Future of Radiation Therapy JP Morgan Healthcare Conference January - - PowerPoint PPT Presentation

Future of Radiation Therapy

JP Morgan Healthcare Conference January 12, 2016 Deepak Khuntia, MD, VP of Medical Affairs Patrick Kupelian, MD, VP of Clinical Affairs

Cancer as a cause of death

CANCER TREATMENT MODALITY: RADIOTHERAPY

Localized Treatments: Surgery Ablative Treatments:

Cryo HIFU Laser Microwave

Systemic Treatments:

Drugs: Traditional ChemoRx Hormonal Therapy Targeted Drugs

Radiation Therapy (RT):

Spectrum of biologic effects

• Ablative: SRS/SBRT
• Biologic therapy

Organ-sparing DNA changes Immune modulation

: less invasive?

Very few curative therapies Minor improvements in subsets of patients

DISEASES TREATED WITH RT

Curable Cancers with RT ALONE:

Prostate Ca Head & Neck Ca Lung Ca Cervical Ca Skin Ca

Curable Cancers with RT as part of treatment (adjuvant):

Breast Ca Brain Tumors Testicular Ca

• Adv. Lung Ca

Rectal Ca Sarcomas

• Adv. Cervical Ca

Endometrial Ca Pediatric Ca

• Adv. Head & Neck Ca

Bladder Ca

Metastatic disease: Bone / Brain / Other…

Improving RT Delivery

1950-60s Cobalt Early Linacs 1970-80s Higher Energy Linacs 1990s Beam Shaping Devices 2000s In-room Image Guidance 2010s Integration of Better Beam Shaping and Aiming Impact Explore new indications

• Treat deeper

tumors

• Decrease

skin toxicity

• Treat smaller areas
• Individualization
• Decrease toxicity in

deeper organs

• Increase in

tumor doses

• Improve

tumor control

• Higher daily

doses

• Faster, Better,

Safer treatments

Aim: Increase Cure / Decrease Toxicity Process: Improve RT Shaping and Targeting

Improving RT Techniques and Outcomes

1995-2000 Beam shaping devices: MLCs 2000-2005 In-room image guidance 2005-2010 Partially integrated systems 2010-2015 Hypofractionation, Adaptive RT 2015-Future Integration of Better Beam Shaping and Aiming Novelty IMRT IGRT

• Dedicated devices
• Multivendor

environment

• SRS
• SBRT/SABR
• ART

Need for increased integration and/or interoperability Clinical Impact

• Head/Neck: improve

saliva / swallowing

• Pelvis: Less bowel

toxicity

• Allows safer

chemotherapy administration

• Prostate Ca:

Enable dose escalation: improve cure

• Reduce traditional

set-up errors

• Increased

complexity

• Decrease

throughput

• Increase safety

concerns.

• Lung Ca SBRT:

improve cure

• Frameless CNS

radiosurgery

• Partial breast

accelerated irradiation

• Faster, better, safer

treatments

• Global RT:
• Simpler set-ups
• Education &

training

Andrews DW, Scott CB, Sperduto PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004 May 22;363(9422):1665-72.

Brain Mets Study: Adding SRS Improves Survival

Treatment Details

• 18 Gy x 1
• 4 non-coplanar arcs
• 1-360, 3-170
• 18 min treatment
• 5 min beam-on
• 708 control points

RapidArc Radiosurgery: Treating 11 Melanoma Mets

SBRT vs. Lobectomy for Operable Stage I NSCLC

Source: Chang JY, Senan S, Paul MA, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015 Jun;16(6):630-7.

Lung Cancer: Patients live longer with Radiosurgery than with Surgery

Zelefsky, IJROBP, 84, 125-129, 2012 PROSTATE CANCER IMAGE GUIDANCE: IMPROVING CURE AND REDUCING TOXICITY Memorial Sloan Kettering Cancer Center Prostate Cancer RT: Outcome with and without Image Guidance Cancer Control Rates Toxicity Rates

Shaping of Radiation Lowers Complications

Reduce Bowel Complications

Cancers impacted: Prostate Ca Rectal Ca Anal Ca Cervical Ca

Reduce Head & Neck Complications

Complications reduced: Less dryness of the mouth Less swallowing problems Less scarring of joints / muscles Chopra et al. ASTRO Plenary, San Antonio October 2015. Gupta et al. Radiotherapy and Oncology. 104:3 (343-348), 2012.

