Tech Savvy Susan Doyle-Lindrud, DNP, AOCNP®, DCC—Associate Editor

Proton Beam Therapy for Pediatric Malignancies

Downloaded on 10 01 2017. Single-user license only. Copyright 2017 by the Oncology Nursing Society. For permission to post online, reprint, adapt, or reuse, please email pubpermissions@ons.org

Susan Doyle-Lindrud, DNP, AOCNP®, DCC

Gray (Gy). Photons travel through tissue

Although major advances have been made in radiation techniques, concerns still
without stopping, resulting in continuous
exist about the treatment-related acute and long-term side effects. This issue is dosing of radiation beyond the tumor
most notable in the pediatric population because of developing organs and tissues (Merchant & Farr, 2014).
combined with longer life expectancies. Proton beam therapy has the advantage of a Proton therapy is an external radio-
reduced dose of radiation with less scatter to normal tissue, which may lead to fewer therapy modality that uses protons in-
adverse side effects. stead of photons. Protons are positively
charged particles that are accelerated by
At a Glance a large, expensive particle accelerator
• Many pediatric patients with cancer receive radiation therapy. called a cyclotron or synchrotron, avail-
• Radiation treatments can cause significant acute and long-term side effects. able at a limited number of specialized
• Proton beam therapy reduces radiation scatter to normal tissues and may decrease centers (Decker & Wilson, 2012). When
acute and late toxicities. a proton beam enters the body, it delivers
a constant dose within a few millimeters
Susan Doyle-Lindrud, DNP, AOCNP®, DCC, is an assistant dean of Academic Affairs and a director of the of the end of the particle range, the so-
Doctor of Nursing Practice Program and Oncology Program in the School of Nursing at Columbia Univer- called Bragg peak (see Figure 1). Beyond
sity in New York, NY. The author takes full responsibility for the content of the article. The author did not
the Bragg peak, protons deliver almost
receive honoraria for this work. No financial relationships relevant to the content of this article have been
disclosed by the author or editorial staff. Doyle-Lindrud can be reached at smd9@columbia.edu, with copy no additional exit dose beyond the tar-
to editor at CJONEditor@ons.org. get. The benefit of this is that the proton
Key words: radiation; survivorship; technology beam stops within the patient’s tumor
Digital Object Identifier: 10.1188/15.CJON.521-523 region, and the radiation does not extend
to normal tissue beyond the tumor. This
allows for radiation absorption to deep
tumor targets with less scatter of radia-

P
roton beam therapy is one of the
latest advancements in radiation
therapy used to treat cancer. Al-
though initially proposed in 1946, the
first patients were treated in 1958 at the
Lawrence Berkeley National Laboratory
in California (Merchant & Farr, 2014; Mi-
tin & Zietman, 2014). The use of proton
beam therapy in clinical practice has
been slowly introduced but has gained
significant ground with increasing public
awareness since 2010 (Mitin & Zietman,
2014). One of the reasons this form of
radiation has garnered interest is because
of theoretical advantages as compared to
photon therapy, with specific potential
advantages in the pediatric population.
About 12,000 new cases of pediatric
cancer occur each year in the United
States, and about 3,000 require radiation
therapy (Merchant, 2013). Although radi-
ation is an important component of many
treatment regimens for pediatric cancers,
it is associated with early and late side
effects that can be more problematic
in children because of their developing
organs and tissues (Armstrong, Stovall,
& Robison, 2010). The possible benefits
of proton beam therapy are the reduction
in dose to normal tissues and a reduction
in adverse effects of radiation treatment
(Merchant, 2013).
Background
Radiation therapy for patients with
cancer commonly uses external beam
delivery techniques that include photons.
This form of ionizing radiation releases
energy and delivers radiation doses to
the specific areas of a patient’s body.
The standard dose of radiation is the
tion to normal surrounding tissues and
the possible safe escalation of radiation
doses to enhance tumor control (Daw &
Mahajan, 2013; Swisher-McClure, Hahn,
& Bekelman, 2015).
Childhood Cancer
With multimodality therapies for pedi-
atric malignancies, the five-year survival
rate exceeds 80%. As many as 60%–90%
of survivors of pediatric cancer expe-
rience adverse side effects related to
the cancer or the treatment received
(Geenen et al., 2007). The challenge for
the pediatric cancer population with
solid tumors undergoing radiation is the
large, irregular volume of tumors close
to critical structures in the body. In addi-
tion, children, when compared to adults,
have longer anticipated life spans and an
increased sensitivity to the radiation from

