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Wikipedia

Proton therapy

April 10, 2023

In medicine, proton therapy, or proton radiotherapy, is a type of particle therapy that uses a beam of protons to irradiate diseased tissue, most often to treat cancer. The chief advantage of proton therapy over other types of external beam radiotherapy is that the dose of protons is deposited over a narrow range of depth; hence in minimal entry, exit, or scattered radiation dose to healthy nearby tissues.

Proton therapy
Proton therapy equipment at the Mayo Clinic in Rochester, Minnesota
Other namesProton beam therapy
ICD-10-PCSZ92.3
[edit on Wikidata]

When evaluating whether to treat a tumor with photon or proton therapy, physicians may choose proton therapy if it is important to deliver a higher radiation dose to targeted tissues while significantly decreasing radiation to nearby organs at risk.[1] The American Society for Radiation Oncology Model Policy for Proton Beam therapy says proton therapy is considered reasonable if sparing the surrounding normal tissue "cannot be adequately achieved with photon-based radiotherapy" and can benefit the patient.[2] Like photon radiation therapy, proton therapy is often used in conjunction with surgery and/or chemotherapy to most effectively treat cancer.

Description

Main article: Radiation therapy § Mechanism of action
 
In a typical treatment plan for proton therapy, the spread out Bragg peak (SOBP, dashed blue line) shows how the radiation is distributed. The SOBP is the sum of several individual Bragg peaks (thin blue lines) at staggered depths. Note that the vast majority of the proton radiation is delivered to the tumor, not to the skin and shallow tissues in front of the tumor or to the deep tissues behind the tumor. The red line shows the depth-dose plot of an X-ray beam (photon or conventional radiation therapy) for comparison. The pink area represents additional doses of X-ray radiotherapy in front and behind the tumor – which can damage normal tissues and cause secondary cancers, especially of the skin.[3]

Proton therapy is a type of external beam radiotherapy that uses ionizing radiation. In proton therapy, medical personnel use a particle accelerator to target a tumor with a beam of protons.[4][5] These charged particles damage the DNA of cells, ultimately killing them by stopping their reproduction and thus eliminating the tumor. Cancerous cells are particularly vulnerable to attacks on DNA because of their high rate of division and their limited ability to repair DNA damage. Some cancers with specific defects in DNA repair may be more sensitive to proton radiation.[6]

Proton therapy lets physicians deliver a highly conformal beam, i.e. delivering radiation that conforms to the shape and depth of the tumor and sparing much of the surrounding, normal tissue.[7] For example, when comparing proton therapy to the most advanced types of photon therapy—intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT)—proton therapy can give similar or higher radiation doses to the tumor with a 50%-60% lower total body radiation dose.[8][1]

Protons can focus energy delivery to fit the tumor shape, delivering only low-dose radiation to surrounding tissue. As a result, the patient has fewer side effects. All protons of a given energy have a certain penetration range; very few protons penetrate beyond that distance.[9] Also, the dose delivered to tissue is maximized only over the last few millimeters of the particle's range; this maximum is called the spread out Bragg peak, often called the SOBP (see visual).[10]

To treat tumors at greater depth, one needs a beam with higher energy, typically given in eV (electron volts). Accelerators used for proton therapy typically produce protons with energies of 70 to 250 MeV. Adjusting proton energy during the treatment maximizes the cell damage within the tumor. Tissue closer to the surface of the body than the tumor gets less radiation, and thus less damage. Tissues deeper in the body get very few protons, so the dose becomes immeasurably small.[9]

In most treatments, protons of different energies with Bragg peaks at different depths are applied to treat the entire tumor. These Bragg peaks are shown as thin blue lines in the figure in this section. It is important to understand that, while tissues behind (or deeper than) the tumor get almost no radiation, the tissues in front of (shallower than) the tumor get radiation dosage based on the SOBP.

Equipment

Most installed proton therapy systems use isochronous cyclotrons.[11][12] Cyclotrons are considered simple to operate, reliable and can be made compact, especially with use of superconducting magnets.[13] Synchrotrons can also be used, with the advantage of easier production at varying energies.[14] Linear accelerators, as used for photon radiation therapy, are becoming commercially available as limitations of size and cost are resolved.[15] Modern proton systems incorporate high-quality imaging for daily assessment of tumor contours, treatment planning software illustrating 3D dose distributions, and various system configurations, e.g. multiple treatment rooms connected to one accelerator. Partly because of these advances in technology, and partly because of the continually increasing amount of proton clinical data, the number of hospitals offering proton therapy continues to grow.

FLASH radiotherapy is a technique under development for photon and proton treatments, using very high dose rates (necessitating large beam currents). If applied clinically, it could shorten treatment time to just one to three 1-second sessions, and further reducing side effects.[16][17][18]

History

The first suggestion that energetic protons could be an effective treatment was made by Robert R. Wilson in a paper published in 1946[19] while he was involved in the design of the Harvard Cyclotron Laboratory (HCL).[20] The first treatments were performed with particle accelerators built for physics research, notably Berkeley Radiation Laboratory in 1954 and at Uppsala in Sweden in 1957. In 1961, a collaboration began between HCL and Massachusetts General Hospital (MGH) to pursue proton therapy. Over the next 41 years, this program refined and expanded these techniques while treating 9,116 patients[21] before the cyclotron was shut down in 2002. In the USSR a therapeutic proton beam with energies up to 200 MeV was obtained at the synchrocyclotron of JINR in Dubna in 1967. The ITEP center in Moscow, Russia, which began treating patients in 1969, is the oldest proton center still in operation. The Paul Scherrer Institute in Switzerland was the world's first proton center to treat eye tumors beginning in 1984. In addition, they invented pencil beam scanning in 1996, which is now the state-of-the art form of proton therapy.[22]

The world's first hospital-based proton therapy center was a low energy cyclotron centre for eye tumors at Clatterbridge Centre for Oncology in the UK, opened in 1989,[23] followed in 1990 at the Loma Linda University Medical Center (LLUMC) in Loma Linda, California. Later, the Northeast Proton Therapy Center at Massachusetts General Hospital was brought online, and the HCL treatment program was transferred to it in 2001 and 2002. At the beginning of 2023, there were 41 proton therapy centers in the United States,[24] and a total of 89 worldwide.[25] As of 2020, five manufacturers make proton therapy systems: Hitachi, Ion Beam Applications, Mevion Medical Systems, ProTom International and Varian Medical Systems.

Types

The newest form of proton therapy, pencil beam scanning, gives therapy by sweeping a proton beam laterally over the target so that it gives the required dose while closely conforming to shape of the targeted tumor. Before the use of pencil beam scanning, oncologists used a scattering method to direct a wide beam toward the tumor. [26]

Passive scattering beam delivery

The first commercially available proton delivery systems used a scattering process, or passive scattering, to deliver the therapy. With scattering proton therapy the proton beam is spread out by scattering devices, and the beam is then shaped by putting items such as collimators and compensators in the path of the protons. The collimators were custom made for the patient with milling machines.[27] Passive scattering gives homogeneous dose along the target volume. Therefore, passive scattering gives more limited control over dose distributions proximal to target. Over time many scattering therapy systems have been upgraded to deliver pencil beam scanning. Because scattering therapy was the first type of proton therapy available, most clinical data available on proton therapy—especially long-term data as of 2020—were acquired via scattering technology.

Pencil beam scanning beam delivery

A newer and more flexible delivery method is pencil beam scanning, using a beam that sweeps laterally over the target so that it delivers the needed dose while closely conforming to the tumor's shape. This conformal delivery is achieved by shaping the dose through magnetic scanning of thin beamlets of protons without needing apertures and compensators. Multiple beams are delivered from different directions, and magnets in the treatment nozzle steer the proton beam to conform to the target volume layer as the dose is painted layer by layer. This type of scanning delivery provides greater flexibility and control, letting the proton dose conform more precisely to the shape of the tumor.[27]

Delivery of protons via pencil beam scanning, in use since 1996 at the Paul Scherrer Institute,[27] allows for the most precise type of proton delivery: intensity-modulated proton therapy (IMPT). IMPT is to proton therapy what IMRT is to conventional photon therapy—treatment that more closely conforms to the tumor while avoiding surrounding structures.[28] Virtually all new proton systems now provide pencil beam scanning exclusively. A study led by Memorial Sloan Kettering Cancer Center suggests that IMPT can improve local control when compared to passive scattering for patients with nasal cavity and paranasal sinus malignancies.[29]

Application

It was estimated that by the end of 2019, a total of ~200,000 patients had been treated with proton therapy. Physicians use protons to treat conditions in two broad categories:

  • Disease sites that respond well to higher doses of radiation, i.e., dose escalation. Dose escalation has sometimes shown a higher probability of "cure" (i.e. local control) than conventional radiotherapy.[30] These include, among others, uveal melanoma (ocular tumor), skull base and paraspinal tumor (chondrosarcoma and chordoma), and unresectable sarcoma. In all these cases proton therapy gives significant improvement in the probability of local control, over conventional radiotherapy.[31][32][33] For eye tumors, proton therapy also has high rates of maintaining the natural eye.[34]
  • Treatment where proton therapy's increased precision reduces unwanted side effects by lessening the dose to normal tissue. In these cases, the tumor dose is the same as in conventional therapy, so there is no expectation of increased probability of curing the disease. Instead, emphasis is on reducing the dose to normal tissue, thus reducing unwanted effects.[30]

Two prominent examples are pediatric neoplasms (such as medulloblastoma) and prostate cancer.

Pediatric

Irreversible long-term side effects of conventional radiation therapy for pediatric cancers are well documented and include growth disorders, neurocognitive toxicity, ototoxicity with subsequent effects on learning and language development, and renal, endocrine and gonadal dysfunctions. Radiation-induced secondary malignancy is another very serious adverse effect that has been reported. As there is minimal exit dose when using proton radiation therapy, dose to surrounding normal tissues can be significantly limited, reducing the acute toxicity which positively impacts the risk for these long-term side effects. Cancers requiring craniospinal irradiation, for example, benefit from the absence of exit dose with proton therapy: dose to the heart, mediastinum, bowel, bladder and other tissues anterior to the vertebrae is eliminated, hence a reduction of acute thoracic, gastrointestinal and bladder side effects.[35][36][37]

Eye tumor

Proton therapy for eye tumors is a special case since this treatment requires only relatively low energy protons (~70 MeV). Owing to this low energy, some particle therapy centers only treat eye tumors.[21] Proton, or more generally, hadron therapy of tissue close to the eye affords sophisticated methods to assess the alignment of the eye that can vary significantly from other patient position verification approaches in image guided particle therapy.[38] Position verification and correction must ensure that the radiation spares sensitive tissue like the optic nerve to preserve the patient's vision.

