It’s hard to categorize the early adopters of Varian’s Halcyon™ system. They are large, small, and medium-sized institutions, ranging from relatively new to very long-standing. Some encompass a single treatment center and some are large multihospital health systems. All, however, report that the Halcyon system is ideal for expanding access to high-quality image-guided radiotherapy and doing it quickly, easily, comfortably, and as cost-effectively as possible.
Queen’s Hospital in Romford, which opened its doors in October 2006, recently became the first site in the UK to utilize the new Halcyon system. According to Dr. Sherif Raouf, Consultant Clinical Oncologist/Oncology Lead, integrated imaging and shortened treatment times are among the features that appealed to him as “two big pluses of the Halcyon system.”
“The system offers full integration of imaging and treatment, and all treatments are image guided and intensity modulated for enhanced protection of organs at risk,” he said. “Currently, we are treating around 40 patients per day on the Halcyon system. This number is likely to increase. The system has the potential to treat five to six patients per hour. We hope to accommodate up to 60 patients per ten-hour day as our facility with the system grows.”
A patient with cancer of the nasopharynx was among the first for whom Dr. Raouf and his team created a Halcyon treatment plan. “These cases are difficult to plan due to the proximity of the target to critical structures such as lenses, optic nerves, parotids, brainstem, and cord,” Dr. Raouf said. “The prescription was 70Gy in 35 fractions with a lower dose target of 56Gy in 35 fractions.”
To assess the Halcyon treatment plan, Dr. Raouf’s team also created a treatment plan for delivery on a Clinac® system and compared the two. “The Halcyon provided improved coverage of the high dose target along with better sparing of lenses and parotids, plus some midline laryngeal sparing,” he said, noting that the speed of treatment will enable his team to offer highly conformal treatments like intensity-modulated radiotherapy (IMRT) to more of their patients.
Patients Experience Increased Comfort, Convenience, and Quiet
In addition to its clinical capabilities, the Halcyon system offers some patient-friendly features that patients seem to appreciate.
“Overall patient experience is vital to us in the design of our oncology facilities,” said Dr. Raouf. “The Halcyon system ideally matched our conception of a modality that maximizes patient comfort and convenience.”
For example, he pointed out, some patients are treated with a full bladder, and they naturally appreciate quick treatments. Others like the fact that all the system’s moving parts are behind the bore and so there is virtually no perception of movement compared with the treatment experience on older linear accelerators (linacs), which can be noisy when the gantry rotates. “The movement of the system’s components—the gantry, collimator, and couch—are very quiet,” he said.
The addition of the Halycon system has also enhanced the center’s ability to optimize usage of other specialized treatment technologies. “Three [C-arm] linacs can treat up to 100 patients per day. Two Halcyon systems can treat similar numbers,” Dr. Raouf observed. “This frees up the Edge™ radiosurgery platform for specialized treatments such as SRS and SABR.”
Speedy Installation, Commissioning, and Training
Installation of the Halcyon system and the subsequent training were completed in much less time than was needed with conventional linacs, according to Dr. Raouf. Clinicians at the Queen’s Hospital Radiotherapy Center began treating patients on the Halcyon system within 25 days of system delivery.
“The radiographers’ training took only three days. The physics training was carried out during the commissioning,” he said.
Lead radiation therapist Emily Borchardt, team leader on the Halcyon project, likes working with the system. “It utilizes the same Eclipse™ planning system, which I am used to. I like the design which is very patient friendly, the speed [of treatment delivery], and the way it makes complex radiotherapy seem very straightforward,” she said. “It took no time at all to ramp up clinically. It was full action from day one."
Penn Medicine, the University of Pennsylvania’s Health System, has its roots in the founding, 200 years ago, of Pennsylvania Hospital, the first hospital in The United States and subsequently the nation’s first medical school. Today Penn Medicine encompasses six hospitals and 10 multispecialty centers in the Philadelphia and neighboring New Jersey areas.
Penn's Management Decides on Halcyon
Penn Medicine acquired the Halcyon system to augment existing operations in order to provide more high-quality treatment for more patients. "We are a very busy center, so efficient high-quality treatment is a fundamental goal," said Kurt Morath, Director of Operations, Department of Radiation Oncology. "The Halcyon system is easy to use, equivalent to the TrueBeam system in terms of treatment quality, and twice as fast. The Halcyon system complements our current configuration and will be the ‘workhorse’ machine for our department.”
Expedited Site Planning and Installation
According to Morath, the site planning and installation processes for the Halcyon system were noticeably different than what he encountered in the past during other technology deployments.
“The installation time is dramatically decreased, shielding requirements have been reduced, and construction costs are significantly less,” Morath said. “Installation was accomplished in a few days whereas earlier linac installations took four to six weeks. The acceptance and commissioning time was decreased from one month to one week. Overall, there was a considerably faster ramp-up from start of construction to first patient treatment.”
Beginning with Head & Neck Cancer
“Head and neck cancers were the primary focus of our initial Halcyon implementation,” said Alexander Lin, M.D., Chief, Head and Neck Cancer Section.
Dr. Lin described one of the first cases the clinical team planned and treated on the new system—a 58-year-old man with a history of mantle cell lymphoma. “He had been treated with chemotherapy and a stem cell transplant in 2008-2009 and had relapsed. All sites of disease were responding to a new round of chemotherapy except for a left level II neck node, which was found to be a squamous cell carcinoma,” Dr. Lin said. “His left neck disease was deemed marginally resectable, and definitive chemoradiation was recommended.”
