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How Effective Is Proton Beam Therapy For Prostate Cancer

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When Will Proton Beam Therapy Be Available To Nhs Patients In The Uk

Proton Therapy for Prostate Cancer

Proton beam therapy has been available to UK patients since 2008 through the NHS-funded overseas programme, and The Clatterbridge Cancer Centre has treated patients with rare eye cancers with low-energy protons for many years.

The Christie is the first NHS high-energy PBT centre in the UK as part of a £250m programme for a national PBT service. A second PBT centre is also currently being built at University College London Hospitals NHS Foundation Trust. The new facility is due to open in 2020 with the PBT service ramping up in 2021.

Who Operates The Equipment

With backgrounds in mechanical, electrical, software, hardware and controls, specialized operators maintain, upgrade and repair the accelerators and radiation delivery system. As with other forms of external beam radiation therapy, such as intensity-modulated radiation therapy , specially trained radiation therapists will be present in the treatment rooms to help patients get set up for treatment, deliver the treatment, and monitor patients closely to ensure safety and comfort during the procedure. See the IMRT page for more information.

Proton Radiation Therapy For Prostate Cancer

editorial processDoru Paul, MD

Doru Paul, MD, is triple board-certified in medical oncology, hematology, and internal medicine. He is an associate professor of clinical medicine at Weill Cornell Medical College and attending physician in the Department of Hematology and Oncology at the New York Presbyterian Weill Cornell Medical Center.

Proton radiation is an enhanced type of radiation gaining in popularity for the treatment of prostate cancer. Men who are contemplating proton radiation need to compare and contrast it with all the other types of radiation to determine if proton therapy is advantageous for them in view of their specific circumstances.

A full course of proton radiation requires five treatments per week continued for eight or nine consecutive weeks. During each visit, patients are positioned in front of an invisible beam of protons that target the prostate gland.

The Truth About Protons

The illustration above was adopted from a prominent U.S. proton facility. Note the inability to target specific tumor sites within the prostate gland to higher dose levels while lacking the ability to minimize doses to the urethra. Protons can also not be utilized to target lymph nodes.

Proton-beam vs Intensity-Modulated Radiation Therapy: Which is best for treating Prostate Cancer? Here are two recently published articles: Prostate Cancer Therapy Too Good to Be True Explodes Health Cost by Robert Langreth on March 26th 2012 explores increasing numbers of breathtakingly expensive proton beam facilities across the country and their questionable treatment efficacy related to favorable reimbursement.To read the complete article, The June 2008 issue of Oncology Journal presents the most current assessment of the heated battle between protons and photons. The article is authored by radiation oncologists at Harvard Medical School, the first institution in the world to utilize proton therapy . The abstract follows:

To read the complete article,

Prostate Cancer Stages& Treatment

What are the disadvantages of getting proton therapy for ...

The stage of prostate cancer is one of the most important factors in selecting treatment. Depending on the stage, combined treatments of surgery, radial prostatectomy, brachytherapy, hormone therapy, chemotherapy and radiation therapy may be needed for some prostate tumors. Treatment options also are affected by the type of prostate cancer, age, overall health and personal preferences.

What Is Proton Therapy For Prostate Cancer

Proton therapy for prostate cancer is a treatment option that involves using a focused ray of proton particles to destroy cancerous tissues. The treatment is capable of delivering precise, high doses of radiation to accurately target cancer cells without causing damage to healthy tissue surrounding the prostate.

Proton therapy improves the quality of life for prostate cancer patients and survivors by offering a number of compelling benefits:

  • It is non-invasive and therefore painless
  • It is more accurate than other kinds of radiation
  • Full or higher doses of radiation can be used for treatment without damaging healthy tissues and organs
  • Treatment is provided in an outpatient setting
  • Proton radiation therapy does not require recovery time
  • The treatment has little to no impact on a patients energy level
  • Proton therapy poses minimal risk of impotency
  • The treatment has lower risk of side effects compared with conventional treatment.

How Do I Prepare For Proton Therapy

Proton therapy facilities are growing in number, but the treatment is still not available everywhere. Your doctor can let you know if theres a proton treatment center near you. If there is, there are a few things to think about in advance.

Treatment usually means going in five days a week for four to eight weeks, so youll want to clear your calendar. Although the actual treatment only takes a few minutes, you should probably block 45 minutes to an hour for the whole procedure.

