Hello, and welcome to the Physics World Weekly
podcast.
This episode explores
precision medicine.
From the perspective of 2 leading medical physicists.
It's produced in partnership with Ip am, the
institute of physics and engineering in medicine,
which owns the journal physics in medicine and
biology,
and and this episode is supported by p.
Our guests are anna barnes,
director of the King's technology
evaluation center at King's College London,
and president of Ip
and Nikki Wilde, who is head of radiotherapy
physics at the mid and south Essex
Nhs foundation trust.
They joined Physics World's Tammy Freeman in a
wide ranging
conversation that defines the key concepts of precision
medicine.
And looks at how they're being implemented by
medical physicists
using magnetic resonance
imaging, radiotherapy
and other technologies.
This podcast is supported by Pt,
a global leader for dos
and Qa
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End to end Qa can help eliminate errors.
With the new Ruby insert for adaptive radiotherapy.
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This new insert enables medical physicists
to check key steps of the adaptive
workflow.
From image
registration and plan
adaptation to dose
verification.
Technology driven medical advances have enabled the introduction
of precision medicine technique into the clinic.
Whether this is targeting at risk
populations with specific screening programs,
tailoring interventions to particular patient subgroups
or truly personalized diagnostics and treatments designed for
individuals,
the overriding aim is to deliver the right
procedure to the right patient.
And underlying the application of these innovative techniques
is the ongoing research and development work by
medical physicists and clinical engineers.
To take a closer look at the development
of precision Medicine.
I'm joined today by Anna barnes,
director of the King's technology
evaluation center in London, I'm President of I
the Institute of Physics and engineering in Medicine.
And Nikki Wilde, Head of Radio
Physics at the mid and South Essex Nhs
Foundation Trust in the Uk. Hello, Anna and
Nikki. Welcome to the podcast.
So first of all, can you briefly explain
what's meant
precision medicine and personalized medicine, and the differences
between the 2.
So I think actually, pun tammy. By You
made a good summary of it there in
the in the introduction where the precision part
is around trying to target.
Appropriate
treatment and diagnostics
at groups of patients,
rather than 1 size fits all,
whereas the person lies is very much based
on that
individual's
health profile, whether it be gene therapy or
immunotherapy,
or or indeed their, own individual ana when
it comes to things like
external beam radiotherapy
or even,
their own,
tailor made molecular therapy doses for their size
and shape and sex.
Looking first to the development of new techniques
for diagnosing and monitoring disease and what's roles
to medical physicists and clinical engineers play in
developing these new approaches.
1 of the first things I think about,
and my career has always been in imaging,
medical imaging is, you know, how can we
adapt the imaging environment for,
the different patients that we have,
coming through our scanners, and that might be
to do with size, height, shape, whether or
not someone's a little bit claustrophobic, whether someone
has sensitive hearing,
whether or not they have some sort of
special implant that means that we have to
be careful
about the environments in which we're scanning them.
Or, we might use special protocols in,
in Ct or Mri where we can,
get the best imaging signal around
metal based implants that people have in order
to, you know, improve their their lives or
or indeed to to to treat them.
I think then you have
on the,
engineering side,
you have a group of,
staff health professionals in the hospital whose
particular
job it is is to maintain and organize
all of the medical equipment
that is dedicated to
patient health whether that be diagnostics
or,
simply monitoring people while they have their Opus
stay hospital. And there's a lot of work
that gets done around making that ergonomic,
appropriate in places like Icu or busy, high
dependency ward units, but also sometimes if we're
working in things like,
respiratory clinics or sleep clinics where you, organize
the
physiological measurement around the patient,
in order to be able to understand
their,
special needs and,
diagnostics
around their experience of their illness or pathology.
There's a lot more that gets done in
in in radiotherapy between planning. I'm gonna hand
them to Nikki to say a little bit
about that. Yeah. I mean, Nikki maybe you
could sort of explain how they help.
In developing various different types of cancer treatments.
Yeah. Sure.
So ready care, as you can imagine, is
highly technical discipline.
And so
it's
very multi disciplinary in in it's
and it's
makeup.
