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Latest proton therapy study shows hypofractionated proton therapy as safe and effective for patients with low-risk prostate cancer

A study published in August 2019 in the International Journal of Particle Therapy by Dr. Slater and his team, highlights the results of their latest phase I/II hypofractionated proton therapy study at Loma Linda University Hospital.

Prostate cancer is the most commonly diagnosed cancer in men, and many of these patients have low-risk, early disease. Prostate cancer at these stages remains highly treatable with local control rates over 90% and very low rates of late morbidity commonly reported for a variety of treatment modalities. The focus then turns to the avoidance of unnecessary negative treatment-related side effects that can occur, particularly through the use of conventional treatments such as surgery and x-ray (conventional) radiotherapy.

Proton radiation therapy has demonstrated itself to be an excellent option for low-risk prostate cancer as it delivers high control rates with very little toxicity. Proton beam thereby enhances the physician’s opportunity to minimise risks for the patient.

Hypofractionation is the process of delivering higher doses of radiation per fraction, but using fewer daily fractions. Doctors and physicists at Loma Linda University have successfully used hypofractionated proton therapy for several diseases, including cancers of the breast, lung, and liver. In each instance, control and survival rates have been maintained and unwelcome side effects have not increased. This experience prompted the medical team at Loma Linda to investigate hypofractionation for prostate cancer.

The purpose of the study was to determine whether a hypofractionated proton radiotherapy regimen can control early-stage prostate cancer while maintaining low rates of side effects similar to results obtained using standard-fraction proton radiotherapy.

A cohort of 146 patients with low-risk prostate cancer (Gleason score 7, prostate-specific antigen 10, tumor stage of T1–T2a) received 20 fractions of proton therapy (3.0 Gy per fraction over 4 weeks). Patients were evaluated at least weekly during treatment, at which time documentation of treatment tolerance and acute reactions was obtained. Follow-up visits were conducted every 3 months for the first 1 years, every 6 months for the next 3 years, then annually. Follow-up visits consisted of history and physical examination, PSA measurements, and evaluation of toxicity.

The 3-year biochemical progression-free survival rate was 99.3%, and the 5-year biochemical progression-free survival was 97.9%.

In conclusion, this study showed that hypofractionated proton therapy (60 Gy in 20 fractions) was safe and effective for patients with low-risk prostate cancer. A prospective multi-institutional randomised study is currently being conducted to confirm these results.

Sources:

Kil WJ, Nichols RC Jr, Hoppe BS, Morris CG, Marcus RB Jr, Mendenhall W, Mendenhall NP, Li Z, Costa JA, Williams CR, Henderson RH. Hypofractionated passively scattered proton radiotherapy for low- and intermediate-risk prostate cancer is not associated with post-treatment testosterone suppression. Acta Oncol. 2013;52:492–7

Mendenhall NP, Hoppe BS, Nichols RC, Mendenhall WM, Morris CG, Li Z, Su Z, Williams CR, Costa J, Henderson RH. Five-year outcomes from 3 prospective trials of image-guided proton therapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2014;88:596–602

Mendenhall NP, Li Z, Hoppe BS, Marcus RB Jr, Mendenhall WM, Nichols RC, Morris CG, Williams CR, Costa J, Henderson R. Early outcomes from three prospective trials of image-guided proton therapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2012;82:213–21

Shipley WU, Verhey LJ, Munzenrider JE, Suit HD, Urie MM, McManus PL, Young RH, Shipley JW, Zietman AL, Biggs PJ, Heney NM, Goitein M. Advanced prostate cancer: the results of a randomized comparative trial of high dose irradiation boosting with conformal protons compared with conventional dose irradiation using photons alone. Int J Radiat Oncol Biol Phys. 1995;32:3–12

Slater JD, Rossi CJ Jr, Yonemoto LT, Bush DA, Jabola BR, Levy RP, Grove RI, Preston W, Slater JM. Proton therapy for prostate cancer: the initial Loma Linda University experience. Int J Radiat Oncol Biol Phys. 2004;59:348–52

