Abstract

Localised therapies (surgery and radiotherapy) are the main curative modalities in cancer treatment. Only 11% of cancers are cured by systemic therapy alone. Definition of routes of invasion, meticulous surgical technique, multidisciplinary management and treatment in high volume centres has improved surgical outcomes in many cancers. Minimally invasive surgery has further reduced surgical complications and accelerated return to normal health. In the future the use of robotic surgery and novel image guidance may further reduce morbidity and improve complete resection rates. Biomarkers predicting response to non-surgical therapy will enable avoidance of surgery in those with sensitive disease and prioritisation of surgery in those with predicted resistant disease.

Radiotherapy (RT) has become dramatically more anatomically precise in its delivery in the last 30 years based on increasingly sophisticated imaging, computerised planning and linear accelerator engineering. This has led to reduction in morbidity and created the potential for dose escalation to increase cure. The introduction of proton beam therapy in 2017 will deliver a further reduction in unwanted dose to normal tissues with reduction in morbidity and second cancer risk, making this the RT treatment of choice for cancers in children and young adults and potentially many other patient groups.

The next phase of RT development will be biologically driven. The efficacy of RT treatment varies with differences in the tumour microenvironment, notably hypoxia, metabolism and immune response, and the DNA damage response. Defining this variability using functional imaging, immune and genetic biomarkers and selecting the appropriate way to modulate treatment using novel targeted therapies or differences in dose delivery to deliver biologically optimised treatment will be at the heart of RT research in the next decade. This biologically based stratification added to the anatomical precision of modern radiotherapy carries great promise in improving outcomes in the next decade.