For ocular tumors, selecting the type of radiotherapy depends on tumor location and extent, tumor radioresistance (calculating the dose needed to eliminate the tumor), and the therapy's potential toxic side effects on nearby critical structures.[39] For example, proton therapy is an option for retinoblastoma [40] and intraocular melanoma.[41] The advantage of a proton beam is that it has the potential to effectively treat the tumor while sparing sensitive structures of the eye.[42] Given its effectiveness, proton therapy has been described as the "gold standard" treatment for ocular melanoma.[43][44]

Base of skull cancer

When receiving radiation for skull base tumors, side effects of the radiation can include pituitary hormone dysfunction and visual field deficit—after radiation for pituitary tumors—as well as cranial neuropathy (nerve damage), radiation-induced osteosarcoma (bone cancer), and osteoradionecrosis, which occurs when radiation causes part of the bone in the jaw or skull base to die.[45] Proton therapy has been very effective for people with base of skull tumors.[46] Unlike conventional photon radiation, protons do not penetrate beyond the tumor. Proton therapy lowers the risk of treatment-related side effects from when healthy tissue gets radiation. Clinical studies have found proton therapy to be effective for skull base tumors.[47][48][49]

Head and neck tumor

Proton particles do not deposit exit dose, so proton therapy can spare normal tissues far from the tumor. This is particularly useful for head and neck tumors because of the anatomic constraints found in nearly all cancers in this region. The dosimetric advantage unique to proton therapy translates into toxicity reduction. For recurrent head and neck cancer requiring reirradiation, proton therapy is able to maximize a focused dose of radiation to the tumor while minimizing dose to surrounding tissues, hence a minimal acute toxicity profile, even in patients who got multiple prior courses of radiotherapy.[50]

Left-side breast cancer

When breast cancer — especially in the left breast — is treated with conventional radiation, the lung and heart, which are near the left breast, are particularly susceptible to photon radiation damage. Such damage can eventually cause lung problems (e.g. lung cancer) or various heart problems. Depending on location of the tumor, damage can also occur to the esophagus, or to the chest wall (which can potentially lead to leukemia).[51] One recent study showed that proton therapy has low toxicity to nearby healthy tissues and similar rates of disease control compared with conventional radiation.[52] Other researchers found that proton pencil beam scanning techniques can reduce both the mean heart dose and the internal mammary node dose to essentially zero.[53]

Small studies have found that, compared to conventional photon radiation, proton therapy delivers minimal toxic dose to healthy tissues[54] and specifically decreased dose to the heart and lung.[55] Large-scale trials are underway to examine other potential benefits of proton therapy to treat breast cancer.[56]

Lymphoma

Though chemotherapy is the main treatment for lymphoma, consolidative radiation is often used in Hodgkin lymphoma and aggressive non-Hodgkin lymphoma, while definitive treatment with radiation alone is used in a small fraction of lymphoma patients. Unfortunately, treatment-related toxicities caused by chemotherapy agents and radiation exposure to healthy tissues are major concerns for lymphoma survivors. Advanced radiation therapy technologies such as proton therapy may offer significant and clinically relevant advantages such as sparing important organs at risk and decreasing the risk for late normal tissue damage while still achieving the primary goal of disease control. This is especially important for lymphoma patients who are being treated with curative intent and have long life expectancy following therapy.[57]

Prostate cancer

In prostate cancer cases, the issue is less clear. Some published studies found a reduction in long term rectal and genito-urinary damage when treating with protons rather than photons (meaning X-ray or gamma ray therapy). Others showed a small difference, limited to cases where the prostate is particularly close to certain anatomical structures.[58][59] The relatively small improvement found may be the result of inconsistent patient set-up and internal organ movement during treatment, which offsets most of the advantage of increased precision.[59][60][61] One source suggests that dose errors around 20% can result from motion errors of just 2.5 mm (0.098 in).[citation needed] and another that prostate motion is between 5–10 mm (0.20–0.39 in).[62]

The number of cases of prostate cancer diagnosed each year far exceeds those of the other diseases referred to above, and this has led some, but not all, facilities to devote most of their treatment slots to prostate treatments. For example, two hospital facilities devote ~65%[63] and 50%[64] of their proton treatment capacity to prostate cancer, while a third devotes only 7.1%.[65]

Worldwide numbers are hard to compile, but one example says that in 2003 ~26% of proton therapy treatments worldwide were for prostate cancer.[66]

Gastrointestinal malignancy

A growing amount of data shows that proton therapy has great potential to increase therapeutic tolerance for patients with GI malignancy. The possibility of decreasing radiation dose to organs at risk may also help facilitate chemotherapy dose escalation or allow new chemotherapy combinations. Proton therapy will play a decisive role for ongoing intensified combined modality treatments for GI cancers. The following review presents the benefits of proton therapy in treating hepatocellular carcinoma, pancreatic cancer and esophageal cancer.[67]

Hepatocellular carcinoma

Post-treatment liver decompensation, and subsequent liver failure, is a risk with radiotherapy for hepatocellular carcinoma, the most common type of primary liver cancer. Research shows that proton therapy gives favorable results related to local tumor control, progression-free survival, and overall survival.[68][69][70][71] Other studies, which examine proton therapy compared with conventional photon therapy, show that proton therapy gives improved survival and/or fewer side effects; hence proton therapy could significantly improve clinical outcomes for some patients with liver cancer.[72][73]

Reirradiation for recurrent cancer

For patients who get local or regional recurrences after their initial radiation therapy, physicians are limited in their treatment options due to their reluctance to give additional photon radiation therapy to tissues that have already been irradiated. Re-irradiation is a potentially curative treatment option for patients with locally recurrent head and neck cancer. In particular, pencil beam scanning may be ideally suited for reirradiation.[74] Research shows the feasibility of using proton therapy with acceptable side effects, even in patients who have had multiple prior courses of photon radiation.[75][76][77]

Comparison with other treatments

A large study on comparative effectiveness of proton therapy was published by teams of the University of Pennsylvania and Washington University in St. Louis in JAMA Oncology, assessing if proton therapy in the setting of concurrent chemoradiotherapy is associated with fewer 90-day unplanned hospitalizations and overall survival compared with concurrent photon therapy and chemoradiotherapy.[78] The study included 1483 adult patients with nonmetastatic, locally advanced cancer treated with concurrent chemoradiotherapy with curative intent and concluded, "proton chemoradiotherapy was associated with significantly reduced acute adverse events that caused unplanned hospitalizations, with similar disease-free and overall survival". A significant number of randomized controlled trials is currently recruiting, but only a limited number have been completed as of August 2020. A phase III randomized controlled trial of proton beam therapy versus radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma organized by the National Cancer Center in Korea showed better 2-year local progression-free survival for the proton arm and concluded that proton beam therapy (PBT) is "not inferior to RFA in terms of local progression-free survival and safety, denoting that either RFA or PBT can be applied to recurrent small HCC patients".[68] A phase IIB randomized controlled trial of proton beam therapy versus IMRT for locally advanced esophageal cancer organized by University of Texas MD Anderson Cancer Center concluded that proton beam therapy reduced the risk and severity of adverse events compared with IMRT while maintaining similar progression free survival.[79] Another Phase II Randomized Controlled Trial comparing photons versus protons for Glioblastoma concluded that patients at risk of severe lymphopenia could benefit from proton therapy.[80] A team from Stanford University assessed the risk of secondary cancer after primary cancer treatment with external beam radiation using data from the National Cancer Database for 9 tumor types: head and neck, gastrointestinal, gynecologic, lymphoma, lung, prostate, breast, bone/soft tissue, and brain/central nervous system.[81] The study included a total of 450,373 patients and concluded that proton therapy was associated with a lower risk of second cancer.

The issue of when, whether, and how best to apply this technology is still under discussion by physicians and researchers. One recently introduced method, 'model-based selection', uses comparative treatment plans for IMRT and IMPT in combination with normal tissue complication probability (NTCP) models to identify patients who may benefit most from proton therapy.[82][83]

Clinical trials are underway to examine the comparative efficacy of proton therapy (vs photon radiation) for the following:

  • Pediatric cancers—by St. Jude Children's Research Hospital,[84] Samsung Medical Center [85]
  • Base of skull cancer—by Heidelberg University [86]
  • Head and neck cancer—by MD Anderson,[87] Memorial Sloan Kettering and other centers[88]
  • Brain and spinal cord cancer—by Massachusetts General Hospital,[89] Uppsala University and other centers,[90] NRG Oncology[91][92]
  • Hepatocellular carcinoma (liver)—by NRG Oncology,[93] Chang Gung Memorial Hospital,[94] Loma Linda University [95]
  • Lung cancer—by Radiation Therapy Oncology Group (RTOG),[96] Proton Collaborative Group (PCG),[97] Mayo Clinic[98]
  • Esophageal cancer—by NRG Oncology,[99] Abramson Cancer Center, University of Pennsylvania[100]
  • Breast cancer—by University of Pennsylvania,[101] Proton Collaborative Group (PCG)[102]
  • Pancreatic cancer—by University of Maryland,[103] Proton Collaborative Group (PCG)[104]

X-ray radiotherapy

 
Irradiation of nasopharyngeal carcinoma by photon (X-ray) therapy (left) and proton therapy (right)

The figure at the right of the page shows how beams of X-rays (IMRT; left frame) and beams of protons (right frame), of different energies, penetrate human tissue. A tumor with a sizable thickness is covered by the IMRT spread out Bragg peak (SOBP) shown as the red lined distribution in the figure. The SOBP is an overlap of several pristine Bragg peaks (blue lines) at staggered depths.

Megavoltage X-ray therapy has less "skin sparing potential" than proton therapy: X-ray radiation at the skin, and at very small depths, is lower than for proton therapy. One study estimates that passively scattered proton fields have a slightly higher entrance dose at the skin (~75%) compared to therapeutic megavoltage (MeV) photon beams (~60%).[3] X-ray radiation dose falls off gradually, needlessly harming tissue deeper in the body and damaging the skin and surface tissue opposite the beam entrance. The differences between the two methods depends on:

  • Width of the SOBP
  • Depth of the tumor
  • Number of beams that treat the tumor

The X-ray advantage of less harm to skin at the entrance is partially counteracted by harm to skin at exit point.

Since X-ray treatments are usually done with multiple exposures from opposite sides, each section of skin is exposed to both entering and exiting X-rays. In proton therapy, skin exposure at the entrance point is higher, but tissues on the opposite side of the body to the tumor get no radiation. Thus, X-ray therapy causes slightly less damage to skin and surface tissues, and proton therapy causes less damage to deeper tissues in front of and beyond the target.[5]

An important consideration in comparing these treatments is whether the equipment delivers protons via the scattering method (historically, the most common) or a spot scanning method. Spot scanning can adjust the width of the SOBP on a spot-by-spot basis, which reduces the volume of normal (healthy) tissue inside the high dose region. Also, spot scanning allows for intensity modulated proton therapy (IMPT), which determines individual spot intensities using an optimization algorithm that lets the user balance the competing goals of irradiating tumors while sparing normal tissue. Spot scanning availability depends on the machine and the institution. Spot scanning is more commonly known as pencil-beam scanning and is available on IBA, Hitachi, Mevion (known as HYPERSCAN[105] which became US FDA approved in 2017) and Varian.

Surgery

Physicians base the decision to use surgery or proton therapy (or any radiation therapy) on tumor type, stage, and location. Sometimes surgery is superior (such as cutaneous melanoma), sometimes radiation is superior (such as skull base chondrosarcoma), and sometimes are comparable (for example, prostate cancer). Sometimes, they are used together (e.g., rectal cancer or early stage breast cancer).