So we... As well as the clinical scientists
and,
engineers we you have clinical technologies or d
we have clinic clinical
oncologists,
contribute as well to development.
So but really,
it is led in my opinion. Not might
be bit controversial by
by the physics staff,
whatever from whatever staff group they come from.
So... And if you think about it really,
you're already therapy since the very first treatment
back in 18 96,
as been personalized, we point
x rays at a tumor
and,
avoid
the healthy issue around it, and that really
is what happened has happened since way back
in 18 96, course,
the changes and then and the advances in
technology,
have meant a lot of changes
and a lot of benefits to patients.
So really like that
the role of the
physics,
staff group,
to the clinical scientists they're evolving research and
development and developing new technique,
making sure that they're implemented safely, make sure
that their quality is assured. They look after
the equipment to make sure that, what is
delivered is what we think it's delivering.
The engineers have the job of looking after
this terribly complex,
equipment to getting more complex really with every
passing year.
And then we are the clinical technologies who
act
actually really
dig down on a patient level,
who,
generate, treatment plans that are very specific to
that particular patient.
If we think how a linear accelerator is
built,
for example, it's,
very complex
bit of machinery that...
In a way generates x rays in the
same way that diagnostic x rays machine do,
but at a very much higher level so
that we can
penetrate the patient and treat.
Deep seated tumors.
Though we have... So we have the electron
gun,
again, in similar way the actual... Filament,
in diagnostic machines.
Those is electrons are accelerated to very high
energies
throughout down a wave guide accelerated by microwaves,
those electrons hit a target,
and that's producers
x rays.
The x rays obviously, have to be then
focused onto the patient, so we have a
lot of shielding
issues. We have to make sure that,
the x rays are only coming out in
1 direction. And also, we want to be
able that
for that
being to come in at a lot of
different angles so that we can optimize for
the patient.
So we have a the gan tree rotates
around 03:60 degrees. Couch will rotate, an internal
c can rotate as well. So we can
get
really d angles in any any angle relative
to the patient. And that that
focus of that
rotation is a iso center that is a
diameter of 2 millimeters. So for these very
heavy machines at odds on multiple of tons,
that the engineer in behind that is really
quite spectacular.
Radiotherapy is are great example because as you
say, each...
Patient has their individual dose prescription. And then
with these sort of more advanced technologies and
the rotation and the more accurate targeting,
I guess, sort of over the last decades.
You've been able to target tumors more and
more precisely for each patient.
Yes. And actually, just to add to that,
I I guess the best way to sort
of sum up is you couldn't take someone
else's treatment plan. And put it onto another
patient and expect it to be exact, you
know, deliver the same thing. It has to
be redone all over again because it it's
done for every single patient that comes along.
Yeah. And also, just this week, I read
about a new study investigating the use of
genetic markers.
To predict whether a particular patient is likely
to have sort of really adverse effects to
radiotherapy.
I mean, I guess that's sort of a
real of new cutting edge. Emerging
approach. But that... You know, I guess that's
more
personalization. Yes. This is really promising
actually it's something that's been talked about for
quite a while, but we've not had the
technology I suppose behind it,
to be able to use that information, but
I think... I mean, you see it every
day, and some patients will have a better
reaction to ready therapy some patients will have
worse.
Skin reactions to radiotherapy therapy than not the
patients. Even though they're having exactly the same
personalized treatment,
you you do see that difference
in reaction,
in different patient groups. So
This is... Yeah, This is going to be
really exciting going forward so it can really
personalize that treatment
even if it's down to radiotherapy not being
the most appropriate even if it comes them
down something else being more appropriate for that
patient. But I think
you know, you could get really granular on
this and say things like, you know, if
someone
has less radio sense. Activity and doesn't suffer
so much from the the dermatitis
cause. You could maybe think about, you know,
really boosting that that dose
to to the the primary tumor. And then
those that,
that are particularly sensitive to to the radiation
in in areas that we don't want to
be sensitive.
