Radiation Therapy is a key part of cancer treatment for many patients providing curative and palliative management of cancerous tumors. The current approach to radiotherapy sees a large majority of patients treated in the supine position. However, this has not always been the case; Radiation Therapy treatment started with patients treated in the upright orientation. The transition to supine treatments came as a result of the fact that much of the patient population was completely bed-bound by the time they were treated. After all, there was only one way to treat a bed-bound patient – in their bed. In recent years, several key institutions have presented data showing the potential clinical, and significant psychological, benefits of upright patient positioning. Thanks to improved access to high-quality imaging systems, we are now diagnosing cancer patients much earlier resulting in dramatically improved mobility in cancer patients at the time of treatment. This improved mobility, alongside improved knowledge of the benefits of upright positioning, means that now is the ideal time for upright patient positioning. Another reason upright radiotherapy hasn’t been widely adopted has been because image acquisition for treatment planning in the upright orientation has not yet been perfected. (3)

Leo Cancer Care was founded with one goal in mind, to be the more human way to deliver radiation therapy. This is a very big goal but breaks down into three aims.

Improve the clinical effectiveness of Radiation Therapy through upright positioning
Improve the access to Radiation Therapy by removing the need for large and expensive rotating gantries and instead introduce slow patient rotation
Empower patients and clinicians to face Radiation Therapy together, eye to eye.

Originally founded in Australia, Leo Cancer Care has been built on research from across the globe showing the clinical benefits of upright patient positioning which we will cover in this article. Combining this with a shift from machine rotation to patient rotation and introducing Proton Therapy and Photon Therapy solutions that allow for upright positioning and imaging in one place, Leo Cancer Care is set to change the face of Radiation Therapy for good.

The Clinical Benefits of Upright Radiation Therapy

From the moment a patient wakes up, to the moment they lie down for treatment, they spend the majority of their time in the upright orientation, either seated or standing. Recent studies show that when a patient lies down their organs drift due to the change in direction of gravity. The liver for instance has been shown to drift for 35 minutes and by 20mm once a patient moves from being upright to supine. Patients are always imaged before treatment; this data suggests the tumour that is being targeted may move throughout the treatment which could lead to the tumour being missed altogether. (4)

The most commonly addressed form of motion within radiation therapy is breathing motion. Data from several high-profile cancer centers have shown that lung volume is up to 50% greater in the upright orientation. For the same tidal volume of air, this increase in lung volume results in a reduction in lung motion of up to 5mm as the patient breathes. This significant reduction in breathing motion improves treatment accuracy and could reduce the need for lengthy and uncomfortable motion management techniques for the patient. (5)

Evidence suggests that left-sided breast cancer patients treated lying on their back with Radiation Therapy are 38% more likely to develop secondary health conditions due to toxicity delivered to the heart and lungs. We commonly see patients treated lying on their front to address this issue, but this can prove very challenging to achieve accurate and reproducible positions; it is often very uncomfortable for the patient. By seating the patient upright, and tilting them slightly forward, we really deliver the best of both worlds; the breast and tumour moves away from the heart reducing toxicity to critical organs, but we avoid the setup and comfort issues of the prone position. (1)

The team at Leo Cancer Care also conducted their own research to review the impact on the prostate in a supine and upright orientation. The primary challenge in prostate treatments is to minimize the radiation dose to the healthy, surrounding area and the displacement of the prostate because of changes in rectal content and bladder filling. Scans showed that the bladder is longer in the upright orientation and that the distance between the posterior edge of the bladder and sacrum was smaller. This appears to show that the bladder will be more effective at pushing the small bowel away from the radiation field, meaning less healthy tissue irradiation. (2)

This means that the Leo technology will be able to be used to treat more than 66% of all cancer incidences, with significant improvements to patient experience and medicinal accuracy for those patients being treated for breast, lung, liver and prostate cancers.

The Financial Benefits of Upright Radiation Therapy

Infographic - The financial benefits of upright radiotherapy

Initial research has shown that setting a patient up in an upright orientation is quicker than setting up a patient in the supine orientation. Setting a patient up in the supine position often means utilising several therapists to correctly position the patient through a manual process of lifting and supporting the patient before fixing any required immobilization devices. In the upright orientation, the patient only has to be sat down on the device, which they could potentially do themselves or with minimal support without lots of manual adjustments. This reduction in set-up time could see a significant improvement in patient throughput. (2)

Currently, most of the commonly used radiation therapy machines feature a large rotating gantry that can weigh up to 600 tonnes. Rotating a patient isocentrically is a lot easier than moving a heavy gantry around the patient. Think of it this way, if you needed to replace a lightbulb in your home, you wouldn’t hire a crane and rotate your house whilst someone stood still with the lightbulb. You simply rotate the much smaller lightbulb into the fixture, whilst the house remains where it is. The treatment envelope is also more predictable and accessible with a fixed radiation beam, meaning the Leo Cancer Care solutions are cheaper to construct, simpler to maintain and easier to install.

