Acta Oncologica

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The contribution, history, impact and future of

physics in medicine

Steve Webb

To cite this article: Steve Webb (2009) The contribution, history, impact and future of physics
in medicine, Acta Oncologica, 48:2, 169-177, DOI: 10.1080/02841860802244158

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Acta Oncologica, 2009; 48: 169
177

COMMENTARY

The contribution, history, impact and future of physics in medicine

STEVE WEBB

Joint Department of Physics, Institute of Cancer Research and Royal Marsden Hospital, London, UK

Abstract
This is an ‘‘Opinion’’ or ‘‘Commentary’’ text to support the Invited Opening Plenary Lecture of the NACP2008
Conference. It is an outrageously broad title, that I have been given, and I have made selections for the focus of the lecture
and for this report. I observe a research methodology in medical physics whereby key developments have come from
standing on the shoulders of those who have come before and I illustrate this by the invention of x-ray computed
tomography and the development of intensity-modulated radiation therapy. The equally key role of somewhat maligned
incremental science is also discussed. Some commentary is made on the enormous range of activities in medicine to which
medical physicists have contributed. Conversely, future gazing is a totally unscientific process. Nevertheless I add my
thoughts in broad generalities and also in specifics for the field (radiotherapy physics) in which I work and might be
expected to be more accurate in my proposals. I conclude with some remarks on the conditions needed to achieve good
scientific outcome.

At the outset it should be said that this is not a paper that time) that one could turn ones hand to almost
in the traditional style. It does not ‘‘state a problem any branch of the subject. There was in the UK very
to be solved’’; it has no ‘‘materials and methods’’; it little grant-driven research and generally medical
has no ‘‘results’’; it does have a conclusion but not in physicists were very free to be inventive, creative and
the usual sense. It is instead a ‘‘Commentary’’ or expansive and to change direction whenever this was
‘‘Opinion paper’’ and represents the transcript appropriate. That was a good thing. The funding for
corresponding to the invited Opening Plenary Lec- this just ‘‘seemed to be available’’.
ture of the NACP2008, the Nordic Medical Physics Very soon afterwards, imported from the USA, a
meeting which took place in June 2008, in Aarhus, culture of grant-driven research emerged in the UK
Denmark. and throughout Europe and medical physics itself
developed many sub-specialties with somewhat
artificial, yet very real, boundaries between them
Overview of medical physics through which passage was not at all easy. It also
The development and implementation of modern became necessary to be more proscriptive as to
clinical medicine owes a great deal to the contribu- what research would be done and then to stick to
tion from physics. Physics as Applied to Medicine or those proposals. I felt that was not wholly such a
Medical Physics is now a recognised, well respected, good move. I might smile a little to see now the
sub-specialty of Physics. Medical physicists are emergence of grant calls for cross-disciplinary re-
employed to do research, to implement the fruits search which, to my somewhat older mind, is a
of research and development in the clinic (some- call to do what we were naturally able to do before
times known as clinical physics or hospital physics) these boundaries ever existed. However, that may be
and to teach the new generations of medical to start on too negative and cynical a note because
physicists both at academic specialty level and also the culture of grant-driven research has also had
with ‘‘hands-on’’ practical training. When I began the immense benefit of providing increased funding
my career in the subject (in the early 1970s) it was for the subject, ever expanding departments and
possible and encouraged to combine all these roles. the influx of a wealth of talent that, at least in
It was also expected (probably unrealistically even at principle (through the Bologna process), knows no

Correspondence: Steve Webb, Joint Department of Physics, Institute of Cancer Research and Royal Marsden Hospital, London, UK.

(Received 2 June 2008; accepted 2 June 2008)

ISSN 0284-186X print/ISSN 1651-226X online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/02841860802244158
170 S. Webb

