In line with its mission, the Editorial Board of MedTvoiLokony makes every effort to provide reliable medical content supported by the latest scientific knowledge. The additional flag “Checked Content” indicates that the article has been reviewed by or written directly by a physician. This two-step verification: a medical journalist and a doctor allows us to provide the highest quality content in line with current medical knowledge.
Our commitment in this area has been appreciated, among others, by by the Association of Journalists for Health, which awarded the Editorial Board of MedTvoiLokony with the honorary title of the Great Educator.
At the end of this year, the Cyclotron Center Bronowice will be ready to welcome the first oncological patients who will be treated with proton therapy. It is currently one of the most modern methods used to remove tumors deep inside the body. I talk to prof. Marek Jeżabek, director of the Institute of Nuclear Physics of the Polish Academy of Sciences.
Aleksandra Gołąb: If you were to explain to a person who has just found out that you suffer from cancer, and together with your doctor, you are faced with choosing a treatment method, what words would you use?
Prof. Marek Jeżabek: Proton therapy involves irradiating a malignant tumor with protons. Protons interacting with matter have a maximum destructive effect at the end of their path. Therefore, by selecting the appropriate proton energy, we can choose the depth at which this effect will be very great – the DNA of malignant cancer cells will be destroyed and they will not be able to divide further. At the same time, healthy tissue is saved as much as possible in the path of protons.
Therefore, proton therapy is ideal when the patient suffers from cancer in which we have a well-located tumor that may be life-threatening as a result of metastasis. If this tumor is deep in the human body, or close to some important organ, the fact that protons damage very little tissue in their path is very useful.
Can you give an example of a specific cancer where this feature is crucial?
Ocular melanoma is a model example of a cancer eligible for proton therapy. Melanoma itself is a lethal threat to the patient, because if it metastases, the patient may die. In that case, this procedure genuinely saves lives.
There are different ways to deal with eyeball cancer. From methods that were used 100 years ago, i.e. removal of the eyeball, through the process of irradiating the tumor with a radioactive source. This procedure, or brachytherapy, is still used today. Brachytherapy is most effective for tumors that are smaller and distant from the optic nerve. Its downside is that in the case of a radioactive source, it is difficult to direct the radiation only to the area to be treated. Thanks to the team of prof. Bożena Romanowska – Dixon from the Ophthalmology Clinic of the University Hospital of the Jagiellonian University, proton radiotherapy conducted at the IFJ PAN successfully replaces the brachytherapy used there since the 60s.
In turn, we can guide protons so well, so choose their path in the eye to destroy the tumor and not damage the optic nerve. Provided, of course, that the tumor is slightly further away from this nerve. With proton therapy, we can achieve precision below one millimeter, and in that case you can see why it is so important.
What does the preparation for therapy and the subsequent treatment look like?
The patient comes to the Institute of Nuclear Physics and the first tests for this therapy take place here. The tumor is located on the basis of special tantalum tags. They are sewn onto the eyeball during surgery in the hospital. Thanks to these markers illuminated with X-rays, we know where the cancer is and we choose both the direction and shape of the proton radiation to destroy this cancer with certainty. Thanks to this, in the vast majority of cases it is possible to save the patient’s eyesight.
What the professor says is very optimistic, but isn’t similar effectiveness achieved at a different cost? Simply put, is this therapy painful?
Medical personnel tries to make this therapy as least invasive as possible. In the case of the eye, the most unpleasant part is putting on special retractors that are used to pull the eyelid away from the proton route during the procedure itself. Apart from sewing in tantalum markers, this is the only time in therapy when you need to use anesthetics. The irradiation with protons is completely painless.
The most difficult in this therapy is the first day when the patient is under great stress because he does not know what awaits him. The next three days are usually much easier.
So the whole therapy only lasts a few days?
All therapy takes place in a three-week cycle. From sewing on tantalum markers to the end of therapy. The irradiation itself consists of four consecutive sessions, typically lasting less than a minute. However, the very positioning of the patient, i.e. ensuring that this very precisely planned beam gets where it needs to be, takes several dozen minutes. If the patient were even a millimeter misaligned, all the effort would be wasted.
Suppose the procedure was successful. Does the patient require hospitalization after all?
This, of course, depends on his health, but it is possible to conduct therapy on an outpatient basis, i.e. the patient comes, undergoes the procedure, gets into the car and returns home. In short, it is not an invasive therapy, the kind that must be followed by an overnight stay in the intensive care unit. On the contrary, it is a therapy in which there is no blood, no pain. If there is stress, it is associated with long-term “targeting” the tumor, and to some extent also with the fact that we are subconsciously afraid of radiation.
Compared to standard radiotherapy, proton therapy is very precise. Does this method also have other advantages that make it better than regular radiation therapy?
This point must be clarified very precisely in order to avoid any misunderstandings. There are many situations in which different therapeutic methods are equally effective, and if the psychological burden on the patient differs, it is not a factor in the first place. If, for example, we are dealing with a skin cancer, then undoubtedly a simple surgical operation supplemented with radiation therapy is completely sufficient.
Proton therapy is approximately 10% recommended worldwide. cases that are eligible for radiation therapy. In these cases it is really worth doing and it should be done – for example, if we are dealing with neoplasms within the central nervous system.
Costs must also be considered. People who deal with ethics very often make judgments denying the need to consider the cost of therapy. I believe that this is a wrong attitude. All factors must be taken into account when assessing whether a patient qualifies for a given method.
The more so when we have a therapy that will give a similar effect at lower costs.
Of course. Proton therapy is expensive, although not much more expensive than the most sophisticated chemotherapy, which does not change the fact that its cost far exceeds the cost of standard radiotherapy. It must be used thoughtfully – where it is really needed.
