SPECIAL REPORT
Advancing the Treatment of Breast Cancer and the Role of Intra-Operative Single Dose Therapy
How Breast Cancer Specialists Are Looking for New Ways of Reducing the Duration of Radiation Therapy Key Considerations When Choosing an Intraoperative Radiotherapy System
Published by Global Business Media
ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
SPECIAL REPORT
Advancing the Treatment of Breast Cancer and the Role of Intra-Operative Single Dose Therapy
Contents Introduction
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Martin Richards
How Breast Cancer Specialists Are Looking for New Ways of Reducing the Duration of Radiation Therapy Key Considerations When Choosing an Intraoperative Radiotherapy System
Published by Global Business Media
Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor-in-Chief Martin Richards
How Breast Cancer Specialists Are Looking for New Ways of Reducing the Duration of Radiation Therapy and Postoperative Treatment Times Without Compromising Patient Outcomes
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An interview with two leading radiation oncologists from the EU and the USA – Dr. Valery Uhl & Dr. Agnès Tallet – showing their perspective of the daily challenges they are facing when trying to provide the best treatment options to their breast cancer patients.
Key Considerations When Choosing an Intraoperative Radiotherapy System – Usability, Precision and Cost Effectiveness
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An interview with Dr. Henning Kahl (DE) about the most important aspects when defining the right IORT option and selecting a treatment device for the own hospital.
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ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
Foreword A
lready before COVID-19, in particular medical
585 patients would have provided enough trial
professionals and institutions were suffering
power, in the end over 2200 patients were recruited
greatly from rising patient numbers and the related
between 2000 and 2012. The study treatment
increase in treatment deliveries needed, regularly
TARGIT-IORT was given with the INTRABEAM®
reaching their limits worldwide. Thus, the pressure
device which offers treating physicians an irradiation
on healthcare providers to introduce more efficient
alternative to whole breast radiation therapy. Today,
treatment methods was already high before.
the trial investigators believe that this cumulative
The current focus on COVID-19 patients further
long-term data provides a substantial amount of
exacerbates the situation for patients with other
evidence to support the future standard of care being
severe diseases such as cancer and even further
the application of IORT for selected breast cancer
increases the need for new efficient treatment
patients. This is due to the fact that the long-term
options freeing up other hospital resources.
results effectively show that patients can be treated
One of the most common types of cancer is breast
directly during surgery in a significantly shorter
cancer. A potentially more efficient treatment option
overall treatment time with non-inferior results, but
here is intraoperative radiotherapy (IORT), given
additionally with less side-effects for the patient and
directly during surgery. This results in a significantly
less financial burden for the healthcare system. On
shorter overall treatment time of IORT compared
one hand, this is a ray of hope for physicians at a
to the standard treatment approach of external
time when patient volumes and disease treatment
beam radiotherapy (EBRT). The recently published
times are even more critical than usual. On the other
long-term data of the TARGIT-A trial, specifically
hand, patients who may have to wait even longer than
investigated within a risk-adapted design whether
usual for their lifesaving treatment due to the current
IORT is non-inferior to EBRT for selected breast
situation will be relieved to be able to additionally
cancer patients. In circumstances of non-inferior
choose a very efficient treatment option in their fight
results, the less expensive, less toxic or more
against cancer. We have taken this groundbreaking
convenient treatment normally becomes a standard
development as an opportunity to look at various
option in treatment guidelines and often the preferred
aspects of breast cancer treatments in this special
choice of physicians.
report. Experienced radiation therapists will also have their say. Stay tuned and read on.
