Cancer Answers: Meet the Host of Yale Cancer Center Answers, September 26, 2010

Dr. Lynn Wison, Meet the Host of Yale Cancer Center
Answers
September 26, 2010Welcome to Yale Cancer Center Answers with Dr. Francine Foss
and Dr. Lynn Wilson.  I am Bruce Barber.  Dr. Foss is a
Professor of Medical Oncology and Dermatology specializing in the
treatment of lymphomas.  Dr. Wilson is a Professor of
Therapeutic Radiology and an expert in the use of radiation to
treat lung cancers and cutaneous lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening Francine is
joined by her new co-host Dr. Lynn Wilson.  Dr. Wilson is Vice
Chairman & Clinical Director of the Department of Therapeutic
Radiology and Professor of Therapeutic Radiology and Dermatology at
Yale Cancer Center.  He specializes in the treatment of
patients with lung cancers and cutaneous lymphomas.  After
receiving his Masters in Public Health from Yale and his medical
degree from George Washington University School of Medicine, Dr.
Wilson returned to Yale for his internship and residency in
Internal Medicine and Therapeutic Radiology.  He then served
as Chief Resident at Yale before joining the faculty in 1994. 
Dr. Wilson is one of only a few radiation therapists in the country
that performs a specialized kind of treatment called total electron
beam radiation, which is specifically for patients with a rare
disease called cutaneous T-cell lymphoma.  It is a very
complicated procedure in the field of radiation oncology that Dr.
Wilson has extensive experience with.  In 2008, Dr. Wilson won
the David J. Leffell Prize for clinical excellence and the Francis
Gilman Blake Award, an award designated by the senior class and
presented to a member of the Yale School of Medicine Faculty for
exceptional teaching of the Medical Sciences.  Here is
Francine Foss with Dr. Wilson.Foss
 We are going to start by talking a little bit about your
background Lynn, and how you became involved in the treatment of
cancer.Wilson
 That is a bit of an interesting story and I think I was
fortunate.  I grew up in Bethesda, Maryland, which is a
Washington DC suburb and happens to be the place where the National
Cancer Institute resides. So as summers rolled around during
college, I was very fortunate to get a summer job at the National
Cancer Institute and the first laboratory I worked in dealt with
neurologic diseases and did a fair amount of laboratory bench
research looking at central nervous system tumors, and that was an
excellent experience and I started learning about oncology at that
time as a college student and I developed more of an interest in
biology. Then I continued those summers at the NCI through college
and actually into medical school which I was able to do since I
went to George Washington University School of Medicine in
Washington DC, and my summer job transitioned into a different
laboratory which was also in the National Cancer Institute but was
in the radiation oncology branch. So that is when I first learned
about the field of radiation oncology early on as a medical student
during the summer.  It was fortuitous that I happened to live
in the Bethesda, Maryland area over the summers, which is where the
NCI is and that is how I really got my first exposure to the field
of radiation oncology.Foss
 What is your current focus in cancer now?Wilson
 The primary areas are cutaneous lymphoma, so you and I obviously
collaborate very closely in that area, and I see all types of
patients with lymphomas of the skin and make recommendations
regarding their treatments specifically in regards to radiation
treatment, and the other area that I primarily see patients is in
lung cancer.  Those are the two main areas.3:48 into mp3 file 
http://yalecancercenter.org/podcast/sept2610-cancer-answers-wilson.mp3Foss             
 Can you clarify for our listeners the difference between a medical
oncologist and a radiation therapist, or a radiation
oncologist?Wilson
 Both of these physicians primarily take care of and evaluate
patients with cancer.  The medical oncologist generally is
involved in the administration of systemic or chemotherapies or
hormonal therapies depending on the type of malignancy, but
generally the type of treatment that the medical oncologist is
recommending and has expertise in are therapies which provide
therapy and are circulating around the entire body.  Medical
oncologists are also boarded in internal medicine, so they
have completed a full internal medicine residency and additional
training in hematology and medical oncology, or perhaps just
medical oncology.  Radiation oncology also involves one year
of internal medicine, generally as an internship but then four
years of specialized residency training in the field of radiation
oncology and during that time that type of physician learns a lot
about oncology and how to administer radiation treatment for all of
the different cancers or malignant diseases and the radiation
treatment can be given in many different forms but that is an
additional four years of training after internship.  Those are
the primary differences.  One provides radiation treatment and
the other provides systemic treatment which is usually in the form
of chemotherapy.Foss
 Lynn, when I trained at the National Cancer Institute, it was true
that the radiation therapy physicians and the medical oncologists
often times worked together, often times had the same conferences
and had training programs that allowed them to overlap to see the
other side of things.Wilson
 Right, so that is really important.  You were at a place that
did that very early on, there are still some medical centers that
do not have much what we call multidisciplinary interaction in that
way but it's really essential and is something that we think is
very important here at Yale. We work very closely together and in
this way the patient can get an opinion and a treatment plan which
is synergistic and the physicians are working together, and it's
