Proton Therapy in the UK – Where are we?

Professor Mark Glaser

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Disclosure

Principles of Radiotherapy• The goal of the Clinical Oncologist is to achieve

the best chance of local control with radiotherapy.

Getting the balance right

The greatest chance of tumour kill vs The least damage to normal tissue

Motivation for Proton / Hadron therapy

• The Bragg peak gives us the opportunity to reduce the dose delivered to healthy tissue while maintaining the dose delivered to the tumour

• But: The mass of hadrons is at least 2000 times greater, making the equipment large and costly.

1. No exit Dose2. Significantly less entrance dose

than target dose3. Most dose deposited in target

1. Substantial exit dose2. More entrance dose than target dose3. Most dose deposited outside target

Proton Beam Therapy v X-ray Therapy

Proton Treatment Centres• Approximately 54 facilities worldwide, but

some of these are dedicated for research• Approximately 120,000 people have been

treated to date

Protons in the UK• NHS - UCL and Christies • Commercial ambitions

– LIGHT technique (Linac guided image technology)– Compact cyclotron (Proteus One Gantry, IBA)

High Energy PhysicsStaffrticle Therapy Group

– Physicists, clinicians, radiobiologists, healthcare economists and engineers

Research and Evaluation– Present and future clinical particle therapy– Clinical indications – Radiobiological studies– Clinical particle therapy / healthcare economics

The question of RBE• The radio biological

effectiveness (RBE) is the ratio between the physical dose required for radiation of type i and the equivalent dose required for radiation of type x for the same biological result.

• But: The RBE for hadrons is less well known than for conventional therapy.

Laser driven ion accelerators• Laser driven acceleration of hadrons allows

for extremely compact accelerators with possible enormous effects on costs.

• But: Energy spectrum of beam and use of conventional beam formation contradict possible savings

Activities: collaboration with other groups including Dublin and RAL

Space Charge Lenses

• For hadrons the focal strength of these lenses exceeds all other lens systems by more than a factor of 40.

• But the control of the space charge cloud was difficult in experiments.

Activities: Development, manufacturing and test of lens prototype. Test using laser accelerated ions in near future at Imperial College.

Advanced FFAG design for Treatment Gantries

• Novel design of beam delivery system will allow beams with large momentum spread being delivered to patient.

• multiple energy particles delivered simultaneously.

• But: New technology with high

requirements concerning field quality. Requires demonstrator.

Activities: Development of theoretical model. Particle tracking simulations performed successfully.

Dedicated Radio-biological Facility • Delivery of

beam with large energy / mass variation

• For in vitro and in vivo experiments

Advanced Setup for Treatment • Significantly

reduced footprint

• Advanced beam handling and beam delivery.

• Novel treatment modalities for reduced treatment time.

Definitive Clinical IndicationsNational Specialised Commissioning

Team

Possible Future Indications• These include the more common tumours and

if there is a therapeutic advantage using Protons, the number of facilities needed will increase enormously

• Increasing incidence. Clinically difficult to treat the edge of the tumour. New surgical technology combined with high doses of radiation may improve survival

• Complex treatment options (eg. robotic surgery). IMRT allows a high dose to be given to the tumour with few lasting side effects. However particle therapy has been used for many years at proton centres in the USA. Further evaluation needed

• Cardiac toxicity and late effects: Being studied. Protons may be useful where extended field treatment is necessary.

Photons Protons IMRT

• Immunotherapy: May improve survival. High incidents of local disease progression in NSCLC. Difficulty in dose escalation if tumour is close to critical structures ( Spinal cord / Oesophagus.)

• Tumour recurrences: Radiation therapy given at the original tumour site. At present dangerous because of necrosis and harm to neighbouring organs. Proton therapy may be of benefit.

The Future• Few clinical trials at present• More radiobiological data needed• Definitive survivorship data• ? Modification of equipment /Healthcare economics• The role of radiotherapy in conjunction with surgery, chemotherapy ,

immunotherapy and genetic treatments• Research into future generations of particles. Eg. carbon ions• Hypofractionation so as to minimise lengths of treatments and to increase

therapeutic ratio• Mixed treatments with Photon and Protons

Thank you