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Radiation Therapy Has Transformed Over the Past 25 Years

Interviewer: Radiation therapy isn't what it used to be, and for patients with prostate cancer, that could mean additional options for treatment. At the Huntsman Cancer Institute, advanced imaging and AI tools are helping doctors tailor prostate cancer treatments to each person, often improving accuracy and protecting a quality of life.

Joining us today is Dr. Jonathan Tward. He is a physician and professor of radiation oncology at Huntsman Cancer Institute, and he's here to explain what some of these new therapies mean in plain English and what a patient can expect.

Now, Dr. Tward, to start, for someone who maybe has just got their diagnosis of prostate cancer, how is radiation therapy today different from what it has been or what a patient may have heard about years ago?

Dr. Tward: Radiation therapy has really come a long way in the past, really, 25 years. I think there was a fundamental change about 25 years ago.

But one of the difficulties that radiation oncologists, in a way, have to battle when meeting a patient who is newly diagnosed with prostate cancer, who may be considering radiation therapy, is that they usually know somebody who's had radiation therapy in a different context. Maybe they knew somebody with breast cancer, or maybe they know somebody who had colorectal cancer who had radiation, and they know that in those people, they may have had some skin changes or skin burns. They may have been uncomfortable. They may have combined it with chemo.

And so, in a way, there's a bias in a patient who is sitting in front of me because they're expecting side effects like that.

And 25 years ago, if you were to radiate somebody for prostate cancer, you would explain to them that they could have skin changes and skin burns, and there would be a risk to their bowels. But around the turn of the 21st century, most clinics really upped their game by investing in computer-controlled treatment delivery machines.

From Broad Beams to Precision Targeting

One of the major innovations at that time was something called intensity-modulated radiation therapy, which is just Dr. Gobbledygook for our ability to basically highly conform radiation to any 3D shape we wanted in the body.

We made the switch to this highly conformal radiation, where we can really just put the high doses right around the target, which would be the prostate gland. And we could use CT-based and MRI-based planning. It dramatically lowered side effects, and that was one major innovation about 25 years ago.

And then falling on the heels of that innovation came what's called image guidance. And so on top of the idea that you can conform radiation, you also have to consider the fact that the prostate can move around inside the body. And so you've got to deal with the motion management.

There are all kinds of technologies that began to evolve about 20 years ago to do some kind of daily imaging before the beam turned on, so that you can see exactly where your target was at that moment before you actually turned on the beam. And that further reduced the risk of both short-term and long-term side effects, and especially did a great job of protecting the bowel specifically.

Then people started to say, "Well, it's one thing to understand where the prostate gland is right before you turn the beam on, but what about while the beam is on?" And so those became tracking technologies.

To this day, there are many facilities that don't even have tracking technologies. We first invested in tracking technologies about 15 years ago. And so we've been able to hit moving targets while the radiation beam is on, and that further reduced the risk to the patient.

Fewer Treatments, Faster Recovery

And then within the past decade, we started gaining evidence that instead of putting people through 45 sessions of radiation or even 28 sessions of radiation, when you combine all these technologies, the ability to highly conform to a target, the ability to see exactly where it is inside the body before you turn on the beam, the ability to track its motion while you have the beam on, this let us reduce the number of treatments to anywhere from one to five treatments.

That's something that's truly amazing, I think, because when most people think about radiation therapy, they think that they're going to be coming in every day, Monday through Friday, for six weeks, eight weeks, which is still what many clinics in the United States do.

When you come to a big NCI comprehensive cancer center like Huntsman, we have these technologies and the expertise and people who are so specialized in treating prostate cancer. Not just the physician, but the therapists who actually treat the patients day-to-day, the dosimetrists who create the treatment plans that we approve, and the physicists who do all the quality assurance. That's been the real game changer.

And honestly, in the year 2025, going on 2026, it's remarkable the patient experience. With all these technologies coming to bear, people have very few side effects from the treatment, and they recover very quickly.

Interviewer: I guess I'm just a lay person out here, but just so I understand, you're able to cut the side effects, cut the amount of treatments, etc., because you're basically able to irradiate or send a beam of radiation to just the area that needs it. It's not like we're doing a full body, not we're doing a whole area, etc. And that technology has kind of made it easier for us to really direct that beam and to kind of treat the area where the cancer is.

Dr. Tward: That's exactly correct. I think the best metaphor to consider this way we do it is imagine you had an arena and a person standing in the middle of the arena, and you wanted to light that person up. In the olden days, you would take a couple spotlights, let's say, and you could illuminate that person inside the arena, but you'd see the beam path all the way through the arena at night.

