A close cooperation is required particularly between medical oncology (chemotherapy), radiation oncology, surgery, nuclear medicine (PET-CT), radiology, biochemistry, pathology and genetics as well as other specialties for the treatment of oncology patients. Through the cooperation of all units within the scope of our hospital, the patient is ensured to receive the most efficient treatment with the lowest adverse effects by way of taking into consideration all innovative treatment methods at the developed country standards following an accurate diagnosis.
As a result of the evaluation made in our clinic, a treatment program peculiar to the patient and his/her illness is arranged. Such treatment program may involve chemotherapy, hormone therapy, immunotherapy (biological treatment) and target driven treatments. The patient is referred to the clinic for such implementations that require different specialties as radiotherapy and interventional proceedings.
- Medical Oncology (Chemotherapy)
Medical oncology is a sub-specialty of internal diseases which deals with the drug treatment of oncology cancers and the research of cancer drugs. Chemotherapy plays an important role in the drug treatment of cancers; however, it is not the only method to be applied. Besides chemotherapy, some other cancer treatments are adopted with the use of hormone regulating drugs, target driven drugs and immunity system related drugs within the scope of medical oncology.
During the implementations of the medical oncology, close cooperation is required between such other specialties as radiation oncology, surgery, nuclear medicine, radiology and pathology. The best results in the treatment of cancer are obtained through these multi-disciplinary studies.
Efficient treatment doses and lethal toxic doses of the drugs used in oncology are very close to each other. Therefore, the doctors who are implementing the treatment should know the adverse effects of these drugs thoroughly. A patient who responds to the treatment well may die due to treatment toxicity. Thus, the doctor, the patient and his/her relatives should effectively communicate during the treatment processes.
Cancer staging, surgical intervention methods and the types of the drugs used vary in time. Therefore, the doctors concerning with oncology should closely follow these variations. However, it has been understood that there are many sub-groups of such cancers that are frequently encountered as lung, breast, large intestine etc. and each of them requires treatment with different methods. For instance the drug called as Trastuzumab is efficient for each 2 positive breast cancers while it is inefficient for each 2 negative breast cancers.
Biopsy and pathological evaluation should be made prior to the commencement of cancer treatment and a treatment program (surgical, radiotherapy, chemotherapy, hormone drugs, target driven treatments) should be arranged following the process when the disease is staged with the help of imaging methods. Medical oncology is generally applied after the operation (adjuvant implementations); however, such treatment can be launched prior to the operation (neo-adjuvant implementations) as well. The efficiency of surgery can be increased with preoperative applications in advanced stage cancers (breast, colon, lung). Oncologic applications have general principles and it is the most convenient approach to evaluate the patients in line with different specialties even at the stage of diagnosis and to arrange a patient specific treatment plan.
- Radiation Oncology (Radiotherapy)
Radiation Oncology (Radiotherapy): Radiation oncology is a department of medicine as a scientific and clinical discipline dedicated to the treatment of cancer and some non-cancer diseases through ionization radiation (alone or with other modalities) to the research of the physical and biological roots of radiotherapy and expert training in this field.
Radiotherapy: It is the treatment method which involves the direction of ionization radiation (particulate or wave type) on cancerous tissues.
The Purpose of Radiotherapy: The purpose of radiotherapy is the complete elimination of the tumour without damaging normal tissues around the tumour in a structural and functional sense.
The Objectives of Using Radiotherapy in the Treatment of Cancer
1. Curative Radiotherapy: It is such a treatment that complete recovery is expected for the patients suffering from a primary disease or loco-regional illness. The radiation dose given to these patients is at a curative level.
2. Palliative Radiotherapy: It is the treatment applied for the removal of such symptoms that cause severe pain and discomfort for the patient and put the life of the patient in jeopardy. The most important benefit expected from such kinds of treatments is the enhancement of the life quality of the patient. The area subjected to radiotherapy is narrower and the dose given is less than the curative therapy.
3. Prophylactic Radiotherapy: It is a type of radiotherapy which is applied in order to decrease metastases rates that can be observed when the tumour progression possibility is 50% and over.
The Management of the Patient Applying to Radiation Oncology Clinic
Cancer treatment should be planned in tumour councils within the frame of a multidisciplinary approach. In this way, the diagnosis, treatment and follow-up stages of the patient as well as the type and time of the treatments to be applied can be planned and carried out in line with a discipline. Tumour councils should consist of tumour surgeons, radiation oncologists, medical oncologists, pathology specialists, radiology specialists, nuclear medicine specialists and if required, dieticians and psychologists.
The treatment of the cancer patient with the use of radiotherapy requires the performance of a team work. This team involves radiation oncology specialist, medical physicist, radiotherapy technician and oncology nurse. It is highly important for the individuals in the team to work in coherence and collaborate with each other in ensuring a more accurate, faster and more sustainable radiotherapy application.