geographical boundaries. Also it has to be acknowl- began in 1895 when, on November 8th, the then
edged that each branch of medical physics has now 50-year-old German professor Wilhem Conrad
become enormously complicated and that under- Röntgen discovered, in Wurzburg, the x-ray in the
standing the long-term goals and the pathway to early evening, probably the only major event of its
them is a necessary part of the research process. kind not just to be dated but timed for its place in
It might also be observed that, whereas in the early history. However, physicists were plying their science
days of medical physics there was almost no formal (and sometimes almost art) to medicine for centuries
induction to the subject, with the passage of time before this. See for example the interesting develop-
have emerged superb training schemes that not only ments in attempting to harness physics to benefit
teach the formal basics of the subject but also ensure medicine in the early 1800s [4].
regulatory compliances and the maintenance of high Those who look backwards are sometimes tempted
professional standards. In most developed countries to regard early days as better days. Certainly if
there are now professional organisations whose remit freedom from associated burdens of grant writing,
it is to foster the development of medical physics. In report constructing, audit, too much burocracy and
the UK this is the Institute of Physics and Engineer- too many committees, etc is valued, then better times
ing in Medicine (IPEM) [1]; throughout Europe it is they were in that medical physicists were largely
the European Federation of Organisations for Med- 100% doing medical physics. But times were not so
ical Physics (EFOMP) [2] and Internationally it is good in other ways. We must recall that for the first
the International Organisation for Medical Physics half of the 1900s medical physicists were numerically
(IOMP) [3]. These training programmes address the
few and often working in totally uncharted territory.
above mentioned complexity of modern medical
Imagine trying to do radiotherapy in the days when
physics. However, they must not be allowed to
the unit of dose was hardly defined and very primitive
become so lengthy and so stifling as to throttle the
ways to measure dose were in vogue. Imagine having
budding initiative of young trainee minds especially
to define the Röntgen and the rad. Imagine having
those anxious to make definitive contributions rather
only primitive x-ray equipment available that could
than have yet more training. Also it is necessary to
only take planar x-rays and even then over-irradiated
ensure that, as medical physicists necessarily focus
the patient’s skin in the process. Imagine having no
narrowly on a complex topic, they do not overlook
the possibility of lateral thinking from other fields functional imaging and having to invent it. Imagine
and even those that are not primarily aimed at no artificial radioisotopes or their use in nuclear
medicine. medicine. Imagine . . . imagine . . . the list is endless.
The early medical physicists were like the early
mariner explorers seeking new continents. The early
How it was and how it is and how it will be medical physicists made what today seem funda-
mental discoveries and clarifications but they had
When can we regard the subspecialty of medical
physics as having been born? At the risk of making little but their intuition and skills from studying
an over-restrictive generalisation, most physicists mainstream physics to guide them. There were very
today work on two broad areas: (i) imaging and few professional societies and those there were were
diagnosis in relation to disease and (ii) therapy in
relation to disease, where the main disease speciality
is cancer. So, it might be said that medical physics

Figure 1. A UK postage stamp of 1994, value 41p, showing CT Figure 2. The hat won by delegate to the world’s 1st IMRT
scans. School in Durango, Co in May 1996.
 The contribution, history, impact and future of physics in medicine 171

largely offshoots of the medical profession. The It is far harder to write about, and there is far less
British Institute of Radiology was an exception that literature on, the future of medical physics. It is quite
in 1920 gave physicists equal professional status with fashionable to ask (sic) luminaries to prophesy the
medical practitioners and even organised some future. ‘‘They’’ usually ask you when you are near
simple training programmes. The UK Hospital career-end and may not be around long enough to
Physicists Association (HPA) was not formed until see if you were correct. I have been asked 4 times
1943 when there were just 53 medical physicists in before to act in this capacity so this is the 5th such
the UK [5,6]. Imagine also the much more primitive request [10
13]. Some might argue that this is a
communication channels
no commercial aircraft, fruitless effort. Scientists are trained to hypothesise,
the need to go to the USA or Far East or Australia by investigate, report their findings and stop at that.
ship, no email (though sometimes nowadays, on bad Prophesying the future is a totally unscientific
overloaded days, we may think that was not such a process. It can however provide insight into future
research channels and can be entertaining; at worst
bad thing), no internet. There are some quaint
writers and lecturers can look egocentric and possi-
stories of slow professional travel around the world
bly ridiculous. An innovative approach was taken for
in a book [7] written by a UK professor of medical
the 50th anniversary of the UK National Health
physics (John Roberts) who was also the 1st Editor of
Service in which a Symposium bringing together
Physics in Medicine and Biology, the journal of which I
forward thinkers was followed up by a book [14].
am currently the 11th Editor. A fascinating retro-
spective has also been recently written by Alan
Jennings, one of the only four surviving Founder Two example key contributions of physics to
members of the HPA [8]. Another fascinating retro- medicine
spective was the Wellcome Witness on the develop- Rarely can or do any medical physicists set out to
ment of physics as applied to medicine in the UK make key discoveries, much as they would like to.
between 1945
1990 which also references many That is not an approach likely to work. Rather, it is
more substantial tomes on the history of our subject with hindsight that one can look back and identify
[9]. There is a mini industry of publishing memories that certain key discoveries or inventions or key
of the early days of medical physics and here it is understanding of a phenomenon came about by
impossible to do justice to that. Those who grow old people, whose names are now forever remembered
in their subject tend to be those with greatest interest and associated with those events, ‘‘standing on the
in retrospective study. shoulders of giants’’ as Newton so eloquently put it.
‘‘Big hit science’’, the science that has changed the
world forever has generally evolved this way. Most
physicists, conversely, have performed important
‘‘incremental science’’, sadly a phrase much disliked
by grant-funding bodies; yet it is this very incre-
mental science that has often led to the big-hit
landmarks. Let us look at some examples.
Commercial x-ray computed tomography (CT)
has been hailed as the greatest revolution in radi-
ology since the discovery of the x-ray. The first
scanner, invented and built by the British EMI
Company, was announced in April 1972. Whilst
work leading up to this announcement was joint
between several scientists in London Hospitals, the
DHSS (Department of Health and Social Security)
and EMI it is the name of Sir Godfrey Hounsfield
(28.8.1919
12.8.2004) which will always be asso-
ciated with the CT scanner. He made a reality what
many others had worked on and even ‘‘nearly
achieved’’. He was knighted, became an FRS
(Fellow of the Royal Society), received the 1979
Nobel Prize for Medicine and was feted with
honours. His original CT scanner stands in the
London Science Museum alongside the Apollo-10
Figure 3. The pioneering Lars Leksell. lunar module that circled the moon, a surely not
172 S. Webb