Is is all these wonderful,
3 d technique and
with all the
the the rise in computing power has meant
that you can really
look at how you can target the tumor
from many different angles,
but spa the areas that
you know, on on the skin on the
surface that that could really flare up. And
and that's what I think is totally amazing
is that you can
you know, if we start folding in this
extra information, we can really start personal
to every single person that comes in.
Absolutely.
And then
Looking at the diagnostic side,
for example, Mr imaging, how has that being
personalized?
Okay. So I'll start from the point of
view of sort of the the big stuff,
and then I'll go in
on on every time a a patient goes
into the scanner. So... I mean,
first of all,
the American market
about 10 years ago started to make extra
large magnet.
With extra large,
we call it the bore, which is the
tunnel that that patients go into because
there's an obesity epidemic in
in in America, and they will find it
that they couldn't fit people into the scanner.
And and and you have to be careful
because if you squish people in too much,
then you end up
concentrating where the the microwaves come and and
and you can burn people.
And we we definitely don't want happening.
The other thing is that they created,
what's called open bore magnets,
where, it's not a closed tunnel, and again,
that can help with people who are big,
but also people who are claustrophobic your fabric.
Then the next thing is that,
you can design, so we we have
receiver coils that fit over the head, but
also on the body and the wrists and
legs and so all of those have being
designed,
not necessary. I would say more sort of
precision medicine.
Because small sort of groups of patient,
rather than,
personalized. Because you don't have a specific coil
for each patient.
But
and and each of the manufacturers will do
something slightly different. So, you know, 1 of
the manufacturers likes to have soft flexible coils.
That fit onto the body, so it's quite
comfortable and they're very light, whereas some of
the other ones, other vendors like to have
big large heavy coils being have less of
them.
And and they do things that way.
And then
you could do quite clever things with,
with the pulse sequencing that the actual way
that the
electromagnetic
radiation is delivered into the body and and
and
in order to get the signal back.
And the way we do that is that
you can do things where
that there's a
development recently that
you call Whisper gradient. So I don't know
if for any of you've been into an
Mri scanner, but it's really loud. Like, you
get some of these resident effects and it's
bang bang bang bang bang. And that's that's
frightening for people or for children
or for people who have...
You know, sensitivity to hearing. So they've, you
can mathematically create a model and then
deliver,
much less noisy
ways of of of of getting the the
acquiring the signal,
that's 1 way. The other way is we
we use computing and mathematical modeling
to
decrease the time
taken.
So for people again who are across Pho
or for children,
you have super far sequences, which mean you
could still get the same information, but they're
in a fraction of the time that you
would normally
collect them. This if I'm really interesting, and
I would like to understand this more so
personally being of that age of having had
my my first m scan recently.
I was a bit
sister to why we still do it this
way.
Whereas in Mri,
you have a special,
breast coil, which is a bit like a
bra, really,
and far more comfortable. But, of course, if...
Taste a little longer than if you're if
you're having,
before plain on.
And then also, because so you have a
static magnetic field,
which which we make as homogeneous as possible.
But then as soon as you put a
body into it,
it dis it disrupts it and disturb it
and changes everything,
So
physicists will work hard on creating
pulse sequences that are suitable for...
Certain areas of the body,
and then the radio,
he's the person no 1 does the acquisition
can tweak those
specifically for the size and shape and fact
density and
blood perfusion area, etcetera for that particular patient
that's in there right now, and you can
change things around,
and
get the best issue that you can really,
for that person he's in there right now.
Yeah. It's interesting because these are the technology
development obviously you're wanting to get, you know,
better imaging and sort of better, diagnostic
outcomes. But also there's the side of making
it more comfortable for the patient and less
distressing and loud noises is, etcetera. So... Yeah.
And that... That's really interesting. Yeah. Well, No
know Just gonna ask Nikki, actually.
So in terms of
external beam therapy delivery.
Do you feel like there has been...
Because we haven't really talked about mold room
technicians, which is phenomenal, really, delivery and and
how we make life a bit more comfortable
for the patients when they're having the treatment
delivered.
