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.
Literature Search Results And Characteristics
Our searches of four databases yielded 6,378 articles. After 413 duplication records were removed, titles and abstracts of these records were screened for inclusion. Full texts of 46 records were read, and 33 studies met the inclusion criteria .
Figure 1 Flow diagram of the literature screening process and results.
Twenty PBT-related studies involved 48,765 patients with a median mean age of 66 years old. Median follow-up across all studies was 43.4 months . The included studies were published from 2010 to 2020. Most of the studies were from the USA , five from Japan , and one from Korea . For the trials from the USA, most of the studies set irradiation dose at 7082 GyE delivered in 544 fractions. For the five trials from Japan, the irradiation dose was usually set at 6380 GyE delivered in 2039 fractions. For one trial from Korea, they set irradiation dose at 3560 GyE delivered in 520 fractions. The basic characteristics of the included studies are shown in Table 1.
Table 1 Basic characteristics of included studies.
Prostate Cancer Treatment Proton Beam Therapy
Overview by Dr Sarah HarrisProfile
In 2022 , the options for the active treatment of non metastatic prostate cancer are many .This provides men with many decisions to make , knowing that the chances of cure or control of localised prostate cancer are likely to be high but the side effects are different .
Within the non-surgical options are radiotherapy treatments which have also evolved significantly in the last 2 decades . This page concentrates on the use of proton beam therapy a less common form of external beam radiotherapy .
Why might Protons be good a Cancer treatment?
Radiation is a form of energy which causes changes to the chromosomes or genetic material of cells as is passes through the body tissues . This damage preferentially kills cancer cells allowing normal body tissues to recover from the damage .
High energy Xrays deliver their highest dose of energy just under the skin and then fall away as they are absorbed passing deeper into the tissues . Protons are charged particles and deliver their majority of their energy at one depth the Bragg peak and then stop beyond this point. The energy or strength of the proton beam is selected to have this peak where the tumour is to be treated .
Why might Protons be good for treating Prostate Cancer ?
Sadly , there is no level 1 evidence comparing proton and X-ray treatment for early prostate cancer yet and clinical trials are now underway to answer this question .
How many treatments do I need?
Summary
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Radiation Therapy For Prostate Cancer
Radiation therapy uses high-energy rays or particles to kill cancer cells. Depending on the stage of the prostate cancer and other factors, radiation therapy might be used:
- As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
- As part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues.
- If the cancer is not removed completely or comes back in the area of the prostate after surgery.
- If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.
What Side Effects Will I Have
During your treatment, radiation must pass through your skin. You may notice some skin changes in the area exposed to radiation. Your skin may become red, swollen, warm, and sensitive, as if you have a sunburn. It may peel or become moist and tender. Depending on the dose of radiation you receive, you may notice a loss of hair or decreased perspiration within the treated area.
These skin reactions are common and temporary. They will subside gradually within four to six weeks of completing treatment. If skin changes appear outside the treated area, inform your doctor or primary nurse.
Long-term side effects, which can last up to a year or longer after treatment, may include a slight darkening of the skin, enlarged pores, increased or decreased sensitivity of the skin, and a thickening of tissue or skin.
Another possible side effect is erectile dysfunction and urinary symptoms such as frequency, bleeding, or, rarely, incontinence. Keep these side effects in mind when considering your treatment options. If you have any concerns, donât hesitate to talk to your doctor about them.
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Proton beam Therapy At the #JohnsHopkins Proton Therapy Center, the action starts in a huge particle accelerator known as a synchrotron, where protons spin a. Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator.Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body. It may also be used as part of adjuvant. Proton Beam Therapy machine – Credit: Mayo Clinic. A proton is a positively charged subatomic particle. Protons are used within Proton Therapy, also known as Proton Beam Therapy, which is a treatment for cancer. At high energy, the protons can kill cancer cells. Examples of diseases that are targeted are prostate cancer, brain cancers, and tumors.
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The machine that will enable cancer patients to receive high energy proton beam therapy on the NHS for the first time has arrived. Manchester’s Christie hospital will be.
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Technical Delivery Of Proton Therapy
A minimum standard of treatment delivery must be followed to ensure the accuracy and effectiveness of proton therapy for prostate cancer. The goals of delivery should be to overcome 3 fundamental radiation therapy challenges: to minimize uncertainty regarding the precise location of the target during beam exposure, to maximize target coverage, and to minimize radiation exposure to organs at risk.