The benefit of external beam proton radiation is in the dosimetric difference from external beam X-ray radiation and brachytherapy in cases where use of radiation therapy is already indicated, rather than as a direct competition with surgery.[30] In prostate cancer, the most common indication for proton beam therapy, no clinical study directly comparing proton therapy to surgery, brachytherapy, or other treatments has shown any clinical benefit for proton beam therapy. Indeed, the largest study to date showed that IMRT compared with proton therapy was associated with less gastrointestinal morbidity.[106]

Side effects and risks

Main articles: Radiation therapy § Side effects, and Adverse effect

Proton therapy is a type of external beam radiotherapy, and shares risks and side effects of other forms of radiation therapy. The dose outside of the treatment region can be significantly less for deep-tissue tumors than X-ray therapy, because proton therapy takes full advantage of the Bragg peak. Proton therapy has been in use for over 40 years, and is a mature technology. As with all medical knowledge, understanding of the interaction of radiations with tumor and normal tissue is still imperfect.[107]

Costs

Historically, proton therapy has been expensive. An analysis published in 2003 found that the cost of proton therapy is ~2.4 times that of X-ray therapies.[108] Newer, less expensive, and dozens more proton treatment centers are driving costs down and they offer more accurate three-dimensional targeting. Higher proton dosage over fewer treatments sessions (1/3 fewer or less) is also driving costs down.[109][110] Thus the cost is expected to reduce as better proton technology becomes more widely available. An analysis published in 2005 determined that the cost of proton therapy is not unrealistic and should not be the reason for denying patients access to the technology.[111] In some clinical situations, proton beam therapy is clearly superior to the alternatives.[112][113]

A study in 2007 expressed concerns about the effectiveness of proton therapy for prostate cancer,[114] but with the advent of new developments in the technology, such as improved scanning techniques and more precise dose delivery ('pencil beam scanning'), this situation may change considerably.[115] Amitabh Chandra, a health economist at Harvard University, said, "Proton-beam therapy is like the Death Star of American medical technology... It's a metaphor for all the problems we have in American medicine."[116] Proton therapy is cost-effective for some types of cancer, but not all.[117][118] In particular, some other treatments offer better overall value for treatment of prostate cancer.[117]

As of 2018, the cost of a single-room particle therapy system is US$40 million, with multi-room systems costing up to US$200 million.[119][120]

Treatment centers

 
Control panel of the synchrocyclotron at the Orsay proton therapy center, France

As of August 2020, there are over 89 particle therapy facilities worldwide,[121] with at least 41 others under construction.[122] As of August 2020, there are 34 operational proton therapy centers in the United States. As of the end of 2015 more than 154,203 patients had been treated worldwide.[123]

One hindrance to universal use of the proton in cancer treatment is the size and cost of the cyclotron or synchrotron equipment necessary. Several industrial teams are working on development of comparatively small accelerator systems to deliver the proton therapy to patients.[124] Among the technologies being investigated are superconducting synchrocyclotrons (also known as FM Cyclotrons), ultra-compact synchrotrons, dielectric wall accelerators,[124] and linear particle accelerators.[110]

United States

Proton treatment centers in the United States as of 2020 (in chronological order of first treatment date) include:[23][125]

Institution Location Year of first treatment Comments
Loma Linda University Medical Center[126] Loma Linda, CA 1990 First hospital-based facility in USA; uses Spread Out Bragg's Peak (SOBP)
Crocker Nuclear Laboratory[127] Davis, CA 1994 Ocular treatments only (low energy accelerator); at University of California, Davis
Francis H. Burr Proton Center Boston, MA 2001 At Massachusetts General Hospital and formerly known as NPTC; continuation of Harvard Cyclotron Laboratory/MGH treatment program that began in 1961; Manufactured by Ion Beam Applications[128]
University of Florida Health Proton Therapy Institute-Jacksonville[129] Jacksonville, FL 2006 The UF Health Proton Therapy Institute is a part of a non-profit academic medical research facility affiliated with the University of Florida College of Medicine-Jacksonville. It is the first treatment center in the Southeast U.S. to offer proton therapy. Manufactured by Ion Beam Applications[128]
University of Texas MD Anderson Cancer Center[130] Houston, TX
Oklahoma Proton Center[131] Oklahoma City, OK 2009 4 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
Northwestern Medicine Chicago Proton Center Warrenville, IL 2010 4 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
Roberts Proton Therapy Center[132] Philadelphia, PA The largest proton therapy center in the world, the Roberts Proton Therapy Center, which is a part of Penn's Abramson Cancer Center, University of Pennsylvania Health System; 5 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
Hampton University Proton Therapy Institute Hampton, VA 5 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
ProCure Proton Therapy Center[133] Somerset, NJ 2012 4 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
SCCA Proton Therapy Center Seattle, WA 2013 At Seattle Cancer Care Alliance; part of Fred Hutchinson Cancer Research Center; 4 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
Siteman Cancer Center[109] St. Louis, MO First of the new single suite, ultra-compact, superconducting synchrocyclotron,[134] lower cost facilities to treat a patient using the Mevion Medical System's S250.[135]
Provision Proton Therapy Center[136] Knoxville, TN 2014 3 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
California Protons Cancer Therapy Center[137] San Diego, CA 5 treatment rooms, manufactured by Varian Medical Systems[138]
Ackerman Cancer Center Jacksonville, FL 2015 Ackerman Cancer Center is the world's first private, physician-owned practice to provide proton therapy, in addition to conventional radiation therapy and on-site diagnostic services.
The Laurie Proton Therapy Center New Brunswick, NJ The Laurie Proton Therapy Center, part of Robert Wood Johnson University Hospital, is home to the world's third MEVION S250 Proton Therapy System.
Texas Center for Proton Therapy Dallas Fort Worth, TX A collaboration by "Texas Oncology and The US Oncology Network, supported by McKesson Specialty Health, and Baylor Health Enterprises"; three pencil beam rooms and cone beam CT imaging.[139] 3 treatment rooms, Proteus PLUS system manufactured by Ion Beam Applications[128]
Mayo Clinic Jacobson Building Rochester, MN 4 treatment rooms.[140] Manufactured by Hitachi.[141]
St. Jude Red Frog Events Proton Therapy Center Memphis, TN 3 treatment rooms
Mayo Clinic Cancer Center Phoenix, AZ 2016 4 treatment rooms.[142] Manufactured by Hitachi.[143]
The Marjorie and Leonard Williams Center for Proton Therapy Orlando, FL http://www.ufhealthcancerorlando.com/centers/proton-therapy-center
Cancer and Blood Diseases Institute Liberty Township, OH Collaboration of University of Cincinnati Cancer Institute and Cincinnati Children's Hospital Medical Center,[144][145] manufactured by Varian Medical Systems
Maryland Proton Treatment Center Baltimore, MD 5 treatment rooms, affiliated with the University of Maryland Greenebaum Comprehensive Cancer Center, manufactured by Varian Medical Systems.
Proton Therapy Center at University Hospitals Seidman Cancer Center Cleveland, OH Only proton therapy center in Northern Ohio. One treatment room with the Mevion S250 Proton Therapy System. Part of the NCI-designated Case Comprehensive Cancer Center, University Hospitals Seidman Cancer Center is one of the nation's leading freestanding cancer hospitals.
Miami Cancer Institute Miami, FL 2017 3 treatment rooms, all using pencil-beam scanning[146] Manufactured by Ion Beam Applications[128]
Beaumont Proton Therapy Center Royal Oak, MI Single treatment room, Proteus ONE system manufactured by Ion Beam Applications[128]
Emory Proton Therapy Center Atlanta, GA 2018 Five treatment rooms, ProBeam Superconducting Cyclotron[147] manufactured by Varian Medical Systems
Provision CARES Proton Therapy Center Nashville, TN Three treatment rooms, Two Gantries and One Fixed Beam, All Pencil Beam Scanning, manufactured by ProNova Solutions, LLC
McLaren Proton Therapy Center Flint, MI The McLaren Proton Therapy System uses the industry's highest energy 330 MeV proton synchrotron to accelerate and deliver proton beam to two treatment rooms, with an opportunity to extend into a planned third room. Both operating treatment rooms are equipped with proton pencil beam scanning, cone beam computed tomography for image guidance, patient positioning system with 6-degrees of freedom that coupled with 180-degree partial gantry allows for complete flexibility of treatment angles.
New York Proton Center New York, NY 2019 A partnership between Memorial Sloan Kettering, Montefiore Health, and Mount Sinai Health System. 4 treatment rooms, manufactured by Varian Medical Systems
Johns Hopkins Proton Therapy Center Washington, DC 3 treatment rooms and 1 research gantry. Manufactured by Hitachi.
South Florida Proton Therapy Institute Delray Beach, FL One treatment room, manufactured by Varian Medical Systems
UAB Proton Therapy Center Birmingham, AL 2020 One treatment room, manufactured by Varian Medical Systems
Dwoskin PTC - University of Miami Miami, FL One treatment room, manufactured by Varian Medical Systems
The University of Kansas Cancer Center Kansas City, KS 2022 Announced Feb 2019[148]
Penn Medicine Lancaster General Health Ann B. Barshinger Cancer Institute Lancaster, PA One treatment room, manufactured by Varian Medical Systems
Penn Medicine Virtua Health Voorhees, NJ One treatment room, manufactured by Varian Medical Systems
Mayo Clinic Florida Jacksonville, FL 2023 (Estimated) Announced June 2019[149]
Ohio State, Nationwide Children's Hospital Columbus, OH Three treatment rooms, manufactured by Varian Medical Systems
Froedtert Hospital Wauwatosa, WI 2024 (Estimated) Announced May 2022[150]

The Indiana University Health Proton Therapy Center in Bloomington, Indiana opened in 2004 and ceased operations in 2014.

