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Borderías-Villarroel E, Barragán-Montero A, Sterpin E. Time is NTCP: Should we maximize patient throughput or perform online adaptation on proton therapy systems? Radiother Oncol 2024; 198:110389. [PMID: 38885906 DOI: 10.1016/j.radonc.2024.110389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Compared to conventional radiotherapy (XT), proton therapy (PT) may improve normal tissue complication probabilities (NTCP). However, PT typically requires higher adaptation rates due to an increased sensitivity to anatomical changes. Systematic online adaptation may address this issue, but it requires additional replanning time, decreasing patient throughput. Therefore, less patients would benefit in such case from PT for a given machine capacity, with results in worse NTCP. AIM To investigate the trade-off between PT patient throughput and NTCP gain as a function of the time needed for adaptation. METHODS A retrospective database of 14 lung patients with two repeated 4DCTs was used to compare NTCP values between XT and PT for NTCP2ym (2-year mortality), NTCPdysphagia and NTCPpneumonitis. Four scenarios were considered for PT: no adaptation using clinical robustness parameters (4D robust optimization, 3 % range error and PTV-equivalent setup errors); systematic online adaptation with clinical robustness parameters; setup errors reduced to 4 mm and to 2 mm. Dose was accumulated on the planning CT. The number of patients treated with PT depended on the extra time needed for adaptation, assuming an 8-hours capacity (assuming 14 patients a day; thus minimum 34.2 min per treatment session if there is no or instantaneous adaptation). RESULTS Baseline NTCP gains (PT against XT without adaptation) equaled 6.9 %, 6.1 %, and 7.7 % for NTCP2ym, NTCPdysphagia and NTCPpneumonitis, respectively. Using instantaneous online adaptation and setup errors of 2 mm, the overall gains were then 10.7 %, 13.6 % and 12.4 %. Taking into account loss of capacity, 13.7 min was the maximum extra-time allowed to complete adaptation and maintain an advantage on all three metrics for the 2-mm setup error scenario. CONCLUSION This study highlights the critical importance of keeping short online adaptation times when using systems with limited capacity like PT.
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Affiliation(s)
- E Borderías-Villarroel
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - A Barragán-Montero
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium
| | - E Sterpin
- UCLouvain, Institut de recherche expérimentale et clinique, Molecular Imaging and Radiation Oncology (MIRO) Laboratory, Brussels, Belgium; KU Leuven, Department of Oncology, Laboratory of external radiotherapy, Leuven, Belgium; Particle Therapy Interuniversity Center Leuven - PARTICLE, Leuven, Belgium.
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Amstutz F, Krcek R, Bachtiary B, Weber DC, Lomax AJ, Unkelbach J, Zhang Y. Treatment planning comparison for head and neck cancer between photon, proton, and combined proton-photon therapy - From a fixed beam line to an arc. Radiother Oncol 2024; 190:109973. [PMID: 37913953 DOI: 10.1016/j.radonc.2023.109973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 09/25/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND PURPOSE This study investigates whether combined proton-photon therapy (CPPT) improves treatment plan quality compared to single-modality intensity-modulated radiation therapy (IMRT) or intensity-modulated proton therapy (IMPT) for head and neck cancer (HNC) patients. Different proton beam arrangements for CPPT and IMPT are compared, which could be of specific interest concerning potential future upright-positioned treatments. Furthermore, it is evaluated if CPPT benefits remain under inter-fractional anatomical changes for HNC treatments. MATERIAL AND METHODS Five HNC patients with a planning CT and multiple (4-7) repeated CTs were studied. CPPT with simultaneously optimized photon and proton fluence, single-modality IMPT, and IMRT treatment plans were optimized on the planning CT and then recalculated and reoptimized on each repeated CT. For CPPT and IMPT, plans with different degrees of freedom for the proton beams were optimized. Fixed horizontal proton beam line (FHB), gantry-like, and arc-like plans were compared. RESULTS The target coverage for CPPT without adaptation is insufficient (average V95%=88.4 %), while adapted plans can recover the initial treatment plan quality for target (average V95%=95.5 %) and organs-at-risk. CPPT with increased proton beam flexibility increases plan quality and reduces normal tissue complication probability of Xerostomia and Dysphagia. On average, Xerostomia NTCP reductions compared to IMRT are -2.7 %/-3.4 %/-5.0 % for CPPT FHB/CPPT Gantry/CPPT Arc. The differences for IMPT FHB/IMPT Gantry/IMPT Arc are + 0.8 %/-0.9 %/-4.3 %. CONCLUSION CPPT for HNC needs adaptive treatments. Increasing proton beam flexibility in CPPT, either by using a gantry or an upright-positioned patient, improves treatment plan quality. However, the photon component is substantially reduced, therefore, the balance between improved plan quality and costs must be further determined.