Before you start treatment, youll have an initial consultation so the radiation team can get set up for future visits. Using a series of images and other data, theyll determine exactly how youll need to be positioned during therapy. It may involve the use of customized immobilization devices. This can be an involved procedure, but its necessary to ensure that protons are delivered precisely to improve your outlook.

No other preparation is necessary.

Protons Versus Photons: Which Is State Of The Art

Many people believe that proton therapy causes significantly fewer complications than does traditional external radiation therapy , which utilizes photons. However, the newest technology in external radiation therapy with photons surpasses both proton therapy and traditional external radiation therapy. It is called 4 Dimensional Image Guided Intensity Modulated Radiation Therapy with Dynamic Adaptive Radiotherapy . This advanced technology allows for inverse treatment planning utilized for the initial IMRT planning phase. Inverse treatment planning provides the oncologist with the ability to plan for and control the amount of radiation received by the tissues surrounding the prostate while maximizing the dose to the prostate. Thereafter, a number of technological advances, including but not limited to SonArray, Cone Beam Tomography, Exact Couch , Portal Vision, On-Board Imaging, and Respiratory Gating are combined to allow for the analysis of organ motion in real-time to achieve unsurpassed accuracy. Once the motion is detected, numerous software programs activate to adapt the radiation to target the organ site which may have moved. This is true Dynamic Adaptive Radiotherapy . Using gating technologies, 4D IG-IMRT can even hit a continually moving target! This ability to optimize and adapt to changes is the basis for DART. None of this is even remotely possible with protons.

What Is Proton Therapy

Is Proton Radiation Safer or More Effective than Other Radiation for Localized Prostate Cancer?

Proton therapy is a branch of radiation treatment. It works like radiation therapy and can treat different types of cancer. Similar to radiation therapy, proton therapy can be a standalone therapy against cancer. However, in most cases, it is combined with additional methods to fight off cancer cells.

To understand proton therapy, it is essential to understand the basics of radiation therapy.

In conventional radiotherapy, you have high-energy X-rays passing through the body. The X-ray radiation is placed in the area where cancer is. Thus, it should destroy cancer tissue. But in doing so, normal tissue is also destroyed or similarly affected.

In prostate cancer, placing a radiation beam targeting the prostate gland exposes the rectum, the bladder, and other organs. As such, external beam radiation therapy complications include urinary symptoms, rectal bleeding, diarrhea, and more.

In an attempt to solve this problem, intensity-modulated radiation therapy was developed. It is known to cause less damage to surrounding tissues. Another option is using proton therapy treatment, which delivers radiation traveling in proton beams.

Developing The Uk Proton Beam Therapy Service

The government committed £250 million capital investment for both NHS proton beam therapy centres. This includes the buildings and PBT cyclotron and gantries, providing 6 NHS treatment rooms .

Both Trusts have more information about the new proton beam therapy centres on their websites. This includes information on the clinical facilities, their location and, for UCLH, progress on construction.

Hifu Treatment For Prostate Cancer

HIFU also known as High Intensity Focused Ultrasound and CyberKnife Radiation Therapy are both used to treat prostate cancer and are alternatives to surgery or other types of radiation therapy.

What You Need to Know About HIFU for Prostate Cancer

· Not FDA Approved in U.S. to Treat Prostate Cancer ONLY FDA Approved for Prostate Tissue Ablation

· Touted as Non-invasive, however it is Minimally Invasive

· Requires Anesthesia

· Not Covered by Most Insurance Companies

· No Long Term Studies to Determine Safety and Effectiveness

HIFU is NOT FDA approved to treat prostate cancer. The Center for Devices and Radiological Health at the FDA reports that HIFU was approved recently for prostate tissue ablation , it has never been approved in the U.S. to treat prostate cancer.

How the HIFU Procedure Works

HIFU is considered a minimally invasive procedure for the treatment of low-risk, localized prostate cancer and for prostate cancer recurrence in the prostate gland. HIFU is an option for men who are not candidates for open surgery or dont want to undergo surgery or radiation therapy.

HIFU uses high-intensity sound waves to heat and destroy cancer cells. It is not indicated for cancer that has spread beyond the prostate.

Heres what happens: At the start of the HIFU procedure, a catheter is inserted through the penis into the bladder to catch urine during the procedure and remains in place for 1 to 3 weeks after surgery.