un-deliberate juxtaposition. He has been cited as one landmarks; they are two I understand. The next
of the 1 000 most influential people of the 20th section introduces a much wider set of landmarks.
century [15]. Yet if one looks back at the history it
can be seen that many shared his vision. Alan
A broad-brush overview of some other past
Cormack (23.3.1924
7.5.1998) performed pioneer- contributions of medical physics to medicine
ing laboratory experiments in 1963 and shared the
Nobel Prize. Gabriel Frank patented the (nearly) In this section we make some brief remarks about
CT principle in 1940. A CT scanner was reputedly the whole field of contributions of medical physics to
built in Kiev for medical purposes in 1957. David medicine. This is an almost impossible task given
Kuhl made a CT scan in 1965 [16]. that whole books are given to each topic, that this
Another key development in medical physics is the paper can have only 25 references and that the
invention of techniques to deliver intensity-modu- stories behind these contributions are huge. How-
lated radiotherapy for curing cancers [17
20]. Most ever, let us try.
acknowledge that Anders Brahme of Stockholm, Concentrating initially on the disease of cancer,
Sweden published the first paper explaining primi- physicists invented many ways of diagnosing disease
tive techniques for achieving this [21]. He visited a by imaging. The earliest was x-radiology (1895),
number of other cancer Centres and work in these simple xerography (1907), then classical tomography
may have been stimulated to commence by his visits: (blurred slice imaging) (1920), optical diaphanogra-
(DKFZ-Heidelberg: Schlegel and Bortfeld; phy (1929), stereoscopy, analogue tomosynthesis
MSKCC-New York: Mohan and Mageras; ICR- leading to x-ray CT in 1972 as already discussed.
RMH-London: Webb). Mark Carol, CEO of the Nuclear medicine imaging started in the 1940s with
NOMOS Corporation announced the invention of the use of simple Geiger counters (1948), scintilla-
tion scanning (1950), Anger camera imaging (1957),
the World’s first commercial IMRT delivery equip-
the technetium generator (1960), rotating SPET
ment, the MIMiC, in October 1992 and this
scanner (1963), analogue single photon tomography
dominated American delivery of IMRT for about 3
(1967) and the commercial gamma camera SPECT
years before multileaf-collimator-based methods
(1978). Positron emission tomography (PET)
caught up and probably overtook. Yet this develop-
started in 1951 and simple PET scanners were
ment also did not come out of nowhere. An
invented by 1953. The principles of magnetic reso-
American mathematician, George Birkhoff ex-
nance were developed in 1946 and the first in vivo
plained in 1940 the principles whereby any drawing
MR imaging was around 1976, pathological MRI
could be composed of the superposition of a series of
following around 1980. Ultrasonic scanners date
straight lines from different directions and of differ-
back to the 1930s but the WWII produced the
ent blackness, including negative blackness, the impetus for technological development and the first
addition of erasure components. Apart from the human ultrasound pictures were made around 1950.
un-physicality of negative x-rays this is the IMRT Imaging of pregnancy by ultrasound started in 1961.
principle if the lines are interpreted as x-rays and the Leksell in Sweden was working on ultrasound
picture is interpreted as a dose distribution [22]. imaging in the 1950s. Electrical impedance tomo-
Basil Proimos introduced the concepts of gravity graphy started in 1982.
blocking to produce dose distributions with concave The detection of gamma-ray photons owes much
isodoses as long ago as 1940 [23]. to the development of the Crookes’ spinthariscope
Key being stressed here is that these are landmarks (1903), the Wilson cloud chamber (1895), the gold-
that most would agree ‘‘matter’’. They have changed leaf electroscope and the Geiger counter (1929).
the way patients are diagnosed and treated. Let us Artificial radioisotopes were first produced by the
not perhaps argue too strongly over which names Lawrence cyclotron (1931) and nuclear reactors at
should be linked to them. The award of prizes and Oak Ridge and Brookhaven and AERE (Atomic
honours can be a divisive business (witness the quite Energy Research Establishment) Harwell in the
high profile writing about Damadian over the non- 1940s.
award of the Nobel prize for magnetic resonance Radiotherapy for treating cancer owed its success
imaging [24]). The key issue for the future and well- initially to the development of big particle-accelerat-
being of mankind is the landmark itself and, as seen ing machines [17]. Gustaf Ising proposed the idea
in these two examples, it stands firmly on the for the linear accelerator in Sweden in 1924. For a
shoulders of the giant work preceding. Finally, it while other methods were used however, e.g. Cool-
should be clearly said that many other similar idge used cascaded tubes to obtain 900 keV (1927).
examples to these could have been cited. I am not Rolf Widerøe from Norway invented the Betatron
wishing to say these are the two most important (1928) and got the linac concept to work; Van der
 The contribution, history, impact and future of physics in medicine 173

