Radiotherapy and clinical oncology
Radiotherapy in the 1980s continued to advance with better tumour localisation related to advances in medical imaging and increasingly sophisticated treatment planning with the aid of simulators.
The 1986 Silvanus Thompson Memorial Lecture was given by RH Thomlinson from Mount Vernon Hospital on cancer and why treatment fails (Thomlinson BJR 1987; 60(716): 735-751). He states that cure is often difficult to prove and that failure is open to analysis in a way that cannot be applied to success. He felt that in investigating a new treatment that analysis of failure would result in a better way forward than concentration on the successes. He believed that this might be difficult for those with a medical mind but that the way of science is often hard.
Effects of radiation
Many papers appeared looking at the effects of how radiation could be administered, such as single doses or in fractions. JR Fowler from Mount Vernon hospital looked at short and long fractionated schedules in August 1987 (Fowler BJR 1987; 60(716): 777-779) and proposed an improvement. The first interim progress report on the second BIR fractionation study for radiotherapy in carcinoma of the laryngo-pharynx was published in May 1989 (Wiernik, Alcock, Bates, Berry, Brindle, Dalby, Fowler, Gajek, Goodman, Haybittle, Henk, Hopewell, Howard, Lindup, Phillips, Pointon, Rezvani and Tobias
BJR 1989; 62(737): 450-456). The first trial had started in 1962 and because of its successful running a second trial had been set up. In August 1989 John F Fowler from Madison, Wisconsin, reviewed the linear-quadratic formula and the progress that had been made in fractionated radiotherapy (Fowler BJR 1989; 62(740): 679-694). Clinical gains had been made using non-standard fractionation schedules planned with a radiobiological basis. Recent examples were hyperfractionation, which was described in the paper and accelerated fractionation. It had only been in the last decade that the biological factors concerning overall time and delayed proliferation after irradiation, and the effect of dose per fraction, had been understood.
In the 1970s radium was being replaced in radiotherapy departments. At the Royal Free Hospital they decided in 1974 to replace their system to treat cancer of the cervix and endometrium which had involved the use of radium tubes loaded into silver Stockholm plaques and Manchester type rubber uterine tubes. In June 1983 TJ Bateman and others described their five years hospital experience with the Amersham caesium-137 manual afterloading system (Bateman, Davey and Skeggs BJR 1983; 56(666): 401-407). In the next paper in the June 1983 BJR we find JW Wilkinson and others from Manchester describing their use of the Selectron afterloading equipment (Wilkinson, Moore, Notley and Hunter BJR 1983; 56(666): 409-414).
Image source: Wilkinson, Moore, Notley and Hunter BJR 1983; 56(666): 409-414
The Selectron pneumatically transfers the pellets of caesium-137 and avoids the hazards of manual afterloading. The authors were using the Selectron to simulate the traditional Manchester System for intracavity therapy. Of interest in the paper is that the Manchester group were using computer programs to extract source position data from CT images and then to display the isodose data superimposed on the CT cross-sectional scans. This role of CT in radiotherapy was further examined by H Jane Dobbs and Janet E Husband in May 1985 (Dobbs and Husband BJR 1985; 58(689): 429-436) when they reviewed CT in the staging of tumours and in radiotherapy treatment planning of prostate cancer.
The use of the Selectron remote afterloading system for gynaecological treatments was reviewed by EM Dean and others (Dean, Lambert and Dawes BJR 1988; 61(731): 1053-1057) from Newcastle upon Tyne. In Newcastle they had used the Manchester system using radium-226 until 1972 when they introduced a manual afterloading system utilising caesium 137. This had been replaced by a Selectron remote afterloading system in 1985 and the group presented an interesting account of their experience.
In December 1981 JA Brace and others from the Royal Free Hospital described conformation therapy on their recently installed (commissioned in January 1980) computer-controlled cobalt unit (Brace, Davey, Skeggs and Williams BJR 1981; 54(648):1068-1974). V Sathiaseelan and others from Cambridge in December 1985 were using a microcomputer (desktop computer) to control a clinical microwave hyperthermia system (Sathiaseelan, Howard, Kedar and Bleehen BJR 1985; 58(696): 1187-1195).
FA Stewart and J Denekamp from Mount Vernon Hospital (Stewart and Denekamp BJR 1980; 53(628): 346-356) examined fractionation studies with combined X-rays and hyperthermia in April 1980. The interaction of hyperthermia and radiation was studied by DD Loshek and others from Glasgow in January 1981 (Loshek, Orr and Solomonidis BJR 1981; 54(637): 40-47) and the subject was reviewed in detail by JW Hand and G ter Haar in June 1981 (Hand and ter Haar BJR 1981; 54(642): 443-466).
AWG Goolden and others from the Hammersmith Hospital and Northwick Park Hospital gave an account of their experience of fractionation of whole body irradiation before bone marrow transplantation for patients with leukaemia (Goolden, Goldman, Kam, Dunn, Baughan, McCarthy, Worsley, Gordon-Smith, Samson, Catovsky and Galton BJR 1983; 56(664): 245-250).
The Sheffield experience of stereotactic radiosurgery of the brain was described by L Walton and others and was published in September 1987 (Walton, Bomford and Ramsden BJR 1987; 60(717): 897-906). In November 1984 the Department of Health had purchased for evaluation a radiosurgery unit of similar design to that used by L Leksell in Stockholm in the Karolinska Institute.