Potential side effects include:

Symptoms include:

Proton Therapy Is Proven To Enhance Quality Of Life

According to a national survey, patients who received proton therapy to treat their prostate cancer reported experiencing a better quality of life with regard to urinary and bowel function during and after proton therapy, compared to those who received traditional radiation. Additionally, more than 70% of prostate cancer patients who received proton therapy noted the treatment had no impact on their quality of life overall.

Two studies conducted by the University of Texas confirm that patients who receive proton therapy treatments for prostate cancer show an improved quality of life compared to those who choose other treatment options.

In general, patients are interested in learning how they will do compared to those treated with other modalities, but, more importantly, they want to know how they are going to do, relative to their own normal state of health, said Andrew K. Lee, M.D., who led both studies. With such a large data set, this study offers us a guide to have that discussion with patients considering proton therapy.

97% of survey respondents who chose proton therapy treatment for their prostate cancer said they would recommend it to other patients, as well.

Pacemakers And Implantable Cardiac Devices

Proton Therapy for Prostate Cancer

Proton beam therapy may cause fewer side effects than standard radiotherapy. This is because normal cells are exposed to less radiation. The possible side effects will depend on:

  • the area of your body being treated and what structures are close by
  • the amount of proton beam therapy you have
  • other treatments you are having, such as chemotherapy.

Below are some of the side effects of proton beam therapy. They will not affect everyone who has this treatment. Your cancer doctor, specialist nurse or radiographer will explain any possible side effects to you before you start treatment. It is important to tell them about any side effects you get.

Advantages Of Proton Therapy For Prostate Cancer

Proton therapy has proven to show remarkable promise and advantages over conventional therapy-especially in the treatment of prostate cancer. Proton radiation therapys accuracy and the control it gives physicians in terms of adapting treatment make it a non-invasive and low-risk option for prostate cancer treatment.

How Do I Know If I Am A Candidate For Proton Therapy

The key to proton therapy is to know when it truly is the best treatment option. The medical care team at MSK has experience and access to every form of modern radiation therapy and will recommend proton therapy when it is truly the best choice for the patient. 

To find out if you might be a candidate for proton therapy, you can call 800-525-2225.

How Is The Procedure Performed

Proton beam therapy is typically performed on an outpatient basis. For most tumor sites, a standard course of treatment is two to eight weeks, with treatments delivered five days per week. The length of each treatment will vary depending upon the tumor type and stage. The delivery of the proton beam to the patient lasts only a few minutes, although the total time spent in the treatment room will be longer for positioning and adjustments to the equipment settings.

For daily treatments, the patient enters the treatment room and is fitted with his or her personal immobilization device. The patient is positioned with the aid of laser lights to within a few millimeters of the needed position, which by comparison with images obtained at the time of simulation to ensure the patient is properly aligned. In some cases, a cone beam CT system will be used to image the target before each treatment. This special alignment and imaging process is repeated before each treatment to assure the highest precision.

Entrance And Exit Dose Defined

Hydrogel improves treatment process for prostate cancer patients undergoing proton therapy treatment

Entrance dose: The dose of radiation that inadvertently makes contact with normal cells before it reaches the cancerous tissue.

Exit dose: Imagine the radiation hitting the tumor, but then continuing on beyond it, taking out normal cells in its path.

The primary difference between proton therapy and Cyberknife is that protons do not have an exit dose, says Dr. Cavanaugh. Both modalities deliver entrance and target dose.

Many insurers have been unimpressed with the differences in outcomes with proton therapy and have declined to pay.

For many patients I prefer HDR brachytherapy to both proton and Cyberknife therapy. HDR stands for high dose rate.

There Is One Marked Difference Between Proton Beam Radiation And Cyberknife

men with prostate cancer are understandably concerned over which treatment modality will be most effective.

Both protons and cyberknife involve precision delivery of radiation therapy, says Sean Cavanaugh, MD, Chief of Radiation Oncology, Cancer Treatment Centers of America at Southeastern Regional Medical Center.

In general, radiation therapy involves delivering the desired target dose to the tumor as well as undesired entrance and exit dose across healthy tissue, continues Dr. Cavanaugh.

In other words, more conventional radiation causes a so-called collateral damage. Think of a bomb being set off in a little town to get rid of dangerous criminals but the good guys will get blasted too.

When Is Proton Beam Therapy Used

Proton beam therapy is not suitable for everyone.

