Cancer Treatment Heads into 21st Century

DETROIT _ Hospitals buy costly equipment all the time. But why a $4 million piece of equipment called CyberKnife?

Over two years, multidisciplinary teams at St. Joseph Mercy Hospital in Superior Township, Mich., pondered what competitors say are small differences among CyberKnife from Accuray Inc. in Sunnyvalle, Calif., and several other radiation oncology systems.

The hospital chose CyberKnife, a robot with an X-ray machine at its tip that delivers precise, computer-plotted doses of radiation. St. Joseph is the first Michigan hospital with the technology. It began treatments two weeks ago, and more than 250 people already have inquired about it.

It has invested $465,000 to advertise the machine on its Web site, www.sjmercyhealth.org, on the radio, in flyers mailed to homes and on billboards around the state.

“We did many levels of analysis on this and CyberKnife kept coming to the top of our list,” said Kathy Kasperek, oncology program director for St. Joseph Mercy Health System. CyberKnife can treat patients, many with inoperable tumors, in one to five sessions, with accuracy and precision that spares healthy tissue and allows more radiation to be used. It delivers radiation within a 1-millimeter target; there are 25 millimeters to an inch.

The discussion that went on at St. Joseph Mercy shows the painstaking purchase decisions hospitals around the country encounter when shopping for the latest generation of radiation equipment for their cancer programs. The new equipment is similar to several other systems that precisely plot radiation doses to minimize damage to nearby tissues.

Still, the advances of all these systems, including CyberKnife, are smaller than those in the past 10-15 years, when bigger breakthroughs came with the introduction of three-dimensional, computer-driven systems, said Dr. Ted Lawrence, chief of radiation oncology at the University of Michigan Health System.

U-M opted for a different system from Varian Medical Systems of Palo Alto, Calif., that uses a CT-machine minutes before radiation treatment to render a precise guide for the path of radiation.

“We had a big debate about it in the department,” Lawrence said. “We evaluated CyberKnife and decided against it for a couple reasons.”

The cone beam CT-guided linear accelerator U-M purchased also cost about $4 million, once all the gizmos and add-ons were tabulated,

The Barbara Ann Karmanos Cancer Institute in Detroit paid about $3 million for a system called TomoTherapy, from TomoTherapy Inc. in Madison, Wis. It delivers radiation in a 360-degree field around a patient, “a flexibility that doesn’t come with other improvements,” said Dr. Maria Vlachaki, interim chief of radiation oncology at Karmanos. “It has excellent accuracy and versatility and can treat multiple cancer sites,” she said.

Vlachaki and Lawrence say that given the similarities in equipment, consumers should get radiation care at high-volume centers with experienced doctors.

“Surgeons have scalpels and some use them better,” Lawrence said. “It’s the same with advanced technologies.”

Vlachaki added: “In the end of the day, it’s not the equipment that makes a difference, but how the doctor uses the technology and relates all the information to the patient.”

St. Joseph charges $37,000 for three treatments and about $50,000 for five CyberKnife sessions. Medicare and Blue Cross Blue Shield of Michigan pay for most of the treatment, but patients might be billed for some charges, depending on co-pays required and whether they have supplemental Medicare coverage, Kasperek said. Dr. Walter Sahijdak, a radiation oncologist at St. Joseph, said patients need to understand that different machines may treat different types of cancer. CyberKnife, for example, treats some, but not all, solid tumors, benign as well as malignant. It is used mostly for brain and extra cranial tumors; prostate, pancreas, liver and lung cancer; facial pain syndromes and a circulatory condition known as arteriovenous malformations.

Patients should understand that the goal of radiation may be stopping the tumor and providing extra months or years of life, but not eradicating the tumor for good, Sahijdak said.

Cathy Shelley, 58, of Plymouth, was the first of five patients at St. Joseph treated with CyberKnife two weeks ago. She has ovarian cancer that has spread to her brain and liver. She is not a candidate for surgery because the tumors are close to the stem of her brain and an operation could put her at risk of serious complications.

“CyberKnife frightened me, but they explained it extremely well and I decided to do it,” she said as she finished her third and final treatment. “I realized four years ago, even a week ago, I wouldn’t have had this option.”

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CyberKnife treatment

Patients come in before the procedure for CT and MRI tests used to help design the delivery of the precise radiation treatment.

Using overlaid, digitalized images, a medical physicist gives a computer the information to map a treatment plan that avoids healthy organs and tissue.

The physicist, a radiation oncologist and a surgeon review the treatment plan. The doctors determine a dose of radiation and the number of treatments the patient will receive.

For tumors that are not in the brain or spine, the patient may undergo a CT scan to implant permanent gold seed markers that guide the treatment. Brain tumor patients are fitted with customized plastic mesh masks they wear during the treatment to keep their heads from moving.

Patients undergo one to five daily treatments, at 30 to 120 minutes each day, on consecutive days.

Patients recline on a foam mattress under the robotic arm of the CyberKnife machine; the arm supports a tiny X-ray machine that delivers a higher dose of radiation than is used in standard radiation treatments. Because the machine directs the radiation with accuracy that is under a millimeter, more radiation can be delivered.

Source: Dr. Walter Sahijdak, radiation oncologist, St. Joseph Mercy Hospital.

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