Slater JD, Rossi CJ Jr, Yonemoto LT, Reyes-Molyneux NJ, Bush DA, Antoine JE, Miller DW, Teichman SL, Slater JM. Conformal proton therapy for early-stage prostate cancer. Urology. 1999;53:978–84

Slater JD, Yonemoto LT, Rossi CJ Jr, Reyes-Molyneux NJ, Bush DA, Antoine JE, Loredo LN, Schulte RW, Teichman SL, Slater JM. Conformal proton therapy for prostate carcinoma. Int J Radiat Oncol Biol Phys. 1998;42:299–304

Slater JM, Slater JD, Kang JI, et al. Hypofractionated Proton Therapy in Early Prostate Cancer: Results of a Phase I/II Trial at Loma Linda University. Int J Part Ther. 2019;6(1):1–9. doi:10.14338/IJPT-19-00057

Zietman AL, Bae K, Slater JD, Shipley WU, Efstathiou JA, Coen JJ, Bush DA, Lunt M, Spiegel DY, Skowronski R, Jabola BR, Rossi CJ. Randomized trial comparing conventional-dose with high-dose conformal radiation therapy in early-stage adenocarcinoma of the prostate: long-term results from Proton Radiation Oncology Group/American College of Radiology 95-09. J Clin Oncol. 2010;28:1106–11

Proton Therapy for Central Nervous System Leukaemia

The guidelines issued by the International Lymphoma Radiation Oncology Group (ILROG) open up new opportunities for the use of proton radiotherapy in leukaemia.

ILROG’s recommendations newly apply also to patients with initial involvement of CNS (positive finding in the cerebrospinal fluid) or patients with a relapsed disease related to CNS who are planned for allogeneic transplantation or have CNS involvement and do not respond to chemotherapy or biological treatment. If patients diagnosed with leukaemia have infiltration of their central nervous system (CNS) or extramedullary involvement (myelosarcoma) and their attending hematologist-oncologist recommends radiotherapy, proton therapy is a suitable choice. This is confirmed both by the newly updated recommendations of the international expert group ILROG, and dosimetric comparisons of the existing forms of available radiotherapy.

In such cases, proton radiotherapy has substantial benefits when compared with other forms of radiotherapy. These include no radiation strain on organs in front of vertebral bodies and minimal systemic toxicity (reduced occurrence of nausea, vomiting, diarrhoea). Proton radiotherapy is suitable for highly pre-treated patients (patients after a few rounds of chemotherapy) with necessary reduction of the dose to which the lungs, intestinal villi, heart and other organs are exposed.

Interview with Dr Kateřina Dědečková on the possibilities of treatment of hematologic diseases with proton radiotherapy

According to the latest recommendations of the International Lymphoma Radiation Oncology Group (ILROG), radiotherapy is also suitable for some patients diagnosed with leukaemia. Which patients specifically?

ILROG is very active in raising awareness on the benefits of radiation in the treatment of hematological malignancies, i.e. blood tumours. Over the past few years, ILROG has issued recommendations for the use of radiation in most haematologic cancers such as lymphomas, leukemias, myelosarcomas, myelomas, and others. For leukemias, in particular patients with central nervous system (CNS) involvement, it is now recommended to use radiation more frequently and to a greater extent.

Why is it now advisable to irradiate the central nervous system (CNS) also in patients with leukaemia?

The CNS (i.e. brain and spinal cord) is separated from the bloodstream by a safety barrier, called blood–brain barrier (BBB), which prevents materials from the blood from entering the brain. Thus, some molecules, including drugs, reach the CNS with limited or no effect. For this reason, in some cases, the CNS may be a source of disease recurrence because part of the cells escape the effects of chemotherapy or biological therapy, leading to a re-spread of cancer cells in the body.

What benefits do patients have from using proton radiotherapy?

Due to the limited possibilities of systemic treatment, irradiation of the entire CNS area is advantageous. This consists of the irradiation of the brain, spinal cord, spaces where cerebrospinal fluid circulates, and craniospinal axis. The aim is also to get to the hard-to-reach leukaemia cells, as well as those that are no longer sensitive to chemotherapy or biological therapy.

