At the quality assurance qa stage, a physicist reviews the treatment plan activity 4. For imrt , two physics associates create a qa plan and apply the treatment plan to a phantom a device for measuring delivered dose , collecting and analyzing data to verify the treatment plan. Radiation therapists then deliver treatment, which is accompanied by review visits with a radiation oncologist over the course of radiotherapy activity 5. Consistent with the radiation costing literature, we grouped resource items into 3 major cost categories: process costs, clinical infrastructure, and supporting infrastructure In the base case, to adhere to the Canadian Guidelines for Economic Evaluation 18 , we estimated costs from the perspective of the health care system—specifically, the Ontario Ministry of Health and Long-Term Care.
To be consistent with the radiation costing literature 14 , 16 , we also estimated costs from the radiation treatment program perspective. The two perspectives differ in that the program costs include neither the capital costs of equipment acquisition and construction , nor physician fees. Process costs are the costs directly related to clinical care, which include staff time for patient care and consumables. We obtained the costs of consumables gold seeds for prostate cancer and immobilizers for each site from two radiation treatment programs in Ontario.
Costs of the radiation oncologists included physician fees and additional annual funding received from the Ontario Ministry of Health and Long-Term Care 19 Appendix a. We estimated staff cost per minute by assuming that staff worked full time days annually and 7. When estimating staff costs for therapists, physicists, and physics associates, we also included additional management-related costs to reflect management costs not directly attributable to an activity Appendix a. To allocate therapist costs to treatment preparation and treatment delivery, we also assumed that, for each hour of treatment delivery on the linear accelerator, 2.
That ratio was based on a therapist staffing schedule in a centre with 3 linear accelerators Appendix a. The unit cost of equipment was calculated based on whether cost was driven by time used or number of patients served Table ii. The calculation assumed that the centre had 3 linear accelerators, 1 treatment planning system, 1 ct simulator, 1 piece of specialized qa equipment used only for imrt cases , and 1 information system. It included the costs of hospital administration, building service, security, laundry, medical records, porters, social work, and clerical staff in the radiation treatment program; clinical nutrition; utilities; hospital general registration; and housekeeping.
To calculate cost per patient, the total cost of the program was divided by the number of patients seen annually in the program. Activity time—the amount of time consumed by an activity—drove the cost of some resources.
Practical Essentials of Intensity Modulated Radiation Therapy
We estimated the average treatment delivery time minutes per fraction for prostate cancer from the historical treatment time for more than fractions delivered at a centre that had been using imrt for more than 3 years. At that centre, image-guided radiotherapy was used alongside imrt , a process that improves the accuracy of treatment by using imaging for guidance. The imrt treatment time therefore included the additional time associated with image-guided radiotherapy. From the historical data, the average treatment delivery time per fraction was the same for both techniques 15 minutes per fraction.
Assuming that treatment for each prostate cancer patient requires 39 fractions, the average treatment delivery time was minutes. Pre-treatment preparation time was estimated based on a survey of 8 radiation oncologists and radiation therapists in Ontario about the typical time required for ct simulation and dosimetry. The average time was the same for imrt and 3D- crt , with 2 therapists being required to perform the ct simulation, each spending 30 minutes on average. The Physics Professional Advisory Committee conducted a survey of physicists in Ontario to estimate the additional time needed by physicists and physics associates to conduct qa for imrt compared with 3D- crt.
Each respondent sketched a flow diagram representing the physics qa process and the time required for each step. To capture the total work time of radiation therapists, we estimated a ratio of radiation therapist work time to treatment time from the radiation therapist work schedule at the centre. We adapted the costing model to estimate the costs of imrt and 3D- crt for head-and-neck cancer and breast cancer by changing the activity time estimates, the number of fractions per patient, and the number of review visits per patient Appendix a , Table aiii.
The disease-site estimates were based on experience at a teaching hospital in Ontario that had fully implemented imrt since To address uncertainty about the cost estimates, we tested various scenarios in which one or more variables were modified to evaluate the effect on the cost of imrt compared with 3D- crt.
