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Proton Beam Radiation For Prostate Cancer

How Proton Beam Therapy Works

Proton Therapy, IMRT, and SBRT | Mark Scholz, MD | PCRI

Proton therapy is an advanced form of radiation treatment that uses protons instead of X-rays.

In regular radiation therapy, the beam of energy goes into the body, through the tumor, and out the other side. This exit dose of radiation might affect healthy tissue beyond the tumor. Protons, in contrast, are larger particles than those used in regular radiation. They release more of their energy within the tumor itself. This burst of energy can appear on a graph as what is called the Bragg peak.

After delivering the energy to the tumor, the protons stop: They do not exit the tumor and go into healthy tissue on the other side.

In this way, proton therapy reduces radiation exposure and potential damage to healthy tissue, especially in sensitive areas such as the brain, eyes, spinal cord, heart, major blood vessels and nerves.

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Risk Factors And Prevention

Risk factors such as age, ethnicity, and family history have been known to influence the chances of a person developing prostate cancer. However, it should be noted that risk factors dont have a direct impact on the development of cancer.

Men over the age of 50 are more likely to develop prostate cancer. In fact, 80% of people who are diagnosed with prostate cancer are over the age of 65.

According to the CDC, African American men are more likely to be at risk for prostate cancer and are more likely to develop aggressive tumors. On the other hand, Caucasian men are just under the average rate of prostate cancer diagnoses. Likewise, Hispanic men also have a lower risk. People of Asian and Pacific Islander descent have the lowest risk of developing prostate cancer.

A family history of prostate cancer can also 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.

While risk factors dont have a direct impact on the development of prostate cancer, they can motivate you to monitor your lifestyle more closely. To lower your risk of developing prostate cancer, its recommended to eat a low-fat diet and exercise regularly. However, its best to monitor your health by receiving routine checkups and prostate screenings from your doctor.

Side Effects Of Radiation Therapy

Compared to earlier radiation methods, these modern techniques reduce the chance of urinary and bowel problems.

With several treatment options available, your doctor will work with you to develop and oversee a treatment plan that precisely addresses your prostate cancer while minimizing the risk to surrounding tissues.

This is why it is important to choose an experienced radiation oncologist who specializes in the management of prostate cancer. High volume centers where practitioners have significant experience and treat large numbers of patients with prostate cancer may be associated with good outcomes and fewer lasting problems related to treatment. The majority of patients who undergo radiation do not have permanent effects on bowel or urinary function, and patients who develop erectile difficulty after these therapies can often be treated successfully with medications such as sildenafil or tadalafil.

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Cancers Types That Are Treated With Proton Beam Therapy

Proton beam therapy is usually used for localized tumors and is used infrequently for stage 4 tumors . It may be used alone or combined with other treatments such as surgery, chemotherapy, immunotherapy, or traditional radiation therapy. Some types of cancer in which proton beam therapy may be used include:

  • Lung cancer: Proton therapy for lung cancer may be used for early-stage cancers that cannot be treated with surgery, or for a recurrence when conventional radiation therapy has already been given.
  • Brain cancer: The precise area of delivery offered by proton beam therapy may be beneficial for brain tumors in which even small amounts of damage to nearby normal tissues could have significant side effects.
  • Childhood cancers: Proton beam therapy, as discussed below, may do less damage to nearby normal tissues. Since DNA damage to normal cells may lead to secondary cancers, itâs thought that this therapy may be a better option at times for children.
  • Head and neck cancers

Some noncancerous tumors, such as benign brain tumors may also be treated with proton therapy.

Two Treatment Centers One Expert Team

Heavily promoted therapy for prostate cancer looks risky

Mass General has the only proton therapy site in all of New England, with two proton therapy centers.

Since the opening of the Francis H. Burr Proton Therapy Center in 2001, we have treated thousands of adult and pediatric patients with proton therapy. In 2020, we expanded clinical operations on our main campus location with the opening of a second center, the Gordon-Browne Proton Therapy Center, making Mass General the only institution on the East Coast to have two proton therapy centers. Both state-of-the-art treatment centers offer the latest technology for patients and are run by one talented, multidisciplinary team.

