At The Princess Margaret, we never settle. We are always pushing the envelope. We don’t just invent technology. We build the facilities and the processes needed to impact every aspect of cancer care.
This has allowed us to explore completely personalized approaches where we take images of the patient just before treatment, design the plan for them, and treat them in ways we could never have achieved before.
We are also continuously adopting new methods, including the power of machine learning and artificial intelligence, to deliver precision medicine.
The Princess Margaret is transforming cancer care for Canadians thanks to advances in technology, fueled by the innovation of our cancer experts and the generosity of our community.
With your support, we will Conquer Cancer In Our Lifetime.
The Guided Therapeutics Operating Room (GTxOR), part of the Princess Margaret Cancer Program, is the most technologically advanced research operating facility in Canada. The unique systems allow our cancer experts to see what’s going on inside a patient before, during, and after surgery.
The team in the GTxOR can acquire high-resolution computed tomography (CT) images during surgery to inform clinical decision-making in real time. This technology enables new, minimally-invasive surgical procedures in the head and neck, lungs, heart, and vascular systems.
Surgical Oncologist, Dr. Jonathan Irish, Medical Physicist, Dr. Robert Weersink, and Radiologist, Dr. Walter Kucharczyk, along with a multi-disciplinary team of specialists, led the development of the GTxOR. It was made possible through a collaboration with the Techna Institute, a research and development centre at University Health Network (UHN) designed to improve patient outcomes through technology.
The GTxOR was made possible through funding from the Ontario government, industry partners, Canada Foundation for Innovation, Toronto General & Western Hospital Foundation, and The Princess Margaret Cancer Foundation.
Acquires CT images without moving the patient.
Multi-axis robotic arm moves the x-ray source around the patient during imaging.
X-ray images form a three-dimensional (3D) picture of the patient’s cancer.
CT uses two x-ray sources simultaneously to reduce imaging time
X-ray sources enable dual-energy techniques differentiating cancer from healthy tissue.
Technology allows the patient on the surgical table to be easily moved to various areas of the operating room during and after surgery.
Technicians in the control room support the surgical team by controlling the systems that acquire, process and display 3D images.
Endoscopes (small cameras) allow surgeons to see internal anatomy during minimally-invasive procedures.
Latest in video endoscopy equipment, including HD and 4K technologies.
Video equipment, suspended from the ceiling, records treatments allowing the cancer experts to review and learn.
Two anesthesia units for room configuration flexibility.
Collaboration with anesthetists ensures imaging procedures do not interfere with anesthesia lines or monitoring equipment.
Large-area screens display intraoperative images acting as “3D GPS for surgeons.”
Helps surgeons remove tumours, avoiding damage to nerves and arteries.
Surgical dashboard software (“GTx-Eyes”) shows in real time the location of surgical tools.
Surgical oncologists, anesthetists, radiologists, physicists, nurses, fellows, engineers, and other support staff work together in the GTxOR. A lot of learning also takes place here, allowing for the improvement of cancer care with each patient.
Scientist, Dr. Benjamin Haibe-Kains sees major potential in what technology can do for cancer patients in the years ahead.
In his lab at the Princess Margaret Cancer Research Tower, Dr. Haibe-Kains works with a diverse group of computer scientists, engineers, mathematicians, and statisticians.
Together, they are using their collective skills to comb through massive amounts of molecular data in an effort to predict the best therapies and drug combinations for cancer patients.
“This is a complex problem that requires multi-disciplinary and complementary expertise,” says Dr. Haibe-Kains.
It’s also a problem that requires the use of artificial intelligence and machine learning because of the scale of the data that is involved.
“Humans are not equipped to crack large volumes of complex data,” says Dr. Haibe-Kains. “You need powerful computers to see what the genes are, the patterns that are important, and how you combine all those complex patterns to do what you want to do, which is design new therapies for patients.”
Eventually, Dr. Haibe-Kains believes it will be possible to identify drugs that help fight cancer, while also boosting the performance of accompanying medications, giving patients a better result.
It’s not an easy task and it’s something that can’t be done without the use of technology.
“Finding the best treatment is already hard. Finding the best combination of treatments is exponentially harder,” Dr. Haibe-Kains says.
“And that’s why we need computers: To find the answers so we can define treatments for each patient.”
A cancer diagnosis comes with a sense of urgency. Patients, families, and health care providers all want treatment to start as quickly as possible. It’s no different for Dr. Tom Purdie, Medical Physicist, and Dr. Chris McIntosh, Techna Researcher. Their efforts to increase efficiency of radiation treatment planning – to get patients the right treatment sooner – led to the development of AutoPlanning, with the support of the Techna Institute.