Scenarios tested the effects of longer dosimetry time for imrt , longer qa for imrt , and the use of volumetric modulated arc therapy vmat alongside imrt , among others. In prostate cancer, vmat has been found to improve and speed up conventional imrt Based on more than fractions of prostate cancer treatment delivered at a hospital in the Greater Toronto Area, we estimated the average treatment delivery time with vmat to be 10 minutes per fraction rather than the 15 minutes per fraction estimated for 3D- crt or for imrt without vmat.
The results of the sensitivity analyses showed how the cost and incremental cost of imrt varied with activity time, cost of the linear accelerator, and the number of patients receiving imrt treatment in a centre Table iv. Compared with 3D- crt , imrt with the addition of vmat created cost savings in prostate cancer.
Of the three disease sites, breast cancer was the least expensive and head-and-neck cancer was the most expensive because of differences in treatment complexity and fractions per treatment Tables v and vi. That finding remained true when sensitivity analyses were applied to the breast cancer and head-and-neck cancer models Table vii.
The largest cost differences were seen in head-and-neck cancer, because delivery took longer with imrt than with 3D- crt 20 minutes vs. Again, the cost difference between techniques was larger from the health system perspective than from the program perspective. Treatment delivery was the most costly activity regardless of disease site. The costs varied depending on the analytical perspective, the radiation technique, and the disease site.
In addition to the resources included in the program perspective, the health system perspective encompassed physician fees and the capital costs of equipment. The distribution of costs in the three major categories process, clinical infrastructure, and supporting infrastructure varied depending on the perspective. The cost distribution from the program perspective was within the range reported in the literature 16 , 17 , although the included resources varied between the studies.
In most cea s, cost estimates based on a mature program are more appropriate, because it takes less than 1 year for a centre to become familiar with the technique Applying the costing model to head-and-neck cancer, radiotherapy was more costly than prostate cancer because head-and-neck cancer requires more time for qa and treatment delivery.
That observation is consistent with findings in earlier studies of imrt 25 — Of all activities, treatment delivery was the most costly—an observation that accords with findings reported in an abc study of imrt in Europe Although our centre reported longer treatment times for imrt than for 3D- crt in head-and-neck cancer, two other studies showed shorter treatment times with imrt in head-and-neck cancer 26 , It is possible that those studies did not count as many time components of treatment or that their process was different.
For example, use of the vmat technique for a similar imrt plan would save 3 minutes per fraction of 8 minutes allocated for delivery in head-and-neck cancer. Our study is the first to estimate the costs of 3D- crt and imrt in Canada for multiple disease sites. To estimate the costs of radiotherapy, we used the abc method, which is considered the best method for this purpose 14 — 16 , and the process that we mapped was aligned with the literature 26 , By changing activity times, the number of fractions per patient, and the number of review visits per patient, the costing model developed in the present study can be adapted to estimate the costs of imrt and 3D- crt in other disease sites.
In prostate cancer, imrt became cost-saving when delivered using vmat , which reduces treatment time by 5 minutes per fraction. A recent timing study comparing imrt with 3D- crt in prostate cancer showed that imrt can be delivered slightly more quickly than 3D- crt , suggesting that our analysis might have overestimated the incremental cost of imrt in prostate cancer Treatment delivery is less complex and thus less costly in prostate cancer compared with head-and-neck cancer, although it requires 39 fractions rather than the 35 required in head-and-neck cancer.
That observation suggests that estimating radiotherapy costs for other disease sites requires more than just an estimate of cost per fraction, because a more complex treatment takes more resources time and effort to plan regardless of dose number of fractions. In other words, a treatment given in fewer fractions can cost more because it is more complex. We have used the cost estimates from this model to inform other cea s of imrt 31 , Our study shows that the capital cost of equipment is a big component of radiotherapy cost and a major source of cost differences by technique and by payer perspective.
Although economic evaluation guidelines recommend that analyses be conducted from a health system perspective 18 , most published studies estimate radiotherapy costs from a program perspective, which omits capital costs That omission affects the results of the cea s, because the costs of and the cost difference between the techniques are both underestimated.
Our cost estimates were derived from two centres in Ontario; further validation might therefore be required for generalizability to other centres with different configurations, because radiotherapy costs depend on patient volume and other process factors Our costing framework can be modified to reflect those differences, as well as differences in unit cost and workflow found in other jurisdictions. For example, if physicists play a larger role in conducting qa in some centres, that difference could be reflected by changing the activity time for physicists in the costing model.