Both of our proton therapy centers are located on Mass General’s main campus in Boston, giving patients access to a wide range of world-class care and services.

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Consensus Statement On Proton Therapy For Prostate Cancer

Corresponding Author:

Curtis M. Bryant, Randal H. Henderson, R. Charles Nichols, William M. Mendenhall, Bradford S. Hoppe, Carlos E. Vargas, Thomas B. Daniels, C. Richard Choo, Rahul R. Parikh, Huan Giap, Jerry D. Slater, Neha Vapiwala, William Barrett, Akash Nanda, Mark V. Mishra, Seungtaek Choi, Jay J. Liao, Nancy P. Mendenhall, the Genitourinary Subcommittee of the Particle Therapy Co-Operative Group Consensus Statement on Proton Therapy for Prostate Cancer. Int J Part Ther 1 September 2021 8 : 116. doi:

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Is Proton Therapy Safer Than Traditional Radiation

Traditional radiation therapy delivers radiation to the tumor and to healthy tissues around the tumor. With proton therapy , the majority of the radiation is delivered to the tumor.

A type of radiation treatment called proton beam radiation therapy may be safer and just as effective as traditional radiation therapy for adults with advanced cancer. That finding comes from a study that used existing patient data to compare the two types of radiation.

Traditional radiation delivers x-rays, or beams of photons, to the tumor and beyond it. This can damage nearby healthy tissues and can cause significant side effects.

Plus, proton therapy is more expensive than traditional radiation, and not all insurance companies cover the cost of the treatment, given the limited evidence of its benefits. Nevertheless, 31 hospitals across the country have spent millions of dollars building proton therapy centers, and many advertise the potential, but unproven, advantages of the treatment.

In the new study, patients treated with proton therapy were much less likely to experience severe side effects than patients treated with traditional radiation therapy. There was no difference in how long the patients lived, however. The results were published December 26 in JAMA Oncology.

These results support the whole rationale for proton therapy, said the studys lead investigator, Brian Baumann, M.D., of the Washington University School of Medicine in St. Louis and the University of Pennsylvania.

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Delivery Of Hypofractionated Radiation Therapy

Although standard fractionation in prostate cancer is defined as doses of 76 to 80 Gy delivered in daily fractions of 1.8 to 2.0 Gy, moderately hypofractionated doses of 2.4 to 3.1 Gy have been used in an effort to make prostate cancer radiotherapy more convenient and less expensive for patients and insurers. In general, evidence has supported its noninferiority to conventional fractionation using photon-based radiation therapy in the management of low- to intermediate-risk prostate cancer , although 2 studies have shown a nonsignificant increase in late complications . In addition, a few studies have documented the safety and efficacy of moderate hypofractionation with proton therapy.

Henderson et al reported outcomes for 215 men treated with proton therapy on a prospective trial. Patients with low- and intermediate-risk disease were treated to 70 GyRBE and 72.5 GyRBE, respectively, using 2.5 GyRBE per fraction. With a median follow-up of 5.4 years, biochemical control rates were 98.3% and 92.7% for patients with low- and intermediate-risk disease. Furthermore, the risks for grade 3 GI or GU toxicity were 0.5% and 1.7%, respectively.

Types Of Radiation Therapy

Proton Therapy for Prostate Cancer

There are two broad categories of radiation therapy: external beam radiation therapy and brachytherapy. They work as follows:

  • In EBRT, an external source of radiation beams photons or particles into the tumor. In the modern era of radiation oncology, the most common external radiation source is a megavoltage linear accelerator equipped with devices that allow precise shaping of X-ray photons and accurate tumor targeting.
  • In brachytherapy, radioactive sources are implanted in the tumor, either temporarily or permanently.

Prostate cancer may be treated with EBRT alone, brachytherapy alone, or a combination of the two.

