Aubrie Rice

DOS 711
Compare & Contrast Article Assignment Part I: Trade Magazine

There are vast differences when comparing an article from a trade magazine and an

article obtained from a peer-reviewed journal. Informally written, trade articles target a broad

audience for human interest purposes. 1 A peer-reviewed article on the other hand has a more

targeted audience of professionals, academics and researchers with a more refined interest on a

specific topic whether it be research, a procedure, etc. 1 When examining the former of the two, a

trade magazine article written by Thomas Rockwell, Helical IMRT New Treatments Taking

Shape for Multiple Myeloma, I noticed several of the key traits of a trade magazine article

including advertisements and a journalistic writing style.1,2 A summary of this article will be

discussed as well as its strengths, weaknesses, and usefulness.

Rockwells article informs the reader of a new technique for treatment of multiple

myeloma, noting its advantages over more traditional techniques. 2 Rockwell starts by giving

some statistics on the incidence of multiple myeloma stating that more than 750,000 people

suffer from the disorder citing the International Myeloma Foundation and noting the annual rise

in new cases.2 A range of 10 to 50 percent is listed for the five-year survival rate. A traditional

method of treating multiple myeloma is discussed which includes chemotherapy with total body

irradiation (TBI) treatment before receiving a bone marrow transplant. TBI involves treating the

entire body with a cumulative dose of 10 to 12 Gy to suppress the immune response the body

would take against the transplant cells.2 While TBIs intent is to target the patients bone marrow,

Rockwell states that the entire body receives this cumulative dose including healthy tissue and

organs. Rockwell also notes non-uniformity of the radiation which means narrower regions of

the patients body such as the neck receive a higher dose. Studies in the 1990s suggested a

higher radiation dose of 16 Gy was more effective in achieving the goals of a TBI. 2 Although,
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Rockwell notes that doses of 10 to 12 Gy cause short term side effects such as hair loss, skin

irritation, nausea, vomiting, diarrhea, and mouth sores and long term side effects such as

infertility, cataracts or a risk of leukemia.2 Rockwell then introduces a new technique to the

reader called total marrow irradiation (TMI) that several cancer centers are using to increase dose

to bone marrow while limiting dose to normal tissue. He explained that opposed to the wide

beam used with TBI, TMI utilizes tiny beamlets in a 360-degree rotation around the patient. 2 A

case where a patient was treated on a trail with TMI is then discussed with several quotes from

the patient and the oncologist that treated her noting fewer and less severe side effects than with

a typical TBI treatment. Some of the other centers using TMI treatments are mentioned at the

end of the article with another quote from the previous patients oncologist that states they are

seeing normal organs receiving less than 65 percent of the total radiation dose and sometimes

this dose is as now as low as 15 percent. 2

In my opinion, the article by Rockwell had several strengths as well as weaknesses. Trade

magazine articles are typically written by staff or contract writers. 1 Though not typical, the

article discussed was written by a cofounder of TomoTherapy and a professor in the departments

of medical physics and human oncology.2 The authors title is a strength for this article and

increases its credibility compared to a typical trade magazine article written by a freelance

writer. Although the authors credentials are a strength, his position can also be a seen as a

weakness of the article when considering biased information. Since the author is a cofounder of

TomoTherapy and the TMI treatment he is introducing to the reader uses TomoTherapy, the

information presented is obviously subject to bias. Do to the informal style of writing and lack of

citations, the validity of the statistics and facts presented is also hard to assess. The author does

reference a few sources such as the International Myeloma Foundation when he discussed
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incidence statistics as well as studies in the 1990s when noting the significant side effects that

result from 10-12 Gy.2 Studies in the 1990s though, is vague and the author does not go into

any more detail about what studies he is referring to which further hinders the ability to access

validity of the article.

Though bias and validity may be a potential concern, the article did an excellent job of

explaining the treatment techniques in laypersons terms. As a source of information for the

public, this article is very useful. Potential patients may see this article and better understand

these types of treatments and their differences as well as potential benefits of TMI over TBI.

Patients could be more informed before having a conversation with their doctor and could then

get questions answered that arose after reading the article. As for practicing medical dosimetrists,

Im not sure this article would be very useful. A peer-reviewed and more recent article would be

more useful in this case. As for myself, I found this to be an interesting article do to the fact that

my clinical site currently does TMI treatments. Instead of TomoTherapy though, VMAT

technique is used. I have learned about the benefits of this type of technique in my undergraduate

education so it was interesting to see literature that patients have access to regarding this type of

treatment.
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References

1. Lenards N. Reading and Writing in Radiation Therapy and Medical Dosimetry. [SoftChalk].

La Crosse, WI: UW-L Medical Dosimetry Program; 2017.

2. Rockwell T. Helical IMRT New Treatments Taking Shape for Multiple Myeloma.

Radiology Today. 2010; 11(4):8. Retrieved from

http://www.radiologytoday.net/archive/rt0410p8.shtml. Accessed January 30, 2017.

