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RefleXion: Targeting Tumors from the Inside Out – In-Depth Doctor’s Interview

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David A. Clump, MD, PhD, Radiation Oncologist, UPMC Hillman Cancer Center in Pittsburgh, Pennsylvania, talks about new technology in radiation for cancer patients.

I wanted to start by asking you about the reflection. Can you describe for our viewers what it is and what it’s designed to do?

CLUMP: Radiation oncology has been a field that’s advanced from the time of the advent of X-ray really utilizing imaging to guide treatment. We’ve advanced from utilizing rudimentary X-rays to C.T.-based planning, and everything’s really been based off of anatomical signatures or anatomical pictures in this instance. The reflection brings our armamentarium the ability to utilize the biological signature of the tumor. What it does is it integrates not only a C.T. scan but also a PET scan into the treatment delivery machine, which is called a linear accelerator.

You mentioned the biological tumor. For our viewers who may not be familiar, what does that mean?

CLUMP: Tumors within the body are emitting a signature that signifies their replication or signifies the immune profile. For whatever tracer that you can develop, this machine has the capability of utilizing it as part of the treatment process.

You mentioned that it kind of marries C.T. scans, which our viewers are familiar with, and PET scans, which they may have also heard of. Can you just explain to me how they’re marrying these images?

CLUMP: A conventional linear accelerator or a modern linear accelerator has a C.T. scan built into it, and that C.T. scan is used prior to the treatment so that we can make sure that we’re targeting the area that we planned. This integrates a PET scan. In this instance, a patient is dosed with a common PET tracer called FDG. That signal is admitted and detected by the machine and it’s able to detect that stream of positrons and adapt the treatment so that it can deliver and account for any motion within the tumor and allow you to acquire an image that can potentially be adopted even for future treatments.

We’ve done some stories about fluorescent markings. This isn’t a fluorescence, is it? This is something that just allows the machine to follow the tumor.

CLUMP: That’s correct, right. Fluorescence is really often utilized to see the surface of a tumor. This really gets at the biological makeup. For instance, we could develop a PET tracer that is targeting the immune system. This machine would actually be able to detect the changes that are imparted in part by the radiation treatment. If we think that radiation can work complementary to an immune therapy and we know that many patients have progressed beyond their first line of immune therapy – and that happens in, really, the vast majority of patients – this is the possibility of utilizing radiation to re-stimulate the immune system so that perhaps immune therapy could be utilized again. If we could develop a PET tracer that detects really any signature of that tumor, even the immune profile. So, for patients that have failed immune therapy in a process that’s called immune escape, we could potentially utilize radiation to reignite the immune system and predict when those patients might actually respond to immune therapy again and be able to detect that in almost real time.

They’ve been dosed and had the PET tracer that’s within their system. Can you walk me through what happens at that point?

CLUMP: Patients are traditionally seen in consultation. They go through a simulation process, which is a traditional planning process where they have a C.T. scan performed. That all remains the same. In this instance, patients would receive a dosing of a PET tracer as a simulation day – it’s almost a separate planning day in its entirety where they’re then taken to the treatment machine and we’re able to determine whether or not this therapy would be appropriate for the tumor based upon its location and whether we’re detecting an emission that can be actually tracked by the machine. We’re then able to take that image, adapt the plan, and bring them back for the subsequent treatments. Many of these treatments will be designed to be delivered in likely one treatment session.

As compared to?

CLUMP: As compared to three to five.

You had mentioned before, that a patient is moving and breathing, so you’re trying to target that tumor.

CLUMP: Right.

How does this help with precision?

CLUMP: It helps with precision because we’re able to be more conformal, which means we’re able to target the radiation in and around the tumor and spare the normal tissues. An interesting part of the machine is that it’s actually capable of delivering the treatment at a much faster rate, so we can treat more tumors than what we’ve previously been limited. The technology up until this point has really limited us to treating somewhere between three and five areas within the body at one single session. This is the first time we can really start to expand beyond three to five areas and treat multiple areas in the body in a single treatment session.

What’s the benefit to patients? One dose as opposed to coming back for multiple?

CLUMP: Right. There’s multiple opportunities here. It’s speed and efficiency of treatment. It’s less time on a treatment table. It’s less time in the treatment facility. But I think the most important aspect is this gives us the first opportunity to really ablate disease in multiple areas of the body in a single treatment session. We know that treatment of one to three lesions, treating those patients aggressively can improve overall outcomes. It can take and build upon that principle and allow us to do it from multiple areas. And ultimately patients live longer.

Is this for patients with early-stage disease or does stage matter?

CLUMP: Stage does not matter. It’s predominantly, in its current form, going to be utilized for treatments of any stage. It could be treating a patient with a conventional treatment similar to any other therapy they may receive, but it has the applicability to move into the metastatic arena where we’ve often been limited. Traditionally, our treatments were limited in that capacity to relieving pain, relieving symptoms. Here, this actually brings up an opportunity to take care of the disease that we actually can see on the images. And usually, when we’re able to do that, patients are feeling better and able to remain more active and have a better quality of life. And that can translate into better overall outcomes.

Are there patients with certain cancers for whom this is a better option?

CLUMP: I think it will be predominately solid tumors, so it will be patients with common malignancies such as prostate cancer, lung cancer, breast cancer. But really it will be applicable across all the primary disease sites that are solid tumors.

What’s the impact or the benefit of having a device like this at your disposal?

CLUMP: I think the real benefit is that radiation oncology has been somewhat limited in being able to expand its indications to these multiple disease sites throughout the entire body or multiple lesions throughout the body. This gives us the first opportunity to rapidly treat patients in an efficient time manner and ultimately improve upon their outcomes.

Is it being tested in clinical trial now? What’s the rollout in terms of when people across the country might start to see or have access to this?

CLUMP: Currently the machine is FDA approved, but it’s FDA approved for treatments such as IMRT, SBRT or SRS. The new indication, which they’re currently in development and clinical trials are ongoing, is for a component called biology-guided radiation therapy or BGRT. That process is really limited to very few centers in the country. At this point, about five or six centers have started to utilize this treatment.

When in Pittsburgh do you anticipate being able to?

CLUMP: January ’22. Beginning of the year. So current installation is at Stanford, City of Hope, UT Southwest, and then there’s going to be another center in California and one in private practice in Texas.

You’d mentioned BGRT. Can you just explain again for our viewers the biology-guided radiation?

CLUMP: Radiation oncology has traditionally utilized a technique called image-guided radiation therapy, and that’s utilizing images and the anatomical localization of the tumor. This actually utilizes the biological signal – so it’s adapting the treatment based upon the actual biology of the tumor and it’s actually using the biology of the tumor to track and account for motion and deliver more conformal treatments.

Is there anything I didn’t ask you, doctor, that you would want to make sure that people know?

CLUMP: This technology enables us to really position ourselves to be able to work with our partners in medical oncology and the commitments that have been made for our immune therapeutic center. This really positions radiation oncology right in line with those therapies so that we can explore novel treatment sequencing and novel treatment combinations to ultimately, again, improve the outcome of our patients.

In a lot of cases, with some immunotherapies, is radiation not an option? Or does this just let them work hand-in-hand?

CLUMP: I think this allows us to potentially adapt the signal based upon what’s happening within the environment.

Interview conducted by Ivanhoe Broadcast News.

END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact:

CYNDY PATTON

412-415-6085

PATTONC4@UPMC.EDU

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