A patient who was diagnosed with cancer and was subjected to evaluation in multidisciplinary tumour councils or applied to radiation oncology clinic prior to or after the implementation of certain treatments directly or by other disciplines is examined by a radiation oncology specialist first and then his/her examination results are reviewed and a pre-assessment is made for radiotherapy application. Such pre-assessment involves the examination of the pathology report (it may not be required in some rare cases), the type and dimension of the tumour, cell structure (histopathological) qualities, the location of the tumour and such imaging techniques in many patients as ultrasonography, computed tomography, magnetic resonance and PET-CT and new examinations are performed if necessary.
Radiation oncologist reviews the results of the examination and the tests performed and if s/he determines radiotherapy indication for the patient, s/he decides first whether the treatment to be applied will be curative, palliative or prophylactic. Afterwards, s/he identifies the treatment mode (external treatment, brachytherapy or both of them), primary tumour or tumour location as well as the volume of the tumour involving the risky areas of progression, the selection of the treatment machine, treatment plan, daily doses and total dose amounts to be given to the patient. After all these parameters are determined by the doctor, treatment preparation stage is proceeded to.
At the stage of the commencement of radiotherapy, a planning tomography is required to be taken alone and/or combined with MR and/or PET-CT as a first step. Before taking the planning tomography, such procedures as thermoplastic head and/or neck masks to stabilize the patients depending on the cancer treatment location as well as vacuum bed applications to ensure immobilization, breast board implementations etc are applied.
Patient stabilization is one of the most important stages of radiotherapy. In this way, the patient is subjected to radiotherapy at the same position each time. If risky organs, tumour or tumour location and if required, regional lymph glands are observed on the images transferred to the planning system taken appropriately either for 2-dimensional planning under simulator or 3-dimensinal conformal RT or IMRT+IGRT or stereotactic radiotherapy where the adverse effects of the radiation can be seen, such areas are separately contoured.
The medical physicist plans the treatment within the frame of the doses determined by the doctor on the basis of risky organs and tumour. Following the evaluation of the plans made, the treatment is commenced with the launch of a set-up application (the determination of relevant areas and the provision of the treatment through such areas at the beginning of the treatment) which involve the patient’s doctor, medical physicist and radiotherapy technician. It is estimated that the period elapsing from the application of the patient to the radiotherapy unit to the commencement of the treatment will be 1-2 weeks unless any additional test is requested.
Total treatment period varies between 1-40 days depending on the mode of the treatment which is either palliative, prophylactic or curative. Daily treatment periods are about 3-15 minutes. During the treatment period, some radiotherapy related adverse effects may be observed in the patient. It is required to monitor and determine such adverse effects and to complete the radiotherapy process of the patient by means of outpatient and/or inpatient treatment.
Linear accelerator (Linac) used in our clinic is called as VERSA HD which is used in limited number of centres in the world and the first in Turkey. VERSA HD is a new generation radiotherapy technology which changes the existing standards and makes a breakthrough in some tumour treatments.
VERSA HD is a highly developed system which recognizes the patient, ensures the highest level of security through patient positioning and ensures protection for healthy tissues while the tissues with tumour are radiated with the help of image monitoring before and during the treatment. It is possible to treat the patient at a millimetre level even in moving tumours and apply radiosurgery (operation with radiation) for some patients thanks to such patient monitoring systems as CATALYST and SENTINEL which work in an integrated way with the system.
- Nuclear Medicine/Pet CT
It is a non-invasive (not interventional) and sectional imaging method which consists of the combination of PET (Positron Emission Tomography) and CT (Computed Tomography) devices.
PET/CT, on the other hand, is a device consisting of the combination of hybrid/two imaging devices for which special drugs that are sensitive to the changes on the metabolism level without any structural variations in ill tissues are used.
Prior to such application, the drugs marked with positron transmitter radionuclides are injected from the vessel of the patient. The most commonly used drug in the world for this purpose, F-18 FDG (Fluorodeoxyglucose) is the most frequently used radiopharmaceutics (the drugs marked with radionucleid). These drugs contain very low level of radiation and cause no adverse effect as proved on patients.
An evaluation is made on the basis of the determination of increased retention of FDG (fluorodeoxyglucose), a type of glucose contained in the given drug, in tumour cells in comparison with normal cells due to the high glucose need in comparison with normal health cells as a result of uncontrolled cell division on the tumour tissue.
It is used in the discrimination of the masses doubted to be cancerous as benign/malignant, the determination of the diffuseness of the disease for the patients diagnosed with cancer, the identification of the response to the treatment at the stage of cancer follow-up for the patients diagnosed with cancer or the detection of cancer reoccurrence.
Non-oncology, on the other hand, is used in the evaluation of epilepsy patients planned to be operated and in the diagnosis of Alzheimer disease and the assessment of viability on the infarction area (heart attack) observed in the myocardium.
Installed in our hospital for this purpose, SIEMENS biograph mCT PET/CT device has ultra HD image quality and its CT section offers very good image quality at very low radiation doses whereas its PET section has 2mm and 87 mm3 volumetric resolution with the latest technology. Our hospital provides service on this respect with the help of its expert and experienced team.