Patients who benefit the most from proton radiotherapy are the ones who, despite intensive systemic treatment, have a positive finding of leukemic cells in the cerebrospinal fluid, a positive cerebrospinal fluid at the time of diagnosis, or leukemic lesions in the brain or spinal cord. Also, patients who are at risk of involvement of the central nervous system future.

Therefore, according to the new recommendations, these patients should preferably be irradiated in the whole area of ​​the craniospinal axis.

Is radiotherapy commonly indicated in these patients or is it a new recommendation?

Previously, because of the high toxicity, it was preferable to irradiate only the skull area. However, thanks to the use of proton radiotherapy instead of classical radiation, it is possible to reduce the adverse effects of treatment that previously impaired quality of life, such as nausea, vomiting, fatigue, swallowing pain, and aphthae in the oral cavity. Therefore, radiotherapy has not been commonly used in these patients and, if so, less extensive exposure has been used, mainly because of concerns about toxicity associated with older exposure techniques, as I have mentioned. Irradiation of the CNS as a risk area has been found to improve the outlook for cure in risk patients. According to the new ILROG recommendation, groups of patients have already been identified who will benefit from the inclusion of craniospinal axis irradiation in their treatment plan.

How does the treatment work?

The patient is placed in supine position with their arms along the body, while the head is fixed with a special thermoplastic mask. A CT scan is done over the entire irradiation range, i.e. the entire head and spine to the coccyx. These CT images then show the areas that are the target of radiation and also the areas that we want to protect from radiation, called organs at risk (OAR). Then, the doctors and physicists collaborate to carefully calculate the irradiation plan. This plan is then checked multiple times, as well as directly in the gantry to confirm its accuracy. Then, the actual treatment begins. Leukaemia is typically treated in 9 to 12 sessions (fractions), applied to the entire craniospinal axis. In some patients, we also irradiate the riskiest areas, such as apparent tumor lesions, up to a total of 15-18 fractions. Irradiation takes place every weekday and may be associated with mild swallowing difficulties, fatigue and a decrease in the number of blood cells.

Is there a difference if a patient is irradiated with photon or proton techniques?

Yes, the difference is that when using proton radiotherapy, the patient is less exposed to radiation. There is less irradiation to the organs in front of the tumor, minimal irradiation to lungs, heart, oesophagus, intestinal loops, kidneys, liver, and bladder, which significantly reduces the possibility of late toxicity of these organs. The patient also better tolerates irradiation of the craniospinal axis.

Do you have any recent experience with this form of treatment? If so, how did the patients tolerate the treatment?

At the Proton Therapy Center in Prague we already have experience with this irradiation technique for hematological malignancies, although there has been a relatively small number of patients (around 10 so far). Our experience so far has so far been very positive, both in terms of toxicity and preliminary treatment outcomes. In some of these patients, radiotherapy was the last treatment option and even here we managed to successfully destroy CNS tumor cells. From our point of view this is a very promising method of treatment, but a longer follow-up of patients and evaluation of a larger group of patients will be required.

Dr Kateřina Dědečková

In 1998-2001 Dr Dědečková worked at the radiotherapy department of the District Hospital in Jičín. Then, from 2001 to 20017, she worked at the Institute of Radiation Oncology of the University Hospital Na Bulovce. In 2009 Dr Dědečková gained specialised competence in the field of radiation oncology. Since 2012, she has been working as a radiation oncologist at the Proton Therapy Center in Prague. Since 2019, Dr Dědečková also leads the interdisciplinary Center of Excellence for Proton Radiotherapy of Malignant Lymphomas at the Proton Center in Prague.

Dr Dědečková specialises in radiation treatment of malignant lymphomas and other hematological tumours, urological tumours and head and neck tumours. She has participated in international clinical trials with independent quality control of radiotherapy (GHSG, ESTRO Equal, QARC) in the treatment of malignant lymphomas and head and neck tumours. Dr Dědečková is a member of the Council of the International Lymphoma Radiation Oncology Group (ILROG) and a member of the Lymphoma Sub-Committee of the Particle Therapy Co-Operative Group (PTCOG). Dr Dědečková publishes professional medical press and lectures at congresses, both domestically and internationally. Dr Dědečková is co-author of the “Diagnostic and Treatment Guidelines in Patients with Malignant Lymphoma” of the Lymphoma Cooperative Group (chapter on lymphoma radiotherapy). Dr Dědečková deals with new techniques of lymphoma radiotherapy, such as proton radiotherapy of mediastinal lymphomas using the pencil beam scanning technique in maximum inhalation.

