Hospital to Use Precision Device Against Tumors Oncology

Doctors at St. Joseph in Burbank hope the multi-leaf collimator will cause fewer side effects. Skeptics wonder about its $250,000 cost.

ED BOND
The Los Angeles Times
Sep 15, 1993. pg. 1

Copyright, The Times Mirror Company; Los Angeles Times

The mortal game cancer specialists have played for decades goes like this: blast the tumor, not the patient.

A group of doctors at St. Joseph Medical Center in Burbank are about to begin a new round in that confounding task, armed with a $250,000 device called a multi-leaf collimator.

The complicated-sounding machine has a simple purpose, to shape the beams of radiation so that most of the surrounding tissue is left untouched, sparing the patient nausea, diarrhea, discomfort or other side effects.

Doctors at St. Joseph plan to use its precision to test the effectiveness of higher doses of radiation on tumors. By better channeling the radiation, these doctors say, the machine will allow them to provide a level of care closer to that found in major medical institutions with multi-million-dollar equipment.

St. Joseph will be the first community hospital to use the device in California when patient treatment begins within two weeks, according to its manufacturers and members of the California Radiation Oncology Society. The machine will soon be in use at Northridge Hospital Medical Center, UCLA Medical Center, Cedars-Sinai Medical Center, and Sutter Memorial Hospital in Sacramento.

Some praise the machine as a breakthrough that finally gives the medical community a reliable tool for attacking a tumor. But others are more skeptical, saying that the machine is expensive and unnecessary.

"Right now we do a fairly good job of confining the radiation dose," said Dr. Donald Fuller, a San Diego radiation oncologist, who said most hospitals now use neither the multi-leaf nor its more expensive cousin. "If it is more expensive (to use the multi-leaf), can it be justified? These are the kinds of dilemmas we are wrestling with."

"This needs to be validated," acknowledged Dr. Christopher Rose, associate technical director at St. Joseph's radiation oncology department, who helped push for the technology to be developed in the mid-1980s. "It may be a $250,000 piece of junk."

The National Cancer Institute is planning a nationwide study next year on the effectiveness of multi-leaf collimators in fighting prostate cancer, said Dr. Dwight Kaufman, acting assistant director of the institute's radiation research program.

"Whether it translates into better control of cancer with less toxicity still remains to be seen," Kaufman said.

But supporters of the new procedure say they're betting it will prove an affordable way to focus radiation doses on tumors.

"This is the latest frontier in answering the question of how do we improve radiation treatment," said Dr. Michael Steinberg, of the Santa Monica Cancer Treatment Center, who is president of the California Radiation Oncology Society.

Here's how it works.

Until now, cancer specialists have had to protect the flesh around a tumor with blocks of a lead alloy, shaped to protect vital organs from a field of radiation.

The multi-leaf, however, protects healthy tissue by covering it with overlapping leaves of metal. Each leaf blocks out an area in the field of radiation, allowing only a shape approximately matching that of the tumor for the beam to pass through.

The multi-leaf also improves that way doctors can aim radiation at a tumor, supporters said. Instead of only being able to fire the radiation through the side or through the front, the new equipment uses a computer to continually change that shape of the beam as it rotates around the patient. This way, the tumor can be attacked from every angle.

The multi-leaf is not the only piece of equipment meant to sharpen the stream of radiation. Science has created far more precise tools, such as the equipment used for proton radiation treatment at the cancer center at Loma Linda University Medical Center. But that equipment cost $45 million, and it is one of only two in the United States.

Proton radiation hits only the tumor, said Dr. Jerry Slater, clinical director for the department of radiation medicine at Loma Linda. Radiation from the multi-leaf, by contrast, still must pass through some healthy tissue to get to the tumor.

Compared with conventional treatments, the multi-leaf collimator is expected to do the most good in reaching tumors in the deep, hard-to-access areas of the body, such as the pancreas or the prostate. Those organs are lodged between the bladder and the rectum, which are particularly susceptible to harm by radiation.

It is already clear that the equipment will not be useful for all types of cancer. About 10% of the 700 cancer patients using radiation therapy at St. Joseph will be likely candidates for the new device, said Dr. Leslie Botnick, director of the Radiation Oncology Department at St. Joseph. Cancers such as lymphoma and Hodgkin's disease are not limited to a small area of the body, so patients with these illnesses would not benefit as much from the machine.

At Northridge Hospital Medical Center, it was the bottom line that encouraged hospital administrators to approve the purchase of their own multi-leaf collimator, which will be delivered in December, said Dr. Aaron Fingerhut, the hospital's director of the radiation oncology department at the Thomas and Dorothy Leavy Cancer Center.

"Right now we have a technician who manufactures these lead blocks, which is time-consuming, and then they have to be lifted up to shoulder height and mounted on the machine," Fingerhut said. A full-time technician earns more than $50,000 a year, so in a few years the hospital could recoup the cost on the device, he added.

With the multi-leaf collimator, treatments could eventually be made faster and more cost-effective, Fingerhut said. Some day, having the machine could increase a hospital's business, because insurance companies and health-maintenance organizations might send patients to the less-expensive program, he said.

One thing doctors at St. Joseph hope to do is use the machine to experiment with giving patients higher radiation doses. Researchers there say that if the machine really spares surrounding tissue, higher levels of radiation can be tried on tumors.

"St. Joseph's clearly wants to be a hitter in the high-dose studies," said Dr. Scotte Doggett, medical director of radiation oncology at Sutter Memorial Hospital in Sacramento, which also plans to use the device. The work at St. Joseph may encourage others, he said.

It is important to note, however, that despite high hopes, the multi-leaf might not be the answer for hospitals struggling to provide appropriate care for patients with cancer.

Loma Linda's Slater said that although he thinks the new machine represents a step forward, proton radiation treatment is "a magnitude ahead."

Buying a high-technology piece of equipment may be an unlikely step for a community hospital in a struggling economy, said Botnick, who came to St. Joseph along with Rose in the early 1980s from the Joint Center for Radiation Therapy at Harvard Medical School, which had begun the nation's first studies in shaping radiation beams.

The two came to St. Joseph to study ways to bring the same level of care found at a university hospital to a community hospital.

"I think if (hospital administrators) had to make the decision in 1992 economics, they wouldn't have done it," Botnick said. "This is not going to help us make more money."

Still, said Rose, the technology is too important to be ignored.

"The issue is, can it be done in a community hospital?" he said. "That's what we're going to try to find out."
[Illustration]
PHOTO: Radiation oncologist Dr. Arnold Malcolm and radiation therapist Carol Nemeth with multi-leaf collimator. Carlos Reyes poses as patient.; PHOTO: Display shows how a beam of radiation is aimed on the cross-section of a patient's body. / RICARDO DeARATANHA / Los Angeles Times

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Section: Metro; PART-B; Zones Desk
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