Radiation oncology (RT) has entered a new era of precision and intelligence. The development of radiotherapy technology and the integration of multiple disciplines have brought promising development prospects for tumor therapy. Themed "Intelligent Radiotherapy and Innovative Development", the 9th Union Medical College Radiation Oncology Forum was held in Beijing from December 1 to 3, 2023. The forum explored the innovation, development and safe implementation of new radiotherapy technologies and the quality control of the whole process of radiotherapy, covering topics such as adaptive radiotherapy, multimodal image guidance, and artificial intelligence (AI). Radiotherapy doctors from all over the country gathered in this grand event to exchange radiotherapy experience and discuss the progress of radiotherapy.
The work of radiotherapy in Peking Union Medical College Hospital (PUMCH) began in the 1920s, which is the earliest hospital in China to carry out radiotherapy. It has trained a large number of excellent talents for the development of domestic radiotherapy and led the healthy and rapid development of domestic radiotherapy. Therefore, Professor Zhang Fuquan and Professor Qiu Jie of the Department of Radiotherapy of Peking Union Medical College Hospital were invited to participate in this special interview to share the practice of radiotherapy and quality control in Peking Union Medical College Hospital in the era of precision and intelligent radiotherapy and the future prospect of tumor radiotherapy, in order to provide more valuable experience and reference for the doctors committed to tumor radiotherapy.
Professor Zhang Fuquan and Professor Qiu Jie are interviewed by the Tribune
In 1921, Peking Union Medical College Hospital (PUMCH) established radiology department, including diagnosis and radiotherapy. Radium was used for radiotherapy at that time. According to Ta Kung Pao, Peking Union Medical College Hospital (PUMCH) performed liver cancer surgery on Sun Yat-sen in 1925, followed by radiotherapy, which was the earliest record of carrying out radiotherapy. Pumch was also the first hospital in China to carry out radiotherapy. With the development of science and technology, doctors gradually realized the difference between radiotherapy and radiodiagnosis. In 1985, the radiotherapy group of Peking Union Medical College Hospital was separated from the radiology department into the
radiotherapy department. In 1986, the Chinese Society of Radiation Oncology was established, which played a positive role in strengthening the internal and external communication of radiotherapy and promoting the rapid development of radiotherapy departments in various hospitals in China.
Radiotherapy is a high-tech treatment method, which involves a large number of people, equipment and processes, and requires close cooperation of multiple links. Therefore, strict quality control (hereinafter referred to as "quality control") is necessary to reduce the uncertainty in the radiotherapy process, curb the occurrence of accidents and errors, achieve the expected tumor control rate, and effectively reduce the occurrence of radiotherapy complications. It is the tenet of Department of Radiotherapy of Peking Union Medical College Hospital to provide timely and high-quality treatment services for patients, and the quality control of radiotherapy is the lifeline. For many years, the Department of Radiotherapy in Peking Union Medical College Hospital has put strict quality assurance and quality management in the first place. A strict and systematic quality assurance system has been established, including detailed and strict procedures for pre-treatment positioning, treatment plan design, treatment dose review, positioning verification, and treatment verification.
"The goal of radiotherapy quality control is always patient quality control. Technological development has brought both surprises and 'scares'. In the past, due to technical limitations, radiotherapy may not be as accurate as expected. In the era of precision radiotherapy, we have the ability to be more accurate and at the same time think and make up for the shortcomings of the past." "Shared Professor Qiu Jie.
The radiotherapy plan is adjusted according to the changes in the target volume during the treatment to provide a more accurate and personalized treatment, which is called adaptive radiotherapy. Imaging techniques such as CT, MRI, or PET are used periodically during radiotherapy to obtain morphological and positional information of the lesion and to align this information with the initial radiotherapy plan. If changes in lesion location, size, or morphology are found, the radiotherapy dose distribution can be replanned or adjusted to ensure the accuracy of radiotherapy exposure and effective disease control.
Always focus on every moment of the patient's treatment, provide objective, true, accurate, and meet the requirements of the plan, accurately implement and record, objectively evaluate the relationship between the patient's prognosis and the radiotherapy dose, determine the influence of various factors on the plan, and verify and modify it. The whole process of detection, verification, intervention and evaluation, what you see is what you get, is really conducive to improving the level of radiotherapy. The plan may not be "perfect," but it will become "perfect."
Making assumptions less and less and measuring more and more data is the direction of modern radiotherapy. Creating a "perfect" plan for one image can provide a more appropriate plan for thousands of different patients. Some people are willing to take risks, some people choose to be conservative; Some people care about survival, others care about quality. There is no perfect plan, only a game of choice. It is important for radiation oncologists to know how much risk to take and the basis for their decisions. The progress of modern medicine and the development of technology allow doctors to gradually see the truth, and let real data support doctors to make choices that are more in line with the needs of patients.
"Physicists and doctors blend and cooperate, understand medicine, understand equipment, and understand plans, so that they can have the opportunity to develop a 'perfect' radiotherapy plan for patients. Science and engineering pursue perfection, but medicine is full of humanistic philosophy, there is no "perfect", only "suitable", radiotherapy is the same, suitable for patients is the best, we should choose the most suitable scheme for patients, which is the goal of radiotherapy quality control. Professor Qiu Jie stressed in the interview.