Figure 4. A famous quotation and Tenniel illustration from Lewis Carroll’s book ‘‘Alice in Wonderland’’.

Graff built his prototype generator in 1929. The 1959 but not commercially available until 1984.
cyclotron was invented in 1931 by Lawrence. Vick- The gamma knife was first used in Stockholm in
ers developed the Cockroft-Walton generator in 1958. Note that all these important inventions and
1937 in London. The Varian brothers invented the applications of technology in radiotherapy were the
klystron in 1937 and a magnetron was developed by work of physicists and engineers (who maybe did not
Randall and Boot in 1939. The Kerst Betatron was all think of themselves as medical physicists) and
available for medical use in 1943. Grimmett pro- also all these developments long predate IMRT
duced the first practical proposal for patient irradia- which stands on the shoulders of these technologies.
tion using cobalt-60 in 1948 after Mayneord had The majority of medical physicists work in ima-
brought radioactive cobalt back to the UK from ging and therapy for cancer, but not all. Medical
AEC Chalk River and Oak Ridge in 1946. The first physicists play an important role in cardiology, in
medical cobalt unit was in Saskatoon in 1951. surgery, in understanding the forces on and within
Leksell introduced radiosurgery in 1951. The first the human body. They work on understanding the
medical linear accelerator was in London in 1953 physics of lungs and breathing, the behaviour of
and the first in the USA in 1954. The first medical electricity within the human body, the understand-
proton irradiation was in 1954 at Berkeley Radiation ing of pressure in the body, audiology, optical
Laboratory and the first cancer patient was treated at behaviour in the eyes and the mechanics of vision.
the Gustaf Werner Institute (now the Svedberg If we can also include people who would rather
Laboratory) in 1957 in Uppsala, Sweden. The first call themselves medical engineers then there are yet
computerised treatment-planning system was in more who design and build equipment for physiolo-
1958. The multileaf collimator was patented in gical measurement and physiological correction of
174 S. Webb