Although 3D- crt has been the standard of care for many patients receiving radiotherapy, imrt is increasingly considered for indications that require an escalated dose of radiation. We developed an abc model that estimates the costs of 3D- crt and imrt in prostate cancer and subsequently adapted it to breast cancer and head-and-neck cancer.
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The cost of radiotherapy varied by disease site largely because of differences in treatment complexity, which affected the planning and qa processes and the number of fractions per treatment. Our costing model can be modified to estimate the costs of 3D- crt and imrt for various disease sites and settings by varying the planning and treatment times and the number of fractions per treatment. We acknowledge Jeff Richer and Peter McGhee for conducting and providing details of their survey of physicists in Ontario to inform our radiation costing exercise.
In addition, we thank Mei Ling Yap for testing the usability of the costing model in breast cancer. Cancer Quality Council of Ontario cqco.
Radiation Therapy Evidence-based Series [Web page]. Toronto, ON: cqco ; Role of intensity-modulated radiotherapy in reducing toxicity in dose escalation for localized prostate cancer. Intensity-modulated radiotherapy significantly reduces xerostomia compared with conventional radiotherapy. Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients.
J Clin Oncol ;—9. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer parsport : a phase 3 multicentre randomised controlled trial. Lancet Oncol ;— Systematic review of the cost effectiveness of radiation therapy for prostate cancer from to Appl Health Econ Health Policy ;— Toxicity and cost-effectiveness analysis of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for postoperative treatment of gynecologic cancers.
Gynecol Oncol ;—8. Cost-effectiveness analysis of intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy for anal cancer. A model of the cost-effectiveness of intensity-modulated radiotherapy in comparison with three-dimensional conformal radiotherapy for the treatment of localised prostate cancer.
Clin Oncol R Coll Radiol ;e— It reported a progression-free survival PFS of 6. They found no clear evidence of effect on OS HR 1. The mainly observed adverse effect was local erythema and dry desquamation especially behind the auricles. There were some other toxicities, but there was no statistically significant difference between treatment groups. These investigators judged the quality of evidence to be moderate i.
It should be mentioned that the sample size in this RCT was small, which could lead to insufficient statistical power for a clinically relevant outcome. The authors concluded that they could make no definitive conclusions from this review based on the currently available evidence. Further research is needed to establish the role of radiotherapy in the management of newly diagnosed diffuse brainstem glioma in children and young adults. Future RCTs should be conducted with adequate power and all relevant outcomes should be taken into consideration.
Moreover, international multi-center collaboration is encouraged. Considering the potential advantage of hypo-fractionated radiotherapy to decrease the treatment burden and increase the quality of remaining life, the authors suggested that more attention should be paid to hypo-fractionated radiotherapy. These researchers retrospectively reviewed the medical records of 26 patients who underwent definitive IMRT for DIPG at a single institution between and ; 3 of these patients underwent reRT for progressive disease.
Median age at diagnosis was 6. With respect to systemic therapy, 1 4. Median follow-up time was 11 months from the date of initial diagnosis. The authors concluded that radiation therapy is essential in the definitive management of DIPG. In the future, it may be reasonable to propose more focal delivery of reRT i. The assessment noted that the high degree of dose conformality achievable with IMRT creates a challenge for the radiotherapist to accurately delineate the target and the organs at risk Van den Steen et al, It is also a challenge to reduce the variation between clinicians.
Another challenge is the accuracy and precision with which the target volume and critical structures can be localized day to day, especially for indications other than head and neck. The assessment noted that image guided corrections for day to day set up errors or for internal organ motion have become important issues. The report also stated that intrafraction organ motion has become the limiting factor for margin reduction around the clinical target volume.
Image-guided radiotherapy IGRT is therefore a growth area. In some cases, a treatment preparation session may be necessary to mold a special device that will help the patient maintain an exact treatment position Van den Steen et al, Prior to treatment, the patient's skin may be marked or tattooed with colored ink to help align and target the equipment.
Radio-opaque markers may also be use e. However, the current evidence available suggests that by reducing treatment related uncertainties, image-guided intensity-modulated radiation therapy may allow the reduction of treatment margins, thus reducing exposure to radiation of normal tissue surrounding the tumour and treatment-related toxicities. This may allow for safe additional dose escalation to the tumour, increasing the likelihood of tumour eradication.
