Radiotherapy

We provide advanced radiotherapy techniques as standard and we continuously invest in cancer treatments and technologies that are proven to provide the best life outcomes

Volumetric Modulated Arc Therapy (VMAT)

Delivers a highly precise and personalised dose to the target area while minimising dose to adjacent organs. Significantly improves treatment outcomes for many tumour types, including breast, prostate, head and neck, skin and palliative treatments.

VMAT is the next generation of intensity-modulated (IMRT), delivering a highly conformal radiotherapy dose by changing intensity as it moves around the tumour site. This reduces treatment time as well as the overall toxicity of treatment. VMAT is used to treat many cancer types, including breast where we are pioneering the use of Partial Breast Irradiation. It is also used for palliative treatment as it preserves the opportunity for subsequent radiotherapy.

We provide VMAT to all suitable patients and use simple automation and Physics QA automation (Mobius) to create highly conformal plans for dosimetry.

Stereotactic ablative radiotherapy (SABR)

A centre of excellence for SABR

Also known as stereotactic body radiation therapy (SBRT), SABR is one of the most important advanced radiotherapy techniques currently available for the treatment of tumours such as in the lung and liver. It focuses beams of high-dose radiation at tumour sites with sub-millimetre accuracy – with the aim of achieving local control in just a few short treatments. There is a large body of evidence that SABR treatment given at the right time, to the right patient, can make a difference to outcome.[1] SABR, and stereotactic radiosurgery (SRS) for brain, are becoming the gold standard therapy for certain primary and many metastatic cancers, often replacing surgery.

GenesisCare is an established provider of specialist SABR treatment. We have invested in a network of lead centres that offers world-class technology, including sophisticated imaging, motion monitoring and the UK’s first MRIdian, for real-time adaptive planning and delivery. Our service is led by a team of expert NHS clinicians with extensive experience of this SABR modality for all tumour types and they oversee a nationwide rapid access pathway.

SABR - a powerful tool in the treatment of primary and metastatic tumours

Stereotactic ablative radiotherapy, or SABR, targets intensely powerful beams of radiation to tumours in a highly conformal treatment. It targets with the aim of destroying cancer cells with minimal damage to surrounding healthy tissues.

SABR is an extreme hypofractionated treatment that can be delivered in just one to five fractions. It has revolutionised the treatment of tumour sites by offering an evidence-based alternative to surgery and to other invasive interventional procedures such as radiofrequency ablation (RFA), microwave ablation (MWA), irreversible electroporation (IRE, ‘NanoKnife’), and cryotherapy. Numerous studies have shown that SABR is highly effective in the management of primary and metastatic tumours, in particular inoperable tumours in the pancreas and liver; secondary tumours in the liver, lymph nodes, lungs, and bones; and recurrent cancer in the pelvis after previous radiotherapy. SABR may also be an alternative to surgery for prostate cancer, depending on the tumour stage.

How SABR works
SABR is an advanced form of precision radiation therapy that exploits the principles of the radiobiology of tumour cells. The high ablative doses used in SABR not only cause lethal damage to the DNA of cancer cells (as in standard radiotherapy), but also damage the tumour stroma (the basement membrane, fibroblasts, extracellular matrix, immune cells and vasculature). The combined effect is to significantly accelerate cell death (apoptosis).[3]

Compared to conventional radiotherapy, the ability of SABR to target tumour volume and yet avoid healthy tissue with sub-millimetre accuracy is critical to outcomes of treatment. For this reason, delivery of a SABR service requires significant investment in technology and expertise, together with a robust clinical framework. This is the foundation of the GenesisCare SABR centre of excellence.

How the dose compares
SABR – dose-per-fraction of 6.7 to 10 Gy in 4 or 5 fractions with total dosage between 33.5 Gy and 50 Gy
Conventional fractionation – doses-per-fraction in the range of 1.8–2 Gy and total dosage can amount to >80 Gy with intensity-modulated radiotherapy
Hypofractionation – doses-per-fraction of 2.5 Gy and above in 20 fractions, so total is 52.5–55 Gy

The GenesisCare SABR service

GenesisCare has established a centre of excellence for SABR and stereotactic radiosurgery (SRS) led by a team of leading SABR specialists operating across five centres.

The service draws on the best practice of the world’s leading SABR treatment centres and is designed to deliver clinical excellence at each stage of the pathway. Our objective is that all eligible patients have an opportunity to benefit from SABR, with treatment starting within five days of their planning scan (or sooner for palliative patients).

