Epidemiological aspects of hadron therapy: A prospective nationwide study of the Austrian project MedAustron and the Austrian Society of Radiooncology (OEGRO)

Patients With Cancer in the Countries of South-East Europe (the Balkans) Region and Prospective of the Particle Therapy Center: South-East European International Institute for Sustainable Technologies (SEEIIST)

PURPOSE

A recent initiative was launched for establishing the South-East European International Institute for Sustainable Technologies (SEEIIST), which will provide a cutting-edge Hadron radiation therapy treatment and research institute for treating cancer patients with Hadron therapy (HT). To justify the initiative for building the SEEIIST facility, a study was conducted to estimate the number of patients with cancer from the SEE region that would be eligible for HT.

METHODS AND MATERIALS

Two different methods for projecting the future annual cancer incidence have been applied: (1) using the International Agency on Research on Cancer@World Health Organization's (WHO) Globocan model which uses country's demographic factors, and (2) averaging the crude incidence data of 3 SEE countries with available national cancer registries, using a linear regression model of combined incidence per 100,000, and applying it to the entire SEE region. Cancer epidemiology data were collected and studied by using the countries' cancer datasheets from WHO. The top 10 cancers were presented for the SEE region. Studies of other countries were used to develop a primordial model for estimating the number of SEE patients who could be treated most successfully with HT upon SEEIIST commissioning in 2030.

RESULTS

A model was developed to estimate the number of eligible patients for HT from SEE. It is estimated that 2900 to 3200 patients per year would be eligible for HT in the new SEEIIST facility in 2030.

CONCLUSIONS

After commissioning, SEEIIST will initially treat approximately 400 patients per year, progressing toward 1000. Creation of SEEIIST dedicated patient selection criteria will be both necessary and highly challenging.

Estimating the Number of Patients Eligible for Carbon Ion Radiotherapy in the United States

Purpose

Carbon ion radiotherapy (CIRT) is an emerging radiotherapy modality with potential advantages over conventional photon-based therapy, including exhibiting a Bragg peak and greater relative biological effectiveness, leading to a higher degree of cell kill. Currently, 13 centers are treating with CIRT, although there are no centers in the United States. We aimed to estimate the number of patients eligible for a CIRT center in the United States.

Materials and Methods

Using the National Cancer Database, we analyzed the incidence of cancers frequently treated with CIRT internationally (glioblastoma, hepatocellular carcinoma, cholangiocarcinoma, locally advanced pancreatic cancer, non-small cell lung cancer, localized prostate cancer, soft tissue sarcomas, and specific head and neck cancers) diagnosed in the United States in 2015. The percentage and number of patients likely benefiting from CIRT was estimated with inclusion criteria from clinical trials and retrospective studies, and that ratio was applied to 2019 cancer statistics. An adaption correction rate was applied to estimate the potential number of patients treated with CIRT. Given the high dependency on prostate and lung cancers and the uncertain adoption of CIRT in those diseases, the data were then reanalyzed excluding those diagnoses.

Results

Of the 1 127 455 new cases of cancer diagnosed in the United States in 2015, there were 213 073 patients (18.9%) eligible for treatment with CIRT based on inclusion criteria. When applying this rate and the adaption correction rate to the 2019 incidence data, an estimated 89 946 patients (42.2% of those fitting inclusion criteria) are eligible for CIRT. Excluding prostate and lung cancers, there were an estimated 8922 patients (10% of those eligible for CIRT) eligible for CIRT. The number of patients eligible for CIRT is estimated to increase by 25% to 27.7% by 2025.

Conclusion

Our analysis suggests a need for CIRT in the United States in 2019, with the number of patients possibly eligible to receive CIRT expected to increase during the coming 5 to 10 years.

Assessment of improved organ at risk sparing for meningioma: light ion beam therapy as boost versus sole treatment option

PURPOSE

To compare photons, protons and carbon ions and their combinations for treatment of atypical and anaplastical skull base meningioma.

MATERIAL AND METHODS

Two planning target volumes (PTVinitial/PTVboost) were delineated for 10 patients (prescribed doses 50 Gy(RBE) and 10 Gy(RBE)). Plans for intensity modulated photon (IMXT), proton (IMPT) and carbon ion therapy ((12)C) were generated assuming a non-gantry scenario for particles. The following combinations were compared: IMXT+IMXT/IMPT/(12)C; IMPT+IMPT/(12)C; and (12)C+(12)C. Plan quality was evaluated by target conformity and homogeneity (CI, HI), V95%, D2% and D50% and dose-volume-histogram (DVH) parameters for organs-at-risk (OAR). If dose escalation was possible, it was performed until OAR tolerance levels were reached.