Yes. It's having it is really important that
patients are comfortable because they're on
a flatbed couch, which is
inherently uncomfortable, and they,
their treatment can... They could be on the
bed, so it is 05:10 minutes. So
we won't stay as still as possible. They're
not gonna stay as still as possible if
they're massively uncomfortable. So
we have a
have a range of accessories that we can
use
from, sort of foot stocks to needs to
pull to,
they had neck shells, which
because there are so many organs at risk
when you're treating your head and neck cancer.
Usually relatively close to the tumor. It's really,
really important that they stay and still join
the treatment. So,
these shells are fixed in 3 or 5
places to the couch,
and they're formed
very closely to the patient's skin, so they
can't,
they can't move. And 1 of the great
advancements that we're just implementing and a lot
of centers in the Uk also so are
doing is is something called surface guided radiotherapy.
So surface guided radiotherapy therapy uses light
to,
reflect
off the patient. So it's sort of structured
light
in
in the ceiling
that,
reflects off the patient reflected back And because
of the disturbance of the structured light,
the computers can construct 43D
outline of the patient,
So this in itself can make treatment a
lot more accurate. And
you know, in it in it's
1 of its most spoken about benefit is
reducing the need with tattoos because we still
hundred years later,
tattooing patients to to, set them up initially
on the on the truman machines.
But
as you can imagine, these head and neck
shells are quite claustrophobic. They literally cover the
hole
of the face and the head down to
the shoulders pad and neck patients as well.
So this technology, this new technology called surface
guided radiotherapy
will allow us to remove the whole of
the central part
of the shell so that patients can have
a much kind
experience much less claustrophobic
experience.
And actually, just... I mean, that... That's that's
really good news because even when we went
through the, you know, the years of having
to wear the mask,
I felt having that
breath right there,
is quite disturbing. And if you're sort of
and also at the same time you can't
move your head. It must be quite
upsetting for people.
I I liked what I saw,
a few years ago,
where,
some of the centers who were doing the
pediatric,
head and neck treatments,
because it was an all labor mask, and
they kinda make it out of this It's
quite a... I think a light material isn't
it? Because it obviously, it needs to not
att any of the x rays.
And it make it into a mesh, but
they did superhero masks on it, which I
think was lovely idea, and and that's a
different level of,
personalized medicine. Right? Yeah. So very skill for
mel technicians out there. Yes. Berry. Yeah. Can
produce things like that. Yep.
So another area of medicine that's used to
lot is a nuclear medicine, so this is
like scans such as pet and spec scans.
Could 1 of you comment on
personalization in nuclear medicine?
Yeah. Definitely.
So
for those of that for those of you
that aren't so familiar, with this form of
of radiation. So we talked a bit about
external beam radiotherapy,
we've also talked about,
you know, x rays, which are, usually, if
you have a Ct scan or an x
rays scan come from outside and they go
through your body. K. The different att termination
properties of the tissues in the body
on on a screen.
With this version, we take
what called radio pharmacy.
So this is molecules
that,
have some sort of either metabolic
job function in the body
or maybe some,
receptor type function, and then we replace 1
of the within that molecule with a radio.
And the most commonly 1 use in medicine
is,
and that's,
terms essentially pure gamma emit, much lower lower
energy than the stuff that Nikki was talking
about.
And in that case, we inject it into
the
per patient, and then we have
radiation detectors around the body, which then,
capture the,
radiation coming out of the body, and then
using
mathematical modeling techniques, we can then,
show where in the body it's coming from.
Okay? So the reason that's important
is that you might want to look at
specific functions within the body
So you might want to label something that
looks at people's digestive system
or someone's kidney function.
Or someone's receptor to function in their brain.
And the way that that this part is
So you've got the sort of purse the
precision side of it, which is your taking
a specific radio pharmacy
and targeting it at a particular function in
the body.
But then the personalization bit comes where you
have to adjust the amount that you're injecting
around the size and weight.
Of that person, particularly pediatrics.
And and more so, I think you know,
when we go forward when we have this
range of different
Bmi. We have we also have guidelines around,
you know, someone's
has you high Bmi than we need to
inject slightly more than we would someone else.