Conventional RT IMRT

New Era Innovation

Knowledge-Guided Oncology | Intelligent Treatment Delivery Advanced Data Analytics

IMAGE – Not Yet Complete

RapidPlan™ Ramp Up

• 300+ Orders
• 3,800 Potential Installs
• Disease Site Models
• Prostate
• Prostate (+lymph nodes)
• Head & Neck
• Lung SBRT
• Breast
• More Models Coming

KNOWLEDGE-GUIDED ONCOLOGY:

University of Michigan: Spine SBRT Study

Manual RapidPlan

Foy J, et al. An analysis of knowledge based planning for stereotactic body radiation therapy of the spine [abstract]. Poster presentation at: American Association of Physicists in Medicine (AAPM) 57th Annual Meeting & Exhibition; July 12-16, 2015; Anaheim, CA. University of Michigan

Equivalent Quality

Manual Rapid Plan Time 60-90 min 15-20 min

KNOWLEDGE-GUIDED ONCOLOGY:

Royal Surrey County Hospital: Prostate Study

Manual RapidPlan™

Time

114 ± 86 min 21 ± 13 min

Equivalent

• r better

30% 90%

Better

10% 90%

Courtesy, Royal Surrey County Hospital NHS Foundation, Guilford, UK Data source on file

50 100 150 200 250 300 350 A1A2A3A4B1B2C1D1D2D3E1E2E3F1F2F3F4F5F6

Planning time (min)

conventional RapidPlan KNOWLEDGE-GUIDED ONCOLOGY:

High Definition Radiotherapy (HDRT)

INTELLIGENT TREATMENT DELIVERY:

Works in Progress

4π Dose Compression for Lung SBRT

INTELLIGENT TREATMENT DELIVERY: IMRT

PATIENT 1 PATIENT 2

VMAT 4 π HDRT 64 Gy 15 Gy

Dong P et al. IJROBP 86(3):407-13, 2013

Works in Progress

High Definition Radiosurgery

Coplanar RapidArc SRS 4π High Definition SRS

Brain Stem Brain Stem

50% Rx Dose 50% Rx Dose

INTELLIGENT TREATMENT DELIVERY:

Works in Progress

Promise of Protons

InSightive™ Analytics

• Operational Efficiencies
• Referral Patterns
• Clinical Outcome Analysis

ADVANCED DATA ANALYTICS

ADVANCED DATA ANALYTICS:

Velocity

TM

• Creates the cancer story from

imaging

• Imaging informatics integrated

with our Big Data Analytics

• Improve outcomes, quality, and

efficiency

ADVANCED DATA ANALYTICS:

Radio-immunotherapy for Cancer Treatment

Hodge, Guha, Neefjes, Gulley. Oncology, 2008 August, 22(9):1064-1084

Abscopal Responses in Metastatic Non-Small Cell Lung Cancer (NSCLC) Patients Treated on a Phase 2 Study of Combined Radiation Therapy and Ipilimumab: Evidence for the In Situ Vaccination Hypothesis of Radiation

E.B. Golden, A. Chachoua, M.B. Fenton-Kerimian, S. Demaria, and S.C. Formenti New York University

ASTRO Annual Meeting October 2016

The Abscopal Effect: Radiotherapy in one site can potentially eradicate tumors elsewhere in the body

• Combining radiosurgery with immunotherapy
• Study of NSCLC
• Study shows that SBRT with ipilumimab could

increase tumor control and survival

• 25% remission; 100% control/no progression

Golden et al. ASTRO 2016.

Targeted Therapies and Immunotherapies: Trend is in Combining Drugs

RT as a combination “drug”

• Available
• Cost-effective
• Reimbursed

Challenges of drug+drug combinations

• Clinical trial design
• Cost
• Commercialization

• 4. Radiation Medicine

Cardiac Arrhythmia (Atrial Fibrillation) Research opportunities in radiation medicine:

• Cardiac arrhythmias
• Emphysema
• Post-thoracic surgery neuropathy
• Plantar fasciitis
• Depression
• Arthritis

NEW FRONTIERS IN RADIATION ONCOLOGY

Works in Progress

Cardiac Arrhythmias: A New RT Frontier?

Affordable, Accessible, Quality Care

Cost of Cancer Care in US 30% increase from 2010 to 2020 Average cost for one extra year of life: 1995: $54,100 2005: $139,100 2013: $207,000

Sources: Avalere study, 2015 National Bureau of Economic Research

$0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 Short course Intermediate Long course Colectomy Cystectomy Lobectomy Pancreatectomy Office Hospital RT Surgery Chemo (1 year)

Average Cost per Patient

Technology Decreasing Treatment Cost: SBRT / SRS

Technology (SBRT) Decreasing Actual Treatment Cost

Time-driven activity-based costing (TDABC), UCLA

SBRT

Utilizing time-driven activity based costing to understand the short- and long-term costs of treating localized, low-risk prostate

• cancer. Laviana et al. Cancer. 2015

Conclusion

• Advanced technology is increasing cure rates and

lowering toxicity

• Advanced technology will improve affordability,

accessibility, and quality of radiotherapy

• Radiation therapy utilization could dramatically

increase with new opportunities outside of cancer

Thank You

$3-4M?

IGRT SBRT HDRT

The Key To Progress: Better Dose Delivery

INTELLIGENT TREATMENT DELIVERY:

IMRT

MR LINAC

3D CONFORMAL

Relative Clinical Value

$10M