disfunction. There are those who work to improve all (Sweden): radiotherapy treatment planning, (iv)
manner of devices for the disabled, the scope far Hans Svensson (Sweden): IAEA contribution, (v)
exceeding mobility devices such as wheelchairs. Jens Overgaard (Denmark): radiotherapy (and the
There is physics and engineering in anaesthetics, in ‘‘green journal’’. And (dare we add?) the ‘‘adopted
sports medicine and treating sports injury. Medical Nordics’’ (i) Pedro Andreo (Spain/Sweden): Monte
physicists have made contributions to the study of Carlo and dosimetry, (ii) Alan Nahum (UK/Swe-
the effects of air travel, of space travel, of the use of den): dosimetry.
mobile phones, of electricity pylons, of domestic Can I add a disclaimer please? The writers of
electrical equipment, of other environmental pollu- history tread dangerously and compiling a list such
tants and concerns. as this will exclude some people who may then be
Medical physicists and engineers have built equip- intensely irritated at their omission. Please forgive
ment for DNA sequencing, for a host of laboratory me. I write in good faith, being somewhat selective.
physics and chemistry associated with drug discov- Regarding elements much used in medicine we
ery and refinement. It might be hard to identify areas may note some major Nordic discoveries. Some of
of medicine where medical physicists do not play the discoverers were from Scandinavia and some
some role. discovered in other countries have been given
Before leaving landmarks we might note there is a Nordic names with reference to http://home.clara.
significant difference between output and outcome. net/rod.beavon/elements.htm: A slide of these was
Output is very easy to quantitate through numbers shown in the Lecture but the full lengthy list is not
of papers, citation indices, h-indices of authors, lists given here.
in reports etc. Outcome is much harder to quanti-
tate. Usually there is a very long time lag between the
Thoughts on the general goals of cancer
fundamental inventions and their impact on society.
research
Whilst not the only focus of physics applied to
Some key Nordic (medical) physicists
medicine, cancer research is a key area. We might
Grouping, somewhat artificially, together a number observe that the goal of cancer research as it was
of physicists whose work has influenced the develop- enunciated early in the 1900s was to cure cancer i.e.
ment of medicine, we may identify several key Nordic arrest tumour growth with possibly little attention
contributors. Anders Brahme (Sweden) has already played to the sparing of dose to normal structures
been mentioned in connection with IMRT. The (largely physically impossible anyway) or to the
Norwegian: Niels Henrik Abel (August 5, 1802
preservation of a high quality of life. People died
April 4, 1829) has given his name to an integral relatively young and so keeping them alive was the
(Abel’s integral) which arises in the only analytically primary goal. With much increased life expectancy,
soluble IMRT problem which is an analytically modern man may expect to live well into his 80s and
soluble inverse problem first studied by Brahme maybe 90s with cancer-incidence age not having
et al. [21]. His name is also given to a branch of changed much. The goal of much cancer treatment
mathematics and much more. Lars Leksell (Sweden) is therefore to put the patient into largely symptom-
(1907
1986) was the pioneer of radiosurgery, stereo- free remission and expect that tumours may require
taxy and the Gamma Knife. Bjarne Stroustrup, born to be re-treated later in life. To that end the
December 30, 1950 in Aarhus as you must surely preservation of normal function and minimisation
know, is the inventor of C. Many inverse-plan- of dose to organs at risk becomes a major focus of
ning codes and other codes in medical physics are attention in addition to treating the primary tumour.
written in C. The Norwegian-American Ernest This is one of the main achievements of IMRT, that
O. Lawrence, born August 8, 1901, died August 27, it can be performed with an eye to the future. The
1958 was a physicist and inventor of the Cyclotron, goal is to ensure that man lives long and dies quickly
much used in nuclear medicine. Rolf Sievert (1896
in contrast to the situation today where there is
1966) (Sweden) showed how to calculate the ab- much chronic disease as health may gradually
sorbed dose to tumours from intracavitary and deteriorate.
interstitial sources. He also invented a number of
ingenious instruments for dose measurements,
The future for medical physics in cancer
among other the world-wide known Sievert chamber.
He gave us the unit for equivalent dose, the sievert. If the future of research in cancer-applied medical
Some other key Nordic contributors are (i) Niels physics were certain we should be little more than
Finsen (Denmark): light treatment, (ii) Søren Bent- implementational technicians. We cannot know, just
zen (Denmark): radiobiology, (iii) Anders Ahnesjö as our forebears did not know, the complete course
 The contribution, history, impact and future of physics in medicine 175

