Assistant Professor of Radiation Oncology at Weill Cornell Medicine in New York City, Dr. Himanshu Nagar supervises the region’s only MRIdian machine, created by a Colorado-based company called ViewRay. MRIdian provides MRI-guided radiotherapy, which leads to a more precise prostate cancer treatment while significantly limiting or eliminating the side effects of treatment.
- Dr. Himanshu Nagar’s bio on the NewYork-Presbyterian website
- Dr. Himanshu Nagar’s bio on the Weill-Cornell Medicine website
- Book an appointment with Dr. Nagar
- Dr. Nagar on Twitter: @HimanshuNagarMD
- ViewRays’ website: viewray.com
- How ViewRay works: viewray.com/for-patients/how-mridian-works/prostate/
- Where to find a ViewRay machine: viewray.com/mridian-treatment-centers/
- ViewRay on Twitter: @viewray
- ViewRay on Instagram: @viewrayinc
- ViewRay on LinkedIn: https://www.linkedin.com/company/1212733/
- ViewRay on Facebook: https://www.facebook.com/ViewRay
The Stay in the Game podcast is sponsored by Cancer Health – online at cancerhealth.com.
Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Launched in 2017, cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention and health policy.
Announcer: Welcome to Stay in the Game, conversations about prostate cancer with Ed Randall. Here we’ll chat with doctors, researchers, medical professionals, survivors, and others to share and connect. This show was produced and shared by Fans for the Cure, a nonprofit dedicated to serving men on their journeys through prostate cancer.
The Stay in the Game podcast is sponsored by Cancer Health — online at cancerhealth.com. Cancer Health empowers people living with prostate cancer and other cancers to actively manage and advocate for their care and improve their overall health. Launched in 2017, cancerhealth.com provides accessible information about treatment and quality of life for people with cancer and their loved ones, along with information about cancer prevention and health policy.
Ed Randall: Hi again, everybody. I’m Ed Randall, the founder and chief advocacy officer of the prostate cancer charity, Fans for the Cure. Welcome back to the award-winning Stay in the Game podcast brought to you by Cancer Health.
Our special guests for this episode is Dr. Himanshu Nagar, Assistant Professor of Radiation Oncology at Weill Cornell Medicine in New York City. Welcome Dr. Nagar to our Stay in the Game podcast. While there are so many aspects of prostate cancer we could discuss today with you, let’s instead focus on what makes you unique, at least in the New York City Tri-state area where our charity is based.
With the future of cancer treatment increasingly trending towards personalized treatment solutions, you supervise our region’s only MRIdian machine created by a Colorado-based company called ViewRay. For prostate cancer, we are encouraged to read in the product literature that MRIdian is also about significantly limiting or eliminating the side effects of treatment. And making side effects disappear is what we like to hear at Fans for the Cure. But let’s not get ahead of ourselves. So take us out, Dr. Nagar. Tell us about MRIdian and how it works.
Dr. Himanshu Nagar: First of all, thank you for having me, and I’m looking forward to our conversation in this podcast. So what the MRIdian is, is combining two different technologies in order to deliver radiation treatment to patients with prostate cancer. So what it is, is taking an MRI imaging technology and then combining that with a radiation technology machine. And combining it is no easy feat, and it’s something that’s quite surprising and revolutionary to our field. So the best way to understand this is to think of how we used to, or a lot of people are still currently doing right now.
So traditional imaging is based on CT or what’s called plain film imaging, which is, for lack of a better term, very simplistic imaging compared to MRI. So many of your listeners have had an MRI either for diagnosis or surgical planning or treatment planning for radiation purposes. Or if they’ve had recurrent disease, they may get an MRI for that. So we know from an imaging standpoint MRI is superior to CT or CAT scan based for diagnosis and determining where significant cancer is. So what this machine does is combine that imaging modality with the trigger modality. In other words, a patient’s getting an MRI while they’re getting treatment.