Martin Richards Editor-in-Chief
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ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
How Breast Cancer Specialists Are Looking for New Ways of Reducing the Duration of Radiation Therapy and Postoperative Treatment Times Without Compromising Patient Outcomes An interview with two leading radiation oncologists from the EU and the USA – Dr. Valery Uhl & Dr. Agnès Tallet – showing their perspective of the daily challenges they are facing when trying to provide the best treatment options to their breast cancer patients. Valery Uhl MD, Radiation Oncologist in the San Francisco Bay Area of Northern California and President of the TARGIT Collaborative Group (TCG), USA Agnès Tallet MD, Head of Radiotherapy Department, l’Institut Paoli-Calmettes, Marseille, France
Case numbers for breast cancer are increasing worldwide. The treatment of affected women is becoming more and more a priority. What does such a diagnosis and treatment mean mentally and physically for your patients? [Dr. Uhl]: When a woman finds out she has breast cancer she is usually shocked and then starts to worry. [Dr. Tallet]: Yes, the announcement of cancer is in itself frightening. It is still in wits a sentence of programmed death, preceded by many bad changes in everyday life, such as limitation in children care, work stopping, troubles in sexual life, social dependence, among others. [Dr. Uhl]: And some women get depressed and this can affect their physical state and ability to cope with their everyday lives too. They just want to get rid of the cancer and go back to their “normal” lives as soon as possible. [Dr. Tallet]: However, breast cancer is one cancer with great hope of a cure, as it has
been widely claimed, and patients initially are very combative and go through every treatment with as much energy as they can. Surgery is not an issue since it rapidly removes the primary disease. Conversely, adjuvant therapies are more reluctantly accepted. Some patients require chemotherapy and are exhausted at the time of radiation therapy. They undergo irradiation but are commonly fed up with it, although they quite all complete the treatment. Endocrine therapy has an intermediate toxicity profile and is often early stopped.
IORT offers numerous advantages. It is applied as a single fraction, at the time of surgery, in an outpatient setting, thus avoiding the several commutes of the patients that are mandatory for conventional external beam radiation therapy and thereby, lowers the whole treatment cost
And what are the key considerations from a medical perspective to support the patients here? [Dr. Uhl]: At first, it is very important that the patient receives the correct work up for her breast cancer so that she is properly staged. This guides the treatment plan and the options WWW.HOSPITALREPORTS.ORG | 3
ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
for treatment the patient may have. Currently, patients with early stage breast cancer have many treatment options. [Dr. Tallet]: In fact, several tracks may be investigated. First, an exhaustive announcement of the whole treatment schedule, as well as its timing, is needed. Each adjuvant or neoadjuvant treatment has to be explained and detailed, including all the expected side-effects. Second, when several options exist, the medical team has to present all the advantages and drawbacks of each and choose the one that best fits the patient’s desire. It leads patients to feel involved in their treatment, and it increases patients’ confidence. Last, supportive care for adverse effects management is also of great value.
The most targeted and effective radiation for early stage breast cancer is definitely intraoperative radiation therapy (IORT). The patient receives all of her radiation over minutes in the Operating Room (OR) when she is getting her cancer removed
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One treatment option for breast cancer is radiotherapy. Could you explain how this treatment option works and what the specific medical hurdle is here? [Dr. Uhl]: Radiotherapy is used for early stage breast cancer when a woman chooses to keep her breast instead of undergoing a mastectomy. Breast conservation has fewer side effects and the cure rate is the same whether a woman opts to keep her breast or have a mastectomy... [Dr. Tallet]...and especially adjuvant radiation therapy was proven to reduce the local recurrence risk by two-third and, thereby, to further improve overall survival. [Dr. Uhl]: The typical radiation portion of her treatment plan usually consists of daily (external beam) radiation treatments, Monday through Friday, for many weeks. This means she may have to take time off of work or away from her children at home for a portion of her day so that she can have her radiation treatments. [Dr. Tallet] But today, additional radiation schemes are validated and can be chosen according to the patient’s and tumor’s conditions. It can last for one day (IORT) to 6 weeks, five days a week. Long treatments, such as six weeks, are exhausting for elderly patients and are, therefore, quite not conceivable. Hypofractionated radiation therapy is, in these cases, a better option. Nonetheless, the elderly often harbor several comorbidities, and the radiation therapist will be more inclined to opt for the shortest treatments, as well as a scheme that best spares both the heart and lungs, provided it is not at the detriment of the local control rate.