The radiotherapy prescription included four dose levels to be delivered in 35 fractions utilizing a simultaneous integrated boost. The left level IB and bilateral retropharyngeal nodes were treated to 5600 cGy. The right neck levels II-IV and left levels II-V, as well as the parotid gland which was clinically involved, were treated to 5950 cGy. Several small indeterminate lymph nodes in the neck were treated to 6650 cGy. The biopsy-proven left neck adenopathy was treated to 7000 cGy.
The clinical team found that this sophisticated treatment could be accomplished with appropriate coverage of planning volumes using a nine-field Halcyon IMRT plan that limited dose to the nearby organs at risk (OAR), including the brainstem, spinal cord, esophagus, and parotids. They also generated a second treatment plan for a C-arm linac to assess the quality of the Halcyon plan.
“We found that the Halcyon plan provided similar target coverage and OAR sparing when compared to the C-arm plan,” said Dr. Lin. “We were very happy with the quality of the Halcyon treatment plan.”
Clinical Team Appreciates Ease-of-Use and Safety Features
Dr. Lin further characterized the Halcyon platform as ‘easy to use.’ “The simpler and integrated workflow uses standardized steps that can potentially reduce the chance of an error,” he said.
Brian Kempsey, B.S., R.T.(R)(T), radiation therapist, appreciates other key features of the system, including the table-mounted camera, which provides a “useful bird’s-eye view of the patient during treatment” and the image-guidance system, which enables accurate delivery of treatment. “All the moving gantry parts are concealed inside the bore, keeping the patient safe from moving parts during treatment,” he noted. “This allows the therapist to feel confident about the patient’s safety once the therapist has exited the treatment room. From the ‘align’ and ‘unload’ features of the table, to the high dose rate and gantry speed, the system helps us get patients on and off the table safely and quickly.”
“Most patients’ first impression of Halcyon is that it appears similar to a CT scanner,” said Kempsey. “For many patients, radiation therapy is an unknown realm and having that familiarity appears to offer them some comfort. Many patients have commented that treatment took less time than they expected. Any relief that can be offered to patients going through such a stressful experience is a benefit.”
Morath concurred. “For our patients who have already had experiences with other linear accelerators, they appreciate the expedited treatment and comment on how much less intimidating the machine looks. They cannot believe all of the components are encased within it.”
Penn Medicine has plans to purchase additional Halcyon systems. “Currently we are planning to install four Halcyon units, two at our main center and two at other network locations,” said Morath.
Hopelands Cancer Centre in Durban, South Africa, was started by three oncologists in the late 1990s. Over the last twenty years, Hopelands has created partnerships to establish six additional satellite clinics at locations across the KwaZulu Natal (KZN) province, making it one of the largest oncology practices in South Africa.
Recently Hopelands and its partner, Busamed Hillcrest Private Hospital in Outer West Durban, acquired and installed South Africa’s first Halcyon system. “This is an introductory unit, the first in sub-Saharan Africa,” said Dr. Ziad Seedat, director of Hopelands Cancer Centre.
Small Size, Built-In Shielding, Speedy Installation, Operational Efficiency, Patient Comfort
Seedat cited several reasons that a Halcyon system was selected for the site: the system’s smaller footprint, its built-in structural shielding (which reduces the amount of shielding required in the surrounding vault), fast installation, operational efficiency, and patient comfort.
“Simplicity and speed of installation and commissioning were crucial at this site. An innovative and accelerated process proved to be feasible” in deploying the system, Dr. Seedat said.
Akshay Budhram, radiotherapy unit manager, noted the user-friendliness of the Halcyon system, calling it “operationally friendly technology with a simplified workflow” that made training “easy to grasp” and the system itself “easy to use.” He particularly appreciates the “follow-the-blue-light” workflow that helps to guide the radiotherapist through the steps of an image-guided, volumetric IMRT treatment.
“The system promotes efficiency,” he said. “Treatment times, as well as overall process flow, are significantly improved, enabling the treatment of a greater number of patients” in a given timeframe.
A Better Patient Experience
Patients seem to like the Halcyon system too. “Patients who had previously received treatment on conventional linac systems have been amazed by the Halcyon system’s design,” said Budhram. “They say they feel more comfortable with the CT-scanner-like appearance, and note how much faster treatments are completed compared with their prior experience.”
Diana Pillay, M.D., radiation oncologist, used the Halcyon system to treat one such patient, who had been treated for axillary node metastases from melanoma on a Trilogy machine back in 2016. He needed a second course of treatment earlier this year for new metastases to the manubrium of the sternum.
“He was very impressed with the speed of his Halcyon treatments, compared with the process when he first received radiation treatment a couple of years ago,” she said. “This time he experienced no side effects other than a Grade 1 dermatitis.”
Halcyon Provides Cost-Savings for the Centre and for Patients
Budhram holds that the faster treatments and automated planning process with the Halcyon system have enabled the center to increase the number of patients served while lowering the per-patient cost of treatment. He pointed out how the dual-layer MLC, Halcyon’s faster treatment times and automated planning not only allow the Centre to increase its patient treatment load but also to treat the vast majority of patient profiles.
“All the system’s features, from the planning and the workflow to characteristics of the dual-layer multileaf collimator, combine to increase efficiency,” he said. “For example: the dual-layer MLC, with its overtravel capability, enables more efficient treatment of larger areas with advanced techniques like IMRT and VMAT. This has enhanced our ability to offer these state-of-the-art treatments to a wider range of patients.”
Note: The information captured herein represents the genuine experience of the attributed individuals and may not necessarily represent the views of Varian or the above referenced institution. Individuals were not compensated for their testimonials. Radiation treatment may not be appropriate for all cancers. Individual results may vary.