also efficient for the patient, so that the patient does not have
to go to multiple different buildings or offices to see a variety
of different specialists.  It is really one-stop shopping, as
you and I take care of cutaneous lymphoma patients together, we are
working closely together, we are talking, we are looking at the
images together, we are consulting together, and trying to do the
best we can for that patient.Foss
 Lynn, could you help us to understand a little bit how you decide
whether or not a patient is a candidate for radiation therapy?Wilson
 So that is a good but complicated question and it really depends
on the situation.  There might be five different types of
patients that you and I see in a given week with cutaneous
lymphoma, but two of them we might feel are excellent candidates
for radiation and the others may not be, and it depends on the
stage of their disease, what type of lymphoma they have, whether
this is a primary presentation of their disease that has just been
diagnosed for the first time, we take their age and other medical
problems into considerations, logistical complications, and side
effects of treatment.  The decision making process is fairly
complicated which again gets back to the advantages of the7:06 into mp3 file 
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 multiple physicians working in concert together in a
multidisciplinary fashion and come up with the best plan for the
patient.  In lung cancer, for example, it is the same type of
thing.  We may see a patient and surgery may be the best
treatment for them.  Perhaps it is chemotherapy alone,
chemotherapy plus radiation, or a combination of all three. 
With the advanced knowledge that we have regarding the diseases and
the complexity that comes along with the diseases, we understand
now in 2010, that these decisions are complicated.Foss
 How do most of your patients come to radiation oncology?  Is
that something that the patient needs to decide on his or her own
or are they referred in by the surgeons, the medical oncologists,
or other physicians?Wilson
 It is almost always another physician and in most cases it depends
on what type of caner it is.  In the case of cutaneous
lymphoma, for example, it might be yourself as a medical oncologist
and in areas or institutions that have significant expertise it may
often be a dermatologist which is often the case at Yale because
that patient will be referred to a Yale dermatologist who has
expertise in skin lymphoma from their outside dermatologist. 
In the case of lung cancer, most of the patients that I see are
typically referred to me either by a medical oncologist or a
surgeon.  I also do some breast cancer work and the same thing
for those patients, it is usually either a medical oncologist or
the surgeon who is referring the patient to me because they have
obviously seen the patient first and they have decided that
radiation may possibly play a role in the patient's care.Foss
 When a lot of people hear the word radiation therapy or radiation
they conjure up a lot of negative images in their mind. 
People are afraid of radiation and perhaps because they do not
really understand what radiation therapy is.  Could you go
through some of the details about radiation therapy and what it
is?  How do you do it?  Is it safe?Wilson
 There are a variety of different forms of radiation
treatment.  The type of radiation that we use most often is
called external beam.  It is generated by a device called a
linear accelerator, which is very expensive, it is very high-end
technology, extremely modern technology, and it generates an x-ray
beam which is aimed at the tumor and the design and shaping of that
beam and getting the proper aiming at the tumor is a complicated
business and involves a lot of treatment planning, a lot of
computer work, a lot of input from the physician.  That is one
type of radiation treatment.  There are other types,
brachytherapy for example is a type of radiation where we would
implant radioactive seeds into a tumor in the head and neck or in
the prostate for example and that is another type. There are
several other types but those are the two primary types of
radiation that we use, but it can be concerning because I think
everybody gets a pretty good sense of what surgery is. We have an
operation, a tumor is removed from the body and the patient is
closed back up, but since radiation comes in these different forms
and is not something that is really well understood by the
patients, it can be very scary and because of potential problems
that could come along with radiation there is an incredible amount
of quality assurance that goes into not only an individual
patient's treatment program, but also an entire department of
radiation oncology.  There is not just a physician or group of
physicians in the standard clinical sense that we're used to in a
hospital or10:41 into mp3 file 
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 a clinic, but we have a cadre or a group of folks called
dosimetrists who are involved in treatment planning design with the
physician and physicists who are involved in calibration of the
machines and also involved in the quality assurance program, so it
is really quite a large team so that safety is ensured for the
program and for the care of the patient.Foss
 How common is it to find a center that delivers radiation
therapy?Wilson
 It is actually very common most places in the United States, all
major cities have radiation oncology and even rural areas
now-a-days, not too far away from any given location have radiation
centers.  They may not be particularly large; they may not
offer the specific expertise of a very large academic center, but
fortunately most places in the United States radiation therapy is
relatively easily accessible.Foss
 When one thinks about radiation therapy and potential side effects
one thinks about skin burning and inflammation, for instance, from