of evolution of medical physics. Indeed, many of the activities; others are more contentious and may even
key past developments have come by lateral thinking be outrageously unthinkable.
from other fields. Predicting the future is a totally Regarding improving diagnosis, more thorough
unscientific process whereby hope, promise and screening programmes should lead to a shift in stage
expectation rule at the expense of cold logical and profile and a greater focus on cancer patient survival.
rational scientific argument. Nevertheless there can Biochemical tests and genetic tests should be added
be goals and key areas in which to work can be to the information from 3D multimodality imaging.
identified. A move further away from anatomical imaging to
Undoubtedly research will continue in the main functional imaging will occur. Telemedecine, which
areas of medical imaging e.g. SPECT, PET, MRI was much talked about years ago, seems to have
and MRS, ultrasound and optics. High-speed digital failed to develop widely; yet it is just this technology
x-ray imaging and CT imaging will make further which could bring the medicine of the highly
progress. The current focus of attention in both the developed world to the less-well-developed world.
imaging and therapy field on understanding and Even in areas with equal development, telemedicine
compensating for tissue and organ motion on many could overcome inequalities in health care provision
different timescales will continue to optimise diag- on a geographical basis (postcode medicine) There
nosis and therapy. Whilst the human genome map- may be no need at all to have the doctor in the same
ping project is complete, exploiting this knowledge is place as the patient. Another early prediction [14]
in its infancy and the development of gene-based that mankind will somehow carry its own biosensors,
therapies will continue. Nanotechnology has been remotely and automatically linked to room-based
diagnostic devices, summoning medical help even to
identified as a key focus with the expectation that
asymptomatic patients, does not seem to have taken
nanoparticles could act as contrast agents, be
off a decade later; but it might. It may appear science
vehicles for drug delivery, act as microsensors of
fiction to those waiting to see their GP (General
local pH, temperature, drug concentration, dose,
Practitioner i.e. family doctor) in today’s cash-
DNA damage and cell survival. Nanocrystals of
strapped medical economy.
semiconductor material coated with a shell to form
Radiotherapy treatment planning should be patient-
so-called quantum dots can fulfil these roles. Already
individualised and based on measuring radiosensi-
ultrasound microbubbles are in use and could be
tivity, response to tissue assays and 3D functional as
further exploited to deliver drugs locally to tissues. well as anatomical imaging. The bottleneck of tissue
It is claimed that high-intensity pulsed electric contouring by automation never seems to go away,
fields applied to cancer cells can enhance the uptake yet needs to. Each patient treatment plan, delivered
of cytotoxic drugs. It is possible that photochemical data and therapy outcome should be entered into a
internalisation can treat cancer by releasing drugs database to form the basis in the future of elaborate
internally by shining light on selected regions. There correlation studies to determine what really does
may be a link between late radiation damage and influence the outcome of radiotherapy. The use of
genetic profile, still to be explored. single-modality treatments may become obsolete as
What is inevitable is that the trends in develop- the possibility to deliver multi-modality treatments
ment in computing will make it possible to solve (combined photon, proton, heavy-ion therapy with
today’s problems faster and also open up the brachytherapy, radionuclide therapy, targeted drug
possibility to solve problems quite impossible to therapy and focused ultrasound). Multiple plans
address today. In my paper [13] I gave the data, might be prepared to select an optimum plan.
derived from help by Gerry Battista at the 15th Planning should rely increasingly heavily on 4D
ICCR in Toronto, on the doubling times for many data with multiple imaging throughout the course
computer benchmarks. Also DNA computing, now of therapy and adaptive readjustment of plans to
in its infancy, may deliver orders of magnitude more cater for changed functional status, the discrepancy
computing power [25]. between delivered and planned dose and other
factors. Finally, regarding planning, MonteCarlo
The future for medical physics in radiotherapy methods should render obsolete the rather quaint
terminology of 20th century radiotherapy physics
I can be more specific in my ‘‘prophetic remarks’’ dosimetry.
concerning the future of medical physics in my own Radiotherapy treatment will also greatly change. 3D
discipline of improving the physical basis of radiation and 4D medical imaging will be used to adaptively
therapy. I can see further ahead, be less vague and adjust the plan both for inter-fraction motion and
also create ‘‘wish lists for the 3rd millennium’’. Some intra-fraction motion. As well as simple re-position-
thoughts are little more than extensions of today’s ing, the fractionally incremented delivered dose
176 S. Webb