Diagnostic imaging – our treatment pathway includes full diagnostics, PET/CT, MRI and CT to ensure appropriateness of patients and minimal delays in commencing treatment planning.

Referral expertise – we have refined SABR referral criteria based on the experience of our SABR specialists, published clinical studies and international best practice. All referrals are peer- reviewed by our senior SABR specialists.

Unified protocols for dose and fractionation – we use standardised dose and fractionation schedules based on tumour size and evidence-based best practice. Our dosimetrists and medical physicists calculate high-quality contouring plans, taking account of the normal tolerance of healthy tissue, organs at risk
and inter-fractional adjustments. We use a sophisticated AI planning system to calculate target volumes and all plans are peer-reviewed in multidisciplinary teams (MDTs).

High-quality imaging and set-up – we use image guided radiotherapy (IGRT) based on 3D cone beam verification immediately prior to treatment for accurate set-up. These are compared and matched with simulated X-rays taken directly from 3D CT data used for treatment planning. Our radiographers have extensive experience of CBCT interpretation and use of specialist positioning equipment to ensure sub- millimetre accuracy in set-up and minimal delay.

Superior motion management – our state- of-the-art linear accelerators integrate surface guided radiotherapy (SGRT) techniques to monitor for movements which could result in dosimetric inaccuracies. This surface data is captured in real time to minimise intrafraction variation. We also use respiratory motion management, such as breath hold, gating and beam hold. Surface data is captured at each attendance to manage interfraction variation.

Peer Review – we are committed to providing a MDT approach to the implementation of safe and evidence-based radiotherapy.

Latest-generation SABR technology – treatments are delivered with the latest- generation linear accelerators. Designed for
the technical demands of SABR, these systems incorporate IGRT and SGRT technologies. We have also introduced MR-guided radiotherapy which uses real-time MR images for truly adaptive SABR treatment.

Combined with our advanced treatment planning imaging capabilities, including 3D CT, PET/CT and MRI, we offer the most technologically advanced SABR network in the UK

MRIdian. Real-time, on-table adaptive radiotherapy - a new frontier for SABR delivery

GenesisCare has introduced the first MRIdian MR-guided radiotherapy system to the UK and is offering this modality as a specialist service within its SABR network.
By combining a linear accelerator with a high definition MR scanner, MRIdian allows clinicians to see as they treat, adjusting the beam to allow for movements and anatomical changes and making truly adaptive SABR possible for the first time.

We are excited to be partnering with the University of Oxford and a team of expert SABR clinicians to build a body of evidence and put us at the forefront of exploring the possibilities for this innovative approach.

Find out more about MRIdian MR-guided radiotherapy in the MRIdian tab.

References

  1. Palma et al. Lancet 393 2051–58 (2019)
  2. Murray et al. Semin Radiat Oncol 27 247–55 (2017)
  3. Bremnes et al. J Thorac Oncol 6 1 209–217 (2011)

MRIdian MR-guided radiotherapy

Almost 10,000 patients treated worldwide with MRIdian

Magnetic resonance image-guided radiotherapy, or MRIgRT, is the most exciting development in advanced radiotherapy for years. By combining a linear accelerator with a high definition MR scanner, MRIdian allows clinicians to see as they treat – adjusting the beam to allow for movements and anatomical changes. It provides a step-change in accurate stereotactic ablative radiotherapy (SABR), bringing a new level of control and confidence with tumour targeting and sparing of healthy tissue. MRIdian makes truly adaptive SABR possible for the first time.

With 5,000 patients treated to date worldwide, MRIdian has been widely used for gastrointestinal, lung and prostate cancer, and is increasingly recognised as a possible platform for partial breast treatments and safer re-irradiation.The possibility of incorporating on-table functional MRI into treatment pathways is just around the corner.

GenesisCare is the first to introduce MRIdian technology to the UK at our centre in Oxford. It is the foundation for an emerging MRIgRT network that will put us at the forefront of exploring the possibilities of this innovative approach. We are excited to be partnering with the University of Oxford and a team of expert SABR clinicians who will work with us to build a UK body of evidence that will impact the lives of many patients.

MRIdian. A new paradigm in radiation oncology

Real-time on-table adaptive radiotherapy brings a new level of confidence to SABR delivery
MRI-guided radiotherapy improves on conventional image-guided radiotherapy (IGRT) by providing improved soft tissue definition without additional radiation exposure through high-quality MR images.

