On cancer treatment in Turkey and developments in the treatment of cancer with radiotherapy
Prof. Dr. Enis Özyar, Head of Acıbadem University Department of Radiation Oncology and Radiation Oncology specialist at Acbadem Maslak Hospital, gives information:
What is radiotherapy? For what purpose is it used? To destroy the tumor cell? Sometimes to prepare a patient for surgery? Sometimes to shrink the tumor a little?
“RADIOTHERAPY IS ONE OF THE THREE MAIN METHODS IN CANCER TREATMENT”
"There are 3 main methods in cancer treatment. These are surgery, radiotherapy and systemic treatments, in other words, the method we know more commonly as “chemotherapy”. Radiotherapy is actually an important leg of these 3 main treatments. Radiotherapy can be applied in different regions and in different ways. There is a method we call external radiotherapy. Radiotherapy is applied to the patient from a certain distance. In another method, some applicators and radioactive sources can be placed inside the body cavities and irradiated. Our aim is actually to destroy the tumor. But is this possible in every patient? It is not. Sometimes there are very resistant tumors. The doses we can give may be limited, but generally, it is possible to destroy the tumor in 80-90 percent with radiotherapy. Except in very early cases, these are also systemic diseases. As you said, we sometimes apply radiotherapy before surgery to facilitate surgery. Sometimes we apply it after surgery to reduce the risk of recurrence. Sometimes we use it as a stand-alone method in some tumors. For example, let's consider a case of prostate cancer or laryngeal cancer. In these two treatment areas, the results of both methods are actually equal. In other words, we can achieve the same result with surgery and radiotherapy. So what is the advantage of radiotherapy? Radiotherapy allows the organ to be preserved. In laryngeal cancer surgery, the larynx may need to be removed. Radiotherapy, on the other hand, can be administered together with chemotherapy to achieve the same result without removing the larynx. In other words, the patient's organ is preserved with radiotherapy. It is a fact that organ preservation is very important for patients today."
DEVELOPMENTS IN RADIOTHERAPY IN CANCER TREATMENT
So, what developments have taken place in the field of radiotherapy today in parallel with advances in medical technology? What is the state of the art in the treatment of cancer with radiotherapy today?
THANKS TO ADVANCES IN MEDICAL TECHNOLOGY, THE DURATION OF RADIOTHERAPY HAS SHORTENED AND ITS SUCCESS HAS INCREASED
"Yes, the impact of technology on radiotherapy is really great. These technological developments have caused radiotherapy to change rapidly. What happened for example? A treatment that used to be done in 40 sessions can now be done in 5 sessions. In fact, there are some studies that are trying to reduce this to two or one session. In other words, the patient's travel time to and from the hospital is decreasing. So how did this happen? By seeing the tumor better and protecting the organs better. The better we protect the organs, the less damage we do to them and the higher the dose we can give, the shorter the treatment times become. As a specialist who has been doing this job for nearly 40 years, it really surprises me how fast treatments have changed. Nowadays, treatments are very short, success rates have increased a lot and side effects have decreased a lot. Therefore, radiotherapy has become a very effective treatment method."
MR GUIDED RADIOTHERAPY. HIGHER DOSE TREATMENT, FEWER SIDE EFFECTS
There is now an approach that shortens the treatment time, targeting the target organ but protecting other organs. Which methods are available today to achieve this?
“In our department, we have been using the method known as ”adaptive radiotherapy", which is performed under MR guidance, for about 8 years. What were we doing in normal radiotherapy? We used to take a film on the first day, make a plan accordingly and apply a certain dose to the patient throughout the entire treatment. However, today, with adaptive radiotherapy, after the patient lies on the table, his/her image is taken and it is determined where the tumor is, whether the organs have moved that day. After all of these are drawn, the treatment is applied. We call this “adaptive radiotherapy”. In other words, the patient is treated with a new treatment plan every day. This leads to higher doses, fewer side effects and, as a result, higher success."
MR GUIDED RADIOTHERAPY IS NOT AVAILABLE IN MOST COUNTRIES!
