Ryan Pohl

Comparative Article Analysis Part I: Trade Journal

Although trade publications are intended to target an audience of a particular trade, it

does so an informal manner that allows a broader audience to understand the topics featured in
its articles. The structure of trade publications is not as rigid as peer-reviewed journals and they
usually do not require a reference section.1 The article I chose to analyze is titled Helical IMRT-
New Treatments Taking Shape for Multiple Myeloma. It was written by Dr. Thomas Rockwell
Rock Mackie and published in the magazine Radiology Today in April 2010. The article
focused on the effectiveness of tomotherapy machines in the irradiation of bone marrow in
myeloma (also known as multiple myeloma) patients that are set to receive transplants. Without
treating the bone marrow, the patients immune system would hinder any subsequent bone
marrow transplant.2 I will provide a brief summary each main point the article made, assess its
strengths and weaknesses, and describe how the information presented can be used by those in
the medical dosimetry field.

The author started this article by offering background information on multiple myeloma.
Myeloma is the second most prevalent blood cancer, with more than 20,000 new cases annually
identified in the United States.2 It has been traditionally treated by combining courses of
chemotherapy and total body irradiation (TBI) of 10-12 Gy before undergoing a bone marrow
transplant. The article then declared that studies in the 1990s suggested TBI doses of 16 Gy are
more effective at treating bone marrow than the traditional prescription. However, the
conventional techniques often resulted in significant side effects to normal tissue so a dose of 16
Gy would cause intolerable side effects. Next, the concept of helical IMRT treatments via
tomotherapy machines was introduced. This treatment system offered radiation oncologists the
ability to deliver targeted doses strictly to bone marrow instead of the entire body, which would
theoretically reduce side effects while maintaining the effectiveness of TBI. The article then
aimed at proving the value of this new treatment technique.

With the endorsement of a few clinical studies and positive patient experiences,
tomotherapy has the potential to be a better option for treating myeloma. The article detailed the
first case of tomotherapy used to treat a patients bone marrow. This clinical trial was conducted
at City of Hope, a California cancer center, in 2005. The patient was able to complete the entire
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procedure with minimal side effects (she just had some nausea and a little itchy skin). At the
time this article was written, the treatment was considered effective as she was noted to be in
remission for nearly five years. Following this personal story, the author concluded by pointing
out clinical trials conducted at the University of Minnesota in Minneapolis and Far Eastern
Memorial Hospital in Taiwan. These early studies indicated that using tomotherapy for
myeloma was feasible; they provided a similar dose to the bone marrow while normal organs
received only 15-65% of the total radiation.2 Having no practical experience with tomotherapy, I
found this article to be both informative and entertaining.

In my opinion, the article was easy to understand and transitioned nicely from one topic
to the next. I liked that the author shared good information about previous forms of treatment
and talked about the basics of tomotherapy. The article also had more support than a lot of other
trade publications I have read. However, some evidence was rather vague and most of it was not
quantified. For example, the author claims that historically the five-year survival rate for
myeloma ranges from 10%-50%, but new treatments enable some patients to live 20 years of
more after diagnosis. Without having a good idea of how many individuals benefitted from that
treatment, it is hard to tell how effective it really was. Does this mean prior to the new treatment
absolutely no patients were surviving 20 years post diagnosis? There also was a tendency to use
relative comparisons instead of absolute statistics, which can be misleading at times. In addition,
it was noted at the end of the article that the author cofounded TomoTherapy Inc in 1997 so there
was obviously some degree of bias.

I chose to analyze this particular article because my internship site was recently visited by
Accuray representatives marketing Radixact (new tomotherapy) systems. Their main selling
point was the versatility provided by tomotherapy and its ability to spare more healthy tissue
when treating complex indications. This article was an opportunity to further explore potential
benefits of having that system. For a student like me, this article served as a nice introduction to
tomotherapy. However, it would not be a reliable source for my clinic to use in researching
tomotherapy before investing in a machine. I think the author did a good job of promoting this
technology, but relied on anecdotal evidence. Therefore, most of the claims should be looked at
with some skepticism.
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References

1. Lenards N, Weege M. Reading & Writing in Radiation Therapy & Medical Dosimetry.
[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry and Radiation Therapy Program;
2017.
2. Mackie T. Helical IMRT- New Treatments Taking Shape for Multiple Myeloma.
Radiology Today. 2010; 11 (4): 8.
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Comparative Article Analysis Part II: Peer-Reviewed Journal

Comparison of radiation treatment delivery for pancreatic cancer: Linac intensity-

modulated radiotherapy versus helical tomotherapy is a peer reviewed article originally
published in the Journal of Medical Imaging and Radiation Oncology in April 2012. In order to
be included in this prestigious journal, the article underwent a rigorous review process by
educated professionals in the field.1 Generally, writings in peer-reviewed journals are held to a
higher standard than trade publications; they are written in a formal manner and designed for an
audience with prior knowledge on the topic. The authors, Taylor et al., main intent was to
assess dosimetric differences between linac-based step-and-shoot intensity-modulated
radiotherapy (SSIMRT) and helical tomotherapy (HT) using real-life clinical examples. A
summary of the articles subsections (abstract, introduction, methods, results, discussion,
conclusion, references) will be presented followed by an analysis of how effective each of these
components were in relaying the authors main message.

