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Radiotherapy Explained: from planning to patient support

• Dr Gavin Nimon • Season 5 • Episode 77

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Cancer therapy isn’t just about hitting tumours harder; it’s about hitting the right spot, at the right time, with the least collateral damage. 

In thuis episode Dr Gavin Nimon (Host) sits down with South Australian radiation oncologist Dr Vincent Pow to unpack how modern radiotherapy blends precision physics with genuine human care, guiding patients from referral to first beam with clarity and compassion.

We walk through the full treatment pathway—MDT referrals, planning CT, MRI and PET fusion, and meticulous contouring—before demystifying what happens on the machine. 

Dr Pow explains why fractionation protects healthy tissue, how IMRT and VMAT shape dose around organs, and why today’s sessions feel more like a painless CT than a procedure. We dig into SABR’s rise in early lung and prostate cancer, and how targeted ablation is changing the outlook for oligometastatic disease by controlling spots in lung, liver, bone, and brain while delaying systemic escalation.

You’ll also hear a frank guide to side‑effects: what’s common, what’s rare, and how teams manage everything from cystitis and oesophagitis to fatigue and skin changes. 

We explore adaptive radiotherapy—seeing tumours daily and adjusting dose on the fly—plus the growing role of AI in contouring and planning. Dr Pow shares why access matters, how telehealth and cancer lodges reduce travel for rural patients, and where education campaigns like Targeting Cancer help GPs and patients make informed choices. 

This conversation brings the science down to earth without losing the nuance. Follow the show, share it with a colleague who needs a clean explainer, and leave a review with your biggest question about radiotherapy so we can tackle it next.

Aussie Med Ed is supported by HealthShare. 

HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of HealthShare's  products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins,  as well as HealthShare's Specialist Referrals Directory, a specialist and allied health directory helping GPs find the right specialist.

Aussie Med Ed is sponsored by Avant  Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.


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Dr Gavin Nimon:

What if treating cancer wasn't just about fighting disease, but about precision, compassion, and the delicate balance between science and humanity? In this episode of Aussie Med Ed, we step inside the world of radiation oncology. Where every beam of energy is carefully calculated to destroy cancer cells while preserving as much healthy tissue as possible. It's a field that combines cutting edge physics, advanced imaging, and human empathy in equal measure, and few people who body that balance better than Dr. Vincent Pow, a radiation oncologist based in South Australia. Dr. Pow joins us to unpack what radiation oncology really involves, how treatment has evolved with technology like IMRT and stereotactic therapy. And why communication and patient-centered care remain at the heart of good medicine. We'll also explore how telemedicine is transforming access to cancer care for patients in rural and remote regions, and where the future of radiation oncology is heading. So whether you're a gp, a medical student, or simply curious about how modern cancer care works, this conversation with Dr. Vincent Pow will shine a light on the precision, compassion, and innovation driving today's radiation oncology. Good day and welcome to Aussie Med Ed. The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture. I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you're practicing or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, please speak to your GP or seek assistance from health organizations such as Lifeline in Australia. Well, joining us today is Dr. Vincent Pow. He's an experienced and compassionate radiation oncologist who consults across multiple icons, cancer centers. Located in South Australia. He completed his medical degree at the University of Adelaide in 2012 and obtained specialist training in 2021. He currently serves as head of radiation oncology at both the Royal Adelaide Hospital and the Lyell McEwen Hospital and chairs the Radiation Oncology Quality and Safety Committee. His expertise spends a wide range of solid tumor malignancies with special interest in genito-urinary, gynecological, gastrointestinal skin, and prostate cancers, as well as stereotactic radiation therapy. He's also an advocate for telemedicine, helping bridge the gap in cancer care for patients in rural and remote regions. Welcome, Dr. Vincent Pow. Welcome to Aussie Med Ed. Thank you very much for coming on board.

Dr Vincent Pow:

Thank you for having me, Gavin.

Dr Gavin Nimon:

Well, what actually is radiotherapy? What actually does it involve

Dr Vincent Pow:

So I think to put it as simple as possible, radiation therapy is high energy x-ray. And it's the clinical use of that. So we use, has to be ionizing radiation. I can explain the slight differences in, in the different types of radiation, but we use ionizing radiation clinically. So not only to treat cancers, but some benign conditions as well. So that's what is simply,

Dr Gavin Nimon:

Right. what is the difference between ionizing radiation and non-ionizing radiation

Dr Vincent Pow:

So, ionizing radiation essentially is on the electromagnetic spectrum. on the top end of it, x-rays, gamma rays, and it has to, essentially, the energy of it has to kick off an electron and that does the damage. So, common things like microwaves and your phones, they're all on the spectrum. But they. They don't have enough energy or enough power to actually do damage. So that's a common misconception about things like microwaves and, but as you push towards the higher end of the electromagnetic spectrum, then certainly that's what we want. We actually want to do some damage killing cancer cells.