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Compare & Contrast Article Assignment Part II: Peer-Reviewed

Peer-reviewed articles, unlike trade magazine articles, offer a formal/scientific style of

writing and appeal to a more narrow audience of professionals employed in the field of interest,

academics and researchers. A peer-reviewed journal presents relevant facts and builds upon the

growing body of knowledge in the profession.1 An article by Springer, Hammer, Winkler, et al

titled Total body irradiation with volumetric modulated arc therapy: Dosimetric data and first

clinical experience2 embodies all of these qualities. This article examined the use of volumetric

modulated arc therapy (VMAT) in the implementation of total body irradiation (TBI) and its

potential benefits.2 The article provided a literature review as well as discussing methods, results

and a final conclusion.

In the literature review, Springer et al gave an accurate explanation of the purpose of TBI

and TMI procedures as well as the benefits of hyper-fractionated treatments compared to one-

dose applications, citing several peer-reviewed sources.2 The researchers discussed several

methods that are currently in use such as irradiation from the patients right and left side while

sitting in a specially designed chair, and also irradiation in the supine and prone position on a

fixed or movable couch.2 Disadvantages of these techniques are discussed such as possible

inhomogeneity of dose due to varying body diameters noting lung dose on lateral fields as an

example.2 Springer et al then discuss the two high precision techniques that have been introduced

to the field recently: helical tomography for either TBI or TMI and also, VMAT with ventro-

dorsally opposed static beams for the legs used for TMI. The problem is then introduced: the

treatment room at this center was too small for conventional TBI methods. Due to this fact,

patients had to be transported to a different hospital to receive TBI treatments. To avoid the risks

posed to TBI patients with depressed immune systems, this center decided to adopt a technique
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that would work for TBI treatments in their smaller treatment room. After test planning, VMAT

for TBI was used at the center in 2012. Presented in this study are dosimetry details of the first

seven patients treated with this technique at their center.2

The research design was clearly explained in the methods section. Seven patients were

presented. Three patients were diagnosed with acute lymphatic leukemia (ALL), two with acute

myeloid leukemia (AML) and two patients with T-cell lymphoma. 2 In my opinion, while this

sample may encompass a majority of diagnoses that are treated with TBI procedures, I believe

that to show reliable results and to have a true representation of the population of patients

receiving TBI that a larger sample size is needed. Springer et al also discuss in detail contouring

protocols as well as patient setup and immobilization. 2 The PTV contour included the whole

body contour minus the lungs but included a small margin of the lungs near the ribs. Patients

were immobilized using a vacuum mattress, a thermoplastic head and neck mask, and bolus. The

PTV was planned to a dose of 13.2 Gy for each patient and was delivered in eight fractions (two

fractions per day) with 6 MV photons. A mean dose of 10 Gy or lower was the constraint for the

lungs and helping structures were contoured to steer the optimizer for this goal. Treatment

planning was performed on the Eclipse treatment planning system, version 10.0. For VMAT, two

field arrangements were used: lower mediastinum and lower pelvis. Placement of isocenters,

field arrangement, and quality assurance procedures were discussed in detail. Pictures and

diagrams were provided which helped the reader to visualize the information. 2

In the results section, average time required for contouring, dose calculation and

optimization, QA and couch-time (patient setup and treatment) were discussed. This time was 5-

6 hours, 25-30 hours, 6-8 hours and 1.5 hours, respectively. Dose volume histograms were

provided for PTV, lung and kidney doses as well as a chart showing percentage of PTV
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receiving 90, 95, 110, 120, and 130 percent of the prescribed dose for each patient. Side effects

and effectiveness was then discussed. Following treatment all patients presented with grade 3

mucositis and one patient with bladder inflammation. No patients presented with lung reactions.

Two patients died after treatment: one of refractory disease 2.3 months after treatment and one

relapsed 8.8 months after treatment and died after 13.4 months. The remaining five patients live

disease free and without severe toxicities.2 In my opinion, these results were presently clearly

and accurately. The authors provided detailed explanations and charts which helped the reader to

visualize.

The discussion section notes several negatives to VMAT-TBI including time

requirements and overlapping arcs. It is noted that VMAT-TBI may have the potential to reduce

pneumonitis related morbidity and mortality but would need to be evaluated on a much larger

scale. It is also discussed that although these seven patients had a low rate of acute side effects,

in order to examine late effects, further follow ups would be necessary. 2

It is concluded that VMAT-TBI with a dose up to 13.2 Gy is feasible and has low rates of

acute toxicities. Its also concluded that more homogeneous doses can be delivered with this type

of treatment and it also allows for selective dose reduction to the lungs. Resources for treatment

planning concerning personnel and time need to be considered. 2 In addition to this conclusion,

the authors provided many relevant sources, a majority of which were current publications.

Overall, I was impressed with this research article. Although I do believe that it would

have benefited from having a larger sample size, it was still well-preformed research.

Appropriate sources were referenced and the authors did a great job of explaining their methods

and results: providing illustrations, graphs and charts for visual aid. Since this is just one centers
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trial with VMAT-TBI, it would be interesting to compare this to other techniques that different

centers are using and compare their results.

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References

1. Lenards N. Reading and Writing in Radiation Therapy and Medical Dosimetry. [SoftChalk].

La Crosse, WI: UW-L Medical Dosimetry Program; 2017.

2. Springer A, Hammer J, Winkler E, et al. Total body irradiation with volumetric modulated

arc therapy: Dosimetric data and first clinical experience. Radiat Oncol. 2016; 11:46.