IORT is proven to be effective and easier accepted by the patients. It has been an appealing treatment each time we proposed it to the patient. Moreover, within the context of the current pandemic, we find new advantages of this technique
And where do you currently see the most promising future development opportunities in radiotherapy to overcome these hurdles? [Dr. Tallet]: Some progress has already occurred; hypofractionation schemes are currently in routine use; conformal radiation therapy and even intensity-modulated radiotherapy are more accurate; the use of deep inspiration breath-hold allows for both heart and lungs sparing and are of great help in patients with left-sided breast cancer. Several treatment plans can easily be compared. Some select patients can be offered partial breast irradiation since several randomized trials showed its safety. Future improvements will include (but not limited to) the investigation of proton therapy and even FLASH radiation therapy for focused treatments. [Dr. Uhl]: Yes, the trend in radiation is definitely “less is more”. Hypofractionated courses of radiation for example have been shown to have the same cancer control rate and survival as extended courses of radiation. Faster courses of radiation also have fewer side effects and interfere less with the patients’ lives.
Which type of irradiation is most targeted and effective for breast cancer patients? [Dr. Tallet]: Radiation therapy is by definition targeted since it utilizes objectives being to encompass a target (the volume to be irradiated), as well as constraints (on healthy tissue to be spared from the radiation dose).
ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
Nonetheless, the technique that best avoids the organs at risk is the one that delivers the full-dose to the target and the least-dose to the surrounding healthy tissue. Two methods meet this description, namely, brachytherapy and IORT. Both were shown in randomized controlled trials to be non-inferior to whole-breast irradiation in carefully selected patients...[Dr. Uhl]:...but the most targeted and effective radiation for early stage breast cancer is definitely intraoperative radiation therapy (IORT). The patient receives all of her radiation over minutes in the Operating Room (OR) when she is getting her cancer removed. There is no way to miss the lumpectomy cavity site since the Radiation Oncologist is in the OR with the breast cancer surgeon who just removed the cancer. The efficacy of IORT also has been proven in a large, international, prospective, randomized, risk adapted trial called TARGIT-A.
And what are the main advantages of IORT from your perspective of a radiation oncologist? [Dr. Uhl]: As said, definitive IORT allows the patient to have all her radiation in one setting: at the time of her lumpectomy. No extra visits to the radiation oncology department so no extra travel, no extra time off of work, no childcare issues, no transportation issues, etc. My patients who received IORT are very grateful they had this option. Also, as a Radiation Oncologist, I prefer IORT. This is especially true for LEFT sided breast cancers because IORT spares the heart and lungs from radiation, unlike External Beam Radiation Therapy (EBRT). The TARGIT-A trial found statistically significant fewer non breast cancer deaths in the IORT arm of the trial. This was attributed to less cardiovascular deaths. [Dr. Tallet]: Although restricted to highly selected patients, IORT offers numerous advantages. It is applied as a single fraction, at the time of surgery, in an outpatient setting, thus avoiding the several commutes of the patients that are mandatory for conventional external beam radiation therapy and thereby, lowers the whole treatment cost. It reduces treatment toxicity and provides better cosmetic outcomes by avoiding whole-breast fibrosis. When used as a boost, this radiation technique facilitates breast-oncoplastic surgery. It also allows for second conservative treatment at the time of local recurrence, if any (patients can be treated as if nothing had happened before).
What effect does this have on your patients on the other hand? [Dr. Uhl]: Patients who have IORT instead EBRT have a faster recovery since there are usually no more radiation treatments after the single treatment given in the OR at the same time as her breast surgery. Women can get back to their normal lives much faster than with EBRT. There are also fewer side effects, like breast pain, with IORT and the cosmetic outcome is superior. And as said before, there are fewer non-breast cancer deaths with IORT, especially cardiovascular deaths. [Dr. Tallet]: And patients are thoroughly satisfied with this option. We observed a low rate of recurrence. As exposed in the first question, patients do not have any problem with surgery, and performing the adjuvant radiation therapy at the same time makes them feel as they had no cancer because the treatment resembles a treatment for benign pathologies.