By capturing MR images of the target many times a second, the MRIdian provides real-time moving images that capture the anatomical positional changes that occur naturally within the body. Uniquely, the MRIdian allows tracking of the target position in real time, coupled with a gating facility that prevents beam delivery when the target is outside the treatment boundaries. This level of accuracy means that uncertainty is reduced, eliminating the need for large margins around the target.

The MRIdian has opened up new avenues of treatment, particularly tumours that move and are within close proximity of organs at risk (OAR) such as tumours of the liver and pancreas, where high doses are achievable while keeping the doses to OARs within tolerance.

How it works
The MRIdian allows clinicians to provide true on-line adaptive radiotherapy. The treatment planning system is clear and intuitive making daily re-contouring of tumour
and normal tissues straightforward. The updated plans are rapidly re- optimised providing a personalised radiation treatment on every patient, every fraction.

  • The MRIdian uses a patented split-magnet MR design, so that the radiation beam is not distorted by the magnetic field and is at the optimum distance for exceptionally sharp, high dose-rate SABR.
  • The MR set-up captures multiple high-definition, high-quality images many times a second, seeing even the tiniest movement of the tumour and surrounding organs.
  • The MRIdian performs real-time on-table plan adjustments to reflect both inter- and intra-fraction anatomical changes or movements.
  • The gating target and gating boundary are visualised on the display. When the gating target moves outside the pre-specified gating boundary, the radiation beam automatically stops until the target returns back inside the gating boundary.
  • Some patients benefit from being able to view this while inside the MRIdian – enabling them to take an active role in gated delivery with adjustments to their breathing.
  • Coupled with the unique target tracking and gating system is a precise stereotactic radiation beam, giving the clinician greater control and confidence in delivering maximal dose to the tumour target while preserving critical structures.

The evidence base suggests that the MRIdian makes it possible to achieve ablative doses without reaching prohibitive levels of toxicity, particularly in the abdomen. This offers the prospect of improving clinical outcomes for previously hard-to-treat cancers such as locally advanced or recurrent pancreatic cancer and inoperable liver tumours.

Compassionate Access Programme for Pancreatic cancer

The GenesisCare Foundation Compassionate Access Programme is making available MR-guided stereotactic ablative radiotherapy (SABR) on the ViewRay MRIdian platform, without cost, to eligible NHS patients with localised pancreatic cancer.

Find out more.

Building a UK body of evidence

Through our academic collaboration with the University of Oxford, we will build on the body of evidence for MRIdian with an ongoing programme of clinical evaluation in the UK.

Our strategy for the introduction of MRIgRT is to align with international best practice based on evidence-based protocols. There is an increasing international evidence base for MR linac and notably the MRIdian system. Here are some of the pivotal studies that have informed our approach.

Prostate
A clinical study from Amsterdam demonstrated a low incidence of early gastrointestinal and urinary toxicity in hypofractionation for prostate cancer. SABR is increasingly used for the treatment of localised prostate cancer. However, with any hypofractionation, concerns remain about early and late toxicity. MRIdian makes it possible to deliver SABR with reduced uncertainty margins and daily, real-time adaptive planning to reduce toxicity. Both clinician- reported and patient-reported outcomes were better than historical controls in this well-designed phase 2 study.[1]

Pancreas
A retrospective study of 44 patients with inoperable pancreatic cancer evaluated the overall survival benefit of higher dose, adaptive MR-guided SABR versus standard, low-dose SABR.[2] High-dose MRIgRT patients (n = 24) had a statistically significant improvement in 2-year overall survival (OS) (49% vs 30%, P = 0.03) and trended towards significance for 2-year freedom from local failure (FFLF) (77% vs 57%, P = 0.15) compared to standard- dose patients (n = 20, 45%). This improved OS was achieved without any increased toxicity in the high-dose group. MRIgRT is now being tested in a prospective trial, which through our academic partners at the University of Oxford, GenesisCare will be supporting.