And
that's something you can medicine side, And then
we also have pos emission with slightly different
kind of,
source of the gamma rays that we'd detect.
Through,
pos
annihilation.
That's mainly flu
radio pharmaceuticals
and
we,
again, we have to adjust for the patients.
Weight
in order to be able to get the
best,
the best images.
The next step from that is that we
would
you can then use this information to work
out
how much
therapeutic
radio pharmacy tool called you could
inject. So with a tech in the fluoride,
a flu,
That's just for imaging we have low energy
gamma rays.
When we want to treat, we can use
alpha part, or beta particle
radiation,
and we'll have already labeled it with the
particular
pharmaceutical
it's gonna go to the right organ that
needs to be treated,
and then you can work out from their
imaging, scan, the imaging version. If you like
the sort of benign version of the Radio
pharmaceutical.
Then we can work out very precisely how
much we need deliver of the
treatment the ion,
bit
for that particular patient. To So that's very
much. In the same way that you have
external being radiotherapy is that you have, you,
your planning Ct,
you, deli it or the organs you want
to,
avoid. So and then also
and then deliver
the optimum treatment to the primary,
then with the nuclear medicine way of doing
things, which which now has got this sort
of trendy name called the.
So therapy diagnostics,
is you you do the imaging part,
you get a really
excellent map of where that radio ice tote
will go. What's sorry, radio
Will go.
And then you can look at you can
completely then
calibrate
how much of the
treatment pharmacy, call. You delivered based on
what... How much was delivered,
for each person when you did the imaging.
And that's... I I
So did... There's really exciting new treatments around
prostate cancer for this of this metastatic.
But actually, there's lots of molecular.
Available.
It's not that well known.
And I think it's a really exciting new
area
and I think that we should... I I
think maybe because radiation had a bit of
a bad press,
maybe that's part of the reason it hasn't
been so popular.
And
but I think this a really exciting stuff
especially when it comes to looking at people's
individual.
Immune systems
and genes and
that dictate
their response to that radio pharmaceutical as well
in the same way that the radiation sensitivity
sensitivity levels.
And I think that if we
if we are able to push forward as
a as a country that can start
manufacturing its own radio isotopes for medicine.
That we can really push this forward and
become
really sort of a a world center if
you like for for therapy delivery
Yeah. I mean, that sounds like a technique
that's just, you know, ideal for real
personalization to eat each patient. That that sounds
really exciting.
And and then moving back to radiotherapy,
and a 1 emerging area here is adaptive
radiotherapy.
In which you use images of the patient
recording during the treatment course to adapt the
planned treatment
could you maybe me Nikki tell me a
bit more about this?
Yes. Of course it's a very exciting area,
and
very alimony if he likes it. I'd like
to... If I can go back to
what radiotherapy therapy looked like when I started
and radiotherapy,
34 years ago, just to kind of put
it in some kind of context.
So,
hard to believe now,
but
when we were treating patients with radiotherapy
to localize the tumor to sort of work
out where we were treating,
we used to have ortho x rays
and a doctor would
draw on those x rays in a altered
China graph.
To
say where they actually wanted the treatment to
be focused on and we had to work,
some
magic, really. But based on the fact that
we didn't really have planning Ct routinely at
that point, we'd take a outline of the
contour with a bit of sold ring wire,
and work it out,
that way. So,
from that, take so been in 19 90
to to now. The change has been for
phenomenal it's been a very
exciting time to be in in radiotherapy.
So just sort of from that
and, you know, a lot of it is
driven by,
increased capacity, computer power, computing power.
You know, from that, we then had the
planning Ct,
which
it started off you it as a as
a slot in the diagnostic x rate department,
But now
departments have their own,
at least 1,
largest centers even more.
Ct that is specifically for radiotherapy therapy planning.
So we scan them in in the treatment
position,
the Ct scans get exported to
a
planning treatment planning system
where the organs at risk,
we talked about before are outlined and, the
treatment,
volume the actual tumor
is outlined on a slice by slice. So
we get a much more 3 d
representation of what we're trying to treat
and the advancement in that area of course,
which I'm very excited about is, Ai artificial
intelligence.
