Future Directions in Cancer Research What does is mean for medical physicists and AAPM?

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1 Future Directions in Cancer Research What does is mean for medical physicists and AAPM? John D. Hazle, Ph.D., FAAPM, FACR President-elect American Association of Physicists in Medicine Professor and Chairman Department of Imaging Physics Bernard W. Biedenharn Chair in Cancer Research Organizational philosophy Organizations must be dynamic to be effective. Recalibrate regularly Look forward as well as back Know who they are and what they want to be Be strategic Leaders must ask disruptive questions to facilitate broad thinking.

2 Disruptive question for AAPM What is the scope of science in medical physics addressed by the AAPM? AAPM definition is the broad application of physics principles to biology and medicine. AAPM vision and mission statements Vision The AAPM is the premier organization in medical physics, a broadly-based scientific and professional discipline encompassing physics principles and applications in biology and medicine. Mission The mission of the AAPM is to advance the science, education and professional practice of medical physics.

3 How has the AAPM practically defined medical physics? Radiation oncology physics Radiological imaging physics X-ray, CT, MR, US Nuclear medicine physics Radiation effects Optical Hyperthermia How should AAPM move forward? Do we continue to focus largely in the sciences and practices of radiation physics, radiological imaging physics and nuclear medicine physics? Do we strive to expand the focus of AAPM activities to include a broader scope of science? What? Who? How?

4 Who will make this decision? Board of Directors Tony Seibert Strategic Planning Committee Mike Hermann Science Council Dan Low Research Committee Rebecca Fahrig and Dick Fraas Work Group on the Future of Medical Physics Robert Jeraj and Thomas Bortfeld Let s start with a big picture Healthcare in America is undergoing great changes. Tremendous pressure to contain the escalating cost Conflict of interest and compliance getting lots of attention Funding of biomedical research is under increasing pressure to produce. Cancer research in particular is under the microscope from the lay community, insurance industry and the government. Education is under fire at almost all levels. The storm is not over --- it may be just beginning! But I m still positive about medical physics!

5 What s driving cancer research? GOOD NEWS Death rates for the four most common cancers (prostate, breast, lung, colorectal), and all cancers combined, continue to decline. The rate of cancer incidence has declined since the early 2000s. Length of cancer survival has increased for all cancers combined. BAD NEWS Incidence rates of some cancers are rising including melanoma of the skin, non-hodgkin lymphoma, childhood cancer, kidney and renal, leukemia, thyroid, pancreas, liver, testis, and esophagus. Death rates for pancreas, esophagus, thyroid, and liver are increasing. Few cures. Cancer treatment spending continues to rise along with total health care spending. 11

6 What is happening at NIH/NCI? While many institutes at NIH fund imaging research, I will focus today on NCI since they fund most of the imaging and almost all of the radiation oncology research. Dissolution of the highly successful National Center for Research Resources (NCRR) was an omen for changes to come in how NIH approaches research. The new leadership at NCI (Harold Varmus, M.D., Ph.D.) wants to focus on fundamental approaches to curing cancer. This approach is echoed by many leaders in the cancer research community, including new MDACC President Ron DePinho, M.D. Investigator initiated research and team research are competing for resources. 13

7 Provocative questions project How does obesity contribute to cancer risk? Are there ways to objectively ascertain exposure to cancer risk using modern measurement technologies? What are the molecular and cellular mechanisms by which patients with certain chronic diseases have increased or decreased risks for developing cancer, and can these connections be exploited to develop novel preventive or therapeutic strategies? Why do certain mutational events promote cancer phenotypes in some tissues and not in others? Can tumors be detected when they are two to three orders of magnitude smaller than those currently detected with in vivo imaging modalities? Are there definable properties of a non-malignant lesion that predict the likelihood of progression to invasive or metastatic disease? Provocative questions project Why do second, independent cancers occur at higher rates in patients who have survived a primary cancer than in a cancer-naïve population? How do we determine the clinical significance of finding cells from a primary tumor at another site? Since current methods to assess potential cancer treatments are cumbersome, expensive, and often inaccurate, can we develop other methods to rapidly test interventions for cancer treatment or prevention? Given the difficulty of studying metastasis, can we develop new approaches, such as engineered tissue grafts, to investigate the biology of tumor spread?

