Advanced Radiosurgery Techniques

June 28, 2021

Information

June 27, 2021

Yale Cancer Center

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00:00Support for Yale Cancer Answers
00:03comes from Smilow Cancer Hospital
00:05and AstraZeneca.
00:07Welcome to Yale Cancer Answers with your host,
00:09Doctor Anees Chagpar.
00:11Yale Cancer Answers features the latest
00:13information on cancer care by
00:15welcoming oncologists and specialists
00:17who are on the forefront of the
00:19battle to fight cancer. This week,
00:21it's a conversation about radiation
00:23oncology with Doctor Krishan Jethwa.
00:25Doctor Jethwa is an assistant professor
00:27of therapeutic radiology at the
00:29Yale University School of Medicine,
00:31where Doctor Chagpar is a
00:33professor of surgical oncology.
00:35So maybe you can start off by telling us
00:38what exactly is a radiation oncologist?
00:41Often I find people confuse a
00:44radiation oncologist with a radiologist.
00:46So can you tell us the difference?
00:49Radiation oncologists
00:49are cancer specialists who care
00:51for adult and pediatric patients.
00:53We use radiation therapy with the
00:56goal of curing cancer or to help
00:58improve the quality of life for
01:01symptoms for patients with cancer,
01:03and often that's part of the
01:05multidisciplinary care which
01:06includes many other specialists.
01:08The other question that I often
01:10get is the difference between
01:13radiation and chemotherapy.
01:15So when people are talking about
01:18using various modalities to help
01:20manage cancer or cure cancer,
01:22people often get these mixed up
01:25and also mix up the side effects.
01:28So can you tell us a little bit
01:31about the differences between the two?
01:34Medical oncologists are
01:36cancer specialists who use medications
01:39or drugs to treat the entire body,
01:42some of which do include chemotherapy
01:45and those specific medications
01:47they use can target the cancer
01:49and help with cancer control.
01:51Radiation therapy is different in
01:53that we use typically high energy
01:55radiation beams targeting the cancer
01:57for a more local treatment effect,
02:00as opposed to a whole body
02:02wide treatment effect.
02:03Often we work together to
02:05help with the goals of care,
02:08whether it be curative or
02:10supportive or symptom directed.
02:13And so tell us a little bit
02:15about the side effects of each.
02:17Very often people are worried
02:20about will my hair fall out?
02:22Will I get really sick?
02:26And so can you talk a little bit
02:28about the differences between the
02:30side effects of radiation therapy
02:33versus more whole body systemic therapies?
02:35The side effects are really
02:38dependent upon which medication is
02:40choosen for systemic therapies.
02:42And for radiation therapy
02:44it's very much dependent upon
02:46which area of the body is treated
02:48with radiation therapy in general.
02:50Some common side effects of radiation
02:53therapy would include fatigue,
02:54people may feel tired.
02:56And there can be some reaction of
02:58the skin similar to that of a very
03:01mild sunburn in most instances.
03:03That is not always the case,
03:05but it can be depending upon
03:07what's treated.
03:09Apart from those more general side
03:11effects it is very much dependent upon
03:13which area of the body is focused
03:15with radiation therapy and part
03:17of the art and care of a radiation
03:20oncologist is guiding and supporting
03:21a specific patient through those
03:23side effects and supporting them
03:25as they recover from the treatment.
03:27Similarly,
03:28with chemotherapy it's very much
03:29dependent upon the medication,
03:31but there can be the more global
03:33general side effects of fatigue
03:35that come along with it,
03:36but many of the other side effects
03:39are dependent
03:40on the medication.
03:41I think that when
03:43people think about radiation, they
03:45have seen movies where people
03:47were going through cancer care,
03:49lose their hair and so on and so forth
03:51that frequently is a side effect of
03:54chemotherapy and not so frequently
03:56a side effect of radiation therapy.
03:58Is that right?
04:00That's true when we're treating
04:02around the brain or head region
04:04there can be hair loss
04:06from radiation therapy,
04:07but apart from that circumstance and
04:10hair loss would not be expected from
04:12radiation therapy.
04:13The other question that I get a
04:16lot is if I take one or the other,
04:19can I avoid the other?
04:21So in other words,
04:22if I take radiation,
04:24can I avoid chemotherapy?
04:25Or if I take chemotherapy,
04:27can I avoid radiation?
04:28More often than not
04:30we combine both
04:32systemic treatments like chemotherapy
04:34and radiation therapy together
04:36because both have different
04:38effects on the cancer control.