Dr Gavin Nimon:

So is a light, a form of electromagnetic radiation

Dr Vincent Pow:

Yeah, so light, it certainly is on. And you know, ultra ultraviolet light is sort of in the middle of the spectrum and can do a little bit of damage obviously. But we are on the, at the top end Yes.

Dr Gavin Nimon:

Okay. And how does that actually kill the cells then? You me mentioned that pushes off the electrons out of the atoms. Is that how it

Dr Vincent Pow:

Yeah. So, we study this when we when we go through our training it's a big part of our curriculum and an understanding of how we use radiation therapy safely. So the key target for us is actually the DNA. So we wanna damage the DNA strands and we want to create, basically damage both strands called double stranded, DNA breaks. And when we can do that with the high energy x-rays, then that can actually kill the malignant cells, obviously can also harm normal cells, but we can go into how we minimize damage to healthy cells while maximizing damage to the, malignant cancer cells

Dr Gavin Nimon:

are cancer cells more prone to be damaged by the electro-magnetic radiation or there other substances you can use to help protect the normal cells.

Dr Vincent Pow:

Yeah absolutely. So, malignant cells certainly don't repair as well. They don't have that repair mechanism as, as robust as normal tissue. And there's a few things that we do to maximize tumour kill while minimizing side effects. And I mean, that's the whole concept of radio biology. I usually describe it I think best with a classic scenario or picture that all radiation oncology trainees. will know. And it's essentially a picture of the Ram's testicles, the ram's balls.

Dr Gavin Nimon:

right?

Dr Vincent Pow:

And so what they wanted to do essentially they thought, okay, we wanna sterilize a ram, so let's give it one big dose of radiation. And yes, absolutely they sterilize the ram, but their scrotum or the testicles were severely burnt. And instead of giving one big dose of radiation, why don't we give smaller packages of doses? Let's split it up into 3, 4, 5 little packets equals the same dose that we gave in the first boom, but we give it into five little treatments. And they found that giving it that way still created the outcome, the desired outcome of sterilization, but allowed the healthy tissue to recover. And the scrotum, although did get a little bit red. It didn't certainly get severe, like in the first scenario with a single fraction. So it's became the, you know, the basis of what we call in radiation oncology is we fractionate we split apart the doses and we give it over multiple doses

Dr Gavin Nimon:

And does that fractionation vary depending on the organ you're treating then?

Dr Vincent Pow:

Yeah. There are varying schedules. Typically when we are treating with a curative intent, then we would do it over a longer period of time. And the idea being to give a smaller dose per treatment, although it's more prolonged, you still maximize that cell kill, but you also minimize, damage to healthy tissue and allow it to recover. So that's one of the main reasons why we fractionate. There are a number of others but I won't bore the audience with some of the other details about our radio biology curriculum. But that's the main one that the concept there,

Dr Gavin Nimon:

is the general health of the patient going through the radiotherapy, does that help the actual recovery then?

Dr Vincent Pow:

Yeah, absolutely. Absolutely. I think the first thing that we do is we are assessing that patient functionally, and then we typically think about the organ that we are treating or the organs around that we're treating. We take that into account when we deliver our radiation dose. So for instance, when we're treating lung cancer, we make sure that obviously they're optimized from a lung function point of view. We get lung function tests and we have different thresholds, I suppose, where depending on their base level of function, whether or not they're a smoker, et cetera. That's just one example.

Dr Gavin Nimon:

What does the process actually involve then for a patient from referral to actual treatment?

Dr Vincent Pow:

Yeah. So, typically the referral comes through, usually from a multidisciplinary team meeting. So we very busy being involved in many MDTs. We do subspecialize, but we usually, have a few areas of expertise. And they're typically discussed in that forum and recommended for treatment there. And so the referrals usually come through from the chair of the meeting, the respiratory physician, and most of the time it's actually from the surgical team. And we see them in the clinic for an initial consultation. And this is where we discuss obviously, the role that radiation plays. And we clearly outline whether or not we are trying to provide a cure or trying to preserve an organ. We're trying to palliate or help with symptoms. So we'll discuss the side effects, obviously the potential outcomes, the success rates and the typical side effects during the treatment and the typical side effects that you could expect long term. If they're all okay. Obviously with that, then they proceed to their first appointment, which is a planning scan. So They need to have a CT scan, that's specific for us. We set them up in the treatment position. We have a few little things to make sure that they're really immobilized in the right position, set up exactly how we want it, some special techniques depending on where we want to treat so we can track their breathing can really make an individualized mask to keep their head really nice and straight. So a few things that we can do to set the patient up and they have their CT scan that gets imported into our system, our planning system. And what we can do now as well is we fuse or we bring in MRI PET scan, diagnostic ct, and we put it all into the one, system and we use that to help us with the targeting. So that's essentially my surgery or my what. How I plan the radiation. So I get on the computer with the program. It's essentially my daughters call it like paint on CT scans. We draw out the tumour where we want to treat, we draw out the areas at risk potentially of that need radiation. We draw out the areas where we don't want radiation to go. So we'll obviously draw out the critical organs, the organs around it. And then once we've provided those volumes, we give that to our planning team. So we have department filled with radiation therapists who will help plan the treatment. So they'll design a radiation plan to our, to, to the goals. So the goals will be set by us as the radiation oncologist. We might say, I want this area or the tumour to receive this dose. I don't want the this organ to receive this much dose. Please come up with a plan based on that. And so they'll come up with, you know, a potentially a plan that has a radiation beams going this way. They'll have it intensified this way or that way to achieve those goals. And then once we approve of that plan, the patient starts their treatment journey. So they typically come in, so again, if depends if it's a curative treatment or a palliative treatment, but they'll typically come in as an outpatient. Usually it's a daily treatment if it's a curative treat. Treatments are like what I describe to patients as having a CT scan. It's as really as simple as that. Usually roughly a 20 minute appointment, they come in, they lie down on the machine. Most of it, most of the time actually, it's setting them up in the right position. We have to be extremely accurate. A lot of checks and balances. And so on top of that, we actually have a whole physics department, medical physics department that checked and QA every single radiation plan to say, this is what we are delivering and we're delivering it safely. Patient lies down, they don't feel a thing, so it's painless. They don't see anything. It is like having a, an x-ray or a CT scan. They have their treatment, they hear some noises, that's it. They walk out and they come in every day until they finish their treatment. We typically see them once a week throughout their treatment as scheduled. And they also see, dietician, nurse, all parts of the multidisciplinary team. And then they finish their treatment and that goes on to the follow up stage. And then obviously we are then monitoring response and recurrence.