“AutoPlanning uses artificial intelligence (AI) and deep-learning algorithms to harvest information from a massive database of high-quality proven radiation therapy plans,” says Dr. McIntosh.
Now, instead of relying on radiation therapy treatment plans generated manually – which can take hours or days – plans can be ready for review in minutes. AutoPlanning technology not only makes the complex radiation therapy planning process more efficient, it generates highly-personalized plans best suited for each patient.
“When I was in graduate school, none of this was on the radar,” Dr. Purdie says. “We require tremendous expertise and experience to generate plans. With AutoPlanning, we are learning from hundreds to thousands of cases we already know are good. We can draw on that experience to improve the way we deliver radiotherapy to patients.”
Radiation treatment plans must be designed to direct sufficient radiation at tumours, while avoiding healthy organs and tissues. Today, AutoPlanning determines the correct balance instantly, speeding up the patient’s access to treatment that’s both tolerable and effective.
“This technology allows the Radiation team to take on more complex cases and provide precision medicine to more patients,” says Dr. Purdie.
Earlier this year, UHN announced the licensing of AutoPlanning to RaySearch Laboratories in Stockholm, Sweden. The deep-learning algorithms of AutoPlanning will be available in RaySearch’s RayStation treatment planning system next year. With this agreement, groundbreaking technology pioneered at The Princess Margaret will be available to patients around the world.
As a Neuropathologist and Scientist at The Princess Margaret, Dr. Phedias Diamandis specializes in diagnosing brain cancer. “Many critical decisions surrounding a patient’s treatment plan are based on their pathology reports. Accuracy is critical.
I help provide some of the answers in hopes of the best possible outcome,” says Dr. Diamandis.
Dr. Diamandis’ quest for precision led him to explore the benefits of artificial intelligence in pathology. “When I was training, the technology of scanning glass slides into digital images was in its infancy,” he explains.
Today’s technology allows for the highest quality resolution. “Our research uses computers to help us precisely measure thousands of informative metrics, such as the diameter of tumour nuclei
and the proportion of tumour cells dividing. This data, which we never had access to before, may help us refine our predictions of how individual tumours behave.”
Over the past year, Dr. Diamandis’ research team developed an artificial intelligence tool they call “brAIn.” It uses cutting-edge technology called deep learning to automate diagnostics.
“This technology could help transform routine pathology from qualitative art to quantitative science, and provide patients with more accurate diagnoses in shorter time frames.” This technology can be shared over the internet, too. Dr. Diamandis explains, “We hope to make brAIn a cost-effective and widely accessible diagnostic aid for remote cancer centres around the world.”
Dr. Diamandis does not see artificial intelligence putting physicians out of work anytime soon. “Computers and humans excel at different aspects of image analysis, creating a dynamic duo for diagnostics. I see brAIn augmenting the services provided by pathologists and, in the end, patients will benefit the most.”
WHAT IS THAT?
Here we see how a pathologist (TOP) and a trained computer known as “brAIn” (BOTTOM) visualize biopsy material from different brain tumours (e.g. glioblastoma). The brown colour highlights the computer-detected tumour within the patient’s tissue. The computer compares the patterns of this abnormal tissue to thousands and millions of previously seen examples and communicates its interpretation to the physician using prediction scores.
Progress in nanotechnology is opening a realm of possibilities for Dr. Gang Zheng, Senior Scientist, and his team at The Princess Margaret. This innovative approach could offer real-time feedback in cancer diagnosis and treatment.
Nanoparticles are small enough to reach almost any part of the body, giving them remarkable potential.
Biological processes happen at the nanoscale. Cancer is no exception. With imaging done via nanoparticles, cancer can be detected in its earliest stages, when just a few cells are affected. These same nanoparticles can also be directed to embed themselves in tumours, deliver targeted treatments, and offer rapid updates on the effectiveness of those treatments.
Dr. Zheng has developed a unique nanoparticle that has caught the attention of the scientific community. This nanoparticle has the ability to transform when activated with light.
“Traditionally, when you’re given a drug, you would hope for the best. Now, you can track what happens with the drug in real time. You can determine the best treatment schedule, design the best treatment strategy, and find out whether this therapy is actually the best fit for the patient.”
In nanotechnology, Dr. Zheng sees an unprecedented integration of the technologies and expertise at The Princess Margaret. “None of this was possible even 10 years ago,” he says. “We’re now seeing that fantasy can become very much the reality if we push hard enough.”
Dr. Zheng hopes his nanotechnology will be ready for a clinical trial in December 2018.
A nanoparticle is one hundred to one thousand times smaller than a red blood cell.