Outside the US

Proton therapy Centres (partial list)[23]
Institution Maximum energy (MeV) Year of first treatment Location
Paul Scherrer Institute 250 1984 Villigen, Switzerland
Clatterbridge Cancer Centre NHS Foundation Trust, low-energy for ocular[151] 62 1989 Liverpool, United Kingdom
Centre de protonthérapie de l'Institut Curie 235 1991 Orsay, France
Centre Antoine Lacassagne 63 1991 Nice, France
Research Center for Charged Particle Therapy 350–400 1994 Chiba, Japan
TRIUMF[152] 74 1995 Vancouver, Canada
Helmholtz-Zentrum Berlin 72 1998 Berlin, Germany
Proton Medical Research Center University of Tsukuba 250 2001 Tsukuba, Japan
Centro di adroterapia oculare 60 2002 Catania, Italy
Wanjie Proton Therapy Center 230 2004 Zibo, China
Proton Therapy Center, Korea National Cancer Center 230 2007 Seoul, Korea
Heidelberg Ion-Beam Therapy Center (HIT) 230 2009 Heidelberg, Germany
Medipolis Proton Therapy and Research Center 235 2011 Kagoshima, Japan
Instytut Fizyki Jądrowej 230 2011 Kraków, Poland
Centro Nazionale di Adroterapia Oncologica 250 2011 Pavia, Italy
Protonové centrum v Praze (PTC, Prague) 230 2012 Prague, Czech Republic
Westdeutsches Protonentherapiezentrum Essen 230 2013 Essen, Germany
PTC Uniklinikum Dresden 230 2014 Dresden, Germany
Centro di Protonterapia, APSS Trento[153] 230 2014 Trento, Italy
Shanghai Proton and Heavy Ion Center 230 2014 Shanghai, China
Centrum Cyklotronowe Bronowice 230 2015 Kraków, Poland
SMC Proton Therapy Center 230 2015 Seoul, Korea
Proton and Radiation Therapy Center, Linkou Chang Gung Memorial Hospital 230 2015 Taipei, Taiwan
Yung-Ching Proton Center, Kaohsiung Chang Gung Memorial Hospital[154] 230 2018 Kaohsiung, Taiwan
Skandionkliniken[155] 230 2015 Uppsala, Sweden
A. Tsyb Medical Radiological Research Centre 250 2016 Obninsk, Russia
MedAustron 250 2016 Wiener Neustadt, Austria [1]
Clinical Proton Therapy Center Dr. Berezin Medical Institute[156] 250 2017 Saint-Petersburg, Russia
Holland Proton Therapy Center[157] 250 2018 Delft, Netherlands
UMC Groningen Protonen Therapie Centrum[158] 230 2018 Groningen, Netherlands
The Christie[159] 250 2018 Manchester, United Kingdom
Danish Centre for Particle Therapy[160] 250 2019 Aarhus, Denmark
Apollo Proton Cancer Centre[161] 230 2019 Chennai, India
MAASTRO Clinic Proton Therapy[162] 230 2019 Maastricht, Netherlands
Clínica Universidad de Navarra 230 2019 Madrid, Spain
Centro de Protonterapia de Quirónsalud[163] 230 2019 Madrid, Spain
King Chulalongkorn Memorial Hospital [164] 250 2021 Bangkok, Thailand
University College London Hospitals[165] 250 2021 London, United Kingdom
Singapore Institute of Advanced Medicine[166] 250 2021 Singapore
Hefei Ion Medical Center[167] 250 2021 Hefei, China
Proton Clinical Research Center of the Shandong Cancer Hospital 250 2022 Jinan, China
Australian Bragg Centre for Proton Therapy & Research[168][169] 330 2023–2025 Adelaide, Australia

Australia

In July 2020, construction began for "SAHMRI 2", the second building for the South Australian Health and Medical Research Institute. The building will house the Australian Bragg Centre for Proton Therapy & Research, a A$500+ million addition to the largest health and biomedical precinct in the Southern Hemisphere, Adelaide's BioMed City. The proton therapy unit is being supplied by ProTom International, which will install its Radiance 330 proton therapy system, the same system used at Massachusetts General Hospital. When in full operation, it will have the ability to treat approximately 600-700 patients per year with around half of these expected to be children and young adults. The facility is expected to be completed in late 2023, with its first patients treated in 2025.[169]

India

Apollo Proton Cancer Centre (APCC) in Chennai, Tamil Nadu, a unit under Apollo Hospitals, is a Cancer specialty hospital.[170] APCC is the only cancer hospital in India with Joint Commission International accreditation.[171]

Israel

In January 2020, it was announced that a proton therapy center would be built in Ichilov Hospital, at the Tel Aviv Sourasky Medical Center. The project's construction was fully funded by donations. It will have two treatment rooms.[172]

Spain

In October 2021, the Amancio Ortega Foundation arranged with the Spanish government and several autonomous communities to donate 280 million euros to install ten proton accelerators in the public health system.[173]

United Kingdom

 
Prince Charles and Dr. Yen-Ching Chang at the University College London Hospitals NHS Foundation Trust proton centre opening ceremony

In 2013 the British government announced that £250 million had been budgeted to establish two centers for advanced radiotherapy: The Christie NHS Foundation Trust (the Christie Hospital) in Manchester, which opened in 2018; and University College London Hospitals NHS Foundation Trust, which opened in 2021. These offer high-energy proton therapy, and other types of advanced radiotherapy, including intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT).[174] In 2014, only low-energy proton therapy was available in the UK, at Clatterbridge Cancer Centre NHS Foundation Trust in Merseyside. But NHS England has paid to have suitable cases treated abroad, mostly in the US. Such cases rose from 18 in 2008 to 122 in 2013, 99 of whom were children. The cost to the National Health Service averaged ~£100,000 per case.[175]

See also

References

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Further reading

  • Greco C.; Wolden S. (Apr 2007). "Current status of radiotherapy with proton and light ion beams". Cancer. 109 (7): 1227–1238. doi:10.1002/cncr.22542. PMID 17326046. S2CID 36256866.
  • "Use of Protons for Radiotherapy", A.M. Koehler, Proc. of the Symposium on Pion and Proton Radiotherapy, Nat. Accelerator Lab., (1971).
  • A.M. Koehler, W.M. Preston, "Protons in Radiation Therapy: comparative Dose Distributions for Protons, Photons and Electrons Radiology 104(1):191–195 (1972).
  • "Bragg Peak Proton Radiosurgery for Arteriovenous Malformation of the Brain" R.N. Kjelberg, presented at First Int. Seminar on the Use of Proton Beams in Radiation Therapy, Moscow (1977).
  • Austin-Seymor, M.J. Munzenrider, et al. "Fractionated Proton Radiation Therapy of Cranial and Intracrainial Tumors" Am. J. of Clinical Oncology 13(4):327–330 (1990).
  • "Proton Radiotherapy", Hartford, Zietman, et al. in Radiotheraputic Management of Carcinoma of the Prostate, A. D'Amico and G.E. Hanks. London, UK, Arnold Publishers: 61–72 (1999).

External links

 
Wikimedia Commons has media related to Proton therapy.
  • The Intrepid Proton-Man, educational comic books by Steve Englehart and Michael Jaszewski for pediatric patients
  • 2019 BBC Horizon documentary
  • 2019 Jove video by the University of Maryland School of Medicine explaining the treatment process: Proton Therapy Delivery and Its Clinical Application in Select Solid Tumor Malignancies
  • 2019 The NHS Proton Beam Therapy Programme
  • Proton Therapy Collaborative Group PTCOG
  • Alliance for Proton Therapy
  • CARES Cancer Network
  • National Association for Proton Therapy
  • American Society for Radiation Oncology Model Policy – Proton Beam Therapy
  • Proton therapy – MedlinePlus Medical Encyclopedia
  • Proton Therapy
  • What is Proton Therapy