Cancers treated

The evidence base for SABR is growing and there is currently a range of clinical scenarios into which it can be integrated. At GenesisCare, we offer SABR in the following situations:

  • Localised prostate cancer, where hypofractionated treatment offers an alternative to conventional therapy
  • Early stage lung cancer
  • Hepatobiliary cancer, including primary liver cancers and inoperable/recurrent pancreatic cancer
  • Pelvic re-irradiation
  • Selected cases of oligometastatic and oligo- progressive cancers

We have defined SABR referral criteria based on the experience of our SABR clinical expert team, published clinical studies and international best practice. All SABR referrals will be assessed for a possible benefit of treatment on MRIdian. For example:

  • Tumours where there is significant movement, e.g. in the upper abdomen and lung
  • Tumours that are in close proximity to organs at risk (OARs), e.g. in the prostate, upper abdomen
    and central lung

For other tumour sites, please refer to our referral criteria via the MOSAIQ tool available on our referral portal.

Delivering clinical excellence

We are committed to an environment of clinical excellence, objectivity and accountability. Our processes are adapted from international best practice and our team has undertaken training with centres including Amsterdam UMC, Miami Cancer Institute, Henry Ford Cancer Centre (University of Wisconsin) and Heidelberg University Centre.

The introduction of MRIdian has been overseen by Specialist Reference Groups in both urological cancers and SABR. The groups are comprised of clinicians who have undergone extensive MRIdian training and have a vast cumulative experience of delivering highly technical radiotherapy. The groups work closely together in a robust forum to guide all aspects of clinical governance, patient selection, peer review, education and credentialing. The groups also oversee research activity, developing joint protocols with our academic partners. GenesisCare will treat more patients with MRIgRT than any other institute globally, and will therefore be at the vanguard of translating research into everyday precision radiation medicine.

Find out more about clinical leads and governance at GenesisCare

References

  1. Bruynzeel, A et al. A Prospective Single-Arm Phase 2 Study of Stereotactic Magnetic Resonance Guided Adaptive Radiation Therapy for Prostate Cancer: Early Toxicity Results International Journal of Radiation Oncology, Biology, Physics.
  2. Rudra, S. et al. Using adaptive magnetic resonance image-guided radiation therapy for treatment of inoperable pancreatic cancer. Cancer Med. 8, 2123–2132 (2019).

Image-guided radiotherapy (IGRT)

We use image-guided radiotherapy (IGRT) based on 3D cone beam verification immediately prior to treatment for accurate set-up. These are compared and matched with simulated X-rays taken directly from 3D CT data used for treatment planning. Our radiographers have extensive experience of CBCT interpretation and use of specialist positioning equipment to ensure submillimetre accuracy in set-up and minimal delay.

We are one of the first companies to introduce MRI-guided radiotherapy (MRIgRT) for cancer treatments with the MRIdian. This is an exciting step forward in the real-time planning and adaptive treatment of tumours and is available for patients across the UK. MRIdian is available for prostate, lung, liver and pancreatic cancer and is an important part of these treatment pathways.

Surface-guided radiotherapy (SGRT)

We use the latest surface-guided radiotherapy (SGRT) techniques in combination with VMAT or SABR to enable 3D and 4D set-up and superior motion management during radiotherapy.

The accuracy of radiotherapy is enhanced when combined with SGRT – a sophisticated stereovision technology that monitors thousands of points on the patient’s skin during set-up and treatment, unlike other commonly used systems that rely on CT imaging – further increasing radiation exposure.

This powerful system reduces positioning errors to improve the overall accuracy, as well as the speed and comfort of treatment.

Examples are:

  • Gating and beam hold facilitating 4D IMRT for moving lesions
  • SABR and SRS couch and patient monitoring for accurate set-ups
  • Intrafraction variation minimisation by capturing surface data in real time
  • Surface data captured at each attendance to manage interfraction variation and dosimetric changes

These advances provide important benefits to our patients including the option of open-face treatment shells and tattoo-free treatments.

Stereotactic radiosurgery (SRS)

Stereotactic radiosurgery

Stereotactic radiosurgery (SRS) is often described as brain area-sparing surgery and has revolutionised the treatment of brain metastases.

It uses high-quality imaging to deliver precisely-focused radiation beams at higher doses in a single or few short treatments. SRS is a highly advanced approach that permits the maximum conformal dose delivery within the targets while minimising dose to the surrounding unaffected brain. By treating with sufficient dose intensity to ensure ablation of tumour cells, treatment can be concluded in a small number of fractions. The aim is to destroy the tumour and achieve permanent local control, while preserving important brain function.

Recent studies are showing that treatment with SRS alone results in less decline in cognitive deterioration and better quality of life. Vitally, this is achieved with no significant difference in overall survival.1 SRS is now replacing conventional whole brain radiotherapy as the procedure of choice for some primary tumours and solitary or multiple brain metastases.