Dr. Kazuhiro Yasufuku works as a Thoracic Surgeon. His focus is on developing surgical techniques that allow him and his team to improve patients’ lives.
Years ago, he was an early adopter of using thoracoscopic instruments for video-assisted thoracic surgery. This was part of a paradigm shift toward minimally-invasive surgery made possible by technology.
More advancements have followed, including robotic surgery, which Dr. Yasufuku says helps patients recover much faster.
“Some of my patients will go home the next day after a major lung surgery,” he says. “This was not possible 20 years ago.”
Today, Dr. Yasufuku is working to develop new treatments using nanoparticles, which could be a game-changer for lung cancer patients.
Some of these high-tech treatments use nanoparticles to deliver medication directly to tumours. In other cases, nanoparticles are used to highlight the location of a tumour so doctors can target it.
This research has been advancing rapidly over the past half-decade, and Dr. Yasufuku believes it may pave the way for major changes in surgery.
“In the future, we might be able to treat these cancers without making any incisions,” he says. “That’s what I call ultra-minimally invasive surgery.”
Surgery performed through a small incision using modern surgical technology. It’s often referred to as minimally-invasive surgery.
Senior Scientist Dr. John Dick has found his most promising clues about cancer in single cells.
Dr. Dick’s meticulous attention to detail, down to the cellular level, is driving his world-leading work at The Princess Margaret.
“People often think of tumours as being nasty hunks of cells where every cell is the same,” he says. “But the reality is that every one of those cells in the tumour can be a little different. And one of the things we’ve come to realize is that some cells have more ability to keep that cancer going over a long period of time. Those cells are cancer cells, yes, but they have the properties of stem cells, or what we call ‘stemness.’ They’re similar to the stem cells in our skin, our blood, our brain and so forth, in that they can keep regenerating tissue.”
Dr. Dick and his team have observed that this “stemness” gives some cancers an unwelcome staying power. “Many of the cells of the tumour are killed by chemotherapy. But often, these cancer stem cells have the ability to lie dormant and to protect themselves from chemotherapy. Eventually, they come roaring back and so does the tumour.”
Today, the traditional studies of whole tumours no longer make sense. “We need to find ways of sampling the individual cells in the tumour,” he says. “And this has brought forward the idea of single-cell biology. We need to take the tumour, split it up into single cells, and then monitor millions and millions of those single cells. We have to ask: Which are the stem cells? Why are they different from cells that don’t have stem cell properties? Why are they resisting therapy? Without question, single-cell genetic technologies are major ways forward.”
In his award-winning career spanning three decades, Dr. Dick has never seen so much potential in cancer research. “Even five years ago, I wouldn’t have imagined we’d be able to generate the kind of data and make the progress we’re making today. That’s partly due to broad advances in the scientific world, of course. But there’s also a recognition that team science is really important. No one person has all the best ideas.”
Acute myeloid leukemia is a disease of great variability, but it isn’t traditionally treated that way. As Hematologist Dr. Jean Wang explains, the seriousness of the disease forces a one-size-fits-all treatment.
“Everybody gets standard chemotherapy upfront,” she says, “because of the time it takes to get the test results that tell us who’s at a higher risk or lower risk, and we really can’t delay treating these patients.”
But in her work as Affiliate Scientist at The Princess Margaret, Dr. Wang is finding better answers in a 17-gene expression signature — a unique indicator called the LSC17 score — derived from leukemia stem cells.
“Leukemia stem cells are the key cells that start and drive the disease, and these are the cells that we have to kill in order to cure patients,” Dr. Wang says. “With the LSC17 score, we can now rapidly identify high-risk patients who we know probably won’t be cured by standard upfront chemotherapy and might be better served by an experimental therapy in a clinical trial.”
Measurement of gene expression used to be expensive and time-consuming.
But a new technology platform called nCounter from NanoString has changed that. Dr. Wang explains, “The nCounter system is a digital barcode platform that counts RNA molecules, so it’s very fast and very cost-effective. We can get an accurate result in days.”
To Dr. Wang, there is great promise at the intersection of clinical practice and big data.
“Technology is advancing at such a rate that it allows us to do more, but at the same time we need to develop new tools to sift through all the data being generated and determine its biological relevance. So we’re working more with Bioinformaticians,” she explains.
“We really need people who have a foot in both worlds, in biology and informatics, to help us dig through the noise and find the important correlations.”
Working with the Cancer Genomics Program at The Princess Margaret, Medical Oncologists Dr. Lillian Siu and Dr. Philippe Bedard have a mission: to help every cancer patient get treatment tailored to their disease. “We deal with molecular profiling. That means looking at cancers and trying to extract out the DNA,” says Dr. Bedard.