04:41Radiation therapy specifically helps
04:42to decrease the risk or control
04:45the cancer at the site that it
04:48originally grew from.
04:49Whereas systemic treatments target
04:51the rest of the body to help
04:54control any microscopic cancer
04:56that may be progressing elsewhere.
04:58So typically it's not an either or,
05:01but usually and often a combination
05:03of both to improve outcomes.
05:05Which brings
05:06me to the question of surgery and radiation,
05:10so surgery, similar to radiation,
05:12is a local treatment.
05:13Are there instances where you choose
05:16between surgery versus radiation,
05:18or are there circumstances in
05:20which the two are combined?
05:22And if so, can you explain why?
05:25Again, a very great question.
05:28Often we're working with our surgical
05:30colleagues to help improve the outcomes
05:33with radiation therapy or surgery.
05:35In some instances,
05:36radiation therapy can be a very
05:38appropriate alternative to surgery.
05:40For instance, for treatment of
05:42many head and neck cancers.
05:45Radiation therapy or surgery
05:46are very suitable options and
05:48similarly with prostate cancers,
05:50radiation therapy or surgery,
05:52often very suitable options
05:54with the goal of cure.
05:56Although there are many other
05:58circumstances where a radiation
06:00therapy is either given before a
06:02surgical operation or afterwards
06:03to help improve the outcomes,
06:05and a great example of that is breast
06:08cancer where often we do surgery first,
06:11follow it with the radiation
06:13therapy to decrease the risk of the
06:16cancer coming back.
06:18And in terms of radiation therapy,
06:19can you talk a little bit about
06:21the different kinds of radiation?
06:23I know people have
06:25heard about things like
06:27photons and electrons,
06:29and now protons.
06:31How does one know what kind
06:33of radiation therapy
06:34one should be getting?
06:36What are the
06:37differences?
06:39There are a tremendous amount of differences between each
06:41of those techniques and in general,
06:43radiation therapy comes in many forms.
06:45A way of differentiating the major forms
06:48would be external beam radiation therapy,
06:50which is somewhat similar to standard X rays,
06:53where the radiation beams are coming
06:56from the outside from a large
06:58machine and directed to the tumor.
07:00An alternative form to that
07:02would be internal radiation.
07:04And that could include procedures
07:06such as what we call brachytherapy,
07:09which involves inserting the
07:11radiation therapy device actually
07:13into or directly next to the tumor.
07:16Or there are some circumstances
07:19where we use radiotherapy releasing
07:21isotopes into the bloodstream that
07:23can be targeted to the tumor.
07:26Part of the art and skill of a radiation oncologist
07:29is determining the most ideal
07:32radiation therapy technique and plan
07:35to help design and target the
07:37cancer while minimizing radiation
07:39exposure to normal organs,
07:40and so it's challenging to say
07:42you know what questions might a
07:45patient ask to help direct which
07:47specific technique is used,
07:49but I do think it's a fair question to
07:52simply ask your radiation oncologist, what
07:54type of cancer treatment or radiation
07:57treatment am I receiving.
07:59And so you know,
08:00there are now
08:03newer therapies or newer therapeutic
08:06modalities that are being considered
08:09in radiation for various tumors and so
08:11when patients want to get more information
08:14for example, breast
08:17cancer patients who are often treated
08:20with photons but who are now being
08:23offered proton therapy and are wondering
08:26should I be getting proton therapy?
08:29Is that the right thing for me?
08:32Where do you suggest that
08:34they get more information?
08:36Or can you shed a bit of light on
08:39in what circumstances different
08:42modalities might be better?
08:44I love this question because it's
08:46one of my real areas of passion.
08:48How can we use advanced radiation
08:51therapy technologies to improve the
08:53outcomes and reduce the side effects
08:55of patients as they go through therapy?
08:57Standard radiation therapy
08:59uses high energy radiation beams and
09:02those often are called photons or X
09:05rays to be focused on the cancer.
09:07A downside of X rays is that they
09:10enter the body and they actually pass
09:13through the entire body deposit,
09:15depositing radiation therapy through
09:17their path, and this can include
09:20normal organs in many circumstances.
09:22Now, unfortunately we have developed
09:24many methods to reduce the exposure of
09:26normal organs and therefore the side effects.
09:29And honestly the technological advances
09:31in radiation therapy over the decades
09:33have been so immense and very exciting
09:35and this has resulted in dramatically
09:38better outcomes for patients.