A fixed beam solution, like that utilized in the Leo Cancer Care technologies, can be installed into existing treatment spaces due to the smaller footprint of the machine, meaning no need for huge construction costs and minimal disruption during installation. The cost of shielding an upright solution is also reduced and potentially two upright systems can occupy one conventional vault space, with a change in the layout of the shielding walls and maze, meaning a treatment center could treat double the number of patients. (2)

The Operational Benefits of Upright Radiation Therapy

Utilising a fixed beam Photon Therapy solution also allows for the option of self-shielded solutions, which negates the need for the construction of expensive radiation bunkers. This also opens up the opportunity to make Photon Radiotherapy even more accessible by creating mobile Photon Therapy units, that can take this form of radiation treatment to more rural areas or be implemented in less economically developed countries. (2)

Diagram - Gantries and fixed beams exist side by side

If you are delivering radiation therapy in the upright orientation, you also need to be able to effectively and quickly image in the upright orientation to ensure effective treatment planning. Cone-beam CT (CBCT) images of the patient can easily be obtained while rotating the patient precisely in a stationary x-ray beam measuring the transmission x-rays with stationary x-ray detectors. The same is true for particle therapy imaging systems such as Proton radiography (P-Rad) and proton computed tomography (PCT) systems where particle images can be obtained in a similar manner providing the beam energy is sufficient for the particles to traverse the specific anatomical region. (2)

The Leo Cancer Care upright radiation therapy solutions allow for imaging and treatment to happen in one place. With faster patient set-up times, patient throughput can be improved with a boost to the clinician and patient experience. With the smaller size of the technology, installation is a lot faster than that of the conventional supine systems and two upright systems can occupy the space of one conventional supine room, meaning even more patient throughput improvements which in turn means an increase in revenue.

The Emotional Benefits of Upright Radiation Therapy

As humans we feel most empowered when we are upright, actively participating in an activity or communicating with others. Treating patients in an upright position comes with several emotional benefits and allows the patient to connect with their clinician eye-to-eye, rather than being looked down upon. Being placed on a radiotherapy table and being asked to lie down can lead to an increased feeling of vulnerability. Cancer is a battle, and anything that can be done to empower the patient during their treatment can only be seen as a positive.

Having patients in the upright orientation can improve the overall patient experience. As mentioned previously set-up times are likely to be quicker in the upright orientation, meaning the patient spends less time in the hospital. For certain types of cancer, some symptoms may be exacerbated in the supine position, some patients may suffer from symptoms such as dysphagia and gastric reflux, which will become more prevalent whilst lying down increasing the discomfort experienced by the patient.

Image - An image of the first ever Leo Cancer Care upright positioning system superimposed underneath a render of the upright scanner which is in development

Summary

Leo Cancer Care is the more human way to treat cancer, harnessing the clinical advantages of upright positioning and using a fixed beam configuration to take Radiation Therapy to places it has never been before. The Leo Cancer Care solutions aim to improve the clinical effectiveness of radiation therapy through upright positioning, improving the access to radiation therapy by removing the need for large and expensive rotating gantries whilst also empowering patients and clinicians to face radiation therapy together.

The Leo Cancer Care solutions can be easily installed into both existing and new treatment centers due to the reduced footprint and utilization of fixed radiation beams. Removing the need for a large rotating gantry means the Leo Cancer Care solutions are more affordable and easier to maintain. Leo Cancer Care is also creating a Photon Therapy solution that can be completely self-shielded, meaning there is no need for a costly radiation bunker.

Leo Cancer Care’s solutions have been designed with the patient in mind, aiming to improve the patient’s experience and comfort levels throughout treatment. With faster set-up times and improved patient comfort, radiation therapy can be quicker and less daunting. Leo Cancer Care’s technologies invite patients to be an active participant in their treatment, they can take in their surroundings and communicate with their clinical team, eye to eye.

To find out more about Leo Cancer Care please visit: www.leocancercare.com

*Please note these products are not currently available for sale in the US

The Clinical, Financial, Operational and Emotional Benefits of Upright Radiation Therapy

The Clinical Benefits of Upright Radiation Therapy

The Financial Benefits of Upright Radiation Therapy

The Operational Benefits of Upright Radiation Therapy

The Emotional Benefits of Upright Radiation Therapy

Summary

Further Reading & Resources