Program of Excellence.pdf - Yale School of Medicine

Program of Excellence
SBRT team is hard at work saving more lives
[This article appeared online in the June 2012
Dialogue.]
Some members of the SBRT team photographed
in a CT scan room: front row (l-r) Roy Decker
and Bryan Chang; back row: Zhe Chen,
Veronica Chiang, Shannon Dingus, Joseph
Contessa, James Picone, Margaret Pinto and
Jun Deng.
Roy Decker, MD, keeps a photograph in his desk drawer of a woman in her 80s with the horse she still loves to
ride. It’s a testament to life after lung cancer.
In 2008, doctors told the woman she was not a candidate for surgery and there was nothing else they could do.
Then she found her way to Yale and became one of the first patients to be treated with SBRT, or stereotactic
body radiotherapy, which delivers high doses of radiation with pinpoint precision. Just a few treatments wiped
away her disease.
“We had a number of patients who were written off, early on, and just told nothing was possible,” said Dr.
Decker, who keeps the patient’s picture at his desk.
Five years later, SBRT is easily a program of excellence that has grown dramatically and takes referrals from
throughout the state. A large staff includes four physicians, seven nurses, three PhD physicists, 15 dosimetrists
and 22 radiation therapists. They all work closely together to plan treatment then deliver radiation to 100-120
patients a year, mostly for lung tumors, but also for a smaller number of liver and spine tumors.
Stronger doses, highly precise delivery
For any one case there are as many as seven
specialists involved in the treatment. “The
planning is very labor intensive, as is the
quality assurance,” said Mary Starno, chief
radiation therapist. “We only have one shot.”
Other programs aggressively market similar
treatments using Cyberknife. While the
Cyberknife has a robotic arm that moves around
the patient to target the tumor from hundreds of
angles, Yale’s linear-accelerators (LINAC)based
SBRT program uses an arc that sweeps
360 degrees around the patient. Yale’s Novalis
Tx and Varian Trilogy (the program is shopping
for a third, more powerful machine), is faster
Mary Starno, left, works with staff on a case.
(30 minutes vs. three hours for Cyberknife).
Yale uses “on-board imaging” rather than
requiring the placement of a radio-opaque marker. “Overall, I feel the linac-based SBRT is easier for the paitent
and more versatile,” said Dr. Decker.

Pulmonary and liver patients typically receive 3-5 treatments—traditional radiation would require 30 or 40—
following detailed treatment design, integrating technologies such as PET-CT scanning, 4-dimensional
simulation(4-D Sim), and comfortable stabilization to minimize body motion during radiotherapy delivery.
Specialists explore a variety of uses
Veronica Chiang, MD
!
James Yu, MD !
ica Chiang, MD
James Yu, MD
Lung cancer patients are the majority of the caseload and have the most successful
outcomes, with a success rate of 80 to 90 percent. They include patients with small
early stage lung cancers and carefully selected patients who have metastatic tumors.
“We have a lot more experience than many other centers in treating situations that
are considered high risk-tumors that are closer to the central airways,” Dr. Decker
said.
Veronica Chiang, MD, a neurosurgeon, and James Yu, MD, a therapeutic
radiologist, together are treating the program’s fastest growing group: patients with
spinal tumors. Because spine metastases are treated in a single dose up against the
spinal cord, they consider targeting a spinal tumor to require even more precision
than a lung tumor, and therefore have been selecting patients very conservatively.
Treatment of spine metastases is currently delivered using the Novalis Tx machine.
There is still lot to learn about non-palliative indications for SBRT treatment for
spinal tumors, because as with all radiation treatments, the rate of local cure long
term is unknown,” Dr. Chiang said. “For those who come with pain as a symptom of
their spine metastases, however, SBRT results in faster pain relief—and more
patients get longer lasting relief—than with standard spine radiation.”
Meanwhile, therapeutic radiologist Bryan Chang, MD is using the technique to treat
an average of two patients a month for liver tumors, including primary liver tumors
and cancer that has metastasized from other parts of the body. Since many patients
travel long distances to receive the treatment, Dr. Chang carefully reviews patients’
scans to determine whether they are suitable candidates before a consultation is
performed. “We look at scans for all patients we see in consultation, but for patients
who are referred from far away, I carefully review the scans in advance to make sure
they are good candidates before accepting the consult,” he said.
“Cancer that has metastasized is generally thought of as being incurable,” he said.
“But we know that in certain selected cases, we can treat one or two tumors in the
liver with radiation, and the patient will survive a long time or even potentially be
cured. That is a fairly radical shift in thinking. In terms of treating metastatic disease,
there clearly is potential for SBRT as chemotherapy continues to improve, making
local control of sites like the liver more important to patient survival.”
An intensive, high-tech team
Another critical element is teamwork, said Starno. “The whole thing is a team effort
and we couldn’t do it without each other. Everybody on the team is important.”
Discussions among team members have resulted in more compassionate patient care.
For example, at first they didn’t schedule appointments until the planning was
completed, but waiting for a call proved to be stressful for the patient. Now new
patients come in for a consultation and imaging, and leave with an appointment,
typically scheduled for a week later.
Bryan Chang, MD
Staff that works directly with patients receive consistently high Press Ganey scores.
“We’re very familiar, obviously, with trying to break the ice and make patients
comfortable,” said radiation therapist Shannon Dingus. Patients also appreciate the simplicity of the treatment
itself, she added. “In short periods of time, doctors and researchers have come up with things that are amazing.
They’re really thinking about the patient as a person.”