09:40Proton therapy, for example,
09:41is a real major advancement,
09:43and similarly to X rays,
09:45proton beams do enter the body and
09:48deliver some radiation exposure initially,
09:50however,
09:51that's where the key advantages is that
09:55they can be designed to actually stop
09:57shortly after the targeting tumor.
09:59So in brief,
10:00there is little to no radiation that
10:03continues to pass beyond the tumor or
10:05through the rest of the patient's body,
10:08and this theoretically may
10:10substantially improve
10:11and benefit some patients.
10:13Not all patients,
10:14but some patients.
10:16That sounds really exciting and
10:18certainly we know that there are
10:20various proton facilities that have
10:22popped up all over the country.
10:24If patients are not near a proton facility,
10:27should they be looking to go to a
10:30facility that offers proton therapy?
10:33Or is that something that is pretty
10:36specialized and still on clinical trial?
10:38Or does it really depend on the tumor type?
10:42It's highly dependent
10:43upon the tumor type and
10:45the individual patient.
10:46I would encourage patients to
10:49ask their radiation oncologists
10:51just the question of what do you
10:54think about proton therapy and
10:56do you think it would benefit me?
10:59And even if they don't live close
11:01to a proton therapy center,
11:03I do think that an individual radiation
11:06oncologist would provide their
11:08opinion or thoughts on that technique.
11:10I get asked that question actually
11:13quite regularly and in many circumstances
11:15standard radiation therapy would
11:17be equivalent to proton therapy,
11:19and I do think that we can
11:22deliver exceptional care with
11:23standard radiation treatment.
11:25As I mentioned,
11:26tremendous advancements have been made
11:29even with standard X rays or photons.
11:32But in some circumstances I must say that
11:35I have recommended patients
11:37to receive a second opinion
11:39at a proton therapy center
11:41Can you talk a little bit
11:43about some of the other techniques
11:45that have been developed using
11:48standard radiation therapy that might
11:50minimize the dosage to normal organs.
11:52Many patients are always worried about,
11:55for example, if they're getting
11:56radiation therapy after a breast cancer,
11:59let's say to their chest.
12:01They're worried about the radiation
12:03affecting their heart or their lungs.
12:05What advancements have been made
12:07to protect those organs and should
12:10patients be worried about the
12:12extra radiation hitting those
12:13normal tissues?
12:16As a radiation oncologist, these
12:17are the things that are on
12:19my mind each and every day.
12:22How do I design a radiation treatment
12:24plan that can minimize effectively
12:26the dose of radiation therapy to
12:28normal organs and with standard
12:30radiation therapy for breast cancer
12:33we've come up with very nice ways to
12:36displace or move the heart or
12:38lungs away from the targeted breast
12:40tissue and for other cancers
12:43we've developed highly sophisticated
12:44X ray techniques such as intensity
12:47modulated radiation therapy,
12:48which, in simplified terms,
12:50involves advanced computer technology
12:53and sophisticated radiation beam
12:54design to better focus the high doses
12:57of radiation therapy to the tumor
12:59and spare the normal tissues so we do
13:02have very effective alternatives to
13:04proton therapy that can effectively
13:07and very well treat patients.
13:10That's really great to hear,
13:11so we're going to pick up this
13:13conversation right after we take a
13:16short break for a medical minute.
13:18Please stay tuned to learn more
13:21about radiation oncology with
13:22my guest Doctor Krishnan Jethwa.
13:24Support for Yale Cancer Answers
13:26comes from AstraZeneca, working to
13:28eliminate cancer as a cause of death.
13:31Learn more at astrazeneca-us.com.
13:34This is a medical minute about survivorship.
13:38Completing treatment for cancer
13:39is a very exciting milestone,
13:41but cancer and its treatment can be a life
13:45changing experience for cancer survivors.
13:47The return to normal activities and
13:50relationships can be difficult and
13:52some survivors face long term side
13:54effects resulting from their treatment,
13:57including heart problems,
13:58osteoporosis, fertility issues,
13:59and an increased risk of second cancers.
14:02Resources are available to help
14:04keep cancer survivors well and
14:06focused on healthy living.
14:08More information is available
14:10at yalecancercenter.org.
14:11You're listening to Connecticut public radio.
14:15Welcome
14:15back to Yale Cancer Answers.
14:18This is doctor Anees Chagpar
14:20and I'm joined tonight by
14:22my guest Doctor Krishan Jethwa.