the beam, but there could potentially be other side effects as well
that people are worried about, often times the worry is not
justified.  I wonder if you could just go through for us what
the side effects of radiation therapy are.Wilson
 That is an excellent point because a lot of times I will meet a
new patient and they all have heard a lot about radiation or
perhaps they will have a friend or a family member who had
radiation, who has had certain side effects and problems.  Not
all of those side effects and problems apply to that new patient
who I have just met, it really depends. The key is the part of the
body that is involved.  When I treat the skin, for example,
obviously the skin can get inflamed, sore, red, skin side
effects.  If I am treating someone with a lung tumor, for
example, they may get fatigue or their blood counts may go down a
bit.  They may get some soreness in the swallowing tube or the
esophagus or irritation of the normal lung, but there may be other
parts of the body that we're treating where the side effects are
quite minimal, it is really site specific.  It depends on the
dose of radiation, how large the radiation fields are, and another
key component is, are we doing the radiation in combination with
chemotherapy? And we often do that so that we can have a better
outcome in terms of tumor control but sometimes, unfortunately,
that is at the price of some increased toxicity.Foss
 Most of the side effects associated with radiation therapy are
reversible, is that correct?Wilson
 That is correct.  Sometimes, again depending on the part of
the body, they can cause problems but usually they almost always
resolve after the treatment is completed within several
weeks.  There can be some situations where there can be some
longer lasting affects of radiation.  Some scar tissue can
form.  There can be scarring of the lung, for example, in the
event of treating a lung cancer patient or scarring of other
tissues, but this is something that we take into account very very
carefully and we have made major advances in the field in the last
even 5 to 10 years at limiting the amount of normal structures and
normal tissues that get exposed to the radiation and the main
benefit is trying to curtail these side effects both acute, that
might happen while the treatment is13:54 into mp3 file 
http://yalecancercenter.org/podcast/sept2610-cancer-answers-wilson.mp3being administered over several weeks, and long term, which the
patient may have to face over a period of years.Foss
 Another question that people ask is, is there any age restriction
for radiation therapy?  Do you do it in infants, and is there
any upper age limit for administration of radiation therapy?Wilson
 There is not an age limit in either direction.  Dr. Kenneth
Roberts actually takes care of all of our pediatric patients at
Yale, and the decisions regarding who should receive radiation and
age limits on the lower end are made purely on what the best
treatment is for that patient. Sometimes there are some very very
young patients where radiation will give them the best chance of
cure or combining radiation with chemotherapy.  In terms of
older patients, again, we do not hold age against anybody, it
depends on the clinical situation and what we think is best for the
patient.  We give the patient full information regarding the
side effects and potential benefits of the treatment and it is
really a decision that is made by the patient with their family
members and the physician.Foss
 This has been an excellent introduction into our discussion about
radiation therapy but we are going to need to take a break right
now for a Medical Minute.  Please stay tuned to learn more
information about radiation therapy from Dr. Lynn Wilson.Foss
 Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and I am joined today by my new co-host and guest
tonight Dr. Lynn Wilson.  Lynn Wilson, as I previously
mentioned, is a radiation oncologist at Yale Cancer Center and we
have been discussing the topic of radiation therapy.  Lynn,
can you tell us a little bit about how radiation therapy has
changed since you first started getting involved in it a number of
years ago?Wilson
 Yeah, as I said, I first got involved in the 1980s actually as a
medical student and things have evolved tremendously over that time
span since the 80's, and what's really evolved is our ability to
target tumors more accurately.  We have incorporated new
imaging modalities such as PET17:04 into mp3 file 
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 scanning, and although MRI has been around for a pretty long time,
we have gotten better at using MRI and PET scan, and of course CT
scans, for designing our treatment fields.  We use all of
these images, we can fuse them together so that we can use
metabolic, what we call functional, and anatomic information to
design the best treatment plan, the most accurate treatment plan
possible for a patient.  Not only are we able to target tumors
much better now than we used to be able to even 10 and 15 years
ago, but a real key to that is eliminating normal tissues that do
not need to be exposed to the radiation treatment.  Not only
are we ensuring that we are doing a better job of hitting the
target we intend on hitting, but we are doing a much better job of
avoiding normal tissues, normal organs that do not need to be
exposed to any radiation.  We can hopefully have a better
treatment outcome in terms of curing the tumor and less side
effects, or less toxicity profile for the patient, so that is where
the main change has taken place over the years, better targeting,
better ability to plan, better dosimetry and treatment design.Foss
 I understand that there are certain dose limits for certain normal
tissues and that somehow dictates the way that you actually do
radiation therapy.Wilson
 Right, and those are exactly the kinds of things that you learn
during your training, what organ tolerance limits there are. 