Dr Gavin Nimon:

Right. So you've got a radiation oncologist, like the, or the conductor of an orchestra. You've got the radio therapist. Yep. who also have a degree in physics, do they or?

Dr Vincent Pow:

Oh So I think they, they go through like diagnostic radiographer pathway, but then they split out and they have a therapeutic. so it is a very niche and highly skilled degree as well.

Dr Gavin Nimon:

So they're like the musicians in the orchestra?

Dr Vincent Pow:

So they're planning the treatment. They're del, they're the ones that actually deliver the treatment. So I'm not actually there on the machine pressing the button. Our radiation therapists do that,

Dr Gavin Nimon:

And you've got nurses looking after them as well.

Dr Vincent Pow:

Absolutely. So we've got a big nursing team as well that helps with the side effects, dressings education. So they play a really important part. Just providing that holistic care. We've got dieticians, speech path, social worker on board as well. So we try to look at the patient, obviously at all facets to get them through their treatment and the physics, I suppose. I don't know what analogy you would say that they are, but they're the ones that are making sure that what we say we're doing is correct. Very important as well

Dr Gavin Nimon:

Excellent. How does it vary from say, chemotherapy or surgery? I mean, how do you consider yourself different in that way and how does the treatment feel different?

Dr Vincent Pow:

So, I think we all play a a part in the whole. Any patient's cancer journey or cancer diagnosis? Surgery and radiation. I would say obviously the, generally the mainstay of trying to cure patients. We sort of provide roughly 30 to 40% actually of cures in cancer. And I think where we play in, depending on obviously what tumour type, we, sometimes we do it instead of surgery. Sometimes we do things to preserve an organ. Sometimes we do things to downstage tumours, so some to help the surgeons get a better resection or a clear margin to downstage tumours. and sometimes we give the radiation. Concurrently with chemotherapy to help our treatment be more effective. And sometimes we give it after surgery just to, for those high risk tumours. So yeah, I think you can break them down into the main roles that we play is curative or radical organ preservation. And those who are not medically fit for surgery, we often play a role there or those who are surgically unresectable. And we come in as well. Then you go into the neoadjuvant or before surgery to, as I said, to downstage, adjuvant after surgery. So usually those at high risk of recurrence, and then there's the palliation. And so I think we all combine and we're trying to find novel ways to combine all the time with chemotherapy, obviously chemotherapy gets a little bit more of a, an understanding in the community. I think. It's more of a systemic treatment. It's more of a treatment that strategy that affects the whole body and can kill tumours all over. Whereas radiation is more akin to surgery that it's certainly more targeted more for local areas, but we're again combining different approaches all the time.

Dr Gavin Nimon:

looking at it. When you talk about the ionizing radiation, what about different types of ionizing radiation there, the different frequencies of the waves you're releasing? Or different types too.

Dr Vincent Pow:

So there's, I guess we can break it down into the different modalities or types of radiation that we give. And broadly speaking, it's external radiation, which is the large majority of what we do that's on our linear accelerator or what we call a linac. And essentially it shoots an electron beam into the machine, speeds it up to the speed of light, hits a target, and we get our x-rays or photons coming out, and that will be our mainstay of treatment. Now we can vary the intensity of that, vary what angles and what beams to deliver the type of dose that we want. And then we modulate that, modify it using Different apertures and different ways of creating that beam coming outta the machine. We also have things like electron therapy. So this time it uses, we just essentially trying to use the best radiation characteristics to suit the tumour. So electron therapy is used and what we call superficial radiotherapy is used very commonly for skin cancers. So it's actually a different profile in the way it delivers its dose. So more superficially that would be the mainstay of our treatment. Then we have internal radiation or brachytherapy. So this is actually where we use a radioactive source. We deliver right into the tumour. So brachytherapy is used in things like prostate cancer, cervix cancer, and we are able to get to where the tumour is. it's more, a little bit more, certainly more invasive. But we deliver a radiation source directly to the area and it delivers the radiation from the actual source itself most of the time, depending on the type of brachytherapy, we will remove it. And it's delivered it's dose internally.