14:25We're discussing radiation therapy in
14:27the treatment of cancers and right
14:30before the break we were talking about
14:33some advanced techniques that have
14:35been developed that can really help in
14:37minimizing the side effects of radiation.
14:41Before I dive into some specific cancers,
14:44one question that we're always asked about
14:47is secondary malignancies.
14:48In other words,
14:51people often say, well, radiation therapy,
14:53it's kind of like radiation
14:56similar to the sun,
14:57but we know that with radiation,
15:00whether it's from sunlight or
15:03whether it's from nuclear explosions,
15:05can cause cancers.
15:06So is there a risk of developing
15:10a cancer from your radiation
15:12therapy which is designed to
15:15help you get rid of the cancer?
15:18That's a really, really good question,
15:20one which I get asked from most patients.
15:24And you're exactly right.
15:26With radiation therapy,
15:27while we focus it directly on to the tumor,
15:30and we do a very nice job at doing so,
15:34there is theoretically a risk that
15:36radiation therapy can increase the risk
15:38of developing a new cancer within or
15:40adjacent to the radiation therapy field.
15:43Thankfully, that risk is not very high.
15:45In fact, it's far less than 1%,
15:48and if it is to happen,
15:50it often takes many,
15:51many years to develop and I mean
15:545-10, 30-40 years to develop.
15:57So there is a relatively low risk of it
16:00occurring and it's a more significant
16:02risk in patients who are younger,
16:05particularly our pediatric patients,
16:06but as a radiation oncologist it is
16:10always something on my mind when
16:11I'm caring for those young patients.
16:14And that is one of the benefits of
16:16advanced radiation therapy technologies.
16:18For instance, proton therapy,
16:20that can theoretically decrease the risk
16:23of what we call a secondary malignancy.
16:26And so during the break
16:28you were telling me that your
16:30particular focus is on GI cancers.
16:32Can you tell us a little bit
16:35more about the use of radiation
16:37therapy in those cancers?
16:39Radiation therapies are used in the vast majority
16:41of GI cancer spanning head to toe.
16:44It has a role in either the curative
16:47intent treatment or in many it would
16:50be the symptom directed treatment.
16:52So that could be for esophagus cancers,
16:54stomach cancers, liver, pancreas,
16:56colon, rectal or even anal cancers.
16:58And we have a very nice role in doing so,
17:02often in combination with our
17:04colleagues from medical oncology
17:05and surgical oncology to help
17:07improve the outcomes for patients.
17:11So let's go through each of those in a
17:13bit more detail so that you can give us
17:16a little bit of color of what radiation
17:19therapy is like for each of those.
17:22I'd imagine that it's different, for example,
17:24in the esophagus versus in liver versus
17:27in the pancreas versus in the anal canal.
17:29How does radiation vary based on the site?
17:33So of course it is a different
17:35anatomical site of the body,
17:37and in many of those different
17:39circumstances we use different
17:40radiation technologies, which we
17:42think are best for the specific site.
17:44So for instance,
17:46when we treat an esophagus cancer,
17:48what's always on our mind is
17:50how do we treat the tumor while
17:53minimizing radiation therapy
17:54dose to organs like the heart,
17:56lungs, liver or even kidneys?
17:59Whereas when we're down in the pelvis
18:02treating a rectal cancer or an anal cancer,
18:05we worry about the radiation effects
18:07on the bowel, bladder, genitalia
18:09and bones like the femur
18:11which can be at risk of weakening or
18:14developing fractures as patients get
18:16older and there's a lot of nuance and
18:18art in how a radiation oncologist
18:20designs those fields and is in part
18:23why it's nice to have a specialty
18:25team involved in the care because
18:28there's such tremendous nuance
18:30in radiation therapy design and the
18:33technical specifics of the treatment,
18:35somewhat analogous to the expertise
18:37you may have from a surgical
18:40team as they design
18:42a complex surgical operation.
18:44And timing is the other issue too, right?
18:47So sometimes radiation
18:49is given before surgery,
18:50and sometimes it's given after surgery.
18:53How do you decide which way that works?
18:56For most of the
18:59gastrointestinal cancers we've
19:00through much research learned
19:02that delivering radiation therapy
19:05prior to a surgery is beneficial.
19:08And often that also includes
19:10delivery of the systemic treatment,
19:12the chemotherapy before the operation,
19:14and we've learned that we
19:16improve the cancer control.
19:18And in many instances,
19:19the survival of patients by
19:21delivering both of those treatment
19:23techniques before the operation.