This sounds as if IORT should be considered as standard of care in the future. What is the current status of IORT in the treatment priority for breast cancer patients? [Dr. Tallet]: IORT can be offered to highly selected patients. It was initially not widely accepted due to a limited follow-up of patients in the first TARGIT-A publication. However, this trial is now updated and confirms the previous results. Due to its easy use, patients eligible for partial breast irradiation benefit from this treatment in our institution. Nonetheless, there are still, in France, few radiation therapy facilities equipped with this system. The major problem is its lack of reimbursement, meaning that we work for free. Thus, any future implementation would call for a large investment without remuneration, which is inconceivable as you can imagine. [Dr. Uhl]: Unfortunately, in the USA, also not all Radiation Oncology Centers have an IORT unit such as INTRABEAM®, so many patients never hear about the option of IORT although they qualify for it. In the practices where the physicians have an IORT unit, IORT is offered to those patients who meet the eligibility criteria. Most women choose IORT over EBRT for the convenience as well as the proven advantages. In my personal practice, IORT is offered as a treatment option on a regular basis and has become a very popular option during the Covid-19 pandemic since it reduces the patients’ risk of CV-19 exposure.
In my personal practice, IORT is offered as a treatment option on a regular basis and has become a very popular option during the Covid-19 pandemic since it reduces the patients’ risk of CV-19 exposure
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ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
Where do you see IORT in the future of breast cancer treatments and why? [Dr. Uhl]: In the USA, IORT is becoming more popular and the use of IORT has increased over 20-fold from 2009-2014. I see it being used more and more as partial breast and hypofractionated radiation courses have become more popular. Also, as the reimbursement for radiation in the USA changes, faster courses of radiation will be used more frequently as they are more cost effective. [Dr. Tallet]: And IORT is proven to be effective and easier accepted by the patients. It has been an appealing treatment each time we proposed it to the patient. Moreover, within the context of the current pandemic, we find new advantages of this technique. Indeed, the elderly are particularly sensitive to getting infected, and we must limit as much as possible their commute to the hospital. Additionally, infection during the radiation therapy treatment course threatens to interrupt the treatment, and in this case, the whole treatment would be useless. Thus, favoring short treatments becomes crucial. Lastly, external beam radiation therapy in patients previously affected by the COVID-19 disease is not well documented and becomes of concern
when the beams are susceptible to encompass some part of the lungs. For all these reasons, I think a wider use of IORT is desirable.
Are there any last considerations you would you like to give your peers on their way? [Dr. Tallet]: As usual, the IORT technique, as well as all other PBI techniques, requires a rigorous patient selection. Patients must be aware of the strict necessity of endocrine therapy uptake because most patients experiencing a local recurrence are those having stopped this adjuvant treatment. [Dr. Uhl]: So, if you are not performing IORT now, please look into this elegant form of very precise, targeted radiation. It is extremely accurate with very few side effects and many advantages to the patient and the health care system as well as globally (IORT has the lowest carbon footprint of all forms of breast cancer radiation). Read the TARGIT-A trial results from the British Medical Journal (Link) and join the TARGIT Collaborative Group (TCG) to learn more about IORT and also to receive support when you are ready to start and/or expand your IORT program. Your patients will thank you!
The statements of the doctors in this interview reflect only their personal opinions and experiences and do not necessarily reflect the opinions of any institution with whom they are affiliated. The doctors in this interview are consultants of Carl Zeiss Meditec AG and have received financial compensation. Carl Zeiss Meditec AG, 2021. All rights reserved. Products, services or offers referenced in this interview may not be available in all countries and product labeling varies by country.
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ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
Key Considerations When Choosing an Intraoperative Radiotherapy System – Usability, Precision and Cost Effectiveness An interview with Dr. Henning Kahl (DE) about the most important aspects when defining the right IORT option and selecting a treatment device for the own hospital. Henning Kahl MD, Senior Consultant & Associate Director of the Department of Radio-Oncology at the University Hospital Augsburg, Germany
Why did your hospital chose IORT as an option and what has finally driven the purchase decision? When we made the decision to get involved with IORT, it was 2007, we were pretty much centered on breast cancer. The TARGIT-A trial was running, and it was an exciting and new indication for IORT, and we had a problem which we thought would be solved by it. So, we were interested in making boosts with the IORT system, because as a radiation oncologist, you always face the challenge to delineate the boost area after breast conserving therapy. And this is a hard thing to do because there are major anatomical changes due to the surgery. And with IORT, you can solve that because IORT happens just after the surgeon has removed the tumor and you are sure that you are in the right place, which is a major advantage of this method. Further on, we foresaw that the demand from the patient side would increase due to the increasing evidence that this method might be equivalent to external beam radiotherapy and certain breast cancer cases.