DNA can provide a precise roadmap for patient care, says Dr. Siu. “There are certain mutations or errors in the DNA that occur across cancers. These are important in terms of thinking about cancer drugs because there are a lot of cancer drugs that work only on patients whose cancers have specific mutations.”
The Cancer Genomics Program was established in 2014. While the program has already had significant impact on cancer research and care, Dr. Bedard believes its greatest achievements still lie ahead. “Most of what we’ve generated has come from testing limited panels of 40 or 50 genes,” he says. “That’s somewhat rudimentary, and we’ve certainly had patients who’ve had clear benefits. Currently, we are using much larger gene panels. As we generate more big data in the future, we’ll be finding large numbers of mutation patterns across cancers and sharing it across institutions.”
OCTANE: ONTARIO-WIDE CANCER TARGETED NUCLEIC ACID EVALUATION
Launched in 2017, OCTANE is designed to expand the use of next-generation sequencing technology in Ontario cancer centres.
Led by Drs. Lillian Siu and Philippe Bedard from The Princess Margaret, the trial is part of a collaboration with four other centres in Hamilton, Kingston, London, and Ottawa.
Tumour samples from patients across Ontario will be analyzed and the results will be shared on a secure genomic data platform. The results will help oncologists identify the most appropriate clinical trial or drug treatment for patients.
This international, multi-phase, multi-year project, Genomics Evidence Neoplasia Information Exchange (GENIE), will aggregate existing and ongoing genotyping efforts from the eight Phase 1 participants into one single registry. This data will improve clinical decision-making and propel new clinical and translational research.
Cancer centres participating include Princess Margaret Cancer Centre, Dana-Farber, Institut Gustave Roussy (France) and Memorial Sloan Kettering, to name a few.
What if your blood could predict your response to cancer treatment? Dr. Suzanne Kamel-Reid, Head, Laboratory Genetics, UHN, has been exploring how that question applies to lung cancer patients since 2016. The results of her study, co-led by Dr. Ming-Sound Tsao, Senior Scientist, and Dr. Tracy Stockley, Associate Director, Laboratory Genetics with The Princess Margaret, used blood to predict the presence of a mutation in tissue to optimize treatment.
“We’ve been able to optimize and validate a simple blood test, and now implement it clinically. We believe we are the first lab in Canada to offer this to our patients,” says Dr. Kamel-Reid.
Samples were studied at laboratories across the country, including Ontario, British Columbia, Alberta, Quebec, and Nova Scotia.
“Tumours shed cells and those cells release DNA, and we are looking for that DNA. It’s at very low levels, so you have to have technology that can detect it very sensitively,” says Dr. Kamel-Reid.
As of October 2017, this liquid biopsy test is being offered to patients across Ontario. Dr. Kamel-Reid says the same non-invasive methodology could also be used to test for mutations in other cancers.
In his role as UHN’s Executive Vice-President of Science and Research, Dr. Brad Wouters pays close attention to new technologies and their potential for cancer research and treatment. Today, he’s particularly excited by a technique based on a fundamental discovery of how bacteria defend themselves against virus infections, known as CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats).
CRISPR has demonstrated its potential as a tool for editing the genome (the complete set of genes) in any organism, including humans. Scientists can make changes to the genome, enabling them to study gene function and modify the genome to target disease.
Dr. Wouters explains that CRISPR is already capable of manipulating genes to understand their function or their importance in tumours. “We can sequence the entire genome of a cancer cell in just a few days. CRISPR allows us to selectively mutate any gene in that tumour and test their importance on drug sensitivity or other important functional features of the tumour.” With that information, doctors can rule out treatments that are likely to fail and focus on the ones with the best chance of success. “These are approaches scientists only dreamed about a few years ago,” Dr. Wouters explains.
He praises the speed and efficiency made possible by CRISPR. “Someone can be trained in a lab in a couple of months, and then be knocking out genes or changing mutations in a matter of weeks.”
A course on Genome Editing Techniques and Applications was developed in 2017 by Drs. Jason De Melo and Linda Penn, in collaboration with UHN Research, the Michener Institute for Education, and the Office of Research Trainees. During the two-week course, 20 undergraduate and graduate students, as well as technicians and academics, learned about the genome editing technique CRISPR.
In their earliest stages, many cancers are highly treatable. Dr. Daniel De Carvalho, Senior Scientist, says that this window of opportunity is often lost because of delays in diagnosis. “The challenge is to identify patients when their symptoms aren’t obvious.”