New study shows proton therapy more effective than conventional radiotherapy in the treatment of intrahepatic cholangiocarcinoma (ICC)

In a recent study by the Massachusetts General Hospital Department of Radiation Oncology, the use of proton therapy for intrahepatic cholangiocarcinoma (ICC) was shown to more effectively control the cancer and improve the chances of survival – particularly in comparison to conventional (photon) radiotherapy.

Cholangiocarcinoma is a cancer that develops in the cells within the bile ducts; both inside and outside the liver. The terms cholangiocarinoma and bile duct cancer are often used to refer to the same condition. This condition occurs slightly more often in males than females and usually affects people who are between 50-70 years old. Signs and symptoms of intrahepatic cholangiocarcinoma include jaundice, abdominal pain, fever, weight loss, weakness and itching. Treatment options may include surgery (when possible) to remove the bile duct and parts of the liver, chemotherapy and radiation.

In certain cases cholangiocarcinoma is an unresectable form of cancer. Unresectable cancer is defined as a cancer or tumour that cannot be removed completely through surgery. In these cases, radiotherapy and chemotherapy offer the best chances of survival.

The aim of this study was to evaluate outcomes for patients with unresectable intrahepatic cholangiocarcinoma (ICC) treated with hypofractionated proton or photon radiation therapy.

66 patients with unresectable intrahepatic cholangiocarcinoma were treated with hypofractionated proton (32 patients) or photon (34 patients) radiation therapy. Median radiotherapy (RT) dose was 58.05 Gy, all delivered in 15 daily fractions. On multivariate analysis for overall survival (OS), compared with photon RT, there was a trend towards improved survival with proton RT (HR 0.50; p = 0.05).

Median follow-up times from diagnosis and RT start were 21 months and 14 months, respectively. In total, five patients (7.6%) developed local failure. The 2-year outcomes were 84% local control (LC) and 58% OS. Among the 51 patients treated with definitive intent, the 2-year LC rate was 93% and the OS rate was 62%.

The study concluded that hypofractionated radiation therapy yields high rates of local control and is an effective modality to optimize biliary control for unresectable/locally recurrent ICC.

At the ESMO World Congress on Gastrointestinal Cancer 2019, it was identified that high dose radiotherapy in unresectable ICC should be considered as a viable treatment option, in combination with systemic therapy.

This study adds to the growing body of evidence suggesting proton beam therapy as a safe and effective treatment for patients with unresectable ICC. It is proposed therefore, that – pending further research – proton therapy be utilised as a curative treatment for ICC.

Sources:

Hong TS, Wo JY, Yeap BY, Ben-Josef E, McDonnell EI, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Goyal L, et al. Multi-institutional phase II study of high-dose Hypofractionated proton beam therapy in patients with localized, Unresectable hepatocellular carcinoma and intrahepatic Cholangiocarcinoma. J Clin Oncol. 2016;34(5):460–8

Ohkawa A, Mizumoto M, Ishikawa H, Abei M, Fukuda K, Hashimoto T, Sakae T, Tsuboi K, Okumura T, Sakurai H. Proton beam therapy for unresectable intrahepatic cholangiocarcinoma. J Gastroenterol Hepatol. 2015;30(5):957–63

Shimizu, S., Okumura, T., Oshiro, Y. et al. Clinical outcomes of previously untreated patients with unresectable intrahepatic cholangiocarcinoma following proton beam therapy. Radiat Oncol 14, 241 (2019)

Smart AC, Goyal L, Horick N, Petkovska N, Zhu AX, Ferrone CR, Tanabe KK, Allen JN, Drapek LC, Qadan M, Murphy JE, Eyler CE, Ryan DP, Hong TS, Wo JY. Hypofractionated Radiation Therapy for Unresectable/Locally Recurrent Intrahepatic Cholangiocarcinoma. Ann Surg Oncol. 2019 Dec 23. doi: 10.1245/s10434-019-08142-9 [Epub ahead of print]

Ustundag Y, Bayraktar Y. Cholangiocarcinoma: a compact review of the literature. World J Gastroenterol. 2008;14(42):6458–66

Gergana’s Osteosarcoma Cancer Story

Hello everyone!

