July 1, 2007

Device Takes Sharp Aim at Cancer: NorthEast’s Robotic CyberKnife Focuses Radiation to Zap Tumors

By Karen Garloch, The Charlotte Observer, N.C.

Jul. 1--Along Interstate 85, billboards boast of NorthEast Medical Center's new CyberKnife, a robot that performs "knifeless cancer surgery" with "precision accuracy."

Ads call it "the world's most accurate robotic radiosurgery device."

Despite the hype, the $3.7 million CyberKnife is just one of a number of technologies that deliver high-energy radiation with pinpoint accuracy to shrink or obliterate tumors with fewer treatments for patients than in the past.

It's called radiosurgery because, in some cases, it replaces surgery with bloodless, but surgically precise, radiation.

Hospitals across the country have acquired the expensive devices -- and market them aggressively -- as part of the ongoing race to provide state-of-the-art treatment options for patients.

But even doctors excited about radiosurgery question whether the machines' submillimeter differences in precision make a practical difference for patients.

"No data exists that suggests that one is clearly superior to another," said Dr. Tony Asher, a Charlotte neurosurgeon who is part of a team that uses the Novalis radiosurgery system at Carolinas Medical Center.

"Let's assume (the CyberKnife) is a fraction of a millimeter more accurate. What is the significance? I don't think that anybody can say definitively."

Radiosurgery options

NorthEast Medical Center in Concord -- which today changes its name to Carolinas Medical Center-NorthEast as part of a merger with Carolinas HealthCare System -- is the first hospital in the area to buy the CyberKnife.Mission Health and Hospitals in Asheville and UNC Hospitals in Chapel Hill also have one.

But several other radiosurgery devices are also available in North Carolina -- the Gamma Knife in Winston-Salem and Greenville and the XKnife and a Varian device in Durham.

"All of them are applying the same basic principle," said Dr. John Kirkpatrick, a radiation oncologist at Duke University Medical Center. "They all have advantages and disadvantages. A lot depends on the individual practitioner who's using it."

Dr. John Konefal, one of two radiation oncologists trained to use NorthEast's new robot, refrains from outlandish claims.

"The CyberKnife has technological advances over other radiosurgery systems," he said, "but how relevant those advantages are, time will tell. ... I don't want to get into 'We're better than somebody else.' "

Konefal's diplomacy is due, in part, to shared allegiance. Some of his partners at Southeast Radiation Oncology Group use the Novalis at Carolinas Medical Center, now a sister hospital to NorthEast.

Targeting the tumor

Not all cancers are appropriate for radiosurgery. Some still require traditional surgery, standard radiation or a combination.

In standard radiation, a linear accelerator delivers high-energy X-rays in small doses over weeks. The beams target the tumor and the surrounding tissue that might harbor cancer cells.

Newer radiosurgery is well-suited for tumors that are contained, without stray cells. Because it's more precise, very high doses can be given in a few days.

It spares healthy tissue from damage and reduces side effects, such as fatigue, for patients.

The focused beams can treat tumors that are otherwise inoperable because they are close to critical body parts, such as the spinal cord. Because there's no incision, there is no blood and no recuperation time.

No head frame necessary

Radiosurgery started several decades ago with development of the Gamma Knife, which treats only brain tumors. During treatment, patients wear circular metal frames that screw into their skulls to hold their heads steady.Newer systems can be used for brain tumors as well as tumors in other parts of the body, such as lungs, liver, pancreas or prostate gland.

Until recently, one of the big differences between radiosurgery systems involved the head frame.

Patients treated with the CyberKnife don't wear one. They lie on a table while the robotic arm moves around delivering radiation from multiple directions.

Patients treated for brain tumors with Novalis also wore a frame until earlier this year. Now, the radiation is guided by X-rays that map the location of bones or metal seeds implanted in affected organs.

'Equivalent' technologies

One distinction of CyberKnife is that it tracks movement of tumors automatically. If a patient's breathing causes a lung tumor to shift slightly, the computer-aided device adjusts to make sure the radiation hits the right spot.

The Novalis system adjusts to movement in a different way. Beams turn on and off as tumors move in and out of the target.

Another difference is that CyberKnife treatments take longer, about one or two hours, and cost more than treatments with Novalis, which last 15 to 30 minutes.

Having the CyberKnife at NorthEast means Concord-area patients don't have to drive to Charlotte or farther for radiosurgery.

But at the same time, neurosurgeon Asher said Charlotte patients shouldn't think they need to travel for the CyberKnife.

"If the patient was in Charlotte, I would treat them on Novalis," he said. "They're equivalent technologies for virtually every application."

Under the CyberKnife

Even before NorthEast's CyberKnife started operating in mid-June, patients looking for nonsurgical alternatives to cancer treatment were contacting the hospital.Josie Maniskas, 70, of Pinehurst is one of them.

She was diagnosed in August with a spinal meningioma, a benign tumor near her spine. If it becomes too large, it could cause paralysis. This spring, an MRI scan showed that the tumor had grown, and Maniskas began to feel tingling in her toes.

Her neurologist recommended surgery. But Maniskas worried about the risks of an operation because the tumor is so close to her spine.

A nurse friend told her about radiosurgery. And Maniskas' husband, John, found out about NorthEast's new device on the Web. On June 20, she was the second patient to be treated.

The CyberKnife weighs 2 tons and stands in the center of a large brightly lit vault in the hospital's basement. Concrete walls are 4- to 6-feet thick to protect other areas from radiation exposure.

The space-age feel is softened by a round photograph in the ceiling, strategically placed so patients who lie still for long periods can look at cherry blossoms, blue sky and sunshine.

During her half-hour session, Maniskas listened to soothing music as Konefal and other specialists monitored her treatment on TV and computer screens in an adjacent room.

Maniskas took a tranquilizer before her treatment. She said she felt no pain or side effects.

After five treatments in seven days, she's hoping her tumor will shrink and she won't need to consider surgery again.

She goes back for an MRI scan and results in August.

Medicare Reimbursement for Radiosurgery

--CyberKnife, four treatments, nonbrain lesions:$11,830.45.

--Other radiosurgery systems, four treatments, nonbrain lesions:


Source: Centers for Medicare and Medicaid Services; Southeast Radiation Oncology Group

Radiosurgery in North Carolina

--Carolinas Medical Center in Charlotte.Radiosurgery since 1990; Novalis since 2003.

About 100 patients per year.

--Carolinas Medical Center-NorthEast in Concord.

CyberKnife installed in June.

Three patients so far.

--Wake Forest University Baptist Medical Center in Winston-Salem.

Radiosurgery since 1990; Gamma Knife since 1999.

About 350 patients per year.

--Mission Health and Hospitals in Asheville.

CyberKnife since 2005.

About 150 patients per year.

--UNC Hospitals in Chapel Hill.

CyberKnife will begin operating this year.

--Duke University Medical Center in Durham.

Radiosurgery since early 1990s; XKnife and modified Varian linear accelerator since 2001.

About 200 patients per year.

--Pitt County Memorial Hospital in Greenville.

Radiosurgery since 2001; Gamma Knife since 2005.

About 60 patients a year before 2005; 189 total with Gamma Knife.

Radiosurgery in South Carolina

--Palmetto Health Richland in Columbia.

Gamma Knife since 1998.

About 240 patients per year.

--Roper St. Francis Healthcare in Charleston.

CyberKnife begins operating in December.

--Medical University of South Carolina in Charleston.

BrainLab system since 1999.

Volume of patients unavailable.

--Greenville Hospital System University Medical Center.

Novalis since 2004.

Volume of patients unavailable.

Karen Garloch


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