In his lab at The Princess Margaret, Dr. De Carvalho and his team are meeting this challenge in an interesting way: they’re developing a universal blood test to diagnose cancer early enough to enable optimal treatment. “That’s the ultimate goal,” he says. “Our main focus right now is to develop a blood test that can identify multiple cancer types and actually tell the clinician, ‘This person might have early-stage breast cancer, this other person might have early-stage lung cancer,’ and so on. We are working cancer by cancer.”
Dr. De Carvalho’s approach focuses on epigenetic profiling — identifying how genes in any given cell have been modified or “tagged” in response to external influences. As Dr. De Carvalho puts it, there are “thousands, if not millions, of changes between a normal cell and a cancer cell.” Epigenetic profiling can highlight those differences more effectively than other types of profiling.
To detect patterns in vast amounts of data more quickly, Dr. De Carvalho’s team is taking advantage of machine learning, a particular approach to artificial intelligence.
“In the case of pancreatic cancer, for example, we will tell the computer, ‘These hundreds of patients are pancreatic cancer patients.’ Then, we will profile hundreds of healthy donors matched for sex and age, and tell the computer, ‘These are not cancer patients. These are healthy donors.’ You do this repeatedly over time to find the modifications and correlations between healthy donors and people with pancreatic cancer. And then you keep doing this with other cancers to build a database of knowledge in classifying multiple cancer types.”
“We have new recruits in my lab who come from a computational science background. We were already combining our expertise in epigenetics with The Princess Margaret’s expertise in cancer. Now, we’re adding experts in machine learning to actually build something that we hope will change how patients get diagnosed and treated.”
EARLY STAGE DEVELOPMENT: LIQUID BIOPSY TECHNOLOGY
In October 2016, Senior Scientists Drs. Daniel De Carvalho, Scott Bratman and Trevor Pugh received funding from The Princess Margaret Cancer Foundation’s Innovation Accelerator Fund to develop a liquid biopsy technology. The goal, at this early stage, is to advance tumour detection in blood samples, allowing clinicians to monitor the slightest signal of cancer in the body using a simple blood test.
The team’s innovation would enable blood tests to detect tumour presence to a much more highly sensitive degree than current imaging or blood biopsy technology permits.
Established in 2011, Techna accelerates the development and application of technologies for the benefit of patients and the health care system. Crossing the silos of traditional research, Techna has created a culture of collaboration between clinicians, scientists and engineers, while also engaging a network of industry partners to exploit technologies that address unmet clinical needs.
The institute has facilitated the clinical development and adoption of an unprecedented number of technologies, including the image-guided Gamma Knife (Elekta ICON), MR-guided radiotherapy, quality assurance systems for radiotherapy, and an Imaging Core Lab, Cyclotron and radiopharmacy that form the backbone of UHN’s Molecular Imaging Program. Techna has also been active in the development, deployment, and commercialization of digital systems such as the Distress Assessment and Response Tool (DART), and the creation of artificial intelligence technologies.
These innovations are transforming the way patient care is delivered, and offer an impressive return on investment. Over the past five years, Techna’s intellectual property and commercialization activities have generated 10 patents, 29 licensing opportunities, seven licensed products, and five start-ups resulting in projections of over $1 million per year of commercialization revenues. The Institute has also attracted over $38 million in research funding to UHN since its launch.
Techna technologies have a direct impact on the treatment and management of over 3,000 patients globally every day.
Techna was made possible through funding from FDC Foundation, the Myron and Berna Garron Family, and Agnico Eagle through The Princess Margaret Cancer Foundation.
A system for quality assurance of radiotherapy equipment
A system for live quality assurance of radiotherapy
Remote patient observation
Image guidance for Gamma Knife therapy
A platform for patient-reported outcomes collection
A platform for clinical documentation
A platform to display patients’ history and collect outcomes
An operating room with image guidance
A platform for automatic radiation therapy QA
A case management system
A platform for management of clinical studies
Imaging Core Lab
Magnetic Resonance guided Radiotherapy Suite
ICON is a next-generation platform co-developed by the team at The Princess Margaret and Elekta Inc. It delivers a high dose of radiation to treat brain disorders, while improving patient care.
ICON incorporates cone-beam CT image-guidance capabilities developed and prototyped at The Princess Margaret into the existing Leksell Gamma Knife device. The image-guidance capabilities unlock new ways of delivering radiosurgery.
The previous-generation Gamma Knife could produce complex, conformal dose distributions, but it required the use of a stereotactic frame to immobilize and position patients’ heads.
“One of the most interesting features of ICON is that we can use the imaging system to take an image of the patient and localize the skull, and then that becomes the stereotactic frame,” explains Dr. David Jaffray. “It’s like having a virtual frame built into the patient.”