Clinical Journal of Oncology Nursing • Volume 19, Number 5 • Tech Savvy 521
 100
80
6 MV
Dose (%)
60
250 MeV
40
20 250 MeV
0 American Society of Clinical Oncology
0 10 20
Depth in Tissue (cm)
Photon Modified proton Native proton
FIGURE 1. Proton and Photon Beams With Bragg
Peak
Note. From “Bragg Peak,” by A.A. Miller, 2005, licensed under
CC BY-SA 3.0. Retrieved from https://commons.wikimedia.org/
wiki/File:BraggPeak.png
developing organs and tissues, which
puts them at greater risk of secondary
cancers and late effects of treatment
(Daw & Mahajan, 2013). Depending on
the location of the tumor in the body and
the associated field of radiation, the late
effects include deficits in cognition, en-
docrine function, vascular abnormality,
dental anomalies, hypothyroidism, car-
diovascular and gastrointestinal toxicity,
and secondary malignancies (Armstrong
et al., 2010; Geenen et al., 2007; Green-
berger et al., 2014; Zhang et al., 2013).
Proton beam therapy has been in-
cluded as a radiation option in pediatric
clinical trials for more than a decade,
and the number of patients treated has
increased (Merchant, 2013). Guidelines
that include proton therapy for pediatric
central nervous system, musculoskeletal,
and solid tumors have been developed by
the Children’s Oncology Group and ap-
proved by the National Cancer Institute’s
Cancer Therapy Evaluation Program
(Merchant, 2013). Biologically, protons
have not demonstrated a significant ad-
vantage when compared to photons,
which leads to similar rates of predicted
tumor control, but the physical prop-
erties of protons lead to less radiation
scatter to normal tissues and a decrease
in acute and late toxicities (Rombi, Ven-
narini, Vinante, Ravanelli, & Amichetti,
2014). However, consensus exists among
522
investigators that proton
therapy is well tolerated
and may hold therapeutic
benefit with certain types
of tumors, such as central
nervous system tumors,
over other forms of radia-
tion therapy (Merchant &
Farr, 2014; Merchant et al.,
2008).
Challenges
30 As the cost of health care
has increased, the cost
and benefits of this new
technology continue to be
debated. The evidence to
support proton beam ther-
apy in terms of outcomes
and cost is limited (Mori-
arty, Borah, Foote, Pulido,
& Shah, 2015). Construc-
tion of a proton therapy
center is costly, ranging
from $25 million to more than $200 mil-
lion, depending on the size of the facility
(Swisher-McClure et al., 2015). The costs
of treatment are about two to three times
greater than photon-based radiation treat-
ments. In addition, because of the cost of
constructing a facility, these centers are
only available in select locations, adding to
the financial burden for patients and their
families because receiving proton beam
therapy may involve travel, housing, and
potential lost wages (Swisher-McClure et
al., 2015).
Conclusion
The use of proton beam therapy to treat
pediatric malignancies is increasing, with
the possible benefit that this modality
may improve quality of life for long-term
cancer survivors (Palm & Johansson,
2007; Rombi et al., 2014). Longitudinal,
comparative clinical trials with long-term
follow-up are needed to assess survival
outcomes and evaluate for late effects and
secondary malignancies of proton beam
therapy, as compared to photon therapy.
With continued advancement in radiation
delivery techniques, the development of
smaller and less costly proton beam units
could lead to an increase in the develop-
ment of proton beam treatment centers
and a decrease in cost to patients (Mitin
& Zietman, 2014).
October 2015 • Volume 19, Number 5 • Clinical Journal of Oncology Nursing
References
Armstrong, G.T., Stovall, M., & Robison,
L.L. (2010). Long-term effects of radia-