Choosing the appropriate radiotherapy plan according to the actual situation of patients is inseparable from the supplier's efforts to achieve the clinical needs. On the current situation and future trend of the combination of medicine and engineering, Professor Zhang shared his views: "The development of a discipline or therapeutic technology is determined by many factors. Doctors put forward radiotherapy needs according to the actual situation of patients, and equipment suppliers should provide support to turn the needs into reality. In order to better meet the needs of patients and promote the development of technology, hospitals should closely contact and strengthen communication with suppliers, and suppliers should improve equipment and technology, and constantly match the clinical needs. There is also a need for continuous exchange and exchange of skills between suppliers to make the equipment better, more advanced and more suitable for clinical practice."
When the department of radiotherapy started, the equipment and technology were not perfect, the tumor location was simple, and the effect of radiotherapy was limited. Since the 1990s, with the wide application of CT, radiotherapy has developed rapidly. Since then, new technologies such as three-dimensional conformal radiotherapy and intensity modulated radiotherapy have been developed, and the positioning mode of radiotherapy has been further changed to maximize the function of CT. Nowadays, CT simulation is an integral part of radiotherapy.
With the continuous development of new technology, doctors' cognition has gradually improved. In recent years, domestic radiotherapy technology has been developed to a high level. In addition to Peking Union Medical College Hospital, other top general hospitals and cancer hospitals in China have perfect radiotherapy equipment, and CT, magnetic resonance imaging (MRI), positron emission tomography (PET) and other multimodal imaging techniques are integrated with each other. At present, PUMC has introduced high-end radiotherapy positioning equipment such as Philips Hawk RT and Elition, and the technical level is comparable to that of top foreign hospitals. Radiotherapy has entered the era of precision, and tumor treatment has become more adequate and effective.
Many tumors are adjacent to important organs or even surround normal tissues. The positional relationship between tumor tissues and normal tissues depends on three-dimensional imaging of CT or MRI. "Precision and accuracy are the main efforts of radiotherapy, which are naturally inseparable from the progress of medical imaging. The introduction of CT and MRI into radiotherapy is a revolutionary change. Professor Zhang Fuquan exclaimed.
Tumor patients need to be simulated for radiotherapy, after which a radiotherapy plan is designed, and then radiotherapy is started after the plan is formulated, which usually takes 4-5 weeks or even longer. During the treatment, doctors should not only pay attention to the patient's external manifestations such as nausea and vomiting, but also assess the tumor's response to radiation (that is, the tumor's target volume shrinkage). If the goal is just radiotherapy, vendors do a good job of providing clear positioning images, but going further requires more powerful, higher-level equipment.
Traditional CT imaging only has a single-parameter anatomical diagnosis mode, while the most significant feature of multi-parameter functional CT is the one-stop anatomical and functional diagnosis mode based on multi-parameters, which can provide a variety of new functional images, and measure and calculate a variety of quantitative parameters of normal tissues and lesions on these images. This multi-parameter imaging mode brings CT into a new color era, which can effectively help radiotherapy doctors to further judge the planning accuracy before treatment and evaluate the treatment effect after treatment, so as to provide individualized treatment plans for different patients.
The integration of functional imaging into radiotherapy is a new development in the field of radiotherapy. The Department of Radiotherapy of Peking Union Medical College Hospital has taken the lead in developing the new technology of multi-parameter functional image-guided radiotherapy positioning in China, and the accuracy of radiotherapy has been improved to a new level. The high-end radiotherapy positioning equipment represented by Philips Hawk RT has special functions that cannot be realized by traditional equipment. In addition to meeting the basic requirements of flat bed and large diameter, it can provide traditional CT value and other information, and can also provide functional imaging information reflecting material specificity, which is helpful to understand tissue composition, clarify the nature of lesions, and help radiotherapy doctors to determine the metastasis of lesions, so as to determine the coverage of radiation area. "High-end radiotherapy positioning equipment can better identify the nature, location, size, invasion range of tumors, and even judge the prognosis of patients. Let precision fall on paper, but also on action." Professor Zhang Fuquan and Professor Qiu Jie said in an interview.
Spectral imaging provides more multifunctional information on the premise of "precision" and "accuracy". The wide application of AI also improves the efficiency of target volume and normal organ delineation and ensures a high level of quality consistency. "Each imaging picture corresponds to a real, specific patient, whose disease course, prognosis and radiation dose can provide doctors with statistically significant outcome information. It is expected that with the progress of high-end medical imaging and the assistance of AI technology, radiotherapy will become more and more accurate. In the face of changing patients, changing devices, we have the ability to master it and control it." For the future development of radiotherapy, Professor Zhang Fuquan and Professor Qiu Jie are full of confidence.
The Radiotherapy Department of Peking Union Medical College Hospital (PUMCH) always adheres to the spirit of "rigor, perfection, diligence and dedication" to escort the treatment of cancer patients. At the same time, in order to better realize the patient-oriented concept and purpose, we always hold an open and inclusive attitude to cooperate with major software and hardware equipment suppliers at home and abroad to provide patient-centered holistic tumor solutions. Among them, Philips, a leading global health technology company, has joined hands with Peking Union Medical College Hospital to open up the whole process of tumor diagnosis and treatment, help precision personalized diagnosis and treatment, and create a road to confidence in precision cancer diagnosis and treatment. With respect to the investment and understanding in the field of tumor diseases, Philips and the Department of Radiotherapy of Peking Union Medical College Hospital have been in agreement to continuously introduce new high-end radiotherapy guidance technology to empower the radiotherapy process. At present, high-end radiotherapy positioning equipment represented by the OCRT and Elition have been stationed in Peking Union Medical College one after another, and continue to provide better and more professional services for cancer patients. Leading China's precision radiotherapy to a new height.