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A Suitable and Effective Treatment Option for Localised Prostate Cancer | Proton Therapy in Japan

There are an estimated 17 million new cases of cancer globally each year. The top four cancers occurring worldwide are lung, breast, bowel, and prostate cancer, respectively. In men, prostate cancer is the most common form of non-skin cancer.

There are a variety of treatment options available when treating prostate cancer, and surgery and radiotherapy are the main treatment options presented to patients. These techniques are, however, associated with sexual, urinary, and bowel-related side effects.

One of the standard treatments for localised prostate cancer is conventional radiation therapy. However, conventional radiation therapy brings considerable acute and late adverse effects to the gastrointestinal (GI) and genitourinary (GU) tract. These side effects continue to be a major concern for both patients and physicians. For instance, in a study conducted by Fiorino et al., the risk of experiencing ≥grade 2 GI and GU side effects is about 5%–20% when undergoing conventional radiotherapy. 

With the materialisation of modern conventional radiotherapy techniques, the risk of toxicity on organs at risk, namely the bladder, rectum, and seminal vesicle, have decreased to 5%–10%. The use of proton beams in radiation therapy further reduces this risk with its characteristic Bragg peak, whereby protons can be controlled to stop directly within the tumour, analogous to its energy.

In order to improve life expectancy and overall quality of life, the Japanese government have applied efforts into funding advanced research for the treatment of cancer, with one such effort being proton beam therapy.

Currently there are 14 proton beam facilities within Japan, and as of April 2018, proton beam therapy for prostate cancer is included in Japanese public insurance coverage, thereby removing the financial burden for patients who will undergo this procedure. The number of patients being treated for localised prostate cancer with proton therapy in Japan continues to increase in popularity, due to its promise as a superior treatment for localised prostate cancer.

In a January 2019 literary review of proton therapy for localised prostate cancer in Japan by Japanese researchers in the Journal of Clinical Medicine, proton therapy for prostate cancer was highlighted as superior to other forms of conventional radiotherapy across multiple studies. The incidence of acute and late toxicities concerning the GI and GU tract, as well as radiation doses to organs of risk such as the bladder, bowel and seminal vesicles, were shown to be significantly lower compared to conventional radiotherapy treatments. Proton therapy has also shown its benefits in patients’ prognosis and quality of life. Biochemical control of patients who completed proton therapy are significantly favourable in prostate cancer patients, including high and very high risk cases. The researchers concluded that proton beam therapy is an effective and suitable treatment option for localised prostate cancer.

To find out if proton therapy is appropriate for you or a loved one, please do not hesitate to contact us.

Resources used:

Cancer Research UK. World Cancer Statistics. Available online (accessed on 12 June 2020).

Fiorino, C.; Sanguineti, G.; Cozzarini, C.; Fellin, G.; Foppiano, F.; Menegotti, L.; Piazzolla, A.; Vavassori, V.; Valdagni, R. Rectal dose-volume constraints in high-dose radiotherapy of localized prostate cancer. Int. J. Radiat. Oncol. Biol. Phys. 2003, 57, 953–962.

Hoshina, R.M.; Matsuura, T.; Umegaki, K.; Shimizu, S. A Literature Review of Proton Beam Therapy for Prostate Cancer in Japan. J. Clin. Med. 2019, 8, 48. 

Sakurai, H.; Ishikawa, H.; Okumura, T. Proton beam therapy in Japan: Current and future status. Jpn. J. Clin. Oncol. 2016, 46, 885–892. 

Takagi, M.; Demizu, Y.; Terashima, K.; Fujii, O.; Jin, D.; Niwa, Y.; Daimon, T.; Murakami, M.; Fuwa, N.;
Okimoto, T. Long-term outcomes in patients treated with proton therapy for localized prostate cancer. Cancer Med. 2017, 6, 2234–2243.

Proton Therapy: An Effective Treatment For Prostate Cancer You Should Insist On

Amongst males in the UK, prostate cancer is the 2nd most common cause of cancer death, with around 12,000 deaths in 2017. Prostate cancer accounts for 14% of all cancer deaths in males in the UK. Prostate cancer patients are usually presented with conventional treatment options such as surgery and conventional x-ray radiotherapy. Another option is proton therapy.

This article will explain why proton therapy in Prague is an effective treatment option for many prostate cancer patients.

The Prostate and Prostate Cancer.