The head frame is an uncomfortable device, and makes it difficult for treatment teams to bring patients in for regular treatments spread out over many sessions. Removing that constraint enables clinicians to harness the full power of the Gamma Knife system. For example, the imaging capabilities allow ICON to perform adaptive dose control, where the system adjusts radiation delivery based on real-time CT data or changes in a tumour that occur through the course of a longer treatment regimen.
This technology will enable our cancer experts to treat a wider variety of conditions and help more patients. ICON is already being used around the world, including at some Canadian cancer centres.
Dr. Fei-Fei Liu
Chief, Radiation Medicine Program
Dr. Vera Peters cures Hodgkin’s disease by radiation, and breast cancer with partial mastectomy and radiation.
Radiation treatments lead efforts to preserve organ function integrated with surgery and chemotherapy.
Dr. Harold Johns leads further development of Cobalt-60 machines and introduction of linear accelerators.
Dr. Jack Cunningham leads the world with the development of computerized radiation planning techniques.
Installation of linear accelerators equipped with multileaf collimators for more precise treatment.
Introduction of intensity modulated radiation treatment (IMRT).
Dr. David Jaffray leads the major development of cone-beam CT imaging in daily treatment.
Dr. Tom Purdie and Dr. Michael Sharpe lead the development of automated radiation treatment.
Dr. David Jaffray leads a multi-disciplinary team in the development of the MRgRT system.
Development of adaptive oncology, which accumulates treatment data to personalize care.
To have precise radiation treatment, you have to be able to see a tumour so you can accurately target it. Hence the need to obtain images from a patient and proceed with treatment in a timely manner.
To solve this problem, a team at Princess Margaret Cancer Centre developed the MRgRT concept–a facility combining the power of MR imaging with radiation treatment. Putting these structures into the same space allows patients to be scanned and treated in a short time frame, without having to leave the facility.
That’s exactly what is happening today at The Princess Margaret, where patients have been regularly treated in the MRgRT suite since 2014.
“It gives us a window, an ability to see things that we were never able to see before, and that opens up opportunities,” says Dr. Michael Milosevic Director of Research, The Princess Margaret’s Radiation Medicine Program.
The MRgRT is anchored around a magnetic resonance scanner that can move between a pair of radiation suites via rails that are mounted on the ceiling. This allows patients to be scanned and treated in the same facility rather than having to visit two or three different locations to achieve the same result.
Dr. Milosevic points out that the imaging alone is not what makes this facility so beneficial for patients. It’s the precision of the imaging and how closely it’s integrated with the treatment. That gives doctors, medical physicists, and radiation therapists the information they need to treat the cancer.
The MRgRT allows us to explore personalized approaches where we take images just before treatment, design the radiation plan, and treat a patient in ways that could never have been achieved before.
The more the MRgRT is used to treat patients, the more we learn to help future patients. That’s because the data captured through treatments provides new information about how tumours change with time and during treatment.
The MRgRT includes an MRI Scanner in the treatment room, a Linear Accelerator, and a Brachytherapy Procedure Suite
Dr. Patrick Veit-Haibach is new to his role as Clinical Director PET-MRI at University Health Network (UHN), but his vision is big and ambitious.
“My goal is to explore combining the functional parameters of PET-MRI technology to deliver improved diagnostic imaging for our patients,” says Dr. Veit-Haibach.
He was recruited to lead this new area of research in the spring of 2017. So far, it shows real promise. “This imaging technology works very well for detection and characterization of tumours, but can be also used to explore cardiovascular diseases,” says Dr. Veit-Haibach. “We have already seen positive results in primary tumour detection that were not well diagnosed before, but more work is needed to exploit its full potential.”
PET-MRI is a hybrid technology that uses state-of-the-art magnetic resonance imaging (MRI)with established molecular imaging tracers like PSMA (pg. 29) and new experimental radiopharmaceuticals to enhance disease characterization. It provides our cancer experts with detailed localized information about a tumour to make a more informed diagnosis and deliver precise treatment.
The PET-MRI machine (above) was acquired in 2016, and it is already being used by imaging specialists who are working with cancer experts at The Princess Margaret and cardiovascular researchers at UHN. The advantage of this fully-integrated system is a dose reduction for the patients and reduced imaging times. It is also more suitable in cases that require a higher soft tissue contrast than what is offered by a standard PET-CT.
Advances in imaging technology are helping Dr. Alejandro Berlin take on complex cancer cases that couldn’t be treated in the past.