RESULTS

CI was worst for IMXT. HI<0.05±0.01 for (12)C was significantly better than for IMXT. For all treatment options dose escalation above 60 Gy(RBE) was possible for four patients, but impossible for six patients. Compared to IMXT+IMXT, ion beam therapy showed an improved sparing for most OARs, e.g. using protons and carbon ions D50% was reduced by more than 50% for the ipsilateral eye and the brainstem.

CONCLUSION

Highly conformal IMPT and (12)C plans could be generated with a non-gantry scenario. Improved OAR sparing favors both sole (12)C and/or IMPT plans.

Epidemiological study of the incidence of cancers eligible for proton or carbon ions therapy: methodology and results of recruitment estimation

Context. Hadrontherapy is an innovative form of radiotherapy using beams of protons or carbon ions able to destroy some radio-resistant tumours. Because these tumours are highly specific amongst all cancerous tumours, it is impossible to determine the incidence of these diseases from surveillance registries. Goal. To assess, within the Rhône-Alpes region, the incidence of cancers being hadrontherapy indications. Method. Prospective, multicentre continuous data collection during 1 year, by practitioners participating to multidisciplinary tumor board. Tumours are inoperable, radio resistant, at primary stage of development, or locally recurrent, with low metastatic potential. Results. Study involved 27 healthcare centres, 52 groups of specialist practitioners. The estimated incidence of cancers eligible for hadrontherapy in the Rhône-Alpes region in 2010, that is, for 34 locations in all, is of 8.5/100 000 inhabitants. Appraisal of the low potential of metastatic progression is impeded, because these are rare diseases, whose outcome is unfamiliar to investigators. Conclusion. Future epidemiological studies will need to focus on prognosis and on the metastatic progression rate of these diseases. Indeed, there are few information available on this subject in the literature that could be used to improve preventive measures, medical care, and the surveillance of these rare cancers.

ENLIGHT and other EU-funded projects in hadron therapy

Following impressive results from early phase trials in Japan and Germany, there is a current expansion in European hadron therapy. This article summarises present European Union-funded projects for research and co-ordination of hadron therapy across Europe. Our primary focus will be on the research questions associated with carbon ion treatment of cancer, but these considerations are also applicable to treatments using proton beams and other light ions. The challenges inherent in this new form of radiotherapy require maximum interdisciplinary co-ordination. On the basis of its successful track record in particle and accelerator physics, the internationally funded CERN laboratories (otherwise known as the European Organisation for Nuclear Research) have been instrumental in promoting collaborations for research purposes in this area of radiation oncology. There will soon be increased opportunities for referral of patients across Europe for hadron therapy. Oncologists should be aware of these developments, which confer enhanced prospects for better cancer cure rates as well as improved quality of life in many cancer patients.

[Particle therapy: carbon ions]

Carbon ion therapy is an innovative radiation therapy. It has been first proposed in the forties by Robert Wilson, however the first dedicated centres for human care have been build up only recently in Japan and Germany. The interest of carbon ion is twofold: 1) the very sharp targeting of the tumour with the so called spread out Bragg peak that delivers most of the beam energy in the tumour and nothing beyond it, sparing very efficiently the healthy tissues; 2) the higher relative biological efficiency compared to X rays or protons, able to kill radioresistant tumour cells. Both properties make carbon ions the elective therapy for non resectable radioresistant tumours loco-regionally threatening. The technical and clinical experience accumulated during the recent decades is summarized in this paper along with a detailed presentation of the elective indications. A short comparison between conventional radiotherapy and hadrontherapy is proposed for the indications which are considered as priority for carbon ions.

The case for particle therapy

Among the most important decisions facing the British Government regarding the treatment of cancer in the National Health Service (NHS) is the purchase of charged particle therapy (CPT) centres. CPT is different from conventional radiotherapy: the dose is deposited far more selectively in Bragg Peaks by either protons or "heavy" ions, such as carbon. In this way, it is possible to "dose paint" targets, voxel by voxel, with far less dose to surrounding tissues than with X-ray techniques. At present the UK possesses a 62 MeV cyclotron proton facility at Clatterbridge (Wirral), which provides therapy for intraocular cancers such as melanoma; for deeper situated cancers in the pelvis, chest etc., much higher energies, over 200 MeV are required from a synchrotron facility. There is an impressive expansion in particle beam therapy (PBT) centres worldwide, since they offer good prospects of improved quality of life with enhanced cancer cures in situations where conventional therapy is limited due to radioresistance or by the close proximity of critical normal tissues. There is a threat to UK Oncology, since it is anticipated that several thousand British patients may require referral abroad for therapy; this would severely disrupt their multidisciplinary management and require demanding logistical support.