The prostate surrounds the urethra and is located beneath the bladder. Cancer begins to develop in the prostate when the cells of the gland begin to grow uncontrollably and form a malignant tumour. Left untreated, prostate cancer can spread to other parts of the body such as the bladder, rectum, bones, and lymph nodes where it can become life threatening.

Modern medicine, however, has made the survival rates of prostate cancer reasonably high.

Common Types of Prostate Cancer

The vast majority of prostate cancers involve adenocarcinomas – these are cancers which develop immediately within the gland cells. It is possible to develop other types of prostate cancer, including:

  • Ductal adenocarcinoma – begins in the ducts of the prostate gland
  • Transitional cell cancer – begins in the bladder and spreads to the urethra, prostate, and nearby tissues
  • Squamous cell cancer – begins in the flat cells of the prostate gland
  • Small cell prostate cancer – a type of neuroendocrine cancer made up of round, small cells

Risk Factors and Prevention

Risk factors such as age, ethnicity, and family history have been known to influence the chances of an individual’s chance of developing prostate cancer. Individuals over the age of 50 are more likely to develop prostate cancer.

A family history of prostate cancer can have an impact on your chances of developing cancer. Only 5% of prostate cancer cases are inherited, but up to 20% of cases are familial, meaning common lifestyle factors and shared genes may have had an influence on the development of cancer.

To lower your risk of developing prostate cancer, it’s recommended to eat a low-fat diet and exercise regularly. However, it’s best to monitor your health by receiving routine checkups and prostate screenings (such as the PSA blood test) from your doctor.

Proton Treatment for Prostate Cancer Patients

Also known as proton beam therapy, proton therapy involves the focusing of proton particles into a beam, which is then delivered to the cancer cells in a non-surgical procedure. The positively charged particles can be controlled to stop at the tumour site, enabling the cancerous tissues to be destroyed with high levels of radiation without causing damage to near healthy tissue and vital organs.

Proton therapy is considered more accurate than other types of radiation therapy, and also non-surgical and noninvasive with minimal side effects. What’s more, the treatment requires little to no recovery time, nor does the radiation have an impact on the patient’s energy levels in comparison to other cancer treatment options. Those who choose proton therapy experience fewer complications than those who choose other types of treatment such as surgery or conventional x-ray radiation.

Proton Therapy vs. Conventional Radiation Therapy

Unlike proton therapy, conventional radiation treatments use x-rays to deliver radiation to the cancerous tumour. Unfortunately, these x-rays cause damage not only to the cancerous tissue, but also the surrounding healthy tissue. Proton therapy uses positively charged subatomic particles called protons. Unlike conventional radiation therapy, the clinician can use the proton beam to target the cancer cells in the body specifically, allowing for a more successful and far less damaging procedure.

Proton Therapy Shown to Enhance Quality of Life

According to an American national survey, those who received proton therapy to treat prostate cancer reported experiencing a better quality of life involving urinary and bowel function during and after their proton therapy treatments, in contrast to patients who received x-ray radiation treatments. More than 70% of prostate cancer patients who received proton therapy additionally noted that the treatment had no impact on their quality of life overall.

Proton Therapy Success Stories

It’s one thing to hear about the success rate of proton therapy treatment for those with prostate cancer in comparison to conventional treatments. It’s another thing to hear the success stories straight from those who have survived and continue to survive today. To learn more about the experiences of others who underwent proton therapy in Prague, click here.

Proton Therapy has the Potential to Reduce the Risk of Long-Term Medical Problems Associated with Anal and Rectal Cancer Treatments​

Proton beam Therapy (PBT) is increasingly used for the treatment of paediatric, central nervous system, skull base, and head and neck tumours. Today, there are over 75 particle therapy facilities in operation worldwide, with more in development. Whether proton therapy can play an important role as well in the treatment of anal and rectal cancer is under active investigation.

Anal and rectal cancers are surrounded by radio-sensitive organs, limiting the treatment options available to medical practitioners responsible for treating these forms of cancer. Proton radiotherapy has the potential to remove these limitations, and could be used to treat certain rectal and anal cancers with greater efficacy than conventional radiotherapy.

In a study published by medical researchers at the Harvard Medical School, the potential use of proton therapy was shown to reduce toxicities associated with treatment, increase patient compliance with treatment, minimise treatment interruptions and enables for the possibility of dose escalation (also known as hypofractionation).