April 10, 2023
proton, therapy, examples, perspective, this, article, deal, primarily, with, united, states, represent, worldwide, view, subject, improve, this, article, discuss, issue, talk, page, create, article, appropriate, march, 2018, learn, when, remove, this, templat. The examples and perspective in this article deal primarily with the United States and do not represent a worldwide view of the subject You may improve this article discuss the issue on the talk page or create a new article as appropriate March 2018 Learn how and when to remove this template message In medicine proton therapy or proton radiotherapy is a type of particle therapy that uses a beam of protons to irradiate diseased tissue most often to treat cancer The chief advantage of proton therapy over other types of external beam radiotherapy is that the dose of protons is deposited over a narrow range of depth hence in minimal entry exit or scattered radiation dose to healthy nearby tissues Proton therapyProton therapy equipment at the Mayo Clinic in Rochester MinnesotaOther namesProton beam therapyICD 10 PCSZ92 3 edit on Wikidata When evaluating whether to treat a tumor with photon or proton therapy physicians may choose proton therapy if it is important to deliver a higher radiation dose to targeted tissues while significantly decreasing radiation to nearby organs at risk 1 The American Society for Radiation Oncology Model Policy for Proton Beam therapy says proton therapy is considered reasonable if sparing the surrounding normal tissue cannot be adequately achieved with photon based radiotherapy and can benefit the patient 2 Like photon radiation therapy proton therapy is often used in conjunction with surgery and or chemotherapy to most effectively treat cancer Contents 1 Description 1 1 Equipment 2 History 3 Types 3 1 Passive scattering beam delivery 3 2 Pencil beam scanning beam delivery 4 Application 4 1 Pediatric 4 2 Eye tumor 4 3 Base of skull cancer 4 4 Head and neck tumor 4 5 Left side breast cancer 4 6 Lymphoma 4 7 Prostate cancer 4 8 Gastrointestinal malignancy 4 9 Hepatocellular carcinoma 4 10 Reirradiation for recurrent cancer 5 Comparison with other treatments 5 1 X ray radiotherapy 5 2 Surgery 6 Side effects and risks 7 Costs 8 Treatment centers 8 1 United States 8 2 Outside the US 8 2 1 Australia 8 2 2 India 8 2 3 Israel 8 2 4 Spain 8 2 5 United Kingdom 9 See also 10 References 11 Further reading 12 External linksDescription EditMain article Radiation therapy Mechanism of action In a typical treatment plan for proton therapy the spread out Bragg peak SOBP dashed blue line shows how the radiation is distributed The SOBP is the sum of several individual Bragg peaks thin blue lines at staggered depths Note that the vast majority of the proton radiation is delivered to the tumor not to the skin and shallow tissues in front of the tumor or to the deep tissues behind the tumor The red line shows the depth dose plot of an X ray beam photon or conventional radiation therapy for comparison The pink area represents additional doses of X ray radiotherapy in front and behind the tumor which can damage normal tissues and cause secondary cancers especially of the skin 3 Proton therapy is a type of external beam radiotherapy that uses ionizing radiation In proton therapy medical personnel use a particle accelerator to target a tumor with a beam of protons 4 5 These charged particles damage the DNA of cells ultimately killing them by stopping their reproduction and thus eliminating the tumor Cancerous cells are particularly vulnerable to attacks on DNA because of their high rate of division and their limited ability to repair DNA damage Some cancers with specific defects in DNA repair may be more sensitive to proton radiation 6 Proton therapy lets physicians deliver a highly conformal beam i e delivering radiation that conforms to the shape and depth of the tumor and sparing much of the surrounding normal tissue 7 For example when comparing proton therapy to the most advanced types of photon therapy intensity modulated radiotherapy IMRT and volumetric modulated arc therapy VMAT proton therapy can give similar or higher radiation doses to the tumor with a 50 60 lower total body radiation dose 8 1 Protons can focus energy delivery to fit the tumor shape delivering only low dose radiation to surrounding tissue As a result the patient has fewer side effects All protons of a given energy have a certain penetration range very few protons penetrate beyond that distance 9 Also the dose delivered to tissue is maximized only over the last few millimeters of the particle s range this maximum is called the spread out Bragg peak often called the SOBP see visual 10 To treat tumors at greater depth one needs a beam with higher energy typically given in eV electron volts Accelerators used for proton therapy typically produce protons with energies of 70 to 250 MeV Adjusting proton energy during the treatment maximizes the cell damage within the tumor Tissue closer to the surface of the body than the tumor gets less radiation and thus less damage Tissues deeper in the body get very few protons so the dose becomes immeasurably small 9 In most treatments protons of different energies with Bragg peaks at different depths are applied to treat the entire tumor These Bragg peaks are shown as thin blue lines in the figure in this section It is important to understand that while tissues behind or deeper than the tumor get almost no radiation the tissues in front of shallower than the tumor get radiation dosage based on the SOBP Equipment Edit Most installed proton therapy systems use isochronous cyclotrons 11 12 Cyclotrons are considered simple to operate reliable and can be made compact especially with use of superconducting magnets 13 Synchrotrons can also be used with the advantage of easier production at varying energies 14 Linear accelerators as used for photon radiation therapy are becoming commercially available as limitations of size and cost are resolved 15 Modern proton systems incorporate high quality imaging for daily assessment of tumor contours treatment planning software illustrating 3D dose distributions and various system configurations e g multiple treatment rooms connected to one accelerator Partly because of these advances in technology and partly because of the continually increasing amount of proton clinical data the number of hospitals offering proton therapy continues to grow FLASH radiotherapy is a technique under development for photon and proton treatments using very high dose rates necessitating large beam currents If applied clinically it could shorten treatment time to just one to three 1 second sessions and further reducing side effects 16 17 18 History EditThe first suggestion that energetic protons could be an effective treatment was made by Robert R Wilson in a paper published in 1946 19 while he was involved in the design of the Harvard Cyclotron Laboratory HCL 20 The first treatments were performed with particle accelerators built for physics research notably Berkeley Radiation Laboratory in 1954 and at Uppsala in Sweden in 1957 In 1961 a collaboration began between HCL and Massachusetts General Hospital MGH to pursue proton therapy Over the next 41 years this program refined and expanded these techniques while treating 9 116 patients 21 before the cyclotron was shut down in 2002 In the USSR a therapeutic proton beam with energies up to 200 MeV was obtained at the synchrocyclotron of JINR in Dubna in 1967 The ITEP center in Moscow Russia which began treating patients in 1969 is the oldest proton center still in operation The Paul Scherrer Institute in Switzerland was the world s first proton center to treat eye tumors beginning in 1984 In addition they invented pencil beam scanning in 1996 which is now the state of the art form of proton therapy 22 The world s first hospital based proton therapy center was a low energy cyclotron centre for eye tumors at Clatterbridge Centre for Oncology in the UK opened in 1989 23 followed in 1990 at the Loma Linda University Medical Center LLUMC in Loma Linda California Later the Northeast Proton Therapy Center at Massachusetts General Hospital was brought online and the HCL treatment program was transferred to it in 2001 and 2002 At the beginning of 2023 there were 41 proton therapy centers in the United States 24 and a total of 89 worldwide 25 As of 2020 five manufacturers make proton therapy systems Hitachi Ion Beam Applications Mevion Medical Systems ProTom International and Varian Medical Systems Types EditThe newest form of proton therapy pencil beam scanning gives therapy by sweeping a proton beam laterally over the target so that it gives the required dose while closely conforming to shape of the targeted tumor Before the use of pencil beam scanning oncologists used a scattering method to direct a wide beam toward the tumor 26 Passive scattering beam delivery Edit The first commercially available proton delivery systems used a scattering process or passive scattering to deliver the therapy With scattering proton therapy the proton beam is spread out by scattering devices and the beam is then shaped by putting items such as collimators and compensators in the path of the protons The collimators were custom made for the patient with milling machines 27 Passive scattering gives homogeneous dose along the target volume Therefore passive scattering gives more limited control over dose distributions proximal to target Over time many scattering therapy systems have been upgraded to deliver pencil beam scanning Because scattering therapy was the first type of proton therapy available most clinical data available on proton therapy especially long term data as of 2020 were acquired via scattering technology Pencil beam scanning beam delivery Edit A newer and more flexible delivery method is pencil beam scanning using a beam that sweeps laterally over the target so that it delivers the needed dose while closely conforming to the tumor s shape This conformal delivery is achieved by shaping the dose through magnetic scanning of thin beamlets of protons without needing apertures and compensators Multiple beams are delivered from different directions and magnets in the treatment nozzle steer the proton beam to conform to the target volume layer as the dose is painted layer by layer This type of scanning delivery provides greater flexibility and control letting the proton dose conform more precisely to the shape of the tumor 27 Delivery of protons via pencil beam scanning in use since 1996 at the Paul Scherrer Institute 27 allows for the most precise type of proton delivery intensity modulated proton therapy IMPT IMPT is to proton therapy what IMRT is to conventional photon therapy treatment that more closely conforms to the tumor while avoiding surrounding structures 28 Virtually all new proton systems now provide pencil beam scanning exclusively A study led by Memorial Sloan Kettering Cancer Center suggests that IMPT can improve local control when compared to passive scattering for patients with nasal cavity and paranasal sinus malignancies 29 Application EditIt was estimated that by the end of 2019 a total of 200 000 patients had been treated with proton therapy Physicians use protons to treat conditions in two broad categories Disease sites that respond well to higher doses of radiation i e dose escalation Dose escalation has sometimes shown a higher probability of cure i e local control than conventional radiotherapy 30 These include among others uveal melanoma ocular tumor skull base and paraspinal tumor chondrosarcoma and chordoma and unresectable sarcoma In all these cases proton therapy gives significant improvement in the probability of local control over conventional radiotherapy 31 32 33 For eye tumors proton therapy also has high rates of maintaining the natural eye 34 Treatment where proton therapy s increased precision reduces unwanted side effects by lessening the dose to normal tissue In these cases the tumor dose is the same as in conventional therapy so there is no expectation of increased probability of curing the disease Instead emphasis is on reducing the dose to normal tissue thus reducing unwanted effects 30 Two prominent examples are pediatric neoplasms such as medulloblastoma and prostate cancer Pediatric Edit Irreversible long term side effects of conventional radiation therapy for pediatric cancers are well documented and include growth disorders neurocognitive toxicity ototoxicity with subsequent effects on learning and language development and renal endocrine and gonadal dysfunctions Radiation induced secondary malignancy is another very serious adverse effect that has been reported As there is minimal exit dose when using proton radiation therapy dose to surrounding normal tissues can be significantly limited reducing the acute toxicity which positively impacts the risk for these long term side effects Cancers requiring craniospinal irradiation for example benefit from the absence of exit dose with proton therapy dose to the heart mediastinum bowel bladder and other tissues anterior to the vertebrae is eliminated hence a reduction of acute thoracic gastrointestinal and bladder side effects 35 36 37 Eye tumor Edit Proton therapy for eye tumors is a special case since this treatment requires only relatively low energy protons 70 MeV Owing to this low energy some particle therapy centers only treat eye tumors 21 Proton or more generally hadron therapy of tissue close to the eye affords sophisticated methods to assess the alignment of the eye that can vary significantly from other patient position verification approaches in image guided particle therapy 38 