based on a particular mechanism. The high dose area can be precisely localized on the tumour, sparing the surrounding normal tissue. Carbon ion therapy can be thought as the most desirable treatment for many cancer patients, providing highly effective treatment without severe side effects. This technology is widely used at the National Institute of Radiological Sciences in Japan. This form of radiotherapy can provide a desirable treatment for many cancer patients, in terms of high anti-cancer effect and low incidence of toxicity, because it has a very high concentration of ionizing radiation and high biological effect on the tumour compared to conventional X-ray therapy. The current outcomes in most cancers, such as certain types of head and neck cancer, inoperable bone and soft tissue sarcoma, postoperative recurrence of rectal cancer, prostate cancer and other slow-growing tumour have been satisfactory, compared with photon radiotherapy. These good results can be achieved by relatively short course of treatment, taken only for weeks, or a single fraction/one day treatment in some lung cancer patients.
In addition, taking advantage of the global explosion in telecommunication technology, one could create an integrated three–tier radiotherapy service, consisting of primary, secondary and tertiary radiotherapy centres in developing countries linked using tele-networks. This strategy could provide most patients access to state-of-the-art radiation therapy, a step towards equality in cancer care within the limited available resources. Immediate and dedicated collaboration among the developing countries, the developed countries, industries, and international organizations such as the IAEA is essential in finding the solutions to effectively address the cancer epidemic today.
The session examined the emerging technologies in nuclear medicine, mammography and radiotherapy that support Breast Cancer Management. By harnessing newer technologies, cancers can be detected earlier and clinicians can detect treatment response at the earliest possible time. This perspective, a personalized approach to cancer management, aims to help clinicians offer cancer patients the best management options. The long-term benefits of these newer technologies would include offering the patient the best and kst cost-effective treatment options available, based upon evidence gathered through advanced molecular imaging and state-of-the-art radiotherapy services. It is hoped that these emerging technologies will be readily available in the near future in order to promote and enhance the efficient and cost effective cancer management in developing Member States.
- Homer Aquino Macapinlac, Professor, Department of Nuclear Medicine, University of Texas, USA.
- Martin Yaffee, Professor, Department of Medical Biophysics, University of Toronto, Canada.
- Hiroshi Tsuji, Research Centre for Charged Particle Therapy, NIRS, Japan.
- Niloy Datta, Professor of Radio-oncology, Rajiv Gandhi Cancer Institute and Research Centre, India.
- Gunilla Svane, Professor of Radiology, Karolinska Institute, Sweden.
- Takashi Nakano, Professor of Radiation Oncology Department, Director of Heavy Ion Medical Research Center, Gunma University, Japan.