Abstracts are concise statements that express the goal of the study, the means to achieve
that goal, and an evaluation of the results produced. The authors of this article organized their
abstract in subsections, highlighting the most important aspect of each segment. This was a
clever approach to summarizing their entire article. It offered the readers an easy way to pick up
significant learning points and gave their article a clear direction. An introduction was then used
to provide background information and help give context to this study. Adenocarcinoma of the
exocrine pancreas has a 5-year survival rate less than 5% and treating the pancreas with radiation
is complicated due to the close proximity of critical and sensitive structures (e.g. small bowel,
stomach, kidneys, and liver).2 The article then discussed technical differences between HT and
SSIMRT. The main distinctions being that HT has a binary MLC design, increased number of
potential beam projections, and delivers radiation in a helical motion. To end the introduction,
the authors mentioned pertinent literature, saying HT has been found to produce a targeting
advantage over SSIMRT in head-and-neck cancer, craniospinal tumors, left breast cancer, and
retroperitoneal sarcoma.2 They emphasized that there was no literature comparing the success of
each modality in treating pancreatic cancer, effectively addressing the purpose of their study.
The introduction provided sufficient background information, a relevant review of outside
literature, and presented the rationale for the study.
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In the methods section of this article, the authors explained how the research was carried
out. Twelve patients, with unresectable pancreatic cancer of comparable size and extent, were
planned for SSIMRT and HT.2 All patients were set-up in the same manner and the same
treatment planning objectives were used for both systems. Three metric models were used to
quantitatively compare the dosimetric differences between the two systems. The uniformity
index (UI) and conformity index (CI) were utilized to evaluate the quality of target coverage.
The quality index (QI) was used to compare the difference in dose received by organs at risk
(OAR). The authors did a good job of describing how each of these indexes were formed and
explained their significance. With the main purpose of radiation therapy being to kill cancer
cells while minimizing dose to normal tissue, these metrics are reliable tools in evaluating a
systems effectiveness.

The information obtained from the study was then presented in the results section and
analyzed in the discussion section.1 The comparison showed that both treatment systems
adequately covered the target volume, with no considerable difference in UI or CI values.
However, QI values indicated significantly less dose to both the stomach and small bowel using
HT plans. Each of these structures showed 16% less volume receiving 30 Gy or more when
using HT instead of SSIMRT.2 The dose to kidneys and liver proved to be comparable for both
methods. The authors then discussed limitations of the study they conducted. One dosimetrist
was solely responsible for all the HT plans while another did all the linac-based SSIMRT plans.
Consequently, there was a huge human factor associated with the outcome of each planning
system. There is a possibility that the difference in OAR doses were a result of a difference in
skill level of the dosimetrists. This factor limits the conclusions that can be drawn from this
study.

Overall, I had a mostly positive impression of this research article. It was well organized,
easy to follow, and referenced a variety of current sources. The authors had no apparent biases;
even though the results of their study supported HT, they discussed some limitations of
tomotherapy machines as well. There were some obvious differences when comparing this
article to the trade publication. The tone was quite different; this article was intent on educating
its readers while it seemed like the trade publication was more interested in promoting
tomotherapy machines. The findings in this report were supported quantitatively instead of
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relying on anecdotal evidence. My biggest critique is that they compared one dosimetrists skill
with HT to another dosimetrists skill in SSIMRT planning. In my opinion, the results would be
more valid if they used a group of dosimetrists experienced with both HT and SSIMRT to make
separate plans for the same patient. I do appreciate how transparent and objective the authors
were when evaluating their own study. Although the results of this study are not entirely
conclusive in my opinion, this article has piqued my interest in tomotherapy and has shown me
that it has a ton of potential. Ultimately, it has caused me to pay more attention to developments
in that market and will lead me to do more research on the capabilities of tomotherapy machines.
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References

1. Lenards N, Weege M. Reading & Writing in Radiation Therapy & Medical Dosimetry.
[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry and Radiation Therapy Program;
2017.
2. Taylor R, Opfermann K, Jones B, et al. Comparison of radiation treatment delivery for
pancreatic cancer: Linac intensity-modulated radiotherapy versus helical tomotherapy.
Journal of Medical Imaging and Radiation Oncology. 2012; (56):332-337.