Whereas how this works today is imagine instead you give every person in the arena a very weak flashlight that they could focus and aim perfectly onto the patient. You could still illuminate that person, but no one beam path would have a very significant amount of radiation, and you may see a very low glow in the arena. That's what's really going on.

So what we're doing is we have a machine, it's called a linear accelerator, and a patient lies on a table. And what it does is it's rotating 360 degrees around the patient, kind of like my arena metaphor.

As it's rotating around the patient, it can shape the aperture of the beam to look exactly like the prostate gland from whatever angle it's at. That right there helps shape, let's say, the dose delivery from any one beam angle.

But then, to get even more geeky with all kinds of computerized and engineering trickery, we can effectively change that aperture into little pixels and change the intensity of the beamlets through each pixel.

So you're arcing 360 degrees around the patient. You could change the intensity and shape of the field and change each individual little pixel of the beamlet effectively. And what this does is it creates extremely low-dose radiation from any angle, but where all these beams converge, you can basically dose paint any shape you want. And that's how we get away with making it so safe and so effective and so low risk.

How AI Is Making Cancer Care Even Smarter

Interviewer: And getting geeky, if I can get even a little geekier, we live in the age of AI right now, etc. It kind of seems like it's on the tip of everyone's tongue. What is the next technology that you think will be coming into the precision radiation realm?

Dr. Tward: Before AI became a buzzword a few years ago, the field of radiation oncology was, shall we say, an early adopter of AI technologies. And for example, one of the things that a radiation oncologist does is they take 3D image sets, CAT scans, MRIs, and in the past, we would go slice by slice, because these are image stacks, and hand-draw the targets, which would be the prostate, the normal anatomy, the bladder, the rectum, etc. And it would create a 3D model.

Now, an AI can help us in suggesting those contours. That's not to say that we don't check them, but we can save a lot of time by having the AI suggest and contour the normal anatomy and the targets, and then I can verify them or alter them.

Sometimes the AI might catch something that was very subtle, let's say, that I may not have seen. And sometimes I can catch errors that the AI might suggest.

But I think together, human and AI, we can get a high degree of precision on what the actual treatment volume should be. So that's just one example.

On top of that, once we create this 3D model on the computer, we have a huge rule set that we give to a very talented professional called a dosimetrist, who actually does what people think I do. What the dosimetrist does is they actually model different beam angles and intensities in a computer, and they spend hours doing this to try to come up with a treatment plan that is going to be safe.

What's interesting how AI technology has helped us there is we can now take any one individual's treatment plan and compare it to our library of hundreds or thousands of other people who've been treated in the past, and can model what we can do to ensure that the toxicity and side effects will be at a minimum based on what is the best plan we can achieve comparing them to hundreds or thousands of others.

I mean, these are game-changing technologies that we've already implemented. They're not even the future.

Interviewer: They're the now.

Dr. Tward: Yeah, they are what we are doing now.

And to get even more into the future or what is now, linear accelerators, or treatment machines, actually have the technology to adapt and shape day-to-day what the beams look like if the anatomy is changing day-to-day.

Radiation oncology, being such a computer-intensive and data-driven specialty, has really exploited these amazing tools.

And just to say one more thing about AI, it's nice to talk about the technology and how conformal the radiation can be, and it's very sexy and sounds exciting. I use AI risk classifiers that I have helped create and worked with collaborators so that before we even come up with a treatment, rather than putting a patient into a stage and treating them all the same way in that stage, or a risk group and treating all the same, we get highly precise estimates of what the best treatment for them would be.

So I'm using AI to help the patient choose a precision oncology approach. And then I'm using AI along the care path to increase efficiencies and improve safety, and ensure we get the highest cure probability along the way. And it's exciting to see what the future may be.

When to Consider Radiation Therapy Over Surgery

Interviewer: Wow. So it just sounds like there's a lot of technology working towards minimizing side effects, and getting down to one to five treatments is so much different than 30 to 40 sessions.

So when you talk about reducing side effects or improving outcomes, etc., what does that look like when it comes to precision radiation therapy with prostate cancers?

Dr. Tward: There are generally three areas that both patients and physicians are focused on when they're pondering treatment for prostate cancer. And one is, will their bladder work the way it used to? The other is, will their bowels work the way they used to? And another is, will their sexual function work the way it used to? These are all primary concerns for most patients.

