On target

ON TARGET MEDICAL TOURISM RADIATION THERAPY

Latest advances in radiation therapy has made it possible to target the cancer cells better without affecting the adjacent normal structures

Little did the world realize the enormity of the development when Roentgen discovered X-rays way back in 1895. Initially, people considered it just a toy which would enable them to see the inside of the body and laugh at the sight. Within a year, these invisible rays were used to cure cancer. Such was the pace at which radiation impacted clinical practice.

Radiation therapy is a key component of treatment of cancerous as well as non-cancerous conditions affecting the human body. More than 80% of the cancer patients require radiation as part of their treatment, either as a sole modality or in combination with surgery and chemotherapy. In the 70s, Tele-Cobalt therapy machines were the only ones available for delivering radiation therapy.

The power of the radioactive source of Tele-Cobalt therapy machines comes down by half in 5.2 years and hence it needs to be replaced once every 10 years. The average energy of the gamma rays emitted by Cobalt-60 radioactive isotope is around 1.25 MV (Million Volts). Compare this with the modern medical linear accelerators which have the capability of generating high

ADVANTAGES WITH MODERN TECHNOLOGY Increasing mortality due to cardiac toxicities has been observed in significant proportions while treating young patients with left-side breast cancer. As the heart lies on the left side, treatment of left sided breast cancers entails a higher mean dose to the heart.

energy X- rays ranging from 4 MV to 15MV.This translates to better penetration of the radiation to deeply seated tumours within the body achieving better control of the tumour.

TECHNOLOGICAL ADVANCEMENT OVER THE LAST TWO DECADES For a tumour to be controlled, an appropriate dose of radiation needs to be delivered in a stipulated time frame with little dose or damage to the normal tissue surrounding the tumour. The challenge in radiation therapy practice is delivering a radiation dose that would maximize the tumour control rates and, at the same time, minimize the side-effects of radiation in the adjacent normal structures in the path of the radiation beam.

The tremendous strides we have made in medical imaging (MRI and CT scans) - linear accelerators with small multi-leaf collimators , functional imaging of the tumours with isotope scans like the Positron Emission Tomogram scans (PET scan), integrated to MRI and CT (MRI PET, CT PET) - have enabled us to visualize the tumour as well as the normal structures with more certainty.

The linear accelerators also have evolved in their design to focus the X-rays precisely on the tumour targets. The most important change that has occurred is the creation of multi-leaf collimators which help us to have irregularly shaped beam to hit complex shapes of the target, without exposing the adjacent normal structures to unnecessary radiation. They also play a crucial role in the intensity modulated radiation treatment planning (IMRT) reducing the radiation dose to the normal structures. This is extensively used in the treatment of cancers of the head and neck region, sparing parotid glands from damage and preventing dryness of the mouth. IMRT is indeed a boon in the radical treatment of prostate cancer, sparing the adjacent normal tissues like bladder and rectum of the side effects of radiation significantly.

Unlike teletherapy, brachytherapy uses a radioactive isotope source placing it in the close vicinity of the tumour. It could be inside a cavity or a lumen or in an area within the normal tissues bearing the cancer. High therapeutic efficiency can be achieved by brachytherapy treatment by delivering the maximum dose to the tumour while exposing surrounding normal tissues to minimum dose. Modern technology with computer controlled after-loading devices enables the tiny isotope source to access even inaccessible areas of the body through the implanted catheters, tubes and applicators placed in the tumour bearing site. Modern linear accelerators equipped with active breathing coordinators help to treat the patients in the deep inspiratory phase while the breath is held for a short period in deep inspiration. The heart moves away from the breast tissues thereby resulting in lesser dose to the heart. The risks in cardiac mortality are significantly reduced by this reduction in the mean cardiac dose.

Lung and liver tumours can be treated in their early stages with ablative radiation therapy doses given in extreme hypo fractionated schedules. The treatment will be over in a week’s time with five daily fractions. Active breath coordinators help in minimizing respiratory distortions at the targets in the organs by delivering radiation at the correct phases of the respiratory cycles with great precision.

The volumes of normal tissue getting irradiated are also minimized, thereby reducing the normal tissue toxicities. Modern radiation therapy thus provides curative strategies for localized tumours in the liver and lung without allowing any major surgery.

33 A Complete Magazine on Healthcare in Asia To spare the normal tissue while delivering optimum dose to the tumour to destroy it completely has been the focal theme of research over the past two decades. The micro multi-leaf collimators were specifically developed to target the small benign tumours (acoustic chwannoma, pituitary adenomas, AVM’s etc.) in the brain. The Gamma Knife and the X-Knife (Linear accelerator based) stereotactic radiosurgery (SRS) has enabled the radiation oncologist to ablate these lesions in the brain without any surgical

intervention. Needless to say, these advances in technology that helps to precisely target the small inaccessible lesions in the brain with sub-millimeter accuracy, has turned out to be a marvel of medical science.

CHALLENGES WITH TECHNOLOGY The advances in technology have posed challenges too. From the caregivers’ point of view, the fundamental question of comparative cost-effectiveness in applying these tools in varying clinical conditions needs to be carefully analyzed. It needs to be carefully evaluated how much significant are they in improving the results for a comparative gain in normal tissue side-effects. With very less social support for high end health care for the common man, it remains a huge challenge for the policy makers to create an equitable society.