My name is Gergana Mihaylova, but all my friends and family call me Gerry. I was born in Sofia, Bulgaria, on April 26, 1981 – it was Easter Sunday! I had a happy and healthy childhood, surrounded by love and attention. As I grew older, I learned that I could do anything with a lot of hard work and faith. I never give up! I love the beauty and music of life. I believe in miracles and that good things always come. I say all this because I think it is of great importance to the story that I am about to tell you.

It all started in the spring of 2017. A small swell appeared in my right temple. I thought it was a consequence of being hit. I had no complaints, but decided to consult it with a doctor anyway. And so my “adventure” began.
The various examinations I did showed that there was a problem, but I didn’t know how serious it was until the swelling started to increase in size to the point it “poured out” and changed the shape of my head.
My first surgery was performed in July by the neurosurgeons at Tokuda Hospital in Sofia. They removed a tumor that showed to be malignant. I was recovering very fast, all my examinations at that point were good, and I felt healthy. I sought the advice of a number of specialists and so I decided to go to Turkey for treatment. I was prescribed radiotherapy there. I passed this ordeal with the support of my family, friends and colleagues. My follow-up examinations showed that there was no trace of the tumour. So, after months of “walking through the pain”, I went back to work. Life went on!

But fate, or Providence, had prepared for me a nightmarish sequel.
In March 2019, during an MRI check, the radiologists noticed that something was out of place compared to my previous MRI. So it all started again from the beginning…
Two months of consultations, research, and a second operation in May – this time I chose Memorial Hospital in Istanbul. The histology report confirmed the diagnosis: osteosarcoma (a type of bone cancer).
I am grateful for the attention and attitude of the entire team and personally of Prof. Dr. Gökhan Bozkurt. It was him and Prof. Fazilet (radiology) who advised me to continue my treatment as soon as possible with proton therapy. Unfortunately, they did not have this technology. In Bulgaria, neither.

As soon as I got back to Sofia I started looking for information. I had all the necessary medical documentation translated to several languages, which I then sent to numerous European proton centres.
Naturally, I also continued with my control examinations. In less than three months the radiologists saw again a new “thing” growing.
An urgent third surgery followed and, a week later, a fourth smaller nasal aeration. Back in Turkey. Back in the same clinic. And again the same recommendation: EMERGENCY PROTON THERAPY!

My friend Vlado (Vladimir) was at the hospital with me all the time. His support has been fundamental and helped me maintain my composure and continue to follow my path optimistically.

Vlado and I started looking again, translating more documents and sending inquiries to all the countries we found to be performing proton therapy. We have received responses from several clinics, but one in particular stood out to us: the Proton Therapy Center in Prague. They always answered the fastest and in the most organized way. Not only via email, but also via phone: they always picked up the phone, which was of great importance to me because there was no TIME.

In early December, I visited the Proton Therapy Center for my initial consultation. From the meeting I had there with Dr. Haas, I realized that there was an opportunity to start proton therapy very quickly. However, I first had to obtain the S2 funding (I could not afford the treatment as self-payer). Both Czech Republic (where the clinic is located) and Bulgaria (where I come from) are EU members and the Bulgarian Health Insurance Fund is able to pay for treatment under this agreement.
I immediately submitted the necessary documents to the National Health Insurance Fund (NHIF) for the allocation of funds for treatment abroad. I had to submit, in addition to all my medical records, an offer from the relevant medical institution regarding the costs and duration of treatment. Again, all necessary documents were provided to me very quickly and accurately by the Proton Therapy Center.

I have received the approval for the S2 funding during Christmas! How not to believe in miracles!