19:25And that includes esophagus cancer,
19:27stomach cancers,
19:28pancreas, and rectal cancers,
19:30each of which we treat with
19:32therapy prior to the operation
19:34in many circumstances, and
19:36one can imagine that doing so
19:39might reduce the tumor burden.
19:42But how does that affect scaring
19:44for the surgeons?
19:46There's many beneficial effects of delivering the
19:48radiation therapy or chemotherapy beforehand,
19:50one of which is that we can actually
19:53see the tumor, rather than treating an
19:56area where the tumor has been removed.
19:59When we can see the tumor, we can focus
20:03the radiation beams more specifically,
20:05and often the area that we have to
20:07treat is considerably smaller when
20:09delivered in the pre surgical setting.
20:12That allows us to reduce the side
20:15effects that a patient may experience.
20:17Additionally, by shrinking down the tumor,
20:20it is often easier or more effective for
20:23the surgeon to remove all of the tumor
20:27with negative margins after the operation.
20:30And after doing this for decades and having
20:34clinical trials look at this for decades,
20:36there doesn't seem to be a dramatic
20:39difference in complications from the
20:41operation when it's done effectively
20:43as part of
20:44a multi disciplinary team.
20:46And yet in some cancers,
20:48radiation is frequently
20:49given after the surgery.
20:50So you had mentioned, for example,
20:53in breast cancer we generally
20:55give radiation therapy after
20:56the surgery is completed.
20:58So why is that?
21:00There's a number of reasons for that,
21:02and I think in the breast cancer
21:05community, now acknowledging I'm
21:06not a breast cancer specialist,
21:08but the typical paradigm has
21:09been to do surgery first,
21:11in part for concern of wound complications
21:14that may develop along the skin.
21:17And in part because it's nice to have
21:20an opportunity to look at the cancer
21:23under the microscope and see the
21:25extent of spread so that we can better
21:28design our radiation therapy fields.
21:30So it sounds like there's good
21:33reasons in GI cancer to do it before
21:36good reasons in breast cancer
21:38to do it afterwards.
21:39So it seems to be really dependent on the
21:43tumor itself.
21:45And individual patients and again
21:48this emphasizes why being
21:49seen and cared for amongst a
21:51multidisciplinary specialty team,
21:53such as that we have at Yale is
21:56really so critical in the care of
21:59our patients.
22:01And you mentioned clinical trials
22:03adding to the evidence
22:05that we have in terms of what we
22:08know works versus doesn't work
22:11in terms of radiation therapy.
22:13Are there ongoing clinical trials
22:15that you're particularly excited about?
22:17There's so many.
22:19My interests are in using multiple
22:22methods of patient and cancer response
22:25assessment to guide the care of patients,
22:28and that can include advanced imaging.
22:31It can involve tumor genetics or genomics.
22:35It can include specific targets on a cancer
22:39cell that may be targeted by medications.
22:43Or it can be specific blood tests
22:45that guide the prognosis for patients.
22:47Potential therapies for patients
22:49can also involve immunotherapy,
22:51and specifically in GI cancers
22:53we've been utilizing
22:54each of those techniques to
22:56help risk stratify and guide
22:58patients for subsequent therapies.
23:00And it's so exciting because many
23:02of these developments are relatively
23:04recent in the past five to 10 years,
23:07and we're really seeing some of the
23:10fruits of these clinical trials now.
23:13Our major cancer conference is ASCO
23:18and it's exciting seeing some of the new
23:21clinical trial developments that
23:22really improve the survival,
23:25but also the quality of life for
23:27our patients as they go through therapy.
23:30Do you think that these novel markers,
23:33the genomic markers,
23:34the biomarkers that we're using to tailor
23:37chemotherapy and systemic therapy,
23:39for example, might actually play
23:41a role in terms of deciding,
23:43for example, whether radiation therapy
23:46should be used or not or what
23:49kind of radiation therapy
23:50I completely do.
23:52I think we're learning so much more
23:55about the prognosis of patients
23:57and the pathways of cancer spread,
23:59which does seem to be influenced
24:01by each of these factors,
24:03and we're learning how to select
24:05patients who may derive more
24:07benefit from radiation therapy.
24:09And on the contrary, we're learning
24:11patients who may derive less benefit,
24:13and that in itself is rewarding because
24:16that provides an opportunity for a
24:18radiation oncologist to help treat patients,
24:21but know that if they do have a side effect,
24:25it was a side effect that developed in a
24:27patient that really needed the treatment.