The authors observe that currently, “… the maximal efficacy of radiation plans for primary and recurrent anorectal cancer is constrained by delivery techniques and modalities which must consider feasibility challenges and toxicity secondary to exposure of organs at risk.”

Given the minimal difference in biological effect between both protons and x-ray radiotherapy modalities, protons have drawn interest as a way of sparing adjacent organs at risk from unnecessary radiation, while delivering “tumoricidal” doses, and increasing the therapeutic effect of treatment.

Researchers are highly optimistic about proton therapy as an effective treatment for anal and rectal cancers (especially as intensity-modulated proton therapy and pencil-beam scanning techniques become more prevalent). Additionally, decreased doses to bone marrow and bowel may “improve tolerance of multi-modal treatment” and allow for dose escalation, in turn improving clinical and patient-reported outcomes.

In summary, proton therapy has the potential to more effectively treat anal and rectal cancers. Proton therapy can result in less short- and long-term side effects, and due to its precision, allows for dose escalation (hypofractionation), thereby increasing the chance of completely eliminating the disease.

To find out if proton therapy is appropriate for you or a loved one, please do not hesitate to contact us.

Sources:

Colaco RJ, Nichols RC, Huh S, et al. Protons offer reduced bone marrow, small bowel, and urinary bladder exposure for patients receiving neoadjuvant radiotherapy for resectable rectal cancer. J Gastrointest Oncol 2014;5:3-8.

Raldow AC, Hong TS. Will There Be a Clinically Significant Role for Protons in Patients With Gastrointestinal Malignancies? Semin Radiat Oncol 2018;28:125-30.

Verma V, Lin SH, Simone CB, et al. Clinical outcomes and toxicities of proton radiotherapy for gastrointestinal neoplasms: A systematic review. J Gastrointest Oncol 2016;7:644-64.

Vaios EJ, Wo JY. Proton beam radiotherapy for anal and rectal cancers. J Gastrointest Oncol. 2020;11(1):176‐186. doi:10.21037/jgo.2019.04.03

Wolff HA, Wagner DM, Conradi LC, et al. Irradiation with protons for the individualized treatment of patients with locally advanced rectal cancer: A planning study with clinical implications. Radiother Oncol 2012;102:30-7.

COVID-Free Clinic

In connection with the spread of the new coronavirus (COVID-19) and in the light of the current situation and information, the Proton Therapy Center has adopted several measures and recommendations in order to protect the safety of our patients and staff.

Thanks to these measures we have promptly introduced, we have been able to continue to operate ensuring optimal continuum of cancer care to adult and paediatric patients worldwide during the COVID-19 pandemic.

🤝 It is prohibited to shake hands due to the risk of transmission of the virus.
🤭 Do not touch your face. Use the disinfectant to clean your hands.
🗣️ Cough or sneeze into your elbow, covering your mouth.
🥵 If you have a fever, call us and let us know before coming to the clinic.
😷 Everyone entering the building is required to wear a mask.
🌡️ Upon arrival to the clinic, patients’ temperature is taken.

It is prohibited to shake hands due to the
 risk of transmission of the virus.
Do not touch your eyes and face. 
Use the disinfectant to clean your hands.
Cough or sneeze into your elbow, 
covering your mouth.
If you have a fever, call us and let us know before coming to the clinic.
Everyone entering the building is required to wear a mask.

Upon arrival to the clinic, patients’ temperature is taken.

Starting March 16, 2020, we have introduced a new system which allows employees to keep a safe distance from each other, a strict hygienic entry regime, and higher level of disinfection of the premises. As an extra precaution, doctors work on rotation in two separate shifts minimising the risk to both medical staff and our patients.

Patients need to follow their appointments schedule strictly, so that the centre is never crowded.

Additionally, in order to meet our commitment and at the same time protect everyone at the Proton Therapy Center (patients and staff), it is necessary that all patients coming from abroad undergo COVID-19 testing. Our treatment coordinators will be happy to help you find the closest clinic to your home.

Patients Coming From Abroad

The first step is to assess suitability for proton irradiation, which you can do remotely from the comfort of your home. This assessment is free and it only takes a few business days.

Should you be suitable for treatment at our facility, we can offer you a remote consultation with one of our oncologists to discuss treatment in greater detail.

