Current concepts in radiotherapy and their impact on oncology.

The constant emphasis on the need for breakthroughs and new modalities of treatments seems to imply that nothing has been achieved, and unless new beams or radiation sensitizers or whatever are discovered, radiation therapy is ineffective. A great amount of information has been acquired in the past 20 years, and innumerable treatment schemes are being used with doubtful outcomes. The fact that patients are at high risk for development of distant metastases is irrelevant if one does not have a treatment that is effective. Multimodality treatments are very popular, but multimodality per se does not make a treatment effective. Medical research is anxious for early and repeated milestones. Cancer is a disease that requires follow-up and, in some areas, like breast cancer, a long follow-up. Baclesse, the great radiotherapist from the Curie Foundation, used to say in his teaching clinics that he was working for the next generation. Radiotherapy exists within the framework of medical practice. To emphasize systemic treatments because of the possibility of distant metastases and, by so doing, to deemphasize freedom of disease in the local area leads to abandoning methods of treatment that have proved effective for control of local-regional disease. An example is the abandonment of postoperative irradiation following mastectomy. It is not disputed that it achieves a very high degree of local and regional control, but it is disputed that it increases survival. Survival benefits with elective chemotherapy are marginally proved in small subsets of patients but do not demonstrably affect the survival rates of the overall population, and there is very little information concerning the local-regional control with elective chemotherapy. Survival benefits are not the only criteria of usefulness of a treatment. Gross recurrence is more difficult to eradicate than subclinical disease by elective irradiation, and there are a number of publications on the poor control of local-regional recurrences in breast cancer. Furthermore, some recurrences, such as invasion of the brachial plexus, are intractable to treatment; recurrences on the chest wall present a terrible problem of management as well as make the patient absolutely miserable prior to death. The present knowledge, primarily of the combination of radiation and surgery in certain diseases, is not applied except to a very small segment of the cancer patient population. The spread of information and the increased use of effective methods should be encouraged.