So,
deep learning,
and algorithms are being developed
literally as we speak that can do that
automatically in seconds. They can,
outline, for example, for prostate cancer, they could
outline the rec, the bladder and the small
bowel, seminal these,
to
in a massively
shorter time that it would take either
a number of the physics staff or or
a doctor to outline those.
So that... That's where we're sort of proceeding
there. And that that speed is actually important,
especially when we come on things like the
online adaptive radiotherapy that I will eventually get
to our promise.
And then we add such of the advancement
of
the the technologies on the linear accelerator like
multi leaf c. So these are tiny little
fingers
of tungsten that can move in and out,
to
to like to conform to the tube window
no chew is a square. Or queue right
is it. So,
there were... Was that kind of development. There
was the,
first of all, we used statically.
Now then moved
actually, while the beams on, generating a dynamic,
flu of dose,
and
we we'll moved on to be able to
use more and more
fields so that we could focus right in
on the tumor
sort of of spreading out,
the the the lower doses,
to the other organs at risk.
And then we sort of moved on to
the imaging side, which is where we really
started
to be able to see the possibility of
adaptive
online adaptive radiotherapy
in the future. So
in the again, when I started, it was
plain film stuck in a in a cassette
underneath the patients,
that was particularly sen to these energies, that
we went onto those being electric
images.
And then we moved on to having
k
generators and,
imaging
ortho to the treatment being.
And so we could start seeing
playing a K images and then finally Comb
beam Cts, and the the quality of the
Comb Ct again is increasing rapidly
with time with their
intelligence
of the the new algorithms being able to
really generate
super quality
on treatment images. So I think where we
are,
almost
as a as a routine for most patients
having megawatts ready
now in the Uk. They will have
cone beam Ct
in treatment position prior to each treatment.
Radiotherapy therapeutic treatments have
risk patients have treatments, let's up with different
fractions, so the treated
daily usually wanted to Friday ever 1 to
6 weeks.
So, they get on the bed the made
as comfortable as possible with the mobilization kit,
they have their Comb beam Ct,
and that is matched to what their planning
Ct looks like.
This in a way is adaptive therapy because
they were moving the patient to close and
matched,
match the position
that they were in where they had a
planning Ct, which is what the treatment was
planned on.
But this is only
geographical adaptive share it to me In this
case, we're only
moving in
6 degrees of freedom in some cases, mostly
4 degrees of freedom. To to to match
every day as close as possible to the
planning Ct. But that
can't account for changes in anatomy.
As I said, these patients are coming
well, 1
once a day for sort of, 05:10,
15 treatments and patients anatomy to changes in
that time if we go back again to
the example of state.
A prostate
is actually quite mobile based on
how full the bladder is, how full the
rec is.
And so
if we want to do proper
online, adaptive radiotherapy but I adapting to the
patient every single day,
We need to be able to image that,
and we need to be able to actually
alter the dos symmetry.
Of the plan to recalculate it if you
like, on the Cone Ct rather than rely
on the original treatment plan
to recalculate it to adjust for those
changes on that particular day and then treat.
This... There's still a lot of,
issues with this
exciting technology.
There... And there are probably
2 main types of I'm land adaptive really
For external be,
Must be careful too. This is only external
being ready therapy.
And,
1 is,
Based on Comb beam Ct,
and the other is based on Mr.
So the mr is
the Mr Ak is
extraordinarily exciting. I think every
clinical scientist we're their clinical scientist in the
country probably secretly cranes want to play with
because
they really are,
very exciting. So the
case of an that that
patient is image.
Again,
artificial intelligence is used to make a start
on what we should be treating what we
should be, saving,
and
that physics staff and clinical oncology then adjust
that to what
they think it should be, and then the
plan is
regenerated,
and then, a, patient is treated on that
new plan. And all the time,
and this is probably the difference between the
Ml in act,
and the comb Ct Lin that
I'll become more and more popular in the
Uk.
