Dr. Peter Chen our Radiation Oncologist

Name: Peter chen – Radiation oncology
Phone: 949-764-4624
Nurse: Nathaniel Joy
Office: Megan
Fax:
Location: Hoag
Date: 12/30/05

Medical history
Physical exam
Neuro exam

After surgery, radiation therapy + temodar is standard therapy.
Options can be tried afterwards.
Daily treatment, make a thermo mask to hold you in same position everyday, so there is a reproducible position that we make sure to treat each time, radiation is not painful, it is a biological effect on cellular DNA, doesn’t burn you

Side fx: hair loss in patches (4-5 weeks into treatment) because of age, hair should grow back but no guarantee, fatigue (may need naps in afternoon, sleep more at night) usually goes away but can last 6-8 weeks after
33 treatments almost 7 weeks of treatments about 20 minutes a day
Will be getting 60Gy total, (Regional radiation that treats 2cm margin around original abnormality for 45Gy shrink down to main tumor area for 15Gy = total of 60gy Dosage?)boost hasn’t been shown effective to the tumor bed, but will focus more in cavity at the end.

Standard technique to treat larger margin around tumor, toward last phase of treatment focus more in the targeted area.
Long term side fx – number of factors in play, depends on if there is a progression of the tumor, anything we can do to halt that will be effective in the end. Effect of radiation on brain can be subtle, some have had trouble with short term memory loss, but it is difficult to measure, may have some difficulty with short term memory and concentration a year out, but not clear if it is from radiation, tumor, other factors?

How many GBM IV patients are being treated here? 3-4 getting radiation now
What is your plan of treatment? Regional radiation that treats 2cm margin around original abnormality for 45Gy shrink down to main tumor area for 15Gy = total of 60gy Dosage?
What does radiation actually do to the cancer cells? Causes damage to cellular dna, cancer cells vs normal tissue have lost that ability to repair themselves so when radiation damages them, they have trouble dividing and then die.
What does it do to the healthy cells? Can also cause damage to normal tissue in same way, but repair of that tissue is much greater which is why we use the dosage that we use so that it keeps up the tolerance of the normal tissue. If we used too high of a dosage we could damage the normal tissue in a way that they couldn’t repair themselves…radiation necrosis Very low possibility of radiation necrosis with this dose limit.
What is different about each radio oncologist? Training, experience, some small difference in equipment, Hoag has some of the best equipment available, ability to communicate.
How experienced are you? 35 years old, trained at UCLA, in private practice year and a half, he would set radiation plan and determining doses and doing followup
Who else at Hoag is a radio oncologist? There are 4 in the group. Russell Haffer (oldest…), Craig Cox, Dr. Brian Kim What is their experience?
Who is the top dog oncologist at Hoag? David Kline, David Burtzo, Neil Barth
Will it always be administered by you or some one else? Administered by the techs
Do you get referrals from other hospitals? Hoag, UCLA
How many glioblastoma patients have you treated? Several hundred
Can we contact any of them? Yes, go through the brain tumor support group
What are the side effects?
What are the long term side effects?
Gamma knife more risk than benefit on gliomas

* radiation/Chemo
* can radiation only be done once? Somewhat true. Once you give a course of radiation, if the tumor comes back, you have relatively less to gain. It would be different in a recurring tumor, you would have to meet certain criteria to receive this type of treatment. Salvage treatment for recurring.
* radiation can be done same time as chemo - this is common now
* radiation to general area, how much will be treated? About ¼ of brain, 2-3cm margin outside of cavity and boost to the cavity.
* what is radiation necrosis? Kill the cells and mimic tumor growth, gamma knife increases that risk. It is a possibility..should keep dose at 5940-6000 dose total
* what is considered a safe level or radiation (55-60gy) 33 treatments, 200 C dose (1500 one time would be bad, but stereotatic boost would be reasonable at the end 180/200) every week day for 6 weeks
* what are the side effects of radiation? Fatigue, loss of taste, buzzing in ears, will lose hair in area directly effected.
* is there brain damage? Can cause it. Radiation damage can be focal or diffuse, which sometime seen in long term survivors.
* long term effects? Cognitive slowing, short term memory loss.

Will he be radioactive after treatments? No Will it effect people around him? no
Shouldn’t do supplements of A,C,E on top of normal multivitamins. Normal vitamin is ok, diet is ok
Told to get blood checked once a week, can we come here to do this? Main hospital
Is there any research going on at this facility regarding treatment of GBM IV?
Immunotherapy (currently open) does require another surgery, take your blood and incubate cells to activate immune cells so they’re ready to kill something and then inject them into the tumor cavity, it is for upfront
Tried – increase radiation dose, but limited to healthy tissue reactions (not good)
Leading edge gamma knife procedure that concentrates radiation on areas that need the radiation. Tried before---just to target tumor bed (not successful. Now treat tentacles, pathways are predicable, white matter pathway spread, cause some swelling reactions that help make them more visible in MRIs with higher dosages, but increases risk of radiation necrosis
What kind of clinical trials are going on at this hospital regarding upfront GBM IV? Immunotherapy, Gamma knife (not subjected to randomized trial (Phase 3) yet, currently Phase 2)
- tried on this type of tumor
What other clinical trials are you aware of at other sites for our situation?
There are always clinical trials going on, Dr. Claughsey would be best person to ask about outside trials.
What is the standard of care at Hoag for treating GBM IV? Crainiotomy, radiation + chemo, some are offered gamma knife up front (if they are leading edge – pathway of white matter spread)
* next meeting is a simulation (planning and targeting day), fit for the mask and CT scan of head which will be fused with pre-op MRI for targeting (we want them to use UCLA’s pre op, not Hoags)
*Mental health. What resources does UCLA have available for patients/families going through treatment? Brain Tumor support groups
Nutrition as part of approach? No proof
We’d like a written transcript of this visit? Yes. Will be in system within a week.