So to take us back a little bit further, a traditional machine will image you with either, as I described, a plain film image or a CAT scan image, but then we sort of close our eyes while the treatment is going on. In other words, we’re just sort of hoping that nothing’s changed while the radiation beam is on. So what this machine does is not only combined the MRI image with the treatment modality, but it actually is providing real-time MRI while the treatment is going on.
So both the imaging machine and the treatment machine are working synergistically and not getting in the way of each other. But at the same time, if something moves while treatment is happening, the machine automatically turns off. So it’s not a human being pressing a button. It’s the imaging machine and the treatment machine working together synergistically to make sure that we are treating what we want to and avoiding the things that we want to avoid radiation delivery to.
Ed Randall: There’s much discussion in the cancer treatment world, whether we are talking about chemotherapy, hormone therapy, or radiation therapy, about providing effective doses. This means not only throttling back from causing harm but also the ability to escalate doses when necessary to targeted areas have high-risk tumors and disease. What makes MRIdian stand out in its ability to deliver effective doses of radiation?
Dr. Himanshu Nagar: That’s a perfect follow-up question because we know that radiation, if we can deliver high enough doses, is therapeutic for many, many cancers. The problem is, is that we have to avoid side effects and harm to the patient when delivering these high doses. So what the MRIdian view rate platform allows us to do is actually deliver potentially even higher doses than we traditionally would deliver. And even doses that we do deliver are delivered with much more confidence because of the real-time imaging and tracking of the tumor.
In our case, what we’re discussing here is prostate cancer. But that and also avoiding what’s surrounding the prostate, which is very important to men, because it’s the organ that control your urinary function, your bowel function, and your sexual function. So while we’re delivering high therapeutic doses with great confidence to the tumor, we also have that competence that these doses aren’t going to lead to short or long-term side effects for these patients because the prostate was just placed in a very critical area, and surrounded by things that we all care about tremendously.
Ed Randall: A couple of follow-up questions. We know it’s personalized medicine, but how long does a single treatment generally last? And what is the average number of daily visits required by someone who chooses radiotherapy via MRIdian as his initial treatment solution?
Dr. Himanshu Nagar: Great question. So the treatment can last anywhere from 20 to 45 minutes. And what I tell patients is that don’t worry about how long it takes to treat you. We are treating you as what you need that day in that given timeframe. Because the main thing is to have the right patient getting the right dose at the right time.
So if a patient undergoes treatment for a longer period of time during that daily session, you know, up to 45 minutes, that’s probably because the organs have moved during that time, the prostate hasn’t been a fixed target the entire time. But some days just take longer, other days are much quicker where you’re in and out in about 20 minutes, because your preparation for the treatment was perfect and your organ didn’t move that much that day. So on average, I would say it’s about 20 to 45 minutes per day. The beam on time, meaning how long you’re actually getting radiation is probably in the 8 to 12-minute range. Every patient is different. As you said, personalized to each patient.
And at least in our practice and many other MRIdian practices, for a patient that’s newly diagnosed with prostate cancer, generally, it’s the men with what we call intermediate or high-risk localized disease will get treatment in five sessions. So to clarify, five total treatment sessions, not five days for five weeks, or five days for nine weeks. Five days generally in a one to two week time period for their definitive treatment from a radiation standpoint.
Ed Randall: Again, we know treatment regimens are personalized and cases are different. But all things being equal, what is the expected number of MRIdian treatments versus conventional radiation? And if there’s a difference, why?
Dr. Himanshu Nagar: That’s the perfect follow-up question to the last one because what we’re seeing, even within our own practice and our own practice changes, is that when we first adopted the MRIdian machine, we were still testing it out, seeing if we can deliver radiation as effectively and as safely as we thought we could. So we quickly transitioned from a longer regimen down to the five-day regimen. So most, if not all patients, in the intact localized prostate cancer setting are getting five sessions of radiation.
Now, the reason men may get longer treatment courses is multifaceted. So, one is that the physician is not comfortable, for one reason or another, delivering shorter courses of radiation in the five fraction or five-treatment regimen. Another is that the technology that they possess is not suitable for that because they don’t have the imaging and treatment delivery techniques that are necessary to deliver shorter courses of radiation.
