• Proton Therapy Treatment
What is Proton Therapy?

Proton therapy is a radiation therapy that uses tiny particles called protons. Protons are excellent cell killers, but because of the way protons deliver their energy, proton therapy does not damage as much healthy tissue as much as photon therapy. Therefore, a higher dose of radiation can be targeted at the tumour without affecting many normal healthy cells.

What type of cancer can be treated with Proton Therapy?

Proton therapy can be effective in treating many types of tumours, including tumours of the brain, head and neck, central nervous system, lung, prostate and gastrointestinal system. Proton therapy is often the preferred option for treating solid tumours in children because protons can be controlled precisely so there is less radiation of normal tissues, helping prevent serious complications and lessening the chance of secondary tumours. Proton beam therapy is the preferred standard for many tumours, including:

  • Ocular tumours, including intraocular melanomas
  • Tumours that approach or are located at the base of skull such as Chordoma and Chondrosarcomas
  • Spine tumours - Primary or metastatic
  • Hepatocellular cancer
  • Paediatric solid tumours - primary or benign tumours in children
  • Brain and spinal cord tumours - Malignant and benign
  • Advanced and/or unrespectable head and neck cancers such as Cancers of the paranasal sinuses and other accessory sinuses; e.g. adenoid cystic carcinoma, Advanced Nasopharyngeal cancer and Advanced cancer of the buccal mucosa
  • Retroperitoneal sarcomas
  • Re-irradiation cases- where radiation is being considered for the second or third time to the same site

The above sites have sufficient evidence available currently, that there is a definite benefit in using proton therapy. However, many other cancers may also have a benefit when proton therapy is used, especially when compared to conventional X-ray therapy. These include:

  • Oesophageal cancers
  • Breast Cancer
  • Oropharynx Cancer
  • Salivary Gland cancers
  • Lung Cancer
  • Prostate Cancer
  • Sarcomas
  • Tumours in the base of the skull
Proton Therapy for Lung Cancer

Proton therapy for lung cancer treatment is one of the many exciting developments in the field. Despite best advances with photon therapy such as IMRT, IGRT, Cyberknife, Helical tomotherapy, the doses received by heart and lungs sometimes remain prohibitive. Even if the dose is within the thresholds, there is significant cardiopulmonary toxicity leading to significant morbidity (upto 80%) and even mortality (up to 5%). Proton therapy because of its unique physical and biological properties can deliver significantly lower doses to critical structures such as healthy lung as well as heart thereby limiting the collateral damage.

Why should you choose Proton Therapy for Prostate Cancer?

Proton therapy is one of the most effective forms of treatment for prostate cancer. Proton therapy may be used as the only treatment or can be combined with hormonal therapy or after other treatments, such as surgery, to manage cancer that has recurred or is at high risk of recurrence.

Because it involves significantly less radiation exposure to normal tissues, proton therapy lowers the risk of side effects and secondary radiation-induced cancers. Proton therapy has an excellent record of success, providing long-term disease control and survival rates equivalent to other treatments, including surgery.

What is the success rate of Proton Therapy?

Proton therapy is at least as effective as conventional radiation therapy, but with fewer side effects. In some cases, proton therapy is not only the best but also the only option. It has been proven to be successful in curing or controlling many cancers when used appropriately. Success after radiation therapy depends on the type and stage of cancer treated. In certain cancers like chordomas, brain tumours or liver cancers, control rates with proton therapy can be as high as 85-90%.

What is Proton Therapy used for?

Proton beam therapy (PBT) is an advanced form of radiotherapy, with radiation treatment delivered by accelerated proton beams rather than X-rays. A proton beam delivers some radiation to healthy tissue in reaching the tumour but very little radiation beyond the edge of the tumour being treated. This means PBT is able to treat cancers just as effectively but delivers less radiation to other healthy parts of the body which surround the tumour.

What is the Physics of Proton Therapy?

The best way to understand how proton therapy works is to take a look at the physics and engineering inside the proton accelerator, or the cyclotron/synchrotron, and the beam delivery system.

