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’ ’s s President President ALATRO

22,5 million Km2

Latin America General Information Information General � LA: 36 countries LA: 36 countries – – 526 526 million million people people (2006) (2006) � Expected: > 800 : > 800 million million people people (2050) (2050) Expected � 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, , Colombia Colombia and and Argentina Argentina Mexico � The The LA LA´ ´s s integration integration copes copes with with dificulties dificulties and and � hindrances due due to to diversity diversity of of cultures cultures, to , to the the specific specific hindrances characteristics of of each each country country´ ´s s state state power power and and to to characteristics diferences of of development development models models diferences

World population 2004 - 2050 millones 2,367 2004 2050 1,941 1,628 1,520 1,437 1,301 1,087 885 778 728 668 549 457 326 a a a a a a e c i c i n c p n d i i i i r o r a h n r e e f r e I C A u m m c E A O A / n h a i i t t s r a o A L N Fuente: 2004 World Population. Data sheet of the Pupulation Reference Bureau

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 of children children with with cancer cancer will will be be cured cured by by � multidisciplinary treatment treatment multidisciplinary � Survivor Survivor’ ’s s groups groups studies studies (CCSS) (CCSS) � 2/3 - - at at less less, , one one late late effect effect 2/3 1/3 - - one one severe severe or or incapacitant incapacitant late late effect effect 1/3 � GEPETTO GEPETTO (324 (324 survivors survivors) * ) * � Anatomical Sequele Sequele: 133 (41,04%) : 133 (41,04%) Anatomical G1=36; G2=34; G3=62; G4=1 G1=36; G2=34; G3=62; G4=1 * Rigon et al: 2004

Latin America Radiation Oncology Oncology Radiation � It is It is integrated integrated part part of of Oncology Oncology attention attention presents presents in in all all � LA countries (excepted excepted Haiti) Haiti) LA countries ( � The The estimate estimate number number of of Radiation Radiation Oncology Oncology Centers Centers is is � about 500 ( 500 (insuficient insuficient to to cover cover the the assistance assistance) ) about � 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 appropriate appropriate strategies strategies for for each each country country develop � The The radiation radiation oncology oncology centers centers have have different different levels levels of of � complexity and and development development complexity

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

2D � Planning Planning based based on on clinical clinical exam exam and and bone bone � landmarks landmarks � Conventional Conventional simulation simulation – – x x- -rays rays films films � Normal organs organs and and crictical crictical structures structures � Normal � visualization: : dificult dificult visualization � 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 on tumor tumor and and normal normal tissues tissues � determination determination � CT CT- -simulation simulation: CT/MRI/PET : CT/MRI/PET � Dose deliver deliver: : improved improved – – image image fusion fusion � Dose � � Field Field arrangement arrangement: : complex complex – – multiple multiple - - non non � coplanar fields fields coplanar � 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% 2D RT Abdomen – pelvis 18% Torax 8% Extremities 4% More than one site 10% 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