could be computed to form the basis for adaptation. generally doesn’t work. Conditions must be
Predict-ahead techniques will be required for over- engineered so that there is a suitable balance
coming system latency between making a measure- for the individual as well as satisfying the
ment of patient motion and correcting for it. ‘‘business model’’ of the employing organisa-
Regarding technology, why should therapy be limited tions.
to the use of one delivery machine at a time. Maybe iv. Research failure should be allowed and toler-
multiple robots could be used just as they are in the ated. At present I submit there is too risk-
car-manufacturing industry. Whilst the role and averse a culture.
importance of hadron therapy is still debateable v. Too much grant-driven research will kill the
(for some), it is not arguable that a country without initiative process. It should be kept in propor-
a hadron facility cannot sensibly contribute to the tion.
scientific debate. For this reason every country vi. Attention to historical knowledge might avoid
should be so equipped by at least one Facility to act unwitting re-invention of topics and problems.
as a National Referral Centre. Micro-beam radio- vii. The clutter of employment and institutional
therapy is just starting and as yet unevaluated. Is diversions, such as committees, scientific pol-
there also the possibility that gene therapy and itics, administration, business and some un-
radiotherapy could be combined in some synergistic necessary professional work should be
way. minimised. Those who serve in these capaci-
Finally regarding radiotherapy the assessment of ties do so because they either were, or hope-
response to treatment is still in its infancy. Post- fully still are, medical physicists first and
treatment data collection must become the normal foremost. They should remain such.
practice and include all the scientific planning and
delivery data as well as the patient’s observed and Conclusions
also self-reported response. Were such data centrally
recorded, it would be possible to conduct trans- In his seminal book for children ‘‘Alice in Wonder-
national studies with large cohorts of patient data. land’’ the professor of Mathematics at Oxford
The biological outcome can then be much more University, Charles Dodgson, who wrote under the
clearly understood. name Lewis Carroll, describes a meeting between
Alice and the Cheshire Cat. The meeting is im-
mortalised in the drawing of Sir John Tenniel. Alice
Establishing the conditions for good progress inquires of the Cat ‘‘Would you tell me please which
As possibly overemphasised here, ‘‘future gazing’’ is way I ought to go from here?’’ ‘‘That depends a great
an unscientific yet required process and some deal on where you want to get to’’ replied the Cat
opinions have been expressed. It is a little more before disappearing leaving only its smile. This wise
straightforward to expound some principles on answer clarifies the need for goals albeit we may not
which the performance of good science should be have available waymarked routes. I have attempted
based. In staccato form we may say: to document some goals on a variety of timescales
and with a variety of confidence. I have also tried to
i. The supply of medical physicists must be indicate the constructional nature of medical physics
ensured by educating schoolchildren to find research and the need to study history and relate this
science, which is difficult to do, rewarding; to key landmarks.
specialisation is useful but medical physicists
are first and foremost physicists and many
breakthroughs have come from untrained med- Acknowledgements
ical physicists who have thought laterally. De- I should like to thank Dr Vibeke Hansen (Denmark
spite increased professionalisation there must and UK) and Ms Maria Holstensson (Sweden
be a route into medical physics for such people and UK) and Dr Phil Evans (UK) for help with
without too great a re-training impediment. some of the ‘‘Nordic associations’’. In view of
ii. Training schemes are, however, vital and need the fact that the invitation to lecture at the
to be (and are) well supported by National and NACP2008 Conference in Aarhus with this title
International organisations. They should not, was almost identical to the invitation to lecture at the
however, become too long or stifle creative EFOMP Congress in Pisa in September 2007, the
initiative. The Bologna process should widen. two lectures had much in common. Consequently
iii. Medical physicists are often required to do 3 there is an overlap of some ideas expressed in this
simultaneous jobs
research, teach and imple- paper and that in [13] which is in the proceedings
ment clinical service. Doing all three fulltime from Pisa. I have, however, attempted to re-write
 The contribution, history, impact and future of physics in medicine 177

those thoughts in a different way, to also substan- future. In: Innovative techniques in radiation therapy.
Webb S, Evans PM editors., Sem Rad Oncol 2006;16:
tially add to them and to show the Nordic contri-
193
8.
bution. [13] Webb S Combatting cancer in the third millennium
the
contribution of medical physics. Physica Medica (EJMP)
2008;42:42
8.
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[4] Duck FA. Nineteenth century medical physics. Scope 1994; /
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