Is that they can also image joint treatment,
and they can always they can also beam
off joint treatment. So you've got... You drawn
around on the sag, for example, where the
tumor is. And you're watching it on the
ml while the treatment is being delivered. If
the patient takes deep breath coughs, and that
tumor moves out,
of the treatment volume, then the beam automatic
switch off. That is so cool. And that
even it just... There are a lot of
technical problems with them Marlin x, which is
why they're not
widely rolled out yet.
The... First of all, the magnetic field doesn't
affect
on the radiation fields,
and the Rf
radio frequency
on the Lin affects the Mr and the
Mr radio frequencies
affect the Lin act. So there's been some
very clever advances in the engineering of these
machines to try and,
the... To the Rf cage for Ml lin
act, for example, is inside the lin. It's
not in the room as it is doug.
It's actually inside the,
inside the Lin.
Casing itself. So
they take quite a bit of time to
treat at the moment,
what we need is advances in skills mix.
You know it's quite difficult to get a
consultant.
Clinical oncologist, down, every retirement patient as a
treatment
and and the physics
staff,
are, you know, well placed to really advance
their,
understanding,
and their,
their skills in this area.
Ai needs to advance probably a bit more,
because we do need these quicker treatment times.
The Com Ct
online adaptive
is being
adapted very widely in the Uk at a
minute. And that's
That is because there aren't the complexities
around e mr. There aren't the
complexities around
having the right staff at the right place
for a long period of time, And they're
also considered cheaper for actually, I have to
say. But, and,
they also show, a lot of
exciting advancement so that we really can
make
it as personalized
as possible.
Yeah you know, actually, nikki, I'm thinking. The
1 thing we haven't really spoke about is
bra therapy. Are there any sort of new
things going on there in terms of being
able to do...
Much more clever to symmetry in this space.
But you right actually. I mean bra therapy
is also
naturally
personalized.
The... For a long time, I think it's
fair to say
the techniques
weren't really changing very much.
But then,
again, with the advancement of
computing
power if you like. And
we've been able to develop
much newer techniques technique. So instead of the
cavity there's also instance
interstitial,
rec therapy
commonly used for prostate.
And so, in theater, the needles are inserted.
Into the prostate date.
And we
then,
calculate the dwell times because bra therapy is
basically
but those that don't know a a highly
active
iridium source on the end of a piece
of wire,
and that
can
insert,
in and out a patient,
with,
he can... And he can vary the dose
deposited by the 12 positions and also the
12 treatment times.
So
Yes, In natural fact you. You you are
completely personal
the treatment to the patient on that day.
The thing that will make it develop now
is that,
we didn't use to take into account or
tissue my We used to treat patients. As
if there were just water,
we can now look looking forward where we
can start and
absolutely.
Taking into account those differences in tissue in
homo although though it's really less sensitive to
external being radiotherapy.
We also
used to plan on Ct only. Now, we're
moving towards planning on Ct and arabic
is much better at showing no soft to
shoot
tumors,
and,
certainly moving away even from doing Ct in
the beginning, just using the Mri,
to to plan a patient's treatment.
Then there are there are exciting times. I
think the a bra therapy as well. III
mean, you know, didn't even just listening to,
Nikki, because I
I did my trainee back in 93, 95,
and then,
where where I did get to do some
radiotherapy, and then I moved into imaging
and and and sort of most recently into
magnetic resonance imaging.
Listening to you talk now
it's just so exciting, and I'm almost en
endless of the coming into the green pressure
now and you know, and if anyone is
out, there listening and they're thinking about it.
Yes, become a clinical scientist in the Nhs
is really cool. There's so much amazing.
New med medical technologies going on at the
moment that that you don't hear about normally
in the news say. Now regret it for
day. And every everyday is different.
Every day is differently. You could be doing
that. Personalized
patient specific
planning, or you could be
writing
you knew it the specification for replacement,
treatment planning system, or you could be,
going down and
analyzing the the the the dos on it
other treatment machine, everything single day different in
every single days.
Exciting.
That's great. I mean, it sounds like there's
been so many new developments, but also that
there's so much more
ongoing and more to come. So, I mean,
finally,
it's sort of looking into the future. Could
you perhaps envision en envision,
a new approach to precision medicine that might
just be on the horizon? Just an example
of that?