And the thing that has really changed the most with all this technologic innovation is pretty much nearly erasing bowel problems.

In fact, there have been recent prospectively randomized trials that have randomized men to either surgery, radical prostatectomy, robotic radical prostatectomy, or radiation therapy. And those trials, which have been completed and reported mature results, some going out now 12, 15 years, have proven that the risk of bowel injury between surgery and radiation is equivalent and practically zero.

So bowel problems used to be one of the bigger question marks when people were choosing between surgery and radiation, and now we can very confidently say that the risk of any long-term bowel injury is the same as surgery, which hovers around a serious problem at about half of 1% of people treated.

On the urinary side, a lot of people with prostate cancer are very concerned about incontinence, which is leaking urine. And one of the things that's always attracted patients to radiation therapy instead of surgery is that the risk of urinary incontinence was much lower, always has been, and remains lower with radiation therapy than surgical removal of the prostate gland.

And that's for an interesting reason, which is that you basically have two ways to control continence. The surgeons have to sacrifice one of those ways, and for most patients, they can regain continence after surgery. But a radiation doctor doesn't destroy one of the sphincters, and so patients just tend not to have as much leak problem.

Now, to be fair to my surgical colleagues, surgeons can improve urinary function in people who may already start off having a lot of urinary frequency, a lot of urinary urgency, waking up at night, that kind of thing. So, patients with those kinds of baseline situations, I often counsel them that they should probably get a radical prostatectomy.

But if people don't have a lot of urinary bother at the baseline, really, whether they choose surgery or whether they choose radiation is both likely to have great oncologic outcomes, but we won't have the urinary incontinence risk. But I won't likely improve someone's peeing. The most likely outcome is we'll keep them the way they are.

I think a lot of patients are worried about getting worse. And they presume maybe before they talk to radiation oncologists that if they get radiation therapy, they're going to get worse. But the most probabilistic outcome is that they will pee the same when all is said and done. And so I think that that's a very gratifying thing for a patient to hear now that all this technology has come to bear to protect them.

And maybe just to touch on sexual function, with an extremely talented surgeon who can do a nerve-sparing surgery, something like 80% of people who have great sexual function to start can expect to maintain sexual function. And the probability is going to be the same if you do radiation therapy.

One of the interesting things is that the function is highly dependent, again, on where you start. If you already have a little bit of erectile dysfunction, then the probability is not going to be so high.

And when you go back and look at those randomized trials I referred to earlier, they pretty much have shown that at the population level, radiation therapy is a little bit more likely to preserve erectile function than surgical removal.

However, I think you can work with a multidisciplinary team. And one thing I value so much about working at the Huntsman Cancer Institute is that I feel like I work with the best and most talented surgeons in the world, and I think we work together to really try to optimize the outcomes for patients.

And so we discuss patients and they get multidisciplinary care, and we ensure that the ones who would be best served by surgery get a surgery, and the ones who would be best served by radiation get radiation.

But most patients fall in the middle, where they're really not best for one or best for the other. It's more of both are options. And I think once people realize that the most probabilistic outcome of either a surgery that you receive at the Huntsman Cancer Institute or radiation you receive at the Huntsman Cancer Institute is that you're going to have your cancer cured and you're going to maintain the same quality of life you had before, or improve it, then it's a win-win for everybody.

Hope and Confidence After a Prostate Cancer Diagnosis

Interviewer: I'm sure you work with patients all the time. And if there's a man out there who just got their prostate cancer diagnosis, as a radiation oncologist, what do you tell patients like that to maybe give them hope? How can we assuage some of the fears they might be having right now?

Dr. Tward: The vast majority of men who are diagnosed with prostate cancer are diagnosed with a localized prostate cancer that hasn't spread beyond the prostate. That's probably 85% of men.

People being told they have a cancer diagnosis is pretty devastating. Their mind goes to a dark place immediately, where they think they're probably going to die. However, localized prostate cancer is highly curable.

And even when a cure cannot be achieved, the probability of dying of prostate cancer within the next 15 to 20 years is very low, because with a talented group of radiation oncologists, urologists, and medical oncologists, we can keep people alive and well for many, many years.

But I think the take-home message for a newly diagnosed prostate cancer patient is that they should speak to both a urologist and a radiation oncologist to make sure they fully understand their treatment options.

That's true if they have localized disease. And if they happen to have a little bit of spread, they're going to be okay. But we'll also include a medical oncologist in that discussion. And working together, we'll make sure that they have an excellent life going forward.