So, are there any other current radiotherapy methods you use?
"This adaptive radiotherapy has actually started to be applied with two different methods. As I just mentioned, we started one of them 7-8 years ago. We call it “MRI-guided radiotherapy”. There is currently no such machine in the geography around Turkey. You know, the closest device to us may be in countries like Italy and Germany. But it is not available in the countries around Turkey. It takes a while for this method to be learned. We have had a great deal of experience in this regard. The first machine we applied is called MR linac, which is actually MR-guided radiotherapy. It is especially preferred for tumors detected in mobile areas. As I mentioned, treatment times have also shortened a lot. Now we can treat the patient in 5 days and send him/her to his/her country or home. "
RADIOTHERAPY ACCOMPANIED BY MR AND TOMOGRAPHY WITH ARTIFICIAL INTELLIGENCE
Effective, Shorter and Less Side Effect Cancer Treatment
Another method is the Ethos system, which we are using for the first time in Turkey. This actually performs the same procedure with tomography. Artificial intelligence comes into play in these methods. Artificial intelligence, which we call “artificial intelligence” and which is used in many places around the world, is now also used in medicine. For example, artificial intelligence can perform a procedure that a doctor can draw in 45 minutes, sometimes better than a human, sometimes with the same beauty within a minute. In this way, doctors save time for other tasks and provide better treatments. But of course, we cannot accept that everything artificial intelligence does is right. After all, medicine is a profession. We always check the processes of artificial intelligence. We can make small changes. It is a fact that our treatment times have shortened thanks to artificial intelligence-supported radiotherapy."
MR AND TOMOGRAPHY SUPPORTED SMART RADIOTHERAPY FOR CANCER PATIENTS FROM ABROAD
"MRI or tomography-assisted radiotherapy has great advantages for patients. Well, let's consider a patient coming from Greece as part of health tourism. What kind of advantages will radiotherapy with artificial intelligence-assisted MRI and tomography-guided radiotherapy have? Does the radiotherapy process vary according to the patient and his/her disease?"
TURKEY HAS MANY NEW TECHNOLOGICAL DEVICES FOR CANCER TREATMENT
"Yes, it can vary. In some cancers, there are treatments we do every other day. Then the treatment can extend to one and a half weeks. Sometimes, when the patient comes to our clinic on Monday morning, they can be treated on the same day and return on Friday. Our foreign patient group usually comes from everywhere Turkish Airlines flies. There is an intense patient traffic from countries around Turkey. But recently, for example, a patient came from Indonesia. So sometimes patients come to us even from the other side of the world.
So why is this business so good in Turkey? Actually, there are several main reasons. First of all, we have a very well-trained human staff. We are a big country of about 80 million people. Therefore, we can train good people in every field. There are doctors, radiotherapy technicians. There are medical physicists involved in this work. We can train and bring them all together and work as a team. Secondly, since we are in the Mediterranean, we are used to working a bit faster. In other words, when a patient arrives, we are a country that is used to starting treatments very quickly rather than saying something like go today, come back in a week or come back in 15 days. Obviously, we are practical, we are fast. So this is also important in terms of treatments. And perhaps the most important factor is that we have a lot of new technological devices in Turkey. For example, if we talk about MR Linac devices, there are about 6 MR Linacs in Istanbul alone. No country in the world has this number of MR Linacs in one city. In short, technology is coming to our country very fast and is being used very widely, especially in our big cities. "
DOCUMENTS AND EXAMINATIONS REQUIRED FROM PATIENTS COMING FROM ABROAD
If we think about a patient from Greece diagnosed with cancer, what kind of documents do you ask for before you apply? How do you plan his/her treatment, how do you determine whether he/she is suitable for smart radiotherapy, which is the topic of our conversation today?
"We ask patients to share with us a detailed report from their doctors. If the patients have any imaging, it can be MRI, PET-CT, it is useful to have their reports and especially their films in a format we call DICOM format, that is, in a format that we can see and examine. Afterwards, we determine which treatment is suitable for the patient, which machine will benefit the patient and we communicate this to the patient. While doing this, we also give brief information about how the procedure will be performed, how many days the treatment will take, and what side effects may occur."