Position verification and correction must ensure that the radiation spares sensitive tissue like the optic nerve to preserve the patient s vision For ocular tumors selecting the type of radiotherapy depends on tumor location and extent tumor radioresistance calculating the dose needed to eliminate the tumor and the therapy s potential toxic side effects on nearby critical structures 39 For example proton therapy is an option for retinoblastoma 40 and intraocular melanoma 41 The advantage of a proton beam is that it has the potential to effectively treat the tumor while sparing sensitive structures of the eye 42 Given its effectiveness proton therapy has been described as the gold standard treatment for ocular melanoma 43 44 Base of skull cancer Edit When receiving radiation for skull base tumors side effects of the radiation can include pituitary hormone dysfunction and visual field deficit after radiation for pituitary tumors as well as cranial neuropathy nerve damage radiation induced osteosarcoma bone cancer and osteoradionecrosis which occurs when radiation causes part of the bone in the jaw or skull base to die 45 Proton therapy has been very effective for people with base of skull tumors 46 Unlike conventional photon radiation protons do not penetrate beyond the tumor Proton therapy lowers the risk of treatment related side effects from when healthy tissue gets radiation Clinical studies have found proton therapy to be effective for skull base tumors 47 48 49 Head and neck tumor Edit Proton particles do not deposit exit dose so proton therapy can spare normal tissues far from the tumor This is particularly useful for head and neck tumors because of the anatomic constraints found in nearly all cancers in this region The dosimetric advantage unique to proton therapy translates into toxicity reduction For recurrent head and neck cancer requiring reirradiation proton therapy is able to maximize a focused dose of radiation to the tumor while minimizing dose to surrounding tissues hence a minimal acute toxicity profile even in patients who got multiple prior courses of radiotherapy 50 Left side breast cancer Edit When breast cancer especially in the left breast is treated with conventional radiation the lung and heart which are near the left breast are particularly susceptible to photon radiation damage Such damage can eventually cause lung problems e g lung cancer or various heart problems Depending on location of the tumor damage can also occur to the esophagus or to the chest wall which can potentially lead to leukemia 51 One recent study showed that proton therapy has low toxicity to nearby healthy tissues and similar rates of disease control compared with conventional radiation 52 Other researchers found that proton pencil beam scanning techniques can reduce both the mean heart dose and the internal mammary node dose to essentially zero 53 Small studies have found that compared to conventional photon radiation proton therapy delivers minimal toxic dose to healthy tissues 54 and specifically decreased dose to the heart and lung 55 Large scale trials are underway to examine other potential benefits of proton therapy to treat breast cancer 56 Lymphoma Edit Though chemotherapy is the main treatment for lymphoma consolidative radiation is often used in Hodgkin lymphoma and aggressive non Hodgkin lymphoma while definitive treatment with radiation alone is used in a small fraction of lymphoma patients Unfortunately treatment related toxicities caused by chemotherapy agents and radiation exposure to healthy tissues are major concerns for lymphoma survivors Advanced radiation therapy technologies such as proton therapy may offer significant and clinically relevant advantages such as sparing important organs at risk and decreasing the risk for late normal tissue damage while still achieving the primary goal of disease control This is especially important for lymphoma patients who are being treated with curative intent and have long life expectancy following therapy 57 Prostate cancer Edit In prostate cancer cases the issue is less clear Some published studies found a reduction in long term rectal and genito urinary damage when treating with protons rather than photons meaning X ray or gamma ray therapy Others showed a small difference limited to cases where the prostate is particularly close to certain anatomical structures 58 59 The relatively small improvement found may be the result of inconsistent patient set up and internal organ movement during treatment which offsets most of the advantage of increased precision 59 60 61 One source suggests that dose errors around 20 can result from motion errors of just 2 5 mm 0 098 in citation needed and another that prostate motion is between 5 10 mm 0 20 0 39 in 62 The number of cases of prostate cancer diagnosed each year far exceeds those of the other diseases referred to above and this has led some but not all facilities to devote most of their treatment slots to prostate treatments For example two hospital facilities devote 65 63 and 50 64 of their proton treatment capacity to prostate cancer while a third devotes only 7 1 65 Worldwide numbers are hard to compile but one example says that in 2003 26 of proton therapy treatments worldwide were for prostate cancer 66 Gastrointestinal malignancy Edit A growing amount of data shows that proton therapy has great potential to increase therapeutic tolerance for patients with GI malignancy The possibility of decreasing radiation dose to organs at risk may also help facilitate chemotherapy dose escalation or allow new chemotherapy combinations Proton therapy will play a decisive role for ongoing intensified combined modality treatments for GI cancers The following review presents the benefits of proton therapy in treating hepatocellular carcinoma pancreatic cancer and esophageal cancer 67 Hepatocellular carcinoma Edit Post treatment liver decompensation and subsequent liver failure is a risk with radiotherapy for hepatocellular carcinoma the most common type of primary liver cancer Research shows that proton therapy gives favorable results related to local tumor control progression free survival and overall survival 68 69 70 71 Other studies which examine proton therapy compared with conventional photon therapy show that proton therapy gives improved survival and or fewer side effects hence proton therapy could significantly improve clinical outcomes for some patients with liver cancer 72 73 Reirradiation for recurrent cancer Edit For patients who get local or regional recurrences after their initial radiation therapy physicians are limited in their treatment options due to their reluctance to give additional photon radiation therapy to tissues that have already been irradiated Re irradiation is a potentially curative treatment option for patients with locally recurrent head and neck cancer In particular pencil beam scanning may be ideally suited for reirradiation 74 Research shows the feasibility of using proton therapy with acceptable side effects even in patients who have had multiple prior courses of photon radiation 75 76 77 Comparison with other treatments EditA large study on comparative effectiveness of proton therapy was published by teams of the University of Pennsylvania and Washington University in St Louis in JAMA Oncology assessing if proton therapy in the setting of concurrent chemoradiotherapy is associated with fewer 90 day unplanned hospitalizations and overall survival compared with concurrent photon therapy and chemoradiotherapy 78 The study included 1483 adult patients with nonmetastatic locally advanced cancer treated with concurrent chemoradiotherapy with curative intent and concluded proton chemoradiotherapy was associated with significantly reduced acute adverse events that caused unplanned hospitalizations with similar disease free and overall survival A significant number of randomized controlled trials is currently recruiting but only a limited number have been completed as of August 2020 A phase III randomized controlled trial of proton beam therapy versus radiofrequency ablation RFA for recurrent hepatocellular carcinoma organized by the National Cancer Center in Korea showed better 2 year local progression free survival for the proton arm and concluded that proton beam therapy PBT is not inferior to RFA in terms of local progression free survival and safety denoting that either RFA or PBT can be applied to recurrent small HCC patients 68 A phase IIB randomized controlled trial of proton beam therapy versus IMRT for locally advanced esophageal cancer organized by University of Texas MD Anderson Cancer Center concluded that proton beam therapy reduced the risk and severity of adverse events compared with IMRT while maintaining similar progression free survival 79 Another Phase II Randomized Controlled Trial comparing photons versus protons for Glioblastoma concluded that patients at risk of severe lymphopenia could benefit from proton therapy 80 A team from Stanford University assessed the risk of secondary cancer after primary cancer treatment with external beam radiation using data from the National Cancer Database for 9 tumor types head and neck gastrointestinal gynecologic lymphoma lung prostate breast bone soft tissue and brain central nervous system 81 The study included a total of 450 373 patients and concluded that proton therapy was associated with a lower risk of second cancer The issue of when whether and how best to apply this technology is still under discussion by physicians and researchers One recently introduced method model based selection uses comparative treatment plans for IMRT and IMPT in combination with normal tissue complication probability NTCP models to identify patients who may benefit most from proton therapy 82 83 Clinical trials are underway to examine the comparative efficacy of proton therapy vs photon radiation for the following Pediatric cancers by St Jude Children s Research Hospital 84 Samsung Medical Center 85 Base of skull cancer by Heidelberg University 86 Head and neck cancer by MD Anderson 87 Memorial Sloan Kettering and other centers 88 Brain and spinal cord cancer by Massachusetts General Hospital 89 Uppsala University and other centers 90 NRG Oncology 91 92 Hepatocellular carcinoma liver by NRG Oncology 93 Chang Gung Memorial Hospital 94 Loma Linda University 95 Lung cancer by Radiation Therapy Oncology Group RTOG 96 Proton Collaborative Group PCG 97 Mayo Clinic 98 Esophageal cancer by NRG Oncology 99 Abramson Cancer Center University of Pennsylvania 100 Breast cancer by University of Pennsylvania 101 Proton Collaborative Group PCG 102 Pancreatic cancer by University of Maryland 103 Proton Collaborative Group PCG 104 X ray radiotherapy Edit Irradiation of nasopharyngeal carcinoma by photon X ray therapy left and proton therapy right The figure at the right of the page shows how beams of X rays IMRT left frame and beams of protons right frame of different energies penetrate human tissue A tumor with a sizable thickness is covered by the IMRT spread out Bragg peak SOBP shown as the red lined distribution in the figure The SOBP is an overlap of several pristine Bragg peaks blue lines at staggered depths Megavoltage X ray therapy has less skin sparing potential than proton therapy X ray radiation at the skin and at very small depths is lower than for proton therapy One study estimates that passively scattered proton fields have a slightly higher entrance dose at the skin 75 compared to therapeutic megavoltage MeV photon beams 60 3 X ray radiation dose falls off gradually needlessly harming tissue deeper in the body and damaging the skin and surface tissue opposite the beam entrance The differences between the two methods depends on Width of the SOBP Depth of the tumor Number of beams that treat the tumorThe X ray advantage of less harm to skin at the entrance is partially counteracted by harm to skin at exit point Since X ray treatments are usually done with multiple exposures from opposite sides each section of skin is exposed to both entering and exiting X rays In proton therapy skin exposure at the entrance point is higher but tissues on the opposite side of the body to the tumor get no radiation Thus X ray therapy causes slightly less damage to skin and surface tissues and proton therapy causes less damage to deeper tissues in front of and beyond the target 5 An important consideration in comparing these treatments is whether the equipment delivers protons via the scattering method historically the most common or a spot scanning method Spot scanning can adjust the width of the SOBP on a spot by spot basis which reduces the volume of normal healthy tissue inside the high dose region Also spot scanning allows for intensity modulated proton therapy IMPT which determines individual spot intensities using an optimization algorithm that lets the user balance the competing goals of irradiating tumors while sparing normal tissue Spot scanning availability depends on the machine and the institution Spot scanning is more commonly known as pencil beam scanning and is available on IBA Hitachi Mevion known as HYPERSCAN 105 which became US FDA approved in 2017 and Varian Surgery Edit Physicians base the decision to use surgery or proton therapy or any radiation therapy on tumor type stage and location Sometimes surgery is superior such as cutaneous melanoma sometimes radiation is superior such as skull base chondrosarcoma and sometimes are comparable for example prostate cancer Sometimes they are used together e g rectal cancer or early stage breast cancer The benefit of external beam proton radiation is in the dosimetric difference from external beam X