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phone conversation 01/03/06



* is this considered photon beams, xrays or something else? Xrays are photon
* Is the therapy we’re using 3D conformal radiation therapy or 2D? 3D
* How many beams will be used? Generally about 5 or 6 beams
* Does the dosage decrease as it reaches tumor area and effect the healthy tissue that it has to go through more than the tumor area? Use multiple beams that conform at central point, so the bulk of dosage happens at conformed point and not as much on the healthy tissue. Similar to beams going through a magnify glass. The single beams don’t burn but the conformal ones do.
* Tumor less responsive to later treatments plus it doesn’t work very well – radiation therapy is the most effect treatment for this disease at this time, it is possible that there could be a resistance to future therapies, but it isn’t really known.
* How do we know this is the best treatment in Mark’s case? Best compared to other alternatives like hospice care, better than older chemo+radiation, showed better on its own
* What is the success rate of this treatment? Averages are quite discouraging, but there are some that have good success rates
* Has it improved in the last 20 years? Conformal radio therapy, other focal techniques, (this case conformal would be the best distribution), tried different fractionation schemes, brachytherapy, particle therapy
* What are the known risks with this treatment? Fatigue, nausea..brain tissue is relatively hardy and part of it is due to the fact that a mature brain even with dna damage they are still able to function, rarely get acute affect of necrosis with this dose
* What are the risks of radiation necrosis of this treatment? Low with dosage we’re using less that 5%
* What are the known benefits of this treatment? Has the effect of killing tumor, but to cure a cancer, you need to kill every single tumor cell it can be reduced quite a bit with radiation, but can’t get them all and tumor does tend to grow back
* Shouldn’t we get a pre-radiation MRI to determine most accurate area? Not helpful to get it prior to radiation, preop is going to give best look at where the disease is. You would be underestimating if you took post op because bulk of tumor is gone
* Not helpful to get mris during because it doesn’t change plan. If clinical reason like fluid cavities in brain swollen if getting more symptoms (confusion) we would do an MRI to check. Won’t see a great effect during radiation, because it takes time to see the effect. If it looked worse we’d continue to make it better, if it looked better, we’d still want to continue to get the most benefit, MRIS are not a prognostic factor during radiation
* What is currently being done to improve the efficacy of this treatment (experimentally, clinically, etc?) some work been done with different radiosensitizers (temodar) there are ongoing trials with other agents, indication is clinical symptoms if something seen, then change
* Are there any other treatments that we can do with the standard or before/during/after that we should consider? May be clinical trials open, talk to Dr. Claughsey
* Probably Friday or Monday would start radiation
* What is exit dose? Radiation is absorbed as it goes through the body, but not all of it is absorbed and some is absorbed by skin on other side of brain. Might cause hair loss or temporary skin reaction on other side.
* What does this treatment prevent you from doing in the future? Does it preclude other types of radiation (ie external treatments like gamma knife & proton or gliasite or other internal radiation therapies) Doesn’t necessarily exclude you, but this method is the best for now. Normal tissues have a tolerance for radiation, you may run a higher risk for side fx if you try another treatment after radiation. It is conceivable, but doubtful that something new and more effective is coming out in the next few months.
* If a tumor shows up in a different part of the brain or body, would standard radiation be applicable on the new tissues? Yes you could do it on new tissues.
* IMRT - same radiation system, delivery is different, will use it in some circumstances of GBM, but more favorable for 3d conformal for this tumor, we do have it here at Hoag, depends on shape of tumor and if located close to optic chasm. It is also xrays (photon). Treatment time is longer than standard radiation.
* IMRT - Supposedly effects less of the healthy tissue vs standard treatment? Complicated ‘cause dose distribution is different, overall can spread low dose regions out. Same dose as standard but distributed differently. It targets same area as standard, but not recommended in this case.
* BNCT - Not at Hoag, problem is getting boron in tumor in appropriate distribution. Technique of focusing radiation. Not as effective on gbm, we can achieve similar effects with radiosurgery
* Proton beams – not as effective on GBMs because they can’t get the full suspect area
* Gliasite/Internal Radiation - Some internal methods are effective in case of recurrent disease. Some benefit of chemo internal, immunotherapy at hoag, etc…local therapies are not the answer to this disease because the area around the tumor that is effective is in the apparent normal tissue
* Radiation via monoclonal antibodies - Usually used for lymphoma, no antibiody as of yet that targets gbm, there is one that targets a receptor on lymphoma. May be trials for it elsewhere?