So that’s why conventional treatments, you know, can be anywhere from, you know, 20 to probably much longer than that in the 40 to 45 range. And it’s just the confidence of the physician, the physics and treatment team, along with the therapist at the machine, and then also what technology you have available to you. Because at the end of the day, our number one rule is to do no harm. And if we don’t think that that’s a possibility with shortened treatments, then you’re going to, for lack of a better term, hedge and protract out the treatment for a limited daily dose because you want room for error, to be honest.
Ed Randall: A feature I found to be fascinating was that MRIdian is so personalized it can adapt to a slight change to a person’s anatomy in real-time while that person is inside the machine. Can you describe what is going on at the controls with the physicians and machine technicians while the patient is inside the MRIdian tube?
Dr. Himanshu Nagar: Exactly. So this is what’s, quite honestly, without trying to overstate it, sort of a phenomenal aspect of this machine. So we’ve already sort of touched upon the MRI imaging that’s incorporated into this treatment modality, we’ve touched upon the real-time gating, meaning beam on and off if things move around. But then day to day, our anatomies change, and that’s even second a second. Just on the call right now, your and my anatomy has changed while we’ve gone through the first few questions here.
So what happens with MRIdian treatment, and what it allows us to do is we set up a patient on the table, and then we will match them up with the previous scan and their previous radiation treatment plan delivery. If that patient’s anatomy has changed, whether it’s the bladder fill or how much urine is within the bladder, what the rectum looks like that day, because you know, the rectum can be a little more full or a little less full on certain days, and the prostate can potentially swell from one treatment day to the other day, particularly or get smaller if they’re on hormonal treatments. So it allows us while the patient’s on in the tube to adapt to their anatomy that day.
So it’s not taking a picture three weeks ago of that patient’s anatomy and saying, Okay, this is what you’re going to look like throughout treatment. It’s saying, if need be, and your anatomy changes at the console while the patient is in the machine, the physician can alter what’s being targeted and where the dose is being limited to and then the therapist then deliver an adaptive plan. So it’s the MRI, it’s the real-time targeting, and is the ability to adapt, when necessary, in order to make sure you’re delivering high safe, and effective therapeutic doses while minimizing radiation dose to the areas that we care about the most, which is the bladder, the rectum, and the blood vascular flow around the prostate, which controls our erectile function.
Ed Randall: And Doctor, let’s continue along this line of discussion. Please make the connection for us between effective doses of radiation, shrinking the margins, and reducing the chances of life-changing treatment side effects.
Dr. Himanshu Nagar: Great questions. So on traditional machines, you would take an image and then presume that nothing would move, but you’d always give an extra margin to that because (a), you were basing a lot of your treatment, what are called contours or targets, based upon what an image looked at in static or a fixed time point before the treatment. And you were also using a CAT scan-based image, so you gave more margins in order to not miss the target to deliver those therapeutic doses.
That being said, you are also probably not escalating the dose because while you’re giving a larger margin to hit the target, what’s right outside or sort of overlapping with that margin is the rectum and the bladder and the vascular blood flow. So the shrinking margin and the effective dose that we can give with the MRIdian ViewRay is because of those three facets, right?
We have (a) superior imaging with MRI, so we can actually see the interfaces much better compared to CAT scan between the bladder, prostate, rectum, and blood vessels that are surrounding the prostate. Then we have real-time imaging, so we know that, okay, if something moves, if it moves out of a certain margin, the machine itself will stop treating it. And then you have the ability to adapt that day. So you’re able to increase the dose you want to to areas that you needed to go to, also shrink the margin because you’re confident that you’re not going to miss, and therefore treat these patients to effective doses.
And to the third point of the side effect profile, if you’re missing the organs that you’re looking to miss, then the side effect profile is and has shown to be less with this technology.
Ed Randall: So at some point NYP does the pros and cons of MRIdian a decides to write a check, hoping to derive certain benefits by adding treatment options to the institution’s toolkit. What has been your learning curve since installing the machine? Does it offer new possibilities and solutions to your team that were not anticipated by the product brochure?