How do you start the process of evaluating which device fits to your needs and which factors play the most important role? When we came to debate this, it was a decision made between the radiation oncology department
and the gynecological department. Because, as I told you, we focused on breast cancer first and both heads of the departments were sure that this would be a game changer. And as the TARGIT-A trial was running with the INTRABEAM® which offered so much extra possibilities to use it in other places as well, they chose to buy this machine.
And how do you come to a decision for an IORT device at the end, is it a single decision or who has the lead and who the last word? The definite decision was made on the financial management level, and for that several calculations were made based on the German DRG system, seeing if we could reimburse the costs of buying such a device. And on the basis of the case numbers at that time, breast cancer cases were calculated and that was how the decision was made to buy this machine.
But just by being part of the surgical process, the understanding of the situs is dramatically better and gives me as a radiation oncologist the opportunity to contour the target volume more precisely
Does patient satisfaction play a role in your clinical practice? Patient satisfaction is of paramount importance in the clinical setting. The highest priority is a cure of the medical issues but even a higher goal is to achieve it in a way that a patient is comfortable with. So, a lot of tumor patients we deal with suffer severely and need life changing WWW.HOSPITALREPORTS.ORG | 7
ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
treatments. So, it is a good thing if you can offer a patient an effective anti-tumor treatment that does affect their way of living only in a very small measure. And this also reflects in the feedback you get from the patients afterwards. In the follow-up decisions, as a radiation oncologist you often face patients that have a lot of fear because of the treatment with radiation, because of the word “radiation”. And afterwards, when they say: “Okay, this was a treatment that was easy to achieve and that was effective” and did not hamper their way of living in any way it is very positive to experience the feedback you get from your patients. And in days when patient advocacy societies have bigger and bigger impact, especially in the breast cancer setting, it is very important. So, positive patient feedback is a good way to get noticed by these patient advocacy societies and you are able to get new patients.
(With IORT) the patients are no longer just surgical patients or just radiation oncology patients, but they are always patients being treated by a multidisciplinary team
Does it make a difference for your patients if you treat with device A or device B and what do they prefer? I think it is not so much the device you use for a treatment, it is more important what the use of the device means for the patient. So, if you use IORT, you often shorten the treatment. And I think for the patient it does not matter that much if you have a device A or a device B that are both able to shorten the treatment in the same way. I think it would be all the same to the patient. But the big difference can be, if you have a device A which is external beam radiotherapy leading to weeks of treatment and you have a device B that offers you a single dose where a patient goes into surgery and anesthesia and after waking up everything is done. In my opinion that is a very appealing thing for the patient. I see this situation often because I use IORT also in the treatment of brain metastases and in this area, I always offer patients both ways: a post-operative stereotactic fractionated treatment or an intraoperative treatment of the tumor bed. And within the talks I had with patients, I always experienced that the patients favor to go into surgery and be done instead of facing another fractionated radiotherapy as this really matters to them.
Could you explain the case mix in your hospital a little bit? My department offers the full spectrum of radiation oncology. We have four linear accelerators; we have a big brachytherapy suite
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and we use IORT for simultaneous radio immuneand -chemotherapy. And within a year we have about 2,500 patients and the full spectrum of radiation oncology with focus on high precision therapy.
So once you chose IORT at the end what is your experience, are you more efficient than before? According to my view, IORT is a valuable tool in my toolbox because there are often situations where the dose limits treatments due to close proximity of organs at risk. Sometimes these organs at risk can be separated easily during surgery by just distancing them with a gauze or something similar. And this offers the patient the opportunity to receive a higher dose in high risk situations. And this is a big advantage and makes my life as a radiation oncologist easier. And another point is that during the time we used the IORT device, we learned more and more indications. And, as I mentioned before, we started with breast and then got into neuro. So, we use it for a tumor bed irradiation after resection of brain metastases as well. We are participating in the INTRAGOtrial to use it as a boost in glioblastomas. But we also use it in other applications. You know, nowadays more and more oligometastatic patients get treatment and sometimes it is hard to achieve high doses big enough to deliver security within treatment area. From a surgical perspective, sometimes you see close margin situations, which you cannot avoid. So, this is a good opportunity to go in with IORT to increase the dose as an addition to a percutaneous radiotherapy.