Dr Gavin Nimon:

There's no way of putting a substance internally than activating it with a beam externally?

Dr Vincent Pow:

No, not quite. But there is for prostate cancer treatment, we have a low dose rate brachytherapy where we actually put. Radioactive pellets into the prostate and it delivers its radiation slowly over time So, and they stay there. So those patients are technically radioactive, although the activity is really so low outside that it's very to be in so that there is some types that we actually purposely do that. And for thyroid cancers as well we actually give patients radioactive iodine and it actually hones out thyroid cancer cells and kills it that way. We're doing a little bit less and less of that now. The nuclear Med physicians are are being a bit more involved in that space.

Dr Gavin Nimon:

What about it's always a single beam when you're doing the external radiotherapy or can use dual beams to actually hit each other?

Dr Vincent Pow:

that's a great question, Gavin. So that probably goes on to the history of radiation and how far we've come. So it used to be literally four beams. One from the front, one from the back, one from the left, one from the right, classically called that the four field box. And literally everything in that box got the same amount of dose and radiation. Oncologists, not so long ago, were drawing on x-rays, just China graph an x-ray, say, this is where I'd like the dose to go and everything in that area. Got it. So that's what the era of 2D planning or 2D radiotherapy. Then we moved to 3D. So then we started using CT scans. We started using multiple beams from different angles. and now we've evolved to nearly all of our treatments are what we would call IMRT or vmat. So a fancy word for volumetric, modulated arc therapy. And essentially the radiation is. Beam is always on and it's always moving in a continuous clockwise fashion. So we go clockwise and anti-clockwise and the beam itself, there's no stop, shoot, stop, shoot, this angle fixed. It's one continuous nice circle back and the radiation's always on, but there's little leaves inside the machine that can modulate the dose. And that's really from the power of computers and the technology that's able to figure that out for us.

Dr Gavin Nimon:

Sounds like the whole area is just a dead sitter for AI technology as well. And is that used much at all at this stage?

Dr Vincent Pow:

Yeah. We love ai. So we do have AI deep learning modules on our planning systems. So now what that has helped us at the moment is helping us contour organs or so we've trained them on data sets. And they've even been trained on our own cases, and it can automatically have contoured all the normal organ structures for us So that's where it's sitting at the moment. Obviously, the sky is the limit. There are programs and ways that are conting automatically areas for you coming up with better plans. It's really exciting.

Dr Gavin Nimon:

Excellent. Well, moving on to what sort of cancers could be treated with radiotherapy? I believe you've produced a website targeting Cancer, which I've looked at and looked like every type of cancer's on there. Which are the most common ones and are there any ones that can't be treated?

Dr Vincent Pow:

The short answer is no. I think. Statistic that is that one in two cancer patients will have radiation play a role in some stage of their journey. So one in two that's quite significant. And I guess we play a role in every cancer because the radiation or the x-ray beam or the it doesn't discriminate There are tumours that, that respond better. Yes. And some tumours that don't respond, but particularly in the palliative setting or the way that we are helping with symptoms, certainly it plays a bit a majority of the role really. There are obviously tumour sites where sometimes radiation is more beneficial. So this is where we think about organ preservation. So for instance early stage larynx cancers radiation is generally preferred. Cervix cancers locally advanced cervix, cancers, bladder cancer, anal cancer. Radiation, is off often the first point of call. And there are some tumour sites that respond well to radiation. So we know that squamous cell cancers or SCCs, respond very well to radiation. So particularly those that are HPV driven, so head and neck cancers, sometimes, anal cancer, cervix, cancers, that sort of thing. We would strongly favor radiation as a way to obviously get rid of the cancer, but try to preserve the organ. so those would be the main sites where we think about organ preservation. And then I think as the evidence evolves and our technology evolves, you might start to see a shift. So I particularly like, for instance, in lung cancer, early stage lung cancer. We deliver a treatment now called Sabre, which is just a technique. It's still the same radiation. Just highly precise and highly targeted, and that performs a more ablative dose of radiation. And that is now an established treatment for those who are not suitable for lobectomy and who knows as the evidence matures and those trials come out, that might be the preferred option in the future

Dr Gavin Nimon:

well, you've mentioned some of the advances, but trying the different technologies with different beams and now this continuous beam, what other advances have occurred over the years? Obviously AI is a new one.

