UK SABR service development experiencesMaria HawkinsGenesisCare Consultant Clinical OncologistHonorary consultant Clinical Oncologist Oxford University Hospitals NHS FT

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Disclosure

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Stereotactic body radiation principles• Method to deliver a high dose radiation to target

• Single/few fraction treatment

• Rapid dose fall-off

• High precision

• Measures to account for motion

• Goal: tumour ablation

• Concept initially developed in 1951by Lars Leksell (neurosurgeon!) allowing delivery of a single session of RT for cranial lesions

Int J Radiat Oncol Biol Phys 2004

Standard Radiation Therapy

• Delivered 5-6 wks, Mon-Fri• Low dose RT/day (1.8 – 2Gy)

• Combined with chemo • Normal tissue can repair

• Acute > Chronic toxicity• Less Convenient (worse quality of

life)

• Good long term data (level1)

Stereotactic Radiation Therapy

• Delivered over one week• High RT/day (5-30 Gy)

• No concurrent therapy• More difficult for normal

tissues to repair the damage• Chronic > Acute Toxicity• Better quality of life

• Less data (level3)

Stereotactic body radiotherapy SBRT requirements

Highly specialized SBRT specific treatment delivery systems and complex patient

immobilization

Linear Accelerators equipped with on treatment imaging systems and conventional patient

immobilization

Stereotactic Radiation Requirements• Accurate imaging to define the target in 3D

• CT/4DCT• MRI/PET

• Motion management/characterization• Abdominal compression• Breath hold techniques• Tracking or gating

• 3D Localization during treatment• Fiducial markers• Cone beam CT (CBCT) imaging

Adoption of SBRT

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Pan Cancer 2011

Cumulative adoption United states

International survey >1000 Radiation Oncologists

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Lewis Am J CO 2015

42%US, 11%=Canada 10% Japan, 7% Western Europe 6% Australia, 3% S Korea

Indications for body SBRT-Primary tumours

Stage 1 inoperable lung cancer Local Control rates >85% at 3 and 5 years dose

>100Gy equiv in 2Gy fractions

Hepatocellular carcinoma not suitable for other ablative techniques

Less evidence: cholangiocarcinoma, renal cell carcinoma, pancreatic cancer

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Lung 50Gy/5 fractions

The aim of SABR in patients with oligometastases is to:

• achieve local control at the metastatic site and prevent the clinical sequelae of disease progression at that site

• improve disease free survival with the aim of enabling the patient to defer systemic therapy, or at least delay time until the next systemic therapy is required, thus maximising quality of life

• improve overall survival.

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Indications for body SBRT- metastatic disease• Metastatic carcinoma with either a histologically or cytologically

proven primary site or a male patient with a PSA>50 and clinical evidence of prostate cancer

• 1-3 sites of metastatic disease (defined after appropriate imaging) which can be treated with stereotactic radiotherapy to a radical radiation dose.

• A maximum of two sites of spinal metastatic disease • Maximum size of any single metastasis 6cm (5 cm for lung or liver

metastases) • Disease free interval > 6 months; unless synchronous liver

metastases from colorectal primary (see liver metastases section) • Not more than three oligometastatic sites treated in total per

patient • Expected life expectancy > 6 months • Performance status ≤ 2

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Paraaortic node Spine pelvic side wall 30Gy/3# 27Gy/3# 30Gy/3#

Minimum technology requirements• Imaging for planning: CT, contrast enhanced CT, MRI, PET,

4DCT• Planning processed: advanced calculation algorithms, 6MV,

beam profile modelling for small field sizes to be undertaken • Radiation beam delivery system: small MLC, high dose rate,

size of the mechanical isocenter sphere should be within 1 mm in radius.

• Immobilization of patient (comfortable and rigid), motion management

• Target definition- unambiguous, set-up margins well defined

• Geometric verification: on line imaging and repositioning Page 14

Patient selection –MDT team • Team: clinical oncologist, radiologist, medical physics,

radiographer• Patient selection – meet clinical criteria ?• Immobilization, planning issues/solutions (tumour close to

an organ at risk, on treatment verification tolerances?• Peer review of contours and plans• Toxicity discussions

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Immobilization- abdominal compression

Workforce• A multidisciplinary working party should develop, implement

and maintain the SBRT service– Additional resources are needed (staffing, training, etc)

– Start with prospective risk assessment and timeline

– Clear documentation and short-term/long-term audit are essential

– Ongoing education is high priority (QA, planning, delivery and verification technologies and techniques)

– Training in all likely treatment circumstances should be provided

Training requirements

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clinician Medical physicist Radiation therapy technologist