The system is intended to improve the accuracy of radiotherapy by tracking the exact position and motion of target organs during daily treatments CMS, Beacon electromagnetic transponders are implanted passive resonant circuits, encapsulated in a hermetically sealed, medical grade biocompatible glass capsule. These miniature electrical circuits are comprised of a copper coil, ferrite rod and capacitor.
Each electromagnetic transponder is approximately the size of a small grain of rice. The Calypso System is an electromagnetic tumor target positioning technology used in radiation therapy delivery. The electromagnetic transponders emit an electromagnetic signal which is detected, measured, and used by the Calypso System to determine the location of the tumor target relative to the linear accelerator beam.
Electromagnetic transponders are implanted into the tumor target tissue prior to the delivery of radiation therapy. This technology is intended to provide clinicians with continuous position information of a tumor target during external beam radiation therapy with sub-millimeter accuracy. Electromagnetic positioning was compared to set-up using skin marks and to stereoscopic X-ray localization of the transponders. Continuous monitoring was performed in 35 patients. The authors concluded that the Calypso System is a clinically efficient and objective localization method for positioning prostate patients undergoing radiotherapy.
Proponents of the Calypso 4D Localization System argue that use of this tumor target position information can improve radiation treatment accuracy, thereby reducing the likelihood of radiation induced complications and improving the effectiveness of radiation therapy. The Calypso system was cleared for marketing by the FDA based on a k application for use in prostate cancer.
Thus, the manufacturer was not required to provide the evidence of efficacy necessary to support a premarket approval application. There are no published clinical trials demonstrating that the use of the Calypso system improves clinical outcomes of radiation therapy. This technology is relatively new, and clinical studies are currently ongoing Aral et al, Sandler et al examined if patient-reported quality of life after high-dose external beam IMRT for prostate cancer can be improved by decreasing PTV margins while using real-time tumor tracking.
Study patients underwent radiotherapy with nominal 3-mm margins and electromagnetic real-time tracking. The 64 patients in the prospective AIM study had generally less favorable clinical characteristics than the comparator patients. Study patients had similar or slightly poorer pre-treatment EPIC scores than comparator patients in bowel, urinary, and sexual domains. Using a change in EPIC score greater than 0. The authors concluded that prostate cancer patients treated with reduced margins and tumor tracking had less radiotherapy-related morbidity than their counterparts treated with conventional margins.
Helical tomotherapy is a novel degree radiation treatment modality that combines a helical computed tomography CT scanner for online imaging with a linear accelerator that delivers IMRT. The on-board CT scanner provides image guidance and dose verification, allowing adjustments for slight, but critical, changes in the shape and position of the tumor. It is intended to be a substitute for the curative or palliative treatment of specific cancers using conventional methods.
The novel features of the Hi-ART system supposedly offer the following advantages over conventional radiotherapy:. Helical tomotherapy is one form of IMRT. However, the function of IGRT, i. Research on the physical and dosimetric aspects suggests that helical tomotherapy may be superior to conventional radiotherapy in terms of radiation-dose distribution including avoidance of sensitive structures and dose-rate. However, no full RCTs have yet been published. Continuous monitoring of the markers is then used for intra-fraction guidance.
Kindblom et al noted that the Micropos 4DRT system is being developed to provide accurate, precise, objective, and continuous target localization during radiotherapy. This study involved the first in-vivo use of the system, aiming to evaluate the localization accuracy of this electromagnetic positioning technique compared with radiographic localization and to assess its real-time tracking ability. An active positioning marker was inserted in the prostatic urethra of 10 patients scheduled to receive radiotherapy for localized prostate cancer. A receiving sensor plate antennae system was placed at a known position in the treatment table-top.
Initial in-vivo system calibrations were performed in 3 subjects. Ten additional patients were then enrolled in a study arm that compared radiographic transponder location to radio-transponder location simultaneously acquired by the Micropos 4DRT system. Frontal and side radiographs were taken with the radiopaque transponder located at 3 different positions within the prostatic urethra. The transponder insertions were all successful and without complications. Continuous transponder tracking capability was also demonstrated. The authors concluded that electromagnetic positioning using the Micropos transponder system is feasible in-vivo.