Helping the program grow
Dr. Decker examines a new patient.
Dr. Decker, who developed the SBRT
Program in 2007 after completing his radiation
oncology residency at Yale-New Haven
Hospital (YNHH), gives partial credit for its
success to time spent upfront educating
referring physicians, and speaking at CME
dinners and tumor boards, among other things.
He is also grateful to Yale-New Haven
Hospital, which invested in the program, and
Frank Detterbeck, MD, chief of thoracic
surgery; Lynn Tanoue, MD, medical director
of the Yale Cancer Center Thoracic Oncology
Program; and Lynn Wilson, MD, clinical
director of therapeutic radiology. “Without
their support we were not going to go
anywhere,” he said.
The program’s latest stride is the pending
finalization of a radiosurgery fellowship that will include training in central nervous system radiosurgery (brain
and spine), lung and body SBRT. While the fellowship is an exciting milestone, Dr. Decker said it’s important to
remember that the SBRT Program is still evolving.
There are questions to be answered about such matters as patients’ tolerance for high doses, SBRT’s
effectiveness for patients with advanced disease, and the increasing number of patients choosing SBRT as an
alternative to surgery, not just as a last resort. “What is the best way to work it into these treatment plans?” Dr.
Decker asked. “We don’t know. For a lot of patients, the precise role of SBRT still hasn’t been clearly defined.
It’s still part of our research.”
SBRT team members
Radiation Oncologists:
• Roy H. Decker, MD, PhD
• Veronica Chiang, MD
• Bryan Chang, MD
• Joseph Contessa, MD PhD
• Suzanne B. Evans, MD, PhD
• Bruce A. McGibbon, MD
• James B. Yu, MD
Certified technologists:
• Helen Civitello, RTT
• Laura Cretella, RTT
• Nancy Deforest, RTT
• Shannon Dingus, RTT
• Daniel Longo, RTT
• Anna McKinzie, RTT
• Heather Montz, RTT
• Charlene Peschel, RTT
• Violet Ratchford, RTT
• Christa Ryszczyk, RTT
• Arhonti Simmons, RTT
• Iris Torres, RTT
• Kathryn Waldron, RTT
Radiological physicists and dosimetrists:
• David Carlson, PhD
• Jun Deng, PhD
• Fanqing Guo, PhD
• Wu Liu, PhD
• Arthur Gifty, BS
• Destinee Fortunato, AS
• Monica Kaur, BS
• John Kim, BA
• James Kimmett, BS
• Huan Liu, MS
• James Picone, BA
• Martha Picone, BS
• Richard Stanton, AS
• Di Wu, BS
• Jing Ye, BS
Clinic staff:
• Margaret Pinto, RN
• Laura Lucarelli, RN
• Carol Kennedy, RN
• Kay Oddie, RN
• Nancy Andaluz, PCA
Additional staff:
• Ann McKeon, data manager
• Jeannie Kluytenaar, RN, research nurse