General methods for SBRT Yes Yes Yes

Patient selection yes

Patient immobilization and accounting for motion

Yes Yes

Imaging acquisition Yes Yes

Target definition yes

Dose planning yes

Dose prescription yes

Treatment delivery yes yes

Toxicity patternsFollow-up

yes

NHS England’s Commissioning through Evaluation• NHS England’s Commissioning through Evaluation (CtE)

programme enables a limited number of patients to access treatments that are not funded by the NHS

There are two main phases to the programme• Phase 1 – an agreed number of patients are recruited to a CtE

scheme within just a few selected centres across England. The National Institute for Health and Care Excellence (NICE) helps to identify the total number of patients who need to be recruited to the scheme to support data analysis

• Phase 2 – the analysis phase will vary in length, depending on the evaluation measures agreed

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SABR available via Commissioning through evaluation programme

Oligometastic Disease 17 centres

• Barts Health NHS Trust• Guy’s and St Thomas’ NHS Foundation Trust• Leeds Teaching Hospitals NHS Trust• Mount Vernon Cancer Centre (North and East Hertfordshire Foundation Trust)• Newcastle upon Tyne Hospitals NHS Foundation Trust• Nottingham University Hospitals NHS Trust• Oxford University Hospital NHS Trust• Royal Surrey County Hospital NHS Foundation Trust• Sheffield Teaching Hospitals NHS Trust• South Tees Hospitals NHS Foundation Trust• The Christie NHS Foundation Trust• The Clatterbridge Cancer Centre NHS Foundation Trust• The Royal Marsden Foundation Trust• University College London Hospitals NHS Foundation Trust• University Hospitals Birmingham NHS Foundation Trust• University Hospitals Bristol Foundation Trust• University Hospitals of Leicester NHS Trust

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Re-irradiation of pelvis and spine8 centres

• Barts Health NHS Trust• Guy’s and St Thomas’ NHS Foundation Trust• Leeds Teaching Hospitals NHS Trust• Nottingham University Hospitals NHS Trust• Mount Vernon Cancer Centre (North and East

Hertfordshire Foundation Trust)• Oxford University Hospital NHS Trust• The Royal Marsden NHS Foundation Trust• University Hospitals Birmingham NHS

Foundation Trust

Hepatocellular carcinoma7centres• Barts Health NHS Trust• Guy’s and St Thomas’ NHS Foundation

Trust• Leeds Teaching Hospitals NHS Trust• Mount Vernon Cancer Centre (North and

East Hertfordshire Foundation Trust)• Oxford University Hospital NHS Trust• The Royal Marsden NHS Foundation Trust• University Hospitals Birmingham NHS

Foundation Trust

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Potential benefits for SBRT• Prospective studies proof feasibility and efficacy

• Local control 60-100%

• Favourable toxicity profile

• Non-invasive

• Convenient • Possibly cost effective

SABR implementation• Audit of toxicity and outcomes key to safe delivery

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Study & Service EvaluationProspective SBRT Clinical Outcomes study for metastatic disease GC16-01 (SBRT Mets)

Aim(s):To prospectively collate clinical indications for SBRT delivered for metastatic disease within GC consortium and to evaluate clinical patient outcomes for comparison to published literature.

This will require data provision of clinical indications and rationale for SBRT and clinical follow-up of the patient using standard measurement tools for treatment related-toxicity, local control, patterns of failure, and disease free survival.

A clinical SBRT proforma form will need to be completed and baseline status recorded.

Following completion of treatment, clinical review of disease control and toxicity will be completed at each follow-up visit where appropriate at intervals of approximately 1 month, 3 months, 6 months, 9 months, 12 months then 6 monthly thereafter.

GCUK Service Evaluation for SBRT for Metastasis and Development of a Prospective Database

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Primary Objective for Study 1• Acute toxicity of SBRT as defined by CTCAE v. 4 treated in this service evaluation.• Primary endpoint: Grade 2 toxicity at 3 months Primary Objective for Study 2• Late toxicity of SBRT as defined by CTCAE v. 4 treated in this service evaluation.• Primary endpoint: Grade 2 toxicity at 12 months Secondary Objectives• To assess deliverability of SBRT and dose constraints achieved compared to published data. • To evaluate local control of the clinical cohort• To evaluate time to secondary therapy (DFS)

GCUK Service Evaluation for SBRT for Metastasis and Development of a Prospective Database

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• Multidisciplinary team effort• Communication• Audit of practice, outcomes and technology

Key to success

Thank-youReferences