In April 1984 (Brown, Greening, McCReady, Shaw and Harmer BJR 1984; 57(676): 323-327) AP Brown and others from the Thyroid Unit at the Royal Marsden Hospital reviewed their patients with metastatic thyroid cancer treated from 1949 to 1981 with radioiodine (131I). The series is quite remarkable for its length. In 1949, Professor Sir David Smithers had successfully treated the first such patient.
Image source: Brown, Greening, McCReady, Shaw and Harmer BJR 1984; 57(676): 323-327
A Helleberg and others from Gävle in Sweden (Helleberg, Lundgren, Norin and Sander BJR 1982; 55(655): 511-515) described their experience of the use of Tamoxifen in early breast cancer in the elderly in July 1982. There had been an established breast cancer screening programme in Gävleborg in Sweden since 1974.
Radiotherapy has a significant role in the treatment of breast cancer. In April 1984 Diana Brinkley and others on behalf of the Cancer Research Campaign described the results of treatment of early breast cancer in a trial that had started in June 1970 (Brinkley, Haybittle, Houghton and The Cancer Research Workng Party BJR 1984; 57(676): 309-316). Their conclusion was that immediate post-operative radiotherapy reduced the risk of local recurrence. In the same issue of the BJR, AM Nisar Syed and others from California (Syed, Puthawala, Orr, Gowdy, Sheikh and McNamara BJR 1984; 57(676): 317-321) described their experience of primary irradiation in the management of early and locally advanced breast cancer and observed excellent local and regional control of the disease and gratifying cosmetic results.
Jeremy Tobias wrote a thoughtful review article in July 1986 on radiotherapy and breast conservation (Tobias BJR 1986; 59(703): 653-666). The patient is central and Tobias concluded by saying that “It is fair to say that a new spirit of optimism has emerged, due to both the improved survival figures resulting from adjuvant chemotherapy and hormone therapy and also the unquestionable improvement in quality of life than breast preserving local treatment can provide.”
Image source: Tobias BJR 1986; 59(703): 653-666
HA Barot and others from St. Thomas’s Hospital reviewed the use of cis-platinum co-ordination complexes in January 1985 (Barot, Laverick and Nias BJR 1985; 58(658): 51-62). These agents have biological effects that resemble those of radiation.
Fast neutron therapy
The first paper in radiotherapy in the BJR to start the1980s was by DE Bonnett and others from the MRC Cyclotron Units at the Western General Hospital in Edinburgh and the Hammersmith Hospital in London (Bonnett, Williams and Parnell BJR 1980; 53(625): 12-20). A second fast neutron beam for radiotherapy had been installed at the Western General Hospital and this second beam was steerable and isocentric. Further papers on fast neutrons appeared such as the paper by JJ Battermann and others in October 1981 (Battermann, Hart and Breur BJR 1981; 54(646): 899-904). There were many papers in the BJR on neutron therapy such as W Duncan and others from Edinburgh in April 1986 on supratentorial tumours (Duncan, McLelland, Jack et al BJR 1986; 59(700): 373-377) http://dx.doi.org/10.1259/0007-1285-59-700-373. In May 1986 a large comparison study of the Hammersmith (1971-75) and Edinburgh (1977-82) experience of neutron therapy in various head and neck cancers was published by the MRC Neutron Therapy Group (Medical Research Council Neutron Therapy Working Group BJR 1986; 59(701): 429-440).
A new high-energy neutron therapy facility was opened in Clatterbridge Hospital in Merseyside at the Douglas Cyclotron Centre and the new unit was described in detail by DE Bonnett and others in January 1988 (Bonnett, Blake, Shaw and Bewley BJR 1988; 61(721): 38-46). In the following paper JE Shaw described the beam parameters of the neutron therapy facility (Shaw, Bonnett and Blake BJR 1988; 61(721): 47-53).
In September 1988, J Glaholm and C Harmer from the Royal Marsden Hospital described a series of patients treated using fast neutrons in 1980 and 1981 (Glaholm and Harmer BJR 1988; 61(729): 829-834) and found that patients treated with fast neutrons following wide excision developed unacceptable late tissue damage and so they decided to terminate the clinical trial.
Image source: Glaholm and Harmer BJR 1988; 61(729): 829-834
EJ Hall in September 1981 reviewed new modalities in cancer treatment and described the use of heavily charged particles such as protons (Hall BJR 1981; 54(645): 773-781) and their use in choroidal melanoma. EJ Hall stated that charged particles “represent the ultimate that the physicist can contribute to the improvement in dose distribution in clinical oncology.”
In June 1984 Jacob Fabrikant from California wrote an interesting paper on stereotactic heavy-ion Bragg peak radiosurgery for intra-cranial vascular malformations (Fabrikant, Lyman and Hosobuchi BJR 1984; 57(678): 479-490). This paper was the first clinical report of the use of a stereotactically directed narrow beam of helium ions from the 184-inch Synchrocyclotron at the Lawrence Berkeley Laboratory for life-threatening vascular disorders of the brain.
Boron neutron capture therapy (BNCT) and their use in the treatment of glioma were described by CA Perks and others in December 1988 (Perks, Mill, Constantine, Harrison and Gibson BJR 1988; 61(732): 1115-1126). The treatment was developed at the Harwell Laboratory.