SRS is central to our neuro-oncology service at GenesisCare as we seek to offer our patients the option of achieving the optimum life outcome for them and their families. We have invested heavily in SRS technology and expertise, as part of an end-to-end pathway that includes early detection, treatment, close monitoring and follow-up. In the management of brain metastases, an approach that focuses on patient quality of life and functional outcome is becoming the norm.

GenesisCare is a specialist provider of neuro-oncology and a centre of excellence for stereotactic radiosurgery for private patients across the UK. We have invested in an end-to-end solution that involves brain-sparing technologies and innovative protocols, delivered through a team of leading clinicians at our centres in London and Oxford.

Refer to us

+44 (0)1865 224 884
Oxford

Refer to us

+44 (0)203 613 9355
London

Stereotactic radiosurgery – a gold standard treatment

Brain metastases (secondary brain cancer) affect up to 30% of all cancer patients and are the most common sequelae of cancer. Lung cancer, breast cancer, kidney cancer and melanoma are the most common primary tumours that metastasise to the brain.

Stereotactic radiosurgery (SRS) has become increasingly recognised worldwide as the gold standard radiotherapy option by professional societies, based on a growing evidence base for the use of SRS alone for a patient presenting with one to four brain metastases.3

SRS is routinely used in re-irradiation after brain radiotherapy or previous SRS. SRS is shown to have the same overall survival in two to four metastases as five to ten.4

Use of stereotactic radiosurgery (SRS) is no longer limited to patients with three or fewer lesions, because data suggest that total disease burden, rather than number of lesions, is predictive of survival benefits associated with the technique.

  • SRS is increasingly becoming an integral part of management of patients with controlled, low‑volume brain metastases. National Comprehensive Cancer Network (NCCN) Guidelines, 2014.
  • Don’t routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases. American Society for Radiation Oncology (ASTRO), Choosing Wisely Campaign, 2014.
  • It is the recommendation by ISRS that patients with one to four brain metastases with reasonable performance status and prognosis be treated with SRS alone, with whole brain radiotherapy (WBRT) reserved as one of many salvage therapeutic options. International Stereotactic Radiosurgery Society consensus.

Who we treat

We have experience of managing a wide range of brain and CNS tumours. Patients can be referred to our Neuro-oncology Advisory Team in Oxford or London for review and assessment. Referring clinicians are involved in decisions and are assured a fast response within five days.

Brain metastases:

  • Brain metastases with a combined total volume of 20cc
  • Life expectancy > 6 months
  • Histological diagnosis of cancer
  • Potentially controllable extracranial disease
  • Surgical cavities after brain metastases resection
  • Re-growth of metastases after previous good response to WBRT for multiple brain metastases (>10)

Re-treatment with SRS is possible:

  • After 3 months for a new metastases
  • After 6 months for a previously treated metastases

Contraindications for SRS:

  • Brain metastases > 3.5cm (volume is >20cc)
  • Histology from brain lesion is needed

SRS is also indicated for:

  • Meningiomas, acoustic neuromas and primary pituitary tumours
  • Other non-cancer conditions including arteriovenous malformations and complex trigeminal neuralgia

Neuro-oncology at GenesisCare

Our ambition has been to design a neuro-oncology service that treats the whole patient, not just the tumour. The incidence of brain metastasis is increasing, due to better imaging surveillance and improved systemic treatment of extracranial disease – up to 30 per cent of primary cancer patients are likely to develop a brain metastasis. Conventional radiotherapy treatments often lead to  cognitive deterioration, with no benefit in terms of survival, but increasingly innovative techniques such as SRS and advanced imaging are offering improved quality of life outcomes. It’s a new way of thinking about neuro-oncology.

Tumours of the brain and central nervous system are a particular specialty for us and we are a specialist independent provider of neuro-oncology in the UK and a centre of excellence for stereotactic radiosurgery (SRS).

SRS at Oxford – Elekta Versa with Brainlab Exactrac

At our Oxford centre SRS is delivered using Brainlab Exactrac, a fast and highly accurate visualisation and patient position monitoring system that is seamlessly integrated with a state-of-the-art Elekta Versa linear accelerator. It is installed alongside the specialist treatment planning system. It employs two low-dose X-ray images, which are captured from two different angles. They are compared and matched with simulated X-rays taken directly from 3D CT data used for treatment planning. A robotic treatment table adjusts for patient position with sub-millimetre movements – maintaining the accuracy of the procedure and ensuring the radiation treatment dose is delivered as prescribed.