Evaluation of this novel non-ionizing localization system, in this study using a transponder positioned in the prostatic urethra, indicated transponder localization accuracy to isocenter comparable with X-ray localization of a radiopaque marker. This was a feasibility study. The clinical value of this novel electromagnetic positioning system needs to be validated by well-designed studies. Shah et al stated that in the past decade, techniques to improve radiotherapy delivery, such as IMRT, IGRT for both inter- and intra-fraction tumor localization, and hypo-fractionated delivery techniques such as stereotactic body radiation therapy, have evolved tremendously.
This review article focused on electromagnetic tracking in radiation therapy. Electromagnetic tracking is still a growing technology in radiation oncology and, as such, the clinical applications are limited, the expense is high, and the reimbursement is insufficient to cover these costs.
At the same time, current experience with electromagnetic tracking applied to various clinical tumor sites indicates that the potential benefits of electromagnetic tracking could be significant for patients receiving radiation therapy. Daily use of these tracking systems is minimally invasive and delivers no additional ionizing radiation to the patient, and these systems can provide explicit tumor motion data. Currently, work is being done to incorporate electromagnetic tracking in several sites e.
Hopefully, while these preliminary investigations are not yet FDA-approved, viable options to treat these sites will become clinically available within the next several years based on this early work. The authors concluded that although there are a number of technical and fiscal issues that need to be addressed, electromagnetic tracking systems are expected to play a continued role in improving the precision of radiation delivery. There are a number of technical and fiscal issues that need to be addressed in the near term, however, to ensure the success of these technologies in improving patient care over the next 10 years and beyond.
IMRT is also indicated in pancreatic cancer, anal cancer and for postoperative use in endometrial, cervical and advanced rectal cancer. Aetna considers IMRT medically necessary for the following indications when there is a concern about damage to surrounding critical structures with the use of external beam or 3D conformal radiation therapy:. Aetna considers IMRT experimental not medically necessary for right breast cancer. Aetna considers IMRT experimental and investigational for all other indications. Review History.
Clinical Policy Bulletin Notes. Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. Intensity Modulated Radiation Therapy. Print Share. Background Note on Definition of Intensity Modulated Radiation Therapy IMRT : For purposes of this policy, to qualify as IMRT, radiation therapy requires highly sophisticated treatment planning utilizing numerous beamlets to generate dosimtery in accordance with assigned dose requirements to the tumor and organs at risk. In contrast to conventional trial-and-error approach, IMRT uses inverse planning automated optimization , computer-controlled radiation deposition, and normal tissue avoidance.
When IMRT is used for head and neck tumors, it allows for the treatment of multiple targets with different doses, while simultaneously minimizing radiation to uninvolved critical structures such as the major salivary glands e. Treatment planning, i. The report noted that it is expected this model will become outdated and be replaced by image-guided IMRT. The report stated that some treatment machines already have an integrated scanner integrated. The report stated that the frequency of imaging CT or other will vary based on characteristics of the tumor dose gradient and the patient, e.
An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision. Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with convetional treatment. The target volume is concave or convex, and the critical normal tissues are within or around that convexity or concavity.
The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures. Primary, metastatic or benign tumors of the central nervous system, including the brain, brain stem, and spinal cord. Primary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment. Selected cases i. Other pelvic and retroperitoneal tumors that meet requirements for medical necessity as noted above.
An implementation strategy for IMRT of ethmoid sinus cancer with bilateral sparing of the optic pathways. Intensity-modulated radiation therapy. Optimisation of radiotherapy for carcinoma of the parotid gland: A comparison of conventional, three-dimensional conformal, and intensity-modulated techniques.
Radiother Oncol. Improvements in target coverage and reduced spinal cord irradiation using intensity-modulated radiotherapy IMRT in patients with carcinoma of the thyroid gland. Potential role of intensity-modulated radiotherapy in the treatment of tumors of the maxillary sinus. Xerostomia and its predictors following parotid-sparing irradiation of head-and-neck cancer.