What dose you can safely give to the lung or the esophagus? 
What dose is safe to give to the breast, and we do not just give as
much radiation as we can until we get to the safety point, but in
fact, the doses of radiation that we administer are predicated
based on research studies that have been done around the world
taking into account the doses of radiation that these tissues can
handle, but in some cases, to give an example, certain tumors may
be extremely responsive to very low doses of radiation, so those
patients are going to not only do well in terms of cancer cure, but
are also going to do very well in terms of the toxicity
profile.  Some other tumors, such as lung cancer to give
another example, require much higher doses of radiation for us to
have a chance of good success and that is where all of the
targeting and the advances have come in over the last 10 to 20
years that have helped us deliver that higher dose.  The doses
really depend on what part of the body we need to treat, how much
of that organ we need to treat, and what the cancer is that we are
dealing with.Foss
 When someone is comparing their experience with radiation therapy
to another person's experience there are vast differences in how
many treatments they had, for instance, and whether they were
treated once a day, or more often, this is all predicated by the
underlying disease and how the radiation oncologist does the
treatment planning for that individual patient.Wilson
 That's right.  It is for the individual patient.  There
are some things that do dictate how many treatments we give based
on the expertise and the technology that may be available at a
given center.  I will give you an example, stereotactic body
radiotherapy for early stage lung cancer in a patient who for
whatever reason, it is unsafe for them to undergo an operation to
remove that small tumor.  Stereotactic body radiotherapy is
something that we might consider in that scenario and we have had
that technology here at Yale for several years and we are actually
a very busy center, so that type of treatment is as follows:
 Very careful treatment planning, of course, is devised,20:40 into mp3 file 
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 but that treatment may only be given to that patient in three,
four, or five treatment visits.  It is a very, very high dose
which is centered on a small tumor though, and we are able to do
that, we actually take the movement of the tumor into account
because when we breathe, obviously a lung cancer is moving, so we
account for all that, but stereotactic body radiotherapy is giving
several fractions to a small area to a very high dose.  At
another center that does not have that technology, or does not have
that expertise, they can still offer treatment to that patient but
that treatment might have to be spread over 6 or 7 weeks, and in
fact, that is how we did that treatment before we had the expertise
here at Yale and the treatment technology to be able to do
stereotactic procedures.  Sometimes it is dictated by how
advanced the center is, what sort of expertise they have, and what
kind of technology they have, so for patients who say I have a
colleague or friend who got the treatment in this many treatments,
it really is dependent on the expertise of the center, it may be a
part of a clinical trial, it often depends.Foss
 Can you segue from that discussion and talk a little bit about
clinical trials in radiation therapy?  Are there trials
ongoing here at Yale Cancer Center?Wilson
 Yes, there are a variety of trials ongoing here at Yale and many
of these trials are supported not just by the radiation oncology
doctor, but again are provided for patients and patients can access
these through a multidisciplinary type of evaluation.  A
clinical trial that you and I are in the process of opening is for
total skin electron beam therapy for patients with skin lymphomas,
you are involved, I am involved, Dr. Girardi from dermatology is
involved, so that is one example of a trial in our particular area
of expertise.  We have lung cancer trials that are available
looking at the combination of radiation treatment and chemotherapy
drugs. In one trial, for example, we are considering trying to
actually lower the dose of radiation by using other agents to
sensitize cells to radiation treatment so that we can get the same
cancer cure rate but eliminate some of the toxicity by using
multiple therapies at once.  We have a variety of central
nervous system trials available that Jonathan Knisely is
supervising, who is one of our central nervous system radiation
oncologists.  We have clinical trials in almost all of the
organ systems that are available and usually there are radiation
based trials trying to address a question for radiation dose or
radiation treatment planning, sometimes it may be a chemotherapy,
medical oncology, or surgical question, and there may or may not be
radiation involved.Foss
 We also have a group of scientists working in the radiation
oncology department here at Yale who are looking at the basic
mechanisms of radiation damage to cells and are doing some real
cutting- edge work that will help us to better understand the
biology of cancer as well as the mechanisms for radiation
therapy.Wilson
 We actually have one of the largest sections of radiobiology in
the United States.  Dr. Peter Glazer, the Chairman of the
Department of Radiation Oncology at Yale, is considered an
international expert in the area of DNA repair and he supervises
all of the laboratory operations.  We have many scientists
working at the very fundamental basic level trying to come up with
solutions, explanations, trying to understand better how radiation
works on a variety of different cell types24:13 into mp3 file 
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 because if we can better understand the mechanisms through which