Should you decide to go ahead with treatment at our facility, we will provide you with an official document which will allow you to travel.

Although airway transportation is limited, there are some flights coming to Prague. Alternatively, it is possible to reach us by car.

Should none of the options above be suitable for you, we cooperate with Meditrans ambulance service which can transport patients to Prague from anywhere in Europe and UK. Should this be your preferred option, our treatment coordinators will be happy to arrange it for you.

We hope you will appreciate and support our efforts. Only with mutual cooperation the therapy will be safe for you, other patients, and the Proton Therapy Center employees.

We are delighted to say, thanks to the favourable epidemiological conditions in the Czech Republic, the situation will soon return to normal.

We will be happy to provide you with more detailed information. Please do not hesitate to contact us.

Study Shows Proton Therapy Improves Overall Survival in Patients with Chordoma and Chondrosarcoma

Chordomas and chondrosarcomas are difficult to manage using conventional cancer treatment methods. Areas of the body frequently affected by this type of cancer include the spine, skull, pelvis, hip, and shoulder.

Effective treatment of these tumours using surgical resection is not usually achievable due to neurovascular involvement. As a result, recurrence of the tumour when surgery is used in isolation poses a significant risk for both chordomas and chondrosarcomas. Due to the low risk of metastasis and relative chemoresistance, the use of definitive radiotherapy or perioperative radiotherapy is very important in maintaining local control.

Previous research has shown proton therapy to be beneficial in treating these types of tumours. Using protons, health professionals are able to treat chordoma and chondrosarcoma with higher doses of radiation due to the increased accuracy of proton therapy.

A 2019 study published in the journal ‘Cancer’ entitled: The role of dose escalation and proton therapy in perioperative or definitive treatment of chondrosarcoma and chordoma has shown that proton therapy improves overall survival for those with these forms of cancer.

This study analysed a total of 863 patients with chondrosarcoma and 715 patients with chordoma treated with proton or conventional radiation therapy. The primary endpoint of overall survival (OS) was evaluated, and clinical features, including age, sex, grade, clinical stage, and Charlson‐Deyo comorbidity index, were compared.

This study found that for chondrosarcoma, a high radiation dose of proton therapy was associated with improved OS at 5 years.

For chordoma, proton therapy was associated with improved OS at 5 years and a high dose for chordoma was significant for improved OS.

The authors concluded that in the largest retrospective series to date, dose escalation and proton radiotherapy were associated with improved overall survival in patients with chondrosarcoma and chordoma. Evidence continues to accumulate in support of improved outcomes with high‐dose proton therapy in the treatment of chordoma and chondrosarcoma with acceptable toxicity.

If you or a loved one are suffering with chordoma or chondrosarcoma, the Prague Proton Therapy Center oncologists are available for consultation.

Associated Resources:

DEGRO. Stellungnahme zur Strahlentherapie mit Protonen in Deutschland Juni 2015.

T. F. DeLaney, N. J. Liebsch, F. X. Pedlow et al., “Phase II study of high-dose photon/proton radiotherapy in the management of spine sarcomas,” International Journal of Radiation Oncology∗Biology∗Physics, vol. 74, no. 3, pp. 732–739, 2009.

E. B. Holliday, H. S. Mitra, J. S. Somerson et al., “Postoperative proton therapy for chordomas and chondrosarcomas of the spine: adjuvant versus salvage radiation therapy,” Spine, vol. 40, no. 8, pp. 544–549, 2015.

B. Rombi, T.F. DeLaney, S.M. MacDonald, et al. “Proton radiotherapy for pediatric Ewing’s sarcoma: initial clinical outcomes” Int J Radiat Oncol Biol Phys, 82 (2012), pp. 1142-1148

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

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, myeloma, 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 leukemia?

The CNS (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 escapes the effect 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 in irradiation of the brain, spinal cord, spaces where cerebrospinal fluid (CSF) circulates, 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;
  • 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 fractions (sessions), applied to the entire craniospinal axis. In some patients, we also irradiate apparent tumor deposits, 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 RT, the patient is less exposed to radiation. There is less irradiation to the organs in front of the tumour, minimal irradiation to lungs, heart, oesophagus, intestinal loops, kidneys, liver, bladder, which significantly reduces the possibility of late toxicity of these organs, and the patient also better tolerates irradiation of 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. In some of these patients, RT 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 specializes 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.