Dr. Himanshu Nagar: Right. That’s an excellent question because truth be told we didn’t actually purchase this machine intentionally for any specific reason, particularly prostate cancer. When it was first quote-unquote, “advertised,” it was a new technology that would combine MRI real-time imaging with treatment delivery. And a lot of the field and ourselves thought that, okay, this is going to be new technology that needs to be proven and tested but it’s definitely beyond different compared to all the other technologies that were out there and being offered at the time.
So the biggest role we were thinking was abdominal and lung tumors because of breathing motion and changes in bowel and you know, our inability to deliver high therapeutic doses to those areas. Because of the day-to-day changes, then we quickly realized that the prostate is also an organ that’s surrounded by organs that move and the prostate can change shape, and the prostate treatment delivery can be changed from one day to the next. So we quickly adapted to understanding that we can actually use this machine to treat prostate cancer quite effectively while minimizing side effects. And therefore started expanding the role.
So the current treatment regimen we have for patients with intact prostate cancer is five sessions of radiation. And now we have a clinical trial going on trying to expand its use testing that is five treatment regimen to a two-treatment regimen because the thought is, well, if you can deliver effective dose in five sessions because you’re avoiding radiation dose to the neighboring organs, then potentially you can do this in two treatment sessions with the same or same side effect profile, and therefore even further limit the treatment burden on men and their families and deliver effective safe radiation dose for less number of visits.
Ed Randall: The two main types of treatment initially offered to men diagnosed with prostate cancer and not eligible for active surveillance are: radiotherapy or radiation and (b) radical prostatectomy, most often performed robotically. Would MRIdian be a possible solution in scenario B for someone who has already undergone robotic surgery, but then sees a real elevation of PSA?
Dr. Himanshu Nagar: Great question, because that is one of the things that we learned very early on. Because we saw, okay, we can treat the prostate and track the prostate in real-time. But what’s the prostate’s gone, can you actually treat the area where the prostate used to be? Generally, it’s an interface between the bladder and the rectum and the connection that the surgeons make called the anastomosis, basically connecting two parts of the urethra together.
And what we found early is that you can actually track and treat this potential space in between all these interfaces. And therefore we quickly adopted treating men that needed what’s called salvage radiation treatment after prostatectomy that had disease limited to the pelvis or the prosthetic bed. And then we launched another clinical trial, testing 20 treatments, which is considered a standard of care treatment for post-operative radiation treatment in the salvage setting back down to five sessions. Because again, the fundamental question and what we’re looking to answer is that if you can target what you want to target with an effective dose and miss the areas that you’re looking to miss, then why are we bringing men from multiple visits if we can do it in a quicker amount of time if it’s just as safe and just as effective?
Ed Randall: So at this point I need to ask you a question. Why is NYP Weill Cornell the only health care system in a hub of prestigious New York, New Jersey, and Connecticut medical facilities to take the leap and purchase a MRIdian machine?
Dr. Himanshu Nagar: Great question. I wish I had the perfect answer for that, but like you said, it was a leap of faith, right? It was our leadership at the time… a new building was going up, we knew new technology and standard technology had to be placed into the new building, and MRIdian ViewRay was the technology that they thought was going to be the future or strong part of the future in radiation oncology because it was doing things that we traditionally considered the holy grail: advanced imaging, real-time imaging, real-time beam delivery, with the ability to stop the beam.
And like I mentioned earlier, we didn’t know exactly how we were going to use it, but the New York Presbyterian leadership had the foresight to say, “Okay, this is technology that can potentially be game changing and practice changing. We need to be at the forefront of this to test this technology and offer it to our patients.” And that’s what we continue to do because new technology always needs to be proven because everybody wants to fancy new toy. But if the toy just works as well as any other toy, why are you going to buy the new one?