8 The hallmarks of cancer The seven hallmarks of cancer and their links to tumor metabolism, Kroemer G, et al, Cancer Cell, 13:472 (2008) Imaging the hallmarks of cancer Padhani A R, Miles K A Radiology 2010;256:

9 The future of cancer research is genomics 19

10 20 instability, thereby increasing the number of mutations (genetic variants). Padhani A R, Miles K A Radiology 2010;256: by Radiological Society of North America

11 Major energetic metabolic pathway of cell associated with 13 C labeled pyruvate, Golman K, et al, Cancer Res, 66:10855 (2006) Small animal IGRT platforms Precision X-ray 225Cx Xstrahl SARRP

12 NCI Centers for Physical Sciences in Oncology The National Cancer Institute (NCI) is exploring new and innovative scientific approaches to better understand and control cancer. The Physical Sciences in Oncology initiative will establish scientific teams and individual scientists from the fields of physics, mathematics, chemistry, and engineering to examine cancer using approaches that have not been followed in cancer research to date. 12 Centers for Oncophysics

13 Article related to the oncophysics centers Nature Reviews Cancer 11, (September 2011) Nature Reviews Cancer 11, (September 2011)

14 Conclusions and outlook The physical laws and principles that define the behaviour of matter are essential for developing an understanding of the initiation and progression of cancer at all length scales. For example, the metastatic process, the generation and maintenance of heterogeneity within and among tumours, the emergence of drug resistance and the ecological behaviour of cell types with differing reproductive fitness and degrees of drug sensitivity, and the delivery of therapeutics to the core of a tumour, as well as its distant metastases, will all benefit from an application of physical science approaches to oncology. Thus, the successful integration of approaches from mathematics, physics and engineering with cancer biology may be our best hope to understand complex systems such as cancer and to develop effective strategies for a cure. Nature Reviews Cancer 11, (September 2011) What is the impact of these changes on AAPM? The shortest term impact will be on the types of research being funded by NIH/NCI. Fundamental instrumentation related research is less likely to be funded as a standalone project. Most instrumentation research will likely be linked to applications of the technology to a specific cancer problem. The intermediate impact will be on what the educational profile should be for a medical physicist. What are the evolving core competencies that will be needed to be competitive for peer-reviewed research grants in the future? Ultimately, this could change the face of cancer care and the role of the medical physicist in delivering that care. What will be the role of the medical physicist in 10 years if the science of medical physics does not continue to evolve?

15 What does AAPM need to do? Take the lead in monitoring and supporting interaction of its members with the funding agencies. We need to develop a robust model for estimating manpower needs across the scope of the organization. We need a good estimate now and a model to project 5 and 10 years out. We need to know therapy vs. imaging We need to know clinical vs. academic vs. research Plan educational programs need to meet these needs. Sustainable educational programs Our educational programs have been relatively homogeneous in preparing medical physicists. Ph.D. programs have been expected to develop clinical, academic and research medical physicists using basically the same educational programs. Special or terminal M.S. programs were developed to meet the manpower needs for clinical medical physics, but until recently have been abbreviated Ph.D. programs. Much of the funding for all these trainees has been on grants and contracts. The preparation for clinical only medical physicists needs to evolve into a financially sustainable program that meets the basic clinical demands. Academic medical physicists that work in both the research and clinical domains will be educated in much the same way as the past. Medical physicists expected to be at the forefront of research will need to be educated in the sciences important for the next generation of research.

16 To quote the most recognized physicist Imagination is more important than knowledge. Albert Einstein Summary Medical physics is vibrant profession. Lots of opportunities Some challenges The world around us is changing and we better pay attention! Continuing to define and refine who we are and, more importantly, who we want to be is critical in developing a strategic plan. The AAPM s role is to provide a framework for addressing challenges and opportunities, and to provide support for us to achieve our goals in patient care, research and education.

17 Acknowledgements Larry Clarke, Jim Deye and Huiming Zhang at NCI Science Council members John Boone, Thomas Bortfeld, Rebecca Farhig, David Jaffray, Robert Jeraj RSNA leadership Hedi Hricak, Dick Ehman and Burton Drayer MDACC research leadership John Mendelsohn, Ray DuBois and Ron DePinho MDACC EAB members