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It Helps Only A Few And At A Wildly Extravagant Cost

On Feb. 18, 2014, Scripps Health in San Diego issued a press release that celebrated the opening of the Scripps Proton Therapy Center, a $220 million facility to bring to southern Californians one of the most advanced, accurate treatments available for cancer care.

It sounded like a weapon out of Guardians of the Galaxy: A 95-ton superconducting cyclotron would use hydrogen and oxygen to create a plasma stream. Protons would be extracted from the plasma and accelerated to a speed of 100,000 miles per second. A beam-transport system would direct the proton stream to different treatment rooms, blasting tumors of the prostate, head and neck, breast, spine, lung and gastrointestinal tract, and many childhood cancers.

For those less intrigued by the technical details, the release touted the centers modular stone walls and wood and tile design accents intended to provide a comforting, emotionally supportive environment for healing. Proton therapy, you might reasonably conclude, was the best thing to hit San Diego since sunshine.

Scripps and its two affiliates in the project Rady Childrens Hospital and the University of California San Diego Health System said they could care for up to 2,400 patients annually.

Just after the centers three-year anniversary, however, the sunny skies turned gloomy. The Scripps Proton Therapy Center filed for bankruptcy protection.

Unique Capability

What To Expect After Treatment

Most side effects lessen significantly in the first 3-4 weeks but you may experience urinary and bowel side effects for several weeks after you complete your EBRT treatment. Full recovery however takes three to six months and some patients may never recover to their baseline urinary and bowel function and may need to continue taking medications prescribed during treatment. Rare patients report continued but lessening fatigue for several weeks or months after treatment ends. The better the urinary and bowel functions are prior to radiation, the more likely full recovery occurs.

After both LDR and HDR brachytherapy, you may experience the following:

  • burning with urination
  • increased urination frequency
  • slow or weak urinary stream
  • incomplete emptying of the bladder
  • a brief period of blood in urine
  • perineal pain or soreness

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What To Expect During Ebrt

The first day of treatment may be longer than other sessions because additional imaging is performed that day as part of quality assurance. In most cases, you’ll be scheduled for daily treatments, Monday through Friday. SBRT may be scheduled every other day, instead of daily. You’ll be assigned a treatment time slot, typically but not necessarily at the same time each day. A specifically trained radiation therapist will administer your treatments.

During treatment, you’ll be asked to lie motionless on the treatment table. The area being treated will be exposed and positioned beneath the linac. To deliver the radiation, the head of the machine will move around your body to predetermined angles. On a gantry-based linac, such as a Varian TrueBeam, each treatment takes from five to 20 minutes. On the CyberKnife, each treatment is typically 30 to 60 minutes. Expect to be in the radiation oncology clinic approximately 30 to 60 minutes each day if the TrueBeam is used or 60 to 90 minutes with the CyberKnife.

Please note that many people will be involved in your treatment â your doctor, residents, nurses, therapists, dosimetrists â but your radiation oncologist will supervise your treatment and ensure all steps are being performed accurately.

Study Population And Characteristics

Proton Beam Therapy for Prostate Cancer

During the study period, 373 patients diagnosed with IR prostate cancer were treated in the Radiation Oncology Department of the CSMC 196 patients were treated with RT with concomitant short-term ADT, and 177 patients with RT alone. Table shows population and treatment-related characteristics of patients treated with RT and short-term ADT and RT alone. Patients in both arms were similar in terms of mean age at time of therapy, Gleason score at biopsy, fiducials implants, RT treatment modality , and the Charlson comorbidity score. The mean follow-up time was 55.9±37.2months and did not significantly differed between the two treatment groups. However, compared to patients treated with RT alone, patients treated with a combination of RT+ ADT had significantly more unfavorable risk factors including: higher PSA levels before RT treatment, more intermediate-risk risk factors, and a higher percent of positive cores on biopsy. Moreover, patients receiving RT and ADT had higher T-stage, however the difference did not reach statistical significance . The vast majority of patients in both groups did not receive pelvic lymph node RT , and a higher fraction of patients receiving RT and ADT were administered pelvic lymph node RT.