  • The proton begins its journey at the ion source. Within fractions of a second, hydrogen atoms are separated into negatively charged electrons and positively charged protons.
  • The protons are injected via a vacuum tube into a linear accelerator and in only a few microseconds, the protons’ energy reaches 7 million electron volts.
  • Proton beams stay in the vacuum tube as they enter the cyclotron/ synchrotron, where acceleration increases their energy to a total of 70 million to 250 million electron volts, enough to place them at any depth within the patient’s body.
  • After leaving the synchrotron, the protons move through a beam-transport system comprised of a series of magnets that shape, focus and direct the proton beam to the appropriate treatment room.
  • To ensure that each patient receives the prescribed treatment safely and efficiently, the facility is controlled by a network of computers and safety systems.
  • The gantry can revolve 360 degrees, allowing the beam to be delivered at any angle.
  • As protons come through the nozzle, a system of electromagnets placed perpendicular to each other bends each beam so that they reach the planned position within the depth of the tumour. This is called pencil-beam scanning (PBS).
  • At Apollo Proton Cancer Centre, we have the latest PBS technology which enables us to deliver highly focused treatments to each tumour, and each tumour is treated with protons, spot- by- spot and layer-by-layer.
  • At maximum energy, a proton beam travels 125,000 miles per second, which is equivalent to the two-thirds the speed of light. From the ion source to the patient, a proton typically travels 313,000 miles.
  • Once the proton enters the body, it slowly increases the energy deposited in the tissue until it reaches a particular depth where it deposits almost all of its energy and comes to a halt. This effect is called Bragg’s Peak Effect. Thus, unlike an X-ray beam that passes through the entire body, the proton beam actually stops at a particular depth within the tumour. By manipulating the energy of the proton beam and the position of the spot, the tumour is treated with a high dose of radiation while the surrounding tissues are spared of radiation dose.
History of Proton Therapy

The advancements of proton technology as a treatment option for cancer began in the 1940s. The idea of using protons in medical treatment was first suggested in 1946 by physicist Robert R. Wilson, Ph.D. The first attempts to use proton radiation to treat patients began in the 1950s in nuclear physics research facilities, but applications were limited to a few areas of the body. In the late 1970s, imaging advancements coupled with the development of sophisticated computers and improved accelerator and treatment delivery technology made proton therapy more viable for routine medical applications, such as cancer treatment.

Only in recent years has it become possible to develop proton beam facilities in conjunction with established medical centres. Initially, proton therapy machines were designed so that a narrow beam of protons that emerges from the nozzle was then widened (scattered) and shaped to conform to the shape of the tumour, by custom-made accessories (collimators and compensators) which had to be mounted on the nozzle. This was called passively scattered proton therapy (PSPT). Earlier machines also had only X-rays placed perpendicular to each other to provide image guidance and so only bony anatomy could really be verified.

In addition, most of the older machines were fixed and the patient had to be rotated or positioned differently so that the beam could be directed to the tumour through various angles. However, this has now given way to Pencil Beam Scanning proton therapy (PBSPT) which is much more versatile and avoids the cumbersome and labor-intensive accessories required to deliver treatments. Also, the use of onboard image guidance and rotational gantries has made the delivery of proton therapy much more streamlined and comfortable to the patient and therapist. This has in turn made proton therapy accessible to many more people around the world.

Pencil Beam Scanning and Intensity Modulated Proton Beam therapy (IMPT)

Pencil beam scanning technology and IMPT are the latest technology in proton therapy. With a proton beam just millimeters wide, these advanced forms of proton therapy combine precision and effectiveness, offering unmatched ability to treat a patient’s tumour and minimizing effect on a patient’s quality of life – during and after treatment. They rely on complex treatment planning systems and an intricate number of magnets to aim a narrow proton beam and essentially “paint” a radiation dose layer by layer.

Pencil beam is very effective in treating the most complex tumours, like those in the prostate, brain, eye, and cancers in children, while leaving healthy tissue and other critical areas unharmed. IMPT is best used to deliver a potent and precise dose of protons to complex or concave-shaped tumours that may be adjacent to the spinal cord or embedded head and neck or skull base, including nasal and sinus cavities, oral cavity, salivary gland, tongue, tonsils, and larynx.

Who is a candidate for Proton Therapy?

When you meet with your cancer care team, your oncologist will give you the options that will be most effective in treating your type of cancer. Together with your cancer care team, you can decide on the treatment option that’s right for you. Proton therapy will be most beneficial to:

  • Paediatric patients
  • Those whose tumour is very close to critical structures
  • Those who are receiving radiation for the second or third time
  • Those who have a long life expectancy after radiation and are at risk for second cancers to develop during their lifetime.
  • Those with inherent conditions which predispose them to excessive toxicity or higher risk of second malignancy after radiation.

However, these are not the only patients who may benefit from proton therapy. Your radiation oncologist will discuss with you in detail the benefits of proton therapy for your particular cancer type and site.

What are the advantages of Proton Therapy?

Proton Therapy has many advantages including:

  • Targets tumours and cancer cells with precision and minimal exit dose.
  • Reduces overall toxicity.
  • Reduces the probability and/or severity of short- and long-term side effects on surrounding healthy tissues and organs (e.g. reduces the likelihood of secondary tumours caused by treatment).
  • Precisely delivers an optimal radiation dose to the tumour.
  • Can be used to treat recurrent tumours, even in patients who have already received radiation.
  • Improves quality of life during and after treatment.
  • Increases the long-term, progression-free survival rates for certain types of tumours.
What are the side effects of Proton Therapy?