Dr Vincent Pow:

AI certainly, certainly a new advance for us as well. I think our specialty is clearly heading into trying to be even more precise and so the more precise we can be and the better our techniques, then we can, we feel safer to reduce the number of treatments. So we have seen a clear shift, particularly in prostate cancer where that used to be eight weeks of treatment. The standard now is four weeks of treatment and now there's really good evidence to say that five treatments is as good as four week treatments many scenarios. So there's a clear shift there, and we can see that in breast cancer, again, five to six weeks was the standard before we've gone down to three, which is the standard and the new standard and what we're doing already is one week of treatment for those, I dunno if it's gonna get. Much lower than that. It may, there are some studies to say that we can do it in even a few treatments, but that really helps the patient because as you can imagine, telling patients to come in every day for eight weeks for it's quite a logistical challenge. And when you can tell patients we can get it done in five treatments and it's an outpatient treatment they jump at that. So smaller treatment schedules. Absolutely. I think we can see that the other exciting area is what we would call adaptive radiotherapy. So again, this is where AI can really help us. At the moment we are a bit more reactive. So you know how I said we do a CT scanning, CT scan. We try to replicate that plan at the start of the treatment, but organs move people. Slight changes in variation. all those little changes we do account for, but we don't change the plan unless it's quite different. So what adaptive is doing is can we be proactive about it? We can actually see the scan or the tumour every day and essentially create a new plan of radiation every single day if needed, and deliver the dose exactly where we want it to. And then that might lead to, well, if we can clearly see it shrinking, do we need to give it that much more dose? Or if we see it not moving, or some areas that are progressing or getting worse, do we need to escalate the dose? And so that comes in with some new technology, some new pieces of equipment. We have an MRI simulator. which we're eventually getting here at the Royal Adelaide. So I'm very happy with that. And some centers have an MRI Linac, so the linear accelerator has an MRI built in. So that's also seen in a few centers interstate so that these bits of kit allow us that, you know, that sensitivity and that resolution to see exactly you know, what we're doing and where we can escalate the dose and deescalate. So I think, and AI can play a big part of that. 'cause that's a lot of, obviously, a lot of processing power data that, that needs to occur. And a lot of manual process at the moment. I think it's getting there. It's nearly there,

Dr Gavin Nimon:

And , in theory it sounds good, but have adaptive radiotherapy. Is, does it actually change the actual percentage in survivorship or in curative rates

Dr Vincent Pow:

the data is still emerging. I think there's good data now that it's safe, it's very safe and that it's actually improved side effect profiles. So I think really where they're looking at is now is can we even increase the the cure rates by giving extra dose to those who aren't responding? So there, there's still emerging data there, but certainly side effects have, we've seen some reductions.

Dr Gavin Nimon:

Well, that's a good introduction to the side effects actually. So good foot in the door there. But what are the side effects of radiotherapy then? Obviously it depends on what area you're treating.

Dr Vincent Pow:

yeah, so the side effects are local and so we describe to our patients acute or short term side effects. And these are. Transient. They occur usually during the treatment. They build up usually towards the end of the treatment. Actually they peak about a week or two after the treatment And then they mostly subside back to your baseline at the four to six in, in general. So those are the ones. So when I counsel a patient it really depends. So I'm thinking, okay, so we're treating your prostate here. So what's near your prostate? What's, what are the organs around it or the bladder, the prostate itself, the rectum, the skin. And so we think of it simply as, okay, we're gonna be causing inflammation, acute inflammation. And what does that manifest in? Well, you know, with the bladder side of things, cystitis, urgency, frequency getting up at night, that sort of thing. Bowels looser a bit more frequent. so I, and I teach registrars, so it really is. As simple as that. So if we're treating your oesophagus, what does that look like when it's inflamed? Well, this is manifests in pain, dysphagia, reflux, that sort of, you know, burning sensation secretions, that sort so it's tolerated differently depending on where it is. And so, we kind of know already areas that are gonna be more difficult to treat. So, you know, head and neck cancer, certainly more difficult because of all the critical organs there and part of their nutrition. Anal cancer can be quite challenging sometimes And certainly the skin nowadays we don't tend to see what we used to see, many years ago that the skin, unless we're targeting the skin doesn't get to the big points of ulceration quite desquamated skin anymore, unless we're treating those clear sub subsites. It's more those internal organs and typically though the symptoms are very mild and manageable. So the good thing for us is we have seen, again, that shift where we used to have a large inpatient cohort of those particularly head and neck cancers towards the end of their treatment really, they're needing to be admitted because of pain to look after them. So we, we don't see that very often anymore, rarely, So, which is really pleasing because not only are we still trying to come up with strategies to help, you know, reduce their side effects, but I think there's better overall supportive care in that as well. I think in general, I think radiation certainly causes some fatigue. And I explain to patients that's your normal cells healing every day. And so fatigue common. Again, not debilitating usually. Men are, well the men that I see with prostate cancer treatment, for instance, we've got them, some of them playing golf during their treatment and be able, being able to work. And that's what we want. there are also long-term potential side effects of radiation. These are things that can occur some months to years later, potentially. It usually is as a result of your short term side effects. And those, there'll be a degree of recovery. And again, it's really dose dependent. It's function dependent how well your baseline function is. But typically any serious reactions or serious side effects are really uncommon. And we'll discuss that with the patient, depending on the area. But again, it, the mechanism is essentially like a scarring or a fibrosis that can occur in that area. And sometimes we can certainly cause that long-term so that some of them are serious. But again as we reduce the short-term side effects we know that we are gonna reduce the potential long-term side effects