it works, we can be much more specific in its application for
certain types of diseases and patients with certain types of
problems.  Some of our clinical physicians are also doing
laboratory research, some of the physicians are doing clinical
research, running clinical trials for example, and seeing patients
and offering clinical trials to them and then we have other
scientists in the department who do not see patients at all, but
are working in the fundamental radiobiology laboratories, and we
also have a fairly large group of PhD physicists who are doing
research in those areas in terms of developing the technology of
radiation delivery, imaging, and dosimetric evaluation, so we have
really got a triple pronged approach, clinical care, basic research
in radiobiology, and research in physics and we all work
together.Foss
 I think it is really important for everybody to know that that
whole conglomeration of people comprises a fairly large portion of
the Cancer Center.  Typically we think mostly about the
clinical oncologist and the surgeons, but certainly your group is
doing some real cutting-edge work and there are lots of folks
involved in that work.Wilson
 A lot of folks involved and we have a very successful radiobiology
program, which is not only large in terms of the number of faculty
and staff, but it is one of the leading centers in the United
States in terms of garnering NIH funding.Foss
 Lynn, another hat that you wear among your many hats is as the
Residency Training Program Director for Radiation Oncology. 
Can you tell us a little bit about that program?Wilson
 We obviously train physicians in radiation oncology, all of them
have graduated from an accredited medical school.  As I
mentioned earlier, the training is a total of five years, there is
a one year internship which is generally done in internal medicine
and then folks come to our department following that for specific
training in the field of radiation oncology which will subsequently
lead to them taking their board examination and being board
certified in the specialty.  The training program is
relatively large, starting next year will be up to 11 trainees at
any one given time, so we take approximately three trainees per
year and our program is a very popular one, I think because of the
amount of quality that we offer, the education is good, we are a
large department as we have touched upon, so there is a lot of
access for the trainees to research projects and a lot of different
clinical excellence from our large faculty group.  It has
become a very very competitive field and we receive approximately
200 applications a year for three positions.  It's extremely
competitive, it was not that competitive many years ago, but it is
something that has really been popularized over the last 10 years
or so, and I think that is probably because of a lot of the
advances in technology.  Much of the field was the same in
terms of what is involved with interacting with patients and
oncology and using the radiation devices, but the technology in our
field and our ability to accurately deliver treatment very safely
has exploded in the last decade so the field has become very
popular.27:30 into mp3 file 
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 And one of the major focuses of your particular work here at Yale
is the treatment of patients with cutaneous T-cell lymphoma. We
have collaborated certainly over the years in that area and Yale is
one of a very small number of centers that delivers total skin
electron beam radiation, is it less than 10 centers in the United
States, Lynn, that does it the way we do it?Wilson
 Probably less than ten do enough of it to really feel very
comfortable offering it to patients on a daily basis and it is one
of the most complicated treatments that we do in radiation oncology
and the reason for that is because we use six different fields to
treat the patient's entire body and each of those fields is
actually divided into two, an upper part of the body and a lower
part of the body, so we have those 12 fields and then we have some
supplemental fields that treat the area between the legs and the
bottoms of the feet, top of the head actually gets treated as part
of the original 12 fields.  We have got all of these fields,
and to some extent there are areas of the fields that overlap with
each other, but that is actually by design and is the way we want
it to work, but there is a lot of calibration involved. 
Patients can get side effects from the treatment and so that is
important, and you and I have a lot of expertise in this, but
physicians who are attempting to do total skin electron beam
therapy at a center where there is not much experience, I spend a
fair amount of time taking phone calls, trying to help these
physicians with their cases because they are not familiar sometimes
with the diseases and the treatment can be very very complicated,
so it works extremely well and smoothly when it is done right at a
center with experience and we have quite a bit of experience. There
are other centers in the United States with a lot of experience but
total skin electron beam therapy, when you asked earlier, is
radiation therapy accessible for patients, that is something that
there are probably certainly less than 20 centers in the United
States that have enough experience to claim true expertise. Dr. Lynn Wilson is a Professor of Therapeutic
Radiology and an expert in the use of radiation to treat
lung cancers and cutaneous lymphomas.  He is
also the new host of Yale Cancer Center Answers.If you
have questions or would like to share your comments, visit
yalecancercenter.org where you can also subscribe to our pod cast
and find written transcripts of past programs.  I am Bruce
Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.