Dr. Berlin is a Radiation Oncologist and a member of The Princess Margaret’s Genitourinary Site Group. He and his colleagues are at the forefront of research into a promising method for treating patients with prostate cancer that has spread, including cases in which conventional treatment is no longer possible.
The technique combines a molecule known as PSMA (prostate-specific membrane antigen) with a radioactive tracer that is created in the Cyclotron.
“This small molecule travels within the body and attaches to an area where there are prostate cancer cells,” Dr. Berlin says.
Using a combination of PET and MRI imaging, it’s possible to see where the cancer has spread by looking at where the PSMA accumulated. This allows doctors to identify the targets for radiation treatment.
“We find deposits of the disease across the body and target those with high precision and focused radiotherapy,” says Dr. Berlin.
It’s a useful approach when tests show the presence of prostate cancer in a patient who has already undergone treatment.
Dr. David Jaffray, Head of Medical Physics at The Princess Margaret, says there are many challenges in trying to figure out how to treat a prostate cancer that has spread, including determining where it is within the body.
“If it’s coming back in some other part of the body because of metastatic spread, where is it?” says Dr. Jaffray. “If you can find where it’s localized, you could actually go after that and treat it aggressively.”
In the past, treatment options were often limited. In some cases, doctors would have to try to treat the cancer with a systemic approach, since they couldn’t precisely target it like they can today with the PSMA-based method.
“Now that we can see the disease, we can target it with radiotherapy,” Dr. Berlin explains.
The Centre for Probe Development and Commercialization, BC Cancer Agency, Terry Fox Foundation and other partners are working to bring this technology to Canadians.
Active since June 2017 - Goal: Treat 37 patients - Complete Trial: End of 2018
A new handheld telephone device, currently being tested in a clinical trial at The Princess Margaret, is helping patients monitor and manage their symptoms from the comfort of their own homes.
Patients can enter their daily symptoms into the device, which then sends self-care advice to patients to manage the symptoms and alerts the clinical team to intervene for those who warrant an immediate response.
Dr. Doris Howell, Senior Scientist, is helping to adapt the technology, originally developed in Europe, for cancer care in Canada. A randomized control trial kicked off in October 2017, with 44 patients using the phone and 44 receiving standard care.
“This device allows us to intervene early to reduce symptom distress, helping avoid unnecessary visits to the emergency room, and potentially improve survival. This system empowers patients in self-care of symptoms and places trustworthy information in their hands,” says Howell.
The Distress Assessment & Response Tool (DART) combines the human aspect of care with technology. “There have been enormous advances
in technology in the last several decades,” says
Dr. Gary Rodin Head, Department of Supportive Care, Princess Margaret Cancer Centre. “But it’s been a challenge to integrate technology with the human side of medical care.”
To change this, we have introduced DART (pg. 23), which allows patients to communicate their symptoms with the touch of a finger from home or on screens located in the Cancer Centre’s clinics.
It leads to a conversation between the doctor, nurse, and patient, and opens the door
to appropriate support.
The data collected from thousands of participants is grouped together to identify trends. It also helps doctors learn about the side effects of chemotherapy, radiotherapy or surgery by looking at the patterns of physical symptoms and the psychological distress associated with them.
Princess Margaret patients now have real-time access to their health information through myUHN Patient Portal, which was designed in collaboration with patients and caregivers. Launched in May 2015, it was made available to seven clinic areas at UHN.
In January 2017, the portal was expanded to all sites at UHN. Patient sign-ups increased from 3,100 that month to over 30,000 in October. Patients can also see and receive appointment reminders, review lab results with links to patient education, and more.
At The Princess Margaret, standard of care is expected, but our cancer experts demand more for their patients. They’re constantly researching and developing unique and novel treatments to save more lives. We fight for patients like Lauren Craig.
In the fall of 2016, Lauren had graduated from university and was working full-time. But, in less than a week, the 23-year-old’s life was turned upside down.
In November, Lauren noticed a large bump on her neck. Tests revealed why she suddenly felt exhausted, stiff, and weak: she had lymphoma.
“Not many people my age are sick. That’s been the really hard part. Why me?” says Lauren.
Diagnosed with Stage 2A Hodgkin’s lymphoma, she began chemotherapy at The Princess Margaret with her family by her side.
On March 29, 2017, Lauren rang the Bravery Bell to mark her final treatment.
“I’ll never forget hearing so many people cheering for me. Now, whenever I hear the Bravery Bell, I tear up because I know the person ringing it is as excited and as relieved as I was,” says Lauren.
One month after her chemotherapy ended, she began a four-week, daily regimen of radiation.
“Lauren received precision radiotherapy to her neck and chest. Our methods dramatically reduce the dose to normal tissue, to decrease the risk of late effects,” says Dr. David Hodgson, Radiation Oncologist at The Princess Margaret.