tion exposure among adult survivors of
childhood cancer: Results from the child-
hood cancer survivor study. Radiation
Research, 174, 840–850. doi:10.1667/
RR1903.1
Daw, N.C., & Mahajan, A. (2013). Photons or
protons for non-central nervous system
solid malignancies in children: A histori-
cal perspective and important highlights.
Educational Book. Retrieved from http://
meetinglibrary.asco.org/content/126-132
Decker, R.H., & Wilson, L.D. (2012). Chapter
40: Radiotherapy. In L.A. Goldsmith, S.I.
Katz, B.A. Gilchrest, A.S. Paller, D.J. Lef-
fell, & K. Wolff (Eds.), Fitzpatrick’s der-
matology in general medicine (8th ed.).
Retrieved from http://accessmedicine
.mhmedical.com/content.aspx?bookid=3
92&Sectionid=41138978
Geenen, M.M., Cardous-Ubbink, M.C., Kre-
mer, L.C., van den Bos, C., van der Pal,
H.J., Heinen, R.C., . . . van Leeuwen, F.E.
(2007). Medical assessment of adverse
health outcomes in long-term survivors of
childhood cancer. JAMA, 297, 2705–2715.
doi:10.1001/jama.297.24.2705
Greenberger, B.A., Pulsifer, M.B., Ebb, D.H.,
MacDonald, S.M., Jones, R.M., Butler, W.E.,
. . . Yock, T.I. (2014). Clinical outcomes
and late endocrine, neurocognitive, and
visual profiles of proton radiation for pe-
diatric low-grade gliomas. International
Journal of Radiation Oncology, Biology,
Physics, 89, 1060–1068. doi:10.1016/j
.ijrobp.2014.04.053
Merchant, T.E. (2013). Clinical controversies:
Proton therapy for pediatric tumors. Semi-
nars in Radiation Oncology, 23, 97–108.
doi:10.1016/j.semradonc.2012.11.008
Merchant, T.E., & Farr, J.B. (2014). Proton
beam therapy: A fad or a new standard
of care. Current Opinion in Pediatrics,
26, 3–8. doi:10.1097/MOP.0000000000
000048
Merchant, T.E., Hua, C.H., Shukla, H., Ying,
X., Nill, S., & Oelfke, U. (2008). Proton
versus photon radiotherapy for common
pediatric brain tumors: Comparison of
models of dose characteristics and their
relationship to cognitive function. Pe-
diatric Blood and Cancer, 51, 110–117.
doi:10.1002/pbc.21530
Mitin, T., & Zietman, A.L. (2014). Promise
and pitfalls of heavy-particle therapy.
Journal of Clinical Oncology, 32, 2855–
2863. doi:10.1200/JCO.2014.55.1945
Moriarty, J.P., Borah, B.J., Foote, R.L., Pulido,
J.S., & Shah, N.D. (2015). Cost-effectiveness
of proton beam therapy for intraocular
melanoma. PLoS One, 10, e0127814.
doi:10.1371/journal.pone.0127814
Palm, A., & Johansson, K.A. (2007). A re-
view of the impact of photon and proton
external beam radiotherapy treatment
modalities on the dose distribution in
field and out-of-field; implications for
the long-term morbidity of cancer sur-
vivors. Acta Oncologica, 46, 462–473.
doi:10.1080/02841860701218626
Rombi, B., Vennarini, S., Vinante, L., Rav-
anelli, D., & Amichetti, M. (2014). Proton
radiotherapy for pediatric tumors: Review
of first clinical results. Italian Journal
Clinical Journal of Oncology Nursing • Volume 19, Number 5 • Tech Savvy
of Pediatrics, 40, 74. doi:10.1186/s13052 Zhang, R., Howell, R.M., Homann, K., Gie-
-014-0074-6 beler, A., Taddei, P.J., Mahajan, A., &
Swisher-McClure, S., Hahn, S.M., & Bekel- Newhauser, W.D. (2013). Predicted risks
man, J. (2015). Proton beam therapy: of radiogenic cardiac toxicity in two
The next disruptive innovation in health- pediatric patients undergoing photon or
care? Postgraduate Medical Journal, 91, proton radiotherapy. Radiation Oncol-
241–243. ogy, 8, 184. doi:10.1186/1748-717X-8-184
Do You Have an Interesting Topic to Share?
Tech Savvy discusses the ways in which technology affects nurses, patients, the
healthcare team, and the oncology setting. Length should be no more than 1,000–1,500
words, exclusive of tables, figures, insets, and references. If interested, contact Associate
Editor Susan Doyle-Lindrud, DNP, AOCNP®, DCC, at smd9@columbia.edu.
523