Dr Gavin Nimon:

What about the risk of causing a cancer by receiving radiation? Obviously Madame Curie didn't do so well from her radiation that she received. What's the chance of a secondary cancer of being developing from radiotherapy

Dr Vincent Pow:

cancer? Yeah, the a great question Gavin. Radiation and I, we counsel this on nearly all patients. we know that it can cause a second malignancy risk and that risk is very hard to quantify. It's, very rare and it depends on the age of a patient, how much dose they're getting. I think any amount of radiation can technically cause cancer. But we try to reassure patients that, that, that can occur. If you're taking a flight the cosmic ray actually, you're getting radiation all the time. And we're trying to we counsel patients that it is, a known side effect. And we have to balance that risk, I guess, with the chance of curing the cancer itself. So, you know, we're, we, obviously where it becomes particularly important is in pediatrics. So we do obviously have a large pediatric cohort and we see them at the Royal Adelaide. And we do see some of the devastating side effects of radiation over their lifetime. These are patients that have a high cure rate with the treatments, but also the known side effects, the late side effects of treatment. And they are at risk of developing, some cancers. So we, particularly in pediatrics survivorship is really important. So we look okay, how much dose did the breast tissue get or how much dose did there, and we will act accordingly in terms of surveying that. Generally the patients that we treat that are older, I generally tell them that there's nothing special that we need to do. It's a known risk. And that risk is small and and we will have to deal with it if we can at that

Dr Gavin Nimon:

Well, obviously with so many cancers being potentially treated with radiotherapy there must be a huge demand for it. Just wondering how many radiation oncologists there are, say for instance, in South Australia and what's the chance of the average person requiring your services at some stage in their life?

Dr Vincent Pow:

Well, I think in terms of how many radiation oncologists in our state say, it's probably in the order of about 20 odd. So not too many of us most of us work, both publicly and privately, so I think I would. If I had to, I'll roughly guess it would be around that figure. Look, I'm not sure how, what the general public will need to see. One of us, I hope, like I tell many, I hope I don't have to see them, that you don't have to meet me professionally. Yeah, it'd be interesting to know what the average person's risk is, but as we know that that we are finding ourselves playing a role and more so as radiation becomes more safe and more effective and more known as a really effective treatment, then we are finding that we are getting busier and busier to

Dr Gavin Nimon:

excellent. some of the terms I've actually been looking up to prepare for this talk today, intensity, modulated radiotherapy and stereotactic radiotherapy. And you've mentioned SABRE as well. That's the one used for breast cancer.

Dr Vincent Pow:

so, intensity modulated radiotherapy or IMRT is the, is what I was talking about with the IMRT. Vmat is just the technique. It's the way we deliver that dose And SABRE is again, another more specialized technique where we give higher dose in a shorter period of time. So really short. So typically can be, you know, as small as one fraction or up to five fractions. And we're typically aiming with a different mindset. We're trying to aim at ablating or killing it all off. In that short treatment. So, we are finding Sabre was used much more than we ever have before. And that's due to the technology. It's due to the clinical trials that have shown its safety and efficacy. So, as I said, in lung, that's quite an established pathway. We are doing Sabre now for kidney cancers. We're doing it for prostate cancer. We're also doing it as a sort of a new-ish pathway where previously patients are either palliative or curative. And now there's this sort of new area called oligometastatic disease where patients fit in between. So they may, might, may have cancer that has spread, but it might it be spread to only a few areas. And so, more what we're finding is if we select those patients correctly and we give stereotactic or Sabre treatment to the lung cancer spot, or the bone spot or the liver metastases or the brain metastases, then we're keeping patients on their systemic treatments longer. We are keeping patients away from needing to escalate to another systemic option and keeping some patients alive a lot longer potentially

Dr Gavin Nimon:

Now one of your interest is telemedicine and access to the rural community. I could see that'd be hard, obviously, 'cause you can't have, these machines out in the, in every country area. can you tell me a little bit more about that, about your telemedicine approach

Dr Vincent Pow:

Yeah. I think it for us and probably like many specialties, COVID was a big impetus to light that fire of how do we deliver this treatment or deliver services, you know, closer to home or for patients who live rurally and, when I first looked into how we can do that for our service it was clearly a challenge for radiation our service and our patients who live rurally because our machines are only located centrally. And that's a big problem. And I think studies have shown that the further you live away from a metropolitan area from a linac, that their outcomes are inferior. And so how do we bridge that gap? Telehealth is the first step. So we have established a quite robust telehealth program where we can see patients locally at the local hospital via video link, or we can now also do that through their phones or their laptops or iPads. So we do that commonly for rural patients. We do that to organize ourselves as well so that when they come down, they really only need to come down for their planning scan and everything's sort of set up and then they can go home and then we can sort out the social logistics where they're gonna stay. So often our patients stay in the cancer lodge and they have transport to and fro. And that we try our best to minimize their disruption. So do little things like having the first treatment of the day on Friday and the last treatment on a Monday so some patients can get home if they want. And I think the next step is how do we minimize the planning scan even needing to come in to the hospital for their planning scan. Can we do it locally? And we are exploring options to doing planning scans locally. Or not needing the planning scan at all. There are some centers that do that. That's been a big help for those patients. And then more broadly is can we put potentially a radiation machine in a bigger rural center? And that has been shown to be really helpful for communities. And so because a lot of the stuff can be done remotely, so I can do my radiation planning remotely. The radiation therapist can do the plans on computer. I certainly know in my private work that the planning side of things can be done nationally because of, it's a program, it's a computer. So there, there are ways that we can help patients who don't have easy access. But there's still a long way to go. I think still a long

Dr Gavin Nimon:

That's brilliant. Well, one of the other ways you give a better access is good information. And your other pet hobby is your website targeting cancer. Perhaps you can tell me a little bit about that and what efforts got into that. It looks pretty impressive, what I've

Dr Vincent Pow:

Oh, I can't take credit. This is not my website, Gavin. I'm part of the management committee, so Targeting Cancer Campaign, or is essentially set up by our college, the Royal Australian College of radiologists, the Department of Radiation Oncology. And it was set up mainly to do exactly what we're doing today. So this is why I when I saw your podcast and and your website it aligned exactly to, to what the targeting cancer aims to do, which is basically to educate the public and educate medical students, other gps, other specialties about what we do, how we do it. so we aim to promote it as a safe, really effective treatment and just dispel some of the you know, the rumors or the bad stories. And it's evidence-based. It's written by radiation oncologists, consumers are involved in that. So we have a few consumer reps and radiation oncologists across the country. And yeah the website is. Built specifically for patients and their carers, and then also built for GPS as well. And I love showing my patients that website. Particularly the videos. I think the videos are really important just to to take away the anxiety. It's a big thing, you know, going through treatment and videos and more information is helpful. And it's Australian. and we recently refreshed the website. So, I'm very happy to be part involved in that committee and refreshing that website. So, would encourage all who are interested to have a look

Dr Gavin Nimon:

Yeah, there is, interface was very easy to work through and it was areas from. Basics to more advanced papers to actually read if you needed more information. So it was great. So I'm very impressed

Dr Vincent Pow:

Thank you.

Dr Gavin Nimon:

obviously Vince, we've talked about the whole team that's involved in radiation oncology and radiotherapy. But one, person that's really important is a general practitioner who might pick up on the area or be supporting the patient behind the scenes. Perhaps you can tell me their involvement, how they can be involved in the whole process

Dr Vincent Pow:

Absolutely. I think the GP plays such a critical role in any patients. Cancer journey from diagnosis. They're usually the ones that pick it up from the start. And they have known these patients for a long time and then they also are the ones involved in that multidisciplinary care. Sometimes there is a gap between seeing their oncologist, seeing the palliative care doctors, or seeing us or the surgeon. So I think they play absolutely critical role in terms of looking at the patient holistically, filling that gap as well. You know, there are many things that they can help with in terms of optimizing, particularly smoking, optimizing their health in preparation for radiation. Often a lot of the things that we prescribe or do like, such as things like I often prescribe hormone therapy for prostate cancer has a lot of side effects that and that can occur from a whole body perspective. So we do rely as well on, on a good GP to, to help us think we've always want to also empower GPS and and that's what the website is there for, so that they have an understanding as well, and equally that they don't have to wait for, to see their oncologists or see their surgeon to say, well, what about radiation? And we are seeing that more and more now that gps feel quite comfortable. If a patient has particularly metastatic cancer and they have a symptom, then we don't need to wait the two weeks or three weeks to see their oncologist. So we certainly want to empower GPS from that regard in terms of early referrals to help the patients. Equally, the other majority of referrals that we see through GPS are through for a lot of skin cancers. So we, we have a role in early stage skin cancers, so for patients who are not keen on more surgery it is an option in those that are surgically difficult to get to But no we wanna work closely with them and and I think, as I said, they play an integral part of the team. So again, if there's any gps that are interested in finding out more, certainly I'd say look at the website equally. We when we get round to it, we are looking at putting on some workshops through targeting cancer which goes through some common scenarios, common indications, and then bring them into the Royal Adelaide and give them a tour of our department. And that way they really understand what's being done to these patients and where they're going and what's involved.

