UCSF announces proton therapy

[IonsAreOurFuture]

Hot off the presses, UCSF announces a new proton center:

UC Regents Approve UCSF Proton Therapy Center for Cancer Care

The UC Board of Regents approved UCSF’s proposal to build a proton therapy facility as part of the redevelopment of the former Dogpatch Power Station, which will join only 45 other sites nationwide and will be the only facility to offer the leading-edge cancer therapy between Los Angeles and...

www.ucsf.edu

I actually thought UCLA, UC Irvine or City of Hope would have beaten them to it, what with the Bay Area being hard to find land in, but it sounds like a brown site power plant is being redeveloped.

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[Gfunk6]

Hot off the presses, UCSF announces a new proton center:

UC Regents Approve UCSF Proton Therapy Center for Cancer Care

The UC Board of Regents approved UCSF’s proposal to build a proton therapy facility as part of the redevelopment of the former Dogpatch Power Station, which will join only 45 other sites nationwide and will be the only facility to offer the leading-edge cancer therapy between Los Angeles and...

www.ucsf.edu

I actually thought UCLA, UC Irvine or City of Hope would have beaten them to it, what with the Bay Area being hard to find land in, but it sounds like a brown site power plant is being redeveloped.

Not saying it won’t happen, but this is the 5th time UCSF announced a new proton center.

 

[Neuronix]

Not saying it won’t happen, but this is the 5th time UCSF announced a new proton center.

They're playing the long game. Before you know it, there will be five proton centers in San Francisco.

Floridaman says this is not a joke.

 

[evilbooyaa]

Still wild that Florida has 10+ proton centers and the state of California has.... I believe just the one in San Diego?

Florida man medical care strikes again

 

[Gfunk6]

Still wild that Florida has 10+ proton centers and the state of California has.... I believe just the one in San Diego?

Florida man medical care strikes again

Well, you forgot to count Loma Linda. But that is more like an undead center.

 

[yesmaster]

Florida is fee for service and capital of Medicare fraud and other schemes.

California is Kaiser and value based care.

There are things I dislike about California and California healthcare but proton gravy train proton grift is not one of its faults.

 

[RickyScott]

Well, you forgot to count Loma Linda. But that is more like an undead center.

did they ever update machine to pencil beam etc or add igrt? Surely they aren’t using same proton tech from the 90s?

 

[evilbooyaa]

Well, you forgot to count Loma Linda. But that is more like an undead center.

Technically, you are correct.

However, unless that center has undergone huge upgrades (not likely), I would NOT consider Loma Linda to be anything resembling contemporary proton therapy. I mean most if not all of the 4 centers in Tampa are likely better than getting treated at the Loma Linda proton center.

 

[Gfunk6]

did they ever update machine to pencil beam etc or add igrt? Surely they aren’t using same proton tech from the 90s?

I've talked to physicists who were formerly employed by Loma Linda and their machine is on life support. The amount of manpower required to keep that thing humming is truly astounding.

For those of you that are familiar with Warhammer 40k lore:

Loma Linda is the Carrion Lord of protons for whom a thousand physicists are sacrificed every day, so that it may never truly die.

 

[medgator]

Technically, you are correct.

However, unless that center has undergone huge upgrades (not likely), I would NOT consider Loma Linda to be anything resembling contemporary proton therapy. I mean most if not all of the 4 centers in Tampa are likely better than getting treated at the Loma Linda proton center.

Have heard something like opposed laterals for prostate?

 

[A_DeMichele]

with only one field treated on a given day!

 

[medgator]

with only one field treated on a given day!

Really old school. That's how they used to do photons/cobalt back in the day

 

[Gfunk6]

Have heard something like opposed laterals for prostate?

And for clival chordomas! Comes with a side order of bitemporal radiation necrosis.

 

[Chartreuse Wombat]

Have heard something like opposed laterals for prostate?

One field per day, because throughput

 

[DoctwoB]

Ugh. As a uro in the region I forsee a sudden increase in billboards and patient interest. UCSF radoncs and uros will go from loudly anti-proton (as those patients were flying off to san diego) to suddenly being able to offer advanced technology you can't get in the community.