Although intrafraction and interfraction variability must be accounted for with both proton- and photon-based treatment planning, there is a proton-specific uncertainty called range uncertainty, which refers to the effect on the proton beam range that the slight variations in prostate position may have on the composition of tissues in the beam path. Range uncertainty is based on modeling studies and includes the addition of a margin to the proximal and distal edge of the target.
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New Study Compares Long
- By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases
Prostate cancer therapies are improving over time. But how do the long-term side effects from the various options available today compare? Results from a newly published study are providing some valuable insights.
Investigators at Vanderbilt University and the University of Texas MD Anderson Cancer Center spent five years tracking the sexual, bowel, urinary, and hormonal status of nearly 2,000 men after they had been treated for prostate cancer, or monitored with active surveillance . Cancers in all the men were still confined to the prostate when diagnosed.
Dr. Karen Hoffman, a radiation oncologist at MD Anderson and the studys first author, said the intent was to provide information that could help men choose from among the various therapeutic options. Surgical and radiation techniques have changed significantly in the last few decades, and at the same time, active surveillance has become an increasingly acceptable strategy, she said. We wanted to understand the adverse events associated with contemporary approaches from the patients perspective.
Roughly two-thirds of the men enrolled in the study had favorable risk cancer, which is nonaggressive and slow-growing. A quarter of these men chose active surveillance, and the rest were treated with one of three different methods:
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Proton Therapy Vs Other Prostate Cancer Treatments
Is proton therapy superior to hormone therapy or chemotherapy? The answer might not be that simple because it depends on what you need.
Each treatment method has its pros and cons. They also have specific applications, and using them or not in a determined patient depends on comprehensive studies that evaluate what works better for most.
However, for educative purposes, lets make a brief comparison between proton therapy and other prostate cancer treatments:
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Advantages Of Proton Therapy For Prostate Cancer
Proton therapy has proven to show remarkable promise and advantages over conventional therapy-especially in the treatment of prostate cancer. Proton radiation therapys accuracy and the control it gives physicians in terms of adapting treatment make it a non-invasive and low-risk option for prostate cancer treatment.
Intensity Modulated Radiation Therapy
IMRT, an advanced form of 3D-CRT therapy, is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity of the beams can be adjusted to limit the doses of radiation reaching nearby normal tissues. This lets doctors deliver an even higher radiation dose to the cancer.
Some newer radiation machines have imaging scanners built into them. This advance, known as image guided radiation therapy , lets the doctor take pictures of the prostate just before giving the radiation to make minor adjustments in aiming. This appears to help deliver the radiation even more precisely and results in fewer side effects.
A variation of IMRT is called volumetric modulated arc therapy . It uses a machine that delivers radiation quickly as it rotates once around the body. This allows each treatment to be given over just a few minutes. Although this can be more convenient for the patient, it hasnt yet been shown to be more effective than regular IMRT.
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Developing The Uk Proton Beam Therapy Service
The government committed £250 million capital investment for both NHS proton beam therapy centres. This includes the buildings and PBT cyclotron and gantries, providing 6 NHS treatment rooms .
Both Trusts have more information about the new proton beam therapy centres on their websites. This includes information on the clinical facilities, their location and, for UCLH, progress on construction.
Is Proton Beam Therapy Safer Than Other Options
Due to the concentrated nature of the radiation in proton therapy, there are usually fewer side effects than in conventional radiation therapy. Thats because theres less damage to healthy tissue around the tumor.
People who have proton therapy may have a significantly lower risk of short- and long-term complications compared with people receiving traditional photon therapy, according to a research study . These findings show a two-thirds reduction of adverse events in the 90 days after treatment, as well as a significantly reduced risk of having difficulties moving and performing daily activities.
However, long-term data is lacking on the safety of proton beam therapy. Furthermore, due to the high cost of treatment, current research has been limited in terms of demographics.
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Who Is A Good Candidate
In most cases, you will be a good candidate for proton therapy if you were initially offered radiotherapy as an option. Patients who receive radiotherapy usually have no problems being a candidate for proton treatment. They are usually patients in an early stage or those with localized prostate cancer. It is also useful to keep advanced cancer under control for as long as possible and treat recurrent prostate cancer cases.
However, some patients may not benefit from proton therapy if they have one of these problems :
- In patients with hip replacements, because proton beams often cant reach beyond the prosthesis. In some proton therapy centers, these patients can still get a session when a hip replacement is limited to one side. But bilateral replacement makes it impossible to treat the patient with proton beam therapy.
- In patients with advanced prostate cancer in which treating the pelvic lymph nodes is fundamental. Since proton beam radiation is less likely to reach other tissues than the prostate, it is not applicable when treating surrounding lymph nodes.