Common side effects of proton therapy include:

  • Fatigue
  • Mouth, eating and digestion problems
  • Headaches
  • Hair loss around the part of your body being treated
  • Skin redness around the part of your body being treated
  • Soreness around the part of your body being treated
How safe is Proton Therapy?

Proton therapy delivers a precise radiation treatment while destroying cancer cells and minimizing damage to healthy tissue. This reduces side effects and lessens the risk of developing complications from treatment in later life. We at APCC have treated patients with ages ranging from less than a year old to 85 years old, successfully and without treatment side effects. Thus proton therapy is preferred because it is a safe treatment.

Is Proton Therapy painful?

Not really. Most patients have no sensation of radiation when the machine is delivering daily treatment. Over time, the skin in the area being treated will gradually become dry, sore, itchy, or burning. These feelings can be uncomfortable, but usually not enough for a person to stop or interrupt her treatment.

Why is Proton Therapy a better alternative to radiation therapy?

Proton therapy destroys cancer cells and minimizes damage to healthy cells by delivering a powerful punch of radiation right to the tumour site. Because proton beam radiation can be more precisely controlled, doctors can prescribe higher doses of radiation with less impact on the health of the surrounding tissue. In contrast to the X-rays commonly used in conventional radiation, protons enter the body at a low energy level and release most of their energy upon impact with the tumour, so there is no "exit" dose of radiation to healthy tissue. This results in a low incidence of side effects and, especially in children, fewer long-term effects.

How many treatments do you need for Proton Therapy?

Depending on their condition, a patient receives proton therapy about 5 times a week over the course of several weeks. The entire session of treatment may take between 30 min to 45 min, but the actual proton therapy only takes about a minute.

Preparing for Your First Proton Therapy

It can be hard to know how to prepare, but a number of general issues are worth considering in advance.

  • Arrange accommodation: Talk to our care co-ordinators who will be happy to provide you with options for accommodation, both within and outside the hospital.
  • Arrange transport: Talk to our care co-ordinators or reception desk about parking arrangements as there will often be spots set aside for radiation therapy patients.
  • Mention Metal Implants: Let your treatment team know if you have any medical devices in your body, such as a pacemaker, cochlear implant or another metal implant. Radiation therapy can affect these devices.
  • Quit Smoking: If you smoke, try to quit or cut down before radiation therapy starts, as smoking may make the treatment less effective and side effects worse.
  • Previous imaging: Do remember to bring most (if not all) of your previous imaging reports (and films/CD’s if available) to your first consult so your physician can have all the information available to decide the best plan of treatment.
  • Consider Fertility: Some types of radiation therapy can affect your fertility. If you think you may want to have children in the future, talk to your treatment team about your options before radiation therapy begins. If you think you may be pregnant do mention this before radiation therapy planning/simulation is done.
  • Shaving/ trimming facial hair: If you are receiving radiation therapy to your face/neck, you may want to consider trimming your beard/moustache or shaving before beginning radiation therapy, as you would need to avoid these during treatment.
  • Music: If you have any special music which can help you relax or which you prefer, please feel free to mention it to our therapists. As you may need to spend some time in the treatment room, we try to make your session as relaxing as possible.
Preparing a child for Proton Therapy

In addition to the mentioned measures for preparation before proton therapy, special efforts may be required for children undergoing proton beam therapy, including sedation to facilitate treatments and simulation. When you meet with your cancer care team, your oncologist will be able to give you the options that will be most effective in treating your child using proton beam therapy. We have a team of specialists in paediatric anaesthetists experienced in providing sedation for proton treatments. In addition, we have already treated children as young as 16 months old. Although you are free to bring your child's favourite toys to help keep them calm, we also have a toy room, where children can relax till their time for treatment.

How is Proton Therapy done?

Proton therapy is delivered by a device called a cyclotron, which sends a high-energy beam of protons through the skin towards the tumour. The first step is a CT or MRI scan to map the tumour in three dimensions. Then our radiation oncologists, in close collaboration with medical physicists, use computer programs to calculate how to deliver the treatment at the precise dose and location. Patients receive proton therapy in a special treatment room, where they are positioned on a treatment table. An immobilization device makes sure they stay in the exact position on the table. The table itself is a specialized robotic couch which ensures that even minute changes in the position of the patient can be corrected to bring the tumour exactly in the desired position for treatment delivery.

A specialized system of surface guidance (VisionRT™) is used to position the patient accurately on the couch as well as monitor their movement during the treatment. Prior to each treatment, the position of the patient is further verified by the use of CT scanners on the treatment machine, called cone-beam CT (CBCT). Once the position of the patient is verified, any corrections needed can be applied using the special robotic patient positioning system which has 6 degrees of freedom and so corrects the patient position very accurately. Then the beam is turned on and proton therapy is delivered to the patient.