It is used to treat children, teenagers and young adults, because their normal cells are still developing. It can be better for these groups than standard radiotherapy, because it:

  • reduces the risk of damage to developing cells
  • helps prevent long-term problems.

It can also be used to treat adults with cancers:

  • that can be difficult to treat because of where they are in the body
  • that are in a position where the side effects of standard radiotherapy would cause serious problems
  • where there is a high risk of late side effects from standard treatments
  • that do not respond well to standard radiotherapy and would need a very high dose of treatment to be effective
  • that have come back after being treated with standard radiotherapy.

Proton beam therapy may be given on its own or in combination with other treatments. For example, it may be given with surgerystandard radiotherapy and chemotherapy.

Proton is still quite a new treatment in the UK. Research is needed to find out more about its long-term benefits and side effects, and to compare it with standard treatments.

It is also important to remember that when treating most types of cancer, standard radiotherapy is a very effective and safe treatment. Standard radiotherapy can cause side effects, but they usually get better when the treatment has finished. Long-term side effects are uncommon.

My Father Underwent Proton

My father underwent Proton Treamtent at Loma Linda back in 1997. He is doing fine today with no cancer reccurance.At time of treatment his was an overall Gleason 6. They gave him both Proton treatments and then some regular radiation treatments at Loma Linda. This was in the early days of proton and they were trying different methods to determine what worked best.

His sides effects at the time were urgent, frequent need to urinate. Mucus discharge from the bowell, tiredness and about 5 years post treatment the loss of erection ability. He will turn 80 this August.

Was it the proton center that made the reccomendation to you?

Larry

Proton Therapy Vs Traditional Radiation

Shorter courses of proton therapy can be just as effective ...

Proton therapy is particularly beneficial for men with high-risk prostate cancer that has spread or is at risk of spreading to the lymph nodes. Compared to conventional treatment, proton therapy can deliver high radiation doses to the lymph nodes while better sparing the healthy bowel and bladder.

Additionally, prostate tumors treated with proton therapy reduce the risks of secondary cancers in the treated areas. Proton therapy is also effective in treating patients with prostate cancer that has returned after previous radiation therapy or prostatectomy.

Proton therapy is outpatient, noninvasive and totally painless. The majority of patients continue on as normal, without having their quality of life throughout treatment impacted by their proton therapy. Entire treatment courses in only five days with proton SBRT and novel clinical trials are offered to appropriate candidates.

I Am A Uk Resident Living In One Of The Devolved Administrations Can I Receive Nhs Funded Proton Beam Therapy At The Christie

The NHS in England is a residence-based system, unlike many other countries, which have insurance-based healthcare systems. This means that visitors to England may have to pay for NHS healthcare, depending on their circumstances.

The devolved administrations, Scotland, Wales and Northern Ireland can access proton beam therapy at The Christie if the respective administrations approve it.

Further information can be found at NHS Choices.

Latest Clinical Studies Of Pbt

The dosimetry advantage of protons over photons has already been established . However, do the potential advantages of the proton beam significantly transfer into clinical benefits for patients? Can the advanced techniques such as 360° rotational gantries and intensity-modulated proton therapy further minimize toxicity and/or improve the clinical outcome? To date, there is not enough evidence to answer these questions due to small cohorts of patients in most published studies and the limited prospective data of comparisons between proton and photon radiotherapy. In this part, we present the clinical experiences and studies in the past few years, which may be provide a valuable understanding of the true value and advantage of PBT.

How Proton Therapy Works

A machine called a synchrotron or cyclotron speeds up protons. The high speed of the protons creates high energy. This energy makes the protons travel to the desired depth in the body. The protons then give the targeted radiation dose in the tumor.

With proton therapy, there is less radiation dose outside of the tumor. In regular radiation therapy, x-rays continue to give radiation doses as they leave the person’s body. This means that radiation damages nearby healthy tissues, possibly causing side effects.

What Types Of Radiotherapy Are There

Proton Therapy for Prostate Cancer

There are two common types of external beam radiotherapy:

  • intensity-modulated radiotherapy
  • 3-dimensional conformal radiotherapy .

Intensity-modulated radiotherapy

This is the most common type of external beam radiotherapy in the UK. A computer uses the scans from your radiotherapy planning session to map the location, size and shape of your prostate. The radiotherapy machine gives beams of radiation that match the shape of the prostate as closely as possible. This helps to avoid damaging the healthy tissue around it, reducing the risk of side effects.