- In overweight patients, because the proton beam can only go through a determined depth. This depth depends on the beams energy, and some centers may have a higher energy device that solves the problem.
Potential Advantages Of Proton Therapy
The relative advantages and disadvantages of proton therapy when compared with photon radiation have evolved over time as the radiation oncology community continues to refine the planning and delivery techniques for both modalities. The results of those comparisons depend on the delivery technique: intensity-modulated proton therapy or double-scattered proton therapy versus static intensity-modulated radiation therapy or volumetric arc photon therapy. The outcomes and costs are further modified by the facility-specific image guidance, motion management, and robust optimization. Nevertheless, some broad conclusions can be drawn concerning the advantages of protons over photons in radiation delivery.
Proton therapy has the potential to improve radiation dose homogeneity, especially within the PTV. Plan homogeneity is desirable with fractionated radiation therapy a homogenous plan avoids delivering hot spots, which are areas of unintentionally elevated dose either within the target volume or in the surrounding organs at risk. Trofimov et al showed that proton therapy reduced the maximum dose and the volume receiving more than 110% of the maximum dose when compared with IMRT among patients treated for prostate cancer.
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Current Indications For Proton Therapy In The Management Of Prostate Cancer
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 .
Time Needed For Each Treatment
In general, a proton radiation treatment lasts about 15 to 30 minutes, starting from the time you enter the treatment room. The time will depend on the part of the body being treated and the number of treatments. It will also depend on how easily the team can see the tumor site with x-rays or CT scans during the positioning process.
Ask your health care team how long each treatment will take. Sometimes, the doctor will need to give treatment from different gantry angles. Ask your team if this will happen for your treatment. Find out if they will come back into the room during treatment to move the gantry or if the gantry will be rotated around you.
It is also important to know that total time in the treatment room may vary from day to day. This is because the doctor may target different areas that require other radiation âfields.” This may require using various kinds of proton beam segments. For example, one treatment may deliver a part of the total radiation dose to lymph nodes and healthy tissues around the tumor that may contain tiny amounts of tumor. Another treatment may deliver a radiation dose to the main tumor.
Other factors can also affect the total time needed, such as waiting for the proton beam to be moved after another person’s treatment is finished. Most proton treatment centers have only one proton machine.
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External Beam Radiation Therapy: How It Works
EBRT refers to the external delivery of any type of radiation, and can use several different types of energy including photons, electrons, and heavy particles . Additionally, there has been an evolution in the methods to deliver this energy , progressing from two-dimensional radiation therapy to three-dimensional conformal radiation therapy , and, more recently, intensity-modulated radiation therapy .
Dose distribution curves of photon and proton beams. The spread-out Bragg peak is demonstrated here to cover the entire target with the maximal dosage.
Schematic of multileaf collimator. Individually positioned tungsten leaflets conform the shape of the beam to the target as used in three-dimensional conformal radiation therapy.
Advances in image guidance such as on-board imaging units have helped to deliver the radiation more accurately to the prostate. These have dramatically decreased the uncertainty in target localization and improved the accuracy of radiotherapy to the prostate. However, despite all of these advances, the physical parameters of a photon beam will always include both entrance and exit doses and, ultimately, a significant volume of normal tissue receiving low to moderate doses.
Protons: A Different Mechanism
Protons can also be administered by two methods. The older method includes large beams of passively scattered protons that are shaped with the use of high-density blocks or apertures to shape the large beam as it exits the nozzle. Compensators are employed within the beam to alter the beam profile to better conform the SOBP to the actual tumor. A second, newer method employs a very narrow, pencil thin beam to paint the dose on the target, and no blocks or compensators are needed. The pencil beam is swept in a raster pattern back and forth across a target guided out of the nozzle by magnets . This allows the delivery of intensity-modulated proton beam therapy , with a greater ability to conform the dose to an irregularly shaped target. Although not widely available, many new facilities are being planned with pencil beam-only systems.
Pencil beam scanning. The pencil beam is swept in a raster pattern back and forth across a target. Reproduced with permission from Mayo Clinic News Network.
aAs determined by Phoenix criteria. bAs determined by American Society for Therapeutic Radiology Oncology criteria. c Determined by a rise in prostate-specific antigen to > 50% than the nadir and > 2 ng/mL.
2D, two-dimensional 3D, three-dimensional GI, gastrointestinal GU, genitourinary HD, high dose IMRT, intensity-modulated radiation therapy LD, low dose.
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