Higher energy: is it necessary, is it worth the cost for radiation oncology?

The physical characteristics of the interactions of megavoltage photons and electrons with matter provide distinct advantages, relative to low-energy (orthovoltage) x rays, that lead to better radiation dose distributions in patients. Use of these high-energy radiations has resulted in better patient care, which has been reflected in improved radiation treatment outcome in recent years. But, as the desire for higher energy radiation beams increases, it becomes important to determine whether the physical characteristics that make megavoltage beams beneficial continue to provide a net advantage. It is demonstrated that, in fact, there is an energy range from 4 to 15 MV for photons and 4 to 20 MeV for electrons that is optimally suited for the treatment of cancer in humans. Radiation beams that exceed these maximum energies were found to add no advantage. This is because the costs (price of unit, installation, maintenance, shielding for neutron and photons) are not justified by either improved physical characteristics of the radiation (penetration, skin sparing, dose distribution) or treatment outcome. In fact, for photon beams some physical characteristics result in less desirable dose distributions, less accurate dosimetry, and increased safety problems as the energy increases for example, increasingly diffuse beam edges, loss of electron equilibrium, uncertainty in dose perturbations at interfaces, increased neutron contamination, and potential for higher personnel dose. The special features that make electron beams useful at lower energies, for example, skin sparing and small penetration, are lost at high energies. These physical factors are analyzed together with the economic factors related to radiation therapy patient care using megavoltage beams.