ray radiation and brachytherapy in cases where use of radiation therapy is already indicated rather than as a direct competition with surgery 30 In prostate cancer the most common indication for proton beam therapy no clinical study directly comparing proton therapy to surgery brachytherapy or other treatments has shown any clinical benefit for proton beam therapy Indeed the largest study to date showed that IMRT compared with proton therapy was associated with less gastrointestinal morbidity 106 Side effects and risks EditMain articles Radiation therapy Side effects and Adverse effect Proton therapy is a type of external beam radiotherapy and shares risks and side effects of other forms of radiation therapy The dose outside of the treatment region can be significantly less for deep tissue tumors than X ray therapy because proton therapy takes full advantage of the Bragg peak Proton therapy has been in use for over 40 years and is a mature technology As with all medical knowledge understanding of the interaction of radiations with tumor and normal tissue is still imperfect 107 Costs EditHistorically proton therapy has been expensive An analysis published in 2003 found that the cost of proton therapy is 2 4 times that of X ray therapies 108 Newer less expensive and dozens more proton treatment centers are driving costs down and they offer more accurate three dimensional targeting Higher proton dosage over fewer treatments sessions 1 3 fewer or less is also driving costs down 109 110 Thus the cost is expected to reduce as better proton technology becomes more widely available An analysis published in 2005 determined that the cost of proton therapy is not unrealistic and should not be the reason for denying patients access to the technology 111 In some clinical situations proton beam therapy is clearly superior to the alternatives 112 113 A study in 2007 expressed concerns about the effectiveness of proton therapy for prostate cancer 114 but with the advent of new developments in the technology such as improved scanning techniques and more precise dose delivery pencil beam scanning this situation may change considerably 115 Amitabh Chandra a health economist at Harvard University said Proton beam therapy is like the Death Star of American medical technology It s a metaphor for all the problems we have in American medicine 116 Proton therapy is cost effective for some types of cancer but not all 117 118 In particular some other treatments offer better overall value for treatment of prostate cancer 117 As of 2018 the cost of a single room particle therapy system is US 40 million with multi room systems costing up to US 200 million 119 120 Treatment centers Edit Control panel of the synchrocyclotron at the Orsay proton therapy center France As of August 2020 there are over 89 particle therapy facilities worldwide 121 with at least 41 others under construction 122 As of August 2020 there are 34 operational proton therapy centers in the United States As of the end of 2015 more than 154 203 patients had been treated worldwide 123 One hindrance to universal use of the proton in cancer treatment is the size and cost of the cyclotron or synchrotron equipment necessary Several industrial teams are working on development of comparatively small accelerator systems to deliver the proton therapy to patients 124 Among the technologies being investigated are superconducting synchrocyclotrons also known as FM Cyclotrons ultra compact synchrotrons dielectric wall accelerators 124 and linear particle accelerators 110 United States Edit Proton treatment centers in the United States as of 2020 update in chronological order of first treatment date include 23 125 Institution Location Year of first treatment CommentsLoma Linda University Medical Center 126 Loma Linda CA 1990 First hospital based facility in USA uses Spread Out Bragg s Peak SOBP Crocker Nuclear Laboratory 127 Davis CA 1994 Ocular treatments only low energy accelerator at University of California DavisFrancis H Burr Proton Center Boston MA 2001 At Massachusetts General Hospital and formerly known as NPTC continuation of Harvard Cyclotron Laboratory MGH treatment program that began in 1961 Manufactured by Ion Beam Applications 128 University of Florida Health Proton Therapy Institute Jacksonville 129 Jacksonville FL 2006 The UF Health Proton Therapy Institute is a part of a non profit academic medical research facility affiliated with the University of Florida College of Medicine Jacksonville It is the first treatment center in the Southeast U S to offer proton therapy Manufactured by Ion Beam Applications 128 University of Texas MD Anderson Cancer Center 130 Houston TXOklahoma Proton Center 131 Oklahoma City OK 2009 4 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 Northwestern Medicine Chicago Proton Center Warrenville IL 2010 4 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 Roberts Proton Therapy Center 132 Philadelphia PA The largest proton therapy center in the world the Roberts Proton Therapy Center which is a part of Penn s Abramson Cancer Center University of Pennsylvania Health System 5 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 Hampton University Proton Therapy Institute Hampton VA 5 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 ProCure Proton Therapy Center 133 Somerset NJ 2012 4 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 SCCA Proton Therapy Center Seattle WA 2013 At Seattle Cancer Care Alliance part of Fred Hutchinson Cancer Research Center 4 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 Siteman Cancer Center 109 St Louis MO First of the new single suite ultra compact superconducting synchrocyclotron 134 lower cost facilities to treat a patient using the Mevion Medical System s S250 135 Provision Proton Therapy Center 136 Knoxville TN 2014 3 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 California Protons Cancer Therapy Center 137 San Diego CA 5 treatment rooms manufactured by Varian Medical Systems 138 Ackerman Cancer Center Jacksonville FL 2015 Ackerman Cancer Center is the world s first private physician owned practice to provide proton therapy in addition to conventional radiation therapy and on site diagnostic services The Laurie Proton Therapy Center New Brunswick NJ The Laurie Proton Therapy Center part of Robert Wood Johnson University Hospital is home to the world s third MEVION S250 Proton Therapy System Texas Center for Proton Therapy Dallas Fort Worth TX A collaboration by Texas Oncology and The US Oncology Network supported by McKesson Specialty Health and Baylor Health Enterprises three pencil beam rooms and cone beam CT imaging 139 3 treatment rooms Proteus PLUS system manufactured by Ion Beam Applications 128 Mayo Clinic Jacobson Building Rochester MN 4 treatment rooms 140 Manufactured by Hitachi 141 St Jude Red Frog Events Proton Therapy Center Memphis TN 3 treatment roomsMayo Clinic Cancer Center Phoenix AZ 2016 4 treatment rooms 142 Manufactured by Hitachi 143 The Marjorie and Leonard Williams Center for Proton Therapy Orlando FL http www ufhealthcancerorlando com centers proton therapy centerCancer and Blood Diseases Institute Liberty Township OH Collaboration of University of Cincinnati Cancer Institute and Cincinnati Children s Hospital Medical Center 144 145 manufactured by Varian Medical SystemsMaryland Proton Treatment Center Baltimore MD 5 treatment rooms affiliated with the University of Maryland Greenebaum Comprehensive Cancer Center manufactured by Varian Medical Systems Proton Therapy Center at University Hospitals Seidman Cancer Center Cleveland OH Only proton therapy center in Northern Ohio One treatment room with the Mevion S250 Proton Therapy System Part of the NCI designated Case Comprehensive Cancer Center University Hospitals Seidman Cancer Center is one of the nation s leading freestanding cancer hospitals Miami Cancer Institute Miami FL 2017 3 treatment rooms all using pencil beam scanning 146 Manufactured by Ion Beam Applications 128 Beaumont Proton Therapy Center Royal Oak MI Single treatment room Proteus ONE system manufactured by Ion Beam Applications 128 Emory Proton Therapy Center Atlanta GA 2018 Five treatment rooms ProBeam Superconducting Cyclotron 147 manufactured by Varian Medical SystemsProvision CARES Proton Therapy Center Nashville TN Three treatment rooms Two Gantries and One Fixed Beam All Pencil Beam Scanning manufactured by ProNova Solutions LLCMcLaren Proton Therapy Center Flint MI The McLaren Proton Therapy System uses the industry s highest energy 330 MeV proton synchrotron to accelerate and deliver proton beam to two treatment rooms with an opportunity to extend into a planned third room Both operating treatment rooms are equipped with proton pencil beam scanning cone beam computed tomography for image guidance patient positioning system with 6 degrees of freedom that coupled with 180 degree partial gantry allows for complete flexibility of treatment angles New York Proton Center New York NY 2019 A partnership between Memorial Sloan Kettering Montefiore Health and Mount Sinai Health System 4 treatment rooms manufactured by Varian Medical SystemsJohns Hopkins Proton Therapy Center Washington DC 3 treatment rooms and 1 research gantry Manufactured by Hitachi South Florida Proton Therapy Institute Delray Beach FL One treatment room manufactured by Varian Medical SystemsUAB Proton Therapy Center Birmingham AL 2020 One treatment room manufactured by Varian Medical SystemsDwoskin PTC University of Miami Miami FL One treatment room manufactured by Varian Medical SystemsThe University of Kansas Cancer Center Kansas City KS 2022 Announced Feb 2019 148 Penn Medicine Lancaster General Health Ann B Barshinger Cancer Institute Lancaster PA One treatment room manufactured by Varian Medical SystemsPenn Medicine Virtua Health Voorhees NJ One treatment room manufactured by Varian Medical SystemsMayo Clinic Florida Jacksonville FL 2023 Estimated Announced June 2019 149 Ohio State Nationwide Children s Hospital Columbus OH Three treatment rooms manufactured by Varian Medical SystemsFroedtert Hospital Wauwatosa WI 2024 Estimated Announced May 2022 150 The Indiana University Health Proton Therapy Center in Bloomington Indiana opened in 2004 and ceased operations in 2014 Outside the US Edit Proton therapy Centres partial list 23 Institution Maximum energy MeV Year of first treatment LocationPaul Scherrer Institute 250 1984 Villigen SwitzerlandClatterbridge Cancer Centre NHS Foundation Trust low energy for ocular 151 62 1989 Liverpool United KingdomCentre de protontherapie de l Institut Curie 235 1991 Orsay FranceCentre Antoine Lacassagne 63 1991 Nice FranceResearch Center for Charged Particle Therapy 350 400 1994 Chiba JapanTRIUMF 152 74 1995 Vancouver CanadaHelmholtz Zentrum Berlin 72 1998 Berlin GermanyProton Medical Research Center University of Tsukuba 250 2001 Tsukuba JapanCentro di adroterapia oculare 60 2002 Catania ItalyWanjie Proton Therapy Center 230 2004 Zibo ChinaProton Therapy Center Korea National Cancer Center 230 2007 Seoul KoreaHeidelberg Ion Beam Therapy Center HIT 230 2009 Heidelberg GermanyMedipolis Proton Therapy and Research Center 235 2011 Kagoshima JapanInstytut Fizyki Jadrowej 230 2011 Krakow PolandCentro Nazionale di Adroterapia Oncologica 250 2011 Pavia ItalyProtonove centrum v Praze PTC Prague 230 2012 Prague Czech RepublicWestdeutsches Protonentherapiezentrum Essen 230 2013 Essen GermanyPTC Uniklinikum Dresden 230 2014 Dresden GermanyCentro di Protonterapia APSS Trento 153 230 2014 Trento ItalyShanghai Proton and Heavy Ion Center 230 2014 Shanghai ChinaCentrum Cyklotronowe Bronowice 230 2015 Krakow PolandSMC Proton Therapy Center 230 2015 Seoul KoreaProton and Radiation Therapy Center Linkou Chang Gung Memorial Hospital 230 2015 Taipei TaiwanYung Ching Proton Center Kaohsiung Chang Gung Memorial Hospital 154 230 2018 Kaohsiung TaiwanSkandionkliniken 155 230 2015 Uppsala SwedenA Tsyb Medical Radiological Research Centre 250 2016 Obninsk RussiaMedAustron 250 2016 Wiener Neustadt Austria 1 Clinical Proton Therapy Center Dr Berezin Medical Institute 156 250 2017 Saint Petersburg RussiaHolland Proton Therapy Center 157 250 2018 Delft NetherlandsUMC Groningen Protonen Therapie Centrum 158 230 2018 Groningen NetherlandsThe Christie 159 250 2018 Manchester United KingdomDanish Centre for Particle Therapy 160 250 2019 Aarhus DenmarkApollo Proton Cancer Centre 161 230 2019 Chennai IndiaMAASTRO Clinic Proton Therapy 162 230 2019 Maastricht NetherlandsClinica Universidad de Navarra 230 2019 Madrid SpainCentro de Protonterapia de Quironsalud 163 230 2019 Madrid SpainKing Chulalongkorn Memorial Hospital 164 250 2021 Bangkok ThailandUniversity College London Hospitals 165 250 2021 London United KingdomSingapore Institute of Advanced Medicine 166 250 2021 SingaporeHefei Ion Medical Center 167 250 2021 Hefei ChinaProton Clinical Research Center of the Shandong Cancer Hospital 250 2022 Jinan ChinaAustralian Bragg Centre for Proton Therapy amp Research 168 169 330 2023 2025 Adelaide AustraliaAustralia Edit In July 2020 construction began for SAHMRI 2 the second building for the South Australian Health and Medical Research Institute The building will house the Australian Bragg Centre for Proton Therapy amp Research a A 500 million addition to the largest health and biomedical precinct in the Southern Hemisphere Adelaide s BioMed City The proton therapy unit is being supplied by ProTom International which will install its Radiance 330 proton therapy system the same system used at Massachusetts General Hospital When in full operation it will have the ability to treat approximately 600 700 patients per year with around half of these expected to be