Even though treatment drained her physically and mentally, Lauren is feeling stronger every day.
“Lauren is one of the most positive and mature young patients I have encountered. Seeing her be successful in her cancer journey is extremely gratifying,” says Dr. Anca Prica, Hematologist at The Princess Margaret.
Lauren is focused on her recovery and getting back to doing all of the things she loves, especially skiing.
“Cancer will probably be the hardest thing I’ll ever go through. Now, I tell myself, ‘You got through chemo. You got through radiation. You can get through anything."
For the past six years, the right side of Lorraine Robbins’ jaw has been swollen and unable to heal.
Following gum-implant surgery in 2016, the 63-year-old knew the problem had gotten dramatically worse. It wasn’t until this year that she finally learned what was wrong: she had sarcoma.
“Cancer, oh my God. I have been a very healthy person my whole life. For all this to happen in my retirement years, it’s surprising,” she says.
Lorraine was referred to Princess Margaret Cancer Centre and Dr. Jonathan Irish, a Surgical Oncologist specializing in head and neck cancer. She knew she was in the right place when she heard about his surgical skills from a complete stranger at a Tim Hortons in Muskoka.
“I was talking to one of my friends about my upcoming surgery and this young man overheard my conversation. He said, ‘Excuse me. I just want to tell you that Dr. Irish did surgery on my father. The same surgery,’” she says.
When Dr. Irish called Lorraine to chat about her case on a Sunday, she told him, “Dr. Irish, you’re a celebrity.”
In preparation for her surgery, Dr. Irish asked his team to make a 3D model of Lorraine’s jaw to study and plan. This allows our cancer experts to optimize strategy and improve technique for future patients.
“The right side of my jaw comes right out. They are going to use the bone in my leg to rebuild my jaw. They have a robotic cone-beam CT scan in the operating room. Dr. Irish will be taking images before, during, and after surgery to make sure all the cancer is gone before I leave that operating room,” says Lorraine.
Dr. John De Almeida, Head and Neck Surgeon and Clinician-Investigator, will be working with Dr. Irish on her reconstructive surgery that is expected to last up to 12 hours.
“For the past five years, I have been looking after my grandchildren,” she says, while getting emotional.
“I want to be around for them.”
Lorraine’s husband, Gerry, says more tests showed spots on her lung and liver. “We already have an appointment for the next set of x-rays,” Gerry explains.
After her reconstructive surgery, Lorraine’s jaw will finally look as it should. She’s thankful to Dr. Irish, Dr. De Almeida and their teams for their ongoing support and compassion during a difficult time.
Lorraine says, “I’m ready to move on with my life.”
3D RAPID PROTOTYPING
At The Princess Margaret, 3D rapid prototyping technology allows doctors to examine, plan, and prepare for the best possible surgical outcome
Robert Kyle survived a heart transplant in 2014, only to be diagnosed with prostate cancer one year later.
Dr. Alejandro Berlin, Radiation Oncologist at The Princess Margaret, laid out Robert’s options. He recommended a clinical study to undergo MR-guided High-Dose Rate (HDR) brachytherapy in the MRgRT Suite, followed by a five-week course of external beam radiation.
“Several large trials have shown this combined approach offers a better outcome than external beam radiotherapy alone in high-risk patients,” says Dr. Berlin.
Robert didn’t hesitate. “I’ve probably got t-shirts older than Dr. Berlin, but he’s a really smart man. I told him that I wanted to maximize my chances for a cure,” says Robert.
When he arrived for his procedure, he was greeted by Dr. Gerald O’Leary, Anesthesiologist-in-Chief at University Health Network, who had been a part of his heart transplant team and would again serve as his anesthesiologist. Robert’s health care team also included two other radiation oncologists, as well as several therapists specializing in radiation, MR imaging, and brachytherapy.
“An extraordinary team, built around the MRgRT, allows us to offer this highly-demanding, aggressive type of treatment to patients who might otherwise have to undergo more conservative treatment,” says Dr. Berlin.
Robert’s brachytherapy procedure started in the morning, and by noon he was in the recovery room. He experienced no significant side effects and was able to go home the same day.
After four days of recovery, Robert began a five-week course of external beam radiation treatment and later, hormonal injections for a year.
This cutting-edge technology is not only saving lives now, but also allows our scientists to advance research that will change the future of prostate radiotherapy and brachytherapy.
The High-Dose Rate (HDR) unit involves placing needles or catheters into the tumour, then pushing a small ball of highly radioactive material through to the site of therapy. The radiation dose is delivered in minutes.