Quality Assurance of Proton Therapy

The quality assurance of Pencil Beam Scanning Proton Therapy is done very meticulously at Apollo Proton Cancer Centre. Daily QA program is done in order to verify the main beam characteristics to assure the functionality of the therapy delivery system and the patient safety system. The daily QA program takes only 20-30 min. At the same time, the checks follow a comprehensive approach to cover all aspects of the beam delivery and treatment apparatus and increase the clinical beam availability. Before every patient is started on treatment, a patient-specific QA is also performed on the machine to ensure the best treatment is delivered at all times.

How long do Proton treatments last?

Depending on their condition, a patient receives proton therapy about 5 times a week over the course of several weeks to months. The entire session of treatment may take between 30 min to 45 min, but the actual proton therapy only takes about a minute. Most of the time is spent positioning the patient properly and adjusting the equipment in the treatment room. Treatment sessions are non-invasive, so patients can often continue with their daily activities.

What machine is used at APCC?

The proton therapy machine at APCC is called the Proteus Plus and is installed and maintained by IBA (Ion Beam Applications), a Belgium-based market leader in proton therapy systems. The IBA is a world leader in proton therapy systems and has been instrumental in implementing the vision of our Chairman, Dr.Prathap C. Reddy, to bring proton therapy to India. A complete team of engineers is present on-site in the hospital round-the-clock to ensure the ongoing maintenance and that the treatments delivered are always of the highest quality.

Why choose Apollo Proton Cancer Centre?

The combination of the best technology- pencil beam scanning proton beam therapy, intensity-modulated proton therapy, robotic patient positioning system, image guidance with on-board cone beam CT, motion management with surface guidance using the VisionRT platform; and the best clinical team- with a comprehensive team of experienced and specially trained doctors, working together as a Clinical Management Team (CMT), ensure that only the highest quality of care is delivered to each and every patient. This is why we have been honored with accreditation by the Joint Commission International (JCI) and are proud to be the only cancer centre in India to be honoured so.

What to expect during Proton Therapy?

After an initial consultation with our radiation oncologist, patients take part in a simulation. Simulation involves gathering information to help pinpoint the exact size, shape and location of tumour or lesion and surrounding critical structures using advanced imaging methods such as magnetic resonance imaging (MRI), CT (computed tomography) scanning and/ or PET (positron emission tomography) imaging. Using images and data collected from the simulation, a customized mould and other devices will be created to position the patient during treatment, so proton therapy can be delivered precisely to the tumour each and every time. It usually takes about a week to generate an appropriate proton plan after which treatment sessions can start. Once treatment sessions start, they are generally held once a day and five times a week, with a break on weekends.

How long does it take to recover from Proton Therapy?

The side effects associated with proton therapy are fewer than those that come from traditional radiation. This is due to proton therapy's ability to effectively deliver radiation doses to the treatment site while doing considerably less damage to the healthy tissue surrounding the tumour. When you meet with your cancer care team, your oncologist will be able to explain in detail about every side effect that you may endure.

Does hair grow back after Proton Therapy?

Depending upon the site of Radiation therapy, there can be loss of hair in the treated area. The hair loss will occur about two weeks after treatment has started. It may be temporary or permanent. Hair will usually begin to grow again 2 to 3 months after treatment is over. Some patients may find that the new hair growth is thinner or sparse than before and the texture or colour may have changed.

What is the cost of Proton Therapy?

The cost of proton therapy depends on the type of cancer. Once you have provided the details of the case, your radiation oncologist will decide on the treatment plan and procedure. The treatment package will also be explained.

Life after Proton Therapy

Radiation therapy usually does not have an immediate effect, and it could take days, weeks, or months to see any change in cancer. The cancer cells may then keep dying for weeks or months after the end of treatment. It may be some time before you know whether radiation therapy has controlled cancer. Life after cancer treatment can present its own challenges. You may have mixed feelings when treatment ends, and worry that every ache and pain means the cancer is coming back. Some people say that they feel pressure to return to “normal life”. It is important to allow yourself time to adjust to the physical and emotional changes and establish a new daily routine at your own pace. Your family and friends may also need time to adjust.

 Winning over Cancer

Winning over Cancer with Apollo Proton Cancer Centre

A breakthrough in Cancer Care! The global growing cancer burden tells an ominous tale. To counter this growing threat, Apollo Proton Cancer Centre provides a complete and comprehensive solution. As cancer care has become one of the fastest-growing healthcare imperatives across the world, we believe it is critical to redefine our purpose, to reboot our commitment on the single-minded focus - to battle cancer, to conquer cancer! APCC stands as a ray of hope for millions, infusing them with the courage to stand and stare cancer down.