PROTONS: does ANYBODY have a crystal ball?

[Kara]

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What role will protons have in radiation therapy down the road?

Even if the scope of Protons broadens and it is proven to be beneficial for the majority of cancers, is it economically feasible within the next 20-30 years that this modality will extend beyond a handful of large centers into the community? Whether this happens is largely dependent on the development of smaller, more affordable delivery systems.....but given the technology involved, is that reasonable to expect in the foreseeable future?

Also, when considering residency programs, should the prospect of training on protons carry any weight? As a graduate of a program with protons, could it later serve you as an advantage?

Along the same lines, given the limited insight of a medical student, is exposure to the latest technology and treatment approaches such as brachy (LDR/HDR) and STS during residency in fact overrated? Please correct me if I am wrong, but it seems to me that as a resident, "the people" you work with matter more because what you fundamentally want out of your residency is to learn about principles of treatment, medical physics, and the pathophysiology of the various human malignancies, and that given a strong foundation in these areas, the specifics of different technologies and different treatment approaches can be picked up down the road. Thoughts?

Practically speaking, however, can having limited exposure to certain technology and treatment approaches impede your job marketability out of residency?

 

[radonc]

What role will protons have in radiation therapy down the road?

Even if the scope of Protons broadens and it is proven to be beneficial for the majority of cancers, is it economically feasible within the next 20-30 years that this modality will extend beyond a handful of large centers into the community? Whether this happens is largely dependent on the development of smaller, more affordable delivery systems.....but given the technology involved, is that reasonable to expect in the foreseeable future?

Also, when considering residency programs, should the prospect of training on protons carry any weight? As a graduate of a program with protons, could it later serve you as an advantage?

Along the same lines, given the limited insight of a medical student, is exposure to the latest technology and treatment approaches such as brachy (LDR/HDR) and STS during residency in fact overrated? Please correct me if I am wrong, but it seems to me that as a resident, "the people" you work with matter more because what you fundamentally want out of your residency is to learn about principles of treatment, medical physics, and the pathophysiology of the various human malignancies, and that given a strong foundation in these areas, the specifics of different technologies and different treatment approaches can be picked up down the road. Thoughts?

Practically speaking, however, can having limited exposure to certain technology and treatment approaches impede your job marketability out of residency?

these are some very good questions, and i think you will find people with varying opinions.

the job market is very good right now that i do not think that limited exposure will hurt you, but definitely the more you know and say you can do, the more it will open doors for you. doing fellowships in certain areas (except protons) may even help you get a better academic/private job, because you can always find a niche at a practice.

protons are very interesting, and their potential uses along with possible reduction in secondary malignancies is attractive, but only a few centers around the US have it, so its still an 'experimental' therapy.

 

[user_name]

It is my understanding that exceedingly few places have protons. I was told Harvard and Loma Linda have them. It was actually billed as a weakness for Loma Linda to me. I was told they do like 75% of their cases as prostate with protons, and you really lack in training in the real "bread and butter" cases. I can't vouch for the validity of that. I think Florida is building a facility in Jacksonville which may not be too useful to the residents as they are based in Gainesville. Indiana has a facility on the Bloomington campus for research only that the PD wants access to I was told. Again, residency is in Indy, so who knows how much exposure you will really get. I have been told the machines are a couple of stories tall, but I have never seen one myself. This shows the difficulty, even outside of price and experimental nature, that would stand in the way of every clinic in the US installing one. Of course, all of the above info is second hand or conjecture.

 

[user_name]

Maybe I knew more than I thought. I found this site: http://www.proton-therapy.org/
They say the three actually treating patients are LL, Harvard, and recently IU. They say MDACC will open in early 06. No mention of UF on main page. There is a video of ABC report showing interior of machine. Looks like it might easily be 2 stories. I will read more and encourage you to do the same. Interestingly, a headline reads that cancer death is decreasing while diagnosis has remained constant and that proton beams tx has contributed. Let's have a contest to see who can come closest to guessing what percentage protons have contributed. Whoever gets the closest without going over gets one free treatment for themselves or a loved one with PBRT. I guess 0.015%.

 

[user_name]

Found info on the center's size. You can buy an integrated center from a company that supplies Loma Linda. It includes an accelerator that supplies three gantries. Each gantry weighs 90 tons and is three stories tall. There is a model on their website http://www.optivus.com/protontherapy/standard.html
Note the facility footprint:. 103' x 224', 3 stories
I promise to stop now.

 

[stephew]

UF has them. Im vising this this week; or will try to while on vacation anyway. UPenn also. but i wouldnt expect in the near to intermediate term that not being trained on them will effect jobs. I wouldnt choose a program *because* it has protons.

 

[3dtp]

UF has them. Im vising this this week; or will try to while on vacation anyway. UPenn also. but i wouldnt expect in the near to intermediate term that not being trained on them will effect jobs. I wouldnt choose a program *because* it has protons.

I know the guy at IU/Bloomington used to be at the Mass/General Cambridge proton facility. He's been at it since he left Michigan in the late '80s, a real good guy, and probably knows more about them than anyone except the folks at LL. I've seen the original machine at Mass General and have sent a few highly specialized requirement patients to him for treatment.