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Affiliation(s)
- Florian Amstutz
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Reinhardt Krcek
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Radiation Oncology, University Hospital Zurich, Switzerland; Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Antony J Lomax
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland; Department of Physics, ETH Zurich, Switzerland
| | - Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zurich, Switzerland
| | - Ye Zhang
- Center for Proton Therapy, Paul Scherrer Institute, Switzerland.
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Gaito S, Aznar MC, Burnet NG, Crellin A, France A, Indelicato D, Kirkby KJ, Pan S, Whitfield G, Smith E. Assessing Equity of Access to Proton Beam Therapy: A Literature Review. Clin Oncol (R Coll Radiol) 2023; 35:e528-e536. [PMID: 37296036 DOI: 10.1016/j.clon.2023.05.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
Proton beam therapy (PBT) is one of the most advanced radiotherapy technologies, with growing evidence to support its use in specific clinical scenarios and exponential growth of demand and capacity worldwide over the past few decades. However, geographical inequalities persist in the distribution of PBT centres, which translate into variations in access and use of this technology. The aim of this work was to look at the factors that contribute to these inequalities, to help raise awareness among stakeholders, governments and policy makers. A literature search was conducted using the Population, Intervention, Comparison, Outcomes (PICO) criteria. The same search strategy was run in Embase and Medline and identified 242 records, which were screened for manual review. Of these, 24 were deemed relevant and were included in this analysis. Most of the 24 publications included in this review originated from the USA (22/24) and involved paediatric patients, teenagers and young adults (61% for children and/or teenagers and young adults versus 39% for adults). The most reported indicator of disparity was socioeconomic status (16/24), followed by geographical location (13/24). All the studies evaluated in this review showed disparities in the access to PBT. As paediatric patients make up a significant proportion of the PBT-eligible patients, equity of access to PBT also raises ethical considerations. Therefore, further research is needed into the equity of access to PBT to reduce the care gap.
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Affiliation(s)
- S Gaito
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK.
| | - M C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - N G Burnet
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - A Crellin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; National Lead Proton Beam Therapy NHS England, UK
| | - A France
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK
| | - D Indelicato
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida, USA
| | - K J Kirkby
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - S Pan
- Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - G Whitfield
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
| | - E Smith
- Proton Clinical Outcomes Unit, The Christie NHS Proton Beam Therapy Centre, Manchester, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK; Department of Proton Beam Therapy, The Christie Proton Beam Therapy Centre, Manchester, UK
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Mendenhall WM, Beitler JJ, Saba NF, Shaha AR, Nuyts S, Strojan P, Bollen H, Cohen O, Smee R, Ng SP, Eisbruch A, Ng WT, Kirwan JM, Ferlito A. Proton Beam Radiation Therapy for Oropharyngeal Squamous Cell Carcinoma. Int J Part Ther 2023; 9:243-252. [PMID: 37169005 PMCID: PMC10166016 DOI: 10.14338/ijpt-22-00030.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/10/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose To discuss the role of proton beam therapy (PBT) in the treatment of patients with oropharyngeal squamous cell carcinoma (OPSCC). Materials and Methods A review of the pertinent literature. Results Proton beam therapy likely results in reduced acute and late toxicity as compared with intensity-modulated radiation therapy (IMRT). The extent of the reduced toxicity, which may be modest, depends on the endpoint and technical factors such as pencil beam versus passive scattered PBT and adaptive replanning. The disease control rates after PBT are likely similar to those after IMRT. Conclusion Proton beam therapy is an attractive option to treat patients with OPSCC. Whether it becomes widely available depends on access.
