Combining Therapies for Better Outcomes

Radiation, chemotherapy and surgery are all effective in treating cancer. Ongoing research shows that combining these therapies can improve outcomes and prevent recurrence for many patients.

Radiation oncologists, cancer surgeons and medical oncologists from Penn Radiation Oncology and the Abramson Cancer Center at the University of Pennsylvania work closely with each other to develop the most effective treatment plan for every patient. Often, chemotherapy and radiation are administered together for better results or to increase the effectiveness of surgery.

Surgery and radiation are considered localized therapies. That is, they treat the tumor at its point of origin and prevent recurrence in that same location. Systemic treatments such as chemotherapy, endocrine therapy and molecular therapy are designed to kill any microscopic cells that have gotten into the bloodstream and traveled elsewhere in the body.

Challenges of Lung Cancer
One of the reasons that lung cancer is so deadly is because it is difficult to diagnose in its early stages, when treatment is most successful. There are usually no real symptoms of lung cancer until it is very advanced and has often spread beyond the lung.

“For advanced lung cancer that has not spread, chemotherapy and radiation given together is the definitive treatment,” said Alexander Lin, MD, a Penn radiation oncologist who specializes in treating lung and head and neck cancers.

Lung cancer presents many treatment challenges. Lung tissue itself is very sensitive to radiation, especially in long-term smokers with poor lung function. There are also vast differences in the tissue components of the chest — including bone, soft tissue and air — that radiation penetrates differently.

“We are continually looking for new ways to measure the radiation dose to the lungs,” Dr. Lin said. “We have to maintain a very fine balance between treating cancer and minimizing exposure of the surrounding tissue. Because of improvements in technology, we have found that we can escalate the radiation dose given for lung cancer in an accurate manner. ”

Numerous studies also suggest chemotherapy makes cancer cells more sensitive to radiation. The two therapies are often used concurrently to achieve the best results.

“Our goal is always to deliver the most effective treatment that maximizes radiation exposure to the tumor and minimizes toxicity to the surrounding tissue,” Dr. Lin said.

CT scans are also now being used to track the movement of the lungs and the cancer through the breathing cycle. Using the scans, radiation oncologists can more accurately target radiation exposure to the tumor while sparing normal tissue.

Penn physicians plan to use proton therapy with the goal of improving the efficacy of radiation therapy for lung cancer.

More Effective Treatment for Breast Cancer
Most patients with breast cancer are treated with surgery—either mastectomy for larger tumors or lumpectomy for smaller cancers—but chemotherapy and/or radiation are often incorporated into the treatment plan to reduce the chance of recurrence.

“Surgical treatment of breast cancer is very effective,” said Robert Prosnitz, MD, MPH, a Penn radiation oncologist who treats breast cancer patients. “But there is evidence to support the addition of radiation as a way to prevent recurrence. Large studies have consistently shown that radiation therapy can reduce the risk of cancer recurrence by about 50 percent in patients with ductal carcinoma in situ (a non-invasive cancer), and by about 75 percent in patients with invasive breast cancer.”

CT-guided therapy is also used in treating breast cancer, according to Dr. Prosnitz. CT scans give a three-dimensional picture of the patient’s anatomy and allows physicians to design radiation fields that treat the breast and, in some cases, the adjacent lymph node regions, while minimizing the radiation exposure to the underlying lung and heart. When planned with care, radiation therapy for breast cancer has very few short- or long-term side effects.

The Penn Difference
Experience is essential to developing treatment plans and accurately targeting radiation therapy. Many of Penn’s physicians, like Drs. Prosnitz and Lin, are subspecialists who only treat specific types of cancer.

Coordination of care is vital when combining therapies, according to both Drs. Lin and Prosnitz. Along with radiation oncologists, Penn’s treatment teams include surgeons, medical oncologists, pathologists and diagnostic radiologists. The team members meet regularly to discuss treatment plans and challenging cases.

“Our cancer programs are all located in the Perelman Center for Advanced Medicine. The fact that we are all in one location facilitates true multidisciplinary care. We are constantly talking to one another and this close communication is essential when patients are being cared for by multiple specialists at once,” Dr. Prosnitz said. “We can truly provide better coordinated, interdisciplinary care to all of our patients.”