children and young adults The facility is expected to be completed in late 2023 with its first patients treated in 2025 169 India Edit Apollo Proton Cancer Centre APCC in Chennai Tamil Nadu a unit under Apollo Hospitals is a Cancer specialty hospital 170 APCC is the only cancer hospital in India with Joint Commission International accreditation 171 Israel Edit In January 2020 it was announced that a proton therapy center would be built in Ichilov Hospital at the Tel Aviv Sourasky Medical Center The project s construction was fully funded by donations It will have two treatment rooms 172 Spain Edit In October 2021 the Amancio Ortega Foundation arranged with the Spanish government and several autonomous communities to donate 280 million euros to install ten proton accelerators in the public health system 173 United Kingdom Edit Prince Charles and Dr Yen Ching Chang at the University College London Hospitals NHS Foundation Trust proton centre opening ceremony In 2013 the British government announced that 250 million had been budgeted to establish two centers for advanced radiotherapy The Christie NHS Foundation Trust the Christie Hospital in Manchester which opened in 2018 and University College London Hospitals NHS Foundation Trust which opened in 2021 These offer high energy proton therapy and other types of advanced radiotherapy including intensity modulated radiotherapy IMRT and image guided radiotherapy IGRT 174 In 2014 only low energy proton therapy was available in the UK at Clatterbridge Cancer Centre NHS Foundation Trust in Merseyside But NHS England has paid to have suitable cases treated abroad mostly in the US Such cases rose from 18 in 2008 to 122 in 2013 99 of whom were children The cost to 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Radiotherapy Versus Radiofrequency Ablation for Patients With Medium or Large Hepatocellular Carcinoma ClinicalTrials gov Md Michael Devera August 2020 Transarterial Chemoembolization Versus Proton Beam Radiotherapy for the Treatment of Hepatocellular Carcinoma ClinicalTrials gov Comparing Photon Therapy To Proton Therapy To Treat Patients With Lung Cancer ClinicalTrials gov August 2020 A Phase I II Study of Hypofractionated Proton Therapy for Stage II III Non Small Cell Lung Cancer ClinicalTrials gov August 2020 Schild Steven August 2020 Phase II Trial of Standard Chemotherapy Carboplatin amp Paclitaxel Various Proton Beam Therapy PBT Doses ClinicalTrials gov Comparing Proton Therapy to Photon Radiation Therapy for Esophageal Cancer ClinicalTrials gov August 2020 Dose Escalation of Neoadjuvant Proton Beam Radiotherapy With Concurrent Chemotherapy in Locally Advanced Esophageal Cancer ClinicalTrials gov August 2020 Pragmatic Randomized Trial of Proton vs Photon Therapy for Patients With Non Metastatic Breast Cancer A Radiotherapy Comparative Effectiveness RADCOMP Consortium Trial ClinicalTrials gov August 2020 Phase II Protocol of Proton Therapy for Partial Breast Irradiation in Early Stage Breast Cancer ClinicalTrials gov August 2020 Phase I Nab Paclitaxel Plus Gemcitabine With Proton Therapy for Locally Advanced Pancreatic Cancer LAPC ClinicalTrials gov August 2020 Proton Radiation for Unresectable Borderline Resectable or Medically Inoperable Carcinoma of the Pancreas ClinicalTrials gov August 2020 Introducing Hyperscan mevion com Mevion Medical Systems 2015 04 19 Sheets NC Goldin GH Meyer AM Wu Y et al April 18 2012 Intensity modulated radiation therapy proton therapy or conformal radiation therapy and morbidity and disease control in localized prostate cancer The Journal of the American Medical Association 307 15 1611 20 doi 10 1001 jama 2012 460 PMC 3702170 PMID 22511689 Tepper Joel E Blackstock A William 20 October 2009 Editorial Randomized Trials and Technology Assessment Annals of Internal Medicine 151 8 583 584 doi 10 7326 0003 4819 151 8 200910200 00146 PMID 19755346 Goitein M Jermann M 2003 The Relative Costs of Proton and X ray Radiation Therapy Clinical Oncology 15 1 S37 50 doi 10 1053 clon 2002 0174 PMID 12602563 a b Bassett Anne Siteman Cancer Center Treats First Patient With First of Its Kind Proton Therapy System PRWeb com Press release Barnes Jewish Hospital Retrieved 2017 10 05 a b Roland Denise September 25 2013 God particle technology to cancer patients The Telegraph Retrieved 2017 10 05 Lievens Y Van den Bogaert W et al 2005 Proton beam therapy Too expensive to become true Radiotherapy and Oncology 75 2 131 133 doi 10 1016 j radonc 2005 03 027 PMID 15890422 St Clair W H Adams J A Bues M Fullerton B C La Shell S Kooy H M Loeffler J S Tarbell N J 2004 Advantage of protons compared to conventional X ray or IMRT in the treatment of a pediatric patient with medulloblastoma Int J Radiat Oncol Biol Phys 58 3 727 734 doi 10 1016 S0360 3016 03 01574 8 PMID 14967427 Merchant T E Hua C H Shukla H Ying X Nill S Oelfke U 2008 Proton versus photon radiotherapy for common pediatric brain tumors comparison of models of dose characteristics and their relationship to cognitive function Pediatr Blood Cancer 51 1 110 117 doi 10 1002 pbc 21530 PMID 18306274 S2CID 36735536 Konski A Speier W Hanlon A Beck J R Pollack A 2007 Is proton beam therapy cost effective in the treatment of adenocarcinoma of the prostate J Clin Oncol 25 24 3603 3608 doi 10 1200 jco 2006 09 0811 PMID 17704408 S2CID 19423315 Nguyen P L Trofimov A Zietman A L June 22 2008 Proton Beam vs Intensity Modulated Radiation Therapy Which Is Best for Treating Prostate Cancer Oncology Williston Park 22 7 748 754 discussion 754 757 PMID 18619120 Langreth Robert March 26 2012 Prostate Cancer Therapy Too Good to Be True Explodes Health Cost Bloomberg com Retrieved 2013 05 16 a b Muralidhar Vinayak Nguyen Paul L February 2017 Maximizing resources in the local treatment of prostate cancer A summary of cost effectiveness studies Urologic Oncology 35 2 76 85 doi 10 1016 j urolonc 2016 06 003 ISSN 1873 2496 PMID 27473636 Yuan Tai Ze Zhan Ze Jiang Qian Chao Nan 22 October 2019 New frontiers in proton therapy applications in cancers Cancer Communications 39 1 61 doi 10 1186 s40880 019 0407 3 ISSN 2523 3548 PMC 6805548 PMID 31640788 Hancock Jay April 27 2018 For Cancer Centers Proton Therapy s Promise Is Undercut by Lagging Demand The New York Times Wise Buy Proton Beam Therapy www medpagetoday com May 19 2017 Particle therapy facilities in operation PTCOG ch Particle Therapy Co Operative Group August 2020 Retrieved 2020 08 01 Particle therapy facilities under construction PTCOG ch Particle Therapy Co Operative Group June 2017 Retrieved 2017 10 06 Statistics of patients treated in particle therapy facilities worldwide PTCOG ch Particle Therapy Co Operative Group 2016 Retrieved 2017 10 06 a b Matthews J N A March 2009 Accelerators shrink to meet growing demand for proton therapy Physics Today p 22 Nafziger Brendon March 20 2012 N J proton therapy center opens today DotMed com Retrieved 2012 03 30 Proton Therapy Treatment and Research Center Loma Linda University Medical Center Retrieved 2013 11 05 Cyclotron Services crocker udavis edu University of California Davis Crocker Nuclear Laboratory Retrieved 2017 10 05 a b c d e f g h i j k l Best proton therapy centers IBA proton therapy iba worldwide com Retrieved 2018 03 16 Proton Therapy Jacksonville Cancer Treatment University of Florida Proton Therapy Institute Retrieved 2013 11 05 Proton Therapy Center University of Texas MD Anderson Cancer Center Retrieved 2013 11 05 Oklahoma Proton Therapy Treatment Center ProCure Retrieved 2013 11 05 Proton Therapy at Penn Medicine Perelman Center for Advanced Medicine Retrieved 2013 11 05 New Jersey Proton Therapy Treatment Center ProCure Archived from the original on 2010 11 26 Retrieved 2013 11 05 Elegant and Precise Mevion Medical Systems Archived from the original on 2015 04 14 Retrieved 2015 04 19 Introducing the Mevion S250 Mevion Archived from the original on 2015 04 14 Retrieved 2015 04 19 Proton therapy cancer treatment center opens first of its kind in Tennessee WATE TV Archived from the original on 2014 01 26 Retrieved 2014 01 25 a href Template Cite web html title Template Cite web cite web a CS1 maint bot original URL status unknown link California Protons Cancer Therapy Center California Protons Cancer Therapy Center Retrieved 2017 12 18 Oncology Solutions Proton Therapy Varian Medical Systems Archived from the original on 2019 01 07 Retrieved 2015 04 19 Texas Center for Proton Therapy Treats First Patient with Isocentric Cone Beam CT and Pencil Beam Scanning Press release Irving Texas McKesson May 9 2016 Retrieved 2017 10 05 Mayo Clinic launches Proton Beam Therapy Program mayoclinic org Mayo Clinic Retrieved 2017 10 05 Hitachi s Advanced Proton Beam Therapy System PROBEAT V Begins Treatments at Mayo Clinic in Rochester MN Press release Tokyo Japan Hitachi September 15 2015 Retrieved 2018 05 01 Mayo Clinic Cancer Center mayoclinic org Mayo Clinic Hitachi PROBEAT V Advanced Proton Beam Therapy System Now In Use at Mayo Clinic in Arizona Press release Tokyo Japan Hitachi March 15 2016 Retrieved 2018 05 01 Proton Therapy at University of Cincinnati Medical Center uchealth com University of Cincinnati Cancer Institute UC Health Retrieved 2017 10 05 Pediatric Proton Therapy Center cincinnatichildrens org Cincinnati Children s Hospital Medical Center Retrieved 2017 10 05 Proton Therapy at Miami Cancer Institute baptisthealth net Baptist Health South Florida Retrieved 2017 10 05 Emory Proton Therapy Center Fact Sheet PDF winshipcancer emory edu Emory Winship Cancer Institute Retrieved 2018 03 05 KU Health System to offer innovative new proton therapy cancer treatment 26 February 2019 Retrieved 2019 05 29 Integrated oncology facility with proton beam therapy planned for Mayo Clinic s Florida campus newsnetwork mayoclinic org 24 June 2019 The Froedtert amp MCW health network to offer new generation radiation therapy to patients froedtert com 16 May 2022 Proton therapy clatterbridgecc nhs uk Clatterbridge Cancer Centre NHS Foundation Trust Archived from the original on 2014 01 15 Retrieved 2017 10 05 Proton Therapy TRIUMF ca Archived from the original on 2017 06 27 Retrieved 2017 10 05 Proton Therapy Center Trento protonterapia provincia tn it Kaohsiung Branch Yung Ching Proton Center www chang gung org Skandionkliniken Nordens forsta klinik for protonstralning Startsida Protonnyj centr MIBS protherapy ru Welkom bij HollandPTC HPTC Corporate information www umcg nl The Christie Danish Centre for Particle Therapy www en auh dk Proton Therapy Centre Apollo Hospitals Maastro is the first true compact proton therapy system in Europe PDF www maastro nl Proton therapy delivered to patient for the first time in Spain 15 January 2020 King Chulalongkorn Memorial Hospital University College London Hospitals Singapore Institute of Advanced Medicine Holdings www advancedmedicine sg Hefei Ion Medical Center hefeihightech chinadaily com cn Australian Bragg Centre for Proton Therapy Australian Bragg Centre for Proton Therapy a b Spence Andrew 10 June 2020 Proton therapy focus of SAHMRI 2 InDaily Retrieved 6 July 2020 www ETHealthworld com Modern cancer treatments ensure that every single mm of the tissue beyond the tumor is preserved Dr Rakesh Jalali ET HealthWorld ETHealthworld com Retrieved 2021 12 06 Apollo Proton Centre gets JCI accreditation The Hindu Special Correspondent 2020 07 04 ISSN 0971 751X Retrieved 2021 12 06 a href Template Cite news html title Template Cite news cite news a CS1 maint others link Israel to Establish National Center for Proton Radiation Cancer Therapy Programme for the implementation of proton therapy in the Spanish public health system Manchester and London proton beam therapy units confirmed Press release Press Association Cancer Research UK 1 August 2013 Ashya King case What is proton beam therapy BBC news story with NHS England figures 31 August 2014Further reading EditGreco C Wolden S Apr 2007 Current status of radiotherapy with proton and light ion beams Cancer 109 7 1227 1238 doi 10 1002 cncr 22542 PMID 17326046 S2CID 36256866 Use of Protons for Radiotherapy A M Koehler Proc of the Symposium on Pion and Proton Radiotherapy Nat Accelerator Lab 1971 A M Koehler W M Preston Protons in Radiation Therapy comparative Dose Distributions for Protons Photons and Electrons Radiology 104 1 191 195 1972 Bragg Peak Proton Radiosurgery for Arteriovenous Malformation of the Brain R N Kjelberg presented at First Int Seminar on the Use of Proton Beams in Radiation Therapy Moscow 1977 Austin Seymor M J Munzenrider et al Fractionated Proton Radiation Therapy of Cranial and Intracrainial Tumors Am J of Clinical Oncology 13 4 327 330 1990 Proton Radiotherapy Hartford Zietman et al in Radiotheraputic Management of Carcinoma of the Prostate A D Amico and G E Hanks London UK Arnold Publishers 61 72 1999 External links Edit Wikimedia Commons has media related to Proton therapy The Intrepid Proton Man educational comic books by Steve Englehart and Michael Jaszewski for pediatric patients 2019 BBC Horizon documentary 2019 Jove video by the University of Maryland School of Medicine explaining the treatment process Proton Therapy Delivery and Its Clinical Application in Select Solid Tumor Malignancies 2019 The NHS Proton Beam Therapy Programme Proton Therapy Collaborative Group PTCOG Alliance for Proton Therapy CARES Cancer Network National Association for Proton Therapy American Society for Radiation Oncology Model Policy Proton Beam Therapy Proton therapy MedlinePlus Medical Encyclopedia Proton Therapy What is Proton Therapy Retrieved from https en wikipedia org w index php title Proton therapy amp oldid 1146499555, wikipedia, wiki, book, books, library,

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