It’s testing it rigorously and then providing the clinical data both from cancer control and cure standpoint and a scientific standpoint. So far the data that MRIdian has been developing and showing through multiple clinical trials is just incredible and sort of the proof is in the pudding in terms of cancer outcomes and side effect profiles that patients themselves are reporting.
Ed Randall: For those men who do not live near New York Presbyterian and whose doctors did not offer them a MRIdian treatment option, how would they go about finding a trusted and experienced radiotherapy oncology team that offers MRIdian in their geographical area?
Dr. Himanshu Nagar: Right. So the best way is to always go on to the MRIdian ViewRay platform website to find out where the closest MRIdian site may be. And then also, you know, now in this virtual world, we’re able to do consultations for many men, women, family members without you having to travel. So there have been plenty of consultations that myself and my colleagues across the country, with this platform, have performed.
And then after that consultation, that patient can find out, (a) if there’s a senator closer to them that can offer this kind of treatment, or if it’s worth the trip for them to get the care with their, you know, local-ish MRIdian experts in prostate cancer. But the consultation is always something that can be done virtually to find out more and understand if they qualify and what the potential benefits may be for them. But the first thing I would say is, you know, look on the website at viewray.com, and from there, you know, call those institutions. And of course, there’s a, you know, website that’ll be provided along with this podcast that patients and their loved ones and family members can visit to find the best treatment for them or their loved ones.
Ed Randall: For all the years that you have been in the medical business, could you have imagined anything like what we’ve been discussing?
Dr. Himanshu Nagar: And that’s the thing, Ed. You know, this is something that we’ve sought for many, many years, right? To sort of take you back into the prostate cancer history, we started with looking at X-rays of patients. X-rays are something we use to diagnose like broken bones, and they’re very simplistic methodologies of seeing these. You can’t see a prostate with an X-ray. And that’s how we used to deliver radiation treatment. So we estimate sort of where it was located, and then we used to see… you know, we weren’t able to deliver high doses of radiation. And even with the radiation doses we delivered, there were bowel and urinary complications from that.
And then we had ultrasound come out. So we had a technique that’s still being practiced called Brachytherapy. Because you’re saying, okay, at least I can see the interface of the prostate, I can put needles or seeds into it, I can see where the bladder is, and then I can see where the prostate is. That being said, sometimes it was a single-day procedure, sometimes you still needed external beam on top of the Brachytherapy, or sometimes it was still two-day procedure. And some men, you know, when they opt for not having a prostatectomy, they don’t want anything surgical at that point. And Brachytherapy is a surgical procedure.
And then we evolved into CT-based. So you said, Okay, at least I can image prior to the treatment and have some level of confidence that I’m delivering the right dose to the right place. But we knew that wasn’t real-time and we know that, you know, it was still CT-based platforms doing that while we’ve been using MRI the entire time to diagnose and actually plan the radiation treatment.
So this was sort of a no-brainer. You’re getting the MRI, you’re getting the real-time, and you’re getting the ability to adapt. It’s sort of the holy grail of what we’ve been trying to do. And now that we have it, it’s just incredible. And honestly, it’s fun to have this technology because you actually hold the power to change the treatment plan any given day, and then have the confidence that you’re delivering safe, effective doses and limiting dose to organs we care about. Because that’s… our patients are going to hopefully live a long time, so we want to cure their prostate cancer but spare them any unnecessary toxicity because it’s not just about the quantity of life they have, it’s the quality of that life. And anything we can do to minimize and mitigate any side effect, that’s what the patient wants, and that’s what we want to deliver.
Ed Randall: Your dreams have come true.
Dr. Himanshu Nagar: Yes, they have.
Ed Randall: We’ve been speaking with a very special guest for this episode, Dr. Himanshu Nagar, assistant professor of Radiation Oncology at Weill Cornell Medicine in New York City. We congratulate you on your great work. We wish you nothing but the best in your future. And we think thank you so much for taking time out of your hectic schedule to be with us.
Dr. Himanshu Nagar: It’s been an immense pleasure, and thank you for having me.
Ed Randall: And thank you, everybody, for listening to our Stay in the Game Podcast. I’m Ed Randall.
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