How to improve the Pediatric Radiation Oncology on Latin America ? - - PowerPoint PPT Presentation

How to improve the Pediatric Radiation Oncology on Latin America ?

Paulo Eduardo Novaes MD, PhD Paulo Eduardo Novaes MD, PhD

Hospital AC Camargo Hospital AC Camargo – – São Paulo São Paulo -

• Br

Bras asil il ALATRO ALATRO’ ’s s President President

22,5 million Km2

Latin America

General General Information Information

• LA: 36 countries

LA: 36 countries – – 526 526 million million people people (2006) (2006) Expected Expected: > 800 : > 800 million million people people (2050) (2050)

• 12% world

12% world population population – – 6% world PIB 6% world PIB

• 70%

70% population population concentrade concentrade in four countries: Brasil, in four countries: Brasil, Mexico Mexico, , Colombia Colombia and and Argentina Argentina

• The

The LA LA´ ´s s integration integration copes copes with with dificulties dificulties and and hindrances hindrances due due to to diversity diversity of

• f cultures

cultures, to , to the the specific specific characteristics characteristics of

• f each

each country country´ ´s s state state power power and and to to diferences diferences of

• f development

development models models

1,520 1,301 1,087 885 728 549 326 2,367 1,437 1,628 1,941 668 778 457

A s i a / O c e a n i a C h i n a I n d i a A f r i c a E u r

• p

e L a t i n A m e r i c a N

• r

t h A m e r i c a

2004 2050

Fuente: 2004 World Population. Data sheet of the Pupulation Reference Bureau

World population 2004 - 2050

millones

Childhood Cancer

World

260.000 cases/year

Brasil

7500 new cases/year 2,5% all cancers < 20 years

Childhood cancer in LA

Peculiarities

The same incidence of developed countries with

small variations between each country

Childhood cancer registers: dificulty to access More incidence of advanced cases Few pediatric cancer centers Few pediatric radiation centers No contact between the specialized institutions Small participation of scientific societies

Childhood Cancer

Multidisciplinary approach success Multidisciplinary approach success

• Improvement on early diagnosis

Improvement on early diagnosis

• More effective chemotherapy

More effective chemotherapy

• Rational use of surgery

Rational use of surgery

• Access to a specialized center and technological

Access to a specialized center and technological facilities facilities

• Collaborative protocols participation

Collaborative protocols participation

• Best supportive care

Best supportive care

• Follow

Follow-

• up of cured patients and program care for

up of cured patients and program care for survivors survivors

Childhood Cancer

Facts Facts

• 75%

75% of

• f children

children with with cancer cancer will will be be cured cured by by multidisciplinary multidisciplinary treatment treatment

• Survivor

Survivor’ ’s s groups groups studies studies (CCSS)

(CCSS) 2/3 2/3 -

• at

at less less, , one

• ne late

late effect effect 1/3 1/3 -

• one
• ne severe

severe or

• r incapacitant

incapacitant late late effect effect

• GEPETTO

GEPETTO (324

(324 survivors survivors) * ) * Anatomical Anatomical Sequele Sequele: 133 (41,04%) : 133 (41,04%) G1=36; G2=34; G3=62; G4=1 G1=36; G2=34; G3=62; G4=1

* Rigon et al: 2004

Latin America

Radiation Radiation Oncology Oncology

• It is

It is integrated integrated part part of

• f Oncology

Oncology attention attention presents presents in in all all LA countries ( LA countries (excepted excepted Haiti) Haiti)

• The

The estimate estimate number number of

• f Radiation

Radiation Oncology Oncology Centers Centers is is about about 500 ( 500 (insuficient insuficient to to cover cover the the assistance assistance) )

• It

It í ís s necessary necessary a a survey survey to to have have a a correct correct number number and and to to develop develop appropriate appropriate strategies strategies for for each each country country

• The

The radiation radiation oncology

• ncology centers

centers have have different different levels levels of

• f

complexity complexity and and development development

Childhood Cancer

Radiation Therapy Radiation Therapy

• Important role on cure and multidisciplinary

Important role on cure and multidisciplinary treatment treatment

Late effects

Cure

Childhood Cancer

Radiation Therapy Radiation Therapy – – Peculiarities Peculiarities

• Patient collaboration depends of age: anesthesia

Patient collaboration depends of age: anesthesia

• Immobilization systems: masks,

Immobilization systems: masks, vac vac-

• fix

fix

• Simulation and mould room techniques

Simulation and mould room techniques

• Family and parents information

Family and parents information

• Radiation Oncologist integration

Radiation Oncologist integration – – Team Team

• Specialized Nurses and Technologists

Specialized Nurses and Technologists

Childhood Cancer

Reducing the late effects Reducing the late effects

• To avoid radiation on therapeutic protocols

To avoid radiation on therapeutic protocols

• To reduce the radiation dose

To reduce the radiation dose

• To know the dose delivered to normal tissues

To know the dose delivered to normal tissues

• To improve new technologies to protect the

To improve new technologies to protect the normal tissues normal tissues Dose > 40Gy – Many clinical situations

Radiation Doses on Childhood Cancers

Wilm’s: 10-5Gy Hodgkin: 20Gy Retinoblastoma: 45-50Gy Ewing: 45-55Gy CNS: 50-55Gy STS/rabdo: 45-55Gy LLA and NHL: no RT Neuroblastoma: 20-25Gy

2D

• Planning

Planning based based on

• n clinical

clinical exam exam and and bone bone landmarks landmarks

• Conventional

Conventional simulation simulation – – x x-

• rays

rays films films

• Normal

Normal organs

• rgans and

and crictical crictical structures structures visualization visualization: : dificult dificult

• Field

Field arrangement arrangement: : simple simple -

• co

co-

• planar

planar

• Dose

Dose distribution distribution studies studies: : limited limited -

• points

points

3D

• Planning

Planning based based on

• n tumor

tumor and and normal normal tissues tissues determination determination

• CT

CT-

• simulation

simulation: CT/MRI/PET : CT/MRI/PET

• Dose

Dose deliver deliver: : improved improved – – image image fusion fusion

• Field

Field arrangement arrangement: : complex complex – – multiple multiple -

• non

non coplanar coplanar fields fields

• Dose

Dose distribution distribution: DVH : DVH – – precise (volume) precise (volume)

GEPETTO – Childhood cancer survivors

Numbers

Registered patients: 1080 (dec, 2008) Radiation therapy: 53% Irradiated Sites

CNS-Neuraxis 37% Orbita – H&N 23% Abdomen – pelvis 18% Torax 8% Extremities 4% More than one site 10%

2D RT

Hospital AC Camargo - Brasil

Who was cured from a childhood cancer ?

1 from each 1000 young adult is a survivor

How to improve Pediatric Radiation Oncology in Latin America

To incorporate 3D technology on clinical practice To develop QA programs To participate on colaborative protocols To stablish clinical guidelines To share experiences with pediatric radiation centers

and pediatric cancer organizations

To make easier the scientific information - web

Pediatric Radiation Oncology Mentality

Multidisciplinary team must be compromised with this reality To Cure is not enough To Care is Fundamental To integrate and to prepair the cured patient to the future is mandatory