Here's hoping bay area nimbyism keeps this from happening until after i retire.

 

[RickyScott]

Ugh. As a uro in the region I forsee a sudden increase in billboards and patient interest. UCSF radoncs and uros will go from loudly anti-proton (as those patients were flying off to san diego) to suddenly being able to offer advanced technology you can't get in the community.

Here's hoping bay area nimbyism keeps this from happening until after i retire.

If it is a single gantry set up, they will probably use it judiciously as they will be limited to 30 pts a day, half of whom will be kids.

 

[IonsAreOurFuture]

did they ever update machine to pencil beam etc or add igrt? Surely they aren’t using same proton tech from the 90s?

Loma Linda is still using passive scatter and lacking CBCT image guidance, so not really comparable to a newer center from 2015 onward.

The accelerator is going on 35 years old - started treating in 1990 - which is really amazing for a piece of medical hardware. They've treated well over 20,000 patients with that one machine pumping out protons.

 

[thesauce]

Loma Linda is still using passive scatter and lacking CBCT image guidance, so not really comparable to a newer center from 2015 onward.

The accelerator is going on 35 years old - started treating in 1990 - which is really amazing for a piece of medical hardware. They've treated well over 20,000 patients with that one machine pumping out protons.

Amazing in the worst possible way

 

[RickyScott]

Amazing in the worst possible way

What a scam.

 

[evilbooyaa]

Loma Linda is still using passive scatter and lacking CBCT image guidance, so not really comparable to a newer center from 2015 onward.

The accelerator is going on 35 years old - started treating in 1990 - which is really amazing for a piece of medical hardware. They've treated well over 20,000 patients with that one machine pumping out protons.

Any patient treated after 2010 (2015?) was 100% unnecessary

 

[NotMattSpraker]

They gave us TACE vs. Protons, which everyone should be using to advocate for SBRT over TACE. Good trial.

Proton beam radiotherapy versus transarterial chemoembolization for hepatocellular carcinoma: Results of a randomized clinical trial - PubMed

PBT and TACE yielded similar OS for treatment of HCC, but PFS and LC were improved with PBT compared to TACE. Patients treated with PBT required fewer courses of treatment, fewer posttreatment hospitalization days, and reduced cost of treatment compared to TACE. These data support the use of PBT...

pubmed.ncbi.nlm.nih.gov

 

[DoctwoB]

They gave us TACE vs. Protons, which everyone should be using to advocate for SBRT over TACE. Good trial.

Proton beam radiotherapy versus transarterial chemoembolization for hepatocellular carcinoma: Results of a randomized clinical trial - PubMed

PBT and TACE yielded similar OS for treatment of HCC, but PFS and LC were improved with PBT compared to TACE. Patients treated with PBT required fewer courses of treatment, fewer posttreatment hospitalization days, and reduced cost of treatment compared to TACE. These data support the use of PBT...

pubmed.ncbi.nlm.nih.gov

Finally taking a page from the pharma playbook i see.

Compare new/expensive treatment against old/ineffective drug and not against effective/cost effective treatment.

See the 10 trials comparing ARSI's to lupron in mCRPC, mCSPC, nmCRPC, etc and none comparing them to abiraterone.

 

[Doctorer]

Finally taking a page from the pharma playbook i see.

Compare new/expensive treatment against old/ineffective drug and not against effective/cost effective treatment.

See the 10 trials comparing ARSI's to lupron in mCRPC, mCSPC, nmCRPC, etc and none comparing them to abiraterone.

If this will at least stop a single IR from recommending TACE over SBRT, I'll call it a win.

It won't though.

 

[medgator]

If this will at least stop a single IR from recommending TACE over SBRT, I'll call it a win.

It won't though.