Vlado and I arrived to Prague just before New Year’s. We were met at the airport by a car sent from the Proton Therapy Center. Prior to beginning treatment, it was necessary to prepare the radiotherapy plan, fixation mask, etc. This happened on 12/30/2019.
During this time, we met Petra and Susi – the girls who coordinated the whole process. I received information from them on everything, even about things beyond treatment! For example, I was invited to attend a gala evening organized by the Nadační Fond Onkologie. There were doctors, patients and healthcare professionals from the Czech Republic. I went with Petra and we had a lot of fun!

And so my treatment began …
The treatment sessions are short and painless, made with the latest and most modern equipment in the world. I had no side effects except for a slight skin redness in the irradiated area. Every week I had a check-up with Dr. Haas, who took care of me during the whole treatment. Every week I also had a control MRI which allowed the doctors to follow my progress very closely.
Dr. Haas always kept me up to date with my progress. I also had a meeting with Dr. Matz, physicist, who helped me better understand the treatment. He also showed me my treatment plan!

In conclusion, I can say that the extremely fast and adequate response I have received from the Proton Therapy Center, as well as the kindness of all people who took care of me there, definitely met my needs! One feels at ease here. In addition, Prague is a city full of fabulous beauty, which is a treat in its own!

Superior Intellectual Outcomes After Proton Radiotherapy Compared With Photon Radiotherapy for Pediatric Medulloblastoma

Proton Radiotherapy Preserves Intellectual Function in Children suffering from Medulloblastoma – New study shows that children treated with Proton Therapy have superior intellectual outcomes, compared to children treated with conventional photon/x-ray radiotherapy.

Radiotherapy is essential for treating children’s brain tumours – however conventional radiotherapy treatment increases the risk of permanent cognitive impairment. Memory problems, learning problems, global IQ decline, and other serious cognitive impairments can occur. A new study published in the Journal of Clinical Oncology on the 27th November 2019 has demonstrated the superiority of proton therapy over traditional x-ray/photon radiotherapy in treating paediatric Medulloblastoma.

Medulloblastoma is an invasive, rapidly growing form of tumour, and the most commonly occurring type of brain cancer in children. This study showed that the use of proton therapy in treating these cancers (instead of conventional photon/x-ray radiotherapy) resulted in significantly improved long-term intelligence outcomes in children.

This study provides the strongest evidence to date that proton therapy preserves the intellectual function of children with medulloblastoma – as opposed to traditional x-ray radiation which can cause damage and result in a lower quality of life for children following treatment. The authors of the study concluded:

“Even in the context of CSI (craniospinal irradiation), patients treated with PRT (Proton RadioTherapy) exhibited stable intellectual outcomes in most domains and experienced significantly better long-term outcomes in global IQ, perceptual reasoning, and working memory compared with patients treated with XRT (conventional x-ray radiotherapy).”

These results expand on previous research suggesting an intellect-sparing benefit of proton therapy in the treatment of paediatric brain tumors, reported Lisa S. Kahalley, PhD, of Texas Children’s Hospital (TCH) in Houston, and colleagues in the Journal of Clinical Oncology.

“It’s getting very difficult to argue that there isn’t a very strong clinical benefit associated with proton, so now it really becomes an access issue. We have to think really hard about ways to improve access to families that aren’t located near proton centres.”

The Proton Therapy Center in Prague has considerable experience treating children’s brain tumours with protons, and has treated many children suffering from medulloblastoma – including British child Ashya King, who received proton therapy at the Prague Proton Therapy Center after an international manhunt in 2014. Ashya’s story received widespread public attention, and his successful proton therapy treatment in Prague resulted in him having less risk of cognitive problems following treatment.

Valentine’s Day Ideas

Every year on 14th February millions of people celebrate Valentine’s day showing their compassion and love for the special people in their lives. When you think of how to express your love on this special day, you may think of flowers, fancy dinners, chocolate, and greeting cards, but this day might be harder to celebrate for those battling cancer. However, it is more important than ever to show your love and support during this time. Here are some ideas that may be a little more low key, but still have a big impact.

❤ Write a love note or poem – express your feelings in writing and let them know how much they mean to you.

❤ Plan an at-home movie night complete with take-away and their favourite snacks.

❤ Buy your loved one a journal so they can write down their emotions and challenges. You can also start your own journal and together write about daily topics or achievements.

