Technical advances in radiotherapy in cancer management “Hobson’s choice or horned dilemma”

The incidence of cancer continues to rise globally, posing a significant challenge to health-care systems worldwide. It is responsible for nearly 10 million deaths in 2020 alone and accounting for approximately one in six deaths globally. According to the World Health Organization, the incidence, prevalence, and mortality in cancer (both males and females) have shown increasing trends as per GLOBOCAN 2022 data [Figures 1 and 2].[1,2]Figure 1: Incidence, prevalence, and mortality due to cancer in both males and females[ 1 ]Figure 2: Cancer incidence, prevalence, and mortality worldwide[ 2 ]The site-wise incidence of various cancers shows that lung cancer is the highest followed by breast, colorectal, prostate, etc., Furthermore, the highest mortality is seen in lung cancer patients as per the GLOBOCAN data [Figures 3 and 4].[3,4] Despite these alarming numbers, advancements in cancer treatment have led to improvements in survival rates and outcomes. Presently, there are various modalities of cancer treatment, including radiation therapy, surgery, chemotherapy, immunotherapy, vaccines, and targeted treatments. Each treatment modality has its benefits and side effects and has contributed to improving local control as well as overall survival in the management of various cancers. In certain cancers, the treatments have contributed to the cure rates of more than 5–10 years, which has led to an increased survivorship in patients of cancer.Figure 3: Site-wise incidence and mortality of cancer as per GLOBOCAN 2022[ 3 ]Figure 4: Top 5 most frequent cancers in both males and females[ 4 ]Radiotherapy has played a pivotal role in the management of various malignancies. Statistics reveal that radiotherapy is utilized in approximately 70%–80% of all cancer cases, either as a primary treatment modality or in combination with surgery and/or chemotherapy. This can be used as a (1) primary modality, (2) adjuvant, (3) nonadjuvant/concurrent, and (4) palliative. The effectiveness of radiotherapy is evident in its impact on cure rates and long-term survival. For example, in cancers such as breast cancer, early-stage treatment with radiotherapy has contributed to cure rates exceeding 90% in some cases. Similarly, in prostate cancer, radiotherapy has significantly improved survival rates, with 5-year survival exceeding 95% in localized disease. The success of radiotherapy exceeds other malignancies as well like cervical cancer, anal canal, and head-and-neck cancers. These advances in the treatment require a plethora of initial advanced radiological and immunopathological investigative workup which may become mandatory in radiation treatment planning of patient-specific situations. However, as with any treatment, it comes with its own set of benefits and potential side effects. Due to fear of such side effects (radiation-induced toxicity to surrounding healthy tissues), many times the patients have left treatment mid-way leading to poor outcomes. This presents patients with a complex decision-making process reminiscent of "Hobson's choice" or a "Horned dilemma." This dilemma is particularly pronounced in cases where the benefits of radiotherapy must be weighed against the risk of long-term complications and financial burden. Despite these challenges, the landscape of radiotherapy has undergone remarkable technological advancements, ushering in a new era of precision radiation oncology reduced toxicity, and improved quality of life of patients posttreatment. Artificial intelligence and artificial intelligence-based applications have made a paradigm shift in the practice of modern medicine from "clinical skills" based practice to radiology-dependent imaging-based practices. Radiology-based tests have entered all stages in the treatment algorithms of nearly all diseases. This has made the clinicians heavily dependent on radiology and imaging results, leading to a large number of radiology tests being ordered by the clinicians. The recent developments in radiology machines, such as computed tomography (CT) and magnetic resonance imagings, have significantly decreased the scanning time. The CT machine manufacturers have already started talking about subsecond scanning techniques for the whole body. These advancements are crucial in the context of cancer treatment, especially with radiation therapy where precise imaging is essential for accurate treatment and planning. There is a new term called radiomics which extracts information from routine medical images and, in the process, creates large databases of quantitative data, also known as "Big Data." These data need to be uniform as far as the imaging and reconstruction parameters are concerned. This uniformity ensures that the algorithms can work in such a fashion so that the subtle differences in the images are easily picked up. The creation of this massive database needs very high-speed processors and data processing units. Another challenge in data processing is the sharing of data across multiple sites.[5] As is the case with other biomarker studies, radiomics also might progress slowly due to suboptimal study designs and inherent technical complexity involved.[6] There are various steps involved in radiomics data collection and interpretation. Radiomics-based biomarker qualification also requires prospective multicentric trials where the biomarker is one of the primary endpoints for large-scale commercial application and validation of this technology.[7] Radiomics uses the concept that any abnormal thing contains a lot of various kinds of measurable entities such as texture, size, and shape. These measurable variables are then evaluated by complex computing operations and algorithms.[8] However, the integration of radiomics in radiotherapy has the potential to enhance treatment personalization, leading to more effective and tailored cancer therapies. These recent advancements in cancer research have created a niche area where the latest tools have not only hastened the early diagnosis of cancer but also assisted in optimal cancer-specific targeted therapies for better patient outcomes. These tools are ever-evolving, and more such tools are expected shortly, which would decrease the turnaround time of diagnosing this dreaded disease and also decrease the overall suffering of cancer patients. Techniques such as volumetric-modulated arc therapy, stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS) have revolutionized treatment delivery. The inclusion of various newer techniques of quality assurance with Deep Inspiration Breath Hold (DIBH)/ Surface Guided Radiation Therapy (SGRT)/fiducial-based image guidance offers highly conformal dose distributions, sparing surrounding healthy tissues and organs from unnecessary exposure.[9] SBRT and SRS enable precise targeting of tumors with high doses of radiation in fewer fractions, enhancing treatment efficacy while minimizing side effects. The integration of advanced technologies and techniques such as SBRT and SRS has expanded the scope of precision radiotherapy, making it an indispensable component of modern cancer management protocols. While the challenges of radiotherapy-related side effects are real, the landscape is evolving positively with technological advancements and tailored approaches. By embracing these advancements and fostering patient-centered care, we can navigate the "Hobson's choice" and optimize a course toward better cancer care and survival. The treatment journey, with its empowering access to information with complexities in decision-making (particularly in the field of radiotherapy), resembles more of a horned dilemma from the patient's perspective. However, for health-care workers, this journey represents a Hobson's choice, where they must carefully weigh the available options and make decisive choices based on patient needs, evidence-based practices, and ethical and financial considerations. Ethical approval statement As this is an editorial and no patients' data is used, it does not require ethical approval.