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Affiliation(s)
- William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jonathan J. Beitler
- Harold Alfonds Center for Cancer Care, Maine General Hospital, Augusta, ME, USA
| | - Nabil F. Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ashok R. Shaha
- Department of Head and Neck Surgery and Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sandra Nuyts
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
- Laboratory of Experimental Radiotherapy, Department of Oncology, University of Leuven, Leuven, Belgium
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Heleen Bollen
- Department of Radiation Oncology, Leuven Cancer Institute, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - Oded Cohen
- Department of Otolaryngology - Head and Neck Surgery and Oncology, Soroka Medical Center, Tel Aviv, Affiliated with Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre, Austin Health, Melbourne, Australia
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan Medicine, Ann Arbor, Michigan, USA
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jessica M. Kirwan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, Padua, Italy
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Nuyts S, Bollen H, Ng SP, Corry J, Eisbruch A, Mendenhall WM, Smee R, Strojan P, Ng WT, Ferlito A. Proton Therapy for Squamous Cell Carcinoma of the Head and Neck: Early Clinical Experience and Current Challenges. Cancers (Basel) 2022; 14:cancers14112587. [PMID: 35681568 PMCID: PMC9179360 DOI: 10.3390/cancers14112587] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022] Open
Abstract
Simple Summary Proton therapy is a promising type of radiation therapy used to destroy tumor cells. It has the potential to further improve the outcomes for patients with head and neck cancer since it allows to minimize the radiation dose to vital structures around the tumor, leading to less toxicity. This paper describes the current experience worldwide with proton therapy in head and neck cancer. Abstract Proton therapy (PT) is a promising development in radiation oncology, with the potential to further improve outcomes for patients with squamous cell carcinoma of the head and neck (HNSCC). By utilizing the finite range of protons, healthy tissue can be spared from beam exit doses that would otherwise be irradiated with photon-based treatments. Current evidence on PT for HNSCC is limited to comparative dosimetric analyses and retrospective single-institution series. As a consequence, the recognized indications for the reimbursement of PT remain scarce in most countries. Nevertheless, approximately 100 PT centers are in operation worldwide, and initial experiences for HNSCC are being reported. This review aims to summarize the results of the early clinical experience with PT for HNSCC and the challenges that are currently faced.
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Affiliation(s)
- Sandra Nuyts
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
- Correspondence:
| | - Heleen Bollen
- Laboratory of Experimental Radiotherapy, Department of Oncology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium;
- Department of Oncology, Leuven Cancer Institute, Universitair Ziekenhuis Leuven, 3000 Leuven, Belgium
| | - Sweet Ping Ng
- Department of Radiation Oncology, Austin Health, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - June Corry
- Division of Medicine, Department of Radiation Oncology, St. Vincent’s Hospital, The University of Melbourne, Melbourne, VIC 3000, Australia;
| | - Avraham Eisbruch
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA;
| | - William M Mendenhall
- Department of Radiation Oncology, College of Medicine, University of Florida, Gainesville, FL 32209, USA;
| | - Robert Smee
- Department of Radiation Oncology, The Prince of Wales Cancer Centre, Sydney, NSW 2031, Australia;
| | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Wai Tong Ng
- Department of Clinical Oncology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China;
| | - Alfio Ferlito
- Coordinator of the International Head and Neck Scientific Group, 35125 Padua, Italy;
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6
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Mohan R. A review of proton therapy – Current status and future directions. PRECISION RADIATION ONCOLOGY 2022; 6:164-176. [DOI: 10.1002/pro6.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Radhe Mohan
- Department of Radiation Physics, MD Anderson Cancer Center Houston Texas USA
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