As the famous physicist educationist, writer C.P. Snow has rightly said, “Technology can offer us lot of gifts but can also stab us behind our backs”. Technology is not just about operating with expensive machines. The people behind the machines also do matter. Regular quality control

(QC) and quality assurance (QA) programmes are mandatory for their safety and accuracy.

Unfortunately, our system of healthcare does not have any mandatory external monitoring policy for medical equipment to ensure their safety and performance. Teaching hospitals have the greatest advantage in this regard. Participation in clinical trials makes it mandatory to participate in external QC & QA programs. The radiation oncology discipline also gets refined with such a supervised approach.

The success behind any enterprising medical technology is the team implementing it. Besides the Radiation Oncologist, high-quality medical physicists and well trained radiation therapy technologists form the backbone in the treatment. Institutions with teaching and training programmes in these disciplines strengthen the quality of the radiation oncology programme. these specialties, which is a mandatory exercise in teaching hospitals involved in training programmes, leads to a healthy oncology practice.

Last but not the least, the penchant for technology needs to be balanced with a compassionate mind for patient care. We need to strongly factor in the cost-effectiveness of care and the incremental cost-benefit ratio when we think of expensive technology for cancer treatment solutions. ‘Choosing wisely’ should be the guiding principle in our decision-making process. Cancer sufferers need a comforting care giver. As Albert Camus very eloquently put, “Who taught you all this Doctor, the answer is ‘suffering’.

We need to etch this lesson in our minds when we render our care to the millions suffering from the perils of cancer and care should always be reinforced with compassion and kindness.

Besides radiation oncologists, a team of devoted medical and surgical oncologists, palliative care specialists and specialist oncology nurses are required for comprehensive cancer care. Regular interaction between Dr. M. Dinesh (Head, Radiation Oncology Division, MVR Cancer Centre & Research Institute, Kozhikode, Kerala)

Stemcell Knee Cartilage Regeneration

Revolutionary Technology To Fight Knee Arthritis

Arthritis affects millions worldwide and 100 million people in India. Knee arthritis is very common and especially among the elderly. While knee replacement surgery is the gold standard treatment, TOSH Hospital offers an alternative, Stemcell Knee Cartilage Regeneration for knee arthritis. Knee cartilage regeneration is an emerging technique to treat knee arthritis and help preserve the natural knee joint. The single stage key-hole (Arthroscopy) procedure is done by harvesting stem cells from the patient’s bone marrow in the pelvic bone and injecting it into their knee joint. The worn-out knee cartilage causing discomfort and pain is first removed by a key-hole procedure. The stem cell mixed with clotting gel is injected into the knee joint. These stem cells help in the growth of new cartilage. The surgery takes about an hour and a half and the patient remains in the hospital less than 48 hours totally. Spinal anaesthesia is given to make both legs numb waist down, and the patient remains awake throughout the procedure. In rare cases, general anaesthesia is given. TOSH is at the forefront of introducing single stage stem cell knee procedures, and the highly proficient team has performed over 350 successful surgeries. As awareness of regenerative therapies increases, the number of patients undergoing knee cartilage regeneration is on the rise. This treatment will substitute at least 50% knee replacement surgeries globally in a decade. It can be performed at any age and a gap of 2-3 months needed between surgeries, for the other knee. While knee replacement surgeries require a revision surgery after 15-20 years and pose high risk of infection and other complications since a foreign material is implanted into the body, the major advantage of stem cell knee cartilage treatment is that it is a natural way to preserve one’s knee and avoids any artificial implant in the body. The minimally invasive procedure is not painful as there is no cutting of bone or muscle. The day care procedure ensures the patient moves the joint fully and allowed partial weight bearing walking on the operational leg on the same day. Mild pain relieving tablets are prescribed for 5 days. The sutures can be removed after 12 days. As the new cartilage forms, pain disappears. Post 6 weeks, the patient can get back to a normal lifestyle. Post-operative physiotherapy is not required and patients can do the advised exercises on their own. The success rate depends on the patient’s condition, age and level of knee damage. Even advanced cases are handled through this procedure after assessment of X-rays. For curved knees, a small alignment correction procedure is additionally needed.

TESTIMONIALS

Dr. S.H. Jaheer Hussain MBBS, M S Orth, M.Ch. Orth (UK) Joint Preservation & Reconstruction Surgeon

ADVANTAGES

Day Care procedure

Retain one’s own natural knee

 Safer alternative to total knee replacement

No metal implants

 No restrictions of joint movements unlike knee replacement

 Squatting, jogging and sports activity allowed gradually

“My wife Mrs. Azza Al Harthi has undergone this procedure for the left knee six months back. I was really apprehensive about the procedure and was wondering if it was actually possible. Now she is happy with the results and planning for other knee. I hope that more people are made aware about knee cartilage regeneration so they can benefit from the minimally invasive procedure that doesn’t use any artificial implants.”

“ Everybody wants to be mobile and enjoy free movement. Dr. Jaheer truly gives a boon for all patients suffering from unbearable knee pain. This revolutionary treatment helps preserve our own knee and offers so much relief. I hope that more people are made aware about Knee Cartilage Regeneration so they can also benefit from the minimally invasive procedure that doesn’t use any artificial implants. “

Mr. Mohammed Naseer Ammar Al Harthi Muscat, Oman

Malathi, Chennai

For more details contact TOSH (Trauma & Orthopaedic Speciality Hospital) #72, Ormes Road, Kilpauk, Chennai For Appointments +91-44 4903 4903 | +91 989 446 7903 | Email : toshenquiry@gmail.com | http://toshhospitals.com