Thinking radiotherapy, there's you knew lots
exciting. Stuff still to come there's
what we call flash radiotherapy
where where we're treating
radiotherapy therapy very, very high doses in seconds
and so that and that chance to move
as much internal organs don't have an opportunity
to sq back.
So that
is still pretty theoretical,
but, it's very very exciting. There's
proton
treatment is still relatively rare,
but, you know, there's a there's a
future in that definitely and that
the difference with that and,
x rite treatment if you like
conventional radiotherapy therapy is that the
protons don't drop their energy
until they reach the end of their track.
So there's much lower dose
coming into a patient with than with x
rays. And then they kinda of dump it
all
in 1 spot. So
again, lots of challenges with protons but,
very exciting prospects there.
The use of sen agents
could be get completely game changing.
There was a bit of work done previously
with the opening investing
around gold, and
gold, while the killed sen.
Skin cancers show that you needed
less radiation to get the same effect.
So there's... Yeah. There's a there's an awful
lot
going on that could really, really
benefit patients.
Yeah. That reminds me actually if I forgot
to say with the with the molecular therapy
is that there's also a group of,
treatments
that
where you basically put the
radioactive substance into little spheres,
and then inject them right into the middle
of the tumor,
and then they...
So so they just they just irr
what's around them, and that's really clever. So
atrium spears is 1
that's been developed. So I think there's more
more to be done there.
And that's that's when you start going to,
like, material science
as well, you know, like, how how can
you
box it into something that will only disintegrate
or or be protect, sort of let the
radioactivity
come out, but also protect it from the
rest of the body and and not be
toxic and, you know, lot lots are really
interesting stuff there. And then the other thing
that,
people maybe don't realize so much. That I
mentioned before about molecular therapy and then teaming
that with a men immunotherapy and genetics.
But there have been,
there has been work already done where you
can look at the
specific
receptors or or
transmitter that are being
expressed by tumors.
And then you can target those
so that they almost act like little magnets
so that whatever to the radio pharmacies call
that you've jet
or sort of get stuck on to those
receptors, and then they'll only
be irr the tumor that's that's some,
expressing those sectors, and and again, prostate cancer
is a good example of that.
There also some press
breast cancers as well.
But there's
the prostate specific antigen that's expressed by
those tumors within the body
can be targeted
using
desired radio pharmacy calls and and and it'll
only latch onto that and and give those
tumors of dose, which is minimizes side effects
and things.
And then you have sort of complicated thing
where you use said some of the tumors
are
expressing those sectors and some of the marks,
and and you can start sort of doing
a mix and match of
things too. But but all of that takes
multi disciplinary teams,
and and careful planning and careful
investigation.
So it... It's how do we
how do we deliver
universal health care at the same time as
having the space and time
to keep pushing forward all these exciting areas
so that you know, 10 for years from
now,
everybody gets their perfect
prescription that's just for them.
And that that's a challenge that,
I guess we all have to face.
Yeah. And challenge
what's certainly worth working towards Yes.
A lot of exciting things ahead where the
sounds of bit. Well, I mean, thanks very
much to both of you for speaking with
today. It's it's been really interesting to find
out more about this personalized medicine. So, yeah.
Thanks again. Thanks for voice me tammy.
I.
I've enjoyed it. I really enjoyed it. Yeah.
And he's been like captain Nikki as well.
Yeah. Thank you. Thank you. Been great.
That was Anna Barnes and Nikki Wilde in
conversation with Tammy Freeman.
I'm afraid that's all the time we have
for this week's podcast.
Thanks to Anna, Mickey and Tammy for their
insights into precision medicine,
and to our producer Fred Isles.
This podcast is supported by Pt
and produced in partnership with ip,
a special thanks to them both.
This podcast is supported by Pt,
the dos
specialist,
end to end Qa
is essential for complex treatment techniques.
Ruby for adaptive radiotherapy
by Pt.
Enables medical physicists
to validate
the entire
adaptive treatment
workflow. From reference plan generation to plan
adaptation and
verification.