❤ Help complete tasks on their to-do list. Cancer can be exhausting and your loved one may need help crossing off some items.

❤ Have a spa night – candles, lotion, face masks, essential oil and a Zen playlist will help set the atmosphere.

❤ Spend quality time with your loved one without any distractions such as electronics, live in the present.

❤ Plan a game night – try a new board game, play charades or have a small tournament with all your favourite games.

❤ Have your own private book club – is there a book you both wanted to read? Get two copies and spend the evening reading and discussing the book.

❤ Cook their favourite meal or recreate their favourite restaurant – sometimes going out can be exhausting so bring the experience to your home.

Are there any ideas that you think we should add to our list? Let us know in the comments ⬇

Extreme hypofractionated proton radiotherapy for prostate cancer using pencil beam scanning: Dosimetry, acute toxicity and preliminary results

Prague Proton Therapy Medical Team Publishes their Latest Results, Using Proton Therapy to Treat Prostate Cancer.

Several treatment options exist for managing prostate cancer in men. Surgery and conventional radiotherapy have been shown to be equally effective at treating prostate cancer, however conventional treatments such as these can result in side effects that can reduce overall quality of life. Proton therapy is equally effective at treating prostate cancer, however causes less side effects, thereby preserving the quality of life of patients during and after treatment.

Proton therapy has been used to treat prostate cancer for over 25 years. Doctors at the Proton Therapy Center (PTC) in Prague have been treating prostate cancer with proton therapy since opening their facility in 2012. The Prague Proton Therapy Center uses the most advanced form of proton therapy available known as ‘Intensity-Modulated Proton Therapy’ (IMPT) – otherwise known as ‘Pencil-Beam Scanning’ (PBS). This highly accurate form of proton therapy allows high doses of cancer-killing proton radiation to be delivered to the tumour, while sparing healthy surrounding tissue from harm.

The PTC medical team have published their latest treatment findings, using IMPT proton therapy to treat prostate cancer. Their success in treating prostate cancer with proton therapy was published in the Journal of Medical Imaging and Radiation Oncology (the Official Journal of The Royal Australian and New Zealand College of Radiologists).

This study follows the progress of 200 prostate cancer patients that received an advanced and accelerated proton treatment program. The results show that this treatment is extremely effective at treating and removing prostate cancer. The research also shows that proton therapy for prostate cancer results in extremely low side effects. The PTC medical team was able to successfully remove the prostate cancer with almost no side effects using an accelerated, 2 week treatment schedule.

Side effects to the bladder and bowel are commonly reported among patients undergoing conventional radiotherapy for prostate cancer. The Radiation Therapy Oncology Group (RTOG) rates side effects on a ‘grading’ scale from 0 (none) to 4 (severe). Patients examined during the PTC study experienced an extremely low degree of bladder side effects, or in many cases, no side effects at all (grade 0). Only 22.5% of patients experienced grade 2 side effects. The majority of these grade 2 side effects completely disappeared following treatment. Patients undergoing treatment experienced absolutely no severe (i.e. no grade 3 or 4) bladder-related side effects.

In addition to low bladder-related side effects, patients undergoing proton therapy in Prague experienced virtually no bowel side effects. 20% of patients experienced mild, short-term bowel-related side effects that disappeared following treatment. Importantly, 80% of patients experienced no bowel-related side effects during or after treatment. Excitingly, no patients experienced severe (grade 3 or 4) side effects!

To read more about their latest results using proton therapy for prostate cancer, click here.

Comparative Effectiveness of Proton vs Photon Therapy as Part of Concurrent Chemoradiotherapy for Locally Advanced Cancer

Doctors at the University of Pennsylvania in Philadelphia published retrospective, nonrandomised comparative effectiveness study that compares proton versus photon therapy for concurrent chemoradiotherapy of locally advanced cancer.

The authors compared adverse events associated with unplanned hospitalisations among 1,483 adult patients with nonmetastatic, locally advanced cancers treated with concurrent chemoradiotherapy and proton therapy (391 patients) or photon therapy (1092 patients). The results were published in August 2019 in JAMA Oncology. This study found that proton therapy significantly reduced severe adverse events in adults with locally advanced cancers without affecting outcomes when compared with photon therapy.