Due to the large number of patients treated, our experienced dosimetrists and clinical teams are experts in precise dose planning and efficient patient set-up. This ensures smooth and professional patient care, with no waiting around.

SRS at London – Gamma Knife Icon

At our new GenesisCare radiotherapy centre at Cromwell Hospital in London, we have installed the latest Leksell Gamma Knife Icon. This next generation system has the flexibility to enable more personalised, high-dose treatment plans across a wide range of patient type. It builds on the established precision of Gamma Knife, offers new technology to enable single or fractionated frame-based or frameless treatments with the same precision and accuracy.

The system is integrated with all components, including a 3D cone-beam CT, built on the same rigid structure and calibrated to one another to improve precision. During treatment, real-time motion management monitors the patient with a resolution of 0.15mm. If the patient moves outside a pre-set limit, beam delivery automatically turns off. These features lead to the increase in precision and accuracy. Studies have demonstrated that Gamma Knife Icon can deliver a 2-4x lower dose to the normal brain, when compared with earlier systems.2

Peer-to-peer team-working in a secure environment

Our multi-disciplinary structure is pivotal to our neuro-oncology service. Bringing together the expertise of neuro-radiologists and neuroimaging scientists, alongside neuro-oncologists and neurosurgeons, we can tailor care to every patient and optimise outcomes for high risk cases.

To facilitate this in an independent setting, we have established a bespoke neuro-oncology eMDT platform which allows peer-to-peer collaboration, accessible at any time. The eMDT enhances clinical processes, using real-time data tracking and video to enable the neuro-oncology team and wider clinical teams to discuss patient care plans while protecting the flow of sensitive data. It will also audit decision-making and outcomes data within a best practice framework. We are the first independent provider to implement a fully integrated eMDT for neuro-oncology.

Referring clinicians are invited to participate in our eMDTs.

A focus on clinical excellence for neuro-oncology

We are committed to creating an environment of clinical excellence for SRS and neuro-oncology services. Our protocols are adapted from international best practice and overseen by a core team of specialists, selected on the basis of their extensive experience and high-quality credentials. Their key role is to align the neuro-clinical service with evidence-based treatments such as SRS to ensure safe, consistent care across all of our centres. This robust forum guides all aspects of clinical governance, patient selection, peer review, education, research and assessment of new clinicians to the neuro-oncology team. In particular, the Neuro-oncology Advisory Team form the backbone of our eMDT system – a multidisciplinary teamworking platform that connects our experts with a wider group of referring clinicians to discuss and review patient care.

The Neuro-oncology Advisory Team reviews all referrals and assesses suitability for SRS.

Patient safety is at the heart of what we do

We are CQC inspected and have a comprehensive governance framework that ensures safe treatment protocols, evaluates consultant practising privileges and reviews cases outside standard treatment protocols.

Refer to us

+44 (0)1865 224 884
Oxford

If you would like further information about our Oxford neuro-oncology service, please contact Jen Ayling (Referrer Engagement Manager):

07881 093 059

jennifer.ayling@genesiscare.co.uk

Refer to us

+44 (0)203 613 9355
London

If you would like further information about our London neuro-oncology service, please contact Younan Estefanos (Referrer Engagement Manager):

07880 338 689

younan.estefanos@genesiscare.co.uk

 

 

References

  1. Brown et al., 2016; JAMA; 316 (4):401-409.
  2. Ma L et al., 2014; Int J CARS; 9:1079-1086
  3. Chao T. et al., 2018; Neurosurgery; 83 (3): 345–353.
  4. Yamamoto et al., 2014; Lancet Oncol; 15:387-95.

Deep inspiration breath hold (DIBH)

We are leading the introduction of Deep inspiration breath hold (DIBH) with VMAT radiotherapy for left-sided breast cancers and complex right-sided cancers when regional nodal irradiation (IMC VMAT) is required. This innovative response to tumour motion provides superior protection of the heart and lung, and improves patient comfort compared with spirometry.

DIBH improves safety margins, enabling more accurate treatment and increased dose without increasing toxicity to the heart or lungs.