The strength of the radiation can be controlled so that different areas get a different dose. This means a higher dose of radiation can be given to the prostate without causing too much damage to surrounding tissue.

3D conformal radiotherapy

As with IMRT, the radiation beams are mapped to the size, shape and position of the prostate. But the strength of the radiation cant be controlled in 3D-CRT, so all areas are treated with the same dose.

IMRT is now the standard type of external beam radiotherapy for prostate cancer in most hospitals, but some still use 3D-CRT. They are both effective ways of treating prostate cancer. Ask your doctor or radiographer which type of radiotherapy youre being offered.

Other types of radiotherapy

Stereotactic radiotherapy

Proton beam therapy

Read more about clinical trials. Or to find out about taking part in a clinical trial, ask your doctor or nurse, or speak to our Specialist Nurses.

Effectiveness And Toxicity: Reviewing The Literature

Although PBT has generated much enthusiasm, its utility can be best confirmed by clinical trials. Unfortunately, there are no randomized trials completed that directly compare 3D-CRT or IMRT with PBT, and thus we must rely mainly on single-arm studies.

Loma Linda University Medical Center was the first center to open a hospital-based proton facility in 1990, and reported the first large single-arm experience. The authors analyzed 1255 patients, 731 of whom received 3D-CRT plus a boost with PBT and 524 of whom received PBT only. Included were patients with low-, intermediate-, and high-risk prostate cancer. Using American Society for Therapeutic Radiology Oncology consensus criteria, the 5- and 8-year biochemical failure free survival was 75% and 73%, respectively. More importantly, there were very low rates of Radiation Therapy Oncology Group grade 3 or higher morbidity: 1% genitourinary and 0.2% GI. To put these numbers in perspective, patients treated with IMRT at our institution had 6% GU and 1% GI grade 3 or higher morbidity.

Who Is A Good Candidate

In most cases, you will be a good candidate for proton therapy if you were initially offered radiotherapy as an option. Patients who receive radiotherapy usually have no problems being a candidate for proton treatment. They are usually patients in an early stage or those with localized prostate cancer. It is also useful to keep advanced cancer under control for as long as possible and treat recurrent prostate cancer cases.

However, some patients may not benefit from proton therapy if they have one of these problems :

  • In patients with hip replacements, because proton beams often cant reach beyond the prosthesis. In some proton therapy centers, these patients can still get a session when a hip replacement is limited to one side. But bilateral replacement makes it impossible to treat the patient with proton beam therapy.
  • In patients with advanced prostate cancer in which treating the pelvic lymph nodes is fundamental. Since proton beam radiation is less likely to reach other tissues than the prostate, it is not applicable when treating surrounding lymph nodes.
  • In overweight patients, because the proton beam can only go through a determined depth. This depth depends on the beams energy, and some centers may have a higher energy device that solves the problem.

Hdr Brachytherapy: What It Is

This technology does away with entrance and exit doses because the radiation is released after a pellet is placed inside of, or very near to, the prostate cancer mass. This is why this form of treatment is often called seed.

HDR brachytherapy is tightly focused on tumors to minimize serious side effects, says the CTCA site.

Exposure of radiation to the surrounding benign tissue is minimized, while the maximum dose is delivered to malignant cells.

Safety And Efficacy Of Proton Therapy

Proton Therapy For Prostate Cancer Criticized

Many people with locally advanced cancers are treated with a combination of chemotherapy and either traditional or proton radiation. For patients getting chemotherapy and radiation at the same time, finding ways to limit side effects without making the treatment less effective is a high priority, Dr. Baumann said.

He and his colleagues analyzed data from nearly 1,500 adults with 11 different types of cancer. All participants had received simultaneous chemotherapy plus radiation at the University of Pennsylvania Health System between 2011 and 2016 and had been followed to track side effects and cancer outcomes, including survival. Almost 400 had received proton therapy and the rest received traditional radiation.

Those who received proton therapy experienced far fewer serious side effects than those who received traditional radiation, the researchers found. Within 90 days of starting treatment, 45 patients in the proton therapy group and 301 patients in the traditional radiation group experienced a severe side effectthat is, an effect severe enough to warrant hospitalization.

In addition, proton therapy didnt affect peoples abilities to perform routine activities like housework as much as traditional radiation. Over the course of treatment, performance status scores were half as likely to decline for patients treated with proton therapy as for those who received traditional radiation.

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