A prospective study of salivary function sparing in patients with head-and-neck cancers receiving intensity-modulated or three-dimensional radiation therapy: Initial results. Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: A comparison with conventional techniques. Toxicity following high-dose three-dimensional conformal and intensity-modulated radiation therapy for clinically localized prostate cancer. Intensity-modulated radiation therapy for pediatric medulloblastoma: Early report on the reduction of ototoxicity.
The role of intensity-modulated radiotherapy in the treatment of parotid tumors. Improvement of treatment plans developed with intensity-modulated radiation therapy for concave-shaped head and neck tumors. Is uniform target dose possible in IMRT plans in the head and neck? Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: An update of the UCSF experience.
Advantages of using noncoplanar vs.
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Chao KS. Protection of salivary function by intensity-modulated radiation therapy in patients with head and neck cancer. Semin Radiat Oncol. Intensity modulated radiotherapy IMRT decreases treatment-related morbidity and potentially enhances tumor control. Cancer Invest. High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized prostate cancer. J Urol.
Zietman AL. Editorial comment. Walsh PC. Letter to the editor. Re: High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized cancer. Potential improvements in the therapeutic ratio of prostate cancer irradiation: Dose escalation of pathologically identified tumour nodules using intensity modulated radiotherapy. Br J Radiol. Prostate cancer. Breast cancer. ACR Practice Guideline. Conformal radiotherapy. Assessment Report No.
Intensity modulated radiation therapy IMRT. Practical know-how for community cancer centers. Oncology Issues. Intensity modulated radiotherapy: Current status and issues of interest. The use of conformal radiotherapy and the selection of radiation dose in T1 or T2 prostate cancer [full report]. Practice Guideline; no. Clinical and cost-effectiveness of new and emerging technologies for early localised prostate cancer: A systematic review. Health Technol Assess. Conventional 3D conformal versus intensity-modulated radiotherapy for the adjuvant treatment of gynecologic malignancies: A comparative dosimetric study of dose-volume histograms small star, filled.
Gynecol Oncol. Quality of life after parotid-sparing IMRT for head-and-neck cancer: A prospective longitudinal study. Intensity-modulated radiation therapy for head-and-neck cancer: The UCSF experience focusing on target volume delineation. Intensity modulation radiotherapy. Technology Evaluation Service. Assessment of intensity-modulated radiotherapy. Clinical implementation of dynamic and step-and-shoot IMRT to treat prostate cancer with high risk of pelvic lymph node involvement.
Preservation of oral health-related quality of life and salivary flow rates after inverse-planned intensity- modulated radiotherapy IMRT for head-and-neck cancer. Toxicity profile of intensity-modulated radiation therapy for head and neck carcinoma and potential role of amifostine. Semin Oncol. Intensity modulated radiation therapy and chemotherapy for locally advanced pancreatic cancer: Results of feasibility study.
World J Gastroenterol. Quantifying the effect of intrafraction motion during breast IMRT planning and dose delivery. Med Phys. Phase I study of concomitant gemcitabine and IMRT for patients with unresectable adenocarcinoma of the pancreatic head. Int J Gastrointest Cancer. Dose-position and dose-volume histogram analysis of standard wedged and intensity modulated treatments in breast radiotherapy.
Monte Carlo evaluation of 6 MV intensity modulated radiotherapy plans for head and neck and lung treatments. The delivery of intensity modulated radiotherapy to the breast using multiple static fields. Intensity-modulated radiotherapy for early-stage nasopharyngeal carcinoma. Dosimetric analysis of a simplified intensity modulation technique for prone breast radiotherapy.
Comparison of three IMRT inverse planning techniques that allow for partial esophagus sparing in patients receiving thoracic radiation therapy for lung cancer. Med Dosim. Simultaneous integrated boost for breast cancer using IMRT: A radiobiological and treatment planning study. Inverse planning in three-dimensional conformal and intensity-modulated radiotherapy of mid-thoracic oesophageal cancer.
Clinical implementation of intensity-modulated tangential beam irradiation for breast cancer. Intensity-modulated radiotherapy IMRT and concurrent capecitabine for pancreatic cancer. Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: Toxicity and clinical outcome. Segmentation of IMRT plans for radical lung radiotherapy delivery with the step-and-shoot technique. Intensity-modulated stereotactic radiotherapy of paraspinal tumors: A preliminary report. Intensity-modulated radiation therapy for prostate cancer. Clin Prostate Cancer.
