Proton Therapy Updates
September 2020

The aim of this newsletter is to promote knowledge on proton cancer therapy form a cross-disciplinary perspective: from development in equipment to impacts to healthcare.

PROF. DR. FELIPE CALVO MANUEL
DR. DIEGO AZCONA

Last April 2020, at the height of the global pandemic, we achieved the healthcare milestone of launching the clinical activity of our Proton Therapy Unit.

Although COVID-19 was the healthcare priority at the time, many patients had tumours whose treatment could not be delayed. Under said circumstances, the daily medical activity carried out at our centre was truly a clinical miracle.

At the beginning of March, just before the expected launch of this unit, the whole world collapsed due to the emergence of an unknown, threatening and lethal disease. As confinement was imperative, we had less healthcare professionals working at our facility while the number of patients requiring this treatment still continued to increase.

Not only did we meet adults who were fighting for their lives and who wanted to beat the tumour, but also parents, such those of Ahinara, who were able to cross the world in the midst of the pandemic so that their daughter could receive proton therapy. These patients have taught us life lessons that can only be learned in the face of adversity. 

Thus, on April 2nd, at the height of the pandemic and with only two weeks of delay with respect to the initial strategic plan designed and approved 28 months earlier, we began our healthcare activity at the Proton Unit.

Following this brief overview of the moments that we have all experienced with great uncertainty, we hereby present you with a new newsletter aimed at strengthening our scientific and educational ties. We are in full swing and spreading the message of facing normality with a passion for making technological innovation available to our patients.

Prof. Dr. Felipe Calvo Manuel 
Dr. Diego Azcona

Clinica Universidad de Navarra Proton Therapy Unit

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Clínica Universidad de Navarra. Sede Madrid
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28027 Madrid, Spain

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Technology-Driven Research for Radiotherapy Innovation

Molecular Oncology 2020

Technological development in the field of Radiation Oncology has occurred at an overwhelming speed over the past 20 years. The application of Physics and Engineering to ensure precise dose delivery in the human body has opened the doors to measuring the clinical benefit of this treatment based on differential biological effects. Hypofractionation allows for examining radioimmunogenicity in multiple clinical models and protecting normal tissues from unnecessary irradiation (“costicity” or the cost derived from the treatment and care of radiotherapeutic toxicity in standard clinical practice).

Protons are part of a technological development whose clinical functionality is expanding by means of instrumental miniaturisation, superior dosimetric distribution, the maximisation of their bioeffects (anti-tumour and functional preservation of normal tissues), the feasibility of transitioning its equipment to flash irradiation, and the possibility of incorporating in vivo dosimetry using positron emission tomography.

Protontherapy Versus Best Photon for Mediastinal Hodgkin Lymphoma: Dosimetry Comparison and Treatment Using ILROG Guidelines

Cancer Radiotheraphie 2019

Hodgkin's lymphoma with mediastinal involvement is a curable disease with a high incidence among young patients. Radiotherapy is used for consolidation purposes at restricted volumes and intermediate doses. In this clinical context (very long-term survivors and intermediate radiation doses), minimising radiation side effects on normal tissues is decisive.

Dosimetric comparisons between photon and proton therapy (guided by the technical recommendations of the cooperative International Lymphoma Radiation Oncology Group [ILROG]) revealed that, compared with photons, protons offered a protection against risks at the level of the lungs, heart, and breasts, all of which are affected by delayed, severe radioinduced effects, such as heart disease and secondary tumours. Thus, medical oncologists, haematologists, and paediatric oncologists should be aware of this treatment option.

Early Experience of the First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Centre

Frontiers in Oncology 2020

Knowing the real experience of the launch of a Proton Therapy Unit in the context of an Integrated Cancer Centre dependent on an academic institution provides insight on the expected activity patterns in a multidisciplinary oncological context. One hundred and thirty‑two (132) patients (22% neurooncological patients, 19% reirradiations, and 42% treated with concurrent chemotherapy) were treated over a period of 15 months. Insurance coverage was denied in 65% of cases (30% were finally approved, with the definitive approval taking a mean of 17 days to be negotiated).

Access to proton therapy in the American healthcare system requires extensive support work for its administrative management. The Integrated Cancer Centre ensures the diversity of the patients, their cancers, and their multidisciplinary coordination (integrated proton therapy in complex healthcare processes).

Phase II Study of Hypofractionated Proton Beam Therapy for Hepatocellular Carcinoma

Frontiers in Oncology 2020

Hepatocarcinoma is an emerging indication in proton therapy. This phase II study performed with 45 patients with a progressing or recurring condition after receiving previous treatments (selected for technical dosimetric feasibility) showed that 70 Gy (equivalent dose in 2-Gy fractions [EQD2]) administered in 10 fractions (moderate hyperfractionation) induced a local control of the disease in 95% of cases and survival in 86% of cases after <3 years of follow-up (median follow-up duration of 35.1 months). Non-local intrahepatic progression (outside the proton therapy target) is the most frequent type.

These results confirm previous observations regarding the potential of proton therapy in the treatment of hepatocarcinoma (in its worst progressive version; that is, recurrent or with primary progression after previous treatments). Moderate hyperfractionation (10 days) makes the proton therapy component more manageable for patients who need to travel or have an overall compromised condition.

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