BACKGROUND

With changing lifestyle & increasing longevity, cancer is fast emerging as a major health problem in India. It is the 4th leading cause of death in the adult Indian population. Every year approximately 800,000 new cases are diagnosed in the country.

Radiation therapy is the use of ionizing radiation for treatment of diseases and the specialized field of using ionizing radiation for the treatment of cancers is known as Radiation Oncology (Oncology = Study of Cancer). Approximately 2/3rd of all cancer patients require radiation therapy as the sole treatment modality or in combination with surgery or anticancer drugs (Chemotherapy). Radiotherapy plays a very important role in curing early stage cancer and in relieving symptoms and prolonging life for patients with advanced cancers.

Very soon after the discovery of X-rays by Röntgen in 1895, discovery of Radioactivity by Becquerel in 1896, and the discovery of Radium by the Curies in 1898, X-rays and Radio-isotopes were used for the treatment of cancer. In the first few decades of the 20th century, "Radium Institutes" were established in various European and American cities for the treatment of cancer.

TELETHERAPY

As the name suggests, "Teletherapy or External Beam Radiation Therapy" involves delivery of therapeutic radiation from a source that is placed away from the body. The therapeutic use of radiation for the treatment of cancer dates back to the discovery of X-Rays by Roentgen in 1895. In the early days kilovoltage (low energy) machines were used for teletherapy. This was associated with a significantly high dose of radiation to skin, subcutaneous tissue, and bone leading to unwanted complications like skin necrosis, severe subcutaneous fibrosis, and osteoradionecrosis. The early 60's saw resurgence in teletherapy with the development of high energy teletherapy machines, treatment planning computers, and dosimetric devices.

Teletherapy at the Tata Memorial Hospital started in 1941 with two "200 KV Deep X-ray machines". This was followed by the first Cobalt-60 teletherapy machine "Theratron Junior" which was commissioned in 1959. The era of linear accelerators and advanced technology treatment planning and treatment delivery machines in the country and at the Tata Memorial Hospital was started in 1978 with the commissioning of the first linear acceletator "Mevatron-12". In 1981 the first treatment-planning computer "TPS TP-11" was inducted into the department. During the same year a "Mould Room" which forms an important component of radiotherapy treatment planning and delivery was established. The first radiotherapy treatment simulator "Therasim 750" was commissioned in 1982. In the last two decades the department has developed into a state-of-the-art facility comparable to any advanced center worldwide. The Cobalt 60 sources used in our teletherapy machines have been produced in the nuclear reactors at the BARC.

BRACHYTHERAPY

"Brachytherapy" involves delivery of therapeutic radiation from a radioactive source that is placed in close proximity to the area to be treated. Brachytherapy can be of various forms depending upon the site of placement of the radioactive source. The radioactive source can be either placed on the surface (Surface Mould), within a body cavity i.e. Intracavitary Brachytherapy (Cervix, Vagina), Intraluminal Brachytherapy (Oesophagus, Anal Canal), Endovascular Brachytherapy (within Blood Vessels), or into an organ or tissue i.e. Interstitial Brachytherapy (Breast, Soft Tissue Sarcoma).

The history of Brachytherapy dates back to 1896, soon after the discovery of X-rays by Röntgen. Modern brachytherapy was initiated by Marie Sklodowska Curie and her husband Piere Curie, with the discovery of a new substance in their laboratory on Sainte-Genivieve hill in 1898 by isolating "une nouvelle substance radioactive contenue dans la pechblende", named radium. The first patient was treated in 1901 by Dr Danlos, a deramatologist at hospital Saint-Louis in Paris. He treated cases of lupus with radium loaned to him by Pierre Curie, consisting of "small bags of rubber, a few millimeters thick, containing radium and barium chloride, which were kept on the skin for 24-48 hrs". The radium caused a blister from 6th day to 20th day onwards, followed by an ulceration that healed in 6 weeks to 3 months. After the initial excitement with brachytherapy, there was a temporary stagnation in its further development during the 1950's. This was primarily due to the rapid developments in radiotherapy in the form high-energy teletherapy machines, computers and advances in treatment planning and dosimetry methods. This was associated with the increasing awareness about radiation hazards associated with preloaded brachytherapy and radiation protection.

Brachytherapy at the Tata Memorial Hospital dates back to 1941 with the introduction of "Radon Seeds". These Radon Seeds used to be manufactured in our own Radon Plant in the hospital. An Indian physicist, Dr. Ramaya Naidu, who had worked as a post-doctoral student under Madam Curie during the late 1930's was responsible for setting up the Radon plant at the Tata Memorial Hospital soon after setting up a similar plant at the Memorial Sloan Kettering Cancer Center (MSKCC), USA. With the discovery of newer radioactive isotopes the hospital acquired pre-loaded Cobalt-60 and Caesium-137 capsules in 1960. Manual afterloading techniques were introduced at the Tata Memorial Hospital in 1972 using Co-60 sources. In 1976 we acquired Caesium 137 tubes from the BARC for use for intracavitary and interstitial brachytherapy. Manual afterloading Cs-137 sources for gynecological applications were started in 1981. Dr KA Dinshaw introduced manual afterloading Iridium-192 interstitial brachytherapy for the first time in the country, at the Tata Memorial Hospital in 1981. The Iridium-192 sources used for the manual afterloading interstitial brachytherapy procedures are produced in the division of Board of Radiation and Isotope Technology (BRIT) at BARC. The LDR remote afterloading units using Cs-137 and Ir-192 were acquired in 1986 and 1987 respectively. A further advancement in the brachytherapy facility came with the induction of the HDR-Microselectron unit using an Ir-192 source in 1994. Endovascular radiation therapy was also started in 1997. From the early beginnings made in the 40's, we have come a long way in the field of brachytherapy to the current status where TMH is considered one of the best centers for brachytherapy in this part of the world.