24:30Those who derive less benefit
24:32can be spared many of those side
24:35effects of therapy.
24:36And what about figuring out which
24:38tumors are more radiosensitive
24:39versus those that are radioresistant?
24:42Are there techniques that we
24:43can use that will help us to
24:46deliver radiation therapy to
24:48tumors that might not be as sensitive to it?
24:51Yeah, this is another very
24:53interesting area of research
24:55which I think we've really just
24:57hit the tip of the iceberg on.
24:59We're learning that genomics or
25:01tumor genetics has an impact.
25:03We're learning that the tissue
25:04surrounding a tumor has an impact,
25:06and I do think that with more
25:08time we'll learn how to combine
25:10new medications with radiation
25:12therapy to improve cancer control
25:14and will learn that there may be
25:17differences in radiation therapy dose.
25:18Or areas that we need to treat
25:20to derive more benefit.
25:22But like I said,
25:23it's really the tip of the
25:25iceberg in regards to that area of
25:27research, which is really exciting.
25:29And so as we think about radiation therapy,
25:31I mean thus far we've really been talking
25:33about using radiation as part of a
25:36treatment paradigm for curative intent.
25:37But you had mentioned early on at the
25:40beginning of the show that radiation
25:42can also be used for palliative intent.
25:44Can you tell us a little bit
25:46more about how radiation therapy
25:47is used for symptom control?
25:50Radiation therapy is very
25:52effective at symptom control,
25:53and I tend to quote that about 2/3 or
25:56more of patients will derive a benefit.
25:59In regards to the specific indications,
26:02often it's for pain control when cancer
26:05has spread elsewhere in the body,
26:08or if it's causing pain in its
26:10original site of development or
26:12radiation therapy can be used to
26:14help prevent organ dysfunction or
26:17complications from cancer growth.
26:19What do
26:20you mean by organ dysfunction?
26:22So a common situation that we end up
26:25seeing is if cancer has spread to a bone
26:28like the spinal column or vertebral body,
26:31that cancer can actually grow into the
26:33spinal canal and start applying pressure
26:36to the spinal cord or to the nerves.
26:39And unfortunately,
26:40one of the consequences of that is that
26:43patients can develop weakness in their
26:45legs or in some circumstances even
26:48the inability to walk because of it.
26:50Radiation therapy can slow down and
26:53shrink the cancer in those bones and
26:55really help relieve the pressure on
26:57the spinal canal or those nerves.
26:59And sometimes that's done in combination
27:01with surgery and sometimes it's not.
27:03We use radiation therapy alone
27:05and it's quite effective.
27:06One of the
27:08things that's so interesting you had
27:10mentioned earlier that when you're
27:12giving radiation in the pelvis,
27:14one of the things you worry about
27:16is the side effects on the bone.
27:18That radiation could weaken the bone.
27:21And yet, at the same time,
27:24when we see patients who have,
27:26for example, bone metastases,
27:28we frequently will use radiation
27:31therapy not only to help with pain,
27:33but sometimes even to help with patients
27:36who might have an impending fracture.
27:39Tell me about how that works.
27:41That seems to be a dichotomy.
27:43Yeah, that's a good question.
27:45When I see patients with bone metastases,
27:48the common questions I ask myself are,
27:50is this metastasis in a bone that
27:53is involved in weight bearing
27:54like the femurs for example?
27:56Or how much of the bone seems to
27:59be destroyed because of the cancer?
28:02If I do think of patients at very
28:04high risk of developing a fracture,
28:07I do ask my colleagues in orthopedic surgery
28:10or neurosurgery to see the patients as well.
28:12Because I do think that surgery
28:15can sometimes be warranted.
28:16In others where it's not a weight
28:19bearing joint or an area that's
28:21involved in a lot of mechanical
28:24strain then radiation therapy is
28:26very effective at shrinking the
28:27cancer and getting control of pain.
28:29Doctor Krishan Jethwa is an
28:32assistant professor of therapeutic
28:33radiology at the Yale School of Medicine.
28:36If you have questions,
28:37the address is canceranswers@yale.edu
28:39and past editions of the program
28:41are available in audio and written
28:43form at yalecancercenter.org.
28:44We hope you'll join us next week to
28:47learn more about the fight against
28:49cancer here on Connecticut Public Radio.
28:55Support for Yale Cancer Answers comes from
28:58Smilow Cancer Hospital and AstraZeneca.