Skin cancerisation radiotherapy

Non-melanoma skin cancer (NMSC) is the most common cancer in the UK. Although it can arise in isolation, a significant group of patients have extensive skin field cancerisation (ESFC) where pre-cancerous lesions (actinic keratosis) pre-exist with cancerous lesions – basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). This carries a high risk of recurrence of pre-cancerous and cancerous lesions, requiring repeated treatment over many years. The ongoing risk of skin cancer and the physical and cosmetic impacts of disease and interventions can affect the patients’ quality of life.

The increasing role of radiotherapy in treatment of NMSC and skin field cancerisation

Although new BCC or SCCs tend to be treated focally, a field-directed approach is optimal for patients who have substantial field UV damage with multiple AKs. Radiotherapy treatment is indicated for moderate to severe degrees of skin cancerisation where topical treatments are ineffective or intolerable in managing ESFC. It may also be used when multiple surgical excisions have made the patient surgically ‘weary’.

Recently, modern radiotherapy techniques such as Volumetric Modulated Arc Therapy (VMAT) have been used in countries, including Australia, for management of ESFC with positive outcomes. This highly conformal technique gives a more homogenous dose delivery and effectively treats large areas of skin while sparing deep tissue from toxicity, even in highly curved areas, such as whole arms or legs. It can also be used where the skin surface overlies organs that could be harmed by radiotherapy, for example, the scalp while sparing the brain tissue from irradiation.

Based on the wide experience and success of this modality by our parent company in Australia, GenesisCare has introduced VMAT to the UK for the treatment of ESFC. We are the first provider in the UK to offer this treatment as part of our evidence-based approach to introducing advanced and innovative treatments.

Evidence based care

In Australia, more than 4000 patients have been treated with radiotherapy for ESFC and a registry has been established to monitor the safety and efficacy outcomes.

A retrospective study of 41 patients with a total of 63 treatment fields for ESFC and 12 months after radiotherapy found that 86% of patients showed complete clearance of fields after their treatment and no cases of invasive cancers were observed.1 However, eight new skin lesions were identified in seven fields, seven cases of Actinic Keratosis and one of Bowen’s disease. Additionally, 98% of patients graded cosmesis as “excellent” or ”good”.

  1. GenesisCare, data on file

Patients eligible for VMAT

The following patients can be considered for VMAT radiotherapy treatment at GenesisCare for ESFC where:

  • The patient has tried other treatments but they have not prevented recurrence of further pre-cancerous lesions (AK)
  • The patient has tried other treatments but they have not prevented multiple skin cancer formation
  • The patient is immunosuppressed (e.g. due to solid organ transplantation)
  • The patient has not tolerated other treatments

Governance

The VMAT skin service has been developed in collaboration with our parent company in Australia, where more than 4,000 patients have been treated. Protocols are reviewed by our UK Clinical Governance Committee and are delivered through the Skin Clinical Reference Group, selected for their expertise and experience of skin radiotherapy treatments.

Partner with us

We are always looking to collaborate with talented consultants.

As a dermatologist, plastic surgeon or related skin cancer specialist, we invite you to partner with us. We welcome requests from individuals and academic institutions to access our state-of-the-art equipment and clinical support for treatment and research. You can also build your knowledge and network with peers at our many CPD events.

Make an enquiry

Please make an enquiry for further information about partnering with us.

Enquire now

Spacing gels

Spacing gels, such as SpaceOAR® Hydrogel, are a game changer in protecting the rectum from toxicity in prostate radiotherapy. The gel is inserted between the rectum and the prostate to temporarily move the anterior rectal wall further away from the prostate. The aim is to reduce the amount of radiation delivered to the rectum and limit toxicity. The gel lasts for the entire course of prostate radiotherapy treatment and is completely absorbed by the patient’s body over time.  

A randomised, controlled trial demonstrated that using spacing gel in men undergoing radiotherapy for prostate cancer was safe and effective in creating perirectal space, reducing rectal irradiation and resulting in fewer patient-reported declines in bowel, urinary and sexual quality of life (QOL).1,2,3 

At GenesisCare we offer spacing gels at no extra cost to all patients with a prostate in situ prior to VMAT radiotherapy. We offer insertion under local anaesthetic at some of our centres or performed as a day-case procedure at one of our partner hospitals. We also work in partnership with Nuffield Health to offer patients the nearest local hospital for their procedure.  

References

  1. Mariados et al., 2015; IJROBP; 92(5):971-977, 
  2. Hamstra et al., 2016; IJROBP; 97(5):976-985, 
  3. Hamstra et al., 2018; Pract Radiat Oncol; 8(1):e7-e15