Table 1 Patient characteristics and treatment

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Pacemakers And Implantable Cardiac Devices

Proton beam therapy may cause fewer side effects than standard radiotherapy. This is because normal cells are exposed to less radiation. The possible side effects will depend on:

  • the area of your body being treated and what structures are close by
  • the amount of proton beam therapy you have
  • other treatments you are having, such as chemotherapy.

Below are some of the side effects of proton beam therapy. They will not affect everyone who has this treatment. Your cancer doctor, specialist nurse or radiographer will explain any possible side effects to you before you start treatment. It is important to tell them about any side effects you get.

Pencil Beam Scanning: Highly Advanced Proton Therapy For Prostate Cancer

At the New York Proton Center, patients with prostate and other genitourinary cancers receive Pencil Beam Scanning. Its the most sophisticated and precise type of proton therapy.

Pencil Beam Scanning allows clinicians to create a highly customized treatment field based on the unique shape, size and location of the prostate cancer tumorsimilar to traditional proton therapy, only with even greater precision.

As the name implies, Pencil Beam Scanning uses an extremely narrow beamjust a few millimeters wideto dot protons onto the cancer. The process is repeated, layer by layer, like paint applied by the tip of an incredibly fine brush. The treatment is ultra-precise, capable of closely regulating the radiation dose according to the volume of the tumor.

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What You Need To Know About The Prostate What Is The Success Rate Of Proton Therapy For Prostate Cancer

A enlarged prostate can also cause blockages in the urethra. A blocked urethra can also damage the kidneys. A patient suffering from an enlargement of the prostate may have pain in his lower abdomen and genitals. If pain is present, a digital rectal examination will reveal hard areas. A doctor may prescribe surgery or perform an endoscopic procedure. If the enlarged prostate is not completely removed, it will shrink.

While the size of an enlarged prostate will influence the extent of urinary symptoms, men may experience a range of urinary symptoms. Some men have minimal or no symptoms at all. Some men will have a very enlarged prostate, whereas others will have a mild enlargement. Generally, the symptoms can stabilize over time. Some men may have an enlarged prostate but not notice it. If they have an enlarged colon, their physician can perform a TURP procedure.

Current Indications For Proton Therapy In The Management Of Prostate Cancer

Proton Therapy Intermediate-Risk (Teal) Prostate Cancer | Prostate Cancer Staging Guide

Proton therapy is indicated in several clinical scenarios in the management of patients with prostate cancer in light of its potential to reduce the risk for acute and late toxicities related to dosimetric advantages compared with photon-based radiation therapy. The indications for proton therapy are listed in Table 1 and are summarized below.

Comparisons of and indications for intensity-modulated radiotherapyvolumetric modulated arc radiotherapy , double-scattering proton therapy , and intensity-modulated proton therapy .

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Side Effects During Treatment

Undergoing EBRT is similar to having routine X-rays and no more uncomfortable. Radiation cannot be seen, smelled, or felt. Patients are usually able to continue with their normal daily activities during treatment. But many do experience side effects. If you’re having conventional radiation treatments, side effects generally don’t appear until the second or third week. They may show up earlier if you’re having prostate SBRT, LDR, or HDR brachytherapy.

Because radiation therapy is a local treatment, any side effects will primarily involve the area where the radiation is directed. With prostate cancer, patients may experience some or all of the following:

  • Increased urination frequency
  • Urinary urgency with rare leakage
  • Weak urinary stream
  • Mild burning or tingling during urination
  • Loose stools or diarrhea
  • Softer and smaller bowel movements
  • Increased frequency of bowel movements
  • Worsening of existing hemorrhoids or rectal irritation with occasional scant blood
  • Generalized fatigue of varying severity

Despite the fatigue, patients receiving radiation therapy usually find they can function and work as usual. Many studies show that regular exercise during the course of radiation therapy can ease side effects, including fatigue.

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