Feasibility of sparing lung and other thoracic structures with intensity-modulated radiotherapy for non-small-cell lung cancer. Dose and volume reduction for normal lung using intensity-modulated radiotherapy for advanced-stage non-small-cell lung cancer. Impact of breathing motion on whole breast radiotherapy: A dosimetric analysis using active breathing control.
Three-dimensional conformal vs. Inversely planned intensity modulated radiotherapy of the breast including the internal mammary chain: A plan comparison study. Technol Cancer Res Treat.
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Treatment planning comparison of conventional, 3D conformal, and intensity-modulated photon IMRT and proton therapy for paranasal sinus carcinoma. Intensity-modulated radiation therapy for head and neck cancer. Curr Treat Options Oncol. Small bowel displacement system-assisted intensity-modulated radiotherapy for cervical cancer. Comparison of conformal and intensity-modulated techniques for simultaneous integrated boost radiotherapy of upper esophageal carcinoma. Reimbursement of intensity modulated radiation therapy.
Policy and Practice. Phys Med Biol. On compensator design for photon beam intensity-modulated conformal therapy. Compensators for intensity-modulated beams. Compensators for IMRT--an investigation in quality assurance. Z Med Phys. Optimization of dose distributions for adjuvant locoregional radiotherapy of gastric cancer by IMRT. Reduction of rectal dose by integration of the boost in the large-field treatment plan for prostate irradiation. Int J Rad Biol Phys. Braaksma M, Levendag P.
Tools for optimal tissue sparing in concomitant chemoradiation of advanced head and neck cancer: Subcutaneous amifostine and computed tomography-based target delineation. Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: Which anatomic structures are affected and can they be spared by IMRT? Spinal lesions treated with Novalis shaped beam intensity-modulated radiosurgery and stereotactic radiotherapy.
J Neurosurg. Simultaneous integrated boost intensity-modulated radiotherapy for locally advanced head-and-neck squamous cell carcinomas: II--clinical results. Phase I clinical evaluation of near-simultaneous computed tomographic image-guided stereotactic body radiotherapy for spinal metastases.
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Cuzick J. Radiotherapy for breast cancer. J Natl Cancer Inst. Risk of cardiac death after adjuvant radiotherapy for breast cancer. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med. Morbidity and mortality of ischaemic heart disease in high-risk breast-cancer patients after adjuvant postmastectomy systemic treatment with or without radiotherapy: Analysis of DBCG 82b and 82c randomised trials.
Development and implementation of conformal radiotherapy in the United Kingdom. A comparison of different intensity modulation treatment techniques for tangential breast irradiation. J Appl Clin Med Phys. Reduction of radiotherapy-induced late complications in early breast cancer: The role of intensity-modulated radiation therapy and partial breast irradiation. Part II--Radiotherapy strategies to reduce radiation-induced late effects.
Clin Oncol R Coll Radiol. Intensity modulated radiation therapy and proton radiotherapy for non-small cell lung cancer. Curr Oncol Rep. Bogardus CR. Comparison of three concomitant boost techniques for early stage breast cancer. Intensity modulated radiotherapy IMRT for prostate cancer [summary]. Rapid Report No. Intensity modulated radiotherapy. Clinical Practice Guidelines in Oncology Version 2. TEC Assessment in Press. Daily ultrasound-based image-guided targeting for radiotherapy of upper abdominal malignancies.
Chemoradiation for ductal pancreatic carcinoma: Principles of combining chemotherapy with radiation, definition of target volume and radiation dose. Comparison of conventional to intensity modulated radiation therapy for abdominal neuroblastoma. Pediatr Blood Cancer. Pisansky TM. External-beam radiotherapy for localized prostate cancer.
A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. Randomised trial of standard 2D radiotherapy RT versus intensity modulated radiotherapy IMRT in patients prescribed breast radiotherapy. Imaging and alignment for image-guided radiation therapy. Advances in image-guided radiation therapy. Should intensity-modulated radiation therapy be the standard of care in the conservatively managed breast cancer patient? Lu H, Yao M. The current status of intensity-modulated radiation therapy in the treatment of nasopharyngeal carcinoma.