Improving cancer outcomes through radiotherapy
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7229.198 (Published 22 January 2000) Cite this as: BMJ 2000;320:198
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Editor - Burnet et al1 quite rightly highlight the prejudicial
effect on outcomes of the lack of UK radiotherapy resources. They cite a
number of cancers occurring in adults but fail to mention children's
cancers.
Cancer is one of the four big killing diseases in childhood and
after leukaemia, tumours of the central nervous system are the most common
cancers in childhood. Brain tumours are categorised as moderate risk
diseases by the Department of Health. Radiotherapy, either as an adjunct
to surgery or as a sole modality, is an important component of the
therapeutic strategy for many of the 400 new cases of childhood brain
tumour occurring every year in England and Wales. In medulloblastoma, five
-year event free survival rates of up to 70% can now be achieved in some
countries2, a figure hardly approached in the UK. In single-site
intracranial germinoma the rate can be 90 to 100%3. There is currently a
lag time of up to six weeks to commencing sophisticated neuraxial
radiotherapy in children. This is unacceptable both for those tumours with
a high doubling time, such as medulloblastoma2 and for those producing
distressing symptoms for which radiotherapy is the most effective
palliative measure, such as diffuse pontine glioma4.
Burnet et al1 also
raise the issue of hyperfractionation; this is a further strategy that may
be of value in treating certain children's brain tumours but which would
be very difficult to adopt without appropriate resources. At the request
of the Department of Health, a UK working party5 produced a Standards
Document in response to public concern regarding the adequacy of treatment
for children with brain tumours under the NHS. It is ironic that
inadequate radiotherapy facilities continue to hamper endeavours to
improve outcomes in this area. Those centres with specialist multi-
disciplinary paediatric neuro-oncology teams should be enabled to deliver
the optimum treatment to children.
On behalf of the afflicted children and
their families we therefore call not only for the provision of more linear
accelerators but also for the clinical oncologists, radiographers and
physicists to operate them.
1. Burnet NG, Benson RJ, Williams MV, Peacock JH. Improving cancer
outcomes through radiotherapy. BMJ 2000:320:198-199.
2. Berger MS, Magrassi L, Geyer R. Medulloblastoma and primitive
neuroectodermal tumors. Chapter: Brain Tumors, Kaye AH, Laws ER Jr (eds).
Edinburgh: Churchill Livingstone, 1995.
3. Shibamoto Y, Takahashi M, Abe M. Reduction of the radiation dose
for intracranial germinoma: a prospective study. Br J Cancer 1994:70:984-
989.
4. Walker DA, Punt JAG, Sokal M. Clinical management of brain stem
glioma. Arch Dis Child 1999:80:558-564.
5. Walker DA, Hockley A, Taylor R, et al. Guidance for services for
children and young people with brain and spinal tumours. London: Royal
College of Paediatrics and Child Health, 1997.
Jonathan Punt
Senior Lecturer/Honorary Consultant in Paediatric
Neurosurgery
David Walker
Senior Lecturer/Honorary Consultant in Paediatric
Oncology
Michael Sokal
Consultant in Clinical Oncology
Nottingham Children's Brain Tumour Research Centre,
University Hospital Nottingham,
Nottingham
NG7 2UH
Competing interests: No competing interests
Editor,
Burnet and colleagues make important points about the adverse impact on
potential cure rates of the shortage of radiotherapy treatment facilities
in the UK (1) and the failure to implement within the NHS on a national
basis the CHART fractionation regime for non-small cell lung cancer, which
confers a 43% increase in two year survival (2).
The impressive improvements in survival in paediatric malignancy over the
last 20 years have been achieved in large part by the rapid implementation
of improvements in cancer outcomes from randomised clinical trials into
routine clinical practice. The same integration of research and service
delivery is needed in adult malignancy.
Burnet et al estimate that cure rates could be increased by 25% by the
provision of adequate radiotherapy facilities from clinical and
radiological data. These are important observations to inform policy
makers responsible for the allocation of radiotherapy resources. It would
be helpful for the authors to clarify the basis of their calculations
which underpin these important conclusions.
Dr. I. H. Kunkler
Consultant in Clinical Oncology
Western General Hospital,
Crewe Road,
Edinburgh EH4 2XU
1. Burnet NG, Benson RJ, Williams MV, Peacock JH. BMJ 2000; 320: 198-
9
2. Saunders M, Dische S, Barret A, Harvey A, Gibson D, Parmar M.
Lancet 1997; 350 : 161-5
Competing interests: No competing interests
Photodynamic therapy
Your editorial entitled "Improving cancer outcomes through
radiotherapy"1, was insightful, thought provoking and exciting, drawing
attention to an apparently very simple way of improving cancer outcomes in
the UK. Unfortunately the simple conclusion to provide more radiotherapy
services generates the challenge of substantial new investment and a long
wait for building of facilities and training of staff. Sadly therefore
patients in the United Kingdom are unlikely to benefit from this very
rational approach for many years.
An alternative to the provision of new radiotherapy services was not
proposed in the editorial, but the potential exists. Today between 40%
and 50% of all radiotherapy administered is for palliative reasons.2 If
alternative, cost effective and simple ways of palliation could be found,
then the amount of radiotherapy services available for curative purposes
could double.
Several photodynamic therapy agents are in development today3,4. Many
patients with a wide range of solid tumours, in many sites in the body,
have already been treated in early phase studies. Photodynamic therapy
can be administered using existing hospital operative facilities and
therefore although requiring clinical trial validation avoids the cost and
time delay of building substantial new infrastructure. If the government,
academia and the oncology community were to show interest and investigate
this treatment modality as an alternative to palliative radiotherapy, a
win-win situation could emerge. Patients requiring palliation would
receive it cost effectively in local hospitals utilising photodynamic
therapy. Twice as many patients requiring curative radiotherapy could
then get the benefit they so richly deserve.
DR ROBERT J DOW
CHIEF EXECUTIVE OFFICER
1 BMJ 2000; 320:198-9
2 Current problems in Cancer - 1997; May/June: 138
3 Drug Discovery Today - Vol. 4, No.11 - 1999 November
4 Reviews in Contemporary Pharmacotherapy 1999; 10: 1-78
Competing interests: No competing interests