New frontiers in cancer care

New technologies are transforming cancer care, but geography, cost and capacity continue to shape who benefits in Pakistan

By Dr Intikhab Ulfat

There was a time when cancer care was largely associated with major surgery, difficult chemotherapy and broad radiation fields affecting both cancerous and healthy tissues. Today, we are moving towards a more precise and personalised approach, recognising that every tumour behaves differently according to its location, biology, genetic characteristics and response to treatment. Modern cancer treatment is therefore increasingly designed around the individual patient, not merely the name of the disease.

Among the most important advances has been the progress in radiotherapy. Radiation therapy uses high-energy rays or particles to damage the DNA of cancer cells so that they cannot continue to grow and divide. It may be used alone or along with surgery, chemotherapy, immunotherapy or targeted drugs. The goal is simple but difficult: destroy the cancer while protecting normal organs as much as possible.

Modern radiotherapy is no longer simply “radiation from a machine”; it is a carefully planned, computer-guided and quality-controlled treatment. With Computed Tomography (CT) scans, Magnetic Resonance Imaging (MRI), advanced software and linear accelerators, radiation beams can now be shaped around tumours with much greater accuracy. Techniques such as Three-Dimensional Conformal Radiotherapy (3D-CRT), Intensity-Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) help deliver radiation more precisely while reducing exposure to sensitive organs such as the brain, spinal cord, heart, lungs, bladder, rectum and eyes.

These techniques can make treatment more precise and, in appropriate cases, reduce exposure of healthy tissue. Image-guided radiotherapy can be used before and during treatment to confirm that the tumour and surrounding anatomy are correctly positioned. This is important because the human body is not a fixed machine. Breathing, digestion, bladder filling, weight loss and small daily movements can change the position of organs. Surface-guided radiotherapy adds another layer of safety by monitoring the patient’s body surface during treatment and stopping the beam if movement becomes significant.

Major advances have also come through stereotactic techniques such as Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS). These methods deliver very high radiation doses to small, clearly defined tumours in only a few sessions, especially for selected tumours in the lung, liver, spine, prostate, pancreas and brain. Because the dose is highly concentrated, accurate planning, precise positioning, trained teams and strict quality assurance are essential.

Another powerful method is brachytherapy, in which radioactive sources are placed inside or very close to the tumour. This allows a high dose to be delivered locally while limiting exposure to surrounding tissue. It is especially important in cervical cancer, which remains a major women’s health issue in countries like Pakistan. Timely access to brachytherapy can make the difference between incomplete and effective treatment for many patients.

Globally, newer technologies are also reshaping cancer care. MRI-LINAC (linear accelerator) systems combine MRI imaging with radiation delivery. Adaptive radiotherapy modifies treatment plans according to changes in the patient’s anatomy during the course of treatment. Artificial intelligence is beginning to help in treatment planning, organ contouring and workflow efficiency. Proton therapy, using the characteristic physical property known as the Bragg peak, can reduce unnecessary radiation beyond the tumour and may be advantageous in selected childhood cancers and tumours near sensitive organs. However, proton therapy is extremely expensive and requires major infrastructure, so even many high-income countries have limited access to it.

Pakistan has also made meaningful progress in cancer treatment. Over the past two decades, several public and private institutions have introduced modern diagnostic and radiotherapy services. The Pakistan Atomic Energy Commission’s network of cancer hospitals has played an important role in expanding access to oncology, nuclear medicine, radiotherapy and imaging services. Institutions such as Shaukat Khanum Memorial Cancer Hospital, Aga Khan University Hospital, Armed Forces Institute of Radiology and Imaging, and other major oncology centres have also contributed to the modernisation of cancer care.

In major cities such as Karachi, Lahore, Islamabad, Rawalpindi, Peshawar and other provincial centres, many patients now have access to techniques such as 3D-CRT, IMRT, VMAT, high-dose-rate brachytherapy and, in selected facilities, stereotactic radiotherapy. This shows that Pakistan is not cut off from global progress. Pakistani radiation oncologists, medical physicists, dosimetrists, radiation therapists, nuclear medicine physicians, radiologists and biomedical engineers have developed impressive expertise despite difficult working conditions.

But the real challenge is access. A patient in Karachi or Lahore may find advanced care, but a patient from Thar, interior Sindh, rural Balochistan, southern Punjab, Gilgit-Baltistan or remote Khyber Pakhtunkhwa may have to travel far, wait long and spend money on transport, food and accommodation. For many families, cancer treatment is not only a medical struggle but also a financial and emotional upheaval. The illness affects the patient, but the burden falls on the whole household.

This is why Pakistan’s priority should not only be to acquire the newest machines, but to build a strong national cancer-care system. We need more linear accelerators, more trained professionals, better maintenance, stronger cancer registries, earlier diagnosis, reliable referral systems and affordable treatment pathways. Machines matter, but people matter more. A linear accelerator without trained medical physicists, radiation oncologists, technologists, engineers and quality assurance systems cannot deliver safe, modern care.

         Prof Dr Intikhab Ulfat

Cancer treatment today is a story of science, precision and hope. But in Pakistan, it must also become a story of equity. Progress should not be measured only by whether an advanced machine exists in one major hospital; it should be measured by whether an ordinary patient, regardless of income, city or province, can receive safe, timely and dignified treatment.

The new era of cancer treatment is here. The challenge now is to ensure that its benefits reach everyone.

The author is Professor and Chairman, Department of Physics, University of Karachi.

Illustrations: AI-generated