The sites above match those that I know have them.

The big attraction for protons is more the dose distribution characteristics than anything else. They have a dose distribution called a Bragg Peak, which in a nutshell says that they impart most of their energy at the end of their travel path. The reason they do this is because they are charged particles like electrons but much heavier. They are directly ionizing and don't depend on creating secondary charged particles. This lead to an ability to deposit dose in a large peak at the end of their travel, in a very precise manner.

They are not high LET particles like neutrons. Their effective dose quality factor is only about 1.1 or so, v. 4-8 for neutrons, but they don't have the toxicity of neutrons either. I think there is an oxygen enhancement ratio for protons (like electrons, photons) but I could be wrong. So, they probably won't be any better for treating hypoxic tumors than other low LET particles, except for one thing: They might be better at localizing tumor dose allowing greater dose enhancement in hypoxic tumors due to the unique dosimetry.

We don't have them, but I think they'd be very useful for in-field residual/recurrent disease treatments once normal tissue tolerances have been exhausted.

Those are the areas that I think protons will have the biggest use, and I don't think that most community centers will need them in the volumes that offset the capital costs. They'll probably remain tertiary referal centers, but I could be wrong. High temperature superconductor technology has substantially decreased the costs of the magnets but they're still way expensive compared to a linac in terms of expense and real-estate needed, but then linacs are way expensive compared to a Co-60 too.

 

[3dtp]

Along the same lines, given the limited insight of a medical student, is exposure to the latest technology and treatment approaches such as brachy (LDR/HDR) and STS during residency in fact overrated? Please correct me if I am wrong, but it seems to me that as a resident, "the people" you work with matter more because what you fundamentally want out of your residency is to learn about principles of treatment, medical physics, and the pathophysiology of the various human malignancies, and that given a strong foundation in these areas, the specifics of different technologies and different treatment approaches can be picked up down the road. Thoughts?

Practically speaking, however, can having limited exposure to certain technology and treatment approaches impede your job marketability out of residency?

In a word, no. I think you must have good exposure to brachytherapy, some would argue both LDR and HDR. I think that there is a role for both, but I'm not sure there's clear evidence that properly managed one is better than the other. There are some folks in east Texas who definitely would disagree, and I can't argue that they're wrong, and am ambivilant on this myself.

Brachytherapy will continue to be an important part of radiation therapy and in some cases, essential. Intracavitary RT in gynecologic cases, particularly cervical cancer is a mainstay of treatment. Even if the HPV vaccine does succeed, we still have a lifetime worth of cervical cancer to cure in the mean time. This doesn't address other intracavitary and interstitial applications such as sarcomas and prostates, and in some cases head and neck.

I agree with you that being with a good group of people is important and can enhance your learning ability, but I think that learning good procedural skills is very important, and you will do that in a program with good brachytherapy. I don't think a surgeon who didn't do procedures would be the best prepared to be out on his/her own in the real world, so I think we should not only know how to do brachytherapy, but should be very comfortable doing it.

In the ideal world if your matched program has a shortcoming in one area, and a strength in another area, an exchange rotation with an outside program might be beneficial, but not all programs allow this.

I don't think that not having these skills will impede you, but I do think that if you become the "expert" in a certain facility, you should be fully prepared or be prepared to refer patients needing that therapy to someone who is.

 

[qwert]

wrong - there's no protons in UPenn. UF facilty is still incomplete.

UF has them. Im vising this this week; or will try to while on vacation anyway. UPenn also. but i wouldnt expect in the near to intermediate term that not being trained on them will effect jobs. I wouldnt choose a program *because* it has protons.

 

[qwert]

The person fixing healthcare system in this country should start with demolishing proton centers, IMHO.

🙂

What role will protons have in radiation therapy down the road?

Even if the scope of Protons broadens and it is proven to be beneficial for the majority of cancers, is it economically feasible within the next 20-30 years that this modality will extend beyond a handful of large centers into the community? Whether this happens is largely dependent on the development of smaller, more affordable delivery systems.....but given the technology involved, is that reasonable to expect in the foreseeable future?

Also, when considering residency programs, should the prospect of training on protons carry any weight? As a graduate of a program with protons, could it later serve you as an advantage?

Along the same lines, given the limited insight of a medical student, is exposure to the latest technology and treatment approaches such as brachy (LDR/HDR) and STS during residency in fact overrated? Please correct me if I am wrong, but it seems to me that as a resident, "the people" you work with matter more because what you fundamentally want out of your residency is to learn about principles of treatment, medical physics, and the pathophysiology of the various human malignancies, and that given a strong foundation in these areas, the specifics of different technologies and different treatment approaches can be picked up down the road. Thoughts?

Practically speaking, however, can having limited exposure to certain technology and treatment approaches impede your job marketability out of residency?

 

[radonc]

The person fixing healthcare system in this country should start with demolishing proton centers, IMHO.

🙂

upenn is building a proton facility, funded by chop. should be done by 2009.

 

[stephew]

wrong - there's no protons in UPenn. UF facilty is still incomplete.

i know there isn't but last I heard they were in the process of obtaining. When the chair comes to visit next month I'll ask him what the status is. UF isn't open for business but they do tour the site.