Dr Gavin Nimon:

Excellent. Well, where do you think the future's heading though? I mean, obviously there's been a lot of advances over the last 20 or 30 years,

Dr Vincent Pow:

yeah, look, it's, it is exciting and part of the reason why I love this specialty is because it is very technology driven. And also very strong, robust clinical trials driven. And so I think we've spoken about ai, yes, we're very happy that it can help assist us in making better plans and efficiency. And I think the other step is we've adaptive, which we've talked about, I think, shorter treatments more access to some more specialized techniques. So we'll certainly see more saber going forward. We'll see shorter treatments we've talked about. Hopefully you'll see, there's some new, you know, emerging evidence now that we use biological scans to say, well, this area of tumour is more aggressive than this area. Why don't we paint the dose rather than give a standard dose? Why don't we paint the dose again to, and that so making it really personalized down to the biological level. I think that's where we can see things going forward. Yeah, who knows

Dr Gavin Nimon:

brilliant. one of the other things I heard about in the future was something like proton therapy, which I presume uses protons instead of electrons as a form of ionizing radiation. Is that something that's around in the future, do you

Dr Vincent Pow:

think yeah. Proton therapy is, Very exciting because of the characteristics of the proton therapy beam. What we see in is actually it deposits a very high dose to where we want it to, and then after that it drops down dramatically. And so proton therapy at the moment is really for pediatric patients. And those where there are critical organs that we need to get in a really high dose. We just can't because it's sitting next to the brainstem, the optic nerve or chiasm. So proton therapy there is really beneficial. So there are a few machines certainly overseas, a fair few machines now. And and hopefully Australia will get their first one shortly because currently our pediatric patients, if they're accepted for proton beam therapy, will have to go overseas. And that obviously that's a real stress on the patients. So we hope that can be brought to Australia very soon. And that will benefit all pediatric patients to begin with. And then there is certainly more indications to come because of the beneficial nature of the actual beam itself.

Dr Gavin Nimon:

Excellent. Well look, watch this space. Well, one of the thoughts that came to mind when we talked about radiation oncology. I went through medical school many years ago, and one of my colleagues, a friend at the time went through and he went down and became a radiation oncologist. And I thought to myself at the time, I thought, how do you get that idea? I didn't even think about radiotherapy as an option. And how do people, head into this pathway? You know, they're more and more doing so. And what does the training look like?

Dr Vincent Pow:

Yeah, that's a great question and we all have our own little origin stories, I suppose, in terms of how we got here. And it's true, I think it starts from medical school and the general public. Part of actually targeting cancer's strategies is actually to deliver more talks and things through medical school So when I also went through medical school, it wasn't told or talked about very much. And I also just luckily enough to be given that rotation in oncology. And there was a week of radiation oncology, a week of oncology, and a week of palliative care. And when I, and, did that rotation in radiation oncology. I knew nothing about it. And often the students that still come through, they don't know much about it. But when I had that rotation, I said, wow this is something that's exciting. It's clearly something I can see has a strong future. And what drew me to it and what draws others, I suppose, is it has a nice balance firstly of the type of patient cohort. So, I think you can provide very meaningful change and meaningful difference in, in any role that you play in a patient, a cancer patient's but it also has a balance of, it's not quite surgery, but we are providing curative treatments. It's. Got a balance of doing things with technology and those who are interested technology certainly from it's one, it's, certainly suited for those sort of people. I also really like the detailed orientated nature of radiation oncology and how it was very data driven. Very clinical trials driven by the evidence and how that all combines into one with the technology, the patient care, the trials. So, it it's certainly become quite popular. I think now we're starting to see that a lot more. the training program is very competitive now and I think that's where we see more and more people wanting to have a career in radiation oncology. The training program is tough. Like, like any training program. we're part of the radiology college, but we actually have our own training program, which is, doesn't go through a physician pathway or a surgical pathway. It's a five year program split into two phases with exams. And you can expect to rotate amongst the different sites. And in, in SA we rotate through Royal Adelaide Lyell McEwin Flinders, and even Darwin as well. So we are networked with Darwin. So it, it's a I trained here. It's a fantastic program. I trained with your colleague, under your colleague, and now he's my colleague as well. And you know, look I've really enjoyed it. I'm originally from Melbourne and you know, I wouldn't now want to go anywhere, any, anywhere else

Dr Gavin Nimon:

That's brilliant. Well, it's been fantastic hearing about this excellent specialty. and hopefully this will generate some information for those and questions where they may go to targeting cancer they'll able to get more information. So thank you very much Vince for giving up your time today and I really appreciate coming on Aussie Med Ed.

Dr Vincent Pow:

Thank you, Gavin. Thanks for

Dr Gavin Nimon:

Thanks very I'd like to remind you that all the information presented today is just one opinion, and that there are numerous ways of treating all medical conditions. It's just general advice, and may vary depending upon the region in which you are practising or being treated. The information may not be appropriate for your situation or health condition, and you should always seek the advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, Please speak to your GP or seek assistance from health organisations such as Lifeline in Australia. Thanks again for listening to the podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.

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Dr Gavin Nimon

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