Of course, I am talking about a situation where the procedure is to be funded from public funds. A patient who is wealthy can buy a Lamborghini instead of a Toyota. It is a question of how much the patient is willing to pay for his health. It is known that it is invaluable, but from a social point of view, we must look at the sum effect.
Can you please tell us what order these sums are?
In the case of eye therapy, a valuation has already been made and the therapy is reimbursed by the National Health Fund. The cost is over 50 thousand. zlotys, of which 70 percent. these are the costs of the procedure itself at the Institute of Nuclear Physics. This includes delivering a proton beam to the station, planning the therapy, and maintaining the device in perfect operation. The remaining 30 percent. are the costs of medical personnel, hospitalization, etc.
The cost of gantry therapy depends on how many fractions need to be given to the patient, and this is related to the type of tumor and its location. Assuming 30 fractions, i.e. thirty doses of irradiation, and let me remind you that in the case of eye cancer, there were four fractions, this cost is slightly over 100. zlotys.
The cost is very much dependent on the number of patients. There is a price you can’t go below. You have to hire enough people to provide at least one shift in physicists and medical staff. During the treatments, it is necessary to have a full team of cyclotron operators, and the rest of the time, on duty of experts. The cyclotron has to run constantly, so there are electricity costs. Finally – you must have a service contract, because if you treat patients, there must be a guarantee that the device will work practically without failure, etc. If there are few patients, the fixed cost is distributed over them in such a way that the price increases.
Ultimately, the maximum number of patients that we will be able to admit is 700 people a year at two gantry stations and 100 ophthalmic patients. Then, with such a level and with the achievement of optimal efficiency of all involved in the treatment, this cost will be much lower. I’m talking about 100 PLN, assuming about 250 patients per year in the initial phase of the project.
So there is a chance that if there is a high occupancy, this therapy will be a bit cheaper?
Of course. However, several conditions must be met. It is not enough that the National Health Fund (NFZ) contracts proton radiotherapy for, say, 700 patients a year and allocates sufficiently high expenditures for this purpose, and all the complicated equipment will be perfectly functional all year round. Doctors, nurses and medical physicists still need to achieve this level of fitness and experience so much that these 700 treatments of multiple irradiation can be flawlessly performed. With the first patients, the procedure takes many times longer. All dosimetric measurements will be doubled or even tripled to make sure that the patients are safe. Here, the first do no harm principle will really be applied with all firmness.
It’s easy to imagine that when a patient is faced with a diagnosis of cancer, the first thing they do is browse the internet for treatment options. If he reads about proton therapy, which is safe and very effective, he will definitely want to take advantage of it. Will patients who can afford such a therapy from their own pocket be able to look for such solutions privately?
Centrum Cyklotronowe Bronowice was established with public funds: EU funds and the Polish state budget. Therefore, it should first of all serve the patients referred here by the National Health Fund. Based on the literature data, we estimate that the annual demand for this therapy will appear in about 2 people. Poles. At our Institute, we will be able to admit a maximum of 700 patients per year. Therefore, it can be seen that such commercial use of this therapy, when we come to a situation where the National Health Fund will contract a sufficiently large number of treatments, will be neither necessary nor possible.
Operation in the initial phase of the project will largely depend on the decision of the National Health Fund. If the National Health Fund allocates funds for 250 patients in the first two years of operation, it will also mean the maximum possible burden, taking into account what we call the learning curve, i.e. the process of achieving the highest efficiency in carrying out a given method.
There are centers – there is one such center in Prague, for example – which were built entirely from private funds. The first two years of operation were based solely on commercial activities.
Poland is a much larger country than the Czech Republic and our center is smaller than in Prague. We have two gantras, there are three. Therefore, it seems to me that the share of commercial treatment should not be too large, because for the next few years what we have at our disposal is less than the real demand.
One can imagine a situation in which more centers will be created and, as a result, it may turn out that there is a certain surplus. In such a situation, if patients from abroad come to us, their commercial treatment will be a natural consequence of our membership in the European Union.
You mentioned the possibility of creating new posts in the future. Do you think this therapy will eventually replace standard radiotherapy since it has fewer side effects?
I do not think so. Currently, it is estimated that for about 10 percent. In cases qualified for radiotherapy, proton therapy is clearly better. Of course, the wealth of the society is at stake here. In the USA, a lot of proton radiotherapy centers are built, and there, as a standard, protons are treated with protons, such neoplasms that in Europe are not recognized as unconditionally eligible for this method.
Prostate tumors are a good example. Proton therapy is a very good method and in this case it provides the patient with great comfort. Here it is like with any area of life. You can give birth without anesthesia, you can give birth more painlessly. We have the same situation with the dentist. This, of course, costs money. It seems to me that Poland is on its way to becoming a wealthy country. For wealthy people, if not next year, perhaps in 10 years, this choice will become possible.
Can we say that the center that will be made available to patients this year is actually the most modern center for the treatment of malignant tumors? It is currently one of the best cancer therapies in the world.
We have two great devices at our disposal, i.e. state-of-the-art gantry stations. Speaking of being ultra-modern, I’m not exaggerating a bit. In Europe, they can be counted on the fingers of two hands. Without false modesty and without exaggeration, I can say that I am very proud to have this resort here. I think this is a real achievement. The funds allocated for this are used as planned. Our people, our engineers, medical technicians, physicists, the whole group that is to conduct this therapy, easily absorbed this quantum of knowledge. We have not made any breakthrough progress in the application of nuclear techniques in medicine, but we provide Polish patients with access to therapy used in the most developed countries in the world. Already today, patients from our country are referred to foreign centers for proton radiotherapy treatments. It is much more expensive and less convenient for patients and their families. Soon it will be possible to see such patients in Krakow. This is a joint work of doctors and nuclear physicists.
Tekst: Aleksandra Gołąb