Concurrent chemoradiotherapy can be associated with substantial toxicity, including
oral mucositis, oesophagitis, nausea, vomiting, signifiant weight loss, and radiation-induced lung injury that can result in unplanned hospitalisations, emergency department visits,
treatment interruptions that can diminish the effectiveness of treatment, and decreased patient performance status.

Proton therapy as part of concurrent chemoradiotherapy may be able to reduce treatment toxicity, but limited data have been so far available comparing results of proton chemoradiotherapy with chemoradiotherapy delivered with photon therapy, and proton therapy remains unproven in this setting. This comparative effectiveness cohort study focused therefore on the rate of severe 90-day adverse events associated with unplanned hospitalisations.

The study comes to a result that compared with photon therapy, proton therapy was associated with a nearly two-thirds reduction in 90-day severe adverse events associated with unplanned hospitalisations. Proton therapy was also associated with significantly lower risk of a decline in Eastern Cooperative Oncology Group (ECOG) performance status and significantly less risk of adverse events causing impairment in patients’ instrumental activities of daily living.

Proton therapy was also shown to be equally effective at treating the cancer – disease-free and overall survival outcomes were similar between the two groups, which included patients with head and neck, lung, brain, oesophagus/gastric tract, rectum, and pancreas cancers.

Before this study, data on the toxicity differences between proton vs photon chemo-radiotherapy have been limited, with relatively small patient numbers, although most studies have found a toxicity advantage and/or dosimetric advantage in favour of proton chemoradiotherapy.

This study mentions 3 important implications for future research:

  • First, proton therapy’s lower observed toxicity raises the possibility that the higher up-front cost of proton therapy may be offset by cost savings from reduced hospitalisations  and enhanced productivity from patients and caregivers.
  • Second, the lower observed toxicity of proton therapy offers an opportunity to explore clinical trials combining proton therapy with intensified systemic therapy and/or dose-escalated radiotherapy, which may, in turn, improve survival outcomes.
  • Third, proton therapy may allow also older, sicker patients with more comorbidities to receive the most effective combined-modality treatments.

James’ Experience At PTC

We would like to share this note we have received from James, who has been treated here at the Proton Therapy Center for his prostate cancer.

Along this path of life, I have met many people. This Institution of the Proton Therapy Center, and even of the Bulovka Hospital, in Prague has been an experience that merits comment. For me, it primarily has to do with the demeanour and quality of the staff I have encountered at all levels. While I do not speak Czech, I have observed the interrelationships between the staff and patients, from children to adults, to be what it should be in all hospitals. There is a great respect from, between and towards both sides, I have met doctors, nurses, various disciplinary specialists, administration and ancillary staff. We have talked, they listen, they respond and any issues, from getting a cup of coffee to knowing what a specialist wishes me to do or that that person wishes to do with or to me, is resolved in a civilised manner. A mutual satisfaction is achieved and we all can procede on our own paths when we part.

Head & Neck Cancer International Conference 2019

This conference will offer an opportunity to discuss the issues of Head and Neck Cancer from the perspective of health professionals and patients and also to review the latest services and treatments.

Dr Eliška Rotnáglová, Ph.D., one of the Prague Proton Therapy Center´ ENT specialists, will discuss the side effects of proton radiotherapy in head and neck cancer patients. Dr Rotnáglová will also present the Proton Therapy Center´s experience with proton radiotherapy.

Dr Rotnáglová reached her Ph.D. focusing on HPV involvement in oropharyngeal carcinogenesis at the Department of Otorhinolaryngology and Head and Neck Surgery of the 1st Faculty of Medicine, Charles University, and Motol University Hospital in Prague. Dr Rotnáglová gained most of her experience with head and neck cancer patients at Motol University Hospital.

When?

Thursday 7th November @ 11am

Where?

Hilton Brighton Metropole
Kings Rd, Brighton
Kings Road
Brighton
BN1 2FU
United Kingdom

The Head and Neck Cancer International Conference 2019 is organized by The Swallows, Head and Neck Cancer Support Group. For more information, please visit: www.yourcancerjourney.org.uk