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UTSW’s adaptive therapy provides a personalized care plan to treat each individual’s cancer

David Sher, M.D., M.P.H.
David Sher, M.D., M.P.H.
David Sher, M.D., M.P.H.

Bradley Metcalf, 67, has lived in Dallas for more than 43 years. Originally from Kentucky, he decided to move to the Metroplex after earning his bachelor’s degree in science. He has two daughters, Lena and Xuma, and works as a freelance special effects artist for food commercials.

In December 2021, Mr. Metcalf noticed a lump on his neck. He thought it was the result of something he had done days prior and decided to wait to see if it would disappear. The lump wasn’t painful, and he even forgot about it. However, once January came around and it remained the same size, he knew it was a serious issue that needed to be addressed.

He visited his general practitioner who performed a biopsy. It was revealed that he had an HPV-associated oropharyngeal cancer with a tumor in his tongue and a couple more in his neck. Based on those results, he was referred to UT Southwestern. He was also told about a recently activated head and neck clinical trial in the Department of Radiation Oncology led by David Sher, M.D., M.P.H.

“I had heard great things about the department and the technology they had,” Mr. Metcalf says. “I actually had a friend who was treated by Dr. Sher, so I knew about him and how confident he was, and that made me feel good as well.”

Dr. Sher, Professor of Radiation Oncology, is Chief of Head and Neck Radiation Oncology Services at UT Southwestern as well as Vice Chair and Medical Director for Clinical Operations and Quality. Treating head and neck cancer has been a strong focus of his since the beginning of his career. Dr. Sher has extensive experience in the formal teaching of residents, fellows, and post-docs, and he has authored numerous papers advancing the field of radiation oncology. Additionally, he is the principal investigator of multiple clinical trials, including a recently opened phase two trial called DARTBOARD. 

DARTBOARD, officially known as Daily Adaptive Radiotherapy to Better Organ-at-Risk Doses in head and neck cancer, is the first randomized study of daily head and neck adaptive radiation therapy – delivering radiation to an increasingly smaller area of tissue based on a patient’s real-time anatomy. UT Southwestern is the only site for the study and will implement the smallest head and neck irradiated volumes ever delivered and analyzed.

The primary goal of DARTBOARD is to determine whether daily adaptive radiation therapy can reduce dry mouth after treatment compared with traditional radiation therapy. It is a randomized study with half of patients receiving focused nodal therapy without adaptation and half receiving focused nodal therapy with daily adaptation. Because each individual fraction is personalized to that day’s anatomy, the “safety margins” for daily setup error are drastically reduced on the adaptive arm, minimizing the amount of normal tissue irradiated.


“The biggest challenge in our field is figuring out how to obtain a superb cancer outcome while improving short- and long-term quality of life, which includes saliva and taste, normal swallowing, skin thickening, and even appearance or voice,” says Dr. Sher. “Our goals are to maximize the oncologic success rate as well as to improve quality of life, and we have chosen to do that using the Ethos technology.”

With Ethos, the contouring and replanning time takes only approximately 15 to 20 minutes instead of hours or even days. This includes taking the patient’s mini scan, recontouring the targets and normal tissues, and quality-checking the final product.

Mr. Metcalf was the first patient to be treated adaptively on the DARTBOARD trial and received 35 treatments over seven weeks. He notes that from a patient standpoint the treatments have run very smoothly, and he commends the staff supporting him and making his daily visits as stress-free as possible. As someone with an interest in machines, he has even been able to talk with a few of the radiation therapists about how the machines’ beams are created and how the motors move them around. These daily conversations not only alleviate any stress but also build and strengthen the trust between him and his treatment team. 

Bradley Metcalf talks with Dr. Sher during a visit.

Bradley Metcalf talks with Dr. Sher during a visit.

For the most part, side effects of the treatment have been minimal. He has lost most of his sense of taste, and shopping for the right foods has become a challenging task. However, there has been little fatigue and he hasn’t had any skin reactions. All in all, he has done extremely well. In fact, by the second week of treatment, his tumor had significantly decreased in size.

“He has exceeded my expectations in sort of every domain of treatment tolerance,” Dr. Sher says. “I try to explain to him that this is not how people usually do. I have the confidence of seeing his anatomy and optimizing his plan every day of treatment; it’s actually very powerful.”

While the primary goal of DARTBOARD is to improve dry mouth and quality of life after head and neck cancer treatments, the hope is that this approach, along with the artificial intelligence-driven process, could become the first steps toward providing daily adaptive radiation therapy for other types of cancer, with even more precision and personalization.

“They are a wonderful department,” Mr. Metcalf says. “For what I’m going through they make it very easy – from checking in to the short proximity of the treatment room and sending me texts and emails to make sure I know what is going on. And the staff who are very knowledgeable and accommodating. It’s been a great experience.”