Should be happening already, but we both know IR isn't ever going to do that (at least not in the community setting IMO)

https://ascopubs.org/doi/abs/10.1200/JCO.2017.35.4_suppl.223

Transarterial Chemoembolization With Drug-Eluting Beads Versus Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Outcomes From a Multicenter, Randomized, Phase 2 Trial (the TRENDY Trial) - PubMed

In this trial, TTP after TACE-DEB was not significantly improved by SBRT, while SBRT showed higher local antitumoral activity than TACE-DEB, without detrimental effects on OS, toxicity and QoL. To overcome poor accrual in randomized trials that include SBRT, and to generate evidence for...

pubmed.ncbi.nlm.nih.gov

 

[NotMattSpraker]

If this will at least stop a single IR from recommending TACE over SBRT, I'll call it a win.

It won't though.

I know at least one center in my town was doing a lot of TACE about a year ago. Like wayyyy too much. It seems to have stopped entirely, now just doing Y-90.

There is hope!

 

[CaesarRO]

I know at least one center in my town was doing a lot of TACE about a year ago. Like wayyyy too much. It seems to have stopped entirely, now just doing Y-90.

There is hope!

My neighborhood they all do Y90 and don't look twice at SBRT

Thankfully med Onc pays more attention to us as an alternative

 

[evilbooyaa]

Finally taking a page from the pharma playbook i see.

Compare new/expensive treatment against old/ineffective drug and not against effective/cost effective treatment.

See the 10 trials comparing ARSI's to lupron in mCRPC, mCSPC, nmCRPC, etc and none comparing them to abiraterone.

?? TACE even though not the most effective treatment (SBRT is) is still widely widely utilized for HCC.

Is the suggestion that TARE is much better than TACE? IR doesn't care what they do as long as they're the ones controlling the patient. Vast majority of HCC and liver met patients who are candidates for both SBRT and TACE/TARE are MUCH better served by SBRT than they are with any sort of IR intervention.

 

[Doctorer]

?? TACE even though not the most effective treatment (SBRT is) is still widely widely utilized for HCC.

Is the suggestion that TARE is much better than TACE? IR doesn't care what they do as long as they're the ones controlling the patient. Vast majority of HCC and liver met patients who are candidates for both SBRT and TACE/TARE are MUCH better served by SBRT than they are with any sort of IR intervention.

Agreed. We have multiple negative trials for TARE in HCC as well as in metastatic colorectal, but despite that, the pipeline (for HCC especially) often starts with IR in terms of LRT.

I try to change it because I enjoy beating my head against the wall.

 

[OTN]

I've been beating my head against a wall for years trying to explain to IR that heterogeneity in dose distribution matters, so, yes, while you can get up to 3000 Gy in a tumor from Y90, you can also get only 30 Gy, so I would prefer SBRT for a solitary lesion over "super selective" Y90.

At this point I believe they are willfully trying not to understand my point.

 

[BobbyHeenan]

I've been beating my head against a wall for years trying to explain to IR that heterogeneity in dose distribution matters, so, yes, while you can get up to 3000 Gy in a tumor from Y90, you can also get only 30 Gy, so I would prefer SBRT for a solitary lesion over "super selective" Y90.

At this point I believe they are willfully trying not to understand my point.

Same. The concept of Dmin is lost on them.

One finally understood when sure enough the HCC relapsed in the corner of the tumor that was under perfused/dosed.

 

[thesauce]

I've been beating my head against a wall for years trying to explain to IR that heterogeneity in dose distribution matters, so, yes, while you can get up to 3000 Gy in a tumor from Y90, you can also get only 30 Gy, so I would prefer SBRT for a solitary lesion over "super selective" Y90.

At this point I believe they are willfully trying not to understand my point.

It is nearly impossible to explain since their livelihood depends on them not understanding it

 

[Mandelin Rain]

TACE + SBRT is a good approach IMO.

 

[BobbyHeenan]

TACE + SBRT is a good approach IMO.

It can be nice to have lipo-iodal as a “fiducial” but I’m not convinced the tace in combo with sbrt does any heavy lifting.

 

[Doctorer]

It can be nice to have lipo-iodal as a “fiducial” but I’m not convinced the tace in combo with sbrt does any heavy lifting.