WHICH CANCERS ARE TREATED WITH ARTIFICIAL INTELLIGENCE-SUPPORTED SMART RADIOTHERAPY?
Which cancers do you primarily treat with MRI and CT-guided smart radiotherapy? How does the treatment approach vary depending on the individual, the type of cancer, and its stage?
"Actually, it can be used in all areas, but we want to use these machines on patients who will benefit most. Our priority is particularly mobile areas, such as the lungs, liver, pancreas, abdominal area, and prostate. This is a method we prefer, especially in MR Linac. Although we can treat similar diseases with the other method, we also apply it to the hip area. After the treatments we perform today, we have come to understand the following. In the treatments we performed 10 years ago, we were actually irradiating patients incorrectly. That is, we were irradiating the wrong areas. But now we can adapt radiotherapy to each patient's specific needs, and of course, this brings success in treatment."
ARE THERE FEWER SIDE EFFECTS WITH SMART RADIOTHERAPY?
So, what kind of side effects occur with these smart radiotherapy treatments? Do the severity and impact of side effects differ from those of old radiotherapy, or classic radiotherapy methods?
"Yes, we actually divide the side effects of radiotherapy into four groups. There are mild side effects, which we call Grade 1-2. Then there are serious side effects, which we refer to as Grade 3-4. There is a significant reduction in all side effects. However, it is not the case that patients will experience no side effects at all because they received this treatment. We still observe certain side effects in patients, albeit fewer than before. However, I can say that we have almost completely stopped seeing the serious side effects we refer to as Grade 3-4."
‘WE CAN PROVIDE A GREEK REPORT DETAILING THE TREATMENT WE ADMINISTER TO PATIENTS’
Let's say a patient comes from Greece. I would like to ask specifically for Health Bridge 9030 viewers. Are follow-ups required afterwards? How do you follow up on a patient who has been treated here after they return to their country abroad?
"Yes, that's a very important question. We are also curious to know how much benefit patients derive from the treatment. Therefore, we provide them with a detailed English report explaining the details of the treatment. If necessary, we can also prepare a Greek report. After giving them this report, we explain what they need to do for check-ups, what tests they should have within 2 years, within 5 years. Of course, if they can come, we prefer to see them ourselves. But if the patient cannot come, we try to help them when they send us the tests they have had done via the internet. We recommend that they be followed up by an oncologist in their own country. This is because it is sometimes not accurate to make a judgement based solely on the tests without seeing the patient. For this reason, we insist that our colleagues there also follow up with the patient. If they have any questions about us, we always try to answer them.
DEVELOPMENTS IN CANCER TREATMENT WITH RADIOTHERAPY
How much have all these treatments, which are supported by artificial intelligence, intensity-modulated, and targeted, and are also performed with imaging, increased the success rate in cancer treatment?
"Of course, it is very difficult to say, but as far as we can see in our daily lives, the success rates have increased significantly. How do we understand this? For example, metastatic patients did not live for so many years in the past. They would be lost in a shorter period of time. We now see that these patients live longer, come back to us more often, and need this treatment again. But of course, it would be beneficial to demonstrate this with scientific publications."
As a cancer specialist, we discussed treatment with you, but we also have responsibilities to protect ourselves from cancer. If we put genetic factors aside, what should we pay attention to for a cancer-free life?
"This is a very important topic indeed. There are two or three important points. Firstly, not smoking, consuming alcohol with caution, not drinking excessively, avoiding overly fatty foods, and eating a balanced diet. And, of course, exercising. If we do all of these things to some extent, we will definitely reduce our risk of cancer. Smoking is something we should especially avoid. Finally, I can say this: radiotherapy is generally a one-time treatment. Therefore, it is beneficial for it to be successful and done correctly the first time. For this reason, patients should carefully evaluate where they will receive treatment. They should see if they have experience in this area and if their technology is adequate, and then make their decision accordingly."