Is IORT lengthening the workflow in the OR? As a matter of fact, yes, it adds some time in the OR depending on the dose you apply and on the size of the applicator, we mostly use spherical applicators, but we experienced truly that there is a steep learning curve. The more you use the machine and the more familiar the OR staff gets with setting up the machine, the less time you spend in the OR. Christopher Cifarelli did a study on the additional time in brain metastases, which would be about 16 minutes* and this is very acceptable, I think. If you look at the breast setting in my experience there sometimes is an additional time of about half an hour. But I think the more you streamline that, the less important that factor becomes.
ADVANCING THE TREATMENT OF BREAST CANCER AND THE ROLE OF INTRA-OPERATIVE SINGLE DOSE RADIOTHERAPY
What happened amongst the colleagues when you started with your IORT program? This is a very interesting question, because when we started IORT and used it more and more often in the OR the surgeons realized this by saying: ”Oh, what are you doing here?”. And as you got closer and closer together in the OR with the surgeon and started to really join and do more work during surgery, the more the surgeons realized that you are a real doctor. And it makes a huge difference regarding the understanding of ways certain diseases are handled and also the surgical strategy becomes more and more clear to me now, because I just join them during the surgery and can see their problems. And on the other hand, the more I join in, they understand what is important for me as a radiation oncologist. So, a wonderful side effect of the implementation of IORT is that you get a closer connection to your surgeons in every field. This is valid in all the fields which I work in from neurosurgery, over breast surgery and also the field of abdominal surgery.
How does the multidisciplinary team work together now? Does it pay off to have an IORT device in your hospital in terms of better outcomes? Yes, as I mentioned already, this is a big difference because of the connection to the surgeons from the surgical perspective, they now realize me as a clinical doctor, a colleague that treats patients. And in my perspective the understanding of surgical techniques has increased dramatically. The next thing is by learning what the problem of the radiation oncology is sometimes their reaction or the perception of treating certain tumors changes. Because if the surgeon knows
there is a chance that I might get an additional dose to it, he perhaps sometimes thinks earlier on discussing cases preoperatively. There are certain cases where I was called to the OR and during the surgery we decided not to perform an IORT. But just by being part of the surgical process, the understanding of the situs is dramatically better and gives me as a radiation oncologist the opportunity to contour the target volume more precisely. And I am definitely sure that the better the understanding between the different disciplines is, the better are the outcomes. Because the patients are no longer just surgical patients or just radiation oncology patients, but they are always patients being treated by a multidisciplinary team. So definitely it pays off for the patient and it pays off for the hospital.
Are there any last considerations you would you like to give your peers on their way? Yes, I think the chance to use IORT really is a valuable tool in the toolbox for radiation oncologists to improve outcomes of surgical patients. And in my field, there is a big change from fractionated radiotherapy to more hypofractionated doses and higher single doses. And there is a lot of change in the understanding of immunological effects of high doses. So, this is a very interesting and evolving field, because with the IORT you apply high doses and you reduce the distance between surgery and adjuvant treatment to zero. So, these are both effects that are very important and are also a very interesting field for scientific research. So IORT is something which is pointing to the future and I expect to have an increasing amount of IORT indications in the future medical development.
IORT is something which is pointing to the future and I expect to have an increasing amount of IORT indications in the future medical development
* Cifarelli, C.P., et al. (2019). Intraoperative radiotherapy (IORT) for surgically resected brain metastases: outcome analysis of an international cooperative study. J Neurooncol 145, 391–397. https://doi.org/10.1007/s11060-019-03309-6 The statements of the doctor in this interview reflect only his personal opinion and experiences and do not necessarily reflect the opinion of any institution with whom he is affiliated. The doctor in this interview is a consultant of Carl Zeiss Meditec AG and has received financial compensation. Carl Zeiss Meditec AG, 2021. All rights reserved. Products, services or offers referenced in this interview may not be available in all countries and product labeling varies by country.
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