Yup, this is part of the game I play as well. I just think of the lipiodol as a fiducial which may or may not treat their cancer.

 

[Mandelin Rain]

It can be nice to have lipo-iodal as a “fiducial” but I’m not convinced the tace in combo with sbrt does any heavy lifting.

I think it may add a bit to the efficacy, but yes, the lipiodol makes the treatment so much easier (assuming it stick around).

 

[evilbooyaa]

TACE + SBRT is a good approach IMO.

SBRT alone is an equally effective approach. If all you need is a fiducial, just have them put a fiducial in. No need to put patients through the toxicity of useless transarterial chemo.

 

[madchemist89]

Problem is you need the fiducial, which is placed by IR. You’ve already lost the patient right there.

 

[Mandelin Rain]

Problem is you need the fiducial, which is placed by IR. You’ve already lost the patient right there.

 

[medgator]

Problem is you need the fiducial, which is placed by IR. You’ve already lost the patient right there.

Do you need the fiducials in every case? I think not. Unless we are talking CK

 

[OTN]

Do you need the fiducials in every case? I think not. Unless we are talking CK

Not in my experience

 

[madchemist89]

No not every case. May need a biopsy though. The gist of my statement is that many of the patients will see IR first. IR is going to go ahead and treat with one of their modalities regardless of evidence. Of course not every IR will do that, but many will.

 

[medgator]

No not every case. May need a biopsy though. The gist of my statement is that many of the patients will see IR first. IR is going to go ahead and treat with one of their modalities regardless of evidence. Of course not every IR will do that, but many will.

Sometimes just need an afp to diagnose hcc, moreover a lot of these patients are getting evaluated at bigger centers and getting sent back to med onc in my experience if they aren't surgical candidates. Those pts then are getting referred to us more often it feels like

Same with liver mets

 

[evilbooyaa]

Do you need the fiducials in every case? I think not. Unless we are talking CK

Vast majority of my liver SBRT pts do not have a fiducial, with following caveats:
1) Most my pts are mets
2) I do not do a high volume of them

 

[drowsy12]

Problem is you need the fiducial, which is placed by IR. You’ve already lost the patient right there.

You don’t need fiducials

 

[pikachu]

Sometimes just need an afp to diagnose hcc, moreover a lot of these patients are getting evaluated at bigger centers and getting sent back to med onc in my experience if they aren't surgical candidates. Those pts then are getting referred to us more often it feels like

Same with liver mets

Don't even need AFP if LIRADS-5

 

[Doctorer]

You don’t need fiducials

Eh, i think there's some variability here. There are different ways to skin the cat, but putting in fiducials in a good KPS patient will allow you to come up with a better plan 99% of the time. Whether that's clinically relevant or not is a different question, I'll admit.

 

[medgator]

Eh, i think there's some variability here. There are different ways to skin the cat, but putting in fiducials in a good KPS patient will allow you to come up with a better plan 99% of the time. Whether that's clinically relevant or not is a different question, I'll admit.

I'm a believer in prostate. Not in lung. Can't say one way or the other regarding liver but I definitely have seen cases where the lesion isn't as clear and I think they would have helped

 

[NotMattSpraker]

I'm a believer in prostate. Not in lung or bone. Can't say one way or the other regarding liver but I definitely have seen cases where the lesion isn't as clear and I think they would have helped

How does one justify putting a fiducial in a solid tumor that is sitting in air? I never understood it.

Bone! Haha come on.

 

[medgator]

How does one justify putting a fiducial in a solid tumor that is sitting in air? I never understood it.

Bone! Haha come on.

Haha true. Was thinking CK with lung back in the day. Had a brain fart with bone. 😂🤪

 

[Mandelin Rain]

I don’t treat a ton of liver, but I’m not sure I’ve ever confidently seen an actual lesion on CBCT. Without a fiducial or lipiodal